CPAP Boussignac peri extuba4on!
Mulier J P. AZ Sint-‐Jan Brugge-‐Oostende AV, Belgium 32 nd int symp Intensive Care and Emergency Med.
Silver Hall 17:30
1 32 int symp Int Care Emerg Med 2012
Gastric tube and stomach aspiration before extubation
to prevent post extubation aspiration
Treat if new red blood detected Empty stomach pouch and oral cavity to prevent post
extubation aspiration
CPAP for the obese J P Mulier 27 6 2011
A deLeon Acta Anesth Scand 2010 Body position and esophageal sphincter pressures in obese patients during anesthesia
Laying flat higher risk of aspiration
Barrier pressure (between stomach and pharynx) before and during anesthesia decreased to same level in all positions:
3 IFSO Hamburg 2011 Anaesthesia induction
Pharynx dysfunction increases the aspiration risk be sure to be fully decurarised
0 50
100 150
Control TOF 0.6 TOF 0.7 TOF 0.8 TOF 0.9
Upper oesophagal Sfincter resting tone
(mm Hg)
Neuromusculair block Eriksson LI et al Anesthesiology 1997; 87: 1035
Partial NMB Volunteers No sedation
CPAP for the obese J P Mulier 27 6 2011
Prevention of Atelectasis in Morbidly Obese Patients during General Anesthesia and Paralysis: PEEP and LRM
Reinius et al. Anesthesiology 2009
Extubation same problem
Use positive pressure, CPAP during extubation and recruit after extubation with a mask.
No suctioning while extubating
If you need to clear the airways before extubation do it under high flow CPAP, small tube size, short intermittent time
32 int symp Int Care Emerg Med 2012 7
Tracheal pressures during aspiration
CPAP for the obese J P Mulier 27 6 2011
closed ventilation
6 6,5 7 7,5 8 8,5 Closed aspiration no peep
blue 8 Ch -8 -6 -7 black 10 Ch -22 -18 -17 whit 12 Ch -48 -24 -20 green 14 Ch -144 -36 -25 orange 16 Ch -350 -59 -32
ETT open to air 6 6,5 7 7,5 8 8,5 Open
aspiration blue 8 Ch -1 -0,5 0 0 0 0 safe black 10 Ch -4 -3 -2 -1 -0,5 -0,5 dangerous whit 12 Ch -24 -11 -6 -4 -3 -2 not done? green 14 Ch -99 -32 -17 -11 -6 -4 orange 16 Ch -300 -90 -38 -23 -13 -8
CPAP 10 Vygon 6 6,5 7 7,5 8 8,5 CPAP 10 blue 8 Ch 8 9 10 10 10 10 black 10 Ch 4 6 7 8 9 9 whit 12 Ch -16 -2 2 4 6 7 green 14 Ch -86 -26 -10 -2 2 4 orange 16 Ch -300 -90 -30 -14 -3 1
ETT size 6 – 8,5
CPAP – PEEP always
From before intubation till after extubation
Keeps the lungs open
LRM lung Recruitment Maneuver when
Low sat, Loss of peep
Re-open the lungs
IFSO Hamburg 2011 Anaesthesia induction 9
But you not always have an intensive care ventilator with CPAP
In the PACU, Older ventilators on ICU
In the operating room even pressure support ventilators have no CPAP in spontaneous breathing mode (except ZEUS)
No CPAP at induction and manual ventilation
No CPAP at extubation
No cpap after extubation
Use of Boussignac mask is not possible during induction
32 int symp Int Care Emerg Med 2012 10
New: boussignac CPAP connected to ventilator through one way valve and T piece
32 int symp Int Care Emerg Med 2012 11
APL peep Boussignac CPAP
32 int symp Int Care Emerg Med 2012 12
Peep set at 10 cmH20 with APL only Fresh gas flow never sufficient
Peep set at 10 cmH20 with APL and Boussignac
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0
2
4
6
8
10
12
0 10 20 30 40 50 60 70
Boussignac 5 CPAP Vygon valve
Boussignac 5 CPAP Intersurgical valve
Boussignac10 CPAP Vygon valve
Boussignac 10 CPAP Intersurgical valve
Conclusion 1. Change every ventilator to a CPAP ventilator with a
Boussignac CPAP air amplifier.
1. Simple easy and cheap and also usefull for intensive care
2. Keep CPAP and PEEP during induction of anesthesia
3. Keep CPAP and PEEP during extubation and after extubation
4. During laparoscopy just peep to keep lungs open? How much?
32 int symp Int Care Emerg Med 2012 15
How much PEEP needed during Pneumoperitoneum ? PEEP 5 tot 10 maximum 15 cmH20 during ventilation of
normal lungs.
Pneumoperitoneum 10 to 15 max 20 mmHg
You need 14 to 19 max 26 cmH20 to equal pressures and 5 more to expand the lungs and avoid atelectasis?
This is never done. Sometimes no PEEP is even used without saturation change but having atelectasis.
32 int symp Int Care Emerg Med 2012 16
EIT could help us to see atelectasis during laparoscopy?
Too high Right place?
32 int symp Int Care Emerg Med 2012 17
PEEP vs Pneumoperitoneum !
Peep 0 5 10 15 cmH20 before pneumoperitoneum
PEEP 5 cmH20 Pneumoperitoneum 0 5 10 15 mmHg
Morbid obese patients with WHR < 1, pear shaped body
JPM 18 05 2010 Anesthesie voor bariatrische heelk 18
Pneumoperitoneum can be handled with normal, PEEP ranges