Скачать или смотреть The Patient is FIGHTING the Ventilator!

The patient is turning purple in the bed, alarms are going off, he is desaturating: he is "fighting the ventilator." Although a widely used description I believe that it is misused to redefine the problem away from an issue of ventilator operator competency and reframe it as a patient problem. It is not. Most of the time that patient have negative interactions with the ventilator it is a problem of triggering, flow or expiratory cycling.
The most frequently seen patient ventilator dysynchrony is scooping of the pressure waveform, usually associated with flow limited volume controlled ventilation. This can be resolved by increasing the peak flow or changing to pressure control.
In general the ambition to establish a patient on spontaneous assisted ventilation is laudable, but oftentimes we have no idea about what is going on underneath the pressure, flow and volume waveforms. In this tutorial I try and correct the narrative about patient-ventilator interaction when using pressure support. I suggest that volume support in some situations may be a superior approach. I point out that the tidal volume in pressure support has little to do with patient effort and more to do with lung compliance.
I finish the tutorial with a discussion about the inspiratory rise time and explain why you must be careful when using older ventilators.
@ccmtutorials www.ccmtutorials.org

Contents:
00:08 Intro
01:20 Clinical Scenario
01:45 Inspiratory Dysynchrony
03:00 Scooping in Volume Control
03:15 Flow Limitation
03:25 Pressure And Flow in Spontaneous Respiration
04:05 Pressure And Flow in Assisted Ventilation
04:50 A Paradigm For Understanding Patient Ventilator Interactions
06:15 Understanding What is Going on With Flow-Demand Dysynchrony
07:00 Respoving the Problem - Increasing the Flow
08:30 Adjusting the Peak Flow and the Flow Waveform
09:00 Why Pressure Control Resolves the Problem of Flow Demand Dysynchrony
10:00 Options for Using Pressure Controlled Modes
11:10 Transitioning to Spontaneous Modes
12:12 Pressure Support Revisited
15:00 Pressure Support - with patient effort overlain
16:10 Why Pressure Support is Like Riding a Bike (and not the way you think)
17:10 Pressure Support and Worsening Compliance
18:15 The Limitations of Pressure Support
18:55 Volume Support Revisited
20:00 Why You MUST watch the Airway Pressure in Volume Support
21:00 Advantages and Disadvantages of Volume Support
22:30 Volume Support and Worsening Compliance
23:30 Flow Control on Modern Ventilators (they are awesomely powerful - that is good and that is not so good)
24:40 The Rise Time and Inspiratory Dysynchrony
28:45 Review of Tutorial and Preview of Next Tutorial