INVASIVE POSITIVE PRESSURE VENTILATION

Yellow Team Group Presentation

02/26/2018
Compliance
• C= V/P
• Compliance comes from chest wall and lungs
in a parallel circuit manner =>
• 1/200+ 1/200 = 1/100
• These compliance are not individual entities
so change in compliance of chest wall will
affect total compliance of the respiratory
system and vice versa.
Assist Control Ventilation
• “Control” – set number of breaths are
delivered
• “Assist” – if patient wants to take a
spontaneous breath, machine will aid in the
process once minimum negative pressure is
triggered.
• Can be volume controlled or pressure control
• VC-AC or VC-PC
VC-AC
• The tidal volume and the RR is set.
• Machine will give whatever pressure is
required to generate set tidal volume.
• Tidal volume should be based on PBW
(depends on height and gender).
• ARDSNET study showed VILI is due to
volutrauma and less barotrauma.
• Recommend 4-6ml/kg of tidal volume.
VC-AC (continued)
• Plateau pressure – relates to static compliance
and reflects pressure in the small airways and
alveoli when there is no airflow
• End Inspiratory Hold Maneuver for 0.5-1sec
• Ideally Plateau Pressure should be 30-35 cm
H2O.
• Compliance and plateau pressure are inversely
related.
• In VC, machine turns off flow once the target
tidal volume has been reached.
VC-AC (continued)
PC-AC
• The driving pressure, the rate and the i-Time
is set.
• The driving pressure is the change in pressure
that occurs during the course of a breath.
• The normal I:E is 1:2 - 1:4 -- > breathing in
takes 1 sec and exhaling takes 2 secs/4secs.
• I:E >=1:1 reverse ventilation – refractory
ARDS and must heavily sedate patient.
PC-AC (Continued)
• Driving pressure = base pressure at the end
of expiration (PEEP) to a Peak Pressure and
holds it for I-time and drops back to PEEP.
• So the tidal volume generated by the driving
pressure depends on the compliance.
• The driving pressure should be set at
whatever pressure generates a tidal volume
of 6ml/kg.
PC-AC (Continued)
PC-AC (Continued)
• Drawback is that compliance can change in
critically ill patients, therefore generated tidal
volumes may be erratic.
• Be mindful of barotrauma due to high Peak
pressures (PEEP + Driving Pressure) and
should not exceed 30-35cm H2O.
VC vs PC
SIMV
• Synchronized Intermittent Mandatory
Ventilation
• Similar to AC that ventilator is set to deliver a
pre-set number of breaths.
• Different from AC, if the machine detects the
patient is trying to breath on their own, it will
delay the machine breath and let patient
breath on their own – “synchrony”.
SIMV (continued)
• Problem is that tidal volume is dependent on
patient’s effort and strength and can be
variable.
• SIMV is therefore usually equipped with PS
(pressure support – different from pressure
control in AC).
• PS is the pressure the ventilator applies
whenever it detects the patient taking a
breath on their own.
SIMV (continued)
• On SIMV, the rate (12-18) and tidal volume
(6ml/kg) are set similar to AC.
• Initial PS @ 10cm H2O and can be changed
based on pulled tidal volumes.
• As PS is decreased, patient can also be
assessed for readiness of extubation.
A graphical presentation of AC vs SIMV
Triggering
• Can be via change in pressure vs change in
flow.
• Pressure trigger requires PEEP to drop by a
present amount.
• Pressure triggers are difficult in a patient with
COPD/Asthma or any condition with
autopeep or dynamic hyper-inflation.
Triggering (continued)
• To make triggering easier, vents allow
triggering to be initiated by inspiratory flow.
• Flow triggering may be too sensitive
(independent of PEEP) and can auto-cycle
with oscillation from water or secretions.
Conclusion
• Ventilator is not a permanent solution.
• Consider dynamic Hyperinflation/auto-PEEP
if RR is increased and PaCO2 remains high.
• Patient will come off the vent when ready –
daily SBT with with T-piece or low level
pressure support.
References
• The Ventilator Book; William Owens, MD.
• The Little ICU Book; Paul Marino, MD.
THE END