296 rrtr-irrioinqardugru
riunr:fiorda 1u Sepsis Campaign Guidetine n.6. 201216finr:}{orrun:.rru1rri louficr:rur
l11nq"?[t (variables) S n'rrnj:64
1. General variables fifl:rurorn
. q finfinlutJlnn'jr ga.o fiiolioEJn'jl 36.0 a'16'rLflfllfiud
. filre:rJ1nn'jr so ai''rrurfi tiorrnnir 2 lvirrlotoirutiu.t[1Ju1]'lsl:3'lu (standard
deviation) rirrir.r rrrda:tJrtorq
c yrshrfr
. n?'l i5lnff"?r Au ttrlan
. firirrflulusYr1|a.:firtru (positive lluid balance) lrnnir 20 ra-hn lutiro z+ rirlr'rl
. ::ri'rrirnrarrnnil 1 40 nJaa. lufirLrufilrildrfl ut!'rlr'l'lulJ1dou
2, Inflammatory variables
. "irurrrfiolfronarrtltnn'j't 12,000/u ,s nia oun'ir /4.000 u.3 fliofitfioltfiootrr
n"teiou (immature form) lJlnn'jl 10%
. rv6'rJ c-reactive protein (cPR) lutaooillnnir z tirtatvrirutiu.lluu:l'16?51u
. l:o! procalcitonin tutfiaournn'il 2 t1i1to{fixixulfiu',ttlulrn:3ru
3. Hemodynamic variables er:revru'jrfinlld'ulafinol"r larterial nypotension) loufi
. Systolic blood pressure tioun'ir go utJ. SoYl fiio
. nxr d'uTnfintadt 1r""n arterial pressure, lvlAP) fiflfln'il 70 tJ.:hovl Mifl
. Systolic btood pressure onntntrn'ir 40 tJlJ. loYl "tufllqJ uionan*rsl'rn'ir z Mr
ro,rdru li u't u.ruur er:grudrtilrir'rorqrfu 1
4. Organ dysfunclion variables
. ?!n-!oonfireul rfioonon,,: (arterial hypoxemia) louii paolrio, tioun'ir 300
. idflrrvaanaoosriasn'ir 0.5 lln./nn./t . adruiauuru z rirlulnudldcr:rir
rfiu.ououdr
o creatinine'lur6onrfirtr*ulrnrdltrrnn'ir 0.5 n,/on.
. fllrr[6,id"]flo{ t6oofinrlnfr Tatfi international normalized ratio (lNR) lrnnil 1.5
lvir vio activated partial thromboplastin time (aPTT) ulnni'l 60 iu1fi
. fio.r6n lorun:rovru'jT'hifirfiu'ln't:tndoulvrtatrfrld (aosent bowel sound)
. rn6etrdoqlioun'ir l oo,ooo /ru.'
. :vri'riia6;fruluta0o (total birirubin) tllnn'il 4 lrn./ola.
dl?ld1firyto't Sun'iviog Sepsis Campai€an Guidcline 2012 @n?un{ }frfitlJg Zg7
5. Tissue perfusion variables
. i:d':J tactare iur6aog.rn.ir t fiaa'knr6n:
. finr:tdudula.: capi ary refi ing time fitosr-ro1u (skin motfling)
adr',rl:fror rnrudtunr:ifirdu sepsislrildri, ruoiro:da.r :;naudrsrnnrdn-rnsitfida
n"{riutunr:ifi edu6r'hlfi qr:nlmrnntr:rlltfl udrn''rp
Severe sepsis
Severe sepsis r'rtrufi l nrrl sepsis itrridotadand.:oio}.td
1. Sepsis induced organ dystunction
2. Sepsis induced tissue hypoperfusion
uanornflunr:ifiodu severe sepsis orlifioauldornnr:rudnuruvlufiotq{ofld.tria.l,Jd
. Sepsis induced hypotension
. ::d tactate "lurfiao:lrnn.irdr:lnfi lTnurirlilrrnn.ir + fin6funt6n:)
. fleorr:oonfiounir 0.5 n.inn.E . arirrfiouuru z d'r1l.l lnufildar:rirotjl,r rfiu,,j
rorrd.l
. Acute tung injury 1flooriu6a mitd AFDS) lnudrir p"o,rio, rioun.ir zso tu{:Jrud
lrifinr:dnmrsa.,,l oo ria paoTFio. riaun.jr 2oo tu{rJrufinr:dnraurar ooadurniou
. lvni! creatinine lurdonlrnnir z tJn./gfl.
. 2::eil birilubin rl.tnn,j.t n./qn.
. rnfiqrfioofiaunir 1o0.oooA ."
. nr:u{.,rdho*6aofiarjnn' Taufi:yd'l tNB mnn.ir 1.5 rvir
rfiofiqr: rqrn rnrurflunr:ifiqdurar severe sepsis ocr#u.irfillr,rdostrdourfirnnrflu
nr:ifioduntt sepsis nir.r flogm;oanaom oun.j't 0.5 n-hn.r . ::n-urn6qr6oo tfiaun.ir
100.000 /ur.' r:d'u INR rrnnir 1.5 rvir rfudu d'irtunr:ificdu severe sepsis dornnlr:.:r.l
niurdu':riu
Sepsis induced hypotension
firnrurinr:ifiedu 6a
. Systolic blood pressure fiauni1 90 ul,:l:at yio
o axt dulflfimradu (mean arterial pressure. MAp) dounil zo lu,:_l:ot tio
. systolic btood pressure aon.,rsirn,ir 40 ul.riray lu{"luqi uSoaon.soirn,ir e Mt
ra.,rdrur:julmurrn:Srusiru:'rtir,:oruriul
rfiu'ln''irrnrulflunr:iricdu sepsis induced hypotension finlurrtrdouniurnn-ni'lun'r:
ificdunrrc sepsis ludruto.t hemodynamic variables !!fl!1fid,rln6'jteir mean arterial pressure
(MAP) 'ldri'rfiaun'i1 70 rJ . tor rsiobiour:nifioagnrt: sepsis induced hypotension ia
298 rrtrjrrinlnqnnrrgru
severe sepsis ldmqrfrij'rn*u atjt,ilrfintlrflrtt'lUllo{nlt resuscitation 'lu{:Jru severe sepsis
fi50 septic shock tu sepsis bundle ti.:n.:ld mean arterial pressure lJ'lnn'jl 65 tJ:J. lovl n.tt6
Septic shock
Septic shock v 1uf,.! sepsis induced hypotension frriln':fiorrlo.ulafinntro{uf ir1fi
nr:uxt o drr rfi o.:fl o ttdr
{odrrnn6o rnrud'lun'uif,?du septic shock dhior:rirotirerfiutlrorrdr lrild:;:.1irda'r
hl:.lirrruoT :riurnriou tfi u.:tn
Sepsis induced tissue hypoperfusion
sepsis induced tissue hypoperfusion t1illufin nT 16nrdadlidrtrrfi onrrttd'ulafi nsir :;d'!
tactare'lu16onq'tdu laisorrloonrlou
:snu!o{rirBu3rh
fl,?ll 'lu sepsis campaign Guideline n.n. 2012 ldfinlrdot:cdt.tla.Jrl'rlluvrjr lourrunoonlflu
2 o-'xtu
drud 1 tfi unr:uun'irnhuu:rirriu
t. fi rn'n3ru16,,rrl:vd'nfdfi qrunrvrdrliorlrunnr':uialil
2. frnruuriuauto',rniuu:rirriuvialri loudo,,frnrliliuurfiu!ftvir{ ::Itrnidfi.rld
llfi:notf-luam^ nNlu
s. lfiflainldiliaiiodad, uriuniolri
a. n"r uuvrirriurir'lfldrivr ur n :{l eir nialri
lnutudrufr t d ovrirntiuunr:dlel'ruu:riraontflu 3 :;d'l6o strong recommendation
{fuurudeunhir recommend lurudrumtutm I) rrflJ weak recommendation dtrrnudrsdljr
suggest (u ud'rur4l1flrffi 2) uonelndu-.tfidxuflfuiqrilrrn{o:vo-uldtiun'it ungrade recom-
mendation (UG)
dT ufi z rfl unr:{o:;rYulo.rrdn3ru r6orl:vdnf Toufr
A. v:rrufi.: nr:6inurur::{rdfin'tln?!q! (randomized control trial) frfiqrunrnd
B. r,r rufi.r nrrdnnru:rr{*rfifinr:nruqrifiqrunrn runor.o viotiunrtfinuruu
A.:rnfinr:ni (observational stuCy; fr fiqrunrn6lrn
c. vurufio nr:6nuruud,:rnnnr:rridfi qrunrvr6fr fi nrrdnr*rrrul{rdfi nr:ntlq*r
D. vrrufir n1l6flB'l!! d,r rnnnr:nidfiqrunrvrno'lfi uia tflunl*rrfiuloo{rdartrrX
6r15d1d2!o{ Sun'i\.ing sc-psis Campai€an Cuideline X0tZ nnSuai rJffrlJS 2gg
Initial resuscitation
1 . n!;frhi'ldLLu'lyl1,r!frlifi (prorocot) tunr::*nurdrr:"1{rtruiifinlr: sepsis induced
hypoperfusion Tnufi rfl ryilrijlunr:inurot-rri {t ct
l.)'1 Centrat venous pressure (CVp) il.lri.t{ 8-.j2 tor (t o-t s ot.rh)
2) lvlean arteriat pressure (h/Ap) urnn.jrr?aMrrYl 65 ul.rj:oyr
3) fldflI?:oon lnn.jtr?orvirrfi 0.s rJn./nn./rrJ.
4) Scvo" rrnnir zo% rio Svo, lrnn'jr 65%
e. 'lunr: resuscitation utu rrwrirlfildrflrvrrudo:vriu ractate oulurnrurijnd drnir
{rJrudfi:;o"u tactate o.rots.lusinaurl:nfiifioau (sepsis induced tissue hypoperfusion) (2C)
Screening tor Sepsis and Pertormance lmprovement
1. nrtrirnr:d'on:a.rtu{:-h u:.ufifilonrnrdrL'.ro,rfie: rfionr:fia rdo:uu:,r ne,:dufiofiqr
lfi nr :inr+r rf ulilodr.rniuvi r,r fi 1t cy
2, nl:iflal sepsis 'hi1dilr;RuBntvlu"u nr:rfluriruyfi.lrorruniruurqrunrraorl:.t
vrululn (1C)
Sepsis Bundle
or_utu o rhllr
1. q:lexlq'L lactate s. fiEr:n.rrl# u*o-"."- lrntdfr tot
2. sioq:rr hemocutture riaunr:l{arfrrulndr lrj6r os lw.rJ:ovt
s. fier:nlrlfiurdrueofivriin:ornqrrd'onirt g.lun:rfifie,ero''ulnfiortiro'rqnaoulnr
tu:ru+ fier:rur}i cryslarroids 30 ra.hn- rrri'ir'lvi volume resuscitation tfiatna*fir
fifi hypotension uior:fii tactate lrnn,jt uionrtfifi:yra"'l tactate u:nri rJ.tnn.j1
tt?otvirrYl 4 mmol/L
4 mmotil}{xja CVp rrfly SvO"
,. bivirnr::"o:rri'l tactate zBr trn::si!
|I tactare u:n ril4,:n.jr!n6
L
Diagnosis
1. nr:vrinr:d.rsr:t"nr:mt rdanrrn'nuru;vrr,:n6finfio{dulnuhinl:ldrrarururflu +s
urfrriounl:G urfirulofin (1c) tufl1:d{err.tQ hemocutture ar:a,ro:rl 2 d'?od.t,rstixefl1,l
peripherar vein 1fr.lnr:u,r'rvrdolunr.r aerobic [[Rr anaerobic) iun:fififinrrid central venous
catheter ulunil 48 d'?Tilt lfid.r hemoculture I odr.:fiarn-radr.lsr:1ar1{ centrat venous catheter
dxu (1C)
Z. n:nidn{ffl invasive candidiasis lfirirnr:oi.rm:.lo 1. 3 beta-D-gtucan assay (28) n6a
anti-mannan antibody assays (2C) tuntrfifrorm:nd.rn:reld
300 rrtrjrfninqordug'ru
g. 'hidrnr:don:rr r{i.tfiirur (imaging study) rdo6utiuurvel.:ni rfiato.ln1lq'otdotiio
fidoilld tuc)
Antimicrobial Therapy
t. nr:lirurfirulnfi nrfltu t irtrlilonrutln"tdifiodu septic shock (18) ttalnru'lu
t d'r1H,:n'ruun-t'lfinr:ifiedu severe sepsis dlrifi septic shock ix fixu (1c)
tz. nr:rdlrrdruXn6nfiaanqrf,nirt Ifiuorctfiurfi'r16urtiorrnn'jr rf,'rrdaoonqvrf
riarsrdo rftdurdrulniudtdur:otnqrf,eirurdordor'firlJ{rrrai.r6nrdaldrfluarirrd (te)
g. n?flJ:sdunrr'lfiurdruldurflu:rliurdotirr:ruljrc;orm:ot duunr:tfiurdrulcdrnr
daanqvrfniroriuurdrulofivliioonq dto r:nrcN'ldrialri 1de-escalation therapy) (18)
4. :io:J procalcitonin fin'rvionrrld biomarker findrunfitriu ar rrntiruvuenrr'ldflr
firuXn6r,riioanqrfni'r,:ld ua:lfitirsnqonr:TdurdruXnfirtunm:findru sepsis ttoilrirrrlrrr'tei't
rirrfi nro,:nr:fi euds (zc)
s. nr':lfi combination tnerapy fifrl{tuntri neutrophil sir (ze) tu:rufrtflu multidrug
resistant organism ?1mda Acinetobacter spp. tlio Pseudomonas spp- (28) druiun:nifirflu
nT :finrdolurr:ldfi respkatory failure drtlnltnm: shock drfiFnrn P*udomonas spp. Bacteremia
fl't?'ld extended spectrum beta-lactamase dufi! aminoglycosides m3o fluoroquinolone (28)
n:ninrrfi n rda Streptococcus Dneumonia bacteremia ordd beta-lactam dtlfil macrolides
(28)
o. nrrtfi empiric combination therapy hinr:'lfisrururfiu g-s tu rfroldrunnrru'lreio
n.trr',rdo (susceptibility test) ff1:d1n'lflJiuurfirula6yr la:.ra (de-escalation therapy) (28)
z. ::rJ:rrarnr:'1fiurfiruladnTnuu'r}.16o z-to iu nr:'hturdrulo6uurun'jr z-t0 iu
fidl$lun:rflfi{rtrunaroua.trionr:'lfiurdrulniudr ii.rnu'[61un:nidnhdorrniitfiordooon]rjmr.ro.
s. aureus bacteremia, nr:6qt6'altrn;rdahiolrotfio. nrrv4fi{r.rriuunndal loutont neutro-
penia (2C)
a. lun:ddo,tduirnrrfin ldahinrflu6t't!fiqno\: severe sepsis nio seplic shock a?:
fierrrurlfiurdruhinfi'ufr (zc)
-lrinr:tdurdru1afinluf,:Jrudfinrto-ntdrl?uLtt\t(severe inflammation) rroilrilrjnr:Fordo
s.
(UG)
Source Gontrol
1. nr::rqorittnltnr:fieldatfildrt'oreu (anatomical diagnosis) ttn;nr:rirnr:nuqrnr:
6er rdotfi ldn r stu t e tirTr,rnr utii''r nr :ifi o o u ( 1 c)
fl1fJd16'ryxaf Sun iving Scpsis Campaign Guiclelinc 2Ol2 raniuni {!frfiL1JS 301
z. lurrufrrflu inlected pancreatic necrosis lrinr:yti intervention 1o1 eunirolfi:ou
!LUn (demarcation) :yilit,Jldodua:rdanrudonu 1Ze1
s. lufiilru septic shock fi:uu:,rdfio,:ar:.lnrunr:6ordo nrrr6oni6fi:unrusiosS:iytur
lo,:fiil':trrioufiqo rriu nrlfion percutaneous drainage rrludo:t6on surgical drainage (UG)
+. nrfifio.:ffl'ir intravascular catheter rflurruei.,:rirrfiala.:nr:6ordafin:r1firfin seuere
sepsis nio septic shock 'Ififi?'rlu1ra16['tu6r?uoanri'ufinrurnd,rfi'lsiaruorulfirildudr (uc)
Infection Prevention
1. orqTi selective oral decontamination yio selective digestive decontamination tdo
iolnlunr:tfio ventilator associated pneumonia oti't.r'l:ffnudrrfludolur: rruli6nr:dr selective
oral decontamination ttio selective digestive contamination risu (28)
Z. nr:ld Oral chlorhexidine gluconate lunr:vrh oropharyngeal decontamination tdo
fl0,,:riunrrrfio ventilator associated pneumonia lufirJ'ttr sepsis do{iunoofilra 1za1
Fluid Therapy for Severe Sepsis
t. nrlfionor:rh crystalloids rfluyrrlr6anrr:n1un'rr resuscitation ftJru severe sepsis
uny septic shock (18)
Z. 'kjnr:ld hydroxyelhyl starches (HES) 'lunr: resuscitation {Lltu severe sepsis ltny
septic shock (1 B)
3. nr:'ld albumin or{dlflunT:ri'ryr,:t6on'lunr: resuscitation firJrl severe sepsis trfly
septic shock 'lun:rfifidotld crystattoids durumn 1zC;
+. il5rrrua, :rirrirrr:nlunr: resuscitate {dru sepsis induced lissue hypoperfusion
fifi hypovolemia jrildrs nr:hiarirniou 30 rn./nn. flB{ crystalloids lnio'lfi atnumln lurJirrnr
Y.l ll.llUll[1]'ln \tTdnfi']:JBUlull'l't:lfle11q!U69' lO' \:
) , tetflfl'll N'lyalaLT'ln'l,'lUlyn11.1tUa,l.l ( l U)
0U1\:
s. nr:triorlirTould,'u,o "n",,"nne d11r1rfili 6'n:rurvirdfiilnqrcmSnrrlvnrtsurfiao
o't*u vr'.:dorefierrrulo'1fl dynamic parameter ltdu nr:rrJfrrlurr:Jn{fl0\t putse pressure, stroke
volume variation) uia static parameter ltriu erruriuTafin 6uer) (UG)
Vasopressors
l.'1, vasopressor fl'rrJr?n'ldrfiunr:inurnouriru urnrfiatrfi-Lf, rr,lnp 6s ror (1c)
2. Norepinephrine !flu vasopressor n"1n:ni'ldlu septic shock (18)
3. Epinephrine dlo, olduyruuso'ldd?rJfi'rr norepinephrine rdolfild MAP 65 rr . loyl
(2sl
302 rrtrirrininqndugru
4. vasopressin nuro 0.03 gfirrAtrfi flltnrntrii-t riu norepinephrine ndardl vep lfi
fu 65 u.t.tJ:on nia rfialflunrroanu'tanon norepinephrine (uG)
s. lilrruvrjrlil'fi vasopressin lurorn'rtfiofnur sepsis induced hypotension tto;rt'll
'lS vasopressin aurnrrnn'ir o.os-o.o+ gfivrrurfi nr:ctruHdrnir.rnt:tflu salvage therapy dttti:t
rdr nnp 'tutrusvroli vasopressor sr"r6uudr (uc)
6. Dopamine !flu vasopressor dlduru norepinephrine taur:n:did{rleu:ruriuLifi
nrr rdu{don'r:rfi orirlctfiufi oo-.rnr; v5olfflu:rudrirlerdudra$ rrd': 1zc1
z. lriuuvrj,irlld phenylephrine 'lunllinul septic shock flnliutuntcfiAobd trcl
1 ) nrrfi frlfi norepi nephrine udr fi rir'ltfiufi oo-tvr:fi lurrrr
z) lu:rudfi cardiac output gstulru:fr n rrr d'u1nfi nal'ro go r.jroeio rflo,l
s) 1fi6u salvage therapy tun:nidid inotrope. vasopressor dttttiu vasopressin
ruron'rufir MAP ridrilfi 6s ru.rj:on
e. lrifr dt#mr dopam i ne $ur osrh rd oinu'r nr:lir,rrua a.:1or ( t n)
o. {ilrur1n:rudt$ vasopressor n'l:ldfunr:ld arterial catheter ri,nrur:o'td1d 1uc;
Inotropic therapy
t. orll,:old dobutamine rfrmruroldfi,r 20 ug/kgr'min louorur:nldrflunrrdurnio'lfi
drln'rnr:l{ vasopressor lun:fifi (r c)
t1 tu:rufifi myocardial dysfunction d,:n:reflll cardiac filling pressure fiqt dlln"u
cardiac output ol'r
2) fisrn1tudn.ffio.,t hypoperfusion Inufi intravascular volume tfiu{vroud?uflt MAP
'ld os ul.rj:orn ufir
z. lrinr:'hinr:Snurniorfjil cardiac index tu:;a"rfigon'jrrir:Jn6 (supranormal level)
{18)
Corticosteroids
t. hinr:lfi corticosleroids nltloaotdaodrtun1:fnu1 septic snocr tu{ilrun'160r:
drodr{rfia,,Jflad'rrJrill vasopressor unvfi nnrf,nfnr:lnariuu16ondn.rdudr tun:riiiiilaarcni
nr:lnoriflulfiaalilewd 6unp lrifir os uu.:Jroyrl orotrl nydrocortisone 1lr'ro 200 xnJill yr'r\t
ynsor6oqni {zc)
z. hifiqrrl.irrfludouir RcrH stimutation tast 1u{ilru{'ln{firfru septic snoct dfi
nllirrfludo'l'ld hydrocortisone (28)
fl-l:tii1frryuo,r Sun iving Sepsis Carnpaign cuideline z0t2 nniwli nfrfiKtg 301
3, fi'rrJ1lflner,u1oflo\r hydrocortisone a'ild rfioIilfin11ro"r lfluiido,:lfi vasopressor 6n
siol:J (zo)
a. 'lrinr:lfi corricasteroids tlnr:inur sepsis finlrifinrr; shock (1D)
s riafio.:ld nyorocortisone ar:'bturrrwnonrfiooo"rodr,rsiardoa (continuous drip) (2D)
Blood Product Administration
t. lun:niiihifi tissue hvpoperfusion ufir uoclrjfinmvriolr.tiifia myocardiar ischemia,
severe hypoxemia, acute hemorrh"ge nr:'hi red blood cell transfusion nr:rfur:rur'lfirda
hemoglobin rioun'jr z ntr/oo. ua::"nur:;or":.tto.,r hemogtobin 'lifi z-s nilrnn. 6 e;
z. 'hjnr:l.fi eryrhropoieiin 'lunr:inurnrr:fio'lu:rEJTofi severe sepsis (I B)
s. 'lilnr:id fresh frozen prasma rfiu.,rldoudbnr*.rfie:Jn6 r,:rlorrJ4'l-finr:'lu:rudhi
ld'fi:lryur16onaonfio:Jn6riolu:rsfr do''ln?fl frM-nnn'r: (2D)
+. Iilar:lfi antithrombin 'lunr:fnur severe sepsis ria septic shock (18)
5. lu severe sepsis nr:fior:rur'hirn6n 16oo lia tzot
t1 mfinrfiooflaun.jr ro,ooo u."tuludlrjfirdoqoanfin n6 (prophytactic treatment)
z1 rnfinrdoadaun'jr zo,ooo uu., lu:rBfrlrjfirfiaoaanfinilnfi lufirl.rliiiarurdulg,,:
rdanr:rfifi 16oooanfi n nn'
3) rn6or6oa lnn-i1 50.000 ll.3 luoirloun.jr too,ooo lu.J "lu:rufifi rdanaanluu:r
fi o.r'tdilnr:nird'o viado,rrirrinnnr:
lmmunoglobulin
'l q'l:ld intravenous immunoglobulin 'lunr:tnur severe sepsis r?a sepric shock (28)
Selenium
lriRr:td intr.u"nous selenium lunr:fnnr severe sepsis t?o septic shock (2C)
Recombinant activated protein G
lilfiiildlot recombinant activated protein C'lunr:fnur severe sepsis tio septic
shock
Mechanical Ventilation of Sepsis Induced ARDS
1, err:t$ tidal votume flu1a 6 rJn./nn, (predicted body weight) lu sepsis induced
ARDS TlA}
304 r':trhrinrinqndugru
2- axlfiogltJ plateau pressure tu{rJru nnos ua;5nur:vn-l1 plateau pressure li1rj
rfiu eo rr.rir 1ts1
s. nr:td positive end expiratory pressure (peep) lSioflo.rriulritfio.rnruvh1ur':nr
rru'haanqo (rdofl o.'triu'h'tfi rfi n atelectrauma) (1 B)
a. nr:'ld high PEEP rtnn'jr low PEEP lu sepsis induced moderate fi50 severe
ARDS (2C)
s. nr:rir recruitment maneuvers nr:drlu:rufirflu refractory hypoxemia (2C)
6. nrrusun'ir (prone position) nr:tfflu:ruiirflu ARDS fifrFi'r Pao1Fio, rioun'jr t00
luanljufi fi :h:ounr:ni'lunr:rirnr:Snrrdrui6d (za)
z. 'lunr:'ldlnialrirurru'h nrdri{ilruuou6:u;q.t 3o-4s a'tq1 rdonoTanrnnr:aian
(aspiration) tta:flaodunr:tfio ventilator associated pneumonia (1 B)
8. nt:'lfi noninvasive positive pressure ventilation tu nnos r;'ufia,lt$fitflnttltts -n::r-.J
Torfi o,rri.r:vn'jT,:rl: ;lurdnn vnrr ufi a.rd fl ilr uo:ldi:-r 1z e1
s. tunr:nrlr{:-huaanelntn6o{tjruurulo nrrtd weaning protocollount:dl spontaneous
breathing trial (SBT) Insfi tr:ruljrn:lrnrudrio'b.tiir3o-lri
'l) lgt'to
z) ina.on5nrrlflarlflurfiaon.rii Irinr:fi vasopresso4
3) .lrjfidn1xJfr?uttl't (no serious condilion)
4) td ventilator support lri4u.rrn llac'l$ pe rp'lu:vn''lm'r
O tS Fio, tu:;fi'!frsiriladq;1fi face mask uia nasal cannula ldodr't oooritt
firrir ser lddrrfq (Toultr'l:1il:: rfiud so urfi) trtfio'r:rurnaqriotirur'rruto 1ln1
1o.hinfilfi pulmonary artery catheter 'lur1n:rufiriu ARDS (1A)
11. at:ld conservative fluid stralegies (:Ji rrunr:rirrioul lrnn'ir liberal fluid strategies
(r.lSrrruRr:rirrrn) 'lu nnos fi'hjfi ti""r" hypoperfusion (1c)
12.'hjnl:lfl beta-z agonist lu{|rrqn:rad lflu nRos riuurilu:rtdfi bronchospasm
(18)
Sedation, Analgesia and Neuromuscular Blockade
t. nrrtd sedation 'lrj'jrrv'lduuu rilunitl (bolus) fi5o'lfiFia tdot (continuous) arrtflu
qulaa'1T6fl fi rfl tvil1ufl 0{n1:iuuf i'otau (1 B)
z. nrrflfinrfiu,:nr:'lfi neuroru"crlar blockade tulufi"lrirflu nRos rfio.lqrnnr:ld
neuromuscutar blockade liurvavtrnrurtr{rlfitfioornr:ndr*rtdoeiauur':ld n:rflfi'l"rrfludot'lfi
fi1fJd16'rulot Sun-iving Sepsis C;rmpaign Guideline 20tZ tonlffili {lfrfrt1J 3Os
neuromuscutar blockadelil'j1eyLfluu:lria+n.i fiia'lfidarfia,: nr:finm rcg''!B?'tNfinlonn1: btock
t9lutnx? train of four (1C)
3. aleliellrul'lfi neuromuscutar btockade tudro:;u;iu (ururjoun'jr aa #tTur) tu
early sepsis induced ARDS fifi paO,ffiO, rioan'jr tsO
Glucose Gontrol
t . r,r'crrrurlfi insutin riia btood gtucose lrnn'ir 180 rlfl./gn. 2 nrs.rfiqdofiu lounr:
nlunr::dr gtucose 'hifioun'i'r 180 n./nfl. iilcidiladn'jrnr:nrunr::d':.r gtucose thiaundr
110 n./nn. (1Al
2. nr:fionr btood gtucose In t-z ri'r1u cun'jrl;d'u gtucose ttnco"nl.lnr:1fi insutin
o gtu::o"rdn':d ua:yd'{a1nfulfi 6qn1rrrl n 4 drllr ( t c)
3. n':lLLllnfln point of care testing glucose (POGT glucose) drunTrl::fint:{.: drfi-ld
areqslrjldcyfioufitrir plasma glucose uio arterial glucose fiurfili,r (UG)
Renal Replacement Therapy
1- nr:lnurdrUnr?ft continuous renal replacement therapy ttflt inlermittent hemo-
dialysis lrifin?'tx uorndrlriu'lu{rJruiitfu severe sepsis iifi acute kidney injury (28}
2. n1?inE1dx8n15!i"r continuous renal replacement therapy filtJ'nnnllJQ 3 'ltu
or:rir'Lil6n'irlur{rhufi yrnnron5nr:lrnriuu16sohinrd tzor
Bicarbonate Therapy
lr.flS sodium bicarbonate tunr:inrr seosis rfiadrs}4vrnfi1f,qrfnl:luntiuutfiaon.td
unr{un:efi pH fioun'jr z.t s
Deep Vein Thrombosis prophylaxis
t. lu{:Jru severe sepsis nr:-ldirurflo,:riunr:tfior deep vein thrombosis (18)laua?:
'ld'low molecular weight heparin flqififirni,J t n*,rsioi'u rrliu!rfiu:-r6'! unlractionated heparin
iua; z rri'r (18) ril?u!rfiuilfr'! unfractionated heparin':iua; 3 ni.r (2c) 'lun:dd creatinina
clearance riaun'jr go iln,/u1fi fie1iru'rtri deltaparin ttio low molecutar weight heparin tfin
6u1 rfi otrrnl"uoonurinrlaunir unf ractionated heparin (2C)
2. tu severe sepsis nr:}luriJarrYunllfio deep vein thrombosis i'xfiunr{d intermittent
pneumatic compression (fiilrn0 (2c)
o. iu{:Jru sepsis fififiafirruro,:nlrlfi heparin lniu rnfinrfioncl'r nr:u{,:d'rta.rr6oorfie
306 rrnirriorinqodugru
infi1uur.: Gonoon lru ln rdaooonlundunnfi:u:1'lrin'r:'lfiurrfiaflor:riunr:tfin deep vein
thrombosis (te) lldm:fla,tfiulnuiidll"tdur niu compression stockings, intermittent com-
pression devices (zc) mnlrifi{ofirrlrrd, 1fi6lnr:ilo{niunr:tfiq deep vein thrombosis lnu
n,:ldur (zc)
Stress ulcer prophylaxis
t. nr:tfinr:io.:fi'udtu H, blocker t?o proton pump inhibitor 'h seu"t" sepsis rtio
septic shock fi r6ilu'reionr:rfi o16aqoon (18)
e. rdodottfi streus ulcer prophylaxis nt:t6on proton pump inhibitor tJlnn'jl H, blocker
(2D)
e. 1u:rufililfi:lc{urdsr kiar:ldfu stress ulcer prophylaxis (28)
Nutrition
t, ficr:ru'rtfi orat nutrition vio enteral nutririon MliifiilxrLq:fild rrnn'jrdo;lrfifirJrt
on otn:ri o'lfi glucose fl 'r\:vno n rd o oo"rodrr: rd urtu +a rirTl.: rr:n (ec)
z. nfinrdmnr:lfi futt catoric feeding tildr,Jdilnrfi[:n uurrir'Ifi bw dose leeding lau
niuJ?mrufir1 wiT d{rleurvirld pey
3- nr:lfionnr:'hi gtucose fi'r{Mnoorfioool'rdrr.rnbnr:}i enteral nutrition urnn'irfia:
l6an parenteral nutrition adr.ttdar v5o parenteral nutrition dx niu enleral nuvition lu:ir.t
drjorriu:nro',:flnfriiedrj ."u"r" sepsis rlo septic shock (28)
+. nr:lfiorvr:dhjfi immunonutrition lrnnirorvr:ifi immunonutrition lu{tJtu severe
sepsis (2C)
fl 1rri1ilun rf, 1ilrrs'lunr:imn
t. afi :rurflrr runr:inur1firfu{:-hu uo;n:ounir 1t e;
2. tuuwlnr:inurnr:firflrfi rutornr:inur:rroqjdra vrno'r ufluda':'ld palliative care
'lfi rJ;1'l-6outa'nnlfl o-t pal I iative care medici ne (1 B)
g. d,,rritrrrulo.rnr:fnurrlsirfiu.i iunjduur:]rvma'hifinvr-iulfi udlrinr:drruorflrrrru
tridrdrn' jrzedrlona"r:-r{rhuliluroon'rrn1zc1
14flf,1:O1\tO\t
'1. Surviving S€psis Campaign: Intemational Guidelines for Management of Severe Sepsis and Septic Shock 2012.
Joumal of Critical Care Medicine, February 2013 Volume 4'1 Number 2, page 580-637.
Mechanical Ventilation: Modes and Settings
nn?uni ffiwg
rnlo',rdrunrulqiu'hfirnu'rvrdrdqlunrrgun{:Jrudaglu:;uvinqn nrrldrnio.nhunrulq
rilunrrfnrrrlrvfiu' ?rnfl,,l {supportive care; ddrn'qdrirurir'1fi{rtrmaniin or-,,rriuarlrflunr:
ldrniordrunrutci.-lfia'nlrhrfudrnilrinifnurrilild uunrirh:firiru uurri'lunuJfirjh un;
{RnnmfliNn11llr{ntifidoroun{:J'rudoflu::uvlnqn drn'rlfi{rleuiifiornrrminrnrirdroniln
uov fi nntvurnndouriotrdqorrrirdoc lfl ul:Id
tfl rnrrsmlnr:'lfi rnCo.lri,lsilrsh
1, [fibnrrc da,roon6r?! (provide oxygenation) lu{:Jrufifinr?coon6rcudlrjsroucuot
rrionrai':unrrnutrtugrlutltloirt1 uiu orygen cannuta, orygen m.rsK, oxygen mask with bag
utolu4rtruddadtnr:rirun'r:yrulclu;:Juuudldriruufihnrr;uia,coonfilru (hypoxemia) rd
{rJ'ru enOS (acute respiratory distress syndrome) dfio.rld pEEp (positive end expiratory
pressure)
z. riru'lunr::rlr o1n1fl (piovide ventitation) rdu {:Jruiinfi'uldo'lunrrmuhdouur,r
mnlnmrtulrl:ys'u ii.rruldlu myasthenia gravis, Guillian-Bare syndrome, motor nsuron
disease n?alunsj'fifi nrr'ftorjn6mrqarn6oudfifi nndandurfolunrrnuh niu nlr jlnurnriuu
lurfionrirprrr lsevere hypokaremia), amvrioorv,lnnrr'lurfiaaluu:l (severe hypophosphatemia),
nrr: urnfi16a*r'lulfiaosl"r:uu:,J (severe hypomagnesemia) nlrIdi!rrr rfiuzuroorn oq,urirrulc
(respiratory center depression) rfl!du
308 rruirrioinqmClgru
3. flqn'rrri'tn'tulo{n1rv1uh (Decrease work of breathing) 6orflui'nqtl:;o'l6v6rnfi
eirdqr.rrnto.rnr:tdra{a.rdruvruh uurtir.iq*novdo,,:ooud.rrnn'fi{rlaaar.rrfldurds'lfirndo,l?i?u
vrstouiolri lnud,rrnn'jrfinr:'ldndrilrdati, u'lun1ril1ulfl$olri (intercostal muscles. scalene
muscles, sternocleidomastoids muscle) drtnolirfinr:ldndrurdaai? lion (abdominal muscle)
rirfl'lunr:fi'ru'tqoonr,rSobi uoncrnddotditnst'j'tnr:lo6oultrta.:vt:'l,ton*nvdrurio.:rfll'lritl
finvn,: rdurniuviolri ftTourlnfirfio{rh firutct{r r:t,tan ttnrdo,:fia'lq:undutufinrr{ rdsrfiu
rdof,rJrtrnrutcoon r:rtonttosria.,:tionavuufi'xa,:'tt-tfififlr'r l6tnriu lnnlltndau'lfix10{vll?{0n
uaydo',tfio.,:ljrfiul1tufisylr't rdulniu tiun'jr abdominal paradox unrrifio.rfrnr:rrfihlouiudxu
4. i:i,trlnvflo,lri R't?; ttYt?ndaufi lfiocrnnr:'ldrn4aldrtnnu'lc (prevent ventilator
comptication) tfiriaafrqa wirde:rirld niu n1?rnxltJd'u1nfimn't (hypotension) q'lnn1rtfirnio.1
tirun, uh dr rfincrnnrrfirndotdxumu'laan venous return ri'rhi pretoad rirlfi cardiac output
aernt nrr;:jono'ntolqrnnr:'ldrn?oodrtrnrl'lq (ventilator associated pneumonia, VAP) fi{
dlriufrirnr:ldrn4o,:ti'ruvrir'lo tflurvlvt'rfl'Iu1l! tl't'ts barotrauma fr tfioornnT :tdrnia,:ti'tu
nlule (ttiu pneumothorax, pneumomediastinum, subcutaneous emphysema tflufiu)
n1?tail\ithvmn$o{ nio.tti?sm ute
d1r.r'r:ntt ,tldfimuil::rnr tufifi'tauri':rdorl:vTusrinrrnr:'ld.:ruriu 2 1rlnvl
'1. Non-invasive positive pressure ventilation (NPPU lfliln']:1i'luurulotoutdrnSoidrfl
rruhnrrrriu::rn (positive pressure) letabjda.:orfuYiallfloofl na (endotracheal tube t3a
tracheostomy tube) 01nlffalntn6o{druvrutne; iirulrtyll't 16uurltl tta;ylr,: t6uorur: nr:'lS
rnio{rjrunru'letfindrtln:nil{rhur:r,tl:: mr rrh {:-hu chronic obstructive pulmonary disease
(COPD) fifi acule exacerbation. {tJ'tu congestive heart failure. {:-hu obstructive sleep apnea
(oS4, {rlxufifia1nr:urutodr!rnnruva'.lnonviotiruvruto (posl-extubation tailure):rsnrt6un
nrdfi rniauirunT utetfiad lri'ldntirrfirturlrnmld
2. Invasive oositive pressure ventilation (IPPV) lflun'nti?unru'lolnutdrnio.crirunr lo
nttruo"urtn (positive pressure)1olufia'Jord'uviovnoqn na (endotracheal tube viE tracheostomy
tube) 01n16?1fl rnia,:tirs ralea:tdr rirrt tFuHlulqfiovrordcn rnio,rdruvrulqtflodldniu
adrrulriuaru drqidndrrlnun;16so'lulrnrr d
grJuuu (mode) rornr:dean,l:ulslc$uu lPPv
arrr:ouri dvnrsil::rnvr 'luiidlo rni'tndoil:c1utfnrrnr:1d',rrutfiu 3 JrylRrl
1. Control mode (CMV, controlled mandatory ventilation) riluilJuunrnirunrmu'lc
Iqflrnia.retinr: i.r6o.rsre,ta'erlnr:firuh (respiratory rate. FR) tolo tlt'rfinrrtjruvrutl z;rJrrl:l
fro
\{echanical Ventilation: llodes and Settings tBrfurrf {Sfrttg 309
1) Volume control - controtted mandaiory ventitation (VC-CMV) u3or?undnadr.r
fifi{'j1VCV (votume controt ventilation) nr:dxurnu'lor uutddorfridt tidat votume
fiV1 {i,to;ti.lnnrirlrteir peak inspiratory pressure (ptp) ulfiuurtilo.: tqufirnt: tiOat
llnvolume ri't peak inspiratory pressure erq\: fl1d-r tidal volume dau dr peak
inspiratory pressure o;dr turr'rilfr:t$fn riun VC-C|VV fiia VCV.j1 ctrlv drrflu
clvFtlrJyulflfilar1rLelyet Fr',rfitrianai.rrfi.r ufir Taflr,rtd:Jnilrufir vc-clv
fiio vcv
2) Pressure control - controllod mandatory ventilation (PC-CMV) tia tiun6nodr.,,:
nd.oit eCv lpressure control ventitation) nr:tirumuh;rJuuuddoofr.,rdr inspireo
pressure (tP) do;ai.,,:nrnrirlfirir tiaa 'otume FV) r duuurJn,r nsirtf,o rirdl inspireo
pressure 1n n1 tidal volume Qytnn filne,J inspired pressure liou rir tidal volume
qcfiou
i2, Spontaneous mode tru!fl'nfirtltqdfiuiltfrilrniatdo6a pressure support ventilation
(PS\4 f,:hu?cfia{ritruoo'rr:rnr:rrt'lo (respiratory rare, FR) ldfirtnuror nsimdofio rjfi:au
T:n::drfirunlo,r (brain stem) iinhtrtrfionr:ruonr:urah lapnea; nr:riiunrtrru'te:!uuJ1i
fio.lnfuir pressure support (PS) {i{c:d,,rilo1irtfieir tidat votume grvl rildauu:Jn,: nrirrda drors,r
pressure support ln tidal volume o;tJ'tn fitdr pressure support fiou rq'r tidal volume c:riau
3. Mixed control-spontaneous mode ? uuunl?rtruhdfillllfilrnfi qnfi o synchronized
intermittent mandatory ventilation (SIMU rfruTrJrruln1ldxun1?firute 2 ?:l!!:JuNflxniu 60 control
mode 1d,:oreriu vCV yio PcV frld) LLoc spontaneous mode (pSV) n-{usu ntfljrunr:flruh
.r1r.r SIMV 6rfi Z ;rJ url
1) VC-SIMV (volume control SIM\4 rflun1?rjxunr:nT U'lctu: [!uJ volume control
dnjru st|v mooe ra"',,:riuc',l6o,tos':nir setting ?a\r vcv rrn: pSV
2) PC-SIMV (pressure control SIMV) !flunlfli?unr: ru'hlu: tturl pressure control
irti'ru stuv mooe d'.rrfud.rdolnsldr setting sa{ pcv u,fl: psv
n1rdrfln1rfiluleurx stMV rnufinrriliiurflflu{rhufirirn.lntitnSomi'lurra'tr lweaning
from mechanical ventilation) odr, :frrnl fin'nllunfidnurrr.,rnfifinluflctriuuu'jrnr:mrilniac
drs sttrlv rirlt{:cu: lrnr'tunr:rdr rnio,:rjr urrEl'lourut*u rfia uliulr rfiurrYl spontaneous
breathing trial d.lflui6lrsr:gru d'rriu 6rnrr'ld stvtv rirr:lu{ilruiintirrnio.rtjrflilrElqldurn
rfionrtrrir rnio,rtirufirut oui6 rm:grufio spontaneous breathing triat drJLMnl niofiilrufifi
:ouI:nyrr,::v:ltl!t ygrvroirunor.:iiia-sr:rnr :r.rr utqbiarh rorJo
l.lofl?1n mode fildnrimfi.l'hufir ti,,ri mode dldlunr:druilru'hdnlrn niu Airway
pressure release ventilation (APRV), Biphasic positive airway pressure (B|PAP), Adaptive
support ventilation (ASV). Proportional assist ventilation (PAVJ, Volume support ventilation
310 rrrnilioinqndugrl
(VS), Pressure regulated volume control (PRVC), Volume zrssure pressure support (VAPS)'
high frequency oscilatory ventitation tHrOU dlfidl#lur':nJfrrjfirial 6,,rlrildnriTrdttuuvrnrtrd
?{e: (phases) nortn'lrri1{llllllatmCa.ldruilrsh
nr:dr,trut o-: tnio*rrjr uvrulqlu m od e oi r.: 1 rrrj.ild rfl u g :v I v d'td
1. start of inspiration tflu::a: t?ld'ulo,tnr:dr,:rula.otn{o{drun1:tru'lq TnuriunTr
n::{unr:nlroruto\: inspiratory valve vistiun'jr inspiratory triggerring dtrirdfiotd.:tu::u;d
6a trigger
2. lnspiration phase tflu:;u;nr:urulet{l n"tcrnii inspiratory valve tioudl 6'tl:fi
nr:pr"'rrdtdrrt d.:ovuarndrlrYulill uno; mode
3. Cycling from inspiration (l) to expiration (e) rflu::u;d inspiratory valve io expiratory
valve liln Btouda: mode otfifi'rn::{u cycling from I to E ttnnfil{liulil loud
. VCV tflu volume cycling dtritruoflau tidal volume
. PCV tflu time cycling aturirnuelnu inspired time
. PSV rflu flow cycling d{rirnunlnu expiratory trigger sensitivity (Etrigger,
E-sense, ETS)
. Bird's ventilalor tflu pressure cycling d.lninuolnfl inspired pressure (lP)
4. Expiration pnase rilurvu:vr'dae'tn expiratory valve tflq[[d'] d.:rnialtirunrulco:1rj
lfuirsnr:r,nu'lo'lu:rord n:rornouofl,rJruev6ufi":nduro'td?u elastic recoir 6.:'[ildo,ldt parameter
setting 'lo1 lu:cuvd
5. End of expiration rflur;u:d'uqotoonr:vruhoon fi.rgTn:ndrtuold z tllllj 6o nr:
oldruartri'uquti riun'jr zero end expiratory pressure (ZEEP) ttfi;n'l:1:Jdrunrlld'uurn
tian'jr positive end expiratory pressure (PEEP)
6. How to control dsnuufitirtfu control mode via spontaneous mode 6.rtfludr
rirnunirdal#,,,:dn:rnr:vruh (respiratory rate, RR) viall 6r1u vcv. Pcv, slMV mode da{
sr'.!d'n:rnr:vru'te usifirrflu psv mooe 1rjfiatdt6'or:rnr:vru'lo rvr:r:firJruda.:rirruna'n:rnr:
nrutrdru0uro,J
rio'lrldc;n.itfi{n'r:tirunrrvru'la'lu mode sir.:'t ldud vcv mode, Pcv mode, PSV
mode, SIMV mode
VGV mode
nnrru:idr6'qlo.,r VCV mode 6a tflu volume guarantee ttutun'ldauvldr tidal volume
d{c;d-rarofr'hidr peak inspiratory pressure (PlP) rlfisilLLiln'lflrtJflurif,ntflao,t on unv
l.lechanical Venrilation: t{odes and Setrrngs nniani 7fiftt1rg 3ll
rdooqrnrflu controt mode irdorsrstd'n:rnr:n1fl'le (respiratory rate. RR) Ld o
f,ori,rdiunr:id VCV mooe
t. {rhuhifi u:.rnrutt ro.r fi Sosurinr:urulonnno
2, da,lnr:nuntnryrtloturia,:nr:iJ1J1ua1n.trl (ventilation) ni'arJ::Tatrig.lqnlunr:
:hur rdu nll altyn"l nrrn tiloulooon-lrd'lud ru# fi n': al a.lu.t (brai n edema)
lrucvthnr :rir sTqyt:rt o n yi o nir n"od o,:fi o.t
lunr:n'.: vcv moae tfins,:nu phase ,lo.,rrRiomirunrtlo o-od
Triggering
ylr r n'.: nr: n: :fiulfi inspi ratory valve rfl n d.:fi nr :n:: fiuldnnr u i6
1. Time triggering (contror. c) vrrunrr:.r'ir fiilru-hifiatoonu:,,:rfian::fiulrtr inspiratory
vatve ri]o rdu rirdlo'n:rrnio.rdruilrutdJ te nf.loiourfi uaer,r.ll1n1 s iurfi rnCo,rtjrufirulo
e :druaT nra'lfi{:Jra r n*.rlodi{rJruhido.:oonu:,,rnr;{u d,,rfid1,fitu{:rrrfifiornrl.r:.roofi:uu:,,r
uiatu{rjrufifindTrrdo'lunrrfirU'lerflua-l.rvnn (respiratory muscte paratysis) ornnrr1lqrirrl rtiu
myasthenia gravis, Guillian-Barre syndrome, :vurrl:vorrdrunfll\:gflnoclnfl,r tSanrrnngtfio
fi aonqvrf,cio::rril:c aryr rYo
2. Patient triggering (assist. A) ruunllrfi d rudo.,roonu:rn::{urfinriauudon:;{u1fi
inspiratory varve rflo tnurda{rJT uaanu:':n:vfirufir lvnr'lfi.ldornronrmiriirillilu mode rir.:1
ttt,:firiruorlt:nn::fiu1fi inspiratory vatve riold'2 r[!]l
1) pressure triggering nrrsfi.r fi:Jtuoonu:.trfiocire arrlri'urflun:Jtur,:crro',: rnio*,
tiruilrattfion::fiuhi inspiratory varve riln nr:n"rdr pr"""rr" triggering do.:nslrirrflunurala
tdarqrnnr:rnru'to rfirlurrnrrjnfi rflunr:nrulqlnu'ldnrrrduar (negative inspiratory pressure)
tt'tlii iunsnatrr'plqresnsutwredtieggfefitJinzgaanatwnuiixtntm$iuawGjreigagnetDulemdIna'{ntdJ?zuanlttiaualonultz,t,ntnazatt6iwuJz(terlig,glret|ffminiafl,itr
ztwtfraonun tigger riJ pressure ezfrfrflu (riaanh o)
312 rrrnitioinqndugru
leutidilqtet{dr.lifi t-l Z - 9 g srr.dr d.rnr:d1 pressure triggering fi't lrndnrneldl']n pressure
time curve fi'.:: fi 1
2) Ftow triggering vilrufi,rnr:dflilruoanu':ttfr a6'larnrordo'(fiIfi 6'n:rrir (rlow) rfi a
nr;{u'hi inspiratory vatve riJn ]nflil-{!qcne,:drrhyrJ't{u 2-B fin:dourfi y'.:d[j-ldrurunru'jr
{i.:rJoru'or:ffiloor,"oatrnigguerrrd{rlh{utorw;oo2-n3u6?s{fri:oifui1n6'itlun1ttdu,r:firpioreussinusrepirtaritgogreyrv'atulvler,r4rJtlfsritffin,or:nfivtl':urtrri'g'rgverqrintfgi
nlilo; n't rfl u pr"..r r" tri g ger 14io f low trigger flIdlil fi
um n si1\: n'utJ1n
vri'nnr'lrliunr:pYt triggering 6o lrinr:si,:tfivfnrfiuhl (hard to trigger) ttu nr:nt': p'"o""
triggering G)t O tu.rh rir'lti{rhuo:oonu:,:'turflo inspiratory valve 1n rir1fi,orudf,:-6ufiorrir
lunr:nruh (work of breathingl lrn uonorndnr1dt trigg", l1n'r:n&.1'fiirlrturfiu1il leasy to
rrigger) giu nr:m'l pressure triggering 1-1 o.s mr.rfi fir{rJrufinrmrir:n'rrfiu.xrfinfisu c:drlfi
rfiernl niuadur.:r: d.,:o:lJnr;{u1fi inspiratory vatve lio d'rutu lunruvii{l?uv1u'lcoonEi.i
lriduqo ornrnrrnrnia.:rjrunru'lqfic;6rir}.t lfiu[}rq1fifinlfir,ta{tuiloourn nrrvd6iJn'jr auto-
trigger (auto-cycling) 01n16?rd'1;'tudrlnr:uruhaonqo riunnl;dir auto-PEEP d':darfinll
urur e:r'rlfir;anfinr:letruq'rotjrlda rdot r3unir dynamic hyperintlation (DHl) ii',rdlruantrt
rfiornllnulafiqsltr (hypotension) i'tnnrtdalld'uluriaun:r.'ronlrndu rirlfiflo preload oneln
dnrr: dynamic hyperinltation u"{1i't'1fi[fig barotrauma ttl11tJr'lddeu n-rr; auto-cycling 6['uJ1ln
ruri'lflldlnunr:rlil trigger'tfi tunr:nn
'tt.tr'JT:ex50ur.tn11:amdannl? trigger n'rn'jlrJn6 neuromuscular disease fi'rfinfi'u
rdOtUnr:lrUheiou[:,] (respiratory muscle weakness) ltiU myasthenia gravis. Guillian-Bane
syndrome, motor neuron disease, myopathy n1:frn trigening 'hil'tn'jr:Jn6 rtiu pressure trigger
"n1i Z uAW flow tine cuye'lu VCV node $uldh1aiuEnaaurt'ttJ'hsan (end of expiratlon) flow
,rrnrolruanqnlilun#qu[ tmati'tfr flow mdad."aaudxn'ru1e aanqn d'tusa"{nYuz*'1
auto-PEEP 1u?nr|,du ttfrdautau1
ivlechanical Ventilation: Modes and Sedng.s lan?ut?i, fifrt1tg 313
(-)0.5 - (-)1 tl.rir uia flow trigger o.s-z fior:riourfi rirlfinr:lir,rruto.rnfitldo'lunr:nru1c
nOfl\t
drfifiordrnrur{rtedalildo mode ?a{ triggering l*jhi mooe ra,: ventitator ncjr16o
VCV mode ttfitflu volume control mode fiR.ur:noYt1fit".l pressure trigger unc flow trigger
nialuvlr.:na'uniu PCV mode fi.rrflu pr"""ure control mode finrm:nri,rldls,: pressure trigger
tlflt flow trigger nio PSV mcde iirrflu pressur" controt mode ffartr:nfr1fin',: pr"""rr"
trigger rrn! flow trigger rdut6urniu
Fio,
FiO, r1?o0 fracttiioonnaall inspired oxygen concentration fifi xlr,utufin.,nl df,adrluxyian',::rrrl rilrdduurtoo,rl
oonfinud{il'luldfi 1oflfln-nnr:fr'r Ro. e:ns,,:}irioudqoMrfiarm:ninur::du oxygen saturation
ld 6.,:'lurrsioyl:nfito udasnriyqydo{nr::yft'':J oxygen saturation ii unnpir.lri'uosn-l:J ra"rd
. i:fi:JrEJ copo dornr:::oril oxygen saturation rru 88% d.:n:oril::n''l eaq
r.l:vlru 5s r.lt.r. :oyt
. fit-hu nRoS darnr:::riu oxygen saturation lt:rJlru 88-92% nioolctridrradulo,l
oxygen saturation go% fi{ot:{n'u:cn" pao, tr lru 55-60 rJN. :ayl
. fitJtu acute coronary syndrome dolnr::;nll oxygen saturation lhttlru 94%o dn
o:,,rriu::d'u pao, ::Mru 80 rJx. :or
. firl'lu post cardiac arrest fiatnr:rynir.l oxygen saturation tl:;trn: 9+o/o {irnrtrYl
Itfi':J Pao, rJ::rrru 80 r.tl.rJ:oyt
. fi:-l, ufioqitunrr;dufiuonrfifioqrndneirdil rtiu pneumonia, asrhma fiounr::;oir.r
oxygen saturation :ytJlru 92-94%
9-.alu nrrlfil'rYud::u'jr{ oxygen saturation !!ni Pao, rflu'l:Jnrl oxygen dissociation curve
e90 gld uaa,t nemogtobin oxygen dlssoc,atlon
80 "u*.Ioai
70 SaO, 95ok nfirilJ PaO, 80 ertJ.ihon,
nln60 PaO, 60 tJsJ.lJ'rfln,
SaO, 90ok
saoz 88vo nNn"u l4o2 55 NN. ffin,
404
nxSaO, 75o/o tL fuO, . ran,
30 sao, 50rh nl,ln"u Pao, 27 NN. 1on
20
to PaO2 mm Hg
314 rrmjrUalnqndugrl
il:cr6usiabddo.tn"rfilfi,,:rdont',: Fio. 6a nlvtiufiucrnoonitou (oxygen toxicily) 6'l
fifloiunri'n Z ilo{u6o Rmlrirduroraanfinu rro:::urr?arlunr:'hloonfinu lnuotnrtualnr:
udn.,:lalntr:rlurln0on6rculfu dlrfluhn'nnrr:nrfln q:fiarnr:uayoln't:u6lor9o,l retinopathy
of prematurity (ROp), bronchopulmonary dysplasia (SeO) druluflnqjostfio pulmonary fibrosis
fioilondfinm:flilnrrrrnna'l6uqinrrsilnfild (irreversibte) udlilldrfiotu{:Lruvlnnu duo{riu
lr rri anrvi #s dur o,J Eo dx u Te ufi v 6'nrtr1:J e'od
. n1r'li Fio, 1.0 c:tfi6 oxygen toxicity riolfii:irl:J::rrru z-s ridul
. nr:'ld Fior 0.8 e:tfin oxygen toxicity rdoldi:i:l:J::rrru za-aa d'frJo
. nr:ld Fio, 0.6 wtfio oxygen toxicity rdaldfil:Jrl::mru t-z drjq,fi
d'.rriurdorl:r{rtrunolf rio, lulurngl i.rfinflr.r'l'rlfludocda{non'll'ltaonfittunl lnu
rliuraCa.':riruvrule rdalfil{ oxygen saturation 'lu::o"1fi tvur:cl rdu nrr'ld PEEP, inverse
ratio ventilation (lRV). alveolar recruitment maneuver, prcne position tflufiu
'lurrl:eviaur*rnrr;fi0.:finrrll::tt-olti,lsdroti*r'lunrrflo':riuh'lfirfinnm;tiuc'lnoanfitlu
LATLN
ir1. Paraquat poisoning 6.rnr:ld:"!ur paraquat ni!oon6lcu'lun'11:l [fitJi1.l11.l1n{"
lvd.rrc3l'lfirfin oxygen free raoical dtnirlfitfio irreversible pulmonary fibrosis
z. tru;ldur amiodarone dlnl:ldi:lm amiodarone irlrilsanfirculuturnql c:domil
tlitnq ireversible pulmonary fibrosis
nr:rlirr:Jduu rio, rfio'lfrlf, oxygenation dfio.rnrt
fi c1: rldcrnn-rodrtsiolld
ti'eorir,,rd {:-humur'rdtl6itinr:ifiqo'ulflu nRos nru;d'lfirndottirunls'lqlnu'Ifi Fio, tri'rn1r
il1.0-[d Pao, rvirdr.r too rl.!:ar dotnr: Fio, lfildir oxygen saturation trirn"l 90% e:
fia.,rld Ro, rrirln
ornnruffi.n{ufnr hemoglobin oxygen dissociation curve ldlrrooilqili s1 ul'jr
oxygen saturation 90% a:nr'ln"!d1 PaO, 60 tJ .:hovl
crnnrr d fiui (Paor/Fior)1 = (Pao,/Fio.),
100/1.0 = 60/FiO,
FiO, = 06
n-rnyudrnr:rJir Fto, trirnil o.o rriolfild oxygen saturation MrrYu gox
nlnr: (PaO1Fio,), = (Pao1Fio,), fi{onr::c{'01unrr1fr6oluuur-oonrvrso{ilonfifin1r
rul6uuu:lnlotjr.::rorir 11iu congestive heart lailure dnolOuo',rdanr:inrrdraarrilflOAlv
yia nRos dfiaT nr:udn,rotjr.::rstir drto,t Pao,/Fio, fildlurrrdnvderrenrl;lilwirriu nsim6a
\{echanical \.-entiladon: |!{odes and Senings mn?zrf nfiittJ 3ls
firilonfrfinsrianrl! 'rn d1 pao,/Fio, qrsir frififio.ri.fi rio, flrnirfirnunerurruld dru:Joono
lrieioufivrurficnrfl fiiono!f,uo,rsionr:inur'ldd rir eao,rrio, l:fin'rg,: riolndr6ura'rrlnfi rirtfi
fiarts rio, n'rnjriirntrrirurruld o-.rriunr:qornrrflr:;i,,rfirr.luodr.rriarda''16rrflud,,rdfin11dr6'q
Tidal volume
Tidar vorume rrrafio irrn:ornrfldfiilruilruterfi'rlurrsinvni,r n.lr#t tiour vorume fi
nrrrdrdrgnrntu VCV mode [vr:lv vcv mode tflu vorume contror mode Llfl:riu vorume
tftllcvcling ventirator nmunrryir r$oroSa.rdrsnrulq&iornrocufi,ldr tidar vorume d#rll
tfiu peak airway pressure alarm) inspiratory valve oyilnrrn: expiratory valve oyrio
firnnr:eY{ tidal volume riurir'tfi peat inspiratory pressure qrn'Jt peak ai*ay pressure
alarm rnComirrvru'loo;ri'o ldr{nr:vru'lcoonriufiflSon rfrur{o.rr6au lnu inspiratory varve rr
ilottn: expiratory valve q:!flo
nr:dl tio"t volume fi otrluqnsir,Jaanl:lnr urionl,rto.r:los n-,,Jd
1, Normat tidat volume ylrsfir nr:d,t tidat volume tuturorjnfi 6o 8-10 ln./nn. n-n
ifflurirtrudlrifrilurBonruiurJao rl?aludarrlo,r niu flrrud!fiirurrfiururoqufifiufiqonr:nrotr
2. Low tidat votume fiuun'r nr:d.r tioat votume lururndfioan.ir:Jn6 6o 6-8 ln./nn,
vioriaunir finli"lu{rhudfi vrur6on.ru.saoJoq,r',1fi n'ldlunrt:rir,,r1 n-ld
1) Restrictive tung disease rflunrryfi oo'lrjcr r:nruruor"rldo' niu nnos,
heart failure, severe pneumonia, kyphoscoliosis tt,,rt:ntun{ldri'a.:"notnog'nes:rtinvre:
yru'lorioufir,lr5r 6olrrrrru to-zq nt.rsiaurfi niorrnn.irfi.rdlflu
2) Obstructive tung disease rflu'n:nr:qnfrurr,r rdurrahdruajr,J niu asthma.
coeo dfl:alun{ dda{n".rdnmnr:nruhdr 6o :;!rru 8-rz nf.rsdourfi rdomrn
fird,rdn:rnrrrra'hr5r arnrqwdrt'luq,onr?udronu'lroanqno;rfi nnr.:; auto-
pEEp d'triu rdo tidat volume n'r udya-n:rn.tlyrutenh i.tdo,Jfl arJlfinrr
errSlaulotoon1t6n"t (permissive hypercapnia) sirnnlfilfin respiratory acidosis
f{i'rcTrr:nuo dii pH :rlnn.jl 7.20
3. High iidal volume flrJ1ufi{fl1:nel tidal volume luturndlrnn,jr nfi n'o t 0-12 ln"lnn.
riorr n nir dtfi iiifflunrr :rir,r1 n'.:d
1) Metabolic acidosis fi:hufifinl,ti metabotic acidosis qyfitu'te tlu Kussmaul
breathing d.:rflunr:yrutqdr tidal volume rl.l't9tfl,J inspired time lrnn.jr n6
ruayo'n:rnr:fi rutclri rfi u go ni,,:oi ourfi fl na rodurJrvurru zo-zs nirq'aurfi )
d'.,rrtu nrlfrlo'n:rnr:nru"hlrnl luftJru metabotic acidosis l'.,ilrj'lfuh:lutf
lrnrin o-,,:riu 6,:fio,:rfil tidat votume trirrnn.jrilnB [ourafiu:]:;lrru ooo-aoo
n.) fi xut.tr,rr,tufio\tnt? tidal votume n',,r 1.000 n. duodflinrrrrulr:tro,rnrr;
metabolic acidosis
316 reni'nin-nqafrugru
2) Neuromuscular disease tliu myaslhenia gravis. Guillian-Bane syndrome' motor
neuron disease, cervical spine inlury {rJrt rlrirdfilluxIiltfltrn1rtfio atelectasis
firlandrurir.'rldiruLdo.relnlrifiurnxrule n''.:funr:tlu,i tidal volume lfillrnn'j'l:Jnfi
r6ndauc;druio':rYunr:rfi nnrrvftd
3) Increase intracranial piessure 'tufirhulr.r:ru olcfinrrtJtirrflufio.ldr hyper-
ventilation rfiotfirfiq cerebral vasoconstriction tdoag intracranial pressure'*-'t
finrrldrrflufio'r uil.t tidal volume tfildu ldorflunr:inurd'rnrrr (bridging therapy)
riaufie:'lfinrrinurdr tnr: ldetinite therapy) riol:J flogiurrur6n"lunlld'] hvper-
ventilation'ttl increase intracranial pressure'lfiilnrrllfiofionnn':
4) Fever f,il?udfilflga ir,:nrtfinmolnuo,tdrunr:vruhtir rrnvld lidal volume ''lfl
n'irrlnfi urdvrs,ldfio,Jrlqr:rurdru'irfi:Jrufirurianrnra.r:Jand6o.:nr: lo* tidalvolume
v5o'hi
rhvrinsrrfildtunr:nu,i tidal volume orlr:nn"rurruldqln predicted body weight d'od
Tl1flt1u PBW 50.0 + 0.91
rrornf.,l eew 45.5 + 0.91
||,lstxq PBW: predicted body weight, height : {on?'ltl{.ttijutru6tlst:
nr:'ldan:n'rurru predicted body weignt fir.tdufu finrrlo'rrflulu{rJrufifirirnrin6'rurn
niu morbid onesity rirulu{rJrufiHalr:rn (cachexia) lrido.:rfrurru predicted body weight
r fl:e:e'rurruldrrnn'jrnrrrtflur3.r tri'ldrirnrinri'rlln (actual body weight) LLYIu
Peak inspiratory flow rate
rrrrufi'rcrrrrtl5rla,rornrsludr,lflrutnt{r f,ur:nn"rurru'ldcrnlS ta{a']n''lfieiafifin
rrirunor finrirrrfiu6n:siau'rfi d.rlunr:ofo peak inspiratory flow rate fididfiasfiqt:rut 2 tJtcnr:
6a ;rJur-rl (configuration) lon peak inspiratory ilow rate dslt{ tta;Fir (value setting) fl0.1 peak
inspiratory ttow rate fidt
;rJtrurto.t peak inspiratory flow rate
firnru; uur udfrldilau'lu7rrrndfinfi G giluu! n-tuon,t'lu;ilfi +
rijor iur.rrfiEJu ftow waveform n"t e ;rlrrulTntd,:r{r tidal volume tri'tfiu evrl'ir inspired
waveform tvfi inspired time #uiiqn ttd; total
time [ri) dr':niu Tnufi "quare deceterating
time urxfiqn o'.rtiu sqrar" waveform ldtufi:-huiida.rnrl inspired time
waveform e:fi inspired
du 6ufifitdtu{rhu lower airway obstruction ltiu coPD. asthma (tldlrildvuruarrtlirdood.i
rflu square waveform girriu oredlrflu half decerelating waveform vio total decerelating
Ir.lechanical ventilation: Ilodes and Setrings nn'zuni lfifrntg 317
-l-L -f-LHelt - decelerating JNl\\-
Square wave form Total - decelerating
wave form wave form
t lii uan,sg uuutan ftow 'lu vcv mode
1. Square wavefom tfluaJuyym,l peak inspintory flow nte ifrdnfltSnanntaMriu
aaaotinmu'lcd'l
2. HaJf decetenting wavefotm fiuTJuuwa't peak inspiratory tlow rate idnel#t?/ai/otnla
filuth t duqn n aunt u'h 6t u a* ndn or iat t ti tr ar a t n t nludx 6ad untuh $'r
3. Totat decelerating wavetorm tfrufluuutat peak inspiratory flow rate iinn6tta,t
ia t n mlud x du q n n a un aIc 6t rflu g u
twaveform frl{ nrndil{ peak inspiratory flow rate rnna :1:nrtsY{tiJu square waveform
riuq:ridri peak inspiratory pressure gtdu; dru total decerelaling waveiorm tdtu{rhud
da.,,:nr: insoired time u1? niu fiilru ARDS dldooudilardar :td peep turoo,,: firl'run'fi
atelectasis tijudu
nrtototia peak inspiratory flow rate
fi q'r:nrrlde'r n dr o rirr siolld
i:otir.rd z {r-truldrnio.rdru rulerruu vcv Inunsl tidat votume 500 ra. n"raln:rnt':vruh 12
niroiaurfi fio,,rnr:'1fi{:lrunru'h'h1.[d t:e rrirn-u t:e rrda.rntr peak inspiratory flow rate trirln
loanivuotrldrrfl square wavelorm
rirurrunnrdtdluu$in: respiratory cycle = 60/12 = s lurfi
dT uerurrnrdtdlflu inspired time
lucotir 1 respiratory cycte finr:nru'h e dru datflu l-time 1 dtt,t, E+ime 2 d'tu
dbriurrn-rntli'luudo: 1 l-time = 5 x (1/3) = 5/3 iu,fi
urln,lrniru tidat votume rflufin: = 0.5 fin:
rfia{ornv rffio.l peak inspiratory flow rate riufim:siaurfi
niururir peak inspiratory flow rate dda{nsr
rxal 5/3 iu1fi 'Ifi tidal volume = 0.5 fin:
r?n1 60 iu1fi ld tidal volume = (0.5 / (5/3)) x 60 = 18 6st:
318 r'rtdrr-ninqorClgru
ritriudlfiotntl peak inspiratory flow rate r 1n"! 18 fin:dourfi
'lun:nidfiotnrrfr.:rflu halt decelerating waveform ria total decelerating waveform 1;
dalfi.r peat< inspiratory flow rate fl,ln'it square waveform lnu half decelerating waveform 'ld
peak inspiratory flow rate 1.5 tvirto,'t peak inspiratory flow rate finhu,lruldl'ln square waveform
trfly total deceleraiing waveform 'ld peak inspiratory flow rate 2 !1i1fl4,i peak inspiratory flow
rate fin'rurrulfiorn square waveform lpruvr-r.lrlfnfrorflu half decelerating waveform via total
deceterating waveform tfiaqjlurir'r 40-60 fi nltulfl
tunr:sl&,') peaf inspiratory flow rate rYu
r. firfteir peak inspiratory flow rate q[{ rirlfi inspireo time du tt rldlu{ raiifi to*er
airway obstruction $u COPD, asthma
z. firpY,,reir peak inspiratory flow rate n'r vth1fi inspired time u't't d.rldlu{ilrl nnos
u5o congestive heart failure filriqouauo.:rionr:'ld eeee :vd':tg't
'lurnia,:riruvrs'lqrr,riu nr:ft cMV mode hldrakir peak inspiratory flow rate ttsi
c:d{rflu{dr l:E ratio ttvn-r ttiu Raphael, Galileo, Halminton, c-s riiudu
Respiratory rate
a-n:rnr:rra'lo nfirilrflu to-ts ni,lrdaurfi lu{TLrudrJonrJn6n, :nvrdor:rnr:rru1c ::mru
lildt o- t s nirriourfi zo nirriourfi a drrd{u lnan"u
rtafi:rnr:vru'leid'r ( 1ru e-te aiteiotrfi) lf1ur{rhuiirflu lower ain/vay obstruction
rriu coPD. asthma rdovfinrdsanrrtfin auto-PEEP o",rriurdodoostJ tidal volume nurofiou
drrfil.ldn:rnr:tru'hdr 6,ido.:uoulfifrrtnriloulnsonltrid.t lpermissive hypercapnia) qan:o
rdr.,ritriu respiratory acidosis firll5uou Paco, rlnn rrnvnnn:qdr'' n6 {:-hucvfi auto-PEEP
dmrrhlfi rfi o barotrauma nSonlr.rdulafi nairorrmld
o-n:rn, :mr'trdrir lrrnn'ir ts niiriourfi) ltrlu{ilrudriuLnta*darJon (tuns paren-
chymal Tol'ld tioal volume flulndau un:{dru metabolic acidosis Tqulfi tidal volume tu're{':
nr:d,rdq:rnr:nrrtoriu nr:lfi4:-harrulcrirn'irrnio.rr6nriou rdoflo'rril respiratory
muscle weakness i rfioqrnnr:tdrerio,tdruvruh t:iu fi'rnsrtr RR 20 n:vt/urfi rrn:{rJruurutt
zo nf.rriaurfi d',:dn'nnn RF n\r rdotrifl,rJrunruier5rn'jlndo'niruv'ru'h16nrioulnun'rl:Irinr:rfiu
s ni.rnnfi
nr:6onu{:Jrud'ti vcv mode nr:6nnrr parameter oir.r1 uial:ld
1. Peak inspiratory pressure (PlP) llin?tnu gs tr.rir tda.:c'lnnr:fin barotrauma eJ
tfind alveolar pressure (plateau pressure) go sx,d. rratlourtrll PIP t!0! plaieau pr"r"ur"1
n':rrd'rrrYulfiu s ttt.fr
l\'lechanical lenrilarioni Modes anJ seningri lani flf ,&-n-rtE 3lg
1e1t'r{f; |'16[0{ parameter setting dfia.{nv{tu VCV mode
1. Triggering : pressure/ flow trigger
Fio,
3. Tidal volume
Peak inspiratory flow rate : grliru. eird*o (rnia,:tiranru'lolt,l,iu}lnsrrflu t:E)
5, PEEP (firfi)
o. Fespiratory rate
2. Exhaled tidal volume ufi'jrtu VCV mode acrflunlttr{ tidal votume fiuuuou (votume
guarantee) ttritflunr:qru rovir: tidat votume qauyluhLdl (inhated tidat votume) rri1lin
3. Respiratory rate rarfi ru mn{Lhu}flulerftn.j.ro"n:r r5.rntd,ililrn fialdrnr:rr
olun unyninr:ufilldo'l
PCV mode
f,nuru;fidrd'qto.r PCV mode 6orflu pressure guarantee tlrufi,rfioonerrd.r inspked
pressure (lP) tt rl:nilnanhlirir tidat votume uJdauurJnilrJnrr.rfiuliflnl rJo,l aa [nyrdoccrn
tflu control moOe irdordtdn:rnr:rnulo (respiratory rate, RR) [dxa
{o:-i,rdiunr:1.fi pcV mode
r. iflu{rtr#fidr ptateau pressure dqon'jr so trr.rii n?afiruurTriujr ptateau pressure
o.ln'ir 30 ?!.d1 rdu ARDS
z. ldlu{rhldfinn'nSruro,rnr:rfin barotrauma alnn't:ldrn{aujruyrub niu pneumo-
thorax iiilaoiln'lndrryii.t rdaalrn:ni!qrJ plateau pressurelritrirfi a pneumothorax
lo':r.lon6ndr,r
Tnuiltrlilnr:r6onm8,o vcV mode y50 pcv moce hifrnrrrunneiroflulufilirurcu duori
fl!nrtfi anr parameter ttn:nt:rfir::r"rnrr:ttt:nSourirul
lunr:fr.r pcv mocelfid,lnu phase no.rreiauirurnru'lc dlrd
Triggering
ydnnr:sr&,rr?iur6flrrftl CMV mode fi,:r;6n11'jr PCV mode d1rJ1t0gY,,r trigger rflu pressure
vigger t?o llow trigger fild rrju16urrYl vcv iour:nmrt pressure trigger io now trigger fi1d
Fio,
u o-n nr:n&.r niu ro' ur fiu vcv mode
320 rrtrirriorinqmfilSru
Inspired pressure (lP)
tfu setting fiatfi'rUiu PCV mode fittcn{n'mtruvto,J pressure control vo'ntunr:otu,t
inspired pressure 6adilfi1d riaal volume n'l n?ltJt tltvfll.ttto,.luutBf,nr tacrlonus{av:l::m
1:rua: 16un1dndrrfi,r ufirtunr:s!",J tidal volume 'lu VCV mode)
dnuru;to,: Pcv frd1,la1n Bird's veniilator 6o pcv rflu time cycling ventilator nju tda
dt inspireo pressure 20 stJ.f1 rdornfoofi inspired pressure fi,: zo tll.rirrrdr tn{0,:qln,l
inspired pressure d eo tr.,.riruiolhun'fi1;duqonnr inspired time fl-i) dos,ill dofi'uqo inspired
ittine drrg.rl{ufir inspiratory valve q;ila lrat expiratory valve ostiln i'rriun pcv mode time
cycting ventilator'lunru:d Bird's ventilator rdotn{al6 inspired pressure fio zo tr.r.r.1r inspiratory
valve rtilOttny expiratory valve qcrilnrfiufi i'r liUn Bird's ventilator'jt pressure cycling ventilator
6olfiu'fii'jr Bird's ventilator lrifin'lugurrolunl?n\: inspired pressure nnonlurir.:trnrlru'lo
nitdur6urri! Pcv mode n'.:riu tio"t volume dldcrn pcv mooe 6.rldllnn'ir Bird's ventilator
Pressure
<_ Tr T" --'+-T" --,-,-,,,,+ Time
gttii s uaat pressure-time curve ?u Pcv mode dttflu ti.. cycting ventitator Iu pCv moae iufr
n?1afi1aixn'luntnt inspired pressure (p) trtatdnaaaluritina'mltJlcdt eutdaduqonat
nltltti't (inspired time, Ti) inspiratoty valve ctflo Ltflt expinaory mlve cztf,a (time cycling
ventilator)
Pregsure
Time
pli a ntiuufiuu pressure time curue'lu Eird's vantilator (rtufi\ uflz PCv mode A#wlO Inttlu
Bird's ventilator tiuLflu prcssure cycling vantitatot d1u PCV mode Lfiu time cycling ventilator
'lrtil,tnnitf,ui'lfrnn 6a tiaat volume (vt)'lu PCv mode wTdutn nh Bird's ventilatol
\{echanical \.'entiladon: Ir.Iodes and Senings tan:rusi nfrfimg 321
fiotrirnmldrh'jl inspired pressure (lP) rrfl: peak inspiratory pressure (PlP) fu
rir,rrYu Tou inspired pressure 1te; rfluri, dfia,,rors'r lir'[:l d.lsrn}firfipr peak inspiraiory pressure
(PlP) d-tLfluHnr?lno\: inspired pressure (lP). PEep trnynrun'u'ludD,,rylt'1,:on (intrathoracic
pressure) firfioorncrrttEdul niu pleural disease, alveolar disease, intraabdominal pressure
lullnu
PCV mode tflt; u:.rltornr:tirutru'lcdgr r:ooo peak inspiratory pressure (PlP) n{
ldrfrarfir:rrYl vcV mode luzru:ii'ld tidat votume ryirniu rdo.,rern pcv mode riju::luulo.l
nr:rra"hfiorrr:on\: inspired pressure ld'naao'ludrrrrnrnr:fllu'lerd't 'lurusfi vcv mooe
rflu: ur::nr:rru'lcdhicr r:nn.l pr"""rr" ldnnan'lurir{nr:nrulerd'l
Pressure
<_ Tr _ ><_ T ,- )< ._- ,- T, _,- ,-+< T. +
Tr= Inspiratory time, T. = Expiratory time, PIP = Peak inspiratory pressure
Ipli uaa,t prcssure-time curve'lu VCV mode
Pressure rise time (P-ramp, PRT)
rfl u reor$asrn4aodlde'rn inspired pressure quti oufi .r inspired pr"""u.. tfl rvrLrrd#s
{U tnur'':lila:shlid so ms (mittisecond) ruur.r:ruda.rnr: PRT #u niu severe metabotic
acidosis difl..lc1ni respiratory drive 61 drufirJru:r1{r1ufio\rn1l PRT r11 ttiu upper airway
obstruction
+P ramp' )+P ramp
pli a uaar pressr/e tse time (P+amp, PRD'lu PcV mode
322 rru.itiolnqadu5ru
Inspired time
lflu parameter d ,'i'j1 PCV rflu time cycling ventilator lnunr:d.: inspired time 611r1:tt
qlldunruii lcuarqd,rorn time constant tt:nhurnrldrrnaln0runa.! compliance (flxi1u6a
UcmHrO) !!flJ resistance lluruda cmHrO/Usec1 lnUf\: inspired time thvllru 3-4 tvirto.:
time constant d'tfi oxygen diffusion 95-99% d,oeioufi,rtirurn i6dirun'l, fionr:os,l l:E ratioloa
rAJ e4 LunllnEno- {ux
nn
1. l:E ratio:lnfi ns,'ttl:vr1ru t:z-1:g
2. -v. expiratory time urrn'jrrinfi nju l:E 1:3, t:a. 1:s d':tdlu{:-l'lu obstructive lung
n'nnl,r
disease tdu COPD, asthma
3. n1iri,,r inspired time ul?n'j1 nfi nju l:E 1:2. 1:1.5, 1:1. t.s:t ftlf1u{rhu nnos fi
lrinarauo,,rrianr:1d PEEP su'roq,c metabolic acidosis iilu!!:',1
lu PcV mode lrido.rd.: pear inspiratory flow rate'lunr:nixue inspired time sl"''lniulu
VCV mode rdo,'rcrn fto* i{:-tra16'iu Pcv mod6 rhrriuo{rfunl*rda,:nr:ta.:{ tu 6tow on
demand) Flow-tim" "uruetu PCV mode ecttflo.:nnufug:to.: decelerating exponential curvetu
lnryd vcv mode n'nuru;:ro': flow-time crrue qvtflul:.Jsrrrtgilirtaol peak inspkatory flow rate
r lon'lfi ft[')
Flow
gtii e uant flow-tirne curue Iu pcv .oa" dtudni:,t,mn vcv mode laalu rcv moae anaucuat
flow erdufunztufratntnats tu (ttow on demad) 6tfra'rn,luztfruduTdtailutixntu'h$t
6unil decelenting exponential cuNe
lvfechanical Vendlarion; ,\todes and Semngs nn?wf nfrfiwg 323
Flow
totrtti unat flow-time cuve lu v)v nnae dadwnuhd?u square waveforn half- deceteating
wavelorm uat total deceleruting waveform dladtdtt
Respiratory rate
fi nnnnr:nrrnlniulduxfiu cMV mode
2r1?1l'd !!f,o{ parameter setting idfiarns{'Iil PCV mode
L Trigerring
Fio
Inspired pressure (lP)
4. Pressure rise time (PRT. P-ramp), Inspired time 60 l:E
PEEP (ftfi)
o. RR
nr:fioonl{rJT udtd PCV mode 6xifino1rJ parameter rirol oioUd
'1. Exhated tidat votume rdorvrnnrrld PcV dor#r inspired prassure dwir'Ifi innapo
ltidal volume n,rd c'rdtflnlfi exhaled tidal uotume lrinodnulrldru
Peak inspiratory pressure lrinrrtfiu g0 !tJ.f1 rdo.rlrn'lu PCV mode u"u PtP lrflc
plateau pressure fieilirniu
3. Bespiratory rate lot{rlru uT n{rJ'!ufi'tu'hrt,lni'ta-n:rrfrdofrl{mn fis,rrirnr:mslyn
run:n:rnrr*r{boio}J
324 rlni'tfainqnftuyu
PSV mode
nnunr;ddrn'ryto,: PSV mode 6otflu spontaneous mooe {:-huda.rdrruso'n:rnr:vruh
(respiratory rate) dxufi!ro,J ot'briu6.rkir{atd,:dsr:rnr:vrulcd'l unnei'1,:11n control mode
dori,,rdrornr:'ld PSV mode
1. rflu mode dli"lunr:ntir rnialrirunrulc (weaning lrom mechanical ventilation)
z. tdtu{rlrutu:rad4utinr:rrulolrignno lou{r"lrufi ornrutr ro.ild
dirriu psv mode itsr alr:nriurtdlu{rt'ludfi nrrulu rr:t *nn1d lilir riufi o.old'lunr:
yrjr rn4o{tiruilru'lerrirrfu louilil:vn''l pressure support lfi4.:uo1fi1d tidal volume ntrfifiilru
do.:nr: usifi o'Jfi nrrrfl r::i':otirtlnfi8n
lunr:n'r psv mooe'lficr&0firil phase ta,:tRiauirsu, ule dtd
Triggering
vnnnr:ns.:njul6urn-:.t control mooe fit::finH'jr PSV mode or rrnc't'l irigger tflu pres-
sure trigger v3o flow trigger fild rtiurdurfi:J control mode iio'urr:ndt pressure triggerttio
flow trigger ff'ld
Fio,
ndnnrrns,Jtdurdurtiu control mode
Pressure support
Pressure support fiotflu pressure control orjror'rfi.: niurdurriu PcV mode vf,n'lunl:
r'''': pro"ur" 6ostetfild tioat votume lfitfi tcf,l.ttit-rvrur6anrnto.::Jon loufirv1r pressure
"rpporr
support u1fl tidal volume d{rtrulde:mn fitnt: pr"""rr" support riou tidal volume filde:dau
PS = Pressure support, CPAP = Continuous positive airway pressure Time
PIP = Peak Inspiratory pressure
g l II uaw pnt"ur.-time curve lu psv mode
Mechanical Venrifation: .\todes and Settings aoniuni nfrfiuJS 325
pressureIPAP = Inspiratory positive airway Time
EPAP = Expiratory positive airway pressure
t2alfr uant proture-time curue lu uppv lu&nnh tidat votume fi7dnn npev duogfriuaad.w
flBN IPAP Ni EPAP
i.,rfidalvrhnrur{rtosiolil6a r:riuto{ pressure support rYuujuorn:;Fr'ufiad !fifio cpAp
(continuous positive airway pressurel fi.'rrfiar iulrfiglfl:.t noninvasive positive pressure ventilator
llteer4 dtfinr:cr&,r IPAP (inspiratory positive airway pressure) q;r,i 'jrfiarr lrflnqir,rn-u lrru
:;niuro.,r lpnp rfuoyriilfuornqud dilrirnfiauniu::ojlrlar pressure suppod driuirlrn cpap
Tidat votume d'lficrn pSv mooe nruoEjril:;nilfloi pressure support lri.lro:l:ylrlfiuu
cpnp riulvirlofinr LLri tidar vorume fildc'rn Nppv q;fltunirJHnsir.rra.J rpAp LLd: EpAp (expiratory
positive airway pressure) ri'.rriud.rinr::Jil EpAp lnulrildifu tpnp onilrldru tidat votume fi
I6e:nonr d.rnntfirfionrrnriloulooon'ltdn'o lrfl:tfi6 respiratory acidosis Ftl rJ' d'
Pressure rise time (P-ramp, pFTl
fi ya'nnrrnyor:iurfi mfu pcv mode
Expiratory trigger sensitivity (E-trigger, ETS)
tfiu parameter firjlir pSV mode riu flow cycling ventilator nltnvr expiratory trigger
sensitivity lnulnfio;dtrliii zsy" ulruerr .jrrdo ftow 'lulru: rutcr{rasa{cur?6o 25% flo.t
peak inspiratory ttow n&\rfiu inspiratory valve QyiJorLa: expiratory valve q;rflfl
tdanvr expiratory trigger sensitivity rirdrol riu o:dtantfi insprred time [[n: tidal volume
nl\tnU tht1l
1, rirf.r expiratory rrigger sensirivity go rrjuft ETS 30% cvrw.jl flow cycting finr5r
n'irnr:nv,r ETS 25% o'olr&u inspireo time c:fun'J duro'lfi tioat vorume dldaonr diriudsfifilfi
lufi:Jrs obstructive rung disease nit,t copD, asthma {i{do'rn'r: expired time uturn:dorntt
tidal volume fiar
326 r'rmirriainqndupl
tstrtti uaat flow time cwue 'lu Psv mode Inu PSv mode tflu flow cycting ventilator intimun
Ff'Taarh exptntory ttigger sensitivity E-triggetlnatlniczi,t Efslid 25% n l\h?1ui?
tfra flow anamur?tfra 25% nn inud p@k inspintory ftow Lrt? inspiratoty valt'4- wfln uat
expintory valve Tiila
z. firns,,t expiratory lrigger sensitivity 4,'r niufi.r ETS 20% ovvu'jr flow cycling n'ndr
ndrnr:nl ETS 25% n-.rriu inspired time cru'lrdu d.lnnlfi tioat rrotume dldmndumlillildlu
nhiu{lfifrldlu metabolic acidosis. atelEctasis
ugfi uantnrlfu ns rilrix1 drrtfinarildl inspintory time uai ti&l wtume fiatl{u ers gt
rtne iu tidd wtuma anat dailfit ets dt rtine u11 tidal wlume ritliu
\{echanical ventilarion: \lrdes and Setrings nniani nfrfitrg 327
rnio,lri':ufirfl'lour.'tiulrioTrr:n:Jir-r expiratory trigger sensitivity ld rdu Benette-7200
cyfi:yurifi6'olfia ftow Ron,J 2s% rdfioufi fl.tr#{ ers lin{fifi zssro
Respiratory rate
hjdarortro'nrrnr:r1u?a Lvi:'r: psv mode !fl! spontaneous mooe firjrufiolnituo
o'rr:rnr:mu'lcfirunul0n n-,,,msun1r'ld pSV mode o'ldorn'on1l respiralory rate [[n; tictat votume
'ir ntu',rwayialri
-lgnrr,.r# ![fln{ parameter setting fida,iFt&rlu esv mode
1. Trigger
Fio,
Pressure support
4. Pressure rise time (PRT, P-ramp)
Expiratory trigger sensitivity
6. oPAP (fr1fi)
nr:finsufir-huild pSV mode nr:6stmr parameter oirrl rioLld
1. Respiratory rate rdomrnlu pSV mode lrildeft RR
2. Exhaled tidat votume rfiolmnnr:'td pSv fiornvl pressure supporr {iadrlfi intrateo
tidat votume lri6,rd q',rdrnrnlfi exhaled tidat votume lrinrd
3. Peak inspiratory pressure lrinr:rfiu go rl.rir rfio.lqlntu pCV mode du ptp rrnt
plaieau pressure fidrrvirniu
SIMV mode (synchronazed intermittent mandatory ventilataon)
tflu:tJttuunl:yrs 4[Asr-flo riu:: 'jr,J control mode un: spontaneous mode oilfipJrrll
ro,lnl:tjrEJnr:r'rule 2 gilr!:Jr 60
1) VC-Sll\,'lV (volume control StwVl rflunr:rjrtnr:firu'letu: [:J:J votume controt d
si1r.l S|MV mooe 6'''rriu6.:fia..:nutrir setting ta.r cMV rrn: pSV
2) PC-SIMV (pressure control SIMV) tflunr:rjtanr:firuh1u;:.lrrr-ru pressure control
iiij1il SIMV mooe n-lriuirfio,lf',rra'r setting non pcv rnc pSV
rujirrrfitlU VC-SIMV uRy CMV mode firqi,trnia.fiiruyru'lq tz nfirioud rrn'{rjru
rrulovY.,rnrn zo n{-:riourfi nr:flruto tz n*,:riourfirir 2 modes qyyruleld ric"t uotrre fid.,rli
drun'r:vru'lo6n e ni.rdrrda 'lu vcv mode ?rllruteld ridat votume orrffi#,:ll druiu vc-
SIMV mode utu tidal votume d{r-tru1fti*unh::d'ura{ pressure support [flrflulAdnlvfla{
rjan'lurru:riu {ioarrLirilrfiu tidat votume dnltlna
328 rrtrirrininqndu3ru
P sEc
cmH20
_10
LITEBS
fl|fi 15 u a,t Prcssure-time curve IL Z volume-time curve synchronized intermiftent mandato(y
ventitation (SIMV'1rt{nLnn spontaneous breathing (4 uai ventilator assisted breathing (B)
laa spontaneous breathing tiu tidal volume d{ilzuldilutiuzzn'n \t prcss?re support uaz
wstiantnsaorJanlut ziu
nr:r,tfi 4 ltf,u{ parameter setting fido':nt:tu SIMV mode
Frucsu*
Control setting : trigger, FiOr. tidal volume, peak inspiratory flow rate (figure, value setting),
PEEP (fi1fi). RF
Spontaneous setting : PS, PRT. expiratory triggering sensitivity (EfS), CPAP (o'r1r)
f,l setting dda,::lfu ,lrigger. FiO,, tidal volume. peak inspiratory flow rate. PEEP, FIF, PS,
PRT. ETS
2, PC-SIMV
Control setting: trigger. FiOz, inspired pressure. PRT. inspired tima (l:E), PEEP (fi1fi). RR
Spontaneous setting : PS, PRT. expiratory triggering sensitivity (EfS), CPAP (fufi)
f,l setting fifio{ itt : trigger. FiOr. inspired pressure. PRT. inspired time (l:Q, PEEP, RR. PS'
ETS
lrr r ruq: lou:Jnfi fnn&r pEep lro: cP,qp lflud1l6u1du
i\,lechanical Venrilatian: Modes and Seftings rar?ur?f , frfiRt1 329
f,flJ
nmr.rflunr:#trnio..ni':uyru'h6otiunrup{ugruddrd'qlunrrnrad ?umr-m'{riumorn:
dguafirJrunrinfufialfinrlrflunr:srs.rraio,rtirunrulo lrfiourY,,re.rmrn6nnrrJ !flr:rtr rrdu
flrgnrdarerfintu'tusrurf4tdrnio.,,nirurrulo rdoli{:hffionfiualnn.nyinqorloufinrr;un:ndou
fioufiqo
[0flf,'l:a1\to{
1. Pinsky MF. Cardiopulmonary interacions: the effects of negative and positive changes in pleural pressures on
cardiac output. In: Dantzker DR. Eds. Cardiopulmonary critical care Philadelphia: WB Sau nde619g1 :87-120.
2. Tobin MJ. Mechanical ventilation. N Eng J Med 199413301056-61
3. Oczenski W Werba A, Andel H. Breathing and mechanical support. Blackwetl Science 1997i143-7.
4. Aldrich TK Prezant DJ. Indication for mechanical ventilation. In: Tobin MJ Eds PrinciDle and Dractice of mechanical
ventilation. New Yoll(: [Ic Graw Hill 1934:155-90,
5. GattitoniL Pelosi P, Suter PM et al. Acut€ respiratory d istress syndrome caused by pulmonary and extnpulmonary
disEse€: Ditferent sFdromes? Am J Respir Cil Care l\4ed 1998:158:3-11.
6. Tobin MJ. Advances in mechanical venlilation. N Eng J Med 2001:3441986-96.
7. Esieban A, Frutos F, Tobin MJ. Et al. A comparison of four methods ot weaning patients trom mechanical ventilation.
N Eng J Med '1995:332:345-50
8. Sessler CN. Mechanical ventilation of patients with acute lung injury. Critical care Clinics 1998i'14:707-29.
9. Jain S, Hanania N, Guntapali KK Ventilation of patients with asthma and obsrtuetive lung disease. Cdtical care
Clinics 199814:685 705.
'10. Buiz Sontana S, Gancia A Estchon A et al, ICU pneumonias:a multiinstitutional study. Crit Care ired 1987:15:
930-2.
.1 1 Brochard l- Rauss A Benito S. Comparison of thro€ methods of gradual withdrawEl from ventilatory support during
weaning from mechanical ventilation. Am J Fespir Crit Care Med 1994150:896 901
12. Thomas AH, Bryce TL. Ventilation in the patient with unilateral lung disease. Critical care Clinics 199814:743-73.
13. Pressure control ventilation. Nichols D - Crit Care Clin - 01 -APR-2007:23(2lt 83-99.
'14. Marini J. J., Wheeler A P.: Respiratorymonitoring. In: Marini J. J., Wheeler A P..ed. Critical care medicine-the
essentials. 2'" edition Williams & Wilkins Baltimore (MD)1997:90-91.
'15. Noninvasive ventilation. Barreiro TJ - Crit Care Clin - 01-APR-2007123(2I\2O1-22.
16. Mode ol mechanical ventilation: volume controlled mode. Koh SO -Cril Ca.e Clin - O1-PFR-2007:23(2J:161-7 .
17. C,onvenlional mechanical ventilation in acute lung injury and acute rospiratory distress syndrome. Ramnath VH -
Clin Chest Med - 01-DEC-2006.27(4):60113.
18. Mechanical ventilation lor cardiac support. Baikhelkar JK - Cit Carc Clin - 01-APR-2007:23(2)291-8.
19. Ventjlatory managemert in patienb with chronic airflow obslruction. Koh Y - Cdt Care Clin 01-APR-2007:23(2):
169-81.
20. Basic ventilator management: lung protective strategies. Donahoe l\4 - Surg Ctin North Am - 01-DEC,2006;86(6):
'1389-408.
Bird's Ventilator
nn&mi gfrfittg
rnialdruflrulc airc gnrt'r.:unvdrnrl$n".rrriil n.R. tgse lou ffl. Forest Bird f,e1uTu
finr:r{ruutaia.:rirufiru'lc Bird lfiu ruart drq {udlfinndqndo tvtart< zn {{rihrld'ir siro's
ventitator rflurnio.njrilnru'hdlsrlurrniunrulrn$qn fil'ru'ulrndqn rflurnlo.nirsflruhdfi
rltllurii :rnrqn rirminrur ldllo',rlfvrdoarusrnrnrti,crirrilnh{flr flSifual:finrr:.rf;otirtd uio
rirbr.n: qni'ldrtu {ilruti rfi nrJ:vluniqoqn
dnuu:drfiqlo{ Bird's ventilator
1. lflu pressure control rrfiv pressure cycling vgntilator ndllfiotdornSaof,fio p.essure
dde.rli inspiratory valve Qlfl oltnr expiratory valve l;tln dolfiunnurulfi ltnndr',:crn
PCV mode
2. rflu pressure guarantee d''rriu d{do{fiofirl tidal volume loltd spirometer odr,t
;ria uiua z nir vl srio undrutfi r fi :lrrL fi ornr :lrinod
tunrrn"*t Bid'. u"ntitator do'luiurccnd, rdr setting'lu eird's Mark z rvirrfu iiofi paramaer
setting u"r{0d1{lfifieu vcv mode 6o peak inspiratory flow rate rl.|noti1,ltt1fial PcV mode 6s
inspircd pressure Tounr:q"{ Bird's ventilator'tfinerntr pnase marnioltilufirule d{d
Trigger
no'nnr:dtuiurdurn'u conlrol mode unv PSV mode flrtq'luriroiurunr:trv',r trigger lu
vcV mode) udlu eiro's ventilator tnuiirLtrvtrldtovrls pressure trigger nilusu Inalfinr1u
Bird's Vcnrilaror @n?uni nfrfirng 331
ztlfi t uaa't Bird's ventilator gJfr z uanvhuni,tn u afianla,t 1maufrttz1
yd s uaa,ta'tuni,tnnit tigg", (unnudt-,1 uflJn1lpfn trigger TawJiu pressure tigger 'lrtld
ir lru H2 - 1-1s rx.it Ia ugh fiudnhooqz frrtaundy dnrtaalud^t duntznta'ledt
332 rru.irrininqordl1ru
i!!!nu trigger dm;a{vrr'rdrufioaot{n% loa:Jil pressure trigger'hfld:Jtlrru (-)2 - C)g
mr.rir lnaq'ir r{rduriroolvfi douno':.l6nriaa'lurir.lrilnr:rruh rdr
Fi02
no, frd.rlu Bhd's ventilatorloudrulndrilu Fio, 1.0 mtrlfi.loon0tcu 100% uns air-
mix ruufit oonirouu?qnfnrnrtilornrqornnrauon dl:lo'uo.l riq i{:Jruldriu dudu
pinspiratory flow rate rfludrdry ndm6a fir inspiratory llow rate {il'lao:daonru'h6',: ror
a1fllnqlnRluuoflri'rmatnlun ririfi nq dtdofr fir inspiratory llow rale oir {ilrul:vruhdl
ro'10'rnrffrlnnluuonrdrrrotnnlrirrn rirlfi riordlddaufr.rgl uano'tndflldadul dfiornoio rio.
d{rnuld;u niu tidat votume, dn:rnr:firu'lc fit tidal volume 4oniadn:rnrtnralurn rio. fi
Idovntr fir tidat uotume rjoun?odnlnrtralqiau Fio,dtddoufi.t{.:1un:rfifido',rnr:rJiu nq
lfinyr6unn'jrnrrld air-mix orerirldlou'ld air-oxygen blender iildortduufllu pipeline filflu
oxygen !!nJ air rirlfiourrorli:.r rio, ldnlr6unlrndu na'nlunrflli! Fio, ii:runct6uqnju
rdu'ri! controt mode uey PSv mode flfigniofimunlldl Fio, 'lu vcv mode)
gas iolrnia:rrfiudr'l:foi i"riur-rrrui*rirriuelariooTtrRTqzol:du1 rio, durjuould o'.rriurdorirnr:q:?? arterial blood
gld I uoot nir-^ix (untoudtttl uf,t air orygen btender
Inspired pressure
nr:crs.t inspired pre""rre lu Bird's uentilator g'tl'nnvr'rldloulrluunu:Jiu inspircd pressure
doo{nrwlfiatotfinl lnurlfulfildi tidal volume rnrnsrisnrflto,ltJoouo{a; ::mr 1:ru
o;r6uolfiqn'rair, unrtdt tidal volume lu vcv mooel dliclnu spirometry taruoiariu expiratory
Bird's ventilatcr laniuni nfrftslg 333
valve nl:fr\: inspired pressure ?o\t Bird's ventilator usu :si,:adrtri peak inspiratory pressure
(PtP) 6,ufl{rnsild?rnr{rd6iinrirrlvrri 1ilifiprfiu 30-35 ril.;1 rfroflo,rniu barotrauma 6raro
rfinduldn'rn peak inspiratory pressure g',:rfiu
lrln'rfil{u inspired pressure filflfi rlilfiu1unil1d1ur.rfir rdrrrn'r{rJfurnio.r; c:r:llfi
ld tioat votume riaua.,r fi'rnr4rl fr''u1ln}lur.rdrundl (fi{uaanr1nfi"tfiililrnlo.r) c:frlfild tioar
volume lfilrdu
strtli uoa,nhunitnz|fu,hspired p/essure llunnufrtttl
Peak inspiratory tlow rate
n'nfls'r peak inspiratory flow rate 1! eirC's ventilatcr ourrnri{fi'lnunrlur]ulil{iroqj
vt't.td'rl:.luto.:tnCo,: 1:rrn:rdrolunrlJr"u peak inspiratory ttow rate higllnrroilrflnllFrs.,r peak
inspiratory flow raie'lu VCV mode) niu,:noihjorm;n irLaanmrfluir (value setting) ld unc
lrintrr:nnhuuo;:Jdrr (configuration) ldrdurdurnju VCV mode nlflJiu peak inspiratory flow
Pli e uaawhuu wzi,t peak inspintory flow rate (nrouds12)
334 ntuhrinrSnqadugru
rate fufiatfietnrl l:E nri1160 peak inspiratory flow rate q,r grrlurlmJiurvrr'rdrufioao.rf,f,l
riottrluvrrurfilu'tfinr) inspired time o;#ulua: expired time csflre firliu pe€k inspiratory
ftow rate n'r 1nr1u{:.r:Jiurrrr.:l'nfiolo,,r{mvt liot,trluoltrt{rurfin1) insphed time c;u'l'l tto:
exoired time l:fru
Controlled expired time
nr:srs.,r controlled expired time tu Bird's ventilator orrr:nriifi'lerun4ur]l:Jil6.roqirrt
druair,:ro,lndo.r'lu Bird's ventilator riubjorl'r:a#to'mmnr:muh (respiratory rate, RR) lousrrn
ld fioorlillouvrrtdoulnunr:m&r controlled expired time unu d,:rfunr:oi,r controlled expired
time 6rdo,rfienrua'n:1nrtfirflto nrim6o firnso controlled expired time du lnrlurlu:JiilrJvn,l
drrfioml{ore.r rionrluurut6rurfinrl t'lnrmu'le oanfiec#u il'r1{a'n:rnr:nruhr{rlsu firn','t
controtted expired time trr 1rr1ur]lrJiil:hrwlfiatalfin"..t niaurlunrl tilulfin'l) !?a'l
firulqaanfic;um rirlfid'srmnr:vruhfirnr filfifioo::i'rfrfioorjrqur]r controlled expired time
\.hr,rmrfiaqoouqe (ot11ou rflv{1;'tur!ilrtLfirn ulo l5r tdo,':qrnfirfirJrun*ror:evrtr'lc nr:finr1u:ll
controtted expired time luqo wirrirers'rdor:rnr:nrt'lorfluqud rnio.tdruvrulqfio;Li6ornretfi
dr {rJT u raa ri"rlfi {rhuuqor'rrulo
fli r uanthuil,tnttfr,t controlled expintory time (unzauilttal
Positive end expiratory pressure (PEEP)
Bird fl'ur1ln apply PEEP Id lna'l$ peep valve Toru apply fi expiratory vatve t$'lu{rJru
dfiflryvr nypo*"ria'[u diffuse atveotar infittration nt'ld rio, uurngrtrdrlrino:.rcua.l r:iu aaos
lfifrrrrnorirnruuald apply PEEP valve ttfi1 tduuvfirrlnlv\rjrrnvdqlutiludrtnrrv,tuha0nq0
(end ol expiration)
Birrl's VenLilatrrr Mniuki nnfrHJf, 335
pli a uam ceee vave d,t appy d expiratoty ra* pli s ufrfl\t prcssure 'luthwultaanqa lend
of expiration) ddnlduadnui
lurr.ronrudfilrifi pEEp vatve ursifi:Jrumufufisr1rJd1rfrufia,rlfi pEEp ol?:J::qnfileru
rdaarudcurrnwr diri:.r expiratory vatve ldvrod un:qrn,rtumnrir r:d'lrornrui4rnilr.nih
fi n rvi,'lo fi o; rfl u pEE p d {il? u1df1lfl u rr.u*r 1mn{rJr abjldr.rr uir6.ru rndo,rl
n1tuDfl setting ro{ Bird's ventilaior
riaurirnr:'ld spiromaer nrlirnr:t6q:.r?r?fu oonnector Toi spirometer d?uuannoaadriou
r'fiiaonnr:uyrdrdo
li1. uon FiO2 fit'fi'j,l!flu 100% oxygen filo Air-mix ntan:nifrlfi air oxygen btender
:ron Fio, d'ldd'ru
2. lon tidal votume filfi lqan't:ld spirometer'[ou appty ir' expiratory valve nr:lonrir
tidal volume funr:lon rflurirradu rdo,rcrn tidat votume frnld'luuoin; respiratory
cycte riulrilvirriu 1ou4ra'r minute ventitation (rvrq t{rfiortfirrnr{o t urfi (r{u15n)
d'oriu{rriru, rurir tidat votume ldmn MV/RR
3. lo RR to{tnian fnuda{?"n 1 ulfi (0ni61:Jil5axfilnr:r"orir minute ventitation Id)
4. uonm l:E
b. uonrh pEEp
o. uonir monitoring rir.r1 lduri pressure trigger. PtP
tntm# uno,rnr:rfi aurird,:nr:inur'lu{rt, a#ld Bird's ventitator
1. Pressure trigger
2. FiO2
3. Tidal volume
4. l:E
5. PEEP (filfi)
t'_T
336 rrtrjrriorinqmClgru
lnufinnu parameter ri'r.:1 oiolld
1. Keeo PIP lrirfiil es tu.tir
Keep tidal votume tfiogtudr{ (n'l lung pathology)
Ke€o RR hilfirflufrniosiourfi
znr:r# urooertusou'lunr:rli! eiro's ventilator
t. oi{rll sarting elfort (trigger) rrldrudrflfiolaunia'r'hia4fifio zo
2. n3'r r prassure limit Yn.rdf-lu!'tlfiato.rrnioilfio{fi6n zo
3. ldbhflodo.rd1ilirlgoornrnnruuantdrl nror.r lair-ri*; idoglfir]r st"rting ettort rdolfiffrsiir{r
dfirlT uriuoonirru t 00% drrirtu:rrd'lrintr;r'rio.raoniterrlutrr{ liritrrrio.rftirdolfiffrt
ufl us oni tqufl o! fi'!fl 1fl 1ff nluua n
+. n4ur]*r inspiratory flow rate iioqjdruluvntdruurirlo.:lnia'rlioglldrttvti,::Jrtrrru 12 urfinr
s. riJo:]rnrrdr':ruto':tnSorfioqjmr'tdruru
6. r-!4r controlled expiratory time d0{dluFil,:fl1,:firurrirto,:tq4o.1 louldnr:fi'lrfitl,luralctfir
aanlfinur:gr ldcrdrurrotnultosnsrr ::rrru z rviraolmru'lor{r, l:E = 1:2) rtn*fi'tfia'nr1
nr:ns'lq t o-t s niroiaurfi
7. do nlu{1ttln?o.'rdrlmrh r{rrYr-rriannoonlaat{rJer
8. ld spirometer iot tidal volume d expiratory vabe d.:og lSteru oruarutaio.:rirurru'lqdaun't
riornonnrto,:{tJ'ru Ioa tidal volume rflulrJqtrnurfiRnrdu an
i'rdo,:nr:rdr tidat votume lfi irlr pressure limit lfirrndu rrsido,r:ti'rhjifirfirdvriri]q:rot
rnio,:r*ulil6,: rfi uin es rr,ri,
firfio':nr:an tidal volume tliilitqeiJlurr':rloan't loruarqdo'rilil:]u inspiratory flow rate drrfi':a
ry; r0+luf rLw6-dnd.2u11n1n1fl41tiILcva[14'lvd
n rnJffu rnrdo*rqir smr atoluT:nuton rev rir rrl
nn?*mi gfrtitxg
tunrnllurnio.niruyrulonlryrurimnruo.:tJoo:J:ymrn'r.*r1orluriuJrvmuro.rilosldrT.td
t. ilonrlnfi (normal lung)
2. ilonilo:JflA (abnormal lung)
1) Obstructive lung disease uulfflu COPD, astnma
2) Restrictive lung disease
1. Diffus€ lung disease ldltri ARDS, cardiogenic pulmonary edema, interstitial
lung disoase
2. Localiz€d lung disease tliu pneumonia, unilateral lung disease
3) Oth€r conditions uiu metabolic acidosis, neuromuscular disease, increase
intracranial pressure, intraabdominal hypertension
:lasilnf, (normal lung)
rlooilnfi tuiflilldnlrun-,0'ir{:-hur.Jnfi urinrrrun',r{rJrufinm:rfinilnfiro,rrvlrdu udfio,,r
ldirn'rr1dviorirunru'hun:rn3ordrurru'h niu {rtrufildfiLalfiuturn {rJ'ludrfrul:nral
rv:.lu:Jr;crndrunnr':
nrrftralo,ld':unrglctuftJrundilf, nrrli controt mooe d.rorilf, vcv mode yia pcv
mooe flld lnu#rrflu trigger rJnfi lf, nq o.e-o.a ld tidat votume n m 8-10 ln-/nn. | : E
:Jrvuru 1:2-1:3, dslnrryrulc to-ts ai.:nr.fi frd'lfid.rrnn'iro"n:rnrms1crjnfirfisfi:-hu1d
laio{tirsnru'lq lrild zo ni.rrurfi odr',rd{llerurfu
338 r:mirriainqnfrunru
Obstructive lung disease (COPD, asthma)
nurBonrvrddrfi'rglu{:J'ltt obstructive lung disease 6o lower airway obstruction 6'l
orfiflqnrturirrnrlrrulcasn d,rfio{tdr;uct?n1u1un'i1!nfi drlfrnrdi:-rrndootirarru'lo'luf,:hu
n4ldr{0.,r}irrnrlunr:nru'lqaon'lfi rfi u.lt{o fi avfue: rfi n auto-PEEP
nnr6iato.tnr:tfl n auto-PEEP
t. nlvruloaonfirr rir'hi oeao space (vd) rfildu d,'rna}iffrtnriuou'lnoanltdd'.,,:
z. fuJrurfrarlfi work of breathing ludr,orirfiun'r:nrrtorf,r rirlfirr:$fiot'ld'lun'r:riia
inspiratory valve undu
3. ftlfi fi n barotraumas l6crnnr:dnldr,:'lu:Jofi
+. dr'lfinruo'u'ludo\trl?.Jan (intrathoracic pressure) rfir.rdu ri,1fi u"nous retum nqfl{
dr!.ra'lfi cardiac output nod{ uavrfionrrln'uTafino'r (hypotensionl lu{rhudfi votume
status !nfi niolu{ilru relative hypovolemia
Flow
tSttii uaat non-time curve Iu n. vCv moae iifinti,t flow wavefom tflu square, hatf decelenting.
totat decetenting wavetorm ntxi.n'u uflt s. Pcv mode fwldiqnduqnnounu'haan lend
of expintion) ftow nautna'loaanqnlilunzfiXui uf,nni1fr flow miafrxaauda,tntahaanqn
druan,tanuanat auto-PEEP luinudutJttdfra xaq dnlunlnn frnffiu.nnnztcldlaantt
flt#u,taxvlu1q1utit,tn'ta'leaansn (end of expintion) fi,tIauJn6ufuwfra,iifrRuffiun1u'lc
ludutnu'haanqn uonotnigtttudfr auto-PEEP cfintz'lfind'lutdarhanlmlulqlud;uniz
tian 1 m t u'lq tfi u t n n i ttl n 6
qnlr iulnfa\rdla luloluTrnusonmvn'r nniunl qfifitvg 339
lru2?'Nlun1fl lfi I reis.rti,rs$r uh
tu:rudrflu copo with acute exacerbation dfi respiratory fairure ar:rfionrflu noninvasive
positive pressure ventilation 1rueeq nrnlrin'dofirltunr:td lun:rfifiLjfirniao t',tppv tfirilrrrur
ldriarirufirulo drun:ddrflu acute asthmatic attacr Sfi respiratory taiture nr:linr:inurTau
nr:tdviodrauruh
1. [/ode ln{a,rrirunru'le r6on1d mode '[ofi'ld' hjirc;rfl,, vcv, pcv rio psv
mooe odr'r'l:fifir:'J,onor':tf pcv mode qvdlhl peak inspiratory pressure (plp) oon{ usidarfiu
?o{. Pcv mooe doirn'rplu{rtrunq'rd6a ::o':.r tidar votume lrin,:fi rir'hinrrarryo-lnriraulo-
oanlrd'lurfiaoldarn {rj'iunq'luiiilqfi'r air trapping dt rilu oead space drfiuurTriffie:rirlfi
nrfuouloaonlrflu16oon"raqiudr fidanr:ff:rnnjr::n-u peak inspiratory pressure frarluftJru
nejlflririou rflud'un:ruriio rfi;Jrniun6irJ restriclive rung disease urn prateau pressure lddr
z. rio, nr:'lff1firioufiqn Mrdc;:"nur:vn'':.rro.,r oxygen saruration lfiodtudx,r s8-92%
lnurarr;'lufi:-hr copo rfja,:lrnrjootor{rJrunrjrdrfl!n6jr chronic tung oisease 6,:fi oxygen
saturation n0il'ctc'1'1ffll ventilation-perfusion mismmaattcchh !!flJ diffusion defect aajttfir sirutu asthma
olirr oxygen saturati on ittzdl g2o/o rdo,rlrn {:_h a n { rdilortiln6ilr ri ou
s. d.,t tloat votume luluretnh tr!1fu 6-8 ln.inn. niorioundrfir,l'tiu uiioio.rriunr:
rfio auto-PEEP rdomrn{rhunnjldnrulcaanrr'rurn nr:ki tioat vorume lusu.rofl.,royn{rirfiq
orfir.:lu:Jonmndu
+. fr{ t:e lorstfi expiratory time amrdononr:lfio auto-pEEp lqu
1) VCV mode riildTntnrrrdr peak inspiratory ftow rate rdo'lfinarnr:yru'terfir
#uru drlfi rrnrnr:nruttoanurudu uonelndor r:ntfilt dl\: (configuration) fl oi
peak inspiratory flow rate tflu half decelerating waveform tia square waveform
rdatfi::u:rrartunr:yrulordrdunr od.r.rl:fi nrrfior6utornr:,rJfirflu square
wavetorm 6o peak inspiratory pressure ey6[{rJ.tn otirol:finu'lu obstructive
lung disease 6{1rn:nfririu tof"t Oecelerating waveform ldurnd\: peaf inspiratory
ttow rate lfiorrfiurvro
z) pCV mode rirldlounr:rl:"! t:E Toun:,:
3) PSV mode lirldTounr:rlil expiratory trigger sensitivity lfiq,:lrnn.jr 2lo/o rfia
ir:rirtri ttow fi'or5'rrsu rflunrntri inspired time fun.o rhlr{-tioal votume floa.,
d{tiruasnr:rfio auto-pEEp
s. o"n:rnr:rrs'la da.rnv.,rfrrj:;urru e-tz oi.rdaurfilu{:Jrldnruhfirr{udrirrsrioo
d',rriurdofr.,r tidal votume sir lrnva'n:rnr: ralcdr i,rr"r'hi minute ventilation nool ridriffrr
nrfuaulqoonlsrin"{ drriunr:rJtrrndo'rrirunrulclufiilrun{liifl,rfiaruartr{flrrnrf:roulooonlsd
i{ r?un'jr permissive hypercapnia lnlJuor.lfld pH 1nn'j1 z.zo nrn{,rJrunrulq rirn.jroer:r
340 rrtrirrininqndugru
ra.:mCo.nixumuhdnslli ortfin.:tn'rrfludo,rl$ sedation 1r1,0lruarefintrll,irrfludo,o'ld muscle
relaxant drudtu
6. nr'ld extemal PEEP 'li'1u{rl'ludfi auto-PEEp fifr wort< of breathing 'lurir'':rilnr:
yru'lerfir lnflnrltd extemal PEEP clri,ltli work of breathing fitfiqorn auto-PEEP noddou
lri.ldaqrurnra.': auto-PEEP at ri'.rrfuq'..rlrifinrlrlirriu6o.rld external PEEP 'lu{rJrufilrifi wort<
of brearhing drfiocrn auto-pErr rdu 1u{rhufr16iuu't sedation tta:fllfidoundl lrloouro'qo
{i.ilrifi worX of breathing iirfincrn auto-PEep 6nudr nr:st3o external PEEP tfrone work of
breathing fitfinrrn auto-PEep }i#.r:J::lrru 80% to,J auto-peEP fiinlfi
Manometer
Airway
obstruction
rc 0
epfr z uanu)aniln d,iifr lower aitway obstruction dnblfi auto-PEEP B. usaa)aadtfi bwer
airway obsttuction un auto-PEEP tfluqu[ mnt auto-PEEP rflu pressure iliuaa'td:.iitiin
c. uan,nlaod,tfr a*e( aitway obstruction frfintia auto-peep Inunrfln locauael expiratory
vatue Turit,tulultoanqa end of expintion) i'flfi tlow ti'rriugui it*tdannan'uhn{fiq,tau
ii,ti;lfi attln nia auto-PEEP Id
qnlr iurn+0{d?u$1a1o1r.rT:nu5onrrysir onfunf nfrfimg Ml
o 10
1?O
o!
.q 0
TL
i;-
==
Time
n37r!fi Ltflanirfrnan extemal pEEp'lun1ffio wotk of breathing fr6ne auto-pEEp tfrufryuan,tiitlla
fr7 ld'ld extemat peep 6ul6itiltlt,fratoanut,tt.tn auto-pEEp to to.i.r aoor tglri u^,
r,.itfra,toanffii figger inspiratory varve dn 1-12 vu.th zex tz
d,:frail# work of breathing
tatn du ttusa,tfi aaifi to-petp il*fvntilai extemar pEEp ufu $ulditfrtJzufr auto-
doeeee ai to rxsi.t '16! extemat pEEp s su.ti.t tlauaanuz,rqud,, s zu.i.t&dzi,t6,nzffino,t
diliexternar PEEq flsaanuz,teialau Hgger inspiratory valve dn dn 1-1e sa.i.t tzu z xu.rh
wotk of br@thing flaat d'tdulditntld extemat pEEp tfiuniloa work of breathing fifloetn
auto-PEEP
ARDS (acute respiratory distress syndrome)
nnos rflun{rornr:firirt#rfinnrr;rru'[clfls1:o io.loan6nu qhypoxemic respira.tory
faitu re) fi fi n rtr drn''4 rrn# ao fi rnrucilunr:ifi od'E, n-,rd
1. Diffuse bilateral alveolar intiltration
2. PaO4FtO2fiaunir soo @op.ulilldtd acute tung injury drrfi paoTno, frrjounir
300)
3. lilfi left atriat hypedension lntqldlrneir putmonary capi ary wedge pressure liou
nir 1 8 lu.:J:ar lfioj,rlonirlrilt cardiogenic putmonary edema)
In a n ai rotnr: nR DS d'a.: rfi on:uo rj'r,: rdulr n'u (acute onset)
ruu?xl\'liln1?:liu miorriasnr ulc
1. Mode rorrnio{tirufiruh rfionld moce lnfild uriflrfi uurlfirirorrrfio barotrauma
daiodr plateau pressure (arveorar pressure) ldlrnn'ilriorvi, rir eo tr,.rh riar-air peak
inspiratory pressure ldunn'irniaMrn'r ss rrt.frlu vcv mode arlrdon'ld Dressure control
ventilation
342 retrirriai n q nfrugru
tnrfl.:fi [cs{ tnrudlunr:if,cdu AFDS (Bedin's definition 2012)
l:u:t'ln'l ornr:rr,:::ruutu'lctflu rnrultr r drlqrfifr rfi odu'lvil niafi rrtia.r
lfluonsruvtiuf,u 2 dl{ (bilateral opacityl 1arlfio,l'hj'ld pteurat
I .,I n1?,tfi'tut0fitl:ull00
effusion, atelectasis, pulmonary nodule
I
da,:'lillrior rnqd rflu cardiogenic pulmonary edema ria volume I
flrrvqtornr:tfin edema I
ovedoad
Oxygenation pao,,Fio,, 200-300lsu'l$ peep Mia CPAP r.nnn'jrltiaMT nlu s tr.rir
1. MiId ARDS lPaoz/Fio,/ loo-200 Toulfi PEEP 1nnj1H6olvirnil s .rir
2. Moderate ARDS pao,lFioJ < toolnuld PEEP lnniiviowird'u s tu.fr
Severe ARDS
LJ
nrfl.:fi z rrfls.!f,1tflqlo{ ARDS
Dlr6et lung iniury . Sepsis (non pulmonary source)
. Acute pancreatitis
. Pneumonia . Massive blood transJusion
Pulmonary aspiration Transfusion related acute lunq injury CrRALI)
Pulmonary contusion
Near drowning Neurogenic pulmonary edema
Smoke inhalation injury
Drug induce pulmonary edema eg. Tocolytics, opioids
I
Obstetric conditions eg. Severe preeclampsia. DFIU, OB I
hemorrhage, amniotic fluid embolism
Post-obstructive relieve pulmonary edema
l i 4 ugawwriluz",tf,nzl,tomar acure res-
pintory distress syndrome (ARDS, frr
ufl n,tdntruv diffuse alveolar infiltration
'lutavdtu1ozaifiilq n6
qnlrriiurpCo.:dxor41alql lrnfitonrryuir nn?uni qfrfrmg 243
(un:dd'irrfluorluorJfr oxygen saturarion fi::li'lrrnn.ir es"z"y rfiaflatryulrjrflo oxygen
toxicity trul u'1rflfi Ro, rioun.j.rnio uirrir.t 0.6
s. dl tioat vorume ru1ngi'r rl:vrrru 6 rn"hn. iaqr'rni"r rfio:lo.'niunr:rfio vorutrauma
(venlilator associated tung injury, vnLll un'turr.:n.ifiorrda,Jnsr tidal votume g.ln.jrd niu 1u
{rJrufifi metaboric acidosis ria aterectasis daid':l lnsn3{ tidar vorume irrJ.rau 6-8 xa.inn_
Tnlrirru"niitd }fr'ld predicted body weight 1eew1 lunrridd.r tidar vorume fi o raJnn. ufir r-n
plateau pressure ldg.rn'ir ao rr.rir 1r5ob'1fi peak inspirarory pressure (prp) rfiu ss ril.f{u
4vcV mode vSohiifi ptp rfiu 30 ru.u*r'lu ecv model o'leflo tidar vorume nrurldfi,r n"inn.
rtsifida nr:r yr"{'jr oro rfi n hypercapnia rr nt*u
+. .tflltn, rc desaturaiion Tnrnr:ts peep ftfrsr'-r pEe p finrrr:nfnurrvo'lrro,r oxygen
saturarion ldfi 88-92% lnuri ern pEEp 8-io r:.r,u*r rfiufinc z-s ru.ri', rn s-rs urfi ldrr,rir
{rdurtrqarcrJfiifirsrn'ird1r:fth'tfi prateau pressure rfiu 30 rr.rih lnio!.r1fi peak inspiratory
pressure (prp) lfiu ss sil.frtu VCV mode vtolr|'tri prp rfiu so rrJ.fr lu ecv mooel vrsed
lfiannudr lung compliance t!flr respirator graphic monitoring 'lunrr:Jil pfep drl
etfr 5 uan,tnatar prrp fifidan,tsx (atveofi dfiu lnos laa peep otillrtnoautstalutniu itlfr
exudate uaj transudate
iirtnlzuanLu,f2la--u3nlzoltu
lun,taxo dwvuanwlqtax dau'\frfr atveorar ventiration diu
5. a"n:rn'r:yrule ntrdaudr.rr5r :l::uru 16-24 ni.:oiaurfiniorrnnirdfirohriu rfioir4
minute ventiration lndriil.rrfir rdo{ornnr:srtr tidar vorume 'lu nRos rc6"dugu,roiin'r
o- lunrrfin"rftlriarurrninrr:;o-unan oxygen saturation ld firrurnr.rlunr:inur ri:,rd
ruiJirf,uorirr1rr)nAr5tvreolfliarnrorleacrr.ruait'm:1enIot umldaanerru:vldeur rruflruonnrr:':lu"nnrrr:rfifdlord(frie:c:dru'ilttmaelnto)xnygrnenr saturation
dtour:n
344 rrtdrrininqnCugT u
n'rldrf.rlu spontaneous mode !1fl3 control mode irliufiuUdr aNeolar recruitment'lU control
mode lnettolrv'lu pressure control ventilation
2) Inverse ratio ventilation vn'nnrrfia'}1lrarn1rfi1fl'lq r{'lil1udu 1nniln1lflluhoon
rir'lrtoan6pufinrrtlantilAuuldil1udu rir'hl otyg.n saturation tfjrldl uo:nratatnt:ri inverse
ratio ventitation rirlfi::u:trarnrtr,truloaandua.: rirlfirfin auto-peEP dsorr.n:nrirlfi oxygen
saturation rfrr.r:tau uancrndli1'[fi mean airway pressure lrfu'riu ri{fi oxygen saturation lfi du
Tout'irll{rteufinhjorrur:orunrrrrulogrJ nurftfi irfinrrlldtfludo.:t$ sedation LLdi muscle
relaxant 11.1'lnq,l
nt: 1 inverse ratio ventilation d'uJ'nnd' d19u
1. VcV mode fl'ltJllntfj inspked time'ld1nunllna peak inspiratory flow rate fl'i
trflctliu?tlil,] (configuration) 1o.i peak inspiratory flow rate tflu half decelerating
waveform ia total decelerating waveform uon1lndET,tf,'llJ1:ntfi! inspired time
Tcsnr:td pause time (plateau time) trliuurofi auraruttrdr rrdrn#ulod,:
2. PCV mode aurrntfir inspired time 1nufl1?:.15! llE
3. PSV mode orlr:ntfjr inspired timeldlosnr:liuno expiratory trigger sensitivity
si,:llalfi lnspired time tfiunsurln: tidal volume tti:ldu
3) Prone position 6an1:do{rJrulia{turiruounir tdollnrJoolatnurJnfio{nrldru
ra.:rJ::rrru z lu g drl rdo{ovir{:Jrulfiuaun.ir :Jooiio{vrrrdrunn-rfiqy6'ura{nrodrurrir
orn.lfileudn6fio,JnorLl*udrulu or''.lusunr:{n{ilrE hiogluviruounrtr 6trflunr:no ventilation-
perfusion mismatch e','rrir}i oxygenation 6du nur:n*filtnmc desaturation ld odr.:]:frn1r
nr:{o{ilrutfio{luviruouni, riufifiant:::i.:rotutl::nr: tdu viariruvruhrdourqo nr:go
ror.ryyrirldu.tn.i.uln lrjorrr:nrirldlufl,:-hadfinoornorfnr:lnarluurfiaohin.rfr {r-trudfiitqr,
6 x'1il a"ulud D.l fi o't g.i
4) Permissive hyperoapnia tflunrtaoulfiffrzariloulooanladniir'dt,,4oo1 Touao fi
pH rnn'j't ioMln-tl 7.20 tdotli orygenation 6du otirtl:fislrilnlfli"t permissive hypercapnia
fidonr:r:itrors rvnr: niu r'r'lfinrrildulunclnnnd:l:4.:du rir'lfitfio respiratory acidosis
rir}hfiorornr:'i'n ri{finT rln"uTafinn'ra.t 'lun:rfidfi metabolic acidosis oqjrtdxnl:illiouht Paco,
6'.lc:ri'rtfilfi0 acidosis ?u[t:,:tJlnriu fi'rdrliiufia,:fiontl:v6'tl arterial pH uflv Paco, odrttnfifio
nr:f, amrfi T;i,r{rleudld eeee
1. oxygen saturation rflufitiidrd'cpdqn ldo.:rrnmqnnddo.rld peep'lu{r-htr nnos
rds.rurcrn desaturation o\riunr:lsi ef EP 6.rfiloriwlruiilir'lfi oxygen saturation niurtu Inu
ri'r1ilnr:inur::n'u'tJo\t oxygen saturation lid goVo (88-92o/o\
qn.r: iurndo\rrilr,r4,rahlu1rau?onrroir nn?uni gfrfrnn 345
0.3 0.7 0.9Fioz 0.4 0.4 0.5 0.5 0.6 0.7 o.7 0.8 0.9 0,9 1,0
PEEP cc
8 10 10 10 14 14 14 '18 18-24
Consider Lower PEEP-Higher FiO, tabte.
l
Assess "lung recruitabiliv"
H20?
2. Increase PEEP 5 * 15 cm H2O:
2. I Dead Space fraction
Yes
Consider Higher PEEP-Lower FiOe tabte
Fio2 0.3 0.3 0.3 0.3 0.3 0.4 0,4 0.5 0.5 0_5 0.8 0.8 0.9 1.0 1.0
24
PEEP 58 10 14 14 18 20 22
i..runfrii uan,Juuznli'lunni,t pEEp Iu ARDi a1N ARDi net trial
2 Hemodynamics lerutanr: brood pressure fi'rn brood pressure srin. do,t6ofilfl1u4n
n,a..rtlj.uA
1) Tension pneumothorax rfluarnrqfifior6ofi{rola ificdu'ld'Toflnr:o:rodronru IFtEJ
nr:srrm'ld tympanic on percussion dr:.rn-!ldu{ breath sound nnardrrfioafi nt::-nsr6o
nlrld intercostar chest drarn lurjr.rdlfin pneumothorax drurJ:; 16uflrpr,trd.irqr6o,:no peep
r'16avsonr:ld pEep vio'lrj duaairfu'Jr eeee dtiogluusuvriufi:-r:rlatrflunr:urarr;d'!oanfireu
tura'oeriolri ln pEEp lfufi:J::luuilunr:rfir oxygenation niu lu RRos rfrolfio tension
pneumothorax firrtodr.ovrio[a;trinr:innrlnanr:rir intercostar chest drainage ufir ]riar:
rirnr:ooviouun PEEP lfio.reln' oordr.,rfi'trjrfio pneumothorax r;r]utirdarnr peep gijatir u rfir
j:o"tt oxygen lur6ono{ nr:drnt:oo tidal votume flu vCV mocel u3o inspired pressure (u
Pcv mode) rfiorirnr:nn prateau pressure (arveorar pressure) a.,r drl:rir'hiilqdurdu.reionr:
tna barotrauma flafl{
2) Felative intravascular volume depletion rfia.larnnrrtd peep cvrfj nrr outu
tio'rn:trsn (invathoracic pressure) drlri u"nous return flffn{ d.rcyflilfi blood pressure on
nT.rrr-ld nr:fnurbildnr:no:rnirron pEEp a{ rdorern pEep rirr lril.r oxygenation ud.: nr:
rirnr:inyrdranr:lfiar:rir rfia rdrrrilrucr:fr'lurnaa rfiooTnulfirilnfin fruid chaflenge test
rfia.rcrnnrr'tficr:ririlirrrumnnSolfior:rir:rn 15murfiu}J r:n"r1fior:utrusuir6rrdtrr'luo.:nr
drhinr: uonr:1fi !uff rsuda.ild
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เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care
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เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care
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