Chapter 2: Mechanical ventilator

History:
The history of mechanical ventilation begins with various versions of the iron lung;
a form of noninvasive negative-pressure ventilator used during the polio epidemics
of the twentieth century, other forms of noninvasive ventilators, also used widely
for polio patients, include Biphasic Cuirass Ventilation. (1)
In 1949, John Haven Emerson developed a mechanical assister for anesthesia with
the cooperation of the anesthesia department at Harvard University. Mechanical
ventilators began to be used increasingly in anesthesia and intensive care during
the 1950s. (2)
In 1952, Roger Manley of the Westminster Hospital, London, developed a
ventilator which was entirely gas-driven and became the most popular model used
in Europe, prior to the introduction of models controlled by electronics.
In 1965, the Army Emergency Respirator was developed in collaboration with the
Harry Diamond and Walter Reed Army Institute of Research. Its design
incorporated the principle of fluid amplification in order to govern pneumatic
functions. Fluid amplification allowed the respirator to be manufactured entirely
without moving parts, yet capable of complex resuscitative functions. Elimination
of moving parts increased performance reliability and minimized maintenance. (3)
Intensive care environments around the world revolutionized in 1971 by the
introduction of the first SERVO 900 ventilator (Elema-Schönander), constructed
by Björn Jonson. It was a small, silent and effective electronic ventilator, with the
famous SERVO feedback system controlling what had been set and regulating
delivery. For the first time, the machine could deliver the set volume in volume
control ventilation. (4)
Microprocessor ventilators: Microprocessor control led to the third generation of
intensive care unit (ICU) ventilators, starting with the Dräger EV-A (5) in 1982 in
Germany which allowed monitoring the patient's breathing curve on an LCD
monitor. One year later followed Puritan Bennett 7200 and Bear 1000, SERVO
300 and Hamilton Veolar over the next decade. Microprocessors enable
customized gas delivery and monitoring, and mechanisms for gas delivery that are
much more responsive to patient needs than previous generations of mechanical
ventilators. (6)
Indications for mechanical ventilator:
Mechanical ventilation is indicated in many situations (table 1). (7) Although these
conditions are useful in the determination of whether mechanical ventilation is
needed, clinical judgment is as important as strict adherence to absolute guidelines.
One indication for mechanical ventilation is imminent acute respiratory failure; in
such cases, initiating mechanical ventilation may prevent overt respiratory failure
and respiratory arrest. On the other hand, depression of respiratory drive from drug
overdose or from anesthesia involved with major surgery is an indication that
doesn’t involve primary respiratory system failure. Briefly, mechanical ventilation
is required when the patient’s capabilities to ventilate the lung and/or effect gas
transport across the alveolocapillary interface is compromised to the point that the
patient’s life is threatened.
table 1: Indications for mechanical ventilation
apnea
Acute ventilatory failure
Impending ventilatory failure
Severe oxygenation deficit

Modes and settings of mechanical ventilator:

A mechanical ventilator is a machine that generates a controlled flow of gas into a
patient’s airways. Oxygen and air are received from cylinders or wall outlets, the
gas is pressure reduced and blended according to the prescribed inspired oxygen
tension (FIO2), accumulated in a receptacle within the machine, and delivered to
the patient using one of many available modes of ventilation.
Ventilators are commonly described by which variable terminates the inspiratory
phase of the breath. They are either volume controlled, pressure controlled, flow-
cycled controlled or time controlled. In volume controlled modes, a desired tidal
volume is delivered at a specific flow (peak flow) rate. In pressure controlled
modes, flow occurs until a preset peak pressure is met over a specified inspiratory
period. Flow-cycled ventilators end inspiration when a predetermined flow rate is
achieved. Time cycled ventilator end inspiration after a selected inspiratory time
has been achieved.
table 2: Conventional modes of mechanical ventilator (8)
Mode Description
Controlled Preset tidal volume and rate; the
mechanical ventilator delivers the tidal volume
ventilation at the rate, and the circuit is closed
(CMV) in between these mandatory breaths
Assist-Control Preset tidal volume, minimum rate
(AC) – also called (control rate), and inspiratory effort
assisted required to “trigger” the ventilator
mandatory to cycle to assist breaths
ventilation (sensitivity); the ventilator delivers
the control breaths of the specified
tidal volume and responds by
cycling additionally if the patient’s
inspiratory effort (negative pressure
is adequate.
Synchronized Preset tidal volume and minimum
intermittent rate; the ventilatory circuit is open
mandatory between the mandatory breaths so
ventilation that the patient may take additional
(SIMV) breaths; because the ventilator does
not cycle to assist these breaths, the
tidal volume of these breaths varies.
Mandatory breaths are
synchronized so that they do not
occur during the patient’s
ventilatory efforts
CPAP When used as a mode of
ventilation, it describes a mode
without additional support.
Pressure support Preset inspiratory support pressure
ventilation (PSV) level; when the patient initiates a
breath, this positive pressure flows
to assist the patient’s spontaneous
breaths; tidal volume and rate are
patient controlled.
Comments
Patient must be apneic or paralyzed
or they “fight” the ventilator.
Guarantees ventilation with a
specific minute ventilation.
Allows ventilatory muscle rest.
More comfortable than control
mode.
Less work of breathing for patient
than spontaneous breathing or
SIMV.
Allows ventilatory muscle rest.
Risk for hyperventilation because
each assisted breath is delivered at
the same tidal volume as mandatory
breaths; sedation may be necessary
to decrease the number of
spontaneously triggered breaths
Allows muscle reconditioning better
than control or assist-control.
Less potential for hyperventilation
because patient-initiated breaths are
at the tidal volume determined by
the patient.
More work of breathing for patient
than assist-control because patient-
initiated breaths are not assisted.
Less need for sedation than assist-
control or control modes
Does not decrease cardiac output as
much as Assist-Control or Control
modes
Frequently used for weaning.
There is no preset ventilatory rate,
and apnea occurs if the patient does
not initiate a breath
Low level (5 – 10 cm H2O) helps to
eliminate the increased work of
breathing associated with an ET
tube; higher levels help to augment
the patient’s own intrinsic tidal
volume.
Lessens work of breathing but also
allows use of respiratory muscles to
lessen muscular atrophy.
Lower mean airway pressures than
volume ventilation.
 May be used with SIMV or alone; if
used alone, patient must be
spontaneously breathing.
table 3: Mechanical Ventilator settings (9)
settings Clinical considerations
Tidal volume The tidal volume is the volume of air delivered with each breath. Some of
the air in the tidal volume simply fills dead space in the lungs while the
remaining air ventilates the alveoli.
Tidal volume can be estimated at 5 to 10 ml/kg of ideal body weight; 5 – 7
ml/kg if poor lung compliance (for example from acute lung injury or
restrictive or obstructive diseases) is present.
Respiratory The number of breaths delivered per minute. This varies from 8 to 12 per
Rate minute.
The rate must be matched with the tidal volume to ensure an adequate
minute volume.
Fraction of Percentage of inhaled oxygen expressed as a decimal.
inspired air Initially the FiO2 is set a 1.0 (100%) and titrated downward based on blood
(FiO2) gas values.
The lowest FiO2 possible (50% or less) should be used to achieve the
desired PaO2 to avoid oxygen toxicity.
Sensitivity The amount of inspired effort required to initiate an assisted breath.
Usually set at -1 to -2 cm H2O
I/E ratio The ratio of inspiration and expiration time. The normal starting I:E ratio is
1:2.
If the patient has obstructive airway disease (i.e., COPD), then the ratio
should be reduced to 1:4 or 1:5 to avoid air trapping.
Peak Airway pressure at the peak of inspiration.
inspiratory
pressure
PEEP Airway pressure at the end of expiration.
It is used to increase the functional residual capacity or the amount of air
remaining in the lungs at the end of expiration. Increased PEEP helps keep
the alveoli open and improves gas exchange.
The maximum amount of PEEP allowed during transfer per MWLCEMS
System policy is 5 cm
Pressure Provides additional pressure during inspiration to ensure a larger Vt with
support (PS) minimal patient effort
Used to help overcome the work of breathing through ventilator tubing
Peak flow rate Maximum flow delivered by the ventilator during inspiration

Alarms
It is the critical care paramedic’s responsibility to ensure all ventilator alarms are
on prior to transfer. At no time will any of the alarms be turned off.
• High-pressure alarm: Alerts the paramedic that the ventilator has to use high
pressure to deliver the tidal volume. It is usually preset at 10 to 20 cm above the
peak airway pressure. Causes include:
1. Increase airway resistance: secretions; bronchospasm; kink in tubing;
displacement of artificial airway; patient coughing during inspiration; patient biting
on ET tube; water condensation in tubing
2. Decreased compliance: pneumothorax (sudden increase); development of
pulmonary edema, atelectasis, pneumonia, ARDS (gradual increase).
• Low-pressure alarm: Activated when the tidal volume falls below 50 to 100 ml
of the set tidal volume. Causes include disconnection in the circuit, cuff leak, &
leak in circuitry.
• Apnea: Always set when the patient is in CPAP or Pressure Support Mode. It
alerts the paramedic that the patient has stopped breathing. Patient should be
immediately disconnected and bagged with high flow oxygen. Causes include
patient fatigue, overmedication, and decrease in level of consciousness.
• Low FiO2: Alerts the paramedic that the oxygen source is disconnected or
depleted.

Complications
table 4: Complications of Mechanical Ventilation (10)
Complicatio Cause Prevention Treatment
n
Ventilator Barotrauma: high Avoid excessive tidal If pneumothorax
induced lung inflation pressures can volumes suspected, take patient
injury cause pneumo- Keep FiO2 less than off ventilator and
Thorax, pneumo- 0.6 (60%) manually ventilate with a
Mediastinum, or Adjust PEEP carefully manual resuscitation bag
subcutaneous notify medical control
emphysema and divert to closest
Volutrauma: high hospital.
inflation volumes and If tension pneumothorax
repeated end-expiratory suspected, take patient
collapse followed by off ventilator and
repeated reopening manually ventilate with a
during inspiration may manual resuscitation bag,
cause release of notify medical control
inflammatory mediators, for orders to needle
injury to the lung decompress and divert to
ultrastructure and ARDS the closest hospital
Aspiration Stomach contents Maintain cuff inflation Suction,
Tube feedings Keep head of bed If increased respiratory
Oral secretions elevated 30 to 45 distress or hypoxia
Gastric distention degrees disconnect from
Impaired gastric Check for gastric ventilator and provide
emptying retention manual ventilations,
Esophageal reflux Stop all gastric feeding Notify medical control
during transport
Infection Immunosuppression Use good hand- Supportive
Artificial airways bypass washing techniques
normal upper airway Use sterile technique
 defense mechanisms for suctioning
Ventilatory equipment is Keep head of bed
a warm moist elevated
environment is good for
bacterial growth
Suctioning procedure

Evaluation of mechanical ventilation in Egypt:

Patients subjected to mechanical ventilation (MV) in the Critical Care Department
focusing on epidemiological characteristics; the initial modes of ventilation used,
and initial settings. Study was to document final clinical outcomes of MV,
including length of stay, weaning, complications, and hospital mortality. Patients
and methods Patients’ data were collected retrospectively from January 2010 to
December 2014 (5 years) through reviewing an electronic database (Medica Plus). 
The study enrolled a total of 1081 patients. The duration of ventilation was 6±10
days, and length of ICU stay was 13±15 days. The predominant indications of
ventilation were cardiac diseases followed by respiratory diseases, neurological
diseases, sepsis, and septic shock. Volume controlled ventilation was the most
common initial mode of ventilation followed by Non Invasive Continuous Positive
Airway Pressure – Pressure Support (NICPAP-PS) and pressure controlled
ventilation. Noninvasive ventilation was associated with shorter duration on MV
and ICU stay
Table 5 Mortality and tidal volume, mortality and positive end-expiratory
pressure
Ventilator setting minimum Maximum Mean SD

Tidal volume 150.00 600.00 440.2840 76.59332

Pressure support 10.00 25.00 16.3302 1.46664

PEEP 0.00 22.00 4.4662 1.52844

Respiratory rate 12.00 30.00 15.5157 1.53665

FiO2 35.00 100.00 53.3858 10.58074

Prolonged ventilation and causes of mechanical ventilation Overall, 89.1% of

patients with cardiac diseases stayed for less than a week on mechanical
ventilation, 5.8% stayed for 2 weeks, 3.1% stayed for 3 weeks, and 2% stayed for
more than 3 weeks. In all, 57.7% of patients with respiratory diseases were
ventilated for less than a week, 18.8% stayed on mechanical ventilation for 2
weeks, 8.7% stayed 3 weeks, and 14.8% ventilated for more than 3 weeks. Overall,
84.3% of patients ventilated for sepsis and septic shock stayed on mechanical
ventilation for less than a week, 6.9% stayed for 2 weeks, 5.9% stayed for 3 weeks,
and 2.9% stayed for more than 3 weeks. Overall, 77% of patients with CNS
disorders ventilated for less than a week, 14.8% ventilated for 2 weeks, 2.7% for 3
weeks, and 5.5% ventilated for more than 3 weeks (P=0.0001).
Prolonged ventilation and mortality rate was 60.4% in patients ventilated for less
than a week, 79.2% in patients who stayed for 2 weeks on mechanical ventilation,
81.8% for patients ventilated for 3 weeks, and 71.2% for patients who stayed on
mechanical ventilation for more than 3 weeks (P=0.0001).
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