เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

346 lrtLirrininqnfrlgru

3. Peak inspiratory pressure (PlP) lun.)rld peep riu e:drtfi ptp gr:du rdo'llrnnrrld
pfep tvrirlfinrtrd'u'lu:;lugwiuri.rludr,rnr:yruhrdlunynr:rra'hoon lrildntrtnrtrn'u'lu
::uq.rdu'luri'xnru'troonqorrirriu dhiu::d'r PEEP iildrfrilfu6ililnr:rirhi PIP tfiiltfiunil

rirdaorilld nri'n6o flrrflu'lu vcv mooehinrrtri PIP tfiu 3s rl.rir drulu PCV model!

nr:'lfi ptp rfiu so ru.ri1

4. Tidat votume lnn PEep fild'bJrfunur:odrlfiqlordrutnqiriJnld e:rir}i tidal volume

rdldu doc:fili oxygenation 6nru

5, Chest x-ray 1u{rlrudldi::nr:'ld pEep rir1finrua-u1urll.:anlrndu lvrir'trirJon
ooru rndu culr{eti.rgrafiol'ir infitvation'h aonqn'tlfirflaocrnfiatJfir trnoolnnnntu uoncrn
dnrrir chest x+ay ti.:rflunt:tiruificduttn:tflr:vr-t barotrauma dolqtfiodu rdu pneumothorax,

pneumomediastinum

6. Arterial blood gas lqadrltlvrnnr:'ld prep riurir}i oxygenation 6du dlnrnlfirir
pao,lFio,6rsu airurir Paco. usu arofirirrdrduvionon,rfild tl*uaqifi'r.l'irnr:1d PEEP liwritfi
alveolar ventilation r dtru rnl ntlulr.rd rfi lt*uviono a.r

Cardiogenic pulmonary edema

congesiive heart failure iififlryvrlunr:lruh rin rflu tett sided heart tanure d.:rir'lfifi

rirfi'.,rlurlonuo:qra*: vnnnrrldtnioorirufiruhfivn'nnr:niut6urniu nRDS rfi rLt usi'lrjfio,rlfi pEep

lururodq,:rrn lrfioun-tL ARDS n'r:td prep lu{tha congestive heart talture fiil:c1utfda
PEEP qvtfirnrrun-uturio,:lm.:an (intrathoracic pressure) lirhi venous return nont d.:nnlfi

cardiac output niir.rduoltrn4to.r Frank-Staling 5.:rirtfrn'nld'ulnfi qrdldu

rrfiirnurionTtrdrjoo1|o.,t congestive heart failure tld; ARDS t:tflu dilfuse alveolar

infiltration lvfioun-u rusi'lu nRos riuq.:nlq;rioldurnn'jrtfia.:crn pulmonary surfactant flon\t
6rrir'hT1u nn os riu fi o.:lfi e eee'lu: ; o''rd 6,o n'j r

Interstitial lung disease

nr:r]i!rnio.trirumu'lqlu interstitial lung disease ueu fiva'nnr:t'tiutdurriunr:rJfi m6o,l

rjruvruletu ARDS un'l$ PEEP'lu interstitial lung disease riubifi:L::Iutri tfja.tqrn PEEP q:
(alveolar lesion) rvitriu nrrtfi PEEP'lu
-ldtarr;:ouT:ntuqtnl interstitial
rufibnrr: desaturation

lung disease rio'hirfinrunufifl6o tflunr:no perfusion lu interstitial lissue rirtti ventilation-pertusion

pn:,ldu r'rtfi hypoxemia lurnodu uonelnrilrnr:ld PEEP titollriotfifin barotrauma ld

rdo.rcrnlu interstitial lung disease q.ror. riarlr':oaurun'r1fi6 ltow compliance)

q wgn1:UffJf n€alrd'lsfi 'raloluT:nuSonmysir M7
nn?unf nfrft

oeirtl:fiolu Yln1IU1BflJr'r1,'/fi:Joerfiu interstitial inliltration d'trn-:.r atveotar infiIration

alet{ PEEp tunrrrfjri oxygenarion ld ugifio,riliL pEEp lfirfix'tyflrrrf:rfi:Jruusiny:.tr.l

Metabolic acidosis

nllc metabolic acidosts rfl n1l;ii'firfioorrflun:o nr:rjf rnio.:riruyrutqlunrrldfiar

rli!rndo':tiruyrule'hlfi minute veniitation irfiu.,:yrofio:snrrurit, metabotic acioosis riulfi

umil1\r'lilnfi :JiJ rn4o.orir dmuk
1. Mode ?o{rnio,rdrflfiruh r6on'ld mooe 1nfi16 lil.irqcrflu VCV, pcv yia pSV

mode odr.rl:6nrlfi:Jru metabolic acidosis d.:urr:,rfinfintrlda*rnr:tunr:tru'lo (respiratory
drive) q.) 6.rnr: fr-r controt mode aTofiflrynrir{ilrur.rru'hlrirdrrnian (patienr-ventilator

dyssynchrony) lun:rfiduu:rjr1ri1.fi PSV mode lou fi:;o-l pressure support 1fi6-ordoli-ld

lldal volume frrfis.rlro

2. Tidal volume fia.:dr high tidat votume Ina'lfi minute ventitation ad::yirl 12-15

ftn:rdaurfi niaorolfi minute ventilation trnn'itdlu:rtdfi metabotic acidosis fi:uu:t1ounr:

tl:":.r tidal volume riDu respiratory rate tflo,:crnfi ru metabolic acidosis ytutqrrlu Kussmaul

lh;breathing fi.rnru'lelould ticat votume rrn Toudo-n:rm:y1uh1rir51il1nu-n Toflrad rru es

ni':siourfi Inurodafirh! metabotic acidosis da{n1: tidat votume :J:; rru ooo-eoo tlo. lu

:rud:urr:,:arqfi o\tn't? tidal volume lrnn'ird

3. 9- l:E Inan"rlfi inspireO time u't?n'j1!nA unrltfi:-hu metabolic acidosis dyru'te
n',r

rul! Kussmaul breathing o:rnru'lolnu'l$ inspired time urr orh.rl:fiorlr{:Jrsnrir.rdfnda,rnr:

inspiratory ftow rate 'lunrmrulordriiq.rdru o',:riunrd:1-r t:E 6,:do{rior:rurfi1 n?1 !fi11i6[rJ

?o,:fiLleulrpinc:ru

+. nr:d.ro'n:rnr:nrn'h irfipirr r5rn'irrjn6 ::rrru to-z+ n*oriaurfi bifiartr"l'lfludoo

n"{dq:rnr:rruhfi.) so-ss ni.,rrjourfi fir peak inspirarory pr"""rr" lrjq,r

Neuromuscular disease

l:nlunojld riu myasthenia gravis, Guillian-Bane syndrome, amyotrophic taterat scterosis.

severe electrolyte imbalance (tiu hypokalemia, hypophosphatemial fiilrulriour:nuruiold
druoura.rviofirfllelfifi0u fi LLurId unr:rfio atelectasis ld'rn

uurnr.rlunr:rliu rnia.nirurr s'le
1. l/lode to,r ln?a{rirufi1u'le nr:rd'on control mode ltiu vCv mode yia pCV mode
rdarcrnfi rEry'rfltcroilrildy5ofiruioldriou dru psv mode ar:rirrrtsldoda..:nr:rrirrnCo,:

(weaning from mechanical ventilator)

348 rrnitininqndugrl

2. Tidal volume nlrnv{'t{ iidat volume rurnfll lnu'lfi tidat votume rhcrJ'trl.t 10-12 rJfl,/

.[6i1u

nn.nio,rtrn{:Jrufi rrurlfiliiqt rfio lower lung atelectasis
g. fr.t t:e lou!tr inspired time urrdurfinfiou rda:latriunr:rfiq lower lung atelectasis
1. VcV mode d1x1?aldu inspired time 16'lnunllno peak inspiratory flow rate fln
rra::Jil;rJdtt (configuration) .i|o.l peak inspiratory flow rate tflu half decelerating
waveform flio iotal decelerating waveform
2. PCV mode il'llJ'lsntfi inspired time launr:rlttt l:E

4. PSV mode crtr:ntfil inspired time lfiTounlT r'!no expiratory trigger sensitivity
ei,rno'ltl insoired time ld duuac tidat votume tfildu

5. nlrri.ro'ert'rn1: T ulc #{'lud'n:rdndrj::urru t o-t s nf.rdourfi

Unilateral lung disease
nrrrirunrahlu{ilrufi fi Unilateral lung disease

n1rfi:flu1:nd:loof,1irfiu'rc:d,'l ndonrr:jruvrubToilflt'r\Jrr:-j,rnrr:doonldrflun{l1rd1

z n{r .ofldu 1uafarn:ofstln.l

1. .I compliance onn{
nFixlfr

2. fl ]r, r dd rt.:Fr compliance tfi lfiu
fl tJyt!0nnluyltJtoEJ

gnr:rld ttaotnr:tnionsjruzo\i unjlaleral lung disease

Unilateral parenchymal disease wilh decreased compliance ot the involved lung
Pulmonary contusion
Unilateral pneumonia
Reexpansion edema
Feperfusion edema
Aspiration
Refractory alelectasis
Massive hemonhage

Unilateral lung problems associated with increased compliance of the involved lung
Bronchopleural {istula
SingleJung transplant in obstructive lung disease
Unilateral hyperinllation

Other reported unilateral problems
Massive unilateral pulmonary embolism
Large pleural effusion

ynrflJfirln+a,id'rdulatduT:nuSonr::rdr nn?uni nftfiwg 349

nr{ldlonf,rudfirssl:nfi comptiance nnn{r

nuritihiilurldandrufifirou1rnii comptiance eoao

rfia{fiu'ldirnr:rirurnra'le nlnra'ledrulnrg'lv}Ju".,,nJood:J:nfi'lurruvntrfioodbJrduu1apr

n'r 2 rir.r o:'lrir:l6iuurrilo.,rilrn nronru.nfifia ventitation perfusion mismatch rfin oxygenation
detect d.rlum,rn:rfiocrdblilldrui'lfioanirrulu:ruro4o nr:ld eeee uioui,lernufibn.r: hypo-

xemia ochi'ldirnua;arrrirftl oxygenation lnrn{ rdo.:qrn petp rJhJluruilondrufi6rrnnir
drufirful:n vrerlfi ventiration perfusion mismarch rflurrntau are!fia barotraum" nrrr.rrld

uurrno'lunr: ir.lnio.:dr nr uh

t. rfion mode frtdtunr:tiruyrulq lnEJorqlfion conrrot mode y;o psv mooe fi'ldTetu

::i,ilritri peak inspiratory pressure fl\rrfiu {:-hudu-,rfi peak inspiratory pressure fl{ nr:dduu

i6nr:tirErfi ru'lerfl u pcv mode

2. nr: fl.l l:e ratto Tnflld inspired time urrnit:Jnfi ySotd inverse ratio ventitation lau

ornroe:rfirl ri*r asdr{6do! vd{crnrfuornrafio:rdrLiri,rrioodrufifir,rurFanru'luri.:',rv'rrtrldr

{i,rlvvr.rlriq,,rnrdrufifil,rurionrurioul rierdufio:riaa1 drhinr:unnuJfiauffrto'du riun.jr

Penduluft effect

1) VCV mode a1'Jr:nrfil inspired time ld'Iounl:on peak inspiratory ftow rate o.t

irlrrn: iur (configuration) to\t peak inspiratory flow rate tflu half decelerating

waveform fi?a total decelerating waveform onqlfldu-.,,:orvr:n rfil inspired time
lnunr:ld pause time (plateau time)

2) PCV mode our:nrfil inspired time Inunr::Jil t:E

3) PSV mode our:nrdl inspired time 161nunr: ilno expiratory trigger sensitivity

d,totn'lfi inspirea time lfi:Jduunc tidat votume rfirssu

3, laterat positioning nr:l"n'lfi{rhuuaun;uni Tfiurqflryrijaror oodrrfi6oqj6'ruairm:rfrl
oxygenation Tnu raur;{rleuifinlt! pneumonia, tung contusion uflr atetectasis rroieclrjld!,{n

'lu pleural effusion nltfifiLhuldNndcrnnr:,i'oyirdourr:noBlruldern ventitation-perfusion

relationship fi6du'luviruaunc unr lnu:Joerdrudrflul:nd.:aqjdrulrio:ldiriorn.rao.rn rnSo.rtiru
trulorrndu fi.rrflun1tfla ventitation perfusion mismatch dru!ondruair,:fi,:lflu:Jootfi}jfinur6-
nnrvrriueylfiiilrdaorrnt*utltonn ventilation perfusion mismatch lriuniu (good lung down position)

adr.,r-l:fimrrnr:rir taterat posnioning lun:rld orlrhlfifinr:n:;oralolnr:finrdororwun; rfioo
ornrjoq{r.ifirfu1:n (drulu) l.rtftrjood6 (drusirl, dependent tuns) rirlfrrn'o:aa1:nn:;rru

n',,lflordru (bitaterat tung disease) nr:nrro{Jruttornr:'ldrnio.]fiaoirl1 fiorrfidochrio

fidan'n::ifiun, :yrh bterat positioning tu{:Jru massive hemoptysis d,lfiimqrJ::o,o6

lu{ rtfirrqndr'iaanlil Tqunr:rir hteral positioning massive hemoptysis riufi1orj.,:nrlrurdo

350 rrtrirfelnqndugru

ilo.rriu1lltirfiondrudfi16oooan (drudfiwsr6nnrfl) lrnl:JrhrJaodrudfi o".:riu'lu{rJradii massive

hemoptysis frfi desaturation riuc-ifia"rarilondrudfinu'rBonrvro{drueir''r rln:druflrjfinmfi

nnrnoqjfiruuu (bad lung down position)

a. ntl'lS independent lung ventilation tf unr:rjrlnruleta.t[sio::Jaq[unffu lalardu

nrld double lumen endotracheal tube d,,tttrlun naoordtutttt unvrirurrulodruiisir.,rr niu

iidfrnrtldu.:grun;fia,oorfrflnt'urlirurrpra.:fld irruu;uitr{1'fitun:rfifr{r.lefli'ldnrfliruflrsle
:Jn fi rrn vnr:{o lateral position i ng rrdr.lri]rfi nrn

s. nr:'lt high frequency ventilation nr:'lftun:rfiiinr:incr{rofiu1ri1dfla tdo',nrnqraii

lfi unndrrriul:J 6nrn3.,rqr.tn:niu".,rurldurn ua;trnrun.t

ne'iirl,T)tfur-o-.n'ign']ullflTou[?nil compllance nIlJllu

{dru'lun{ldolfia1n1fi?iT u}Ju-.nla0iifiI:nrrnn'ir:lanfirJ:nfi nrrvdrn'rglunsjldfio tron-

chopleural fistula fiffiomn pneumothorax ttnvfi persislent air leakage rirunrr:du1 dru.[d6a

un'.rilr6'n single lung transplantation unilateral hyperinflation

rtururolunr:rjfi l raiosrir umah
1. Mode frdxulunr:nrtrlq lrururrudn dut control mode ut:rcdltfiomtn'u1ujia.l

ttjn:xon4,l rir'lfi brochopleural fistulalrifln n'::6an spontaneous mode PSV mode liianeln

nrr:ro"utu:;u:-rlriq'urnrfiar:Jiur lfiu!fi! control moce vruratrlfifl.:-hundT tnio,':tj'lunrutqlfi

|l?YtflAfl'tytltfl

2. ms.,: tidal volume lurndt :vlrru 6-81n"/nn. lGofiaonir rdoaoturnta,t brochopleural

fistula

3, flo insoired time lou
1) VcV mode drld1erunr:rfiil peak inspiratory flow rate rfi otfi lrarn'r:nr u'lo rfl1

#un.,: n"rlfrrrnrnr:mu'leoonrrud! uonrrndclrtin irg iro (configuration) oao

peak inspiratory flow rate tflu half decelerating waveform yia square waveform
ldalfi::a:rrnr'lunr:rnulo rd1#un.J
2) PCV mode rirldlnsnr:rJf! l:E lsrunr.l
3) PSV mode riidTnunr:rli:-r expiratory trigger sensitivity lfr4olrnn'ir 25o/o tfia
dlvrirlri ftow m-qrirdu riluruntfi insoired time dun,o rirlfi tioat votume floo.t
filtiruonrurmo.t bronchoDleural fislula

4. d'srrrnr:n'ru'h fioosi,: rir!::ilrru to-zq nts.:piaurfiviarrnnirfirdr rflu lorfiooru ptt

Ltnv PaCO, Qln arterial blood gas

s. ndnrdu.rn,:ld pEep rdormnntfi bronchopleural fistula lrifls

qn1: iu[n40\rdxs; .ralrlul:nuianrrysir nntunf nfrftutg IEL

Traumatic brain injury, Increase intracraniat pressure

l fiirifiiolh',{lhu TBt rnnflunt:snrl-l rfia.,ro.,: 30 alnr nr:rfianriu vcv uia pcv mode

nr:ld psv fri tidar vorume 6-to rn.hn.loruo'rdn phreau pressure 1l1figr rfiu so ur.fr rfja
asaonnn:;vroia rcp bildrir pacq :Jner' llrnn'lr
.:Jror) unriud'a.,:nr:v:'r hypervenriration

tnerapy nr:ld pEEp 0-b tl.r,u*r r;tdcirq,,rn'jrurfirioriiadrrflufio,:lfirdoufiflrgnr oxygenation

turhvrduaornr:lfi peEp r.r"n rdair peep qcdl'lfi intracraniar pressure (cp) fl,rdu ud

fi'rfr'ngruopld'h pEEp ? 'rofl{olerfj' tcp duufinriouiu{rJrafifi rcp lnfi upie*ilunrdu ti'r
{:Jrufi tce 9.,:o{riauudr lnararliluurnto': pEEp fi]ilffiu to tr.rir finlilrilfi intracranial

pressure gtdu

'lu :vrdula,rnrrrir hyperventiration riu rrsir6rJfu[u:rir'lfirir hyperventiration !figflfl

cerebrar vasodilatation Tnu:"nrr:;o'rj paco? liri 25-35 tJlr.:l:avr lrn'fifln{r.:16u,,,:fi'drri'q6onr1fia

cerebrat ischemia :lclfu6,iuu:dtlfindn rduonr:rirlfi Paco, finitriatn.ir ss rl. :oy Tnl

tarr;lurirr e+ tirll,r urnra.rnrr:.nor5ri:*.ofiorrrrdr.:oia cerebrar ischemia q,rfran nr:ni

ravn::ru'lufl udfi relractory increased intracranial pressure

Intraabdominal hypertension

'lu:rafifi intraaoaominat pressure fl{ ecdr'lfi 3 rn:m,J aaaan.,,: nrdilrniouirunru'lo
lunEldliu'bi venliration ror{rJ':arfiuwro loguarJ'lfi peak inspiratory pressure (pte) ardul

Touuoil'lfi ere q,'rdulltwi, ri'l prp daolilrfir:udl intraabdominat pressure ntinld' ({niartrry

]lrtvirualctd abdominal pressure/z rfluy rtiu raluar rte 4,ilr fiu so rlr.fr io intraabdominat
pressureld zo rr.ri't ptp tvildratJi:idfio-lrirfiu so rr.rir rnqrunfiuor ere qrdu}Idrf,o,rlrn
ptp iomr*u dru d.,:rflullo reln intraabdominar pressure n6,ootuaol*ilrnnlrilfio barotrauma

r'rrnlrjuadrX intraabdominar pressure g,odu lvrirlfilfin hypovenritation d.,:rirlfilfin respiratory

acidosis fr'trJrlid

n:fi fi fi a'lrlfi nilnGrnr uodr{luf,rh u:ru 16 uerTu

rriu fi:Jru:rufid.Jificdu COpD *ncfi metabotic acicosis n:nilrifio.i1 parameter setting

ro': z nrr:dt-nnJ,rriu nnim6o lu copo nr::JirJrnCo{deufirertefia.rilfrilfi ridar vorume n'r E-
time fl'r1 (t-time #u1 un: nR pir lusru:ii metaboric acidosis nr? iuLnio,:tjrufirulefio.'rilir.Jtri
tidat votume fl\: t-time riautrr ua; RR rioudr,lfr d.lq:uiuirn:dd parameter setting flo,t

rioooonm:d:r-nufl,'rriu n:rf,fi"hfirler:flirirornrrvourvdourfinornarlrqlolrnn,irniu d'rrfioorn

coPD xlnnil hirliurnCo.,rri'rlurutclnfltd parameter setring frlflu copo rfluno-n un:'hi

inrrotnqfirir'hirfin merabotic acicosis lour5'liqn fitfioarnr:ralrydaarfioorn metabotic
acidosis rrnn'jr 'hi ir.lniaJrieuura'hToald parameter setting r,rdls'l metabolic acidosis rflu
na"n unc'lfi nr'rinur rdanrrnllnrr;rarrydoufr rfi nlrn copo

352 rrni, riolnqdugru

Imnsd unoruurnr$unr::lfum{0,:'rjru rulsluTrn}rlon'n:0hn'l

8-10 mukg 1:2-1i3 '10- t 5
'l:3, 1 :4, ..,
0,2-0.6 6-8 mukg or less
1:2 (arl'td
02-0.6 I 6-8 mukg or less Ftime urndu

6 mukg or less

da high PEEP

6-8 mukg or less 1 :2-1:3 <5 16-24
or more

Unilateral 6-8 mukg or less arddlrn or morg
ung n'ir s drfi
diseasg |0.4-1.0 6-8 mvkg or less
ALYARDS
Metabolic
acidosis 1:2 <5 16-24
lncreasad ICP
or more
-" a".*.
0.2-0.6 6-8 mukg 1:2-1:3 <5 16-24
0.2-0.6 or less s5 or mor€
I t,e, t,t.s, t 't <5
0.2-0.6 | 10-12 mukg 16-24
or more 1:2
0.2-0,6 1:2 16-24
10-12 mukg
or morg 10-15

10-12 mukg
or mor6

nx tfl{: P tigg€r : pressure tigg€r, F trigger : llow uigg€r, ILD : irterstitial lung diseasa NM disease : neuromusculsr

dis€Esg

{?r

mrlf;lurn:nt'lrniondrurld'le6orflilnrtrjntuguddrd'qlunr:qua{rhuminn'miuqnnrn:

fiqrrn{rlrurninftfiorfinr, lflunr:rf,,rrnia{rirurnulq illsilrirsrrnrnfinnlil $'nvi.r rh;$uflEnr

frorrrnnfiIurru#ltrnlo,,rdT uilrulclCatl{tJru:onriumnnlr;inqnlerufirne;trrnndourioudqe

gnr: fiJrn*o{ri?uulololul:nulonrrvoir nn?unf nftftwt 3Sl

[onf,1td1\ra'{

'1. Pinsky lv1R. Cardiopulmonary interacions: the effects ol negati\€ and positive changes in pleural pre6sures on

cadiac output Inl Dantzker DR. Eds. Cardiopulmonary critical care Philadelphia: WB Saunderl gg 1:87- 120.

2. Tobin i/J. Mechanical ventitation. N Eng J [Ied t g94:930i1 056-61
3. Oczenski W Werba A, Andet H. Breathing and mechanicat support. Btackwell Science 19g7:t43 7.

4 Aldrich TK Prezant DJ. Indication for mechanical ventilation, In: Tobin MJ. Eds Principle and practice ol mechanical

ventilation. New York: lvlc Graw Hill '1994:185-90.

5. Gattitoni L Pelosi P, Suter PM et al. Acute respiratory d istress syndrome caused by pulmonary and extrapulmonary

diseases: Ditferent syndromes? Am J Bespir Cit Care Med 199BlS8:3-i1.

6. Tobin lVlJ. Advances in mechanicat ventilation. N Eng J Med 2001;3441986-96.

T Esteban A, Frutos F, Tobin MJ. Et al. A comparison of four methods of weaning patients from mechanical ventilation.

N Eng J Med 1995:332:345-50

8. Sessler CN. Mechanical ventilation of patients with acute lung injury. Critical care Clinics 1998:14:707-29.
9. Jain S, Hanania N, Guntapali KK. Ventilation of patients with asthma and obsrtuctive lunq disease. Critical care

Clinic€ 199814:685 705.

'10. Huiz Sontana S. Gancia A, Estchon A et.al. ICU pneumonias : a multiinstitutional studv. Crii Care Med ]987:15i

930 2.

'11. Brochard L Hauss A. Benito S. Comparison of three methods of gradual withdrawal from ventilatory support during
weaning lrom mechanical ventilation. Am J Respir Cdt Care Med 1994:150:896-901

12. Thomas AR. Bryce TL. Ventilation in the patient with unilateral lung disease. Critical care Clinics 1998:14:ru1-73.

13. Pressure control ventilation. Nichots D - Crit Care Ctin - 01-ApB-2007:23(2)l g3-S,9.

'14. Marini J. J., wheeler A. P.: Respiratorymonitoring. In: Marini J. J., wheeler A p.. ed. critical c€re medicine-the

essentials. 2"r edition Williams & Witkins Baltimore (MD)1997:90-91.

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16. [,4ode of mechanical ventilation: volume controlled mode. Koh SO -Crjt Care Ctin - 01-ApR-2007;23(2Jl 6.1-7

17. Conventional mechanical ventilation in acut€ lung iniury and acute respiratory distress syndrome. Ramnath VR -
Clin Chest Med - 01-DEC-2006:27(41:601- 13.

18. Mechanical ventilation for cardiac support. Ftaikhetkar JK - Crit Carc Clin - 0 t -ApB-2002:23(2):291-8.

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169 81.

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1389-408.

354

22

Tailored Made Ventilator Adjustment

nn?uni gfrfitxg

rfluduoiliuriuleBrtr\i'jr nr:tsraia.rdrufiru'lc rflunr:inurfrfinrrrrfrcrqorjrrii.,r'lufirtrr

dfin, r;inqnnrl:;!!firutoleuro r:{ilrafioqjlunrr:nrmru'hdrtuar (respiratory failure) n?1
friornr:l.firnio.rtirurlrutr6tfinl 6irdrgoirniruvuriun:r,rrrrrafi:Jfr1"fi':rutulofg

tunr::Jfi rnio.rdrunr utrrfufi Rtfi tio'r rirfit n',r q fi : nr: 6 a
t. nr:1fi:sa'roan6rcrtul6oarvtJr:d! (provide adequate oxygenation)

2. Rr:'hlnr:T'utua'rn1fl[]ttJ'l:dtJ (provide adequate ventilation)

s. turru:frl'firnio,:d'ruvrfllq nr:lir roiardrryr ute t l'ona nr:fli':ru1o,:nr:yr ute

(decrease work of breathing)
+. turrurfrtfrlniatdrtrrrruh nr:flatflunrrr ur:ndoudrfierduernnritdrn€o,:rirunrule

lfi rfi nduriauiqo (prevent complication)

nr: ilrnio,:druvru'lenr rurrr'iJirifi (guidetine) ardritvurvrrdrrdl{r-hulnnu
rdo'':crnfi 1fludov:rufinrr unnsir.:fi'u luuvrol dq:ldnrirrfitnr:rjir reSo{tirutru'lqfou

:.lSrul6uutfintrryailu{rhr udn::ru (tailored made ventilator adjustment) louq:r6onn6irr

fi ,t taltrvlrt :: t6ua"toiolld

t. nr::Jfi rnia.rrirurrulc rfialfild oxygenation fi rvrr: or.t

e. nr:rlir laio,rtirufiruie rfioilild ventitation firvm:an
s. nr:liu raio'rrir urr u'te'ht lv'r: or.ron :nrianr r :oirr1

drunr::Jiurn?a.:druvru'tctfjonnnr:rir':rutornrrvru'lq tJ'nfia.'r6.:dnuru;ta.r respiratory

waveform rdoudrurn ir'lrildritnnairr'l{lulrrnrrld

Tailored \{ade Ventilaror Adiusrmenr $n:runi nfrfrmr JSs

nr:rJfit raia'rrirunrulerf, o"h?tf, o4ygenation fi rulrsrl

nr: $.rrnSo.rriruvrflhrfiatri'l{ oxygenation dr rt'rrfl ricr:rurldcrn oxygen saturation

fi{uenril,rriulilnrlll:nr?anrr;rir.r1 o'',r uaoolunrm,rd t

tnrflrtd trgq.r:yoT:l oxygen saturation firr rct nr:i:sfl5anr.::rirr1

. fiLhu COPD fio'rnr:::fri orygen saturation rl:: rru gg% {i,tq:.onilrlo! F,aO, ::x1ru ss

lltJ.rJ:a1|

. fithu nRoS doonrt::q"u oxygen saturation t: 1.u gg-90% fi.tn:ln-l:vril pao. trtl.lau

!55-60 .rjtoyl

e fi:ht acute coronary syndrome dolnr:::d'l orygen saturation tyulru 94% dcn:,tn-u::ryl

PaO, x! tru 80 r.J . tofl lnr n'rlu:rirtar CpR guideline 2010, ACC/AHA guidetine)1

frJra post cardiac arrest fiarnrr:voTl oxygen saturation iJrJlcu 94% ir',:n:orir:vdrJ pao,
rr.r.hctJ1 80
ror lmrrct"r ru:rjrto.l CpR guidetine 2010. ACC/AHA guidetine)1

{rJrauonttioernnttvo"lnritt do,rnrtrr6'r oxygen saruration ry lru 92-94% rrr.r oneumo-

t' nla, asthma, atelectasis

i'rorirrfr r.r firhu:rlvfioldfunr:ifirdurfru nnos rruvu'ldrnio.:rirunru'hTo!'ld rio. rrirnll

il1.0 ld Pao, rvirrir too u:l:am da.:nr: no" tfildeh oxygen saruration rrirryu 900/o e:

daild rio" rrir'lo

u.lStng t,Jny o{ e1flu1

1. qrnnfludrJfliudntr oxygen hemoglobin dissociation curve l'r:.r'ir oxygen saruration
90% e;n?\:n-!Fi1 FbO, 60 rJr,. rafl o,:lan.,rlu::Jd t

pPrr€os=8uo,rsygaBl n!vphai5rlial
h€nogtobln b 510%

Satrraigd

rli t uaat
6090ok
for'xrnyguenPahOermoglobjihnadnis, sSoaciOartSiognV"oua*zeviIunufufrOS" uS}Srgus%u. nttniu fuOr B0 enJ7f,n, SaO,
fln. SaOr TSyo 6rniy fuO, 40

axshon uaz SaO, 50To ffinriL tuO, 27 yul7afi

356 rrtdrrinlnqorCusru

2, f,1rJ1:nfl"r1-lxrunlr:Jf)Jno/ rfru RO, ldlT nnrnr:fi t

1flNn11d (PaO"/FiO,), (PaO',/FiO2)2

100/'1.0 60/Fio,

Fio, u,o

r;r'''liu6.,rnr:rJfu Fio, tli'tri! o.o rfiotfild oxygen saturation trirrT:.r go%

3. drn1r (Pao,/Fio,)r = (Paoz/Fio2l, fifionr:::irlun, :'ld6o lunarionrffio,,l oqfi
iinr:6Jduuurln.:otjr.::rnt5r t:iu congestive heart failure fifl0!ouolrionr:innrdruurduicon:
fiio ARDS dfisrnr:udn,radr':trsrtfr Fi'uJoo Pao,/Fio, dtdlurrsinv'dr,:nn'rq:lil rvirdu nrirr6o
ririloofifilrurBon'r rn Fir PaoJFio2 c:oir dTlfifia,fld rio, g.:n'irfirnun'rurnrlfi drur.lonfi
Ljriaufiuuricnln y6amor.rsuoo0ienr:inr*rldd eir eaoTrio, orfirirgo nialndrdu',tdrrlnfi m'rlfi

da.rl$ riqdrn'irdrnuriru?ruldd-rfunr:6orrnrtflr'lli.t{rJruadrloiardo'n'rrflud.rdfinrudrri'rp'

6'rarir.ri t.2 firJrrrruorq +s fl ldilnr:ifiqdulflu ventilator associated pneumonia
ldrnlo,niruyruterflu pcv mode: pressure trigger G)2 tr.ril, riO, 0.5, inspired pressure

ra tl.,.rl'r. r:E = r:2. peep s sr,.f''. RR zo nf.rrurfi oiamriruldfirn,:rrd$r{rJrutfioflrlnr

desaturation riruldrirnrrrJnorrnCoidrstra'louovfiu self inflating bag rrdr orur:ni:Lldd lri

firu or r:n'ldsrugo rorr;ld fi,lfiEr{ ao !fil6lu,,t crepitation rrndu rirufirru'lvlr,rlunrtJitl

rnio.:riruilruh or.ir'rI:riolrl

rJ::rffif,orf,rrmn

t. {ilruldiunr:liqo'u ventilator associated pneumonia domtfiofltpttt desaturation
t'fi ifi ufiltfl rum l:jo,,rduo-,luootluueru4fi d

z. riodrn'r:ufilumuiid',rnrirr{r,rduuudr tfin'rnr:rfr}r Fio, dul:J nrntfir Fio, ufir

fir !desaturation crrtEdrulrn{r-irlvtflraln ventilation-perfusion mismatch fi1n desaturation

tlrlrivrub rjro:rfi oornortrqdu n"ruandurroru4fifi z'

3. n?dn1rJflefl'r nrnrfir riort*urrd? desaturation rrsld drtJfilnr:nt?e'ld crepitation

rfirdu nnlndru'lsqfuo.r hypoxemia rtvtfioern ventilation-perfusion mismatch r.rrndqo {i.r

fioonarruqriohl'lr crepitation dlfiodufrormqornavl: nrna{lunrr:oT trirrfiu (volume overload)

orlrfioornnr:ldiroraihlrn rfiu}j, nrr:rirlerru d,:fia.rlfinr:inurd?uur1T!floarr: rrnlilld

agtunr'::ri'rrfiu aroffinern ventilator associated pneumonia drflulrndu d.:orlrfinernrda

rhrniordo'lyri 6'.:riuuyrvrrido,:rirnr:r':rttnuvd't'irfirdalv*iriolri $5auvY,:n:mnrfldrsi'rd

r:r.:on'irii infittration rfi odutrriniolri tfi nrrinurntrrdorioT':aiuu

Tailored ,\Iade \.enrilaror Adiusrment nn?uni nfifimg 357

Hypoxemia zujldrn€a,rdasmulo

inda,:drufi ruh q:ro:rr! ao.rri)

drunru?o Fr-T suction rl:"urfr

n e,r SanrrrFrrfl r.r+nndl flr,rurBanrfltuiirfiodr-r td sr6o,?flu nr s?rin'qr n nr s
-Chest physical therapy
-ARDS / pulmonary -Aspiration / pulmonary -ET-T suction
edema / pneumonia / edema / nosocomial -Bronchosopy
-Peritoneal dialysis
ate lectasis pneumonia

-COPD/ asthma -Pnemothorax
-Eronchospasm
-Shock

tunugfri uaa,tuuent{lunttufilfiryntiatdudaf, desaturction truzii'ldnio,tthuntalq

n-rs:ir'rfi t.3 {rJ'lumuorr 4s fl 1d5:-Jn1?iiqduriu ventirator associated pneumonia ldrnio,r
drunrutcrflu PCV mode: pressure trigger 1-)Z nr.rir, FiO, 0.5, inspired pressure 1B ttJ.dt. l:E
= 1:2, PEEP s ru.ti',, RR zo n:3.rlurfi oiorrviruldiunr:u{,:'hfi:Jrurfioikpfil desaturation vi.ru

ldvrhnr:rlaoraiamirur,rlu'le rn:fiu setf inftating bag ufi.l orlr:n:iilfid Lirfiru nr r:n'lda1u

oororn:ld fl.rrda,r anrrfirfiu,i crepitation lrndu rirnr:rfir Fio? rfl! t.o lriorrrrnufilr

desatu ration 16 virufi uurvrr,rlunr:r.lt! rni o,rtirunr ulco Eir,il:rioll

rltcrSufids.,rfierrur

t. {rJruldfunr:ifildu ventirator associated pneumonia dartfioflqnr desaturation

'lrinarouardan, :ld Ro, t.o

2. nnlnsor desaturation 'lu.:.)ud rjro:rfiocrn intraputmonary shunt rJrnfiqn lfiafi1n
ilrlfir.,r crepitation ldurndud.,:uoo,lfu:oul:nluq,lnl d.rorcrflu nRos rianrt:fior:rirrfiu

358 rrrnilio-nqnfir5ru

Normal A-a gradient (Fio, o.2) A-a $adient
near normal PaoJFio, (Fior>o.2)
PoO, /FiO,

wide A-a gradient (Fio, o.2)
Low Pao2 /Fioa (Fiopo-2)

Central / neuromuscular

hypoventilation

rJ{ulfi minute ventilation
(rfi*r tidal volume, rdr RR)

Dead space PEEP *rilanm: lo,v
(eg. pulmonary
Inverse ratio 0, delivery /
embolism / severe ventilation
high oxygen
purmonary anery . Prone
consumption

-Thrombolytics /

anticoagulant
-Pulmonary vasodilator

2utal{Ir,-y)4l 4 ufiflnuuln1nlun1Jn1f,1m4woullvll2lrnMl11J hypoxema

Taiiored lVlade Vendlaklr Adjustmenr nniuni ?frfrt1Jr 3Sg

(votume overroadl duo{fi'un'nuru:vrr,rrrfiindsr:rcil! d.,:tu:rEJiltnr:rfir pEEp rlu rdotfi0unil

dflooqjoTn:n rijnoonld Teuorctdufiu Incrementat pEEp 6oFiou'i rfjt] prep orn:vo':roi.bg,r
fiioorcld decrementat peEP 6o1d Prre turvd'rdg,rriou drfiorrir atveolar recruitment maneuver
ud'rrioul fler pEEp n'r{:;dr.rdr lorla'r:l:ntd peep uurorvirdlririr'hr ptateau pressure lfiu

z8-30 ru.dr'o

s. rdarfir pEEp du fi:J:cr6ufra?rfinntr d'od

. oxygen saturation or:hiog1u::o"l 88-92%o o.terJln iorjoun.jrdrrdr rrrinrr:ii

ll!1unJ1.l

. Blood pressure 1nn?.r dulnfisrnn tfin:roq,jrfi tension pneumothorax yialri

firnrtru tension pneumothorax t{ld intercostal drainage tu ocdrido.rffu drunr:srnaonr:'ld

pe ep uSohi dloqjn"r:oaI:nlun.,rouflldrdrg nrnu-.:ii:aulrntuqrnldna:Lauorsian.rlf peep
aqj filriarm:nnqonr:'li peepld urifirnlrii:alI:qtunrordorououo.rq'onr:'ld peep niu copo

nr:nqonr:lf perp

n:rf,finrudulnfinnna,,,:udLild tension pneumothorax d1[ fllnnein intravascurar
volume depretion rdo,,,:qrn prep rirtfiorrlo'uluvnrran (intrathoracic pressure) qodu dwnbi
venous return nnao rirlfi pretoad flann crrr:oufiltldlounr:tfinr:rir usifio.,rhllrir5tJrnlnu

ldunf,a ttuio chaflenge test" rdo,{rrnJoqriu nRos nr:lfiar:rir rirrfiun.irdrjooo:illi r:

rihirfi o nypoxemia pu:.ild

. Peak inspiratory pressure 1ete1 rfio\rorn pefp rfluomlo'udfiadnnonnllutir,l

nrulcrdrun:rru'leoon hildfiagrovrrvoraunubaanqorvi,riu ri'rriunr:ld peep q:flh'hl prp
rtg,,:duraro d',rfu{,,,:do.rfionru
Lil.f,n, gs 'r.fr"lu vcv mode un:lrirfiu so t,J.fr lu
PCV mode rio PSv mode

. Tidat votume nr:ld peep ril nrnrir'h1q.:ol Oooanld tiolrirlfi exhated tidal

votume rfirdu udrnn peEp rfulrjorm:odrlfiq.lorlriJooonld fic:lilruruylru6u?rulcrrylu r'.r'hi

exhaled tidal volume nqft.t

. Lung comptiance nr:'ld pEEp f1r nrnrirlfiq,:olriaoonld darririfi comptiance

ufir:du uoinrn pEEp fulriffrrlr:nrirhin,rnrrilnaonld fic:ll.,,ururrtrfiuvrutruvru rirtfi

compliance ffnn.r

. Arteriat btood gas : n,rrld pEEp 'lutirrurn ufi.iro: riloqlnildfrnril urifio:rijo

'ldrfiu*finriou uqi peep fiovrirlfi airway ruroldnrurrn-r rnrju rirtfi dead space rrndu
n"rlfi eaco, n-.r d,rarn'h{lflu acute respiratory acidosis ludr.:rr:n vrnnr:ld peep nrnrirlfi

qtnrrilnoonld o:dr'Ifi pao, ufilriu eaco, nnor rdo{qln arveorar ventiration rfjlr,*u un:on

n':orir.rrflu acute respiratory arkarosis fi1nn1r'ld peep lrjaur:orirt#q.rol liolfi paco, ?:

360 rr"ud'rrYoinqmCupu

rfjildu rdo{crn pEEp rfjil dead space ventitation d':nra'tfi eao, non,: rrn:rir'lfiqnnrooir'r lflu

acute respiratory acidosis

r n1ndra:-.tf,u:r{on (chest X-ray) n?:{.:lflndnuolYno.t barotrau.u drfrd'ry6o

:pneumothorax. pneumomediastinum LLfl subcutaneous emphysema

a. rfiotd PEEP eu-ld orygen saturation slt tfltv 'lu r5o1d tung compliance fidfiqo
rudr 6,,rniar1 rirnr:oa Fio, fl{inv 0.05-0.10 oilld Fio, :;tnru 0.6 tfiaaonr:tficnrr:rflutic

a'rfl 00n8rcl,l (oxygen loxicity)

frorjr.rd t.+ firJrumuarq 45 i ldiun1rifi?dutflu ventilator associated pneumonia ldtnial

trirunruhriiu pcv rode, pressure trigger (-)2 tl.rir, Fio, 1,0, inspired pressure 15 .!s1, l:E

= 1:2, PEEP 15 !il.ril, RR 20 Frte,tntlfi ria rvirulfiSrJnr:rr{t'irfiilrelrflorrft1fi1 desaluration

rirunlrr:nldoruqorrolv:ldInu'ld:cuflo (close suction; fl.:rdu.::Joollufitfiu,: crepitation lltn

du rirufi uurvrr.,,:lunr: ir rnioltirunrutoatit:kdolj

rlrc r6uddo.:firr:rur

t - {ilrcirf,ilnr:ifiqdu ventilator associated pneumonia oialrtfi nfl rgltr desaturation

lrinounuo.rdonr:'ld rio, r.o unvlrino quo',tdon1:1i PEEP fl1nd.t

z. crrrqido't uunoonl:,lriou6a pneumothorax {iturlldlu{fiufrtflu ARos rfio'rcrn
lrjnur:nufilt'ldlerun1: Slrtn4ondlutrrule uoido't Ltfiblqun'l:td int"r"ostal drainage

3. ilTlrt1ti pneumothorax rrdr nr#rflo desaturation riorfinr, n{r-hunruhlxif,rtluf
riurnia.: lp"tient-ventilator dyssynchrony) arqtfioorn:auI:ndmndu lunrdd{rhunruleLi

d:.rvrTu6'rtrrnlor drhjttinru.rqduirfluoufl:ru o1cnofifi sedation lfi d.:rdarfi:.truvruled'lr{uf

ni!lnio.r nr':c dosaturation fic:dsut 6du

+. n:rfldfioorn:au1:ndlrndu arrflulrn:oukah ttiu volume overload 6a:au

T:a16#rflu ARDs ue1fiarnr:1uu:tdu tun:ddrflu volume overload nr:dc;ificdulfiorqfio,l
gnr:rirrrrdr un:t1o0n (intake/ output balance) d1 n':Jnr:n:rqir.tnru'irnrtfrtfiuttiaLi olr

dalg cve, pcwp nia non-invasive rest 6u1 vrnul'jliu volume overload orefilr:rultfi

urrl-rflcnrr: lSarit renal replacement tnerapy firl'rrflu

s. urnrflu ARos lrnduuln:u-{n.tfi desaturation o$ orofirrl16onlunlrfnu{d 3 il5!nlr

FlU

. Alveolar recruitment r"n"uu"t lounr:1dnlr.rn'ugilunr:rilnrjoo d,lorlrflal on

dlu continuous positive airuay pressure (GPAP), PEEP uia inspired pressure fi'rfirn'rugn:

tunrr:Jitl rnioodr uvr ulq

Tailored Made Ventilator Adjustment nn?uni nfrfirxy 361

. Inverse ratio ventilation (lR\4 fin'nni:rilunllrfir mean airway pressure Tounlt

rfir.rtrnrmuhrdr linspiratory time) rfrarfilrrnrdaanin 'luq{o Lln.lruanr duuriu6an (oxygen

diffusion time) uoxthlfirnn auto-pEEp du d,rorctiuldne.,turj trE = t:1 rfllfill:l danr::;i,:

lunr:ni tRv 6o

t I rdo.rrrnnr::irufirutcu,ru tnv rflunr:yralcfifluo::rmd ndm6a(?o.r'lunl:filu'h

rdr rnn'irnrfirutoaan 6,,rdadd sedation r!o! muscte retaxant dr drurora
z1 nr:tirrvru'loulJll tRV dllfirfio auto-pEEp ldo,ocrnrrar'lun.]:yru'hoonfiaun.jr

trutlrd, 6,lyrhlfio'sr:rlunr:Iflnrla\to1fl'rF ru rrnrfiluhaonnn lrjrvirrirqud dtrun
lfi exnated tidal votume nnor drbirfio barotrauma. nruo'uTnfinrrn. nrir-rou'ln-

oonltrilurfiaod',t rrn:firhu do'rld wort< of breathing tunr:n:ydr.r}{ inspiratory
valve liJnurndu rirlr{trudfi o,:1dtun'r:yru'lc (work of breathing) rrndu

. Prone position 6onr:{o{ilrutriodtuviruaun'ir rfi0,,:rrnloolarnu:Jn6atirrrdrurn",l

:;mru z lu 3 dru rdainvir{rJrulfiuounx31 0cfiadni.,rdrund.{fietn'uuradmrrdruyrir ornrn
Inuilnfifio.rnoududrultu o-.:riunr:l-n{rhulfiogluriruauar'r 6{rflunr:as ventitation-perfusion
mismatch 6,:dr'lfi oxygenation fidu orl.rr:nufilznrr: desaturation'[d odr.il:fimrrunr:do{r-hu
iriagluriruoln'irriufiflonr::tl,,rnnrtlrvnr: rtiu viruaun'ir.lrilrur:drr,til{r-lruifi nsrofl5
nrr'lnoriuurfioprhjn.rfi nr:uaunr'rarcdrlfiyioli?urruleriaorunrurirrl 6ourqn nr:uaun.ir
'lrl u'rrr : ohnil {rh ufi nrtr ri'u'lu:ia.:rio,r o.,r

. nr:rirunrflleloEfld mode 6u1 niu airuay pressure retease ventitation (APR\4. high

frequency oscillatory ventilation (HFOV)

fiarir.od 1.5 fi lut'luo-ru zo iJ'tdi:inr:ifiqii'ri liJu Ventricutar septat defect with Eisenmenger's
syndrome dllnil ventilator associated pneumonia tdrniardrunru'lctflu VCV mode: pressure

trigger -2 cmHrO, FiO, 0.6. tidal volume 400 mL peak inspiratory flow rate 50 LPM, PEEP 5

cmH,o, RR 2o/min ia oxygen saturation'ld oox loudrnfirnninr:lynriuulfiaedun-rfi {:-lT u

vrulardrfi'uraioa:irunru1o166'kjfia'nuuytrrnfifinror tissue hypoperfusion virufiuuur*rh
nr::Jir rn*ouirryr ulqo eirrl:siob

ilt:rdudf,otn-rr:an

r . firhulddr.Jnr:ifioa'u Ventricutar septal defecr wilh Eisenmenger's syndrome :lltlLt

ventilator associated pneumonia lfioflrynt desaturation '[rjnoloua.:riont:'ld FiOr 0.o

2. fl.Uxl desaturation 'lu:rud 1rififrnuzu:rrrnfifinlo.: hypoxemia loufitonranfnr:
lynrl!urfioodun,rd firiruilru'lcrdrfiirnio.rtirurrsloldn'lrifid'nuru:nr,rnfifinro,r tissue

hypoperfusion

362 ntrirrioinqndugru

3. d'ltfiq1o{ desaturation 'lu:rudrfin ldo.tcrfl Eisenmenger's comptex dlrirlfirfion'lu

rloll'rlcinrner{ildru lrignt to teft shunt) dlriunur6anrrfiflltr1lnufi'hldlqunllsj'rdn rd

LXJ Lfl LUflTU;U

+. n-rriutu{:-hr:ruddofi desaturation Lteihjfi d'nuruvvll,tnfifi nrron hypoxemia l-. rj

do.rlhnr:rliurnfo,,rrirunruh parameter setting ffi ltrtlrvolttdt

dradrs$ t.o f,:-lrumuorq zo iJlfii!nrtificdEluflu ventricular septal defect with Eisenmenger's
syndrome dttflu ventilator associated pneumonia lirnia{tirufiru'hrflu VcV mode: pressure
trigger (-) 2 or.tir, FiO, O.O, riOal volume 400 tlo., peak inspiratory flow rate 50 fic:rurfi' peep

s ou.tir, RR zo aitlu'tfi io oxygen saturation ld oox lnulrifin"nun:;rttnhiinto.t tissue

hypoperfusion oiolrio oxygen saturation 'ld +sx fltrfrut crepitation lfimndu {:-hlfiarnr:
drcu n::dr n:vsirs rufr tturr"i unr:rlirl raio',:tir uvrfl'ltadr''tl:ti olil

rJ*riiudf;o,nr-nmn

t. f,ilruldilnrrifila'u Venvicular septal defect with Eisenmenger's syndrome itlJtiu

lventilator associated pneumonia t6l oxygen saturation ooX rfinirytr desaturation qo:-l

ouoroianr:'li Fio, o.o

2. flqJfir desaturation luflud fia'nunr;rrtnfifinto,t hypoxemia n:irrfiod 'lufiarnr:
duou n:;#rnr:d'tu 'l"o oxygen saturation -[d 45%

s. flrumutu{ilru:rsd6onrnjiuroioniruvrutehi'ld oxygen saturation'lnfitdulriu ooort

d1lriu'lu:rodnr:rirnr:rdr rio. dubriau mnlrisrorouarorqirnr:rfir eeee rdolfiqrnrtio
[qifia.]::io!.lalar PEEP'j1o1crh'lfi right to left shunt rflutrnt*u ri'r'lfirfio nypoxemia rrnril

irodtrii 1.7 {:hutluo1u 45 i ldiunr:ifi?dutiu ventilator associated pneumonia 'ldtn3o.t

tirunruhriu PCV mode: pressure trigger (-)z t1J,ri., Fio, 1.0, inspired pressure 15 tu.fr, l:E
= 1 :2, pEEP t s ru.rir, RR 20 ni,:/u1fi sioilryiruldfilnr:udt'irf,:Jrurfinrlryfll desaturation io
oxygen saturation ld aoo/o virucrilr:olaioruqn rolv;1d19tu'ld::u:Jilo (close suction) 'il.:tfru.:
:lorryrlfirdu,,: crepitation r.rrndu {rhunrule dlvriufrilrn€a.rtitunT uloldd nl?e EKG vtll

n'nrru; n-.rntu virufi uurvrr,:'tunr:rJfir rn*o.rtirurr utc o iir,il:tial:J

:l:crduddoorlrr:nn

t. f,.rJruldfinr:ifitdu ventilator associated pneumonia rdorrrfi orlqlr desaturation
!u

1*inoucuo.rdonr:'ld Fio, 1.0 unllrinaucuoroianli'ld PErp turnd.t

Tailcred \{acLe Venrilator Adjustmcnt nniani nfifinry 363

zali uaat ERG fifrfr'ntrtuntan sle3Tg pattem

2. orrfinfifio,ruunoon'hlriaudo pneumothorax frrvu16'lu{r_hdrflu RRos rda{c.tn
lriarlr:n uflltldlor-rnr:rlfitrnso,rtirur.rrEr'lc rFida,Jufiltlounr:tai intercostat drainage

3. dnufurra{ EKG riu St esrg pattern fiuhfu RV pressure overload rfiactn pulmonary
artery hypertension fitlridrrflu'irdat rfiortn acute purmonary emborism odr.,:rdsr orcrfioorn
hypoxemia fi:uu:.:'ld rfja.,,:ornnrr: hypoxemia dluu:.1 l:n'r1fifinr:ron-rra.,ruaanrdoo putmo-
nary artery rfiorirbi ventitation-perfusion mismatch 6du uo:lu:rurflrjfin-nuruvrr,]nfifinfitod
fil acute pulmonary embolism

+. 1u:rildlfio.:qrn'ld peep auro4.r*dr fl,:orouflllflryrr hypoxemia firuu:,:lounrr
li1 alveolar recruitment maneuver. prone position fiio inverse ratio ventilaiion

s. lun:fifilrisrauouaroianr:inur 'lfiritnr:rlmru intake-output batance y1n intake
rnn'il output ficr:rur'lfiilaor't; rrnydrn'nrlil'rrurirrrrfir alcdr renat reptacement therapy

n1a'rrllu

o. lu:rfldnrnified'tfioFlu:n'jrrflu putmonary embotism ua;yrn rlryrjdarnr:6utiu
nr:ificduToanr:lrh cr chesr fi:-huq:finrur6itrunqrnnr:rn6ourira rfio,rtrndo.,rld peep tu

nr:rnfiouriru{rJrt lricrrr:n}lyrh CT chest drunr:riu setf inftating bag uult::rorld

nrdfilniouirsflrflleriiabild ventitation fi'rnrrsat

Tou nA ventitaiion firyurcflHflr r:nrJ::rfiuldcrn eacq o{lutir,: ss-qs .:J:ayt [0i
finr:drsyrshur,:nrrcfida.tfla 'hlrfin permissive hypercapnia rriu {:Jrufifi tower airway
obstruction nio nRDS fida ':1d pEEp rulgfi,r od'r.r'[rfiortrnr:rirunrutlTnrtdmnfia permissive

:rtfihypercapn i a fi da nr:: ytt n-.: rro nr.,rtu nr z

364 retthrialnqndugru

mi1{# 2 ttf,q-tdofil u't{:Jrsn1ln1:ri1 permissive hypercapnia

1- Intracranial hypertension

. Head trauma

e Intracranial hemonhage

. Cerebral edema
. Space-occupying lesion

2. Seizure
3. Cardiovascular disorders

. Heart failure
. Coronary artery disease

4, Rrlmonary artery hypertension
5. Uncontrolled metabolic acidosis

firarirod 2.1 {il1ut1uortl qs iJ ldirLnrrifiedutflu community acquired pneumonia lruvfli
rnio'nirflrrulo ld rio. wiT rYu 0.4 tidal volume 400 a. dn?ln1l 'luh t s ni':daurfi ld

t+.co, ryi'rfl'u 50 rrr,:J:or dotnr:rlirrnia.rtjrofirulctfildrir Paco, wi'lliu +o rr.:J:ovr {:-hu
nrlhr{rrfu rnio',nirunruto rirufi uurvrr.'rtunr:rliurniauiruil'lu'tlodr,il:

rJrsrffif,o.rf,ermn

t. nrr ufib rdorw a'r{uouloo o nlsda",: dru'lrqj rrln:n rrfi ltldln anr::Jir'lfi minute

ventitation ldrduld o-rnrnrrd z

(PaCOr)r x MV, = (PaCOr), x MV,

cr nnrlJdrJfiuf,:;ll'ir.: PaCO, llflY minute ventilation

(PaCO, x MV), (PaCO, x MV),
50 x 400 x15 40xMV
50 x 400 x15
MV
40

7,s00 n. (7.5 6nr)

s. fidrorrriolil'jmvrfionrhltl tidal volume tia respiratory rate tfifirr:rulir

t1 rfionrlil tidat volume n:riid pear inspiratory pre$ure lriglrfiu so-ss nr.rh
r'rio ptateau pressurelritfiu 30-35 m.rir

z) lfionrlir respiratory rate n:rfifi {ilrulrifin'txc auto-PEEP

Tailored Made ventilator Adjusrrenr nn'|unf nfrfrMS 365

firlrifi peat< inspiratory pressrre dflr riolilfi auro-pEEp qyldan fu tidat volume

ttio respiratory r.t" fltd lrifinruunndrrniu
+. lun:nidvu{rhufr fifl qurn-6uoulnoonbdn',,r }iytrnrlrfilsnrlunru4fifi s.

Low minute ventilation

-shivering rfiHrLmAUinnul5terJl.v1enU..tO.ilaaltion viotiruflrsiqurr
-Convulsion
-High carbohydrate intake volume +/- rdn RR

rioos;tu aveolar -ni'lzt arruq

hypoventilation lu - i! ventilator

intrapulmonary 1.o tidal volume

shunt eg. ARDS 2..r, RR

3.a E-time

i ort:lri6fu

Ill PEEP ,Apply external PEEP
I tfioao work of breathing

lutirrGrnrsursh

unupfrii e uanrnnufihflryn$iawyntiuaulaaanltdri,t

drarir.rd z.z {rJrur,uora co fl 16i:Jnt:ifioo'u rflu community acquired pneumcnia lu:d

ldrnio{tirurrfltc td rio, rvirrit 0.4 tidat votume 400 ra. dn:rnrryruto ts n{roiaurfi {:Jru
wrsh gz nirnrfi ier exhated tidat volume 16 5s0 rJn. mtxa arterial btood gas tw.j1 pH 7.s2.

PaCO, 25 mmHg. PaO, 80 mmHg. HCO3- 20 mEq/L yi1ufi lru?ytrohnr:rJilrnio.,rtjrrLyrulo

otir',r1:

rjrc6ilfido.rf,mflur
1. Arterial blood gas rrdo.ldnuru:too mild hypoxemia. hyperventilation ![ny acute

respiratory alkalosis

366 rernirriainqnfrugru

z. ilqrroio}Jfi'it:ilfiufibflEnr hyperventilation !tQ! acute respiratory alkalosis

otir.:l: unvn:rfidoTrr:ntdqn: (PaCo,), x MV, = (PaCo,), x MVrldYialil

3. n'r5'ld{rr:n".rn6j'rx fi'ln6o,rn"n1i1'1fi eaco, tnfiu6aorird, :Jn6 cvfiotdrnl:nq minute
ventilation a.: drunvrtifio,rntrnlinrr tidal volume ttio respiratory rate odr,:'loodr':ttdoniavr*,r
ao'radrr lun:dd'hiaTrrrn'lfi4ur: (PaCo,). x MVr = (Paco,), x trlv,ld rdomrnn:min exhaled
tidat votume ldrrnn'jr tidat votume fis'"d{ tLe;o"n:rnr:trratolo.:{!rurnnjra"stnnr:tru'le
aotrnia,rtjrurrl'lofintl'li nrrno exhaled tidal volume viaao respiratory rate n'to:rir'hi{rJeu
fllutero!rvfioulrrndu droornnrudotnr:ro.r{ rumnn'jrrirdns.ili

+. lun:nidfufiotc'rrfiun'nnralnqro,,:nT :d{rJrunru'lor5r uovufilliqnrouuruu4fifi
4t d.:orelir respiratory rate rfrrdurfjodrunn work of breathing to.o{rhaoildtirn:rt rfio
lufiltmor nrqldrrdr 6trioul fln respiratory rale n\:rt'l nl1ll Lfixr:f,rtto.:fi ru

rHrolnfrury?'r

irlfiu alarm 5u '1

ruilzr)ryurnrl lfl u{ rg rrr or nr: nmBanrntlrJoo/ flu1Ban'r?i onUon

alarm fu 1 fi': re*a,Jd'r u ur uta aiar;{r'ttfiu.: - i/etabolic /

- Lung endocnne

parenchyma d isorder

- Airway - CNS
- Pulmonary
_ PNS
vessels

- Pleura
- chest wall
- Abdomen

Iwuqfii uaa,tnzufrltf,tynttianufithantu'lq5t nia nign rcspiratoty rate alarm

ildd'rrnodriorr,nrd- r2u.y3ruPlc?u'tirrruiofl"qrv+irroi:.r ldirlnr:ifiodutiu community acquired pneumonia rru;d
0.4 tidat votume 400 rn. d'm:rnr:vrah ts n:s.:0iourfi {ilru

nr!'lc gz n{rpiourfi q:'re arterial blood gas n:.r'ir pH 7.52. PaCOr 25 mmHg, PaO,80 mmHg.

HCO3' 20 mEq/L nr'rlvrx pressure-time curve fidnuruvd',rnu virufiuuflr.,r1unr: i:.irniar

tirurruleadr,,il:

Tailored \Irde Vcnlilrurr Adjuslment /fniuni nfrfiffi| 367

nfr e mat pressure-time .u*t firttJnnn'llnnlu'rluzifrnlianannan pressurc laufinzanadu

d1,t mi d - i nsp iratory phase

rj:cr6ufifio.rf,m:.ur

1. Arterial blood gas rrf,g\tfl'nB :flo{ mild hypoxemia. hyperventilation Ltai acute

respiratory alkalosis

z. f,rynrriolilf irr:ilirLrrfibilrpnr hyperventita'tion [[Ry acute respiratory atkatosis
otir.,r'lr unyn:nidfillJ'lfntdflfli (PaCo,), x MV, = (paCo,). x tVV. ldfiia1rj

3. dncfu;tat pressure-time curve |,!do{dnuruyto{n1ta6n{10.i pressure tudr.: mid-

inspiratory pnase ittr lfflluowprreastesunre:f-itfimlrjeoT"rrTre:niiafoiorens6pifriaottouryflbralotesnldr:lrfdiroJ'rftlindoasl Evo1lnum1fefluf'iliqo
tlitJ peak inspiratory

na.,rdllxu lnnjlon:rnr:rrulomorRia.niruyruledn'.Jid.re:riorilgo:1eaco"), x MV. = (paco,),

x t\,'tv, n: nidi.il fl r rJ'l?nidd nrn",r n 6i1x16

a. tuffJru:rud rijo:Jir tioat volume tfjrdu r:drlfi respiratory rate dtfl.: rnyrfiarrar

l.jrulilrjrwd.r respiratory drive ?ioflan ailruofilfi minute ventitation aonn fie:[fi.lfliJefir
hyperventilation'L{ dtHntfirir eaCO,'lnfir6urfrtldrrJnfi

s. n:rJ nr: ufi l1fl 11 1 pressure lu::uufi analor'.ludo{'lu [slu{ifi 53

d1odtd 2.4 d lusluorq qo fl ldfinrrifiro'u rflu community acquired pneumonia trurdld
rnia{.Iirunrah td FO, lyilriu 0.4 tidal volume 400 a. a-ofln1rfi1ulq t s n*.r/urfi {r-lrur,r, ulo

te ni,tfurfi ni'r? arterial blood gas rujr pH 7.48, PaCO,30 mmHg, PaO2 80 mmHg, HCO,-

20 mEq/L yiruesfi uurrr.rlunr: tlrnia.:drurrrLleodrJr

rJ:crdufif,o{fiq1rilr
1. Arterial blood gas ttdo':6'nsru:lo'l mild hypoxemia, hyperventilation lLfly acute

respiratory alkalosis

368 ntrjrtialnqndu5ru

Low arrway pressure alarm

/arirfi4rlrn /irrnoaru airj'lu n nrs6.'Jrn€oidauHruln
arurvlulqrdr
drgur volume leakage
Inadequate volume / flow

r n?4u?u uand'rrllru uriialounrsrjir-r tidal volume rdndu
- Endoiracheal cuff
- Ventilator circuit rar nlri dr ri o
leakage
leakage udlzlnunrsuiurfi$ flow
- Dislodgement of v€onJ6surflu Pcv/PSV modes
- Bronchopleural
endotracheal tube urnlildrrEo
fistula
- TrechesophaBeal arodo.'flri sedation +/- muscle

fistula retaxanr

suxugfri uaa,tntuilzflrynttio pr.""rre lurzvvanao nia low ain*ay pressure a[arm

z. irgnroia}Jfi'jrr:rJilrrfiltirgnr hyperventilation [td: acut6 respiratory alkalosis
adr.rl: uo;n:dda'ur:n'ldqor: (paco,)r x MV, = (paco,)" x MV,ldviolil

3. nrriiftildlil1rnna respiratory rate ld' rfio,rerno'sr:rnr:v, t'lota.t{rJru rnn'irastm

nr:mulorarrn{o{dluv,utedrfuli dro:tTnfillgor': (paco.), x MV, = (paco"), x MV, nrddil
lriour:o'ldgn:ftndrrtfiaon respiralory rate ld usiaro iufln tidal volume n.,:16'lnuniurru

ldrrngn:er',rnrirr

q. odr.obfirnilrdorJilrnq tidat votume udr lfidonrxdru'l'r{:jrufiornr:urulenor rndou

{unia.tri il1nidxufin1?vlubrirdu nr:rJir tidat votume ltntrdr16r un;1rido,'riirrniatti, a

rruh6n rfiorornndi{:hunruhrfrn'iraio.rdruilruhfirorvol{lrirfiu s atv':hjrfludun:rudoflrhu

Tailored lvlade \renrilator Adjustment nnfiinf nfrfrftg A69

siradr.rfi zs firhutruoru 70 fl ldirnr:i0?o'uliu copD with acure exacerbarion 'ldirnr:

drumu'lodru noninvasive positive pressure venlilation (Nppu lqu'ld spontaneous time mode

n"o rio, o.+, tpnp a qr-fi. epRp + sr.f1 {rrruuru'lcrdrri'rrncoid6 oiaufirrrunruhTosld

accessory muscte turru:6rfiu:irunru'lerdr rrunri{qrrnanfi.rnrry auto-pEEp o'rdrnr:rfir

epnp rflu o rl.rir 6n z rhTuodolr {ilrufilo,,r c??e arteriat btood gas I'tlt?1 pH 7.0s. paco,

80 mmHg, PaO, 80 mmHg. HCO3- 32 meqL riru6o.irornrriuro,,rfirhurfincrnclyq'lntrn

dqn un;o:fl o,lri'ulritfi rfi oornr:6lldodr.olr

rlrsr6udfia,rfie1flur

1. Arterial blood gas ttdq.:n-nnru:tar: mild hypoxemia, hypoventilation ttoy acute

respiratory acidosis

z. d'r rflrlflo,ra'rn't:lrllu{:Jru:rudrfioorn cq narcosis filLllerflornriraulaoonlzri'n",r

rfinernnr:d tidal volume aoar rdo,,nrnt:o-uto\: pressure support agfl{ iittu nppv orur:n

dlu'rnt pressure support ldlrn lpAp-EpAp d{:cd'uto,J pressure support q;finnriarir

nr5uauln oo nb6lorun:.t

e. 1u{rhu:Tadnr?rfi EpAp + su.;l riu o nr.ri'r Talii rpnp n,ld6a e mJ.;r
6,,:rirhinrundo nir.r EPAP i:o1u press"runre
support nofl{ sioora'hiffrrrdrnrSrauleaonlndntr

o"'rriurfioninr:rfil EpAp ufi? nr:rirnrtrfil tpnp d?uFirdrdrfiu rdotri::d'tr pressure support

6{tn

+. nr:ufibfleynrronr;nrir'lu{ilrumud nrn{rhafr.rrrn nr:fiqr:rurlairiatirunrulc
lfi o,:l'rn t'tppv lriaur:n'ldlu{:-hudfi ornr:6r.rrrnld

IPAP = Inspiratory positive druay pressure

:EPAP Expiratory positive airway pressure

Inlfr nna,t pressurc-time cuNe'lu Nppv lu{,ttnnh tidat wtume ild?1n ueev dua2lriunahwa,t

IPAP uai eee dtdatou pressure support2.a

370 rrttitintnqndugru

nr:rlfi .lnior:ieslnstelfi *r$'l cf,r m x&6ilion1?! d1{'l

in-rorjr.rrt 3.t {:Jrutraorq 45 ldfunrrefica'utflu community acquired pneumonia ldiu

nrrinurlulofiguovldrnds,'rdruv, u'lo riau'rornr:1u u:tdurflu acute respiratory distress

syndrome 1nnosl to.,td4ttrunruhr5r :laoT:oon 15 a/! . Nnnl:ttl'ia arterial blood gas
rl'jr pH 7.24, P&o2 25 mmHg, Pao, 60 mmHg. Hcor 10 meq/L virufiuurmr nr:rjil

rnio.:drflvruhodr,il:

rJ:crduido.lficrtilr

t. nr:rJiurnds'lrirunrutotu ARDS 'idildnn1flB{ Lung Protective strategies ntirrda

'ld tidal volume tuton'rfia 6ln./nn. to{ predicied body weighlsoe'o]nulr.r'hi pl"t."u pressure
rhu so til.f1 Tnuinr+r:cn''! oxygen saturation 88-92% 6.lel'uJ ARDSnet trial rflunlr 5!

rnlo.,rd, unruto'lu ARDS iinlilfinltcdtdrldru drunrrld \r'olume control ventilation llo pressure
controt ventilation riuduaqjrYlirflfirndordrufirulectlr:nfnutlvn-t-t plateau pressure ld
rioun'jr za-go ur.rh nialri urnuurlir pbteau pressure 4,:n'j, za-so ml.rir nr:rfranld

oressure control ventilation rdoilo.:fi'unr:rfi o barotrauma

2. Arterial blood gas (ABG) fid'nbru;so\: hypoxemia, hyperventilation LLo: metabolic

acidosis d.:1un'nrJfurniafiirurrutt metabolic acioosis do.:ld tidal volume rulrtg{ 1o-12
rn,lnn, niorrnnjrdrci lflu dfu t:r :Jtmru 1:2 fi{ 1:1 u'r:r:{rtrun{lddo\tn'li inspiratory
time urrn'ir:lnfi :Jir respiratory rate }ir5rnirrlnfi noi'lrjnr:rfiu 25-30 ni.:/urfi tdo{qrnnr:
:Jirrndo{tiruflrulctu metabolic acidosis tflunrdi:ltfja rduuu:.1:t Kussmaul breathing dttfu

n'ncruvnr: rutclnuld tidal volume ru'rcrg.o narlunr:rrulordrur':n'jtln6 un:o"nnnr:vru'ht5r

rudLirS'urn

e. {rJru:T uflfiirnr:ificdurflu nRDs dx n-! metabolic acidosi" lun:rf,di.:'lrjorlr:n
:JirrnSo'rdrrvruloloild L-ung Protective svategies otir',rrrfic3.ild n".:riulu:'rudnr:rJfil rnio.:

rirunruhlnuti ttdar votume dlrnnir AFtDsnet triat 60 6-a rn-znn. rniorrnn'irdfi.d.,flt lt
nrrfififi metabotic acidosis fi1uu:l d,t nj inspiratory time u'l?n'j't nA uai respiratory rate

rrnn'itln6

+. nr:finnrrfirirr:rudtunrfin"ifi tidat votume turnc,rn'ir:Jn6tu ARDS fiotfianl

ptateau pressure llti4on'h zg-go tu.ti. fisnruriruic6lr:r.ronrdog'jtfio barotruma nioLi
fionl arteriat btood gasloug pH 'jrrfirduniolilrdodorld tidat votume turnfrq.rn'jrilnfi

s. rmvrti{gunda,r$!'ru1}J14'rdlrfie,nfl{ metaboticacidosislun:nidfltrul6funrrifiqd'urflu
community acquired pneumonia irlnirflonrrvoonriou o.:r,rzuort?lr' o.r metabolic acidosis rjr

lvrfinrrn sepsis drl.rril acute kidney iniury (AKl) uvrnti{fnrT o'redotmreq'irfirdolnridrirlfi

tfia ventilator associated pneumonia n€o'lri iruriufiqT :rutnLt renal replacement therapy dr

gTailored lvtade \,'enrilaror Adiusrm€nr en?unf nfrfrL 371

oi riju rir:rdnlirolodrnr:diurnSo.,niruyrutdu metabotic acidosis riurflunr:fnu1finlrli1
srtrrrc{oournn rrsilriltinr:inurdnr':: fio,ltrnt lyq6uflfl,i metabotic acidosis llnytfinr:inu.r

ir drurcrJo

frrarjrofi' 3.2 ffiJrurruaru so it firJri6drqrlrfluhc"i.r ni.:d:rr1:.ruurrrnldo.:ernfiornr:

rhoriot l6iunr:irieafl rflu acute atcohotic pancreatitis oialtfiornrrro:t rrdou 1d:"ln'r:ld

vioriruyrutc[rn;ldrniootirufirulqrfia.rcrnifcdu ARDS fiilxufiolnrrrlor6orrn n??q arrerial

nlirblood gas pH 7.24. PaCOr 60 mmHg, paO. 60 mmHg, HCO3 30 mEq/L ltcuydin tidal

votumeld ts0 ra. io plateau pressure ld eo flJ.lil fo intraabdominal pressure ld eo m.tjl
(flharrin eo filnnir.r1 virufi rurnr.,r'lunr:rii!rndo,rtirfl ilralcoEir,:l:

rlrcrdufidorfier:ilr

t. nrrrJir lnio,ltirunrulolu AROS TnarJnfi'ldya"n Lung protective Slrategies rd. d tidal

volume tulO0''l

ABG Rflo'ld"nE yfloi hypoxemia, hypoventilation LLng respiratory acidosis

J. lour.lnfinrrtdrnfo,:riraylfllcnr::;x',rbi'hl ptateau pressrr"'[ rfiu zg-gO mr.dr rfro
iqla.oedtutr'?it!t.itfrn barotrauma n[u;rJ, uurdrrl urio: r€fiutut,d.t 'jituD{inlru:rufi nr:nl ptateau pressure
'lfio{1u::d'rolntirr drhhfi n hypoventitation d,,rHolfi eaco, g,:

4, n1?fi plateau pressure a.:tu:rud rflunrnernor'trJd' utiorfio.r (intraabdominal
pressure) f,'r nri ptateau pressur" fi4.:l*utunrrfld lriooarorirlfirfin barotrauma rda.,rcrnrflu
nrrrduotnntuuandfirunrion.onl oiurarirlin.rnruvltl 4iluernd'xrrn ptateau pressure fifl.nrn

I:nrJan drlfiq':orturuer'roon d.rrdurrdonrlfio barorrauma o-,:riulun:rfidorm:nror.r'lfi ptareau
pressure aun'lrrir n6ld

s, irynroial:Jfi'irr:uortfi ptateau pressure grnirnirrJnfildrvirto "lun:rfidotrr:nuot
trl pl"t""u pressure omiuldornalnr:d 3

7*onrta t Plateau pressure fiuoili!-ld = plateau pressure tun:nltJnfi +

2)(intraabdominal pressure/
I

6. nrninltlflrurrr c'{nr rrnuo hi ptateau gwsuldrvhfi'l 30 + 1solzl orrr:naarf:t
+s m,rir
ptateau pressure 'h -ldfr

. tflnrflu Volume Control Ventilation 1VCV1 otuolli:t Peak Inspiratory Pressure

erp) inillii so gu.ti', rfia{crn ptP tu vcv mode rrnhifif,rlrrria.r airway resistance fifl,:

drrar PtP !!oy ptateau pressure o:oirrriurJ:uJrru 5 rt.rir dtriui.roultnrJiu tidat votume

372 letrirrYai n q urfrugru

}fiqduU tiorrilrlfi high pressure alarm timit du}ld so t1.rir fuo:rrfildrynl hypoventilation

1d

. v'tntflu Pressure Control Ventilation (PcU etuolJi pfp lnilldnt 45 tlJ.l.il

rdorotn pr"rrur"-time curve 'lu PCV mode riu rir ptp tlfl: Plateau pressure qlfirillvilfi11
rioriui,,ralrr:o:Jiu inspired pressure 1re1trigtdulil nior:rilrJil hign pressure'hlqdu'hd as
n.rir 6m; nfilderfl hypoventilation ld

t+P ramp + P ramp)

gld s umt pressure-time curve 7u PCV mode

dodrrnnornoYratir',rn"rn6i'rr o; niuld'irorrn4no.J plateau pressure g,,: ororfioldcrn

-t}',Ifl'lud1l?1q o{u

1) fl1rfiqa1nrdoilao (lung parenchymal dtolo lflunul6onrvrtu alveoli vi0 interstitium
frlfi rdu nnoS, left-sided heart failure, alveolar hemorrhage

e1 ar$rqflnrfi a{rrloo triu pneumothorax, hemothorax, pleural effusion

S1 ortvqrrnzuritn??\tan (chest wall) r'du massive subcutaneous emphysema. morbid

obesity

4) orrvqq'rnda,ilio.r ttju ileus, hollow viscous perforation
5) d1!xq9in right endobronchial ir{ubation tda.:mnJoodrutrrevtnoarrv hype nflaiion

rir'lfi atveotar pr"""ur" godu d.'rnrnrir'tfiiaeir plateau pressure ldqrdu

ifrrodr.rd s.e {rJrunftorq 40 ldirnl?iieduuiu gram negative septicemia, ARDS tto:

acute kidney inlury tru:daqjuuno{rhuarriqrrn:ti,,,:hiorrr:nrir renal replacement lherapyld
lurru:d n:rqr-o PlPld 35 tu.rir s':ro arterial blood gas l/lJ pH 6.98, PaCo, 20 mmHg. Pao,
60 mmHg, HCO3'5 mEq/L uoncrnnr:hluriifiru: rrarnr:'lrt sodium bicarbonate ltdr viru
fi uurvrr.,r'lunr:lir lniordr uvT uhotir.:1:

il:criudfioofie1rm

t , nr::.lirrniatti?ux''tu1c1u ARDS lnarJn6ldva'n Lung Protective Strategies d',r'lfi tioat

Tailored \,lade Vendlator Adjusrment nnfuni nfrfiug i7B

volume rt1.l'rqsre'r nyt respiratory rate t6r drunr: i!rnio,rti,:uyrutdu metaboric acidosis dor:
td tidal volume rurnfl.: n",t respiratory rate t5l

e. ABG ueo.tanraucra{ hypoxemia. hypoventiration ltnr respiratory acidosis irrd!

metabolic acidosis

g- lu:rudur:rcio ptp'ld ss mr.rir d,,rq'rn'jrltn6 uavuurrrr"lunr:rjiurnia'rirurru'h
oo.rnmvdn-n*furiu fldrnio'nirwrra'loorcfiilr:r6u.jrfirrfru nnos nr::Jirrnio,nirunruloTnu'ld
tidal vorume oir Taunrlnr.J'lrjlfi prateau pressure rfiu za-30 tu.ri. ,rrn prp fltn.jld a1efl"1lfi
tfi ot barotrauma IoUlallr: pneumothorax

a. rfjofirj::16unr:rjirrnio,rrirunru'lcdrToufirriuro-:rdud ftiilm€o.rtirunr'redar6o
'jrnrr:lorsiun'irvionnnrrrio6in (rife threatening condition) *rrnn.jr lun:nidniulfid'nreuir
pH 6-98 rrnsrfiofiqlrful ABG rrfirltuir metabolic acidosis roiun.ir respiratory acidosis 6n
r'rs,rrrnr.lojauvrlrlfl6nhjuru {ilraorlrfin cardiac arrest r1nflr1; metabolic acidosis firu[:,:
d{riue'.:arr:Jftl rniotdrunru'h'hlvrr metabolic acidosis rflurd'n drunlrrn-,:.:ntoofi'ldrnCor
tirunrulcrtnd'1'irorerfin pneumotnorax ldriu riilrirircvrfinluaruyd yiofitnnlfint*ul3,rfi
otrT :nld intercostal drainage ld

s_. o-"rZu,"qu-h-,{,ilru:rtfXi -c.,rnr:r.Jilrnio,rtirufirfltolouuortd tidat votume ruroo.,.: nju 10_

12 xn.inn. niou'rnn'ird fnuao ptp g.: oroaaildfir so-oo nu.rir nio'rirufiloarruqna.r

metabolic acidosis mylAeTrurrit renal replacement therapy louiloiru

gntrrlfr rrfln{fl1rMqflon cardiac arrest ,'bH. S'l-' qltJ CpR guideline 2O1Oj
. 5H : hypovolemia, hypoxia, hydrogen ion {acidosis), hypo-/hyperkalemia hypothermia
' 5T :lension pneumothorax, tamponade (cardiac). toxins. thrombosis (purmonary). thrombosis

(coronary) I

|

in"rorir.rfi s.+ {ilTur'rf'rorq zs ldiunr:ifiqdurilu morbid obesiry rrfly nRos ornrdohfo

H1N1 nt?e ABG 1,l! pH z.iB. paCO, 70 mmHg, pao, 60 mmHg. HCO3-30 meqZf tot eteld
so rr.rir yiruo;fi uuryr,r'lunrr:-lir.lniartiruyrulootir.rl:

rJ::rfufif,o.rf,cr:nn

t . nraliurnio'rdrunrs'ldu nRos lourJnq'lfiin"n Lung Protecrive Strategies ii.rti tidal

volume lu'tqo|t1 n3,,1 respiratory rate [5')

2- ABG rtdn.ta"nHrugtJa{ hypoxemia, hypoventilation ttny respiratory acidosis

a. {rJru:rrdrflu morbid obesity d.lflunrrcdlonsuluurn (restrictive rung disorder)
st'r rfiurrianr:rfio arveorar colapse ufi'irlrifi nnos finril d'*rriuiu:-rfldufi.irrflu ARDS finlri

374 rrtritiolnqordugru

rusi atveotar coltapse ii rfiodu lrjldrfioc1n ARDS rfluOlnql6odr',:rdar uritfiocrn morbid obesity

tfi n?

+, ete d4dutu:rud arcrfioldern ARDS lrflv morbid obesity o'.oriunr:rlirrnio'l
ti.ruurulchi tiOat votume 4.:n'jr nfitfinriau rdu a-tO un-znn. rjm:drurtfiltilqrl hypoventilation
ld Tnulontnnr:rfin barotrauma 1q:rinn:uldriou rvr:rv ptp frrfiuiuriulrildrficrcrn nnos ud

rfiu,rarir't16ur

{a-rodr.rd 3.5 {rJrutruorl +s iJ ldirLnr:ifico'ti nnos etn pulmonary tuberculosis rut$

roda.:drunrulelnu'l{ pCv mode: pressure trigger (-)2 tu.ti't, riOr 0.8, inspired pressure 18

rll.fr. t,e = 1:2. PEEP tz t*r,ri,, RR zs nr3,rnlfi rdarrfinruri'ulnfinnn fl.r rfifll! o ndrudr u

asn.: ificofl left tension pneumothorax 'ldvlhntt'ld intercostal drainage flr,rfiru vo".ltdarril

o'llofi nnobr.nrfl urlnfi rirufi uu'urtlunr:q",r tnCo{tirufi rslqodr,,r1:oiohl

rJ:crdudfis{firrrm

t. {:lru:rudificdu nRos q'lfl pulmonary tuberculosis tturvn.:'lunr:sls,'ttnio.ldru

nr utq tflul:Jnrilv f,n Lung protective Strategies t't'r'[:J

z. dourfio bft tension oneumothorax d\:tfluarclflu barotrauma rniatflunrr: urnnSou

ornirul:nrJoofrld

s. orlfi{rdr'leirrfratfier pneumothorax ttdr nr:t$ prEp rflu{ofirlrailo d,oorclritflu

olnrtrqiora n'r:td prep r v rfluflor{u'lu pneumothorax rfis'lrjfi:oul:afrrJoadtfltl alveolar

infilrrarion ddo,lnr: pe ep tunr:fnrr lu:rudr, nlulfi peep rnu aovtlaat{r.rdrflu nnos ev

rfin cottapse *nrrirbirfin hypoxemia dSun:,oorrlmld rrfi'jro:1fi'ld intercostal drainage udl

n0l1ll

a. d'oriulu:rud6.:arrld prep tvir t6nvioorenna.:rrnnoludrlrirfin desaturation ttsi
lrinr:nqo PEEP lilrau $ior.rniud}ivrururtron setting rdalfirfia barotrauma lrndqo lnuno

$itidat votume rfifio q-6 xd.inn. respiralory rate ldti'tc'1lflutdolfiIfi minute ventilation 1nd

r6u{l6rJ 6qnr nBG lurl:;rdutan hypoventilation ttncfionr nrYldrui,:fivr:rtonrdog'lrrfio

barotrauma t oitJoqfi r.:1r1rio1ri

ifrarir'rd o.o {:Jrutraorq +s ldiunr:ificdu ARDS o'tfl pulmonary tuberculosis {dru'ld

rnSo'rdruvrulc1nutd pcv mode : pressure trigger C)2 ll.rir. rio,0.8. inspired pressure 18

m.dr. t:E = 1:2. PEEP 12 $ilJh, RR 25 Fi.t/u1fi doil'tfinlild'uIofiqnn f,,ltfiu{ilaqdlufilu

onnl ifiedu left tension pneumothorax ldlhnttd intercostal drainage ir',rfru ooon g iu

yn,l'td intercosiat drainage atJaDnnaao virufi tturlr',rlunr:rJfurnCaujrunrdootir',rl:

Tailored Made \renrilator Adiusrmenr @n:ruvf nfrfiL1Jg Z7E

rltsrf;udfio.tf,ertrur

1 . dd1fl fl udifi q{i'u ARDS a.t n pulmonary tubercutosis uuryn,rtunr:n!.: rnia{tiruyrulc

tflu'l:Jnrlra-n Lung prorective Strategies r{rl:J

2- dalrrfio reft tension pneumothorax strrfluarrrflu barotrauma uiarfluatt;urnndau

ornirul:nrlonfild ua;rioufiuiraon r.t intercostar drainage naon d'.lusuo.,rdaofiofi,,rnr.::

bronchopleural tistula

a. yfintunrrdlrnda.rdrumu'lc'lu bronchopteural fistuta rfiu1:Js-lqr:r,rfi +

. il4. ufinru rfiueirulrr! uiu'i{rinr:1d pe ep bronchopreurar fistura frnrr ucflu{rJru

ludrflu bronchopreurar fisrura tu Rnos drnr':'ls peep iu ARDS rftn.rfi:l*Iutrio! i.,r'hi

orrrrnrfinrdmnr:'ls prep lufi:-hu:ruftfi dhilftnr?v,iu'ur'r fla setting rdobirfin barotrauma

rfirniion lnunn ridar vorume ru6a q-o a.lnn. respiratory rare Ififirc\fluliiotrild' minute

ventilation tndr6u,rrdr 6nnrr nec turl:vr6uso,r hypoventitation ua:6nnrrnrrriruf,rfiy:rron
rdoo'irrf,a barotrauma la..::Jooflr,:lrrt?olri

1-I . r*1oTrj1l"ioun.unrah1u bronchopleural fistuta,

1. Mode fi1i, Ulunr:nrtr'le uarururfinrFu.J contror mode rlnr:rir'lfinrrud'ulurio,rn:r,ronar rir'lfi

bronchopleural fistula lriiJq nr:r6an spontaneous mode niu pSV mode rf aacrnqrtld'u'lu

::uiriqurrn rfi o uJi tr:l rfiuuilr controt mode r ur uubhbJrurt tir rnia.,rri.:unr ulolfirirfi oorfirrirld

::2. ors'r tidal volume lutnqh rnr 6-g rn./nn. rioiotrnir rdonnrllrqsa.r brochoDreurar tistuta

3. nq inspired time lsu

. vcv mode rirldlnunr:rfil peak inspiratory frow rate rfiatrirrnrnr:vrulcr{rtua,r ?irtlirrnr

nrrfirulcoonu,l1]f'u uanqrndflrrr:ou:*1lt dt{ (configuration) fl on peak inspiratory flow
rate rflu hatf deceterating waveform ttio square waveform rfiobi::ustrnrlunr:firu'lqtdr

flun{
. Pcv mode rirldTorunr: iL t:E lsuq:,l
. ilPSV mooe rirld'Tnunr: expiratory trigger sensitivity 1fi6,,r lrnn.jr zsx rdafiq:drlli ftow

n:s r5rdu riuflobi inspiratory rime tus{ fr'hi tioat uotrr" ^ruo fiujrsnoruroao,:

bronchopleural Jis'tula

4. a'onrnr:nrslo dowso6rrj::rrru to-zq ai{0iaurfirio:rrnn.jrfirirrfiu lorufionrrt ptt rm; paco,

91n arterial blood gas

s. ninrfialnr:ld peep uio,,rcrnrirlfi bronchopteurat Rstuta lriflor

376 rTtrirrinlnqadugru

nearird a.Z {'rhurruarq OS fl ldfrLnr:ifioa'u intracerebral hemonhage fifi midline shift lrnr
fi aspiration pneumonia riorrarnrmo.,:f:a?uttr.idulflu ARDS llrusftdilJnT {dviodxufiluta
luovldrnio{tirsyrulqlouU FiO, 1.0 ufi116 oxygen saturation ZS% llns'ldrir hyperventilation
rdoaanrr: increase intracranial pressure rrdr rilufirrurrn.,r1unl:rJiurnSand,lu ru'tqOdr'ilt

siolil

rJrvr6uifio.rfie1:rur

t, {dru:rudifiod'u ARDS q1n Aspiration pneumonia ttulvll\:'tt.rn'l:d{tnlo.rdrunru'lo

rflul:inT lndn Lung Protective Strategies rirl:j

z. {rhu:rudfinrl: increase intracranial pressure o1n intracerebral hemorrhage dl

16r.rnr:ilirro{ordruvru'loo'rclir hyperventilation rdolfi eaco, nern{ rda'lfifinan16oodbJdst
f,l.rotvnd'r (csrebral vasoconstriction) dr'lrt intracranial pressure noa,:16 rroiflll:iunrutdo
1 n'nd1 hyperventilation 'iu increased intracranial pressure daul ooaludr

s. Inailnfinri'Ifi peep rfludofirilu increased intracranial pressure rfio{mn PEEP c:

rirtfi venous return sln internal jugular vein non{ crnnm:Jdulutiotan lintrathoracic pressure)

ii,*
1I LfiIJflU

a. orlii{rdrtvirnr:'ld peep rfiuiafiu'lu increased intracranial pressure 'lurlnn:fi
d,lflunrurfrhfilrigndor ur:tmnrfluarrrfr PEEP ldJ:y1und niu lu nRos dfi increased
intracraniat pressure tdutu{ ru:rud rfl:rcrrnbjl'fi perp rau fiIilfirr'lfrccinB1 desaturation

ld rrn:vrnr.leioutfirfior desaturation sio1il evrfior brain ischemia *rrndu d.rnrn'lfiolonulrLLac

rfin increase intracranial pressure lrndil:J6n

s. dhiulu{rJrumud lunr:fnrrr desaturation i.:nr:'ld peep 1u::olt6urfii-rnr:inur
ARDS li"rl:J rSorrirtfinr:inrrdudd, uno intracranial pressure vthnr:njrn"nrlr'afifiorj'rd rrnc
rirnr:'tei intracranial pressure monitoring rfiofinor flonl:inul'lugoT ufrfiarlr:nn"rld

dmrirld a.e $hw1ua1q,rcilldflnfiifiodu!flu ARos riruldviotiruvrshrraddrniomirunruh
oY,l rnia{drunrub PCV mode: pressure trigger (-)2 tu-ti., ri0,0.8, inspired pressure 15
ru.ti . t'e = 1:2, PEEP ts t*r.rir, RR z4lmin in exhaled tidal volume ld 400 n. qtle arterial

blood gas lr:J pH 7.32, PaCO.48 mmHg, PaOr 200 mmHg. HCO3'28 mEq/L Yi'lufiruxfl1n

'lunr:ilfi rnCaorirurarubodril:

ilrvriudfia.rf,e-nrur

1, niflilr1ililrumriluninifif,,thflfiornr:fiduufir tfiatorn Pao, 200 .lloYl nt'rflu

oxygen saturation 98-1 00%

Tailored }lade Ventilator Adiustment nn?uni nfrfinty 3jz

2. Arterial blood gas rrdond'nr ;fla.r hypoventilation !!flg respiraiory acidosis

s. lunr: i!rnSo,rtirrrrulotrild oxvgenation drurLrrd:.r fir}1rrii6o,ofior:rur.jrc:rrfirno

noz r5o:Jtloo peep tudflr{6ona'n'fi paramerer setting'1nfiil::Tufiin.ir 'lfin. { d.:u parameter
setting lonitfirfiaorodr.':16u.,rrrnnir tfiltiuno lufidrflumfidtdir.rnr:ificdu nRos rdalrjuru
u.d n"ou'l pe ep 6,:rflu paramerer setting nifi:Jr;Tuni rfio,rornrirtr{qrorrflod.:n"r'lfinr:*an

rlfisuffrra'du drrflu parameter setting derr:arli dru Hor 0.8 rflu parameter setting fi
aurrnnnl6 rdo.rcrnlrnfr.illu.rufiTanrorfio oxygen roxiciry ld

q. tun, :rjfi rnio{:irunruhhild ventitation firnrrynl n.lrJfr tidat votume rfitdu

nlrfluaiusr:rutufit'rg:rud rdo,rcrnorrrfin barotrauma ld rtrlnr::Jfu respiratory rate usuhifi

uirlflurfro'rern u'u pH u-.rogjtulnruriiiuariuld lrrnn'jr z.zo1 o-,ou'ul'rlrifinrr q"'rrfludo,r
:Jil minute ventilation 6fl

fiearir.rd s.s {rJromuorq +o flldfunr:ified'urflu nRos viruldviotir lrr u'h ua:'ldrnio,rtiruyr ule
o'trniorti, utrrutc PCV mode:pressure trigger (-)2 tll.utl, FiOr 0.B, inspired pressure 15
tl.utt, l,E = i :2. PEEp 1s t:l.u*t, RR 24lmin 1-q exhaled tidal volume 'ld +00 n. nrndrg
Srdy:'l.oontuautalv"':'hdrufirufro rou:ttn n??? arterial blood gas ru pH 1.32, pa]o2 4g

:mmHg, PaO, 100 mmHg. HCO3- 28 mEq/L vi1ufi !r ?ytr.flunr:rJfirnio,lrirullraleoijr,

:Jlcrfiudfia.t^rfi.ur

t, n:dn'*r:)rlurrflun:rfidfirhufiarnrr6duudr fio.rqrn p"o, 200 ur.:Jrsn n:,:ni'

oxygen saturation 98-'100%

2. Arterial blood gas !!6tfi\rn"nr*Iuglto\: hypoventilation uay respiratory acidosis

e. tunrrr.l:"lrnio,nirlnrulotrild orygenation firnrr:fi1 fiiryrrfido,rfilr:zur.jrc; i!nn
Ro, rSo ilnn peep tudfiriEqfia-n.Jr parameter setting 1nfiil::Tuffiin.ir Lin.ili dru parameter
setting lon"'r'trlrfinrundrr16u,rrrnn'jr trilliuao n:rfirintrrirrfrfir:r,:anyryjrtollrla.rrirlqdru

firut"ntcurl1n uao'r'hfinrru:n::nirur'rtlrrovrdarjan {i',ruoo,:6.r pneumomediastinum durilu

:barotrauma ulryfi.r fi,:rfluarnqrnnrrts peep lrnnirnr:'ld Fio, luroc*r o-.:riu'lu:rudnr:

ficr:rur ir.Joo pEep a,rriourvi.rfi oxygen saturation rrnn.ir 90% louororlilon e-s ril.dh
lnutfinr rio, lifr::dr16rriou

+. lunrdilrnioldrufirillohild ventilation firumydr nr:rjil tidal volume nildu
lfluo"un:ru1u{r.l'lu:rud rltolernorerfin barolrauma ld drunr:rjfi respiratory rate rfulrifi
nrr ahrflurfio,rern u"u pH ri.roglurnnrdiilorflld' lrrnn'jr z.zo1 d'rlYui,rlrifin.lu<ir rfludo,l

tji:.t minute ventilation 6n

378 retrirfoinqnfiugru

n'rodr.rd 3.10 ti ?fls'tuo'tu zo il ldirinr:ifiedlrfru CopD with acute exacerbation fio1n'l:
xluh oxrJlfl n:rrir.:nru rtflu{ wheezing tlan ooneloaldrt unldd accessory muscle fs
rruJfi1uhrdlunJmutoaan nrll ABG u pH 7.19, PaCOr S0 mmHg. PaCO255 mmHg. HCO.'
32 mEo/L fiu:d1fi[n5o,,11i?unT ulq rflu PCV mode : pressure trigger G)2 flx-li1' FiO, 0.5,
inspired pressure 25 sil.ti1. l:E = 1:3. peep s tr,.rir. RR 24 ailrurfi in ridat votume ld 300

tJfl. firu'h sz nttr^lrfi uan?1nn1{fiu1llllufioanfl ttnv dexamethasone rtdr virufi rrurvrr.:'lu

fl 1r!i! !nifl .rd1ufl r aho rirt'[:

:J:srdu#fio.rf,cr:fll

1. fllfllir tFia.0?irunrutl'lu obstructivs lung disease firfu lo*e|. airway obstruction
trTl.fi tioat votume tutott:t 6-8 n./nn."utfi expiratory time u1xflil n6 rtn:}i respiratory rate

eir lfiariinlanratri expiratory time u'l?

2. ABG uAn.:frnu Yflo.r hypoxemia, hypoventilation trfl; acute on top chronic

respiratory acidosis

e. {rhmrudfi bronchospasm d't 1etfi auto-PEEP i'rrdru lfiotqrnfint:ld accessory
muscle lru:dfirulot{r ai':unr:'ld accessory muscle ntuv rutooanliu ironn'.: bronchospasm
rudlrilduoo.rfir'jrfi auto-PEEp v6o1ri riio{rJrufi auto-PEEP q:riolfifin dead space ventilation

du d.,rnrrufibritulltd.rnr:rofi s

lun:ddrfu PCV mode i.lrfionfre vno inspired pressure fln expiratory time 'lfiul')
oon ns respiratory rate al irlnl-rnr:}i sedation tdolttn{rhulraler5'ln'jr respiratory rate

nT:r# s uos.rnrr iutnia,rdruvruh rdafi auto-PEEP

1. flo tidal volume rfiaan iurruariidr':nolriltnru'lcoonqo
vcv mooe lfrrirnrtfl9 tidal volume a,l
PCV mode 'hif1n15flFr inspired pressure rSono insplred time

. PSV mode'h{ri, fi15flo pressure support uiorfi expiratory trigger sensitivity (ETS)
2. !fi expiratory time rfr orriirrrnrlinrtru'lqaon:vlruoonlfi

. VcV mode 'trlrirnr:rfit peak inspiratory tlow rate liovirnr:lfil tlow waveform tflu haff
decelerating waveform tio square waveform rrginrr:liltflu square wave{orm fiian'l:

:gi.t6odrhi peak inspiratory pressure g':du

. PCV mode lfrrirflTfln inspired time ol r5o fi.l expired time 'hiu'l?aan
. PSV mode'lfthm5!fi expiratory triggsr sensitivily (ETs)
3. eq respiratory rate d.:fiarfunr:rfi expiratory time iilfi.r
. vCV mode lmy PCV mode d'rlr1r0f,tl respiratory rate ldlouono 6$Lroni.rorcda{'ld seda-

tion i?tJfilu

. lPSV mode dlr.trrnnq respiratory rate'lfi

g'l'ailored r\.Iade \ientilaror Adiu.sment nnEuni nfrfrL 379

ro.r Ln€B,riiet&.rli rilr rflu'lt'[i'trirfi o n seoation fifiqrdrulufiaoon]J niu propofot t4.rnq'1rijufio,r
ldrrvdounfiurdo n?rfifinrfiu,iulfiaonqytfnrJdunrryn'r histamine Lru atracurium

+. n:rfinrtflryrr .lrjororjil minute ventitation lottd4n: MV1 x (paco,)1 = MVz x
(Paco,), ld rfiarernqn#ldraln;n:rf,frbjfi dead space ventl"arion fi}irio}irfi#rynrrirriu
lila, lr:nlfi qn:drJ:ilndootiruuru'lo'lun.:fito.,r auto-peEp ld

fi'eodr.rfi 0.11 fi xuyruo'ru zo fl ldirlnr:iiqdu rflu copo with acute exacerbation fialfl.n
uru'lqtorrrn n:mdr'rnruhivrr.r rfru.: wheezing nio rhonchi nl:;u:rrorlunrrrrulcoonurr

rfianhnr:r.lnnfirJreroonornrnio{tjrunrrjhrvjrfir sett-inftating bag u'rn 1n trucdldrnia.Jdrfl
tru'lcrflu Pcv mode : pressure trigger (-)2 tlJ,u*t, Fio, 0.s, inspired pressure 2s gu.rir, t,r =

r:3, PEEp s ou.rir. RR zq n+.J/urfi tn tidar vorume Ifi too rn. vrsh sz n{.r/urfi loncrn

nrdriulrurufinonnrJLrfl; dexamethasone Id? vi'rufiuurur,rlunr:r.lirrndo,rdruyruleadrol:

rj:crdufif,a,o -rrr r
t nr::Jir rnio,rtirfl ru'htu obstructive rung disease firflu tower airway obsrruction

'hil'fi tioat votume 1J lon'1 o-e r.ra./nn. 'bi expiratory time umn.irrjnfi un:hl respiratory rate n'r
rdorilolonrc'lfi expiratory rime u1.l

ilz. rjlc r6ufido.,rdrnr.urdrlcria}l6onr: t:E rfia.:lrnorofifirdrtlirdadfi inspiratory

time fulrn.l rglo {i.ilriliunrrul?.:rouol rdooornlu{rLrur'fi bro.,-"ho"p"", :ru:.ru"u rr.a

nrrru'looonllin o frevr"{ria nru'lorfr'lunr:vrfl'hroroiolltrflulltldmnr{rr d'triulu{d.run{rd

6tdo fi inspiratory fime fiurrni'r nfi uo:do':rl:-:.r expiratory tme'trirmaonhl6nryirfiornrfi

q:oanldvlo d-:oT eo'ldernnr:n:rcd'r.onru'il6lu.tfi'rutqoanirfi?ir{vua (pause) lo{rfiuofl1u'lc
oonriorti vrEJhririr:ourTn'hlvio'[rj rsoaToqldorn frow-rime curve laud,:rnn'lud'r,:iiuqo
nr:yluhoon (end of expiration) .lr ftow rflugudn6oki o*,r rrao.r'lu: fi o

g. n4nrin6nt::nr:yfi..r'lunr:oB:Jru.jr{:-trmrudri'o.otfi inspiratory time fiEjr.tn.jr!n660

nr::Jfiltnio.rrjrrurutcTnuilnfinr:ti:J inspiratory rime lfild 3-+ ryirro.r time constant rdo'Ifi
1d o"yg"n diffusion g5-99% louor r:nn'rurruldernR nr:fi a

aanttfi I Time constant = Compliance x Airway resistance

Tou time constant firrjruriluiurfi, comptiance fiyr-ira rflu 6n:rrr.rh Ufl; airway
resistance fivrirtrflu rr.rivfiar:fiurfi

'lu{ilru Coeo fi comptiance fi.o un:fi airway resistance 4r'lurirorrl"hrfir 1'lun:nlao,r
bronchospasm fi1uu:.ry iwirlfirh time constant arrn'jr n6 ai.,rnalfinr:n'r inspiratory time

380 r'rttirriainqnduSru

ilipld o u*at flow-time curve 'lu n. cuv moae flow waveform [auv square waveform, hatf

Idecelercting wavefom LtsJ total decelerating waveform ntudlau uav PcV node fiuIfr

it1oduqonaunultBon (end ot expimtion) tlow nauxla'llaanqabiuatigui uaa,ti'tfr ftow

ffifradl,,naudxnrlltlloaanqn d'tusntdnvruzlrr^t auto-PEEP 1u?nadulztfrda lflU dn'lu

n't,tafrfrna:rlttaazzcldlaurntf,,t6a,ra tnulcluit'tntu'loBanqo Gnd of exphatiofl d,tlart

iln6udn#adifitfraiaslnrrl{luit,tnru'leaanqn uannndffi]1adfr auto-PEEP tzflntzli

ndwtdadnnzvla'lclud:^tntt Buntmv'lc dfltnnit n6

douurroonl 6ru *nr".nfro inspiratory time dun'jr nfi doilvt'r'hirfio turbulent tlow lu upper
ainvay duabi upper airway ununtnrutdmlo.l Bemoulli

irorirl# g.r2 {r| Ufi€{alq 50 il rilllx'rfi1rusfinfi z ldu1 glipizide rtn: metformin rrl:,t
rlu'r!1ndluo1fl1r al lvfiau tdflrlllniulr tz tir1r.rt rnrvrfirla,:qnriuld'ldvio:irunrfllctrnvld

rnioudrufiru'ic 0ille ABG n:J pH 6.9, PaCO, 15 mmHg, PaO. 1g0 mmHg, HCO3- 5 mEq/L'ld

Tailored Macle \.enrilaror Adjusrment Lani ni nftftfip 381

Fio, 0.4 n:?c ractate ld z0 n./Fro.nmohivlr ufi6i{r0{n1rfio rda viruflrufirJrurfirlofigrroo rir

sLEDD (sustained row effrciency dairy diarysis) rirufiuurur,rtunr::l:lrraia,,rrirsr,rru'horjr..:I:

eiolJ

rjaiiuiif,o.rfirr:nn

1 ABG'lrilll hypoxemia vrr hyperventiration ttnv metaboric acidosis d{tu:rudrl:rqvr!

lactate g{ Tollrinurrmri.:rirrfioro'rnr':fisrdo Linunfrngrutor tissue hypoperfusion q'{6nf,,J

metformin induce lactic acidosis lrndqo

z, nr:r.liurniomi?ufl'tulqlu metabotic acidosis lflunr::Jilrniorrfior6luur.t:.r Kussmaul

1breathing lntnr:'ld tidat volume turocu lr,rooioottdrriufio.,rldrl:: 800-1.000 e.)

inspiralory time ulrn'jr n6rfinrjoa un:d.r respirarory rate rfrn'ir:Jn6rfinriotr florrJnfihjnr:

rfiu zs-eo ni.rrurfi1 nlorernn, :lh sLeoo doriu continuous renar repracement rherapy (CRRT)

::.luuufi.r lriorrr:nnialdr{ufi 6rdarrl:il rnio.:drunra'htri minute ventirarion rrnvlofro;rorsu

fiinr:cirln:o (acid production) iirdllrndulnulrjfiioohryo

g. il:yrfiudaIil6o nr:r6on'16 mode ro{lerio.:tirufiru'lq rrnfi:irufivraoroninr:lnoriuu

rfioprhinld miu nrrilo"u1afiosir nr:rfion'tfi vcv rio pcv mode rrnvrnnrcnfnr:'harisu16ao

n'rfiarlno,r'ld pressure support ventilation (psv) mode rfio,:ernnlrvru'lcao,rfi ruc:rdrfiu
nil tnio,:riruvru'lorJ'rnn'j''r contror mode tta:rir'lfinr:ld sedation/ muscre relaxant fioun,,t rir'lrt
nrrrtnGnmrruornr:rr,r:slrrl:hsflryt16 rfiarqrnnr:'lfi sedation/ muscte relaxant rirtr1 tioat

votume vr"ldra.:rn5o.rnnnr rrairicrr.lfinfiasrr ornr:vnm:u ::arvrld urirs,rddooogjlun.ltr

n un o rir,rlnfi 6n To u nr: or"..: atarm tfi rylrr yor.t

4. nr:rir sreoo ourirlfi metabotic acidosis nnff.r n"rriurfiodr SLEDD lilldilryillru
t-z rirtl.': orqfilr:rutnq minute ventilation nr Teudnnru arteriar brood gas u5o serum HGO"-

vrn'hir{rnr:ao minute ventilation n.J orqlfin respiratory alkalosis 0,ttJ d, d

ryr

nr::.Jfitrnio.:ti?ufiralqhildordunmillflr.rivrurslaniiidrr6lernra-ngrurrrnr:uyryrri

(evidence base medicine) ryirusu firn rroiil-.rdo{ord'rJdarlv (art) tunr::.lil nlduurnia,tdruyrllc
hirulr;olril{:huurdn::rufirfl d{nr: iuraioltirunrulctfildfiu:u.r"r rfludo.,rorflunr:g*afi:_lro
odr.:sisrda.,: luriahirfior{nr+y (skil) 1 n.ti i:lnio,,rrirunru'lo rfrobinr::Jfirnio.t:rirurra'lor:rq

inqrl:;o.,rdnr#cr3,rli o'uo:rirlfi rfi a:J:;Tumiud{,rJru4,rqe

382 rernirfainqaiugrl

ranfl:d1{6{

'1. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardio\ascular

Care. Circulalion 2010J22:S640-946.

z rinonEivuenryi d4ayifiPnrgac.tiecera. cntic:{atlnMflalc:hua.nfiicuaotuvdentdriuHrifolna.fllu$::froirnn"iow: zi s4sof.ifinrqir,'hzouoi-n+roi rfilfiqn. lmrul6nr: Critical Care

S. roniuni 4ifim3. Bespiratory Monitoring: Atarms. Iu : ron'zutf 4firlrrg, bainri rfilfiqn. l::nninr: Critical Care
: Towards optimal Perfection. n1,lllYi'1 : l.fiuaud r6utlofllrf irfifr: zssz mlr zst-oz.

+. roniuni 4fifin3. Noninvasive Positive Pressure Ventilation, 'lu : Lsniuni 4fifirt3,1tu5ci tfiltiqa. u:rrurinr: tm

rirrininqndu3ru tundamental in Critical care. nlttwtr : u.iaoufi tEurroflurd 'irria: zsss. urir zzt-e8.

ARDS Netwo*, Ventihtion with low€r tidal volumes as compared to traditional lidal volumes lor acute lung iniury
and the acute r€spiratory di$tress syndrome, N Engl J lvled 2000i342:1301-8

ARDS Network Higher versus lower positive end expiratory pressures in patients with acute respiratory distress
syndrome, N Engl J Med 2004;351 :327-36.
7. Ventilatory management in patients with chronic airflow obstruciion. Koh Y - Crit Care Clin - 01-APR-2007:23(2):

169-81.

B. Jain S, Hanania N. Guntapali KK. Ventilation of patients y,/ith asthma and obsrtuciive lung disease. Critical cate

Clinics 1998141685-705.

L Conventional mechanical ventilation in acute lung injury and acute respiratory distress syndrome. Famnath VR -

Clin Chest Med - 01 -DEC-2006:27 t4):601-13.

10. Basic \€ntilator management lung protective strategies. Donahoe M - Surg Clin North Am - 01-DEC-2006:8'6(6):

1389-408.

tt. ran?uni 4ifirt3. Practical Point in Shock Management; General Concept 1u : roniuvrf 4fifilt5..1ttinri rfirfiqe

l::rurfinri criticat Care : The Model ot Holistic Approach 2008-2009. nl.llanl : u.iioud u6uifltflltr{ 'irn"ar; zssz,

fi 1 115-59.

23

n'r:ufi'tqrfl ruatmTrdarrfr urdotfi rrr":ouqieufi rutq

nniuyti qfifitxg

rflufrvr:unir6loari'rh.j. nruflun.r:tfirnio,rdruyrEr'hfinrrile'rrfluod.rrO,r'lunr:oua

fnnrsi rurrin raiartjrsvru'lofinrrruehrfuadrr0rtunr:tirudrhi{rJrtnoniin {i.lfiunr:insr

:;nr ::nor (supportive care) od1,r fi*r flru;fi:aflnnr::"narc'r tfl.t; (specific treatment) otirJ:

finrrollrloooriulunr:'ldrniagi'runratofinml.ir rfluodr,.rD,r 1o a ravr r: ld 0,,: drl u11r ru r 6 o
(atarms)'lugr-Jrnloir.:1 ua:nr:ufihnr:rirrruro,:rniami.ruyruloriio'[di!nr:rdou'lu: u:.rrrir',r1

rvrnrudryl6'ndTfi,rnr:r,r*-r atarm uncnr:rLfib:lrlurrnCo.rriruuru'hrda rfiq "t"r. rir,r1

frqqrrurdau (Atarms)

dryryrrurfiour5o alarms riu riud.rddrrLrsr'ouunrriuo;narrrnfinunfirjrsd'ldrn5o,:riru

vrErtctli::fq:yirfi{nriun:r ufiare rfiorrufi'r{rJru r,rtrlarrrrnufib{rJruldorjr,:niuvir.,:fi tu

rrr rrt:.lil:firfr'bJ unmririonsrlradd,,rrniofiirurrt'lcdu fno:ovturirir (parameter setting) fi

fro.rnr:ldrvirriu vrs'rfic3{udrnr:sr"'r atarms finrrrdrnryhiriorLnirnr:nc{FirtnFdttlurnio.rtjrs

yruh rfiallrnuuur unr:rflr::i.,rfirhtrda unnsir.,rdul nrlrir.rrrnr rriu lu{rJ.laiifinrrl
metabolic acidosis i:urr:r otqdo''gt'.t minute ventilation rurnqr rfiodrhirfienllc respiratory

alkalosis ttiotnttrrYu metabolic aciOosis ludr.rd{.:do.:n",: v"eln.trilratimoninunteernvteontdilartti'ol:nfifnlur1ilo6.ilrl
metabolic acidosis 6njurrdr 6rfr.: alarm minute
lfionlxY

tnSo{dr rrul,ec:dryqrnl6au (atarms; 6rfiur'larimrl fiIrior:.rr:nrergunrrn:lqi1,tnrufin::.r

riruld n-.rusuurvrdun: ur!rniilfirniatrjrrrTuhl'rfio.rrfufrrlnnrrnvrflrr;i',r{,rJruotir,'rar'rroro

rrurvrr.,r'lunr:ntl atarms rflu'l riron:r,,rfi t

384 rtnirrininqndu5tr

In1?r\tfi udn{uulfl 1{'hn1:qY.t atarms rdo'litn{a.rtiratlrule

Alarms parrmetgr 5-10 cmH2O above average PIP
5-10 cmHro below average PIP
High airway pressure alarm 25Yo above average level
Low airway pressure alarm 25o/o below average level
High tidal volume alarm 25olo above average level
Low tidal volume alarm 25% below average level
High minute ventilation alarm 10 beatvmin above average level
Low minute ventilation alarm 10 beatvmin below average level
High respiratory rate
Low respiratory rate

nlrns{ atarms lunr:'ldrniomirumrJte 1ilehtfl!fi0tftnuorrr,:fi 1 t6[ al flltJ1ln

r]:'ru]6rutrturrrr;o d'ntrnnrunrrni udu tu{ilrufit$tcrio,rdlun'ru'le vcv mode Tounii'n'ki
orrr'o nign atarm pressure rfiu ss ttJ.fr rroirfir{rJ'ru:rufufioo6n rirlfi intraabdominal pressure
g{ 6.rfia,:ns.: high alarm pressure rfiunir gs uu-ti nrns,to high alarm pr"""ure Ljtf,u ss ou.ti't

tun:nififi intraabdominal pressure q{ q:d.:ctnlfi tidal volume fios rirtfirfin hypercapnia ttn;

respiratory acidosis n1! {d rialun:ni{ilru eRos lnuva"nre1il'lrinr:'hi plateau pressure

rfiu so mJ.fr uoidr{rlru ARDS urutfinernsrirejaudn laulSslnfiu (acute pancreatitis) i:'':fi
nrrvfio'tdnrrn rir'lrt invaabdominal pressure gt lirtfifio.raoruil plateau pressure 4ttiu d':

ri, trlfi or uor:"r nr:or&,t high alarm pressure aon'jrrit:.Jnfi dr u

ltarms fi urrio u rlac[luxm{lun1ttfrt!
1. High airway pressure alarm
2- Low airway pressure alarm
3. Low tidal volume alarm
4. Low respiratory rate
5. High respiratory rate

High airway pressure alarm

High airway pressure alarm dnriludrgqrrur6oufirdd:..iaufiqn'lun'r:'ldrnio'rrjruvrstr
{,r rfl urlernrfi vu:jauun:fi nrudrer'rg rfi a'ldrniorti':trnrub

rfran:.r{:.lrufifiir1 'r high airway pressure atarm tfirier:rurriau'jr:Jr!x1 high airway
pressure alarm r'rriiurio*rfi'ltnialri ru:r;firvrn high airway pressure tfiotflult{ni.ru1,lnt1x
or{rjfia.r'ldi:lnr:uflla nju {:J':ufi1orfiuolr'rn5t'r tlSonrunffinr:lirnr:qn tnrtrv (endotracheal

tnr:ufr'lnflrymrrdo,rfiurdolrirnloorjraural nnluni nfifimn 3BS

suction) l4rn ?y!fiuud?'j'r]qfi1 high airway pressure ararm riurfio,,rldirnr:rrfib oTn:nrfiIr
:llqrrldn u rf ro'':to"od

t. :Jaa tniomhurruhooncrnfi:hu (disconnect) oonlrnrn{altirarrale ]prrril1\ftjriau

fiducr:ru udbi:ci'lflufirnslunrrfidfl:Lrul* parameter setting ro.,rrnia,:thufi'ru'lclururoo.,r

rtjll da'rld Fio? ?i.r'lqf,n ld perp (positive end expiratory pressure) luronr riafio,rtdnr:

firs'louuu inver€e ratio ventitation {i,rnr:ld selt inftating bag lrjfirrr:nfir:drunru'hldryiiau
nr:tdrnrto,':rirurrulc filfiriolfirfina"un:rrLurifi:Jruudor''rnr: oofi raoonnrnra6a.rdrflyrulold
lunaffJrulafigrrr$vi,rfinr:rir:cur crose suction ultuiordn rn'u.rnr: narrnio.,lriruurule
oonqrnfi ru'lulufild setting rll.lefl,:

z. druilralcloil'ld seffi inftating uag dofidofierr::ri.:Tor ravrrl{rhrdld peep rda,rlrn

self inflating oag fiidrr'ldfi peEp o'.rriu6rda.rrda pEep varve rdorirnrr and,:saanmn
rnia',:ri'llilruhd'ls perp rilooriruwru'ledru self infraiing bag ufir 'hid,: rnnirfiu:,:drutunr:

uulfio ur

e.t ntnlrjfiu:rdru'tunr:fi1 setf inflating bag tldo,ii.tf,rul1.t high airway pressure
atarm rfi qornrn4o.rriruyruh lrildrfi ntrnfi:-hu iiloro rfi nldornarnrqdr.rl o:,rd

t) nr:dr high airway pressure atarm dfrm'r rfiu}l niu f{ hign airway pressure

atarm 20 m.rit lu{ilrudrJonilnfi ruflrTounr:dl high airway pressure atarm

+tfi.fl{1Ilu

2) n't:el".J parameter setting ao,l rnia,:rirufiru'lekirfl rvol d,,r uanldnu mooe

n1it.l 6\tu

. VCV mode gtcrfifiqlnnttn".t tidal volume lrnlfiu nrrrit peak inspiratory

flow rate dmnrfiu niont:cvt flow configuration rflu square waveform

r PCV mode orerfioernnr':#.: inspired pressure I'rnrfiu d.rd,:Hnrirtfi tioat

volume oldt

. PSV mode arerfiocrnnr:d{ pressure support lrnrfiu iirrirnnfrtrt tioat

votume flrdu orirol:frsrrillu pSV mode nr:rfin hign atarm pressure e1n

nr:f.,,: parameter setting imnrfi uhlfinlrkiaufiiqyrtlnr.,,:rrnJ$tifi

z.z trnfiu:,lfiru'lun'nfi! self inftating oag :.r.rn uon.o.hflqylalalhneln endotracheal
tube. tracheostomy tube. airway riarfluiryurdiinan::rnltdorJoo *'.,r1uuu:iirirnr:iu setf inflating
bag rrn:iuudrfi rr:lfirulrn lfid,rrnnnrtrndoulfixtonr?tnon (chest movemen e',lsiolld

1) fi1nfi! setf inftating bag udr hjfinr:rndoulyrronr:?,lon rau arqrfiocrn

orrrr4oiohd

. n'uqorYrno{vrl,lfi uyrahdruruqrn roilycdfi qnf,:tuviotirufi ru'tq

386 rrtdrrYainqndugru

. arirlu:loodrfindufir z {ro (bilateral pneumothorax)
. nl?iHflaofl otn5t1utt:o (refractory bronchospasm)

o vrfl1Bfln1 tu aofi rfio'iu1uur.rvre.: z dr.: nir ARDS filutL:{

z1 nrnfir setf inflating oag ufir finr:terdaulvrsa.tl:l,tsnrfiu.td1itfiur arlrfin
rrnorrrqoialild

. r:rrondrutrr:ra"r rfi s.:drttdur oretfi ocrnfiodrunrglefinqordauLlu".r

vnannrdruttr (right endobronchial intubation) v6orfioarir'lu:Joodru

ira lteft pneumothoraxl rlotfi otdooror#rlurdarlurJondrudra rio on

rrr|ludrutrg (left hemothorax/ pleural effusion/ atelectasis) 6ogur:n
ruunldTouirufio vrnrflunrrc right endobronchial intubation viatirutlrutc

e:a{fi nn'jrr.Jnfi Torud.:tnqtrn mark ?onyiod?uvruhfi upper incisor 1ou

:Jn61u{mu mark fl o{yioli'r ulnuloor:aqjfi 22-24 ttufirlsn tu{nf ,,r marr
no.ryiori?u ruhnnaud zo-zz mu6nn: urnviatiruuru'lolriogjfinrfiurnruri

rrcn.:ilorctfiqqrn left pneumothorax/ hemothorax/ pleural effusion/ ate-
tectasis duoqjrir ruan'r:o:redr.,tn1 ufi 'ld
r:tandrudrura-urfi u.rdr{ t6ur aro tfi qerno dr'lu ondrutrr (right pneu-
mothorax) r4iornnrfi aolar:rirlurdarirllaodrumr ffiarlorrrMrdrutrr lrignt
hemothorax/ pleural effusion./ atelectasis) d2ud'trl4qfi rfi octnilodruvrute
dnqo#aurirlrtluvaoen drudru (teft endobronchiat intubation) tfiodu
tauafl

s1 nrnfiu self inflating bag udr finr:rodau1rtrlo.,tr:roonoardr.t orctfincrn
orwrq do'bd
o COPD fi?a asthma

. uur6anrn'lu aodrfluri'l z {r.r niu pneumonia, congestive heart failure,

ARDS

. vrurBnnrnlurda{l:.laorYr z {r': niu pleural effusion, hemothorax
. vrfl'rBonl drfiotutiatfio'r ttiu ileus, hollow viscous perforation

s. trldrnrrqororrs (endotracheal suction) d.:rnn'i'rc'ru1fn'ld6t.ruga r6tun:ldqoriohj
rrn'idoruqnrcu,rvli'lilqn 1fi4'rduliriouirfinr:qon"utorvianrr rfiurru'lo (endotracheat tube)
iisorlrfioldmnnr#rarrrr;rrfiuurnluaocr'u r?o16oaroanlurr.rr6unrulooufifia!rdao??1noei

'luvia r,rrfiu ruh rdonurrro',rndre 'hlntrnrrrilduuviariravrulqri'ufi hinT:tfiidyuondlrda

ri,:nonrravnru rn*rfiseuururfiunlt lounr:ln?urRm+ru5o+rrirudrti:.l{r-hufrfi:Jrsifitdviodru

?ruhurn (difficult intubation) rrriau nrnldoroqoualuvlilnulilfinn'er tririrnr:fl:rcir,rnrs
r4r.,r: :-r rabriall

tnr:rri'lnf, qurrdo,rfiurdoldrn4a,:ri.ra1.rra1 nnfiunf nfrfintn 3&7

4, firflldf,1flRorflililcld1eulilfinfl"a tfili.rnrrn:roir,:nrt,yr.r,::yrryrulodol:J r'r:J:r r6u
lunr:q:roirrnrrddr6'r1tu{rJru high airway pressure alarm fifi'.:d

1) n11fi\t !6U{ wheezing, rhonchi nolnnr:rfin wheezing ria rhonchi riu fiorrnn

'ldqrn

t. yrr,,r rdunrutlairudrdlunl (lower ain /ay obstruction) rt rnuld"lu{rh urio}J

u

. rr\l;td?^nsuaafr)dI votume status rfru bifiorfi,,: wneezing fifiarruonrnT:nrirle lcardiac

asthma) Iourarrlrvtu{r-huq.larqfilrirnufiil::i6 wheezing rrlnou n?:

ni nr:ot:tonrn rir uf,rfi r:rron ua; adulv{fl ti'rtq rfioyror rfi q

. firJrufifi votume statusldrfiurialro nr:6ri6.rn{r asthma. COPD. hyper-

reactive airway, anaphytaxis d,lriua$riln'nurultr.rn6f nirr{rldfi'u}ntia
nrr:to

z . yr,: rduyr ulcdrudrrhildfir un:r uoifi dm:rnr:'lynro{o1n1n (air fl ow) nj.tuyt.t\t
rfiunru'lodruoir'rlrnn.ir nfi rtu metabolic acidosis, hyperventilation

2) nrrlil\:r6u,r crepitation lratesl firuildlu{:-hudriul,lul6anrntorq,:ar:lurdarloo

Lliu left sided heart failure. pneumonia, alveolar hemorrhage oejr,:l:fiou nr:
r1nrfi u.t crepitation fidoqr::;fdufitltu acute respiratory distress syndrome

(ARDS) dfio1n1?1uur.,r rfio,rcrnfiilrunsjudn crnrr,ir6uylutcq;kjcr rrnr.jru

atveoti'ldrau 6ililfi Tanrcld8urSiul crepiration udfi rndrhu rfl u nnos sfi er'lxj

:u*:,: arqn:re'ldlfi ur crepitation ld lflom.rnfir_jrunajldnlornlrrr6uyruh

orrrrnairuLJti.l atveoti 'ld d.irsr.l rn hnr:inur{rhufrritl ARDS tur!?.tTaunr:

'ld positive end expiratory pressure (pEEp) ufir q,:ariilnufloodfiql ritflld 6,,:rfiel
firfiu,J crepitation rfi odunrayn-oe r n nrr'ld pEEp

3) Decrease breath sound firn[6u{fi 'tuhro.r:iaooqoidr,,rto arorhgtunr:ifilatr

\-- 3
tAO\:U

t. tdu'ryrulcnooldrufira orerfioornnurionrn'lurdoririlaodrudru qeft pneu-

mothora>l/ hemothorax/ pteurat effusion) vioorelfi oqlnyjo?irflyrulerdourqn
}Jyrr.,rdrulrr (right endobronchial intubation)

2. rfi uttnuhaaa{dru?m orerfi arrnr,rur6onrr'lurda{lrJaodrurrr (right pneu-

mothorax/ hemothorax/ pleural effusion) ffiofl .teLfi ncrnyiodruvlulqrdauuAo

l:Jnr.,Jdrudru (left endobronchial intubation) s'.tilildliau

5. rrnnr:n:rqdrrnru'[rjld'n"rnou utiu luftJrudtrildourfiu,Jlrrutorou tfirilnr:n:roio
peak inspiratory pressure (PlP) lrfl: plateau pressure dolj

388 rrtrirrininqmdlg,u

n1lnflqin plateau pressure

nrrflt't9{g plateau pressure v;a alveolar pressure tflunrrnmoinnrtroiufi:rn'uqool
d,rfiilur{uflnfiSodlnr:rfio barotraum"lnu platea, pressure fintltdlr{u6'ril peak inspiratory
pressure (PlP) q''lc nr:

PIP = Plateau pressure + Airway pressure

Airway pressure ltdflrildnmsfio peak airway pressure d.rrfruelrrlnlluadrtn{r'l
rroi ainr,ray pressure luiidfinlufilruodrrtror nrimfiarllufiniiodlntol peak inspiratory pressure
tlnt plateau pressure

tunr:l-o platea, or"""rr. rft 6f']tJ't?flritn, i{oldd''ld

1. r:JduuglLtrlrtnl:tirunruhtflu vcv mode tfia.rerndo':finr:,i'lflt-tnci'l inspiratory flow

rate rruvr{rnr:io plateau pressure {i.:nrn'l$ pressure control mode l:lriorm:nninuo

inspiratory {low rate 'ld

z. iliu high pressrre duhl :c rru 55-60 4il.d1 Lflqfiniifionfinlrliu high alarm
pr"""ur" dul tdo.:ot"ntatrrmu:dfinr:in plateau pressure do.ltJfi inspiratory waveform tflu square

wavelorm d.,,:rirlfi pear inspiratory pressure f,ln'ir nn'

0)

E

o

ID

.E
(t

ID

Itl,

o
E
7
tL

afr t uaannia plat&u pressure lfrdtnnitdaitn'tt?ai pt tuu time (inspintoty pause) lJi$i

flow'luttuuana,tmdagui uaz$iaitnria plauau pressurc dtuitflu plateau pn""ur. tiu

dottfluduaz,t ntnl tfluduntt ozltildcit plateau pressure d frei,t

txgnn1:ufr1fl fl ryr4lda,Jfiurn'oldrn4o,rriraurut
nniunf 4frfi 3g9

g. rY! inspiratory waveform tflu square waveform rda.rq'rnfio,:nr:tfitfiunrulrnndr,r

:vrjrt peak inspiratory pressure [[n: phteau pressure atjr.:forou

4. ri'rvuo inspiratory pause (prateau time) ?crJ'rfu 0.5-r.0 iu1fi g'oilhtii flow iurr-t
r6unrutorfluquri rir'lfi ainay pressure rfluguri 6.,:rrt6oudnrud'ufin{flrJ (atveoti) rvirusu yrilfi

nrr riuqrn:cn"'! peak inspiratory pres"ur" nnnllrd plateau pressure

5. Eilua'l plateau pressure

-Iourjn6rfiodrnr:inur{rhaToildrnia.:tiru
'ru'lo Fn:fnur::d'l prateau pressurehlfirfiu

30 tr.dr rrtnr:6nuruol.r plateau pr""srr" ki'hirfiu ze ru.ti, nrrrrunnoi.r,:roe peak inspiratory
pressure t!flJ plaleau pressure "lrinrflfiu t o tl,rih d,:nrurrnnn'rsan peak inspiratory pressure
[[Ry plateau pressure fl,] ,t:od,]x't ttunfilfi1nlftro{ high airway pressure alarm lfiri,ud

t. rfiar"ndr peak inspiratory pressure ldfl.: rrnviofilttnndrtla\r peak inspiratory

pressure !1fl! ptateau pressure ldrfiu to ril.rir d,rfnq:iod1 plateau pressure ldlrilfiu s0

ttJ.u1 ltflgni1fi1Lflnto{ high airway pressure alarm lfir]q.rn utBonrl'lum,rr6unruh rtiu nrr
rfio bronchospasm fi 1uur.o nr:ufi ornlu;uiofiourdooqnnuluvrr.ur6uuru'lo

e. rfrainFir peak inspiratory pressure ldg,: llny,:-onttlrrnnpit{fl0,t peak inspiratory
pressure [[fl; plateau pressure ldlrirfiu t o fl.r.rir g'.rrinctiodr ptateau pressure ldrfiunir so
ttJ.r.ri uflo"i'1ff'rrfiqflo\r high airway pressure atarm '[ri'[dlfiolrnnur6anrl'r'lur'],ir6ur1ule uei

rfi norncr ruqn'r.o1 ri'.rd

11 crrumrrnriiorJon (rung parenchymal fitoro lfluvrur6afll 'h arveolifi?a interstitium

fi1d rriu nnOS. left-sided heart tailure, alveolar hemonhage

z1 arm4ern16a{l oo rrju pneumothorax, hemothorax, pteurat effusion
3) d'tlume'tnru1i\ryn?{afl (chest wall) rdu massive subcutaneous emphysema

41 Rr mmarntio,rrlot niu ileus, hollow viscous perforarion, ascites

5) al'tI n n right endobronchial intubation njo.rcrn ondrurrrlvtfinn.n; hyper-

inftation tittfi alvectar pressure nrdu drnrndrlfir-orir plateau pr"""rre ld4rdu

n1:inu1f,1 $tstidrirbirns h i gh airway pressure a larm

1. cluqrrnnr: iilrnSo.rdrunrulchirrrrvdn

1) VCV mode riet:tulnn tidal volume. fln peak inspiratory flow rate, r:Jduu {tow
tflwaveform
half decelerating waveform nio total decelerating wavelorm

2) PCV mode ficrtrurao inspired oressure

3) PSV mode fie.mrutoo pressure support

2. flrrfi nclnnrtqod'u'luyiorirunrs'h htfier:ilruJ6uuriodtuyru'lo

390 rrtrirriainqnfruSru

S. fl.]l]lqeln right endobronchiat intubation 1firirnlrrfiauyioti?u]rlulohioglumhunil'r

firfi 1cn!
4. fllttqalnn1?qorYuflr,:tfiuvrutodtudt,l (lower airway obstruction) tl1n!flu broncho-

soasm 'lun:rflri'rl ricrrru{fiEJrlul1ynaofl (bronchodilato4 rrrifiTrflu cardiac asthma lfi

fiq1:rurinsr heart failure lnunr:L{elrtTuflnnrrv

High ain^,ay pressure
alarm

Disconnect {tbuoonorn ventilator

oio self inflaiing ba8, ET-T suction

iu self inflating bag ,i1u fir self inflating bag urn €r self inflating bag urn
ldaru suction lririr
tdaru suction rdr ldaru Suction rin

r{lurJ rgr.n fi ventilator rl't breath sound, rfl r.rrSrgurfi endotracheal tube

crepitation, wheezing drnrsrdf,ru endotracheal tube

f,'lt?tq:

- Pulmonary edema
- Pneumonia /ARDS
- COPD /asthma

PIP-Pleteau pressure < lo PlP-Pleteau pressure > 10

ttvtugfrii udn,tuuentilunteufiTziltynt{tJau high ahway pressure alarm

nl:BdlnflqJulldo'lf, rda1filn':o,rrj.:anralt nniani pfifiwg 39I

5. 6[']rfi ole1n u1ifln,ly|lilrdoiloo
1 ) Cardiogenic putmonary edema fim.lrurhlu1r"uiJfl fl .lx;
2) Non-cardiogenic pulmonary edema lfinr::"nurnuc1rfiq [rn::Jl-urniolrirutru'h

trirrrrrar

6. ot m4orntar6nnrlluldafir:Jaer udu pneumothorax n6a hemothorax fier:rurtd
intercostal drainage (tcD) il1nrflu pteurat effusion tun:rflrtrll areri thoracentesis Lfiohjfi

fiarirl.l

7. f,rtvqnur6onTrrtutio.rfia,,r rdu ileus, rapture hoflow viscous 1fint::-nutn,ru6{.ln1q

arofiaouou'lfi peak inspiratory pressure grn'fi::niudaa illd fiolusur:rfinflelr1 hypo\€ntiration

uurnr'r1unr:ufi1?i1{U 1 high druay pressure atarm rflu}Jn',runru4fid t
orccr Lrurrr, unr:ufiItirynr high airway pressure atarm drour:nrir1il'ldlrnr:
rur{1tr]4r'uljordl]ldluvrn atarm ldd'rd : disconnect-fir bag-suction-ifu rung 3 :J:;rfiu-crep-

wheez-decrease breath sound

Low airway pressure alarm
'lfirir.rdurhnr:ufirlqrrlnt disconnect-l1J bag-suction-flr tung o rJ::r6u-crep-wheez-

decrease breath sound

rfiaru{rJrufififlq r bw airway pressure atarm 'hifinfirwr nrqn-od

'1. ltn't?l?no{a1nlFt

e. fi:Jruyruloe'.r rnia{rruyn.rfltcrdr

iln1Tt1to{01fl16

t.r,Andfl.lt] xn'l:l??.to{01n1ff (air leakage) U0n{lneyuu low airway pressure alarm $dl

ri.lorlyrl low tidal volume alarm lddru figtynftd

1. finrrirto.oornronruuann'r{rhu niu riodrurru'hlrildoio rfirriurniairirt'rrtr'le

(ventilator discon nection)

e. finr:irrorornrsqrnrn€a,:drufiru'lq a{r unu,riiluld:-iou6o humidifier un:lir.:ruvr'

U bronchodilator

3, fi nrrirrooar nr nnr utun"r {!.lu rfi oldlnor u,rq
1) Endotracheat cuff finr:ir (teakage) fi{fl:rc1fi1nu1ru:dflruh q;fin:rrioonrJr

ernurhnlorfirjru iaarcnmrTounr:io cuff pressure drovnoornirrdljnft lrirrJn6lrin.r:rfiu
25 rJ!.rhor) nrnirhduld'jrfi endotracheat cutt tir nr:'ldiin.n bbw cuff lun::utraririiryr.r
ilrnr, ul,J Linr:ldiiujduuriarirafiru'lqlilrnu nrl:fllnqarnrfinern cuff diturorfino.rrar

392 rrtdrrininqnCug'tu

lusid'rvrn blow cuff rJirrrurrnrrfirfltfiar*rvrrl4rrJrnaqi o'rlrfio16ern

. vioriruflruhrir.rrdounqo loarJaruriodrurruteoqild vocal cord ud endotracheal

cuff oqjrufia vocat coro {i',:aEjlu larynx dlfiturortduoiruqutino, r'brqin'jt trachea

nr:ifiqdunmvdtfid,: tnmr{r llvrjltot endotracheal tube d upper incisor 'jrdu

ni1lnfr

. Endotracheal cuff perforaiion nrrvddot rrfi'hTounr:L:lduu endotracheal tube

lnri

z1 riarirur,rruh16ourqol tirraaotornr: rsoldrdauvqolJu".runooarnr:udr (esopha-
geat intubation) tuftilrudnrahro.rlillfi e:1il1d0u breath sound rroicvldfiurfiuinu'lunlrt 'lY
arur: urih {rh uiivr ulc ra-ild urivio:irunrahrdounqo}-fluvnaoorrar: finrrr:nfltrdu.l breath

souno l6dru fnrulu{fiudi uur}il'tunr:6':riarirutnuteoanto.: (self extubation) ot.:ril6.:do'o

dr rnnoiruu,,,: (mark) fl a,tti odlavrulodr s wro

e1 firr.,r rdaroia:;v'jr{flco9ra fllllrlt6lorvr: (tracheoesophageal fistula) rinlrulu{

rlruqri6m4iifi tracheobronchial injury r:idriou

iu{:hufifi air leakage ludrtrfufioflqtr low tidal volume alarm riu fl'ttJ1:nnt,)QL't

rdnXruto,rrJ?lrnraln16fi qrUmu}h1n volume-time curve

Vt leakege Vl leakege

7li z suatdn,tbavsoetutinmeeu-tinm'Ieu"nutf*r"ii dfrdnwuv tea*age 'lfiffunn'lutiz,tntutcoan nfrdunflvtct&a,Ja,J

teaxage dunfl luil,ortuloaansrlthwuwi au"aine

nrrrrfi bf, qnr low airway pressure alarm drfi oqrnnrrS'rtoto'tnra

t1 rndattirunrulclillddardrrYrf,:-trutfidrnr:rdacrurn{o{drunruter{lfiuviodravrah

it2) Endotracheal cutt vrni':rFnriou o'rcldi6nr: blow endotracheal cuff fi'lni? 'ln

fi o.rrirnT :ulduuviarirunra'lo

s; viotirunratrrdourqorSorirn-*rr;rn'ourqol u-.rnnooarvr:tfirirnr:'kiviodrafiru'lehli
fi i orjfusr"r lni{ (mark} I fl .rdodluvr utctfi ttrr r or

nlrur{lxflru}i, rdo\:fild0lfirndoodrafiraTa nnhuni gilfimg 393

a1 n:rflfinrtrdaroio:! 'jl.Jflnoon dlrvntld o.ifi'r: (tracheoesophagearfistutal lfirirn.r:
f n ur ar ru qIo u nr: lfi :-rtia r gr'r

frtr unr uh6,r rndo,rsrusrn utt rdr

lun4uro{:-hurralofi,Jrnio.rzru: ru'hri'r lonorne;nr tow airway pressure atarm !ld.r
rI,larcfl! high tidal volume atarm lddlu

rdod:hafinrrfi1ule ro.r?ru;fi rnio..riru?lu'lcqruolnrariu qvdrlfinrrrri'uhrrlr!nnff{

tdo"lmnnr:rru'lo ro.rusu {r-hudo.Jair.,lnluo'urfluau lnegative inspiratory pressure) rdotfiornrn
'lvnrdrl:Id d.,:nr:m:rcdr{nrflqcvrilir{:-trul.finfirrrdodrurrrh laccessory muscres) flrus1i1n1:

firuhrtr rrn:ttng,lrnn pressure-time curve e: un,t1tJfiorJn6o',ruoo,ilu:rJd g

nr:filtl{ilroo'lra?a.:rirufirulol:rirtfi,rrufirfioqrnnr:rru'lo lwork of breathing) rfin
rirarjr,:rrn de rflunr,cdhifit ::o'rd crrnnddrFr"Fiidrrri metaboric acidosis ri.rtfi{r-hrfio,rnr:
tidat votume filrndu d..n'rrfllfia.rvrarrvnloaiudru n?anr:d{r-hufi stress ufirrfio hyper-

ventilalion

7li s uaa't pressure-time curve Tutiainlu'lctit c:fintzanalzai pressure nlndtutu ttf,Ftnn.Rfrfr
luittanxa,t pressure
mid-inspiratory phase ntndluci.t,s lafrannltaaa\laon pressure ?uix

early inspiratory phase

394 retrirfainqniiugru

nr?fnE1rfio unlr:d lfiinr1nlud1lxo! ixllfiun']: ilrnioui, umu'htfirfi 1Y6[ lnu
n1: fir tidal votume lfi5fir1du trn!i:.-r tidal votume rrdrlild1n lfirirnr:rfir inspiratory flow

rate [!fl nlia"rr ru{d6\:d

1) VCV mode rjiln;in tidat uolume mnlrildoralfirfil peat< inspiratory flow rate

il2) PCV mode rJitlfi inspired pr"=surel f,tut:0 inspiratory ftow rateld tdamrn

inspiratory fl ow tu Pcv mooe t*unilnru fi a,i n.lltlo,tf, rlx u
3) PSV mode rJiltfirl pressure support bjarlr:nrJil inspiratory flow rate ld tfjotorn

inspiratory flow tu PSv mooe durilnrtrdalnr::ro.l{ ru
yrnrirnr:ttfi}rlounl?:Jiulfi tidal volume niorfil peak inspiratory flow rate ttfixl

lfinrn orcda.rr"rnrrtfiuruoulta'u (sedalive orugs) tiohiutrti0uflfil:J[d0 (muscle relaxant) fit

aIL U

ttuxu1,l1un]:ttflltflqnr{rJ'ru low airway pressure atarm riu'bJn'lrrruu4fifi e

Low arrwav Dressure alarm

ns:aqs'jirrffii mssiritraa'l ventilator circuit /arirfi4lr}r n

lfi{,,lnn'h {rJru Fnr: fi'r rnda otir u!-n ulordr u€ai

ns?0fl u'irfi n1:iruor ventilator {tl:u fr nrsfi u rnd ooti':sm ulo
circuit /ar*rnJ4lrhn /d'?m,Jars IcD flrulurtilotdr

lrgur volume leakage Inadequate volume / flow

lud'-r{rJ':u uondt'r{!ru rrr{lulprunrsrlil tidal volume rdpdri

- Endotracheal cuff - Ventilator circuit rnnldihr€l

teaKaEe reaKage ui'hlounrsrliurnl flow
H€ouJduulfl u PCV/PSV modes
- Daslodgement of - Bronchopleural

endotracheal tube fistula

- Trechesophageal urnlri#rir

fistu la

orqdai'tfi sedation +/- muscle

relaxant

zunu4fid uflattutnt,t'lunteufiltflrynt low airway pressure alam

n1rrffhflryulrdood uXolriradaurir€, ralr nnFunf nfrfiwg 395

Low tidal volume alarm

ijrufi'r tow tidar vorume ararm finkirrrfluflqrr r6sr a-nrfioirrniu high ai*ay pressure

alarm rlo tow airway pressure atarm 'lfiGlfiurirnr:rrfiilrpyldru disconnect-f,:L bag-suction-

fi't lung .3i tvtdu-crep-wheez-decrease breath sound fict:rutrrunfitdlrnqlio:,:d

1 Low tidal volume alarm fi rn'nirln5ofi*urTrir:rfinirlnr":t high airway pressure atarm

'lti rortfinrdutdu'ln"u higtr airway pressure alarm

2. Low tidar vorume ararm iirfiodrrn?ofirrurlir rfinirrri:-r row airwav oressure ararm
r"nrfi oirln"rsrrundfi ornrsir (air teakage)

iu{:lrudfinrrlfto:Jnfiroo vorume-time curve fiuaqln'nrru:ro.r voIume reakage fi-.r
glfi z ruldrilar t4lorfioorn high airway pressure ararm Lrfly low arrway pressure ararm

1. rrntld?rjfilo.tlHm0\: high airway pressure atarm 1fi6nfi.,r pneumothorax. auto_

PEEP

2. fi'rnnud'r niufi,rlfiqron row airway pressure ararm 'lfifiofi.rnr:irto,tornr6 (air reakage)

uurrr*r'lunr:ufib{rtrudfiflrpm tow tidat votume atarm rfllr'l:Joouflunfi# g

Low tidal volume alarm

Alarm nialriu/ rEafluu:hir alarm Alarm ft6o ri!/ fiuu':lfi] alarm
nionfii high ainaray pressure alarm lrSolril low airway pressure alarm

rurllufl rg r-rr high airway
pressure alarm

tttugfii a uuanxlunttufiInilrynt{tlaa tow aiway prcssure alam

Low respiratory rate alarm

irylr bw respiratory rate alarm u5arrnrflulurr:rorenurflu apnea alarm tflu alarm

dnr'lu sponianeous mode ttrnvulu contror mode utoot'ito"t ararm respiratory rate il{fl1l

respi ratory rate r a.: rndalrjr un.r u'lod.rLjne: rfi on*u

tiot't:r low respiratory rate ararm nio apnea atarm'[u spontaneous mode fi.raieultai
fn rfi olu pSV mode 6t1tJ 1Tn ri"1 tfi u nr:rr ar tlr nldn-.rd