Basic Principles of

Mechanical Ventilation
 Introduction
The ventilatory needs of a
patient depend largely on the
mechanical properties of the
respiratory system and the type
of abnormality in gas exchange.
 Pulmonary Mechanics
A. The mechanical properties of the lungs are a
determinant of the interaction between the
ventilator and the infant.
B. A pressure gradient between the airway opening
and alveoli drives the fl ow of gases.
C. The pressure gradient necessary for adequate
ventilation is largely determined by compliance
and resistance.
 Compliance
Compliance describes the elasticity or distensibility of the lungs or
respiratory system (lungs plus chest wall).


Compliance in infants with normal lungs ranges from 3 to 5

mL/cm H2O/kg.
Compliance in infants with RDS is lower and often ranges from
0.1 to 1 mL/cm H2O/kg.
 Resistance
Resistance describes the ability of the gas-conducting parts of the lungs or
respiratory system (lungs plus chest wall) to resist airflow.

Resistance in infants with normal lungs ranges from 25 to 50

cmH2O/L/sec.
Resistance is not markedly altered in infants with RDS or other acute
pulmonary disorders but can be increased to 100 cmH2O/L/sec or more by
small endotracheal tubes.
Normal lungs: 20-40 cm H2O/L/sec
RDS: 20-40 cm H2O/L/sec
Intubated infant: 50-150 cm H2O/L/sec
 Time Constant
Time constant is the time (expressed in seconds)
necessary for the alveolar pressure (or volume) to reach
63% of a change in airway pressure (or volume).
 Time Constant
A duration of inspiration or expiration equivalent to
3 to 5 time constants is required for a relatively
complete inspiration or expiration.
The time constant will be shorter if compliance is
decreased (e.g., in patients with RDS) or if resistance is
decreased.
 The time constant will be longer compliance is high (e.g.,
large infants with normal lungs) or if resistance is high (e.g.,
infants with chronic lung disease).
 Time Constant
Patients with a short time constant ventilate well with
short inspiratory and expiratory times and high ventilatory
frequency,
whereas patients with a long time constant require longer
inspiratory and expiratory times and lower rates.
If inspiratory time is too short (i.e., a duration shorter
than approximately 3 to 5 time constants), there will be a
decrease in tidal volume delivery and mean airway
pressure.
If expiratory time is too short (i.e., a duration shorter
than approximately 3 to 5 time constants), the result will be
gas trapping and inadvertent (auto) PEEP.
 Goals of Mechanical
Ventilation
Achieve and maintain adequate
pulmonary gas exchange
 Minimize the risk of lung injury
 Reduce patient work of breathing
Optimize patient comfort
 Ventilation
The goal of ventilation is to facilitate CO2 release and maintain normal PaCO2
• Minute ventilation (MVE)
• Total amount of gas exhaled/min.
• MVE = (RR) x (TV)
• MVE comprised of 2 factors
• VA = alveolar ventilation
• VD = dead space ventilation
• VD/VT = 0.33
• VE regulated by brain stem, responding to pH and PaCO2
• Ventilation in context of ICU
• Increased CO2 production
• fever, sepsis, injury, overfeeding
• Increased VD
• atelectasis,ALI,RDS,pulmonary embolism
• Adjustments: RR and TV
variables and pulmonary mechanics that determine
minute ventilation
during time-cycled, pressure-limited ventilation
 Oxygenation
The primary goal of oxygenation is to maximize O2 delivery to blood (PaO2)
• Alveolar-arterial O2 gradient (PAO2 – PaO2)
• Equilibrium between oxygen in blood and oxygen in alveoli
• A-a gradient measures efficiency of oxygenation
• PaO2 partially depends on ventilation but more on V/Q matching
• Oxygenation in context of ICU
• V/Q mismatching
• Patient position (supine)
• Airway pressure, pulmonary parenchymal disease, small-airway disease
 Oxygenation
What (other than FiO2) determines oxygenation?
Mean Airway Pressure (MAP)
 MAP is the average pressure to which the lungs are
exposed during the respiratory cycle.
 Mean Airway Pressure (MAP)
For the same increase in MAP, changes in PIP and
PEEP increase PaO2 more than Changes in I:E ratio.
Very high MAP may cause over distention of alveoli
leading to right-to-left intraparenchymal shunting.
The amount of MAP transmitted to intrathoracic
structure is inversely related to lung compliance.
If very high MAP is transmitted to intrathoracic
structures, CO may decrease.
Thus, despite adequate oxygenation, O2 delivery may
decrease
 Ideal Mode of Ventilation
Delivers a breath that:
Synchronizes with the patient’s
spontaneous respiratory effort
Maintains adequate and consistent tidal
volume and minute ventilation at low
airway pressures
Responds to rapid changes in pulmonary
mechanics or patient demand
Provides the lowest possible WOB
 Ideal Ventilator Design
Achieves all the important goals of
mechanical ventilation
 Provides a variety of modes that can
ventilate even the most challenging
pulmonary diseases
 Has monitoring capabilities to adequately
assess ventilator and patient performance
 Has safety features and alarms that offer
lung protective strategies
 Classifying Modes
of Ventilation
A. Start
Trigger mechanism:
B C
What starts the breath?
B. Limits
What is controlled
and what is variable? A
C. End
Cycle mechanism:
What causes the
breath to end?
What Starts the Breath?
Time (IMV)
Pressure
Flow
Chest
impedance
Abdominal
movement
How does the ventilator know when to give a
breath? (Trigger)
•Time
• CMV, paralyzed patient on A/C or SIMV
• Often combined with flow or pressure
•Flow – patient achieves set flow
•Pressure – patient achieves set negative pressure
•Can be issues with Auto-PEEP
 Which Parameters are
Limited or Controlled?
Pressure limited
Pressure is controlled, volume is variable
Volume limited
Volume is controlled, pressure is variable
What Ends the Breath?
Cycling Mechanisms
Time
Volume
Pressure
Flow
Phase Variables
Ventilator Parameters
Peak Inspiratory Pressure (PIP)
 maximum pressure measured(or set) by the ventilator during
inspiration.
An increase in PIP will increase tidal volume, increase CO2
elimination, and decrease PaCO2.
An increase in PIP will increase mean airway pressure and thus
improve oxygenation.
An elevated PIP may increase the risk of barotrauma,
volutrauma, and bronchopulmonary dysplasia/chronic lung
disease.
It is important to adjust PIP based on lung compliance and to
ventilate with relatively small tidal volumes (e.g., 3 to 5 mL/kg).
Positive End-Expiratory Pressure (PEEP)
pressure present in the airways at the end of
expiration.
PEEP in part determines lung volume during the
expiratory phase, improves ventilation-perfusion
mismatch, and prevents alveolar collapse.
A minimum “physiologic” PEEP of 2 to 3 cm H2O
should be used in most newborns.
 Positive End-Expiratory Pressure (PEEP)
Gas exchange effects
1. An increase in PEEP increases expiratory lung volume(FRC
capacity) during the expiratory phase and thus improves
ventilation-perfusion matching and oxygenation in patients
whose disease state reduces expiratory lung volume.
2. An increase in PEEP will increase mean airway pressure and
thus improve oxygenation in patients with this type of
disease.
3. An increase in PEEP will also reduce the pressure gradient
during inspiration and thus reduce tidal volume, reduce
CO2 elimination,and increase PaCO2.
Positive End-Expiratory Pressure (PEEP)
Side effects
1. An elevated PEEP may overdistend the lungs and lead
to decreased lung compliance, decreased tidal volume,
less CO2 elimination, and an increase in PaCO2.
2. Although use of low to moderate PEEP may improve
lung volume, a very high PEEP may cause
overdistention and impaired CO2 elimination
secondary to decreased compliance and gas trapping.
3. A very high PEEP may decrease cardiac output and
oxygen transport.
 Frequency (or Rate)
breaths per minute.
The ventilator frequency (or rate) in part determines
minute ventilation, and thus, CO2 elimination.
Spontaneous breathing rates are inversely related to
gestational age and the time constant of the respiratory
system. Thus, infants with smaller and less compliant
lungs tend to breathe faster.
Use of very high ventilator frequencies may lead to
insufficient inspiratory time and decreased tidal volume
or insufficient expiratory time and gas trapping.
 Inspiratory Time (TI), Expiratory Time (TE), and
Inspiratory-to-Expiratory Ratio (I:E Ratio)
The effects of TI and TE are strongly influenced by their
relationship to the inspiratory and expiratory time
constants.
A TI as long as 3 to 5 time constants allows relatively
complete inspiration , A TI of 0.2 to 0.5 sec is usually
adequate for newborns with RDS, Infants with a long
time constant (e.g., with chronic lung disease) may
benefit from a longer TI (approximately 0.6 to 0.8 sec).
A very prolonged TI may lead to ventilator asynchrony,
A very short TI will lead to decreased tidal volume.
Inspired Oxygen Concentration (FiO2)
Changes in FiO2 alter alveolar oxygen pressure, and thus,
oxygenation.
Because both FiO2 and mean airway pressure determine
oxygenation, the most effective and less adverse approach
should be used to optimize oxygenation.
When FiO2 is above 0.6 to 0.7, increases in mean airway
pressure are generally warranted.
When FiO2 is below 0.3 to 0.4, decreases in mean airway
pressure are generally preferred.
A very high FiO2 can damage the lung tissue, it was
determined that toxic levels of FiO2 are that above 0.6.
 FLOW
volume of gas per time.
Inadequate flow may contribute to air
hunger, asynchrony, and increased work of
breathing.
Excessive flow may contribute to turbulence,
inefficient gas exchange, and inadvertent
PEEP.
Effect of Ventilator Settings changes on Blood Gases