Mechanical ventilation

Ruswandiani
 introduction
• A machine-driven method of assisting or replacing spontaneous breathing
• In order for gas to flow into the lungs, a pressure difference between the
atmosphere and the alveoli is required
• In spontaneous respiration, the respiratory muscles expand the chest wall,
generating negative intrapleural pressure that draws air in
Pilbeams mechanical ventilation 6th ed 20
 Mechanical Ventilation

tive Pressure Negative

Ventilation
Pressure Ventilation
Types of Mechanical Ventilation

• Positive Pressure Ventilation

• Occurs when a mechanical ventilator moves
air into the patient’s lungs by way of an
endotracheal tube or mask (NPPV).
 Types of Mechanical Ventilation

• Negative Pressure Ventilation

Chest Cuirass

Iron Lung
INDICATED

• Any cause of hypoxaemic and/or

hypercapnic respiratory failure (type
I and/or type II, respectively), where
the airway is compromised, in non-
respiratory disorders where oxygen
delivery is impaired and shock
ensues, and post-operatively
 PERBEDAAN ANTARA NAFAS
SPONTAN DAN NAFAS VENTILASI
MEKANIK
Ventilation modes
Phase variables
• Like normal respiration, ventilators provide active inspiration and passive
expiration
• The inspiratory time (TI) and expiratory time (TE) represent the duration of
inspiration and expiration, while the transition from one phase to another is
known as cycling

 The cycle time is the sum of TI

and TE, expressed in seconds,
 RR or frequency is the number
of cycles per minute.
 The usual ratio of TI to TE is 1:2.
Mandatory modes
• If the ventilator determines both inspiratory and expiratory
cycling  patient has no control over ventilation,
• This is the mode used intraoperatively, as patients are often
paralysed or their respiratory drive is abolished by deep
anaesthesia.

• Intermittent positive pressure ventilation (IPPV),

• Continuous mandatory ventilation (CMV)
• Intermittent mandatory ventilation (IMV) : the patient is
allowed to take other breaths in between
• If the patient’s respiratory effort determines the inspiratory
cycling, then the breath is said to be triggered, and the
ventilator is on a demand, assist, or support mode
• A hybrid mode is a combination of mandatory and
triggered ventilation
• Synchronized intermittent mandatory ventilation (SIMV) is a
hybrid mode where mandatory breaths are set at a certain
frequency
Mechanical ventilation variable

1. The Trigger
sinyal untuk membuka katup inspirasi, sehingga udara
dapat mengalir ke paru pasien; ventilator mulai
memberikan inspiratory flow

2. The Limit
faktor yang membatasi banyaknya udara yang mengalir
ke paru pasien;

3. The Cycling
sinyal untuk menghentikan proses inspirasi bersamaan
dengan pembukaan katup ekspirasi.
 CONtrol variables
Volume Control ventilation ( VCV)

Variabel kontrol

Pressure Control Ventilation ( PVC)

Volume controlled
• A target tidal volume is set on the ventilator
• Flow is constant for a fixed time period.
• Inspiration and expiration are determined by the time
allocated for each respiratory cycle (frequency) and the TI:TE
ratio
• The ventilator will deliver the tidal volume to the patient, and
the pressure generated will be determined by the patient’s
compliance
• Larger tidal volumes or a shorter TI produce higher peak
pressures.
• The consistency of minute volume with VCV results in more
predictable CO2 elimination elimination.
• Disadvantage : Barotrauma & patient– ventilator asynchrony.
 Pressure controlled ventilation
• The inflating pressure is set on the ventilator, and the
breath is delivered using a decelerating flow pattern
• The tidal volume delivered depends on the patient’s
compliance and airway resistance
• Cycling is flow-dependent, and expiration occurs when
flow drops below a predetermined levelv which is
usually 25% of the peak flow
• Patient comfort is improved, because an increase in
the inspiratory effort is matched with an increase in the
gas flow; however, changes in compliance will
increase or decrease the tidal volume proportionately
and risk volutrauma
 Dual modes
• the variable that drives the gas flow is labelled as
‘control’ while the limiting variable is labelled ‘limit’ or ‘target’
or ‘regulated’,
• Contoh : pressure-regulated volume control (PRVC)
• The full tidal volume will only be delivered so long as the
pressure remains below the pressure limit. If the pressure
limit is reached, then the ventilator cycles to expiration
and sounds an alarm.
 ASYNCHRONY
• fighting the ventilator  mismatching of the patient’s intrinsic respiratory
rhythm and the ventilator settings.
Ventilator associated
lung injury
( VALI)
 volutrauma
• Overdistension of alveoli leads to direct damage to the alveolar– capillary
membrane as a result of excessive wall stress (ratio of alveolar wall tension
to thickness)
• This leads to a rapid increase in permeability, with leakage of protein-rich
fluid into the alveoli and interstitium
• The action of surfactant is severely impaired, leading to alveolar collapse
and a reduction in lung compliance.
• This is related to the high volumes and not the increase in pressure 
associated with the delivery of a high tidal volume
 atelectrauma
• Repeated cyclical opening and closing of small airways and alveoli that
occur with ventilation at low lung volumes
• Ventilation associated with supine positioning and a reduced FRC,
particularly in the absence of PEEP, results in an atelectatic (collapsed) lung
where the air–liquid interface is more proximal at the terminal conducting
bronchioles instead of in the alveoli
• The high shearing forces required to open these airways are associated with
surfactant depletion and physical disruption of the alveolar epithelium
 barotrauma
• Use of excessive pressures leads to epithelial damage and air
leakage, causing pneumothoraces, subcutaneous emphysema, or, less
commonly pneumomediastinum or pneumopericardium
 biotrauma
• The release of pro-inflammatory cytokines, such as tumour necrosis
factor alpha (TNF-α) and interleukin 1 (IL-1) and interleukin 6 (IL-6), contributes
to lung injury, and enter the systemic circulation to cause systemic
inflammation and MODS
Lung protective
ventilation strategies
 Lung protective ventilation
strategies
• Low Tidal Volumes
• Low plateau pressure
• PEEP application
 Positive end expiratory pressure
• Synonymous with CPAP but applies to the continuous airway pressure
applied during ventilation with a mandatory or assisted mode
• It maintains the small airways and alveoli open and helps to return the FRC
(functional residual capacity) towards the normal physiological range.
• Preventing derecruitment reduces atelectrauma and allows adequate
oxygenation to be achieved using lower tidal volumes
• Reduces shearing stress and cytokine release and curtails surfactant
depletion
• No easy method of establishing optimal PEEP for each individual patient
• In reality, the level of PEEP used is based on clinical judgement, depending
on the patient’s body habitus, and underlying pathology, with the aim to
minimize the FiO2, and is usually no more than 10 cmH2O, except in patients
with ARDS.
• Clinical trials have failed to show a mortality benefit between low or high
PEEP, although there may be a reduction in ventilator days which was
greatest in those with more severe lung oedema
 Low tidal volumes
• Ventilation with traditional tidal volumes of 10–15 mL/kg is harmful,
particularly in patients with pre-existing lung injury, lead to high peak and
plateau pressures and significantly increase the risk of both volutrauma and
barotrauma
• ARDS network : tidal volumes of 6 mL/kg and plateau pressures
<30 cmH2O. PEEP set according to the FiO2 and ranged from 4 to 15 cmH2O.
The PEEP and FiO2 required to maintain oxygenation in the lower tidal volume
group was significantly higher  Showed lower mortality
 Permissive hypercapnia
• Low tidal volumes  hypercapnia and acidosis.
• Mechanically ventilated patient with ARDS tend to tolerate very high CO2
and low blood pH without any adverse sequelae; however, a population of
cardiac patients may behave very differently
• CO2  PH, vasodilation, reduction in SVR, and tachycardia increase in
cardiac output. These effects are transient and do not cause myocardial
depression in patients without cardiac disease.
• Hypercapnia - increases both end-diastolic and end-systolic volume and
impair LV contractility, particularly in conjunction with acidaemia..
Vasodilation  increases coronary blood flow  decrease the perfusion of
ischaemic areas not recommended in the ischaemic or failing heart,
arrhythmias, and active CAD
Laki-laki : 50 + 0.91 (tinggi dalam cm – 152.4)
Perempuan: 45.5 + 0.91 (tinggi dalam cm – 152.4)
 lung-protective ventilation in ARDS, based on the
ARMA trial protocol

1. Set the FiO2 to below 70%, if possible, aiming for saturations

of above 88%
2.Set the tidal volume to 8 mL/kg of predicted (not actual) body weight
3.Set the RR to 35 breaths/min or tonachieve a minute volume of 7–9 L/min
4.Set PEEP to at least 5 cmH2O or higher
5.Reduce the tidal volumes to 7 mL/kg, then 6 mL/kg over the next 4 hours
6.Adjust the ventilator settings to keep the plateau pressure below 30 cmH2O
7.Increase sedation, if necessary, to achieve this, and minimize patient–
ventilator dyssynchrony
• PCO2 x RR X TV = PCO2 X RR x TV ( yang kita inginkan)
• 56x 20x 455 = 40xRRx455
• RR setting mesin = 28
VT : Tidal volume (cc/ml)

RR : Respiratory Rate  beat/menit (kali/menit)

MV : Minute Volume = VT X RR (liter/menit)

FiO2 : Fraction of inspired Oxygen (konsentrasi O2 yang

diinspirasi)

PEEP : Positive end expiratory pressure (cmH20)

(I:E) Ratio : Ratio of inspiratory to expiratory time

(perbandingan waktu inspirasi terhadap ekspirasi)

Ti : Inspiratory time (waktu inspirasi)

Flowrate : Speed of gas flow in liters per minute

(kecepatan hantaran gas atau volume tidal yang
diberikan mesin dalam liter per menitnya)
• Plateau : tekanan rata2 intrapulmonal selama
pause time pada akhir inspirasi
• Rise time : suatu manuver untuk menentukan
seberapa cepat PIP dapat tercapai
• PIP : Peak Inspiratory Pressure
Tekanan tertinggi yg akan dicapai saat
ventilator memberikan bantuan nafas
berupa pressure saat Inspirasi 
menggambarkan compliance paru
• Inspiratory flow pattern: suatu manuver utk menentukan seberapa lama
aliran flow dpt mencapai peak flow yang ditentukan
• PIF : Peak Inspiratory Flow : jumlah volume udara
inspirasi yg dialirkan dalam satu menit
• TCT : Total Cycle Time : suatu periode waktu untuk satu siklus
pernafasan = Ti + Te