Mechanical ventilation and RAD

Prof. K. Chellum Oration / CMC Vellore 26th June 2004

Dr Satish Deopujari

Incidence of M.V. in RAD in India ? Do we under ventilate these patients.

Aggressive management .. Proper oxygenation warmed and humidified Continuous nebulization what dose ? Look for hypokalemia Steroids / Ipatropium bromide / MgSO4 Hydration / Ensure good Hemoglobin level. Avoiding agitation Ketamine Newer modalities

MgSO4
Mechanism of Action
Antagonizes translocation of Ca across cell membrane, leads to SM relaxation and Inhibits degranulation of mast cells Decreases release of ACH (decreases excitability of muscle fibre membranes)

Side Effects:
Facial warmth/flushing, hypotension, nausea, emesis, muscle weakness, sedation, loss of DTRs, resp depression

Dose:
20-40mg/kg IV over 30 min

 The decision to intubate pt in SA , is made on the basis clinical deterioration, Altered level of consciousness Exhaustion / P. paradoxus Inability to protect airway Increasing arterial PCO2. Quiet chest, absence of audible wheezing
PaO2 < 60 mmHg : not responding to adequate oxygenation PaCO2 > 50 mmHg and rising more than 5 mmHg/ hour

 Zimmerman et al, reported that one or more complications occurred in 46% of intubated asthmatics. More than one-third of all complications occurred during intubation. 47 % of complications during the intensive care unit stay Difficult and esophageal intubations occurred in about 15% of all patients

Standard preparation for rapid sequence intubation .

cardio-respiratory and blood pressure monitoring Assistance monitoring of oxygen saturation careful aspiration of oropharynx bag and mask ventilation with 100% oxygen emptying of the stomach by nasogastric tube benzodiazepine should be considered (e.g., midazolam 0.1 - 0.2 mg/kg) permitting relaxation during preoxygenation

Ketamine hydrochloride (1 to 3 mg/kg) Good choice for its sedative and analgesic effects as well as its bronchodilating characteristics.

Concomitant use of a benzodiazepine can suppress the dysphoric effects of Ketamine.

Ketamine increases laryngeal secretions but does not block pharyngeal and laryngeal reflexes, increasing the risk of laryngospasm and aspiration in the preintubation period

Endotracheal tube.

largest endotracheal tube.. lower airflow resistance Suctioning of thick mucosal secretions Fiber optic bronchoscopy : facilitated A cuffed endotracheal tube Sometimes useful even in small children (<5 years) when insufflation pressures become very high (Hubert 1996).

Intubation.
oxygenation H2 blockers , prokinetics . atropine Proper monitoring Lignocaine 4 % neb. 4mg / kg ( 1ml = 40 mg ) Sedation midazolam + ketamine / cricoid Oxygenation & Circulation pressure Paralysis ( Vecuronium .1 to .2 mg / kg ) Intubation Suction Confirmation of tube and proper fixation Avoid positive pressure V. without cricoid P.

status

Fluid bolus for circulation

Lt heart pumps what the right heart gives it

Ventilatory strategy

Permissive hypercapnia low rate 50 % for the age low pressure Avoiding barotrauma low pressure Minimal PEEP Intrinsic PEEP Dynamic hyperinflation (DHI)

PEEP Controversies remain about the role of PEEP in status asthmaticus. Majority of cases, no PEEP should be applied during mechanical ventilation (0 3 cm H2O maximum)

PEEP

Intrinsic PEEP Air leak syndrome

A 'rapid sequence' for extubation is justified by the risk of further bronchoconstriction induced by the presence of the endotracheal tube.

 Adding adjuvant therapy despite lack of evidence is reasonable given the risks associated with intubation and mechanical ventilation More research is required in childhood status asthmaticus!

THANKS
M. Ventilation is a BLEND of Art and science

 Adding adjuvant therapy despite lack of evidence is reasonable given the risks associated with intubation and mechanical ventilation More research is required in childhood status asthmaticus!

Mechanical ventilation
Less than 5% of patients with SA required intubation and MV, braman et al, jama 1990

Indications:
To decrease work of breathing. To maintain adequate oxygenation . Augment alveolar ventilation in face of airway edema and diffuse mucus plugging of of the small airways

Indications of mechanical ventilation

PaO2 < 60 mmHg or cyanosis not corrected by oxygen administration PaCO2 > 50 mmHg and rising more than 5 mmHg/ hour Not governed by numbers but by the clinical conditions. The decision to intubate and ventilate a child with status asthmaticus is primarily based on clinical criteria: respiratory muscle fatigue, obvious exhaustion, disappearance of pulsus paradoxus diminution of thoracic amplitude during respiratory movements diminution of air entry in the lungs : quiet chest, absence of audible wheezing pulsus paradoxus > 20 - 40 mmHg (inspiratory decline in systolic blood pressure) deterioration of mental status (lethargy, agitation, confusion, coma) diaphoresis in recumbent position

ideal ventilator settings reduce dynamic hyperinflation (DHI): limited minute ventilation (MV) using an appropriately low but adequate tidal volume (Vt) and respiratory rate, with an extended expiratory time (TE)