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Ventilation Strategies in ICU
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Proportional Assist Ventilation (PAV)
Augments patient's efforts in proportion to their demand, indicated for patient-ventilator synchrony and weaning. Settings include proportionality factors for volume and flow assistance.
Prone Positioning
Not a ventilation mode but a strategy used in ARDS patients to improve oxygenation and promote more uniform ventilation. The patient is turned prone for 12-16 hours a day with continuous monitoring and support.
Lung Recruitment Maneuvers
Periodic application of increased airway pressure to open collapsed alveoli, indicated in patients with ARDS and atelectasis. Precise settings for duration and pressure of recruitment maneuvers must be titrated carefully to patient response and oxygenation.
Extracorporeal Membrane Oxygenation (ECMO)
Indicated for life-threatening respiratory failure unresponsive to conventional therapy, settings are tailored to provide adequate oxygenation and CO2 removal while minimizing ventilator settings to allow lung rest.
Volume Control Ventilation (VCV)
Used to control minute ventilation, ensure adequate ventilation, and to rest the respiratory muscles. Settings include tidal volume 6-8 mL/kg of predicted body weight, rate to match patient's need, and FiO2/PEEP to maintain acceptable oxygenation and ventilation.
Inverse Ratio Ventilation (IRV)
Used in severe ARDS to improve oxygenation by increasing mean airway pressure. Settings include an inverted I:E ratio (e.g., 2:1 or 3:1), a controlled respiratory rate to avoid breath stacking, and careful monitoring of sedation and PEEP/FiO2.
Pressure Support Ventilation (PSV)
Indicated for weaning from ventilation and patient comfort, it augments spontaneous breathing. Settings include pressure support level (usually 5 to 15 cmH2O above PEEP), PEEP, and FiO2 to achieve adequate oxygenation.
Adaptive Support Ventilation (ASV)
Closed-loop ventilation mode adjusting pressure support to meet the patient's needs, indicated for a wide range of patients. Settings are automatically adjusted to achieve an optimal minute ventilation.
Airway Pressure Release Ventilation (APRV)
Alternative mode for ARDS and hypoxemic respiratory failure, provides continuous positive airway pressure with intermittent release phases. Settings include high CPAP level (P-high), time at P-high (T-high), release pressure (P-low), and time at P-low (T-low).
Continuous Positive Airway Pressure (CPAP)
Used for spontaneously breathing patients requiring increased functional residual capacity and oxygenation. Settings include a constant level of positive pressure during spontaneous breaths and appropriate FiO2.
Pressure Control Ventilation (PCV)
Used when compliance of the lung is variable, such as in ARDS, to minimize barotrauma. Settings include Inspiratory pressure to deliver desired tidal volume, respiratory rate to match patient's need, and FiO2/PEEP to maintain acceptable oxygenation.
High Frequency Oscillatory Ventilation (HFOV)
Indicated for severe ARDS when conventional ventilation fails. Settings include a constant distending pressure (mean airway pressure), high respiratory rate (1-15 Hz), and small tidal volume to reduce lung injury.
Neurally Adjusted Ventilatory Assist (NAVA)
Uses diaphragm electrical activity to control ventilation, indicated for improved patient-ventilator synchrony. Settings include NAVA level (gain) settings and PEEP/FiO2 to maintain oxygenation.
Bilevel Positive Airway Pressure (BiPAP)
Used for both spontaneously breathing patients and those needing assistance, indicated for COPD, cardiogenic pulmonary edema, and hypercapnic respiratory failure. Settings include inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) levels, backup rate, and FiO2.
Synchronized Intermittent Mandatory Ventilation (SIMV)
Integrates spontaneous breathing with mechanical breaths. Indicated for weaning. Settings include a set rate of mandatory breaths, tidal volume (6-8 mL/kg), pressure support for spontaneous breaths, and appropriate FiO2/PEEP.
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