MECHANICAL

VENTILATION

Marc Charles Parent

Presentation
Different settings to consider
Monitoring of the patient
Different type of patient
COPD,

Asthma

ARDS

Trouble shooting

Ventilator settings

Ventilator settings
1.
2.
3.
4.
5.
6.
7.
8.

Ventilator mode
Respiratory rate
Tidal volume or pressure settings
Inspiratory flow
I:E ratio
PEEP
FiO2
Inspiratory trigger

CMV

A/CV

SIMV

PSV(pressure support
ventilation)
Spontaneous inspiratory efforts trigger
the ventilator to provide a variable flow
of gas in order to attain a preset airway
pressure.
Can be used in adjunct with SIMV.

Respiratory Rate
1. What is the pt actual rate demand?

Tidal Volume or
Pressure setting
Maximum volume/pressure to achieve
good ventilation and oxygenation
without producing alveolar
overdistention
Max cc/kg? = 10 cc/kg
Some clinical exceptions

Inspiratory flow
Varies with the Vt, I:E and RR
Normally about 60 l/min
Can be majored to 100- 120 l/min

I:E Ratio
1:2
Prolonged at 1:3, 1:4,
Inverse ratio

FIO2
The usual goal is to use the minimum
Fio2 required to have a PaO2 >
60mmhg or a sat >90%
Start at 100%
Oxygen toxicity normally with Fio2
>40%

Inspiratory Trigger
Normally set automatically
2 modes:
Airway

pressure
Flow triggering

Positive End-expiratory
Pressure (PEEP)
What is PEEP?
What is the goal of PEEP?

Improve oxygenation

Diminish the work of breathing

Different potential effects

PEEP
What are the secondary effects of PEEP?
Barotrauma
Diminish cardiac output

Regional hypoperfusion
NaCl retention
Augmentation of I.C.P.?
Paradoxal hypoxemia

PEEP
Contraindication:
No

absolute CI

Barotrauma
Airway

trauma
Hemodynamic instability
I.C.P.?
Bronchospasm?

PEEP
What PEEP do you want?
Usually,

5-10 cmH2O

Monitoring of the
patient

Look at your patient

Question your pt
Examine your pt
Monitor your pt
Look at the synchronicity of your pt breathing

Pressures

Compliance pressure
(Pplat)
Represent the static end inspiratory
recoil pressure of the respiratory
system, lung and chest wall respectively
Measures the static compliance or
elastance

Pplat
Measured by occluding the ventilator 3-5 sec
at the end of inspiration
Should not exceed 30 cmH2O

Peak Pressure (Ppeak)

Ppeak = Pplat + Pres
Where Pres reflects the resistive
element of the respiratory system (ET
tube and airway)

Ppeak
Pressure measured at the end of inspiration
Should not exceed 50cmH2O?

Auto-PEEP or Intrinsic
PEEP
What is Auto-PEEP?
Normally,

at end expiration, the lung

volume is equal to the FRC

When

PEEPi occurs, the lung volume at

end expiration is greater then the FRC

Auto-PEEP or Intrinsic
PEEP
Why does hyperinflation occur?
Airflow

limitation because of dynamic

collapse
No time to expire all the lung volume (high
RR or Vt)
Expiratory muscle activity
Lesions that increase expiratory resistance

Auto-PEEP or Intrinsic
PEEP

Auto-PEEP is measured in a relaxed pt with

an end-expiratory hold maneuver on a
mechanical ventilator immediately before the
onset of the next breath

Auto-PEEP or Intrinsic
PEEP
Adverse effects:
Predisposes

to barotrauma
Predisposes hemodynamic compromises
Diminishes the efficiency of the force
generated by respiratory muscles
Augments the work of breathing
Augments the effort to trigger the ventilator

Different types of
patient

COPD and Asthma

Goals:
Diminish

dynamic hyperinflation
Diminish work of breathing
Controlled hypoventilation
(permissive hypercapnia)

Diminish DHI
Why?

Diminish DHI
How?
Diminish
Low

minute ventilation

Vt (6-8 cc/kg)
Low RR (8-10 b/min)
Maximize expiratory time

Diminish work of
breathing
How:
Add

PEEP (about 85% of PEEPi)

Applicable

in COPD and Asthma.

Controlled hypercapnia
Why?
Limit

high airway pressures and thus

diminish the risk of complications

Controlled hypercapnia
How?
Control

the ventilation to keep adequate

pressures up to a PH > 7.20 and/or a
PaCO2 of 80 mmHg

Controlled hypercapnia
CI:
Head

pathologies
Severe HTN
Severe metabolic acidosis
Hypovolemia
Severe refractory hypoxia
Severe pulmonary HTN
Coronary disease

A.R.D.S.
Ventilation with lower tidal volume as
compared with traditional volumes for
acute lung injury and the ARDS
The Acute Respiratory Distress Syndrome
Network
N Engl J Med 2000;342:1301-08

Methods
March 96 March 99
10 university centers
Inclusion:
Diminish

PaO2
Bilateral infiltrate
Wedge < 18

Exclusion
Randomized

Methods
A/C 28d or weaning
2 groups:
1. Traditional Vt (12cc/kg)
2. Low Vt (6cc/kg)

End point:
1. Death
2. Days of spontaneous breathing
3. Days without organ failure or barotrauma

Results
The trails were stopped after 861 pt because
of lower mortality in low Vt group

Trouble Shooting

Trouble Shooting
Doctor, doctor, his pressures are going
up!!!
What is your next step?

Trouble Shooting
1. Call the I.T., he will take care of it!
2. Where is the staff?
3. I dont know this pt, and run!
4. Ask which pressure is going up

Trouble Shooting
Ppeak is up
Look

at your Pplat

Trouble Shooting
If your Pplat is high, you are faced with
a COMPLIANCE problem
If your Pplat is N, you are faced with a
RESISTIVE problem
DD?

Trouble Shooting

Trouble Shooting
Doctor, doctor, my patient is very
agitated!
What

is your next step?

Trouble Shooting
1. Give an ativan to the nurse!
2. Give haldol 10mg to the patient!
3. Take 5mg of morphine for yourself!
4. Look at your pt!

Trouble Shooting
At the time of intubation, fighting is
largely due to anxiety
But what do you do if pt is stable and
then becomes agitated?

Trouble Shooting
1.
2.
3.
4.
5.
6.

Remove pt from ventilator

Initiate manual ventilation
Perform P/E and assess monitoring indices
Check patency of airway
If death is imminent, consider and treat
most likely causes
Once pt is stabilized, undertake more
detailed assessement and management

Trouble Shooting

Conclusion
Type of patient

Tidal Volume

RR

PEEP

FIO2

Ins. Flow

I:E

Normal

10 cc/kg

10 to 12

0 to 5

100%.

60 l/min

1:2.

ARDS

6 cc/kg

10 to 12

5 to 15

100%.

60 l/min

1:2.

COPD

6 cc/kg

10 to 12

5 to 10

100%.

100 to 120 1:3 to 1:4

Trauma

10 cc/kg

10 to 12

0.

100%.

60 l/min

1:2.

Pediatric

8-10 cc/kg Varies age 3 to 5

100%.

60 l/min

1:2.

Note

Note

PH>7.2
PCO2 <80 mmhg
Trigger to consider

Trigger to consider