Lecture 1 Mechanical Ventilation An Introduction

BASIC MECHANICAL
VENTILATION COURSE
LECTURE 1
MECHANICAL VENTILATION:
AN INTRODUCTION
Subcommittee Emergency Critical Care
Malaysian College of Emergency Physician ,
Academy of Medicine ,
Malaysia
1
Thursday, April 18, 2013
LEARNING OBJECTIVES
To know the indication for intubation

and mechanical ventilation.
To understand the conceptual

differences between positive and
negative pressure ventilation.
BASIC MECHANICAL VENTILATION COURSE
SUBCOMMITTEE EMERGENCY CRITICAL CARE
MALAYSIAN COLLEGE OF EMERGENCY MEDICINE
WHAT IS MECHANICAL VENTILATION
Mechanical ventilation is any means in

which physical devices or machines
are used to either assist or replace
spontaneous respiration.
NEGATIVE VS POSITIVE PRESSURE
VENTILATION
Negative Pressure Ventilation - Pressure lower

than atmospheric pressure is applied to the
extrathoracic space during inspiration.
Positive Pressure Ventilation - Pressure higher than

atmospheric pressure is applied to the
intraalveolar space during inspiration.
NEGATIVE VS POSITIVE PRESSURE VENTILATION
At Rest
LxLernal Lo Lhe lung ls Lhe ouLslde world where we wlll seL Lhe aLmospherlc pressure Lo zero for reference. 1he slngle oval cavlLy ln Lhe mlddle represenL all Lhe lnLra-alveolar
space when aL resL, aL equlllbrlum, Lhe pressure ls also zero. 1he half shelf represenLs Lhe pleural space. 1he lung Lhemselves exerL lnward forces from Lhe pleural space due Lo
elasuc recoll. Llkewlse, Lhe chesL wall exerLs ouLward force on Lhe pleural space due Lo lLs own elasuc recoll. 1herefore, Lhe pressure on Lhe pleural space ls negauve aL resL.
Mlnus 3 cmP2C ls Lhe lnLrapleural pressure value.
!"#$% ' (#)'%*+# ,$#--.$# /( %0# #"%#$('1 20#-%
3#2$#'-*() %0# *(%$'%0/$'2*2 ,$#--.$# 4.$*() *(-,*$'%*/( '11/5- '*$ %/ 6/5 *(%/ %0# 1.()7 811*() *%- +/1.9#
:0;-*/1/)*2'11;7 %0*- %;,# /< '--*--%#4 +#(%*1'%*/( *- -*9*1'$ %/ -,/(%'(#/.- +#(%*1'%*/(
=% *- .-#4 9'*(1; *( 20$/(*2 $#-,*$'%/$; <'*1.$# '--/2*'%#4 5*%0 (#.$/9.-2.1'$ 2/(4*%*/(- -.20 '- ,/1*/9;1#*%*-7 9.-2.1'$ 4;-%$/,0;7 ' 9;/%$/,0*2 1'%#$'1 -21#$/-*-7 '(4
9;-%0#(*' )$'+*->
NEGATIVE PRESSURE VENTILATION
llrsL, wlLh negauve pressure venulauon, Lhe enure body/Lhorax was enclosed ln an alrughL chamber, leavlng Lhe head exposed. lnsplrauon ls Lrlggered by negauve pressure lnslde
Lhe chamber. 1hls lncreased Lhe ouLward pull of Lhe chesL wall and ls Lransmlued Lo Lhe pleural space and Lhe lungs so LhaL Lhey expand up.
1he exLernal negauve pressure does noL equal lnLraalveolar pressure. 1hls dlscrepancy ls due Lo Lhe elasuc recoll of Lhe lungs. lf Lhe aLmospherlc pressure ls zero, lL wlll drlve alr
lnLo Lhe lnLralveolar space (whlch ls negauve). Alrow wlll cease when lL reach equlllbrlum buL Lhe lnward force ls sull roughly equal Lo Lhe ouLward force due Lo elasuc recoll of
Lhe lung.
Lxplrauon ls Lrlggered by Lhe lnslde chamber pressure reLurnlng Lo aLmospherlc pressure. now Lhe lnward force wlll be greaLer Lhan Lhe ouLward force. 1hls pulled Lhe lung back
ln and lncreases Lhe lnLra-alveolar pressure. And Lhe alr geLs explred ouL agaln.
!"#$% ' (#)'%*+# ,$#--.$# /( %0# #"%#$('1 20#-%
3#2$#'-*() %0# *(%$'%0/$'2*2 ,$#--.$# 4.$*() *(-,*$'%*/( '11/5- '*$ %/ 6/5 *(%/ %0# 1.()7 811*() *%- +/1.9#
:0;-*/1/)*2'11;7 %0*- %;,# /< '--*--%#4 +#(%*1'%*/( *- -*9*1'$ %/ -,/(%'(#/.- +#(%*1'%*/(
=% *- .-#4 9'*(1; *( 20$/(*2 $#-,*$'%/$; <'*1.$# '--/2*'%#4 5*%0 (#.$/9.-2.1'$ 2/(4*%*/(- -.20 '- ,/1*/9;1#*%*-7 9.-2.1'$ 4;-%$/,0;7 ' 9;/%$/,0*2 1'%#$'1 -21#$/-*-7 '(4
9;-%0#(*' )$'+*->
NEGATIVE PRESSURE VENTILATION
now leL's look aL Lhe resplraLory cycle's graph, Lhe gray llne aL zero, represenL aLmospherlc pressure. And Lhe red llne wlll represenL Lhe exLernal pressure seL by Lhe parameLers.
WlLh lnsplrauon, Lhey provlde negauve exLernal pressure. WlLh explrauon, Lhe lnLraalveolar pressure goes Lo zero and lnLo some posluve pressure and push Lhe gas back ouL.
IRON LUNG
llrsL negauve pressure venulaLor was lnvenLed ln 1928. 1hls ls Lhe plcLure of lL. 1he pauenL whole body lnslde and head sucklng ouL of lL. lL ls called lron
lung.
IRON LUNG
1hls ls Lhe vlew of a ward ln 1920s. 1he lron lungs are very resLrlcuve Lo Lhe pauenLs, Lhough Lhey looked comforLable.
IRON LUNG
1hls lady llved lnslde Lhe lron lung for 38 years due Lo pollo. She goL pollo aL age of 3 years old and unllke mosL ollo cases her lung falled Lo recover lLs funcuon.asL away ln
2008 because of power fallure.
IRON LUNG
1hls ls a porLalung, porLable negauve pressure venulaLor.
POSITIVE PRESSURE VENTILATION
8esearch lnLo posluve pressure venulauon dld noL occur ln Lhe hosplLal. 1hey occurs ln 1940s when Lhe mlllLary are lnvesugaung beuer ways Lo dellver oxygen Lo plloLs aL hlgh
aluLude.
osluve pressure venulaLors dld noL enLer hosplLal use ull 1960s.
!"#$%&#' #'")&*$)&+" ,-%) .%'/ $) 0$%%$12.%'))% 3'"'-$* 4+%5&)$* &" 67889
?0.- @#)'( %0# #$' /< ,/-*%*+#A,$#--.$# 9#20'(*2'1 +#(%*1'%*/( B'(4 %0# #$' /< *(%#(-*+# 2'$# 9#4*2*(#C>
POSITIVE PRESSURE VENTILATION
osluve pressure venulauon ls glven Lhrough Lhe endoLracheal Lube lnLo Lhe lnLraalveolar space. 1hls drlve alr lnLo Lhe lungs due Lo dlerences ln Lhe pressure gradlenL unul reachlng equlllbrlum. 1here ls
posluve pressure ln Lhe lnLra-alveolar space and aLmospherlc pressure ln Lhe exLraLhoraclc space.
Lxplrauon happens when Lhe posluve pressure on Lhe endoLracheal Lube ls removed and alr ow ouL from Lhe lungs due Lo pressure gradlenL. Llasuc recoll from Lhe lung reduces Lhe lnLraalveolar slze.
now leL's look aL Lhe lnLralaveolar pressure vs ume. Agaln Lhe dash grey llne wlll be Lhe aLm pressure. l seL aL zero for reference. 1he dashed red llne represenLs Lhe seL pressure applled Lo Lhe endoLracheal
Lube. 1he appllcauon of a consLanL pressure lnLo Lhe lnLraalveolar push lL lnLo posluve pressure. When Lhe pressure ls removed, lnLra-alveolar press dropped back down agaln.
NEGATIVE VS POSITIVE PRESSURE
VENTILATION
Major Advantages
Negative
Pressure
No need for sedation
Negative
Pressure
Non-invasive
Negative
Pressure
Patient able to eat and talk
Negative
Pressure
Probably lower risk of aspiration
Positive
Pressure
Able to provide higher levels of FiO2
Positive
Pressure
More effective for providing large driving gradients
Positive
Pressure
Increased ability to individualize treatment
Positive
Pressure
Can provide full ventilatory support for unconscious patients
INDICATIONS FOR MECHANICAL
VENTILATION
Need for high levels of inspired oxygen (Hypoxic

respiratory failure)
Need for assisted ventilation ( hypercapnic

respiratory failure or surgical procedures)
Protection of airway against aspiration.
Relief of upper airway obstruction.

Main Problem Associated Problem Associated Problem

Clinical Scenario 1

A 22 year old male found collapsed in the street, pinpoint pupils, respiratory rate
of 5 and a PH 7.12 , PCO2 of 70 mmHg, PO2 60mmHg.
Solution
This man has ventilatory failure, as you can see from his high CO2. He is also somewhat hypoxemic, which is not surprising, as CO2 will displace O2 from the
alveolus when it builds up (we know this from the alveolar gas equation: PAO2 = PiO2 PaCO2/R).
The combination of meiosis and bradypnea immediately suggests narcosis, which can be reversed, at least temporarily, with naloxone.
The mechanism of his respiratory failure is thus loss of respiratory drive due to opioids reducing the sensitivity of the respiratory center to carbon dioxide
Clinical Scenario 2
A 47 year old male with a two week history of upper respiratory tract infection
is admitted to ER with a history of bilateral lower limb weakness and shortness
of breath. Poor respiratory effort and his pCO2 is 70mmHg and pO2 60mmHg.
Main Problem X X
Solution
This patient has ventilatory failure, as evidenced by his inability to clear carbon dioxide. His diagnosis turns out to be Guillain-Barre syndrome, which is
characterized by motor, sensory and autonomic neural demyelination and thus neuropathy, which usually eventually reverses. The low FVC is a sign of poor
physiological reserve, and this patient requires controlled mechanical ventilation.
Clinical Scenario 3
A 74 year old female is admitted unconscious, GCS 3, Cheyne Stokes breathing pattern,
in atrial fibrillation, BP 170/100mmHg, PCO2 70mmHg, PO2 60mmHg.
Main Problem X Main Problem
Solution
This patient is failing to ventilate and failing to protect her airway. A comatose patient with this breathing pattern is a brain stem stroke until otherwise proven.
The cause is either a bleed (hypertension) or an embolus (atrial fibrillation). Mechanical ventilation in this circumstance is invariably futile.
Thank You

Lecture 1 Mechanical Ventilation An Introduction

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Lecture 1 Mechanical Ventilation An Introduction

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BASIC MECHANICAL

To know the indication for intubation

To understand the conceptual

Mechanical ventilation is any means in

Negative Pressure Ventilation - Pressure lower

Positive Pressure Ventilation - Pressure higher than

Need for high levels of inspired oxygen (Hypoxic

Need for assisted ventilation ( hypercapnic

Protection of airway against aspiration.

Relief of upper airway obstruction.

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