Ventilation: Basic Principles

Jamie Ranse
Registered Nurse
Emergency Department
The Canberra Hospital

Overview

• Introduction to Ventilation Principles

• Respiratory Anatomy and Physiology
• Indications for Ventilation
• Modes of Ventilation
• Patient Management
• Complications
• Questions

Introduction

• Ventilation is the movement of air into and out of the alveoli.

Mechanics of Ventilation:
• Elasticity
• Compliance
• Resistance
• Pressure
• Gravity

Anatomy and Physiology

• Respiratory Structures
• Respiratory Zones
• Partitioning of Respiratory Pressures
• Boyles Law
 Air flows from a region of higher pressure to a region of lower pressure.
 To initiate a breath, airflow into the lungs must be precipitated by a drop in alveolar pressures.
• Respiratory Volumes and Capacity
• Ventilation and Perfusion

Indications for Ventilation

• Airway Compromise (potential)

• Respiratory Failure
– pH: <7.25
– PaCO2: >50 mmHg
– PaO2: <50 mmHg
• Increased Work of Breathing
• Head Injury Management

Objective of Ventilation

• Support though illness

• Reversal of hypoxemia
• Reversal of acute respiratory acidosis
• Relief of respiratory distress
• Resting of the ventilatory muscles
• Decrease in oxygen consumption
• Reduction in intracranial pressures
• Stabilisation of the chest wall

Modes of Ventilation

• Controlled
– Pressure Control (PC)
– Volume Control (VC)

• Supported
– Continuous Positive Airway Pressure (CPAP)
– Pressure Support (PS)

• Combined
– SIMV (PC) + PS
– SIMV (VC) + PS

Modes of Ventilation:Control

Controlled Mechanical Ventilation:

• The Minute Volume is determined by the ventilator
• The patient has no option to override the ventilator

Pressure Control:
• A preset peak inspiratory pressure is delivered to the patient at a preset
respiratory rate
• Volume is not preset and is determined by the mechanics of ventilation.
(elasticity, compliance, resistance, pressure,gravity)

Volume Control:
• A preset tidal volume is delivered at a present respiratory rate
• 7 – 10 mls/kg
50kg = 350 – 500mls
70kg = 490 – 700mls
90kg = 630 – 900mls

Modes of Ventilation: Support

Continuous Positive Airway Pressure:

• A spontaneous breathing mode, where the patient generates their own breath
• The ventilator maintains a constant positive pressure on expiration (PEEP)
• Aims to increase Functional Residual Capacity

Pressure Support:
• A spontaneous breathing mode
• Need for additional support to achieve optimal tidal volumes
• Ventilator delivers a constant preset pressure on inspiration

CPAP + PS = BiPAP

Modes of Ventilation:Combined

Synchronised Intermitted Mandatory Ventilation:

• Similar to IMV
• If the patient initiates a breath and the ventilator synchronises so the ventilator doesn’t deliver a
breath at the same time

SIMV (PC) + PS:

• Pressure controlled ventilation with pressure support on spontaneous breaths
SIMV (VC) + PS:
• Volume controlled ventilation with pressure support on spontaneous breaths

Patient Management
• Monitoring
• Suctioning
• Other
– Sedation
– Positioning
– Oral and Eye Care

Monitoring

• ECG
• SpO2
• ETCO2
• Alarm limits
• Air Entry / Work of Breathing
• Ventilator observations and alarm limits
• Full assessment

Suctioning

• PRN
– Increasing airway pressures
– Decreasing SpO2
– Increased work of breathing
• Pre-oxygenate (100% oxygen)
• Less than 15 Seconds

Other

• Sedation
– Propofol, Morphine and Midazolam
• Positioning
– 2/24
• Oral and eye care
– 2/24

Complications

• Airway
– Aspiration, decreased clearance of secretions, predisposition to infection
• Endotracheal Tube
– Tube kinking, sputum plug, right main bronchus intubation, tube migration, cuff failure,
laryngeal oedema
• Mechanical
– Ventilator malfunction, hypoventilation, hyperventilation, barotrauma, pneumothorax