Gas trapping Dynamic hyperinflation PEEPi

Oxygen Nebulized B2 Agonists Nebulized Ipratropium Bromide Steroids MgSO4 IV Bronchodilators Adrenaline

Indications for Intubation

Absolute Coma Resp or Cardiac Arrest Severe Refractory Hypoxaemia Relative - Adverse response to initial management - Fatigue and somnolence - Cardiovascular compromise - Pneumothorax

Peri Intubation
Hypotension
vasodilation Reduction in sympathetic tone on induction Absolute hypovolaemia Decreased venous return due to increased intrathoracic pressures

Goals of Ventilation
Correct hypoxaemia Reduce dynamic hyperinflation Wait for medical management to work

Sedation
Morphine Midazolam Ketamine Propofol + fentanyl NMS Rocuronium Pancuronium NB Atracurium= histamine release

Venitlator Settings
Low rates ( 12- 14 breaths/min) Tidal volumes (4-8ml/kg) Fi02 (Maintain sats> 92%) Relatively long expiratory times Little or no PEEP Volume controlled ventilation

Goals
Pplat < 35cm H20 pH>7.2

 Pplat> 35cmH20 dec Ve (Vt and/rate) pH<7.2 and Pplat <30 cmH20 increase Ve pH < 7.2 and Pplat > 35cmH20 No change

Complications of MV in life threatening Asthma

Hypotension Cardiac stunning Arrhythmia Rhabdomyolisis Lactic Acidosis Myopathy CNS injury

Permissive Hypercapnia
pH>7.2 NB Cerebral Anoxia sec Resp Arrest
Control of intracranial pressure

Additional considerations
Inhaled anaesthetic agents ECMO Bronchoscopy Heliox Antibiotics NIPPV Leukotriene antagonists Monoclonal anti-IgE antibodies

Low tidal volume Low respiratory rate Prolong expiration time Shorten inspiratory time Monitor for dynamic hyperinflation