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SEMINAR ON

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

 Achieve and maintain adequate pulmonary gas


exchange
 Minimise the risk of lung injury
 Reduce patient work of breathing
 Optimise patient comfort
Classification
1. ICU Ventilators
 The condition of lung is poor
2. Anaesthetic ventilators
 The condition of lung is good
3. Transport ventilator
 The ventilator is compact and used for transportation of
victim/patients from one site to other
4. Other/special
(a) High frequency ventilator
(i) High frequency positive pressure ventilator
(ii) High frequency jet ventilator
(iii) High frequency oscilitation ventilator
ICU ventilator

A. Positive pressure ventilation (PPV)


(a) Non invasive PPV
(i) Nasal mask
(ii) Facial mask
These has less complications and as effective as
invasive ventilators
(b) Invasive PPV
(i) Nasotracheal tube
(ii) Oro tracheal tube
(iii) Tracheostomy
B.Negative pressure ventilation
 Iron lung machine

The machine creates a negative pressure to expand the


chest wall so that the lungs can expand inside it with the
negative intrapleural pressure.
Ventilator cycle

inspiration pause

pause expiration
Principles

– Gas flows only down the pressure gradient,


i.e. from areas of high pressure to low
pressure.

– Exhalation is a passive process, ventilators


expend energy only during inhalation
– Mechanical ventilation is produced through the
interaction of only 5 variables
2.Time
3.Volume
4.Pressure
5. inspiratory: expiratory (I:E) ratio
6.Flow
Objectives

 Improve O2 &CO2 gas exchange


– Reverse hypoxemia
– Prevent progressive hypercapnia
– Reverse acute respiratory acidosis

 Improve ventilation distribution


– Prevent and reverse lung collapse
– Reduce venous admixture
 Assist respiratory muscle
– Decreased O2 cost of breathing
– Relieve resp. distress
 Improve lung compliance
– Increase alveolar recruitment
- Return lung to resting lung volumes
Indications
 On the basis of blood gas analysis
1. PO2 <50mmHg on room air
<60mmHg on oxygen support (FIO2 >50%)
2. PCO2 >50mmHg
3. pH <7.25
4. PO2/FIO2 <250mmHg
5. p (A-a ) O2 gradient >350 mmHg on 100% O2.
 On the basis of pulmonary function
• Resp. Rate >35/min
• Vital capacity <15ml/kg
• Dead space volume (VD/VT) >0.6 (60%)
• Tidal volume <5ml/kg
Basic physics related to
mechanical ventilation

 Paw = flow× resistance + volume ∕ compliance + PEEP

 Pressure at point B is equivalent to the alveolar pressure and is


determined by the volume inflating the alveoli divided by the
compliance of the alveoli plus the baseline pressure (PEEP).

 Pressure at point A (equivalent to airway pressure measured by the


ventilator) is the sum of the product of flow and resistance due to the
tube and pressure at point B.
 Flow, volume and pressure are variables while resistance
and compliance are constants.
 It follows from the relationship between pressure, flow and
volume that by setting one of pressure, volume or flow and
the pattern in which it is delivered which includes the time
over which it is delivered the other two become constants.
 It also follows that it is not possible to present more than
one of these variables at a time.
Components of I nflation
Pressure
1. PIP
2. Pplat/Alveolar Pressure
1
A. Airway Resistance
B. Distending Pressure
2

Paw
(cm H2O) A B

Time (sec)

Begin Inspiration Begin Expiration


Cycling
 Time cycled
 Pressure cycled
 Volume cycled
 Time cycled – these cycle to expiration once a
predetermined time is elapsed since inspiration.
 Tidal volume is determined by set inspiratory flow
and inspiratory time
 Used in
– Operation theaters
– In neonates
 Pressure cycled
These cycled to expiration once a predetermined
pressure is reached, so if there is leak in circuit the
predetermined pressure will not reached and pt. will
remain in inspiration conversely, if airway pressure is
high, bronchospasm or tube kinking there will be
premature end of inspiration and patient can be
hypoventilated.
 Volume cycled – Inspiration is terminated when a
preset tidal volume is delivered.
So theoretically, the patient cannot be hypoventilated
even if the lung compliance (airway pressure)
changes but actually this is not the case, a portion of
tidal volume is lost (120-150ml) in the ventilator
breathing circuit and if patient’s pulmonary
compliance is decreased (peak inhalation pressure
will increase) the delivered tidal volume can further be
decreased.
 The accurate, tidal volume reaching to patients can only be
calculated by putting a spirometer at the endotracheal tube.
 e.g. most commonly used in ICUs

 Disadvantage – they deliver fixed tidal volume so if airway


pressure becomes high and still same tidal volume is be
delivered the chances of barotrauma are increased.
 Dual control – can work in both volume control and pressure
control mode and can switch over from one mode to other
depending on requirements.
Modes of mechanical
ventilations

 Characterized by three variables

 The parameter used to initiate or ‘trigger’ a


breath
 The parameter used to ‘limit’ the size of breath,
and
 the parameter used to terminate inspiration or
‘cycle’ the breath.
 In controlled ventilation modes – time triggered
Inspiratory phase is concluded once a desired volume,
pressure or flow is attained but the expiratory time (Et)
will form the difference between the inspiratory time (It)
and the preset respiratory cycle time.
 In Assist mode – the ventilator is pressure or flow
triggered
 The magnitude of the breath is controlled or limited by
one of three variables
 Volume, pressure or flow.
 Controlled mode ventilation(CMV)/ intermittent positive pressure
ventilation (IPPV):
in this mode patient’s own effort is nil. Only ventilator is delivering the preset
tidal volume at preset frequency
 Assist controlled ventilation(AC): in this mode assist means the ventilator
supplementation of patient initiated breath (which itself doesnot have
adequate tidal volume) and control means back up rate which is set up by
clinician.
 Synchronized intermittent mandatory ventilation (SIMV): in this
mode ventilator will deliver only between patient’s efforts or to
coincide with the beginning of spontaneous effort.
 Advantages of SIMV over CMV
3. Less haemodynamic depression
4. Patient on CMV/IPPV need heavy sedation or muscle relaxant.
5. Less V/Q mismatch
6. No sense of breathlessness between ventilatory cycles
7. More rapid weaning
 Disadvantages
1.increased work of breathing can cause muscular fatigue.
2.increased chances of hypocapnia (due to
hyperventilation)
Positive end expiratory pressure (PEEP)
 indications
pulmonary edema
ARDS
In thoracic surgery to minimize postoperative bleeding.
 Physiological PEEP (in normal intubated patient to prevent
atelectasis)
 Mechanism of PEEP
Positive pressure given at end expiration prevents alveoli to collapse and
small airways to close. So more time is available for gaseous exchange
 Side effects of PEEP
4. Hypotension and decrease in cardiac output: PEEP compresses venules
in alveolar septa leading to decreased venous return. So optimal PEEP is
the value which maintain oxygen saturation >90% without decreasing the
cardiac output significantly.
5. Increased pulmonary artery pressure and right ventricular strain: it is due
to compression of capillaries in alveolar septa.
6. Increased dead space because of overdistension of normal alveoli.
7. Increased pleural and mediastinal pressure.
8. These increased pressures can cause pulmonary barotrauma
 Inverse ratio ventilation (IRV): ratio of inspiration to
expiration is reversed(2:1, while normal ratio is 1:2).
Prolonged inspiration will maintain positive pressure. So
more or less it acts like PEEP. It is better than PEEP and
there is even distribution of ventilation.
 Pressure support ventilation (PSV): if a patient is on
spontaneous respiration with adequate frequency but not
adequate tidal volume,this mode is helpful in increasing
the tidal volume.
 Pressure controlled ventilation (PCV): in this mode
pressure is preset and ventilator terminates inspiration once
preset pressure is achieved. So if airway pressure varies
patient is prone for ventilation but advantage is that chances
of barotrauma is less and there is choice of extending
inspiratory time, facilitating better oxygen.
 BIPAP: bipap means positive pressure both during
inspiration and expiration. Typical setting is 8-20 cm
H2O positive pressure during inspiration and 5 cm H2O
during expiration.it is combination of PSV and PEEP.
 Airway pressure release ventilation (APRV) applied to
patient on CPAP where there is periodic release of
CPAP to decrease the incidence of barotrauma and
hypotension.
 High frequency ventilation: this mode is
applicable in conditions in which adequate tidal
volume cannot be delivered. So minute volume is
maintained by high frequency.
TYPES OF WAVES FORMS
 Pressure waveforms
– Rectangular
– Exponential rise
– Sine
 Volume waveforms
– Ascending ramp
– Sinusoidal
 Flow waveforms
– Rectangular
– Sinusoidal Flow Patterns
– Ascending ramp
– Descending ramp SQUARE DECELERATING
– Exponential decay

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

Goals PIP PEEP RATE FiO2 Ti

PCO2 ____ ____

PCO2 ____ ____

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

 Capillary gas determination

 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

 Before surfactant administration

 After ET tube change

 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

 Fluid & electrolytes

 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

 Obstructed Tube ( blocked 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

 Surgical aetiology decides results

 Monitoring clinical and laboratory criteria

 Avoid as far as possible ; difficult weaning

 Elective ventilation useful armament

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