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Recommendations for mechanical ventilation of critically ill children

12.06.2018
Author: Süha Demirakca, Reviewer: Paul Garbarini

Common clinical practice in pediatric mechanical ventilation is largely based on personal experience or what has been adopted from adult and neonatal studies. There is a fundamental lack of clinical evidence to support the daily practice of pediatric mechanical ventilation, due in part to the extensive variability in lung size, maturity and range of acute and chronic respiratory conditions existing in all age groups of children.

pediatrics, airway mechanics, respiratory system, oxygenation, targets, inspiratory time, frequency, pressure, tidal volume, PEEP, guideline

Monitoring respiratory mechanics in mechanically ventilated patients

30.04.2018
Author: Dr. med. Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France, Reviewer: Paul Garbarini, David Grooms

The term respiratory mechanics describes the mechanical properties of the respiratory system that is inflated during mechanical ventilation. Monitoring respiratory mechanics is useful for diagnosing the lung condition, assessing the evolution and severity of the lung impairment, and adjusting ventilator settings.

respiratory mechanics, monitoring, time constant, rcexp, expiratory time constant,

Clinical practice guidelines for use of noninvasive ventilation for acute respiratory failure

22.02.2018
Author: Clinical Experts Group, Hamilton Medical , Reviewer: Paul Garbarini, David Grooms, Jean-Michel Arnal

The use of noninvasive ventilation (NIV) has increased considerably over the last two decades and is now widespread in the acute-care setting for management of acute respiratory failure (ARF). A guideline committee selected 11 questions relating to the clinical application of NIV for various etiologies of ARF based on their perceived clinical importance, and assessed the evidence currently available to develop corresponding recommendations [1].

NIV, guidelines, acute respiratory failure, ARF, noninvasive, noninvasive ventilation, weaning, asthma, post-extubation, respiratory failure, chest trauma, palliative care, post-operative, de novo ARF, immunocompromised, cardiogenic pulmonary edema, pulmonary edema, hypercapnia, hypercapnic, COPD exacerbation, respiratory acidosis

High flow oxygen therapy after planned extubation

19.12.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms

Oxygenation and ventilation impairment after planned extubation is frequent. Post-extubation respiratory management aims to decrease the risk of early acute respiratory failure and reintubation, which is associated with a poor prognosis (1).

high flow oxygen therapy, HFOT, extubation, oxygenation impairment, reintubation, post-extubation respiratory failure, high-risk patients, NIV, non invasive ventilation

Clinical practice guidelines for mechanical ventilation in adult patients with ARDS

02.10.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

Acute respiratory distress syndrome (ARDS) is characterized by an inflammatory pulmonary edema resulting in severe hypoxemia. The recent LUNG SAFE study showed that ARDS is common in the ICU, occurring in 10% of all patients admitted (1).

ARDS, VILI, guideline, mechanical ventilation, mortality, tidal volume, inspiratory pressure, prone positioning, HFOV, PEEP, recruitment maneuvers, ECMO, recruitment

Hyperoxemia in the ICU

05.07.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

Hyperoxemia can be defined as an increase in arterial oxygen partial pressure (PaO2) to a level greater than 120 mmHg (16 kPa) (1, 2). It is considered to be moderate for levels ranging between 120 and 200 mmHg, and severe if PaO2 exceeds 200 mmHg (27 kPa) (3). Hyperoxemia is caused by hyperoxia (an increase in oxygen) and occurs in 22% to 50% of mechanically ventilated patients in the ICU (1, 3-6).

hyperoxemia, hypoxia, hyperoxia, mortality, PaO2, SpO2, pulse oximetry, oxygenation, closed loop, Intellivent

Driving pressure in ARDS patients

08.05.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms

ARDS is characterized by lung collapse and consolidation leaving just a small portion of aerated lung remaining, which is at risk of ventilator-induced lung injuries (baby-lung concept).

driving pressure, lung safe, limiting driving pressure, hospital mortality, ARDS

Acute Respiratory Distress Syndrome In the Adult and Pediatric Population

03.04.2017
Author: Joe Hylton, M.A., RRT-ACCS/NPS, NRP, FAARC, FCCM, Clinical Account Manager, Hamilton Medical, Inc., Reviewer: Paul Garbarini

Acute Respiratory Distress Syndrome (ARDS) is a potentially devastating clinical disorder, affecting critically ill patients of all ages. Hypoxemic respiratory failure is a common characteristic, requiring invasive or non-invasive mechanical ventilation. Mechanical ventilation provides critical support while clinical interventions and recovery time allow potential resolution of the acute disease process. However, clinically inappropriate techniques utilizing mechanical ventilation can further precipitate lung injury and possibly delay or prevent recovery.

ALI, acute lung injury, ARDS, distress syndrome

Findings from the "Lung Safe" ARDS Epidemiology Study

03.04.2017
Author: Paul Garbarini MS, RRT, VP Product Research and Development US, Hamilton Medical, Inc., Reviewer: Mark Soucy

The Lung Safe study Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries (1) evaluated the recognition, incidence, mortality and management of ARDS in 450 ICU’s in 50 countries. The results of the study may be somewhat surprising in comparison to common perceptions.

ARDS, study, epidemiology, lung safe, criteria

Clinical practice guidelines for weaning critically ill adult patients from mechanical ventilation

03.04.2017
Author: Dr. med. Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France, Reviewer: Paul Garbarini

Due to the complications associated with mechanical ventilation, clinicians should implement strategies to liberate patients from mechanical ventilation as soon as the underlying cause for mechanical ventilation has sufficiently improved, and the patient is able to maintain spontaneous breathing unassisted.

Weaning, guidelines, liberate, liberation, recommendations, protocol, mechanical, ventilation

Test your IntelliVence (Vol 15 Issue 3)

12.06.2018
Author: Simon Franz, Reviewer: Süha Demirakca, Paul Garbarini, David Grooms

A 6-month-old infant with combined tracheal stenosis and malacia both located in the subglottic trachea (therefore extrathoracically) is ventilated noninvasively with Heliox due to respiratory distress. In addition, abdominal distension is limited by a cast (reaching up to the abdomen). How would you explain the biphasic shape of the waveform for both the inspiratory and expiratory flow?

flow limitation, expiratory phase, inspiratory phase, biphasic shape, stenosis, malacia, trachea, extrathoracic, obstruction

Bedside tip: Using measured airway mechanics in pediatrics

12.06.2018
Author: Süha Demirakca, Reviewer: Paul Garbarini

The expiratory time constant (RCexp) is measured breath-by-breath on all Hamilton Medical ventilators. As RCexp is the product of compliance and resistance, this single variable gives us an overview of the overall respiratory mechanics.

Rcexp, respiratory mechanics, compliance, resistance, time constant, settings, flow interruption, restriction, obstructive condition, mixed disease, pediatric

Test your IntelliVence (Vol 15 Issue 2)

25.04.2018
Author: Dr. med. Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France, Reviewer: Paul Garbarini, David Grooms

This patient is passive and ventilated in pressure-control mode. Why is the flow curve shaped this way?

pressure control mode, flow limitation, COPD, expiratory flow, bicompartmental expiration, choke point, brochospasm

Bedside tip: How to use the expiratory time constant

25.04.2018
Author: Dr. med. Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France, Reviewer: Paul Garbarini, David Grooms

The expiratory time constant (RCEXP) is a dynamic measurement of respiratory mechanics measured breath-by-breath on all Hamilton Medical ventilators.

rcexp, time constant, expiratory time constant, compliance, resistance, monitoring, respiratory mechanics

Test your IntelliVence (Vol 15 Issue 1)

20.03.2018
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini

Why is the flow shape different for the second breath? The patient is ventilated in pressure-support mode with no backup respiratory rate (RR).

auto triggering, inspiratory effort, esophageal pressure, pressure, flow, slope, inspiratory flow, asynchrony, mechanical breath

Bedside tip: How to set expiratory trigger sensitivity (ETS)

22.02.2018
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Jean-Michel Arnal

Optimal patient-ventilator synchrony is of prime importance, as asynchronies lead to increased work of breathing and patient discomfort, and are also associated with higher mortality and prolonged mechanical ventilation (1, 2, 3).

ets, expiratory trigger, inspiratory trigger, expiratory trigger sensitivity, asynchrony, delayed cycling, late cycling, trigger adjustment, double triggering, IntelliSync

Test your IntelliVence (Vol 14 Issue 5)

19.12.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms

Why is the end-expiratory flow positive (above baseline)?

NIV, noninvasive ventilation, leak compensation, end-expiratory flow, leak rate

Bedside tip: How to set high flow oxygen therapy

15.12.2017
Author: Clinical Experts Group, Hamilton Medical , Reviewer: Paul Garbarini, David Grooms

High flow oxygen therapy combines several physiological effects: Oxygenation, PEEP, an increase in the end-expiratory lung volume (EELV), a lower respiratory rate (RR), a decrease in intrinsic PEEP and work of breathing, lower PaCO2, and improved humidification and comfort (1, 2). The optimal flow setting depends on the indications and the desired physiological effect.

high flow oxygen therapy, HFOT, settings, oxygenation, PEEP, flow

Test your IntelliVence (Vol 14 Issue 4)

02.10.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

What causes this temporary stop in breathing?

Cheyne stokes, CSR, apnea, stop breathing

Bedside tip: How to perform a recruitment maneuver

02.10.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

A recruitment maneuver (RM) is a transient increase in transpulmonary pressure applied to reaerate the collapsed lung.

recruitment, recruitment maneuver, ARDS, PEEP, sustained inflation, PV Tool

Test your IntelliVence (Vol 14 Issue 3)

05.07.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

What causes the distortions of pressure and flow during the second breath?

triggering, reverse triggering, muscle contractions, insufflation, double inspiration

Bedside tip: How to select SpO2 targets

05.07.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

In mechanically ventilated patients, SpO2 targets are selected according to the previous lung condition and the actual severity of the disease.

spo2, spo2 targets, ARDS, normal lung, hypercapnia, brain injury, PEEP

Test your IntelliVence (Vol 14 Issue 2)

09.05.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms

Why are there oscillations in the pressure and flow waveforms?

oscillations, pressure waveform, flow waveform, proximal airways, distal airways, secretions

Bedside tip: How to measure driving pressure

09.05.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms

Airway driving pressure is associated with clinical outcomes in ARDS, post-surgical, and normal-lung patients, and is a measure of the strain applied to the respiratory system and the risk of ventilator-induced lung injuries. Evidence suggests we should keep driving pressure below 14 cmH2O. But how can we measure it?

driving pressure, hold maneuver, end-expiratory, end-inspiratory, plateau pressure, PEEP, ASV

Test your IntelliVence (Vol 14 Issue 1)

05.04.2017
Author: Dr. med. Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France, Reviewer: Paul Garbarini

What does this small bump at the beginning of expiration represent?

expiration, premature, cycling, cycles, inspiratory, effort, insufflation, trigger sensitivity

Bedside tip: How to wean with ASV®

03.04.2017
Author: Dr. med. Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France, Reviewer: Paul Garbarini

The American Thoracic Society and the American College of Chest Physicians recently provided recommendations to help optimize liberation from mechanical ventilation in adult ICU patients (1). They suggest using a ventilator liberation protocol and performing spontaneous breathing trials (SBTs) with modest inspiratory pressure support (5-8 cmH2O). So how do we implement these recommendations using the Adaptive Support Ventilation (ASV) mode?

weaning, wean, ASV, recommendations, liberation, protocol, criteria, readiness-to-wean