Most important item(s) to evaluate patient’s pulmonary status : pulmonary compliance

 

SHORT VERSION OF EXPLANATION :

Pulmonary compliance = how easy it is to move volumes tidally in and out of the lung.

Pulmonary compliance formula = dV / dP = 350 / 35 = 10 mls / cmH2O) in this image.

Relevance :  To move 300 mls of spontaneous tidal volume, a patient has to generate -10cmH2O of negative pressure while a normal person would generate -3cmH2O of negative pressure.  The patient spends 3x more energy than you trying to breathe the same sized breath.  That will translate to increased WOB and increased likelihood of respiratory failure and an increased need for proper caloric intake.

 

LONG WINDED VERSION OF EXPLANATION :

Evaluate your patient’s pulmonary compliance.

Some quick definitions :

PIP = peak inspiratory pressure.

PEEP = positive end expiratory pressure.

dP (delta P) = change in pressure, during tidal breathing.

dV (delta V) = change in volume during tidal breathing.

Compliance = ease of lung distensibility.

Compliance = change in volume (tidal volume) / change in pressure = delta V / delta P = dV / dP.

If you are in any Pressure mode (ex : PCV, PSV) , this is very simple :

delta Volume = 350 mls (see above image).

delta Pressure = 35 cmH2O (see above image :  PIP=49 ; PEEP=14 >> dP=35).

Compliance = 350 / 35 = 10 mls / cmH2O.

What is the value of  normal pulmonary compliance?

100 mls / cmH2O.

What is the average pulmonary compliance of a “normal”, intubated ICU patient ?

30 mls / cmH2O.

What exactly does pulmonary compliance mean in practical terms ?

This means for every 1 cmH2O, 100 mls of volume will be moved (the normal non-intubated patient).

This means for every 1cmH2O, 30 mls of volume will be moved (the average ICU patient).

This means the patient works 3x as hard as a non-intubate patient.

For better understanding, the statement can be rephrased as :

(With the caveat statement that we all move approximately 200-300 mls of spontaneous tidal volume).

How much pressure must be generated by a diaphragm to move 300 mls of spontaneous tidal volume in a normal patient?

If the pulmonary compliance = 100 mls / cmH2O, then only 3 cmH2O of negative inspiratory pressure has to be generated.

How much pressure must be generated by a diaphragm to move 300 mls of spontaneous tidal volume in an an average ICU patient?

If the pulmonary compliance = 30 mls / cmH2O, then 10 cmH2O of negative inspiratory pressure has to be generated.

This difference can translate into work of breathing (WOB) and if the patient is underfed, this can start to become a significant impediment to quick weaning and liberation from mechanical ventilatory support.

 

 

 

Most important item(s) to evaluate patient’s pulmonary status : P/F ratio

Evaluate your patient’s P/F ratio :

P/F ratio = PaO2 / FiO2 ratio.

It is a great way to index your patient’s oxygenation status.

It is cheap and not complicated but tells a lot about your lung in 30 seconds.

HOW  TO  CALCULATE  P/F  RATIO :

Divide PaO2 by FiO2 (in decimal format).

Normal P/F ratio value : 500-600 (on any FiO2).

Normal patient : (breathing room air)

PaO2 = 100 ,  FiO2 = 21%  >>  PaO2 / FiO2 ratio = 100 / 0.21 = 500.

Normal patient : (breathing 100% FiO2 via NRB (non-breather)).

PaO2 =  600,  FiO2 = 100%  >>  PaO2 / FiO2  ratio = 500 / 1.00 = 500.

WHAT  ARE  DIAGNOSTIC  VALUES :

P/F ratio > 500-600  =  Normal.

P/F ratio < 300  =  ALI.

P/F ratio < 200  =  ARDS.

P/F ratio < 150  =  AHRF (acute hypoxemic respiratory failure).

WHAT  IS  THE  AVERAGE  SURGICAL  PATIENT’S  P/F  VALUE :

P/F ratio on arrival from operating theatre / room :  PaO2 = 250,  FiO2 = 100%  >>  P/F ratio = 250s.

P/F ratio 4 hours after surgery :  PaO2 = 120,  FiO2 = 50% >> P/F ratio = 250s.

The ICU patient – evaluating the patient in 2 minutes

 

today-icu-bed

Why would you want to evaluate a patient in 2 minutes?

>> To be able to answer anyone who asks : “How’s my patient doing?”

> answer quick and BE READY to defend your stance!

>> Why you think the patient is faring well vs. why you think the patient is decompensating.

>> if they like your answer over the course of 1 to 2 patients (and you were correct),

they will trust you for the rest of your life with anything respiratory related and

patient related as well.

How do you evaluate the patient in 2 minutes?

>> 7 zones to focus on :  2 min = 120 seconds

>> patient.  10 sec

>> patient monitor.  10 sec

>> IV pumps.  30 sec

>> ventilator.  10 sec

>> chest tube.  10 sec

>> urine collection bag.  10 sec

>> any other unusual device in room.  10 sec

>> conclusion and defense thesis.  30 sec

PATIENT :  10 seconds

cyanosis / pale / normal

MONITOR :  10 seconds

HR :  hi  /  lo  / normal
BP :  hi  /  lo  / normal

PA :  hi  /  lo  / normal

CVP :  hi  /  lo  / normal

SpO2 :  hi  /  lo  / normal

IV PUMPS :   30 seconds

Vasoactives :  constrictors  vs.  dilators

Cardiotonics :  inotropes  vs.  chronotropes

Sedation :

Analgesics :

Paralytics :

Epi  /  Levo  /  Neo  /  Vaso  /  Milrinone

Diprivan  /  Ativan  /  Versed  /  Fentanyl

VENTILATOR :   10 seconds

Type & Mode of Ventilation :   VCV  vs.  PCV  ;  AC  vs.  SIMV  vs. PSV

PEEP :    hi  /  lo  / normal

FiO2 :    hi  /  lo  / normal

P/F ratio :  hi  /  lo  / normal

Lung compliance :   hi  /  lo  / normal

CHEST TUBE :   10 seconds

Qualitative analysis :

Quantitative analysis :  hi  /  lo  / normal

URINE COLLECTION BAG :  10 seconds

Qualitative analysis :  clear  /  yellow  /  pink  /  red  / green  /  blue

Quantitaive analysis :    hi  /  lo  / normal

UNUSUAL DEVICES  :  10 seconds

EEG  /  Hypothermia Induction Device  / IAB / VAD / ECMO, CVVH, hemodialysis, wound VAC, compression stockings, external pacing device, cardio-defibrillator, video monitor, patient escape alert device.

CONCLUSION :  immediate

Rationale :  30 seconds

(MORE TO FOLLOW next week)