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VENTILATION
DR. SHIVAM MOHAN PANDEY
Introduction
Others
• Intubation to facilitate procedure (bronchoscopy), bronchial suctioning
Important Pitfalls and Problems Associated
with PPV
Potential detrimental effects associated with PPV
• Heart and circulation
- Reduced venous return and afterload
• Lungs
- Barotrauma
- Air trapping
• Gas exchange
- May increase dead space (compression of capillaries)
- Shunt (e.g., unilateral lung disease - the increase in vascular resistance in the
normal lung associated with PPV tends to redirect blood flow in the abnormal
lung)
Important Effects of PPV on Hemodynamics
Decreased preload
• Positive alveolar pressure ↑ lung volume compression of the heart
by the inflated lungs the intramural pressure of the heart cavities rises
(e.g., ↑ RAP) venous return decreases preload is reduced stroke
volume decreases cardiac output and blood pressure may drop. This
can be minimized with i.v. fluid, which helps restore adequate venous
return and preload.
Dead space
Oxygen transport
Alveolar Pressure
Note that as airway pressure increases above a certain level (e.g.,
high PEEP [positive end-expiratory pressure]):
• Oxygen transport start to decline despite the rising PaO2 as cardiac output
starts falling.
• Dead space also tends to increase due to compression of alveolar
capillaries by high alveolar pressure, creating ventilated but poorly perfused
alveolar units.
Other Potentially Adverse Effects of Mechanical
Ventilation
Excessive airway pressure and tidal volume can lead to lung injury
(ventilatorinduced lung injury) and contribute to increased mortality.
Upper Panel: When airway resistances are high, there is for a few
breath more air going in than coming out of the lungs (dynamic
hyperinflation). Subsequently, a new equilibrium is reached.
The amount of air trapped can be estimated in a passive patient
by discontinuing ventilation and collecting the expired volume
(lower panel).
The work required to deliver a tidal breath (Wb) = tidal volume (VT) x airway pressure
The pressure (P) associated with the delivery of a tidal breath is defined by the simplified equation of motion of the
respiratory system (lungs & chest wall):
Volume
Volume
WR = resistive
work
VT
VT
VT
Dynamic
FRC Hyperinflation
Pressure
PEEPi
PEEPi = intrinsic or auto PEEP; green triangle = tidal elastic work; red loop = flow resistive work; blue rectangle = work
expended in offsetting intrinsic PEEP (an expiratory driver) during inflation
The Pressure and Work of Breathing can be Entirely
Provided by the Ventilator (Passive Patient)
Ventilator
+ +
₊ + + ₊
Work of Breathing Under Passive Conditions
When the lung is inflated by constant flow, time and volume are linearly related.
Therefore, the monitored airway pressure tracing (Paw) reflects the pressure-
volume work area during inspiration. A pressure-sensing esophageal balloon reflects
the average pressure change in the pleural space and therefore the work of chest
wall expansion.
The Work of Breathing can be Shared Between
the Ventilator and the Patient
The ventilator generates positive pressure within the airway and the
patient’s inspiratory muscles generate negative pressure in the pleural
space.
AC mode
PAW
patient machine
PES
time
How the work of breathing partitions between the patient and the
ventilator
depends on:
• Mode of ventilation (e.g., in assist control most of the work is usually done by the
ventilator)
• Patient effort and synchrony with the mode of ventilation
• Specific settings of a given mode (e.g., level of pressure in PS and set rate in SIMV)
Common Modes of Ventilation
Combination modes
• SIMV with PS and either volume or pressure-targeted mandatory cycles
Pressure and Volume Targeted Ventilation
Pressure and volume targeted ventilation obey the same principles set
by the equation of motion. Pressure and volume targeted ventilation
obey the same principles set by the equation of motion.
In pressure-targeted ventilation: an airway pressure target and
inspiratory time are set, while flow and tidal volume become the
dependent variables.
In volume targeted ventilation (flow-controlled, volume cycled), a
target volume and flow (or inspiratory time in certain ventilator) are
preset and pressure and inspiratory time (or flow in the ventilator where
inspiratory time is preset) become the dependent variables.
The tidal volume is the integral of the flow during inspiration = area
under the curve of the flow time curve during inspiration (see next
slide).
Pressure and Volume Targeted Ventilation
VT
Set variables
• Volume, TI or flow rate, frequency, flow profile (constant or decel)
• PEEP and FIO2
Mandatory breaths
• Ventilator delivers preset volume and preset flow rate at a set back-up rate
Spontaneous breaths
• Additional cycles can be triggered by the patient but otherwise are identical to
the mandatory breath.
SIMV
Key set variables
• Targeted volume (or pressure target), flow rate (or inspiratory time, Ti), mandated frequency
• PEEP, FIO2, pressure support
Mandatory breaths
• Ventilator delivers a fixed number of cycles with a preset volume at preset flow rate. Alternatively, a
preset pressure is applied for a specified Ti
Spontaneous breaths
• Unrestricted number, aided by the selected level of pressure support
Peak Alveolar and Transpulmonary Pressures
meanPaw
Palveolar
+ +
_ + _ + _
Ppleural
Intrinsic PEEP
External PEEP
The difference between the Ppeak and Pplat tracks the resistive
pressure, as dictated by the equation of motion. During an
inspiratory pause, flow becomes zero, the resistive pressure is
eliminated and the airway pressure drops from its peak to the
plateau pressure.
Airway Resistance and Respiratory System
Compliance
Mandatory breaths
• Ventilator generates a predetermined pressure for a preset time
Spontaneous breaths
• PCV-AC mode: same as mandatory breaths
• PCV-SIMV mode: unsupported or PS
Important caveat
• It is important to understand that in pressure-controlled ventilation the relation between the
set rate and minute ventilation is complex. Above a certain frequency (e.g., when intrinsic
PEEP is created due to a reduced expiratory time), the driving pressure (set PC pressure –
PEEPtotal) starts to drop--and so does the delivered tidal volume.
• A pneumothorax or other adverse change in the mechanics of the respiratory system will not
trigger a high alarm pressure but a low tidal volume alarm instead.
Pressure Support
Spontaneous breaths
• Ventilator provides a preset pressure assist, which terminates when flow drops to a
specified fraction (typically 25%) of its maximum.
• Patient effort determines size of breath and flow rate.
PCV: Key Parameter to Monitor is VT
Change in mechanics
• airway resistance:
. e.g., bronchospasm
• respiratory system compliance .
.e.g, pulmonary edema,
pneumothorax
AutoPEEP
• expiratory resistance
• expiratory time
e.g., rate
Inspiratory time
• e.g., rate if I:E ratio constant
Auto-PEEP (Intrinsic PEEP, PEEPi)
Note that AutoPEEP is not equivalent to air trapping. Active expiratory muscle contraction is an often under appreciated
contributor
(left panel) to positive pressure at the end of expiration
PEEPi
Time
AutoPEEP is commonly measured by performing a pause at the end of expiration. In a passive patient, flow interruption is associated with
pressure equilibration through the entire system. In such conditions, proximal airway pressure tracks the mean alveolar pressure caused by
dynamic hyperinflation.
Approach to MV
Is MV indicated ? NO
YES
Conservative
NO Contraindication to NIPPV ? treatment and
periodic
reassessment
NO
NIPPV
YES
Success ? Invasive MV
NO
Noninvasive Ventilation
Initial settings:
• Spontaneous trigger mode with backup rate
• Start with low pressures
- IPAP 8 - 12 cmH2O
- PEEP 3 - 5 cmH2O
• Adjust inspired O2 to keep O2 sat > 90%
• Increase IPAP gradually up to 20 cm H2O (as tolerated) to:
- alleviate dyspnea
- decrease respiratory rate
- increase tidal volume
- establish patient-ventilator synchrony
Success and Failure Criteria for NPPV
Advantages-
Dec. patients work of breathing.
Better patient ventilator synchrony.
Less V/Q mismatch.
Prevents disuse atrophy of diaphragmatic muscle.
Disadvantages-
Alveolar hyperventilation
Development of high intrinsic PEEP in obstructed pts.
Inc. mean airway pressure causes hemodynamic disturbances.
Intermittent Mandatory
Ventilation (IMV)
Advantages-
Maintain respiratory muscle strength and avoid atrophy.
Reduce V/Q mismatch d/t spontaneous ventilation.
Decreases mean airway pressure d/t lower PIP & inspiratory time
Facilitates weaning.
SIMV
Disadvantages-
Desire to wean too rapidly results in high work of spontaneous
breathing & muscle fatigue & thus weaning failure.
Positive End Expiratory
Pressure (PEEP)
Indications-
Refractory hypoxemia d/t intrapulmonary shunting.
Decreased FRC and lung compliance
Physiology of PEEP
PEEP
Improves ventilation
Increases V/Q
Improves oxygenation
Complications
Dec. venous return and cardiac output.
Barotrauma
Inc. ICP d/t impedance of venous return from
head.
Alteration of renal function & water imbalance.
Continuous Positive
Airway Pressure (CPAP)
PEEP applied to airway of patient breathing spontaneously
Disadvantages-
Not suitable for patients with central apnea. (hypoventilation)
Development of high airway pressure. (hemodynamic
distubances)
Hypoventilation, if inspiratory time is short.
Adaptive Support
Ventilation (ASV)
Available on Galileo ventilator.
Patient body weight (deadspace) & percent minute volume are
feed in ventilator.
Ventilator has pre determined setting of 100ml/kg/min.
Test breath measures compliance, airway resistance & i. PEEP.
Ventilator selects and provide the frequency, inspiratory time, I:E &
sets high pressure limit for mandatory and spontaneous breaths.
May be either time triggered or patient triggered.
Proportional Assist
Ventilation (PAV)
Indications-
Spontaneously breathing patient
Intact respiratory drive
Intact neuromuscular function
Generally, a patient considered suitable for pressure support ventilation could
be considered for PAV.
PAV
Advantage-
The patient ‘drives’ the ventilator
Better patient ventilator synchrony as pressure vary to augment
flow & demand.
Disadvantage-
Barotrauma- if elastance & resistance show sudden improvement.
Volume Assured Pressure
Support (VAPS)
Incorporates inspiratory pressure support ventilation &
conventional volume assisted cycles to provide optimal inspiratory
flow during assisted/controlled ventilation.
Desired TV & pressure support level are preset.
Once triggered desired PS level reaches asap & delivered volume
is compared with preset TV.
If volume delivered = 0r > preset volume, it is PS breath.
If volume < preset volume, ventilator switches to volume limited,
resulting in longer inspiratory time until preset TV is delivered
Pressure Regulated
Volume Control (PRVC)
Advantages-
Low PAW, less V/Q mismatch, less barotrauma
Ventilator Waveforms:
Basic Interpretation and
Analysis
Outline of this presentation
Goal:
To provide an introduction to the concept of
ventilator waveform analysis in an interactive
fashion.
Content:
Outline of types of ventilatory waveforms.
Introduction to respiratory mechanics and the
‘Equation Of Motion’ for the respiratory system
Development of the concept of ventilator
waveforms
Illustrations and videos of waveforms to
illustrate their practical applications and
usefulness.
Types of Ventilator Waveforms:
Scalars and Loops
Scalars are waveform representations of pressure, flow or volume on the y axis
vs time on the x axis
flow vs time
scalar
Inspiratory
arm
expiratory
arm
pressure vs time
scalar
volume vs time
scalar
Types of Ventilator Waveforms:
Scalars and Loops
Loops are representations of pressure vs volume or flow vs volume
Expiratory
arm
Pressure Vs volume
loop
volume
pressure
Inspiratory
arm
Flow Vs volume
loop
Expiratory
flow
arm
volume
Understanding the flow-time waveform
• There are two components to the flow-time
waveform
– The inspiratory arm:
• Active in nature
• The character is determined by the ventilatory flow settings.
– The expiratory arm:
• Passive in nature
• The character is determined mainly by elastic recoil of the patients
lungs and airway resistance.
• Also affected by patient respiratory effort (if any)
flow
Expiratory
Inspiratory time = Tidal volume arm
Flow rate
The ‘decelerating ramp’ flow pattern
flow
Expiratory
Inspiratory time = Tidal volume arm
Flow rate
Now let us try to understand the
following in the next few slides
ventilator
ET Tube
PLungs= + Chest
Flow wall
Resistance + Volume Paw
THUS Airways
aw
(elastic element) Compliance Airway pressure
(resistive element) airways
Chest wall
Flow resistance
Volume Diaphragm
compliance
Palv
Alveolar pressure
Understanding basic respiratory mechanics
Rairways
Echest wall
Thus to move
The total air into
‘elastic’ the lungs
resistance (Eat a given time (t),
rs) offered by the
The total ‘airway’ to the(R
resistance (P) of
the ventilator
respiratory hassystem
to generate
is equala pressure aw
sum applied) Diaphragm
Let us now
in theunderstand
that is sufficient mechanically how the respiratory
ventilated patient systems’
elasticto overcome offered
resistances the pressure
by thegenerated
inherent
is equal elastance
to the sum and
of theresistance
resistancesto airflow
offered
by the elastic (PLung el (t)) Eand airway
and (P
theaw ) resistances
lungs generated within a
determines the pressures (R ET
offeredby the
by theendotracheal
respiratory
chest wall
tube
system
E chest tube)time.
at that
mechanically ventilated
and the patient’s airways ( R airways) system.
wall
Understanding the pressure-time waveform
using a ‘square wave’ flow pattern
Ppeak
pressure
Pres
ventilator
Pplat
Pres
RET tube
time
Pres
Rairways
Scenario # 1
pressure
Ppeak
Normal values:
Pres Ppeak < 40 cm H2O
Pplat < 30 cm H2O
Pres < 10 cm H2O
Pplat
Pres
flow
time
Scenario # 2
pressure
Ppeak Normal
e.g. ET tube
blockage
Pres
Pplat
Pres
flow
time
‘Square
wave’ flow
pattern
Ppeak
Pplat
Pres
Waveform showing high airway resistance
due to high flow rates
Paw = Flow Resistance + Volume + PEEP
Compliance
Scenario # 3
pressure
Ppeak Normal
e.g. high flow
Pres rates
Pplat
Pres
time
flow
The increase in the peak airway pressure is driven time
Normal (low)
entirely by abnormal
This is an an increase in the airways
pressure-time resistance
waveform flow rate
pressure caused by excessive flow rates.
‘Square wave’
Note the shortened inspiratory time and high flow flow pattern
Waveform showing decreased lung
compliance
Paw = Flow Resistance + Volume + PEEP
Compliance
Scenario # 4
pressure
Ppeak Normal
e.g. ARDS
Pres
Pplat
Pres
flow
time
The increase in the peak airway pressure is driven
entirely by the decrease in the lung compliance. time
This is an abnormal
Increased airways pressure-time waveform
resistance is often
also a part of this scenario. ‘Square wave’
flow pattern
Waveform showing decreased lung
compliance
‘Square
wave’ flow
pattern
Ppeak
Pplat
Pres
Now lets look at the same pressure-time tracings
using a ‘decelerating ramp’ flow pattern
Normal Normal
Pplat Pplat
pressure
High
Normal Pplat
Pplat
time
Now let us try to understand the
practical aspects of ventilator
waveform analysis in an
interactive fashion.
Clinical applications of
ventilator waveform analysis
Ventilator waveforms can be very useful in many
different situations including:
Diagnosing a ventilator that is ‘alarming’
Detecting obstructive flow patterns on the ventilator
Detecting air trapping and dynamic hyperinflation
Detecting lung overdistention
Detecting respiratory circuit secretion build-up
Detecting patient-ventilator interactions
Dyssynchrony
Double triggering
Wasted efforts
Flow starvation
Some ventilators with waveform displays
PB 840
Ventilator
Select different
waveforms
Size
adjustment
Time scale
Push to start
waveforms
Waveform selection on different ventilators
Respironics
Espirit
ventilator
Push to select
waveforms
Waveform selection on different ventilators
Switch between
waveforms
Respironics
Espirit
ventilator
Press to
adjust size
Switch between
Loops and scalars
Variables that govern how a ventilator functions and
interacts with the patient
Control variable
‘The Mode of Ventilation’
Pressure, flow, or volume
controlled
Limit Variable
Volume, pressure or flow
can be set to be constant
or reach a maximum
Triggering variable
pressure, flow or volume
sensing that initiates
the vent cycle
Cycle variable
Pressure, volume, flow,
or time that ends the
inspiratory phase
should I be
observing and
analyzing?
LOOK AT THE WAVEFORMS THAT ARE VARYING
BASED ON THE SETTINGS YOU HAVE ORDERED
Mode of ventilation -> useful waveforms
Mode of Independent Dependent Waveforms that will Waveforms that
ventilation variables variables be useful normally
remain
unchanged
Volume Tidal volume, Paw Pressure-time:-> Volume-time
Control/ RR, Flow rate, changes in Pip, Pplat Flow time
Assist- PEEP, I/E ratio Flow-time (expiratory): - (inspiratory)
Control >changes in compliance Flow-volume loop
Pressure-volume loop:->
overdistension, optimal
PEEP
Pressure Paw, Inspiratory Vt, flow Volume-time and flow- Pressure-time
Control time (RR), time: -> changes in Vt and
PEEP and I/E compliance
ratio Pressure-volume loop:->
overdistension, optimal
PEEP
Vt=tidal volume; RR=respiratory rate; Paw=airway pressure; PEEP= positive end expiratory pressure; I/E ratio= inspiratory/expiratory time;
VE= minute ventilation; Pip = Peak inspiratory pressure; Pplat = Plateau pressure
Waveforms to observe during volume
assist control ventilation
Pressure-time waveform:
Affected by patient effort and changes in
resistance and compliance
Flow-time waveform:
Expiratory flow is not fixed, waveform is dependent
on elastic recoil pressure of respiratory
system/patient effort
Therefore this scalar is nearly always of interest
Waveforms to observe during pressure
targeted ventilation: PCV
Any abnormalities? : No
PEARL: always look at both inspiratory and expiratory arms
of the flow-time waveform. Make it a habit!
Basic ventilator waveforms
Any abnormalities? : No
PEARL: At similar flow rates, the inspiratory time is shorter (and
peak pressures higher) for the square wave flow as compared to the
decelerating flow pattern.
Basic ventilator waveforms
Any abnormalities?: No
PEARL: notice how each breath differs in flow pattern and
tidal volume.
Basic ventilator waveforms
Any abnormalities? : No
PEARL: tidal volumes and flow rates are determined by lung
compliance. Increasing inspiratory time beyond a certain point will
only decrease expiratory time, without any increases in tidal volumes
achieved.
Let us now shift gears and see how waveforms
can help us recognize some common ventilator
related problems!
Common problems
that can be diagnosed
by analyzing
Ventilator waveforms
Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP Secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
Now let us learn to recognize
Lung overdistension
and the development of
Auto PEEP
Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP Secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
Let us briefly revisit the flow-time
waveform
Peak
Inspiratory
pressure
Upper
Inflection
point
Lower
Inflection
point
Lung overdistension based
on pressure-volume loops
Recognizing
Auto-PEEP
Detecting Auto-PEEP
Recognize
Auto-PEEP
when
Lluis Blanch MD, PhD et al: Respiratory Care Jan 2005 Vol 50 No 1
Understanding how inspiratory time affect I/E
ratios and the development of auto-PEEP
Recognize
Airway obstruction
when
Patient-ventilator
Abnormal ventilatory Ventilatory circuit related
Interactions
Parameters/lung mechanics problems
E.g. flow starvation,
E.g.. Overdistension, E.g. auto cycling and
Double triggering,
Auto PEEP secretion build up in the
Wasted efforts
COPD Ventilatory circuit
Active expiration
Recognizing:
Wasted efforts
Double triggering
Flow starvation
Active expiration
Recognizing ineffective/wasted patient effort