Mechanical Ventilation and Blood Gases

Resident Lecture Series

Soo Hyun Kwon, MD

Goals

Understand the principles of respiratory physiology Learn differences in respiratory physiology of neonate Learn different modes of mechanical ventilation Discuss some of complications of mechanical ventilation and issues related to weaning the ventilator Review how to interpret blood gases and causes of acid-base disturbances

Objectives

List indications for mechanical ventilation Describe the basics of respiratory mechanics Describe the interaction between the ventilator and the infant Compare modes of conventional ventilation Delineate the factors on which ventilator adjustments should be based Describe how mechanical ventilation may cause lung injury Interpret blood gases and changes to ventilator settings based on a gas

Definition

Assisted ventilation: movement of gas into and out of lungs by external source connected directly to patient

Factors to Consider

Pulmonary mechanics Gas exchange mechanisms Control of breathing Lung injury

Normal Respiration

Pulmonary Mechanics

Compliance

Elasticity or distensibility of the respiratory structures (eg, alveoli, chest wall, and pulmonary parenchyma) C=V/P

Resistance

Inherent capacity of the air conducting system (eg, airways, endotracheal tube) and tissues to oppose airflow R= P/F

Pulmonary Mechanics in Newborns

Shape of chest

Compliance of chest wall

More cylindrical and ribs more horizontal Less elevation of ribs therefore less volume Little resistance to expansion Little opposition to collapse Largest contributor to recoil on exhalation High surface tension will lead to atelectasis Surfactant reduces surface tension

Surface tension

Normal Gas Exchange

Gas Exchange in Newborns

High metabolic rate Propensity for decreased functional residual capacity (FRC) Increased resistance Potential for right-to-left shunts through the ductus arteriosus, foramen ovale, or both

Ventilation and Hypercapnea

Ventilation (CO2 removal)

Function of minute ventilation

Alveolar Minute Ventilation = Tidal Volume x Rate

Oxygenation and Hypoxemia

Oxygenation

Function of FiO2 and MAP

MAP = [RRxItime/60] x (PIP-PEEP) + PEEP

Time Constant

Time Constant: time required to allow pressure and volume to equilibriate

Time constant (0.12s)= Compliance x Resistance

Indications for Assisted Ventilation

Absolute Indications

Failure to initiate or sustain spontaneous breathing Persistent bradycardia despite BMV Major airway or pulmonary malformations Sudden respiratory of cardiac collapse with apnea/bradycardia

Relative Indications

High likelihood of subsequent respiratory failure Surfactant administration Impaired pulmonary gas exchange Worsening apnea unresponsive to other measures Need to maintain airway patency Need to control CO2 elimination

Goals of Mechanical Ventilation

Improve gas exchange Decrease work of breathing Ventilation for patients with apnea or respiratory depression Maintain airway patency

Changing MAP and TV

A: Flow B: PIP C: Insp time D: PEEP E: Exp time

Ventilator Modes and Modalities

Ventilator Settings

(Pressure-targeted ventilation)
Rate PIP

PEEP

visible chest rise adequate breath sounds 4-6 cm H2O

Tidal volumes (measured, not set)

Itime +/- PS FiO2

preterm: 4-7 ml/kg term: 5-8 ml/kg

Ventilator Induced Lung Injury

Barotrauma Volutrauma Atelectrauma Biotrauma

Suggested Strategies For Conventional Ventilation in RDS

Conservative indications for conventional ventilation Permissive hypercapnia

Accept higher PCO2 values

Lowest PIP (tidal volume) that inflates the lungs

Low tidal volume ventilation

Moderate PEEP (4 - 6 cm H2O) Aggressive weaning from conventional ventilation

Weaning from Assisted Ventilation

Physiologic requisites

Elements of weaning

Adequate spontaneous drive Overcome respiratory system load Maintenance of alveolar ventilation Assumption of work of breathing Nutritional aspects Infection Neurologic/neuromuscular dysfunction Electrolyte imbalance Metabolic alkalosis Congestive heart failure Anemia Sedatives/analgesics Nutrition

Impediments to weaning

Complications of Assisted Ventilation

Airway

Lungs

Upper: trauma/injury, abnl dentition, esophageal perforation, acquired palatal groove Trachea: subglottic cysts, tracheal enlargement, tracheobronchomalacia, tracheal perforation, vocal cord paralysis/paresis, subglottic stenosis, necrotizing tacheobronchitis

Misc

VA-PNA Air leaks Ventilator induced lung injury CLD/BPD Imposed WOB PDA IVH PVL ROP

Neurologic

Other Modes of Invasive Mechanical Ventilation

High Frequency Ventilation

Jet ventilation Oscillatory ventilation

Other Modes of Positive Pressure

Nasal Intermittent Positive Pressure Ventilation (NIPPV) Continuous Positive Airway Pressure (CPAP) High Flow Nasal Cannula

Blood Gases

Objective evaluation of a patients oxygenation, ventilation and acid-base balance Balance between lungs and kidneys

Buffer Systems

Lungs

Kidneys

Cellular metabolism CO2 CO2 in lungs + H20 carbonic acid (H2CO3). Carbonic acid changes blood pH Triggers lungs to either increase or decrease rate/depth of ventilation In an effort to maintain the pH of the blood within its normal range, the kidneys excrete or Excrete or retain bicarbonate HCO3 to maintain normal pH As pH increases, kidneys excrete HCO3 through the urine

Components of Blood Gas

pH/PCO2/PO2/O2 sat/HCO3/Base excess or deficit Measured

Calculated

pH PCO2 PO2

O2 sat HCO3 Base excess or deficit

Normal Values

Steps to Interpreting Blood Gases

Determine Determine PCO2 Determine Determine

acidosis or alkalosis based on pH acidosis or alkalosis based on if metabolic or respiratory compensation

For every 10 change in PCO2 above or below 40 0.08 change in pH in opposite direction Acidosis and alkalosis may be partially or fully compensated by the opposite mechanism Body NEVER OVERCOMPENSATES!

Approach for Analysis of Simple AcidBase Disorders

Before Making Vent Changes

Do you believe the blood gas result? Look at the baby

Look at the ventilator

Is Is Is Is

the chest moving? there good air-entry like? there increased WOB? the baby very tachypneic or is the baby apneic?

Other things to consider

What tidal volume is the baby getting? Is there a significant leak? How stable has the baby been over the past few hours or days? Are there lots of secretions?

Vent Changes
Problem
Low oxygenation High oxygenation Over-ventilation Under-ventilation

Possible Solutions
Increase FiO2, MAP Decrease FiO2, MAP Decrease TV, Rate Increase TV, Rate

Common Causes of Acid-Base Status in Neonates

Question 1

Baby Brown is a 24-week-gestation male infant who is 4 days old. His birth weight was 600 grams and he is on a conventional ventilator. Vent settings: 30 19/5 PS6 40% Na: 151 Glucose: 180 Weight today: 510 grams ABG: 7.17/45/55/-10 What is the abnormality based on gas? What is the most likely cause of this abnormality? Metabolic acidosis

Question 2

7.22/61/70/-1 What is the abnormality based on this gas? Uncompensated respiratory acidosis

Question 3

33 weeker SIMV 25 18/5 30% CBG: 7.49/26/+2 What is the abnormality based on this gas? How would you change the vent settings? Uncompensated respiratory alkalosis. Decrease Rate, PIP.

Question 4

CBG: 7.37/29/-3 What is the abnormality based on this gas? Metabolic acidosis with Respiratory compensation

References

Fanaroff A, Martin R, Walsh M. Fanaroff and Martin's Neonatal-Perinatal Medicine. 2008.

Thank You