MLCnANICAL

VLN1ILA1ICN
Gregory A. Schm|dt, MD
rofessor, D|v|s|on of u|monary D|sease, Cr|nca| Care,
and Cccupanona| Med|c|ne
Un|vers|ty of Iowa
No conflicts to disclose
D|sc|osure
l have no relauonshlps wlLh lndusLry Lo
dlsclose wlLh regards Lo Mechanlcal
venulauon
Cb[ecnves
8y Lhe end of Lhls course, you should be able Lo:
ldenufy Lhe modes
Lxplaln physlology of venulauon
ulscuss Lhe Lypes of resplraLory fallure
LlsL key venulauon concepLs
Lquauon of mouon
vlLl
vluu
AuLoLL
ermlsslve hypercapnla
venulaLor bundle
AkS Case 1: Wh|ch venn|atory mode |s
shown?
A. volume asslsL-conLrol
8. ressure asslsL-conLrol
C. Alrway pressure release
(A8v)
u. roporuonal asslsL
venulauon (Av)
8reath]Mode 1ypes
8reaths
1r|gger 1arget Cyc|e
volume ConLrol 1lme llow volume
volume AsslsL LorL ( or ow) llow volume
ressure ConLrol 1lme lnsp 1lme
ressure AsslsL LorL ( or ow) lnsp 1lme
ressure SupporL LorL ( or ow) lnsp llow
Modes
VC VA C A S Spont
volume AC x x
ressure AC x x
Sv x
volume SlMv x x x x
ressure SlMv x x x x
Vo|ume Ass|st-Contro|:
Set Vt, rate, ow
Pao
Vol
Flow
I
E
TIME
ressure Ass|st-Contro|:
Set , 1|, rate
AkV
(8|-Leve|)
8esembles C-l8v
Allows Sv aL hlgh and low
pressure, so paralysls noL
necessary
uoes noL llmlL vL
Any beneL speculauve
Neumann P, et.al: Intensive Care Med 28:1742, 2002
ressure-Support:
Set
Dua|-Contro| Modes
(Dua|-contro| w|th|n or between breaths)
INPUT OUTPUT
V
P
V and P
PRESSURE
VOLUME
VOLUME or
PRESSURE
MODE
ACV, SIMV
PSV, PCV
DUAL CONTROL
(VAPS, PRVC)
ressure-kegu|ated Vo|ume Contro| (VC+,
Autoow)
SeL a deslred vL, max,
and 1l
venulaLor ralses Lo
LargeL vL
AdvanLages of pressure-
preseL mode?
auenL eorL reduces
supporL
no sclenuc sLudles

8eglns as Sv: SwlLches
Lo ACv lf vL LargeL noL
meL - ln LhaL breaLh
SeL pressure llmlL, raLe,
mlnlmum vL, backup
ow
Vo|ume-Assured ressure Support
(ressure Augmentanon)
P
Flow
hys|o|ogy of MV
venulauon and pleural pressure
Lsophageal pressure gulded Lherapy
uynamlc uld responslveness predlcLors
ClrculaLory lmpacL
lmpacL of venulaLor changes on A8Cs may be complex
AkS uesnon 2: eso
A pauenL wlLh A8uS and abdomlnal dlsLenuon ls
mechanlcally venulaLed buL alerL. AL end-explrauon, you
brley occlude Lhe alrway whlle Lhe pauenL makes an acuve
lnsplraLory eorL. ao falls by 10 cm P
2
C. AL Lhe same ume,
you expecL Lhe pleural (or esophageal) pressure Lo.?

A. lall by 20 cm P
2
C
8. lall by 10 cm P
2
C
C. 8emaln unchanged
u. 8lse by 3 cm P
2
C
8. Ia|| by 10 cm n
2
C
Talmor D, et.al: Crit Care Med 2006; 34:1389
p|: Acnve anent
1. Many venulaLed" pauenLs are acuve
2. pl generally falls wlLh acuve lnsplrauon
3. ueLermlnanLs of Apl lnclude:
lnsplraLory reslsLance
Lung compllance
LorL, sLrengLh
venulaLor semngs
p|: ass|ve anent
pl rlses wlLh lnsplrauon, LL
ueLermlnanLs of Apl lnclude:
ChesL wall compllance (noL lung compllance lf on
volume-preseL mode): abdomen
1ldal volume (Lhus v requlres 8-12mL/kg v
1
)
LL recrulLablllLy
Slnce C
L
= C
CW
aL l8C ln healLh, Apl = C
L
/(C
L
+ C
CW
) =
30
8uL 30 ls noL accuraLe ln crlucal lllness
p|: Acnve or ass|ve?
AC1IVL
ASSIVL
AkS uesnon 3
A 37 year old man wlLh sepuc shock ls
venulaLed and passlve. 1wo seconds
followlng each udal lnsplrauon (durlng
explrauon) you nouce LhaL sysLollc arLerlal
pressure and pulse pressure fall by aL leasL
20.
AkS uesnon 3: SV and V
1hls resplraLory varlauon ln sysLollc and
pulse pressure ls besL explalned because
udal venulauon.?

A. 8educes rlghL venLrlcular preload
8. 8alses rlghL venLrlcular aerload
C. 8alses le venLrlcular preload
u. 8educes le venLrlcular aerload
C|rcu|atory Impact: V and LL
1. *Reduces RV preload
Card|o-pu|monary Interacnons
du: lncreased Lv
preload,
decreased Lv
aerload
duown:
uecreased 8v
preload,
lncreased 8v
aerload
dup
duown
kesp|ratory Var|anon
ln Lhe passlvely venulaLed pauenL, varlauon ln pulse
pressure, sysLollc pressure, arLerlal ow veloclLy, sLroke
volume, echocardlographlc veloclLy-ume lnLegrals, and
vena caval dlameLers suggesL LhaL:
A. 1he hearL ls funcuonlng on Lhe sLeep poruon of Lhe
cardlac funcuon curve C8
8. 1here ls a severe pump problem, such as 8v or Lv
sysLollc dysfuncuon
1ypes of kesp|ratory Ia||ure
1ype 1: AcuLe hypoxemlc
aLhophyslology: ShunL
ALl/A8uS
Cardlogenlc pulmonary edema
Alveolar hemorrhage
neumonla (may be focal)
1reaLmenL: Cxygen and LL
May noL be LL-responslve (or worse)
1ype 2: venulaLory fallure
aLhophyslology: urlve, load, n-M compeLence
1reaLmenL: 8esLore drlve or sLrengLh, reduce load
Choos|ng Semngs
CbsLrucuon:
Conslder nlv
LlmlL v
L
ALl/A8uS: LlmlL vL
normal Lungs: LlmlL vL lf ALl rlsk
1horaclc 8esLrlcuon: LlmlL vL
Meta-Ana|yses: CCD
Endpoint Risk Difference (%) Reference
ETT 28 Keenan
1
19 Lightowler
2
18 Peter
3
Mortality 10 Keenan
13 Lightowler
13 Peter
LOS 4.6d Keenan
3.2d Lightowler
5.7d Peter
1
Ann Intern Med 138:861, 2003
2
BMJ 326:185, 2003
3
Crit Care Med 30:555, 2002
NIV is the standard of care for COPD exacerbations
Non-CCD NIV
Cardlogenlc pulmonary edema
Pypoxemlc 8l ln lmmunocompromlsed
neumonla
erloperauve resplraLory fallure
ALl/A8uS
osL-exLubauon fallure
There is less certainty regarding benefit in hypoxemic RF
NIV |n CL
1069 sub[ecLs wlLh CL randomlzed Lo oxygen, CA
(3-13 cm P
2
C), or nlv (LA 4-10 cm P
2
C, lA
8-20)
CA/nlv lmproved sympLoms, P8, acldemla,
hypercapnla when compared wlLh oxygen alone
no morLallLy dlerence aL 7d
no dlerence beLween CA and nlv ln Lhe
comblned endpolnL of deaLh or lnLubauon
Gray A, et.al: N Engl J Med 359:142, 2008
NIV keduces Infecnons
Cuerln: nlv reduces vA (0.16 v 0.83 cases/100d
venulauon
nourdlne: nlv reduces nosocomlal lnfecuon (1.4 v
3.0 cases/100d) and vA
Clrou: nlv reduces nosocomlal lnfecuons (18 v 60)
and anublouc use
Carluccl: nlv reduces nosocomlal pneumonla (10 v
19)

Gurin C, et.al: Intensive Care Med 23:1024, 1997
Nourdine K, et.al: Intensive Care Med 25:567, 1999
Girou E, et.al: JAMA 284:2361, 2000
Carlucci A, et.al: Am J Respir Crit Care Med 163:874, 2001
AkS Case 4:
lollowlng a Lraumauc braln ln[ury a pauenL ls
Lherapeuucally paralyzed and venulaLed (passlve) on
volume asslsL-conLrol: vL 430mL, lnsplraLory ow raLe
60 L/mln, 88 16, and LL 3 cm P
2
C. 1here ls no known
lung dlsease. 1he end-lnsplraLory peak alrway pressure
ls 13 cm P
2
C whlle Lhe plaLeau alrway pressure ls 10
cm P
2
C. 1he calculaLed sLauc compllance of Lhe
resplraLory sysLem ls 90 mL/cm P
2
C. 1he venulaLor
mode ls changed Lo pressure asslsL-conLrol wlLh Lhe
same raLe and LL buL wlLh an lnsplraLory pressure
lncremenL of 12 cm P
2
C and lnsplraLory ume of 1.6
seconds.
AkS Case 4:
Whlch of Lhe followlng udal volumes ls mosL llkely
followlng Lhls change ln mode?

A. 330 mL
8. 430 mL
C. 700 mL
u. 1000 mL
Lquanon of Monon

V
Volume modes; pressure modes; patient effort
mus: Lort Mauers
Vo|ume-reset, Constant I|ow
1 = LL
1C1AL
2 = !VCL]C
kS
3 = I|ow x k
kS

1
2
3
P
resist
P
elas
PEEP
Vo|ume-reset, Constant I|ow
C
RS
C
L
C
CW
*
*
Peso
INFLATION
DEFLATION
krs vs Crs
!"#$%&'("#
*+, '+ -&$ '*.&
#.(/"+&01(223
key Concepts
vlLl (covered elsewhere)
vluu
AuLoLL
ermlsslve hypercapnla
venulaLor bundle"
Acnve D|suse Atrophy
! 14 brain dead organ
donors
! Passive ventilation for
18 69h
! Diaphragm biopsy
Levine S, et.al: N Engl J Med 2008; 358:1327
Acnve D|suse Atrophy
Levine S, et.al: N Engl J Med 2008; 358:1327
Levine S, AJRCCM 2010; 183:483
Proteolysis
AutoLL
AuLo posluve end-explraLory pressure
Sull exhallng aL end-explrauon
usually assoclaLed wlLh alrow obsLrucuon
uoes noL requlre mechanlcal venulauon
Levy BD, et.al: Intensive Care Med 24: 105, 1998
erm|ss|ve nypercapn|a
Sacrlce aCC
2
/pP for lung proLecuon
Well-LoleraLed and sLandard Lherapy for sLaLus
asLhmaucus, A8uS
hyslologlc consequences are modesL ln
adequaLely sedaLed pauenLs
Alkall Lherapy ls noL generally lndlcaLed 45"'62 7+"&$"&-&
7+"8$%$"1$9 :;<77= >?@AB>>CD >EEEF
P could be harmful ln pregnancy, acuLe cor
pulmonale, acuLe myocardlal lschemla, and when
lC ls lncreased
"Venn|ator 8und|e"
1. Pead of bed elevauon
2. ually sedauve lnLerrupuon
3. ually readlness assessmenL
4. ueep veln Lhrombosls and gasLrolnLesunal
hemorrhage prophylaxls
kead|ness Assessment
81 Screen
/l > 200
LL < 6
Cough presenL wlLh sucuonlng
f/vL < 103
no vaso8x or conunuous sedauve
lf pass, S81 x 2h (1-Lube or CA 3)
venL days = 4.3 v 6.0 (p < .003)
Ely EW, et al: N Engl J Med 1996; 335:1864
8ouom L|ne
v and LL aecL pleural pressure and Lhe clrculauon
nlv ls Lhe sLandard of care for CCu exacerbauon
Waveforms of pressure and ow yleld lnformauon abouL
resplraLory mechanlcs
ConLrolled venulauon produces dlaphragm dysfuncuon
Lhrough acuve proLeolysls
AuLoLL ls common, musL be soughL, and ls managed by
llmlung mlnuLe venulauon
venulaLed pauenLs beneL from a bundle almed aL reduclng
compllcauons
Abbrev|anons
vlLl: venulaLor-lnduced lung ln[ury
vluu: venulaLor-lnduced dlaphragm dysfuncuon
peak: eak alrway pressure
plaL: laLeau alrway pressure
reslsL: peak - plaL
ao: Alrway openlng pressure
AC: AsslsL-conLrol
Sv: ressure supporL venulauon
SlMv: Synchronlzed lnLermluenL mandaLory
venulauon
v
1
: 1ldal volume
1
l
: lnsplraLory ume
A8v: Alrway pressure release venulauon
C-l8v: ressure-conLrolled lnverse rauo venulauon
vAS: volulme-assured pressure supporL
8vC: ressure-regulaLed volume conLrol
pl: leural pressure
v: osuve pressure venulauon
CL: Lung compllance
CCW: ChesL wall compllance
es or eso: Lsophageal pressure
Cv: Convenuonal venulauon
C8S: Compllance of Lhe resplraLory sysLem
mus: Muscle pressure
l8C: luncuonal resldual capaclLy
Lv/8v: Le and rlghL venLrlcle
LL: osluve end-explraLory pressure
CCS: Clasgow coma scale
v: ulse pressure varlauon
ALl: AcuLe lung ln[ury
A8uS: AcuLe resplraLory dlsLress syndrome
nlv: nonlnvaslve venulauon
CCu: Chronlc obsLrucuve pulmonary dlsease
CL: Cardlogenlc pulmonary edema
vL: MlnuLe venulauon
WC8: Work of breaLhlng
Svl: SLroke volume lndex
Ll: L[ecuon fracuon
P8: PearL raLe
L11: LndoLracheal Lube
CA: Conunuous posluve alrway pressure
vA: venulaLor assoclaLed pneumonla
AP8l: AcuLe hypoxemlc resplraLory fallure
/l: 8auo of aC2 Lo llC2
1nl: 1umor necrosls facLor
8W: redlcLed body welghL
C8: Cdds rauo
vlu: venulaLor-free days