Tag Archives: pulm

I-TRACH Score to Predict Risk of Prolonged Mechanical Ventilation

  • Intubation in ICU (hospitalized in ICU for >24 hours prior to intubation)
  • Tachycardia (HR > 110)
  • Renal dysfunction (BUN > 25)
  • Acidemia (pH < 7.25)
  • Creatinine (>2.0)
  • decreased HCO3(<20)

*Threshold of 4 or more good Sp and Sn in predicting prolonged mechaniascal ventilation

Note: This study excluded neurological patients and therefore cannot be applied in the NSICU setting.

 

Reference:

Clark, P. A., R. C. Inocencio, and C. J. Lettieri. “I-TRACH: Validating A Tool For Predicting Prolonged Mechanical Ventilation”. Journal of Intensive Care Medicine (2016): pages 1-7.

Advertisements

SETScore for Early Tracheostomy in Stroke

Capture

**APS acute physiology score, LIS lung injury score

 

  • initially an in-house screening tool for tracheostomy prediction
  • performed within 1st 24 hours after admission – use worst value in the first 24 hours
  • Dysphagia either
    • reported from a transferring neurological department or
    • observed by clinical signs on admission
      • non-successful swallowing test
      • impaired saliva handling
      • loss/reduction of gag reflex
    • if already intubated on admission, scored with “0”
  • (Neuro)surgical intervention
    • decompressive surgery, hematoma removal, non-cranial major surgery
    • NOTE EVD or probe placement, thrombectomy, angioplasty for vasospasm or coiling
  • Diffuse lesion = a multilocular or widespread affection of brain (i.e. SAH, brain edema, multiple infarcts, hematomas)
  • hydrocephalus = distension of ventricles requiring EVD
  • total sum ranges between 3 and 37

Previously used (with score of >10) to screen for eligibility to be included in pilot trial of SETPOINT study for early tracheostomy (within 3 days) to standard regimen (late tracheostomy between day7 and day14).

 

 

Reference

Schönenberger, Silvia et al. “The Setscore To Predict Tracheostomy Need In Cerebrovascular Neurocritical Care Patients”. Neurocritical Care 25.1 (2016): 94-104.

 

Pressure-time and Flow-time Graphs

Idealized pressure–time and flow–time graphs for mechanical ventilation. Note that the plateau pressure can be measured when flow returns to zero.

PIP peak inspiratory pressure, Pplat plateau pressure

Capture.JPG

 

Trigger and cycle variables for each of the most common types of conventional mechanical ventilation

Capture.JPG

 

Idealized pressure–time and flow–time graphs with PEEP set above zero for volume-controlled modes of ventilation

Capture.JPG

Idealized pressure–time and flow–time graphs with PEEP set above zero for pressure-controlled modes of ventilation

Capture.JPG

 

Idealized pressure–time graph for controlled mandatory ventilation (CMV) with PEEP set above zero. In this mode of ventilation, each breath is triggered after a specified time has elapsed. The breaths can be delivered in either volume controlled (shown) or pressure controlled (not shown), depending on the ventilator settings

Capture

Idealized pressure–time graph for assist control ventilation (ACV) with PEEP set above zero. In this mode of ventilation, each breath is triggered either due to patient initiation (asterisks) or after a specified time has elapsed (no asterisks). The breaths in ACV can be delivered in either volume controlled (shown) or pressure controlled (not shown), depending on the ventilator settings

Capture.JPG

 

Idealized pressure–time graph for intermittent mandatory ventilation (IMV) with PEEP set above zero. In this mode of ventilation, each set breath is triggered after a specified time has elapsed. In addition, the patient can breathe spontaneously between these machine- triggered breaths. The spontaneous breaths create a small relative negative pressure that are depicted in this graph and noted with asterisks. The machine-triggered breaths in IMV can be delivered in either volume controlled (shown) or pressure controlled (not shown), depending on the ventilator settings

Capture.JPG

Idealized pressure–time graph for synchronized intermittent mandatory ventilation (SIMV) with PEEP set above zero. In this mode of ventilation, each set breath (or mandatory breath) is synchronized to a patient trigger after a specified time has elapsed. In addition, the patient can breathe spontaneously between the mandatory breaths. The spontaneous breaths create a small relative negative pressure that are depicted in this graph and noted with asterisks. The mandatory breaths in SIMV can be delivered in either volume controlled (shown) or pressure controlled (not shown), depending on the ventilator settings

Capture.JPG

Idealized pressure–time graph for synchronized intermittent mandatory ventilation (SIMV) with PEEP set above zero. In addition, pressure support is being applied to the additional patient-initiated breaths between the mandatory breaths

Capture.JPG

Idealized pressure–time graph for pressure support ventilation (PSV) with PEEP set above zero. In this mode of ventilation, each breath is triggered by the patient

 

Capture

 

Reference:

Layon, A. Joseph, Andrea Gabrielli, and William Friedman. Textbook Of Neurointensive Care. London: Springer London, 2013. Print.

 

 

 

 

 

 

Tidal Volume for Mechanical Ventilator

The easy way to determine tidal volume based on Kg body weight:  see attached PDF file for clear version.

Capture.JPG

Tables in ICU

Ventilator Settings

1. Mode of ventilation – start with A/C mode, SIMV if tachypneic
2. Tidal Volume – use 8ml/Kg of predicted BW then reduce to 6ml/Kg over next 2 hours
**Monitor peak alveolar pressure (goal </=30cmH20)
**Inspiratory Flow Rate – set at 60mL/min; higher (>/=80mL/min) if respiratory distress or high MV (>/=10L/min)
**I:E ratio – normally >/=1:2, if <1:2 then inc IFR or dec TV or dec RR
3. Respiratory Rate – set at patient’s MV prior to intubation, not to exceed 35 /min; check PCO2 after 30 minutes
4. PEEP – initial PEEP at 5 cmH20
**If with occult PEEP, then increase I:E ratio or ad extrinsic PEEP
5. FiO2 

Fleischner Society Recommendations Incidental Pulmonary Nodule Follow-up

Radiology, 2005 Nov;237(2):395-400.

Transdermal Nicotine Patch Orders

Heavy smoker:  [>1/2 PPD]

21mg/day x 6 weeks, then 14mg/day x 2 weeks then 7mg/day x 2 weeks

Light smoker: [<1/2 PPD]

14mg/day x 2 weeks then 7mg/day x 2 weeks