Mechanical Ventilation

Anang Achmadi, SpAn. KIC

Mechanical Ventilation

Abbreviations:

• VT: Tidal volume (mls)

• RR: Respiratory Rate (bpm)
• MV: Minute Volume = VT X RR (lpm))
• FiO2: Fraction of inspired Oxygen
• PEEP: Positive end expiratory pressure (cmH20)
• (I:E) Ratio : Ratio of inspiratory to expiratory time.
• Ti: Inspiratory time
• Flowrate: Speed of gas flow in liters per minute.
Definitions:
Mechanical Ventilation

Volume Ventilation: Pre-set Tidal volume will be

delivered to the patient.
Pressure Ventilation: Pre-set Inspiratory pressure will
be delivered to the patient.

• Mandatory breaths: Breaths that the ventilator

delivers to the patient at a set frequency, volume,
flow.
• Spontaneous breaths: Patient initiated breath.
Definitions: (Cont’d)

• Triggering: The sensitivity of the ventilator to the

patient’s respiratory effort.
• Either flow or pressure setting that allows the
ventilator to detect the patient’s inspiratory effort.
• Allows the ventilator to be in synchronization with the
patient’s spontaneous respiratory efforts improving
patient comfort during mechanical ventilation.
Factors that effect Ventilation:

• Minute Ventilation = RR X VT ( 6-10 lpm)

• VT = 6-8 ml / kg (IBW)
• RR = 10-12 bpm (average)

• PaCO2 = 35-45 mmHg

• ETCO2= 30-43 mmHg
• pH = 7.35-7.45
Factors that effect Oxygenation:

• FIO2
• PEEP
• PaO2 target 80-100 mmHg
• PaO2 / FiO2 > 200
• Pulse Oximeter Saturation > 95 %
oxygen toxicity :
a) can occur as early as 24 hours after high oxygen exposure
b) more frequent if the FiO2 is > 0.5
c) clinically resembles adult respiratory distress syndrome
d) very important to avoid since this often results in an inescapable
vicious cycle of high oxygen requirements ultimately resulting in
fatal respiratory failure.
Modes of Ventilation (most commonly used)

A/C : Assist-Control
SIMV / (PS) : Synchronized Intermittent Mandatory
Ventilation (with Pressure-support)
PSV: Pressure Support Ventilation.
PCV: Pressure Control Ventilation.
NIPPV : Non-invasive mechanical ventilation.
CPAP: Continuous positive airway pressure.
BIPAP: Bi-level positive airway pressure.
A/C : Assist-Control Ventilation

Parameters set:
• VT
• RR
• FiO2
• PEEP
• Flowrate
• The ventilator will deliver the set VT for all mandatory and
spontaneous breaths. The VTR assumes most/all of the
work of breathing. Some patients may tend to
hyperventilate on this mode.
A/C : (Cont’d)

Background:
• ventilator provides full tidal volume at a minimum preset rate
• additional full tidal volumes given if the patient initiates extra
breaths
Advantages:
• provides near complete resting of ventilatory muscles
• an be effectively used in awake, sedated, or paralyzed patients
Disadvantages:
• patients can hyperventilate and become alkalotic
• patients can "stack" breaths (air trapping) and develop barotrauma
• patients can develop "autoPEEP" with barotrauma or hypotension
SIMV / (PS): Synchronized Intermittent
Mandatory Ventilation (with/without Pressure support)
Parameters set:
• VT (6-8ml/kg)
• RR
• FiO2
• PEEP
• PSV
• Flowrate
• Synchronized : the VTR will sets up a window of opportunity
for the patient to trigger a breath spontaneously and if they
don’t or the time window elapses a mandatory breath will be
delivered. The mandatory rate set (at VT set) is guaranteed.
Spontaneous breaths greater then the rate set can be
supported with a pressure support to decrease the work of
breathing imposed by the VTR, circuit, ETT.
ARDSNET: NEJM 2000; 342
 SIMV / (PS): (Cont’d)
Background:
• ventilator provides set tidal volume at a preset rate
• when a ventilator breath is programmed to occur, the ventilator waits a predetermined
trigger period; any patient-initiated breath during this trigger period results in a
programmed ventilator delivered breath the patient can take additional breaths but tidal
volume of these extra breaths is dependent on the patient's inspiratory effort
Advantages:
• in theory, results in improved blood return to the right ventricle owing to intermittent
negative pressure (spontaneous) breaths
• patients often more comfortable since they have more control over their ventilatory
pattern and minute ventilation
Disadvantages:
• can result in chronic respiratory fatigue if set rate is too low; in this situation, the
following may be seen:
• high respiratory rate
• rising pCO2
• air trapping can occur
PSV: Pressure Support Ventilation.

Initial settings:
• set PS at the pressure required to generate VT of 6-8 ml/kg
(this will usually be about the same as the plateau pressure)
• FiO2 = 1.0
• PEEP

Spontaneous mode of ventilation.

• Can be used alone or in combination with mandatory modes.
Mode used to wean patients from VTR.
• VT is variable, dependant on PS level set above PEEP, patient
effort, chest compliance, resistance to flow.
PSV: (Cont’d)

Background:
• not a volume-cycled mode
• when the patient triggers the ventilator, a set pressure (1-100 cm) during the
patient's inspiration; this air pressure is stopped when patient ceases to inspire.
• tidal volume and minute ventilation are dependent on the patient
Advantages:
• avoids patient-ventilator aschrony
• patients often more comfortable since they have full control over their ventilatory
pattern and minute ventilation
• often avoids breath stacking and autoPEEP (especially in patients with COPD)
• ability to permit self-determination of respiratory rate and to permit forced
exhalation offers substantial advantages in status asthmaticus (Meduri, 1996)
Disadvantages:
• cannot be used in heavily sedated, paralyzed, or comatose patients
• respiratory muscle fatigue can develop if the pressure support is set too low
PCV: Pressure Control Ventilation.

Parameters set: (Mode: Either SIMV or A/C)

• PC (Inspiratory pressure above PEEP)
• PEEP
• FIO2
• RR & (I:E) Ratio & Ti
PCV:(Cont’d)

Background:
• the breath is pressure limited rather than volume limited
• best reserved for patients with ARDS
Advantages:
• in ARDS, pO2 may increase 10-15%
Disadvantages:
• there is no guaranteed tidal volume and thus there is no guaranteed minute
ventilation
• you must be very attentive to changes in the patients respiratory mechanics since
unstable reactive airways disease can dramatically affect minute ventilation
• air trapping can be a problem
• CO2 retention frequently occurs (although this may be acceptable in "permissive
hypercapnia" strategies for ventilation of some patients with acute respiratory
failure)
• in general, patients must be heavily sedated since this is an uncomfortable mode
for most patients
Whats the difference between PEEP &
CPAP ?

• PEEP is a term used for Positive end expiratory

pressure delivered invasively via a mechanical
ventilator to an intubated / tracheostomized patient
during mechanical ventilation.

• CPAP is a term used for the delivery of End

expiratory pressure non-invasively via a face mask or
nasal mask using a non-invasive ventilator device
while the patient breaths spontaneously.
(Respironics Vision or Respironics ST/D)
PEEP: Positive End Expiratory Pressure
CPAP: Continuous positive airway pressure

Initial settings:
• 5 cm is fairly standard and in many hospitals is used on most patients initially placed
on the ventilator
• changes in PEEP may not be reflected by changes in arterial blood gases for 20-30
minutes so changes in the PEEP setting should usually not be made faster than this
• the ventilator circuit should not be broken unless absolutely necessary; disconnecting
the patient (for example, to transport him/her) can result in an immediate loss of the
benefit of PEEP which can require 20-30 minutes or more to restore
• PEEP is added in increments of 2-5 cm until the "best PEEP" is obtained
• there is no optimal way to assess "best PEEP"
• some PEEP authorities choose the level which provides the highest static compliance
(in other words, the lowest airway plateau pressure)
• in general, use the lowest amount which gives the desired effect on pO2 without
lowering blood pressure, reducing cardiac output, or increasing the plateau pressure
on the ventilator
• PEEP over 20 cm is rarely beneficial and usually results in additional pressure-
induced lung injury
PEEP: (Cont’d)

Background:
• ventilator provides a fixed positive airway pressure at the end of expiration
• when used with assist-control ventilation, the term PEEP is used
• when used with spontaneous breathing, the term CPAP (continuous positive airway pressure) is used
Advantages:
• opens closed alveolar units thus improving lung compliance and oxygenation
• to a point, peak and plateau airway pressures actually decrease since there are more alveoli open at the
beginning of inspiration
• may improve secretion drainage from otherwise closed alveoli
• can reduce right ventricular venous return and also lower left ventricular afterload
• can be given on the ventilator or via a CPAP mask in the non-intubated patient
Disadvantages:
• barotrauma
• can be risky and counterproductive in patients with obstructive airways disease
• may worsen hypoxemia in patients with localized (as opposed to diffuse) lung disease (eg, pneumonia)
• hypotension and reduced cardiac output
• increased cardiac shunt (especially PFOs)
• increased intracranial pressure
• decreased renal perfusion
• hepatic congestion
Mechanical Ventilation
“Standard VTR Parameters”

• Mode: SIMV / PSV

• VT : 6-8 ml/kg
• RR: 12 bpm
• FiO2: 0.5
• PEEP: 5 cmH20
• PSV: 10 cmH20
• (I:E) Ratio: (1: >2)
• Flowrate 40-60 lpm
NIPPV : Non-invasive mechanical ventilation.

• Mechanical ventilatory support delivered to the

patient via face mask or nasal mask versus artificial
airway.
• Modes: CPAP
BIPAP (or Pressure-Support)
• Equipment: BIPAP VISION or BIPAP ST/D
• Mask cycled ventilation = using a conventional ICU
ventilator non-invasively (by mask) with either PSV or
A/C with PEEP.
BIPAP: Bi-level positive airway pressure.

Parameters set:
IPAP : Inspiratory positive airway pressure
EPAP : Expiratory positive airway pressure.
Back-up Rate : The unit will cycle from IPAP / EPAP a pre-
determined number of times per minute however does not
guarantee a VT delivery.

FiO2: O2 flow can be added to the circuit from an external

source, in which case O2 is diluted by the flow from the
unit. (FiO2 max + 0.5)
BIPAP Vision has an internal O2 blender allowing FiO2 1.0
BIPAP: (cont’d)

Indications:
• chronic muscle dysfunction
• ventilatory muscle fatigue
• Hypoxemia despite FIO2 0.55
• post-extubation difficulty in whom you wish to avoid reintubation
• upper airway obstruction due to laryngeal / supra or sub-glottic
edema,
• Sleep Apnea (Obstructive, Central)
BIPAP: (cont’d)

CONTRAINDICATIONS & Relative Contraindications:

• Patients requiring high FiO2 may not tolerate the BIPAP.
• Incapable of maintaining life sustaining ventilation in the event of
malposition of the mask.
• BIPAP is a relatively contraindicated in patients with a full stomach or
conditions that can result in delayed gastric emptying or regurg and
vomiting.
• Full stomach or conditions that can result in delayed gastric emptying
or regurg and vomiting.
• pre-existing bullbous lung disease represent a relative contraindication
to PPV.
• Hypotension induced by Positive pressure ventilation.
• History of allergy or hypersensitivity to plastic or latex. (Face mask,
nasal mask)
BIPAP: (cont’d)

• COMPLICATIONS: The following is a list of some of the possible

complications associated with the use of BIPAP:

• Skin rash, breakdown on the nose or ears, cheeks

• Eye problems : Drying , Conjunctivitis
• Aspiration of stomach contents : Aspiration Pneumonia
• Pressure sores from the face mask or strap
• Tachypnea, SOB, anxiety and panic, claustrophobia
Pediatric Considerations

• Infants (< 5 kg)

• Time-cycled, pressure-limited ventilation
• Peak inspiratory pressure initiated
at 18–20 cm H2O
• Adjust to adequate chest movement or
exhaled tidal volume ~8 mL/kg
• Low level of PEEP (2–4 cm H2O) to prevent
alveolar collapse
Pediatric Considerations

• Children
• SIMV mode
• Tidal volume 6-8 mL/kg
• Flow rate adjusted to yield desired
inspiratory time
• Infants 0.5–0.6 secs
• Toddlers 0.6-0.8 secs
• Older 0.8–1.0 secs
• Rate <18–20 breaths/min
• PEEP 2–4 cm H2O
–
Weaning from Mechanical Ventilation:

Factors to consider:
• Awake, and off sedation (as much as possible).
• Adequate nutrition, fluid status.
• Free of infection.
• Hemodynamically stable (preferably off pressors, angina controlled, no active
bleeding)
• Normal acid-base status
• Bronchospasm controlled
• Normal electrolyte balance
• Oxygenation (O2 requirements <0.5 and PEEP <5 cmH20)
Weaning Parameters:
• RR/Vt <100breaths/min /L
• RR<30
• Vt >6-8 ml/Kg
Causes of failure to wean:

1. Hypoxemia
• Diffuse pulmonary disease
• Focal pulmonary disease (Pneumonia)
• Pulmonary edema (removal of positive pressure can increase preload and lead
to worsening heart failure)
2.Insufficient Ventilatory Drive:
• response to metabolic alkalosis
• Inadequate function of CNS drive (Ex: sedatives, malnutrition)
3. Excessive Ventilatory Drive:
• Excessive CO2 production (sepsis, agitation, fever, high carbohydrate intake)
4. Respiratory Muscle Weakness:
• Neuromuscular disease
• Malnutrition
• Drugs (Neuromuscular blocking agents, Corticosteroids,aminoglycosides)
Causes of failure to wean: (Cont’d)

5. Excessive Work of Breathing:

• Airway obstruction
• Bronchospasm
• Secretions
• Increased Raw (ETT)
• ETT too small
• Chest motion restriction (pain, bandages)
6. Acid base disorders
7. Phrenic nerve Injury
(especially with contralateral pulmonary disease)
Troubleshooting:

RULE OF THUMB: If your not sure if the Ventilator is

working properly, you must manually ventilate the
patient with the Ambu-bag & 100% O2 until the RT is
present.
Alarms & Troubleshooting:
Alarms & Troubleshooting:

High Peak Inspiratory Pressure:

• Secretions
• Patient biting ETT
• Patient coughing
Low Pressure Alarm or low PEEP alarm:
• Disconnect (check all connections)
• Apnea (Servo B,C)
Low Tidal Volume Spontaneous:
• Circuit disconnect
• Secretions
Complications associated with
Mechanical ventilation:

Ventilation-related complications:
• Disconnection
• Malfunction
• hemodynamic effects:
a) decreased cardiac output due to impaired venous return to the
right heart and increased pulmonary venous resistance due to
positive pressure alveolar distension
b) autoPEEP
• Barotrauma or Atelectasis
• Oxygen toxicity
• Respiratory alkalosis
• Increased intracranial pressure
Complications associated with
Mechanical ventilation: (Cont’d)

• Suctioning-related
complications:
• Hypoxemia
• a) patients should always be
pre-oxygenated with 100%
oxygen prior to suctioning
• b) suction time should be limited
• Arrhythmias
• Nosocomial infections

Fig. A Closed Suction System

Fig. A Closed Suction System