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Management Of Patients With Increased intracranial pressure

Specific Conditions: • Intracranial pressure (ICP) is the pressure within the cranium (skull).

Increased Intracranial Pressure • Normally less than 10 mm hg.

• The most common cause of increased icp is an acute head injury in
(ICP),COPD, Asthma, Congestive which the brain is shaken. (Closed head injury)
• Other causes of increased ICP include craniotomy for brain tumor
Heart Failure, and ARDS resection and stroke (cerebral vascular accident).
• Any significant increase in pressure within the skull will further injure
Mark Joshua S. Cruz
the brain.
• When the icp exceeds 20 mm hg, the patient’s outcome significantly
worsens.

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Increased intracranial pressure To decrease the PaCO2 level, always increase the
• The A/C mode usually is selected with constant volume ventilation so ventilator rate. Do not increase the VT or
that the patient is assured of a set minute volume if apnea occurs. inspiratory pressure because this may cause an
• It has been demonstrated that hyperventilating the patient to a
PaCO2 between 25 and 30 torr results in a reduced ICP. increased intrathoracic pressure obstructing
• This is the result of the lowered carbon dioxide pressure causing a venous blood flow from the upper body and head
reduced hydrogen ion concentration and increased pH, which causes
cerebral vasoconstriction which in turn decreases the ICP.
back to the heart. Therefore, ICP may increase as
• Because the cerebral blood flow is decreased by hyperventilation, it is the venous blood returning to the heart
important to maintain the patient’s PaO2 in the 90-110 torr range. decreases.
• Hyperventilation is used for a short period of time (usually less than Caution must be exercised when suctioning because this tends to increase ICP as a
24 hours) until other therapeutic measures reduce the ICP. result of hypoxemia.

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Chronic obstructive lung disease Chronic obstructive lung disease

• When the patient must be ventilated, it is important to maintain baseline
“normal” blood gas values. • If the patient has air trapping and auto-PEEP, a small amount of
• This usually means accepting moderate hypoxemia and hypercarbia with a therapeutic PEEP may be added to help the patient exhale and to
compensated respiratory acidosis. trigger the ventilator.
• The A/C or SIMV mode may be used with a constant volume set or PC used • Increase the therapeutic PEEP in 1 cm water steps until the patient is
to set the tidal volume. synchronized with the ventilator.
• A patient with COPD must have the ventilator adjusted, including the
addition of mechanical dead space, to maintain the patient’s normally • Many patients with COPD need 5 cm water of PEEP or more.
elevated PaCO2 level. • When the condition that caused the sudden deterioration is
• A PaO2 of 60-70 torr usually is adequate. Keep the plateau pressure corrected, the patient should be weaned off of the ventilator as soon
(alveolar pressure) less than 30 cm water to avoid overdistention of the as possible to prevent atrophy of the ventilatory muscles.
patient’s compliant lungs and resultant volutrauma.

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Asthma Congestive heart failure

• The patient with status asthmaticus needs mechanical ventilation when the • Patients with congestive heart failure (CHF) usually also have a pulmonary
increased airway resistance and increased WOB lead to exhaustion. This edema problem. This results in hypoxemia and low CLT.
results in hypercarbia and respiratory acidosis. • Mechanical ventilation with the A/C or SIMV mode with constant volume
ventilation is needed to reduce the patient’s WOB, deliver supplemental
• Air trapping and autoPEEP are also significant concerns. In these serious oxygen, and add therapeutic PEEP.
situations, three ventilator strategies can be implemented:
• If the PEEP level is increased and the patient’s CO is decreased, the PEEP
(1) Small tidal volume breaths and permissive hypercapnia. If a smaller than should be reduced to its previous level.
ideal tidal volume is delivered, air trapping is less likely. A longer than
normal expiratory time may also be needed. • The patient must be given a diuretic such as furosemide (Lasix) to increase
urine output.
(2) Heliox (helium/ oxygen) therapy. Heliox can be delivered through some • The patient’s heart function is improved by giving digitalis (Lanoxin,
ventilators and will reduce airway resistance. digoxin).
(3) Inhaled bronchodilator therapy and systemic corticosteroid therapy • Reduce the PEEP and inspired oxygen as the pulmonary edema problem is
corrected.

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ARDS ARDS
• Target VT of 6 mL/kg of ideal body weight (IBW) • Permissive hypercapnia: With the use of lower tidal volumes and
• Maintenance of alveolar (plateau) pressure <30 cm H2O. therefore lower peak pressures, CO2 levels may begin to rise,
resulting in respiratory acidosis. Studies indicate that a higher
• Use of relatively high PEEP levels (up to 24 cm H2O). percentage of patients recover with minimal side effects from the
• Oxygenation target: PaO2, 55 to 80 torr; SpO2, 88% to 95%; acidosis if the pH does not drop below 7.20. In fact, acidosis may
PEEP/FiO2 adjustments produce some positive effects. As CO2 increases, the patient will
• Target pH of 7.30 to 7.45. become sleepy and easier to control on the ventilator. Also, an
acidotic environment shifts the oxyhemoglobin curve to the right,
• Avoidance of excessively high FiO2 levels (try to maintain below 0.60). which means that hemoglobin (Hb) releases O2 to the tissues more
easily and increases the level of tissue oxygenation.

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Noninvasive Positive Pressure Noninvasive positive pressure

Ventilation ventilation (NPPV) is a technique of
Mark Joshua S. Cruz providing ventilation without the
use of an artificial airway.

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ACUTE CARE SETTING

• • Improve gas exchange
• • Avoid intubation
• • Decrease mortality
• • Decrease length of time on ventilator

Goals of Noninvasive Ventilation • • Decrease length of hospitalization

• • Decrease incidence of ventilator-associated pneumonia
• • Relieve symptoms of respiratory distress
• • Improve patient-ventilator synchrony
• • Maximize patient comfort

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LONG-TERM CARE SETTING

• • Relieve or improve symptoms
• • Enhance quality of life
• • Avoid hospitalization INDICATIONS FOR NONINVASIVE
• • Increase survival
• • Improve mobility VENTILATION

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ACUTE CONDITIONS ACUTE CONDITIONS

• • Hypercapnic respiratory failure - primary indication • • Acute cardiogenic pulmonary edema
• • COPD exacerbation • • Respiratory failure in immunocompromised patients
• • Asthma • • End-of-life care and DNI orders
• • Facilitation of extubation, especially in COPD • • Postoperative respiratory failure
• • Hypoxemic respiratory failure but cautiously • • Prevention of reintubation in high-risk patients
• • Postextubation respiratory failure

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CHRONIC CONDITIONS NIV should be considered the

• • Nocturnal hypoventilation standard of care for treatment of
• • Restrictive thoracic disease hypercapnic respiratory failure
• • ALS secondary to COPD exacerbation
• • COPD and should be available as first-line
• • OHS
therapy in all institutions treating
patients with COPD.

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RULE OF THUMB RULE OF THUMB

All patients with an acute COPD A trial extubation directly to

exacerbation should
NIV should be considered
be evaluated for NIV as an
for patients with COPD and
alternative to intubation and
invasive mechanical ventilation. hypercapnic ARF who are
NIV is the standard of likely to receive a
care in these patients. tracheostomy for failure to
wean.

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RULE OF THUMB

CPAP of 8 to 12 cm H O with 100% O

Extra caution is recommended for patients
who present with cardiac ischemia,
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should be considered first-line therapy in

acute pulmonary edema. NPPV should be hemodynamic instability, arrhythmias, or
used only when hypercapnia is depressed mental status. Patients with
present. these risk factors should be intubated and
invasively ventilated.

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Nocturnal hypoventilation is common with neuromuscular

diseases, severe kyphoscoliosis, COPD, obesity, and central and RULE OF THUMB
obstructive sleep apnea.
Symptoms may include excessive sleepiness
during daytime hours; fatigue; morning headaches; and
cognitive dysfunction, such as difficulty concentrating. Patients with restrictive thoracic
NIV rests fatigued respiratory muscles, improving disorders should have symptoms of
their performance during the day. nocturnal hypoventilation before
NIV reduces PaCO2 and may reset the central ventilatory NIV is considered.
controller to a lower baseline PaCO2.
Improvements in lung compliance, lung volume, and dead
space that result from NIV may be beneficial.

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RULE OF THUMB

NIV should be considered for SELECTING APPROPRIATE

management of respiratory
failure in patients with ALS
PATIENTS
because it probably slows the FOR NONINVASIVE VENTILATION
rate of decline of lung function
and lengthens survival.

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Noninvasive Ventilation Selection Criteria for Exclusion Criteria for Noninvasive Ventilation
Patients With Acute Respiratory Failure in Patients With Acute Respiratory Failure
• Two or more of the following should be present: • • Apnea
• • Inability to protect airway/high aspiration risk
• • Use of accessory muscles
• • Hemodynamic or cardiac instability
• • Paradoxical breathing
• • Lack of patient cooperation
• • Respiratory rate ≥25 breaths/min • • Inability to use a noninvasive interface because of facial burns,
• • Moderate to severe dyspnea (increased dyspnea in COPD trauma, or abnormal anatomy
patients) • • Excessive amounts of secretions
• • PaCO2 >45 mm Hg with pH <7.35
• • PaO2/FIO2 ratio <200

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Predictors of Noninvasive Ventilation Success

in the Acute Care Setting
• • Minimal air leak
• • Low severity of illness
• • Respiratory acidosis (PaCO2 >45 mm Hg but <92 mm Hg) EQUIPMENTS USED FOR
• • pH <7.35 but >7.22
• • Improvement in gas exchange within 1 to 2 hours of NONINVASIVE VENTILATION
initiation
• • Improvement in respiratory rate and heart rate

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Patient Interfaces
The effectiveness of NIV is greatly influenced
by the interface chosen to deliver positive
pressure to the airway Nasal masks

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Advantages Disadvantages
ØEasy to fit and secure to patient’s face ØMouth leaks
ØLess feeling of claustrophobia ØEye irritation
ØLow risk of aspiration ØFacial skin irritation
ØUlceration over nose bridge
ØPatient can cough and clear secretions
ØOral dryness
ØMaintains ability to speak and eat
ØNasal congestion
ØLess mechanical dead space
ØIncreased resistance through nasal passages

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Advantages
• Reduces air leakage through the mouth
• Less airway resistance
Full-face masks
(oronasal masks)

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Disadvantages
ØIncreased risk of aspiration
ØIncreased risk of asphyxia Nasal pillows
ØIncreased dead space
ØClaustrophobia
or
ØDifficult to secure and fit Seals
ØFacial skin irritation
ØUlceration over nose bridge
ØMust remove mask to eat, speak, or expectorate secretions

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Advantages Disadvantages
• Easy to fit and secure to patient’s face •Pressure sores around nares.
• Less feeling of claustrophobia
• Low risk of aspiration
• Patient can cough and clear secretions
• Maintains ability to speak and eat
• Less mechanical dead spAace

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Advantages

•Facilitate communication
•Less feeling of claustrophobia
•Low risk of aspiration
Mouthpieces •Patient can cough and clear secretions
•Low risk of CO2 rebreathing
•No headgear requirements

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Disadvantages RULE OF THUMB

• Nasal air leaking • Use a full-face mask for patients in
• Hypersalivation ARF. If the patient is unable to
• Possible orthodontic deformity tolerate a full-face mask, try a nasal
mask before accepting NIV failure.

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• 6. Hold the mask on the patient’s face or have the patient hold the
Initiation of Noninvasive Ventilation mask until he or she is comfortable with the sensation of NIV.
• 7. Adjust FiO2 or bleed in O2 flow to keep SpO2 >90%.
• 1. Choose a location with appropriate monitoring based on the
severity of the patient’s condition. • 8. After the patient becomes comfortable with the initial settings,
• 2. Position the patient with the head of the bed elevated ≥30 degrees. increase inspiratory pressure until VT is about 4 to 6 ml/kg
• 3. Select a ventilator and an appropriately sized interface. predicted body weight or signs of respiratory distress improve.
Increase PEEP to reduce asynchrony from air trapping or to
• 4. Turn on the ventilator and humidifier, and connect the interface.
improve oxygenation.
• 5. Set initial settings at a low level of support: PEEP 0 to 4 cm H2O,
ventilatory pressure 2 to 4 cm H2O. • 9. Check for air leaks, especially around the eyes; adjust mask as
needed.
• 10. Reassess frequently for tolerance and efficacy of NIV (at least
every 30 minutes) for the first 1 to 2 hours.

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RULE OF THUMB
Modes of
• Heated humidity (about 30° C) should always be Ventilation
provided with NIV to avoid nasal symptoms, to
avoid the accumulation of secretions in the back of
the oral pharynx, and to enhance patient tolerance. ØBIPAP
ØCPAP

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Indications Noninvasive Positive Pressure Bilevel positive airway pressure (biPAP) two pressure
Ventilation levels whereas

inspiratory positive airway pressure (IPAP) setting

provides mechanical breaths and an
ØReduction of respiratory workload in obesity
ØAcute respiratory failure Unable to handle secretions expiratory positive airway pressure (EPAP) level
ØAcute hypercapnic exacerbations of COPD functions as positive end-expiratory pressure (PEEP)
Ø TIMED
Ø SPONTANEOUS
Ø SPONT/TIME

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TIMED
ØSolely machine triggerd
ØGive mechanical breath according to preset RR

BILEVEL POSITIVE AIRWAY ØEx: RR = 12 breaths per minute

Ø60 / 12= 5
PRESSURE ØEvery 5 seconds the machine will give mechanical breath

BIPAP

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SPONTANEOUS SPONT/TIME (ST)

ØSolely patient triggerd ØEither machine or patient triggered
Ørequires the patient to initiate each assisted breath.
Øallows the patient to breathe spontaneously while
ØGive mechanical breath according to patient triggering having a time-cycled minimum respiratory rate set by
the therapist.
ØWorks like A/C mode
ØSafer mode

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Contraindications for Noninvasive Positive

Active exhalation is Pressure Ventilation
recognized by the
spike on
the pressure
waveform at the end
of inspiration. The
patient uses ØApnea
abdominal muscles
to increase airway ØFacial trauma
pressure and cycle
the ØClaustrophobia
ventilator into
exhalation.

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Inspiratory positive airway pressure - To avoid gastric distention,

IPAP ventilating pressure should be
• 1. Controls peak inspiratory pressure during
inspiration less than the normal esophageal
• 2. Initial pressure settings for IPAP from 8 to 12 cm
H2O
opening pressures of 20 to 25 cm
• 3. Must be at least 4 cm H2O above the EPAP H2O.
• 4. deliver a tidal volume base on patients mechanics
(Clt and Raw)

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Expiratory Positive Airway

Pressure (EPAP)
1. Same as PEEP during mechanical ventilation or CPAP
during spontaneous breathing.
2. Increases the functional residual capacity thus imporving
oxygenation The difference of IPAP and EPAP
3. Also relieves upper airway obstruction with its splinting
action. is the pressure support.
4. Initial EPAP is 4 to 5 cm H2O
5. If EPAP is increased, IPAP must also be increased to
maintain PS level

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A, Spontaneous breathing
on CPAP of 5 cm
H2O. B, Adding IPAP of 10

If EPAP is increased, IPAP must

cm H2O results in higher VT.
C, Increasing IPAP to 15
cm H2O delivers even

also be increased to maintain PS higher VT. D, Increasing the

baseline
EPAP without a

level. corresponding increase in

IPAP results in lower VT
because the difference
between IPAP and EPAP is
less.

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RULE OF THUMB CONTINUOUS POSITIVE

AIRWAY PRESSURE (CPAP)
• Most patients with ARF can be stabilized with an expiratory
pressure setting of 5 to 8 cm H2O and ventilating pressure of 1. Provide a maintained positive pressure above the baseline
8 to 12 cm H2O. Avoid using peak pressures greater than 20 throughout the inspiration and expiration
cm H2O 2. Can also be done if the IPAP is equal to the EPAP
3. Can be incorporated with Pressure Support
4. CPAP of 5 cm H2O is the standard initiation

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The following blood gas levels have been obtained from a

When given a patient using 60% O2 or higher who is patient using a 60% aerosol mask.
pH 7.47
ventilating adequately (normal or low PaCO2) but has PaCO2 31 mm Hg
hypoxemia, place the patient onCPAP. The exception PaO2 58 mm Hg
to this rule is if the question states that the patient What should the respiratory therapist recommend at
has hypotension, a low cardiac output, or an elevated this time?
intracranial pressure. Positive pressure should not be A. Place the patient on CPAP.
administered because the increased intrathoracic B. Increase the O2 to 70%.
pressure may worsen these conditions. Thus in these C. Intubate and place the patient on mechanical
situations, increase the FiO2. ventilation.
D. Change to a nonrebreathing mask.

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Pressure Support Ventilation

• 1. Spontaneous mode of ventilation that augments patient tidal
volume by decreasing the work of breathing needed to overcome the
resistance caused by the ET tube.
Expected Results of Changing
Noninvasive
Ventilator Settings

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Increase IPAP Decrease IPAP

•↑ VT, ↑ minute ventilation, ↓ PaCO2 •↓ VT, ↓ minute ventilation, ↑ PaCO2

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Increase EPAP Decrease EPAP

• ↑ FRC, ↑ PaO2, ↓ VT Ø↓ FRC, ↓ PaO2, ↑ VT, ↓ PaCO2

• Improved patient-ventilator synchrony ØPossible rebreathing of CO2 if EPAP <4 cm H2O
with intrinsic peep

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Increase FiO2 Decrease FiO2

•↑ PaO2 •↓ PaO2

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Increase Rate control Decrease Rate control

• ↑ minute volume in timed modes, ↓ PaCO2 •↓ minute volume in timed modes, ↑ PaCO2

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Criteria for Terminating NIV and Switching to

Invasive Mechanical Ventilation
• 1. Worsening pH and arterial partial pressure of carbon dioxide
(PaCO2)
• 2. Tachypnea (>30 breaths/min)
• 3. Hemodynamic instability Side Effects and Complications of
• 4. Pulse oximeter oxygen saturation (SpO2) less than 90%
• 5. Decreased level of consciousness
Noninvasive Ventilation
• 6. Inability to clear secretions
• 7. Inability to tolerate interface

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Discomfort Common Loosen straps

Refit, reposition, or change interface

Erythema Caommon Apply skin barrier or hydrocolloid

dressing or both
Loosen straps, adjust forehead
support, or add spacer
Alternate the use of 2 masks

Interface-Related Side Effects Claustrophobia Infrequent Change interface

Consider anxiolytic
Pressure ulcer Infrequent Apply hydrocolloid dressing
Change interface
Skin rash Infrequent Apply topical steroid or antibiotic

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Air Pressure–Related or Flow-

Related Side Effects

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Serious Complications

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THANK YOU & GOD BLESS!

KEEP SAFE ALWAYS!
GOODLUCK ON YOUR EXAM!

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