Académique Documents
Professionnel Documents
Culture Documents
MECHANICAL VENTILATION
Guide
Dr. G.Singh (MS)
Co-Guide
Dr. A.M. Lakra (MD)
-Rajan Kumar
Introduction
Cornerstone for intensive care medicine
Ventilate is derived from Latin word
“ventus” meaning wind.
Ventilation is movement of air into and outside
the body
The ventilators must overcome the
pressure generated by the elastic recoil of
the lung at end inspiration plus the
resistance to flow at the airway.
Ventilators provide infusion of a blend of air
or oxygen into the circuit.
History
In 1543, Vesalius demonstrated the ability to
maintain the beating heart in animals with open
chest.
In 1780, such technique were first applied to
humans
In 1887, fell-o-dwyer apparatus was used for
translaryngeal ventilation via a bellows.
In 1928, the drinker–Shaw iron lung based on
negative pressure ventilation
From 1930-1950 – such machines were the
mainstay in ventilation of victims of polio
epidemics
Basic anatomy
Respiratory physiology
Tidal volume
Respiratory rate
Minute volume
Inspiratory Reserve Volume
Expiratory Reserve Volume
Inspiratory Capacity (IRV + TV)
Residual Volume
Functional Residual Capacity (ERV + RV)
Vital capacity (IRV + TV + ERV)
Total Lung Capacity (IRV + TV + ERV + RV)
Compliance
Dead space
MECHANICAL VENTILATOR
Ventilators are specially designed pumps
that can support the ventilatory function of
the respiratory system and improve
oxygenation through application of high
oxygen content gas and positive pressure.
Components
Bacterial filter
Pneumotachometer, valves & solenoids
Humidifier
Heater/ thermostat
Oxygen analyser
Pressure manometer
Chamber for nebulising drug
Compressor
Battery
Goals
inspiration pause
pause expiration
Principles
Paw
(cm H2O) A B
Time (sec)
ACCELERATING SINE
Setting of ventilator
Tidal volume 5-7 ml/kg
I:E ratio 1:2
Frequency 10-12 bpm
PEEP 3–5 cmH2O
Trigger sensitivity (for -1 to -2 cmH2O
assist mode)
FIO2 50%
Normal ABG Values
pH 7.35 - 7.45
PaCO2 35 – 45 mmHg
PaO2 70 – 100 mmHg
SaO2 93 - 98%
HCO3¯ 22 – 26 mEq/L
Base excess -2.0 to 2.0 mEq/L
Ventilator parameters adjustment
according to blood gases
PO2 _____
PO2 _____
Monitoring
Clinical
Radiological
Biochemical
Bacteriological
others
Clinical monitoring
General Appearance
Level of activity
Response to stimulus
Eye opening
Posture
Perfusion
Color
Edema
Adequacy of mechanical breath
Movement of chest
Retractions
Synchronization
Air entry
Monitoring of O2 & CO2 status
Pulse oximetry
EtCO2 monitoring
ABG analysis
Transcutaneous monitoring
Oxygenation indices
Ventilator Parameters
PIP
PEEP
MAP
RR
Ti & I:E Ratio
FiO2
VT
Trends of Ventilator Parameters
Pulmonary Graphics
Hemodynamic Stability
Oxygenation
Adequacy of Circulation
Radiological Monitoring
When to do Chest X-ray ?
At the start of ventilation
Sudden deterioration
Prior to extubation
Post extubation
Biochemical Monitoring
Blood Gases
Blood Sugar
Serum calcium
Serum electrolytes
Bacteriological Monitoring
Blood culture
ET tube culture
Other Monitoring
Humidification & warming of ventilator circuit
gases
Position of patient
Skin
Nutrition status
Sensorium
Infection control
Sedation in Mechanically
Ventilated Patients
Benzodiazepines
Opioids
Neuroleptics
Propofol
Ketamine
Dexmedetomidine
Maintenance of Sedation
Titrate dose to ordered scale
– Motor Activity Assessment Scale MAAS
– Sedation-Agitation Scale SAS
– Modified Ramsay Sedation Scale
Rebolus prior to all increases in the
maintenance infusion
Daily interruption of sedation
NEUROMUSCULAR
BLOCKING AGENTS
Difficult to asses adequacy of sedation
Polyneuropathy of the critically ill
Use if unable to ventilate patient after
patient adequately sedated
Have no sedative or analgesic properties
Troubleshooting
Is it working ?
–Look at the patient !!
–Listen to the patient !!
– Pulse Ox, ABG, EtCO2
– Chest X ray
– Look at the vent (PIP; expired TV;
alarms)
Troubleshooting
When in doubt, DISCONNECT THE
PATIENT FROM THE VENT, and begin bag
ventilation.
Ensure you are bagging with 100% O2.
This eliminates the vent circuit as the
source of the problem.
Bagging by hand can also help you gauge
patient’s compliance
Troubleshooting
Airway first: is the tube still in? (may need
DL/EtCO2 to confirm) Is it patent? Is it in the
right position?
Breathing next: is the chest rising? Breath
sounds present and equal? Changes in
exam? Atelectasis, bronchospasm,
pneumothorax, pneumonia? (Consider
needle thoracentesis)
Circulation: shock? Sepsis?
Troubleshooting
Well, it isn’t working…..
– Right settings ? Right Mode ?
– Does the vent need to do more work ?
Patient unable to do so
Underlying process worsening (or new problem?)
– Air leaks?
– Does the patient need to be more sedated ?
– Does the patient need to be extubated ?
Troubleshooting
Patient - Ventilator Interaction
– Vent must recognize patient’s respiratory efforts
(trigger)
– Vent must be able to meet patient’s demands
(response)
– Vent must not interfere with patient’s efforts
(synchrony)
Troubleshooting
Improving Ventilation and/or Oxygenation
– can increase respiratory rate (or decrease rate if
air trapping is an issue)
– can increase tidal volume/PAP to increase tidal
volume
– can increase PEEP to help recruit collapsed
areas
– can increase pressure support and/or decrease
sedation to improve patient’s spontaneous effort
Trouble Shooting
Ventilator alarms
Airway pressure
-high/low
Tidal volume
Inspiratory flow
Expiratory flow
Triggering
FiO2
Weaning from ventilator
It means discontinuing the ventilatory
support.
Guidelines are:
1. pO2 >60 mm Hg (or oxygen saturation >
90%) on FIO2 <50% and PEEP <5mmHg.
2. pCo2 <50 mmHg
3. Respiratory rate <20/min
4. Vital capacity >15ml/kg
5. VD/VT <0.6
6. Tidal volume > 5ml/kg
7. Minute ventilation <10 litres/min
8. Inspiratory pressure <-30 cm H2O
9. rapid shallow breathing index (RSBI) should be <100
= respiratory rate (breaths/min)/tidal volume (in
litres)
10. Arterial pH is normal
11. Normal cardiac status
12. Normal electrolytes
13. Adequate nutritional status
Method of weaning
Although weaning process vary from patient to patient and is
possible to wean patient in any mode of ventilation except control
mode ventilation
Complications
Pulmonary barotrauma
Pneumothorax
Pneumomediastinum
Bronchopleural fistula
Pneumocardium
Air embolism
infection
Pulmonary (ventilator assoc. pneumonia)
Urinary
Wound infection
iv cannula related
complications due to prolonged intubation
Airway edema
Sore throat
Laryngeal ulcer and granuloma
GIT
2. stress ulcer
3. paralytic ileus
cardiovascular: right ventricular strain or even rt ventricular
failure
nosocomial infections
liver and kidney dysfunction due to decreased cardiac
output
neuromuscular weakness
ciliary activity impairment
oxygen toxicity
prolonged immobilization
bed sores, thromboembolism
Acute Deterioration - DOPE
Displaced tube
Pneumothorax
Equipment Failure
Gradual Deterioration
Increase in primary pathology
Infection
Anemia
Hypo tension
Dyselectrolytemia
Hypoglycemia
Progression to CLD
CARE OF THE PATIENT ON
VENTILATOR
Care of unconscious patient
Sedation
Analgesia
Care of conscious patient
Care of all vascular lines and tubes
Nutritional support
Respiratory care
Care of ET Tube/Tracheostomy Tube
Antibiotic
Bronchodilators
Mucolytic
Physiotherapy
- chest
- limb
Humidification/ warming of airway
Prevention of aspiration
TAKE HOME MESSAGE
Learned by surgical resident