Webinar Series No.

Managing a Mechanically
Ventilated Patient
 OBJECTIVES
1. Discuss mechanical ventilator adjustment
in specific pulmonary disease state.

2. Discuss weaning parameters or criteria for

successful extubation.
 Acute Respiratory Distress
Syndrome (ARDS)
- A life-threatening form of respiratory failure
characterized by inflammatory pulmonary edema
resulting in severe hypoxemia

- Caused by direct and indirect factors

- AECC criteria (1994) and Berlin Criteria (2012)

 AECC vs Berlin Criteria for ARDS
Evaluation AECC (1994) ARDS (2012)
Parameter
1. Timing Acute Onset Risk factor to ARDS
development: within 7 days
2. Oxygenation PaO2/FiO2 ratio: PaO2/FiO2 ratio:
ALI: ≤300 mmHg Mild: 201 - 300 mmHg
ARDS: ≤200 mmHg Moderate: 100-200 mmHg
Severe: <100 mmHg
Note: Regardless of PEEP
level Note: PEEP ≥ 5 cmH2O
3. Chest Bilateral chest infiltrates on Bilateral chest infiltrates not
Radiograph frontal radiograph explained by effusion,
collapsed lung or lung nodule
4. PCWP ≤18 mmHg when measured REMOVED from the criteria
(PCWP) or no clinical evidence of left
atrial hypertension
CXR of an ARDS patient
 Clinical Practice Guidelines
• Strong recommendations FOR treatment of ARDS
– Tidal Volume: 4-8 ml/kg of predicted body weight
– Maintain plateau pressure <30 cmH2O
– Prone positioning for severe ARDS (>12 hours/day)

• Strong recommendations AGAINST treatment for ARDS

– Routine use of HFOV for moderate to severe ARDS

• Conditional recommendation FOR the treatment of ARDS

– Higher PEEP in moderate to severe ARDS
– Recruitment maneuvers in patients with moderate to severe ARDS
CPG: Low Tidal Volume and Prone Positioning

• Strong recommendations FOR treatment of ARDS

– Tidal Volume: 4-8 ml/kg of predicted body weight
• Suggestive of relative risk reduction of mortality by
30%

– Maintain plateau pressure <30 cmH2O

– Prone positioning for severe ARDS (>12 hours/day)

• PROSEVA (Proning in Severe ARDS) Trial – ET
obstruction and pressure sores
• Risks vs Benefits: Favors the intervention
CPG: High Frequency Oscillatory Ventilation

• Strong recommendations AGAINST treatment for

ARDS
– Routine use of HFOV with moderate to severe
ARDS

• Six RCTs (1,715 patients)

• Excluded trials that used other interventions (higher
PEEP) or did not mandate lower tidal volumes
• Analysis: No significant difference in mortality,
oxygenation in 24 hours and carbon dioxide tension
at 24 hours
CPG: Higher PEEP and Recruitment
Maneuvers
• Conditional recommendation FOR the treatment of
ARDS
– Higher PEEP in moderate to severe ARDS
– Recruitment maneuvers in patients with moderate to
severe ARDS

• Eight RCTs: P/F ratio (oxygenation) was significant

higher in higher PEEP patients
• IPDMA of 3 RCTs: Significant lower mortality with no
significant effect with mild ARDS
 Ventilation Strategy in ARDS
• Keep PaO2 over 55 mmHg

• Avoid volutrauma or barotrauma by keeping tidal

volumes in the 4-8 ml/kg range and airway plateau
pressures below 30 cmH2O

• Peak airway pressure (PAP or PIP) 20-40 cmH20 or

<20 cmH20 above PEEP

• Preventing alveoli decruitment with PEEP application

 Initial Settings for ARDS
(based from ARDSNET)

1. Volume-controlled ventilation
2. Assist/Control Mode
3. Keep PPLAT <30 cmH2O (reduce as low as 4ml/kg
PBW to reach PPLAT target.
4. Set initial rate: (20-35/min)
5. Set the PEEP using FiO2/PEEP combination to
obtain O2 sat of >88%.
FiO2 % 30 40 50 60 70 80 90 100
PEEP (cmH2O) 5 5-8 8-10 10 10-14 14 16-18 20-24
Goals in Mechanical Ventilation: ARDS
• Oxygenation Goal:
– PaO2: 55-80 mmHg or SpO2: 88 – 95%
– Use of minimum PEEP of 5cmH2O

• PPLAT Goal: < 30 cmH2O

– Check plateau pressure (0.5 inspiratory pause) at least 4 hours
and after each change in PEEP and VT

– If Pplat > 30 cm H2O: decrease VT by 1ml/kg steps (minimum =

4 ml/kg).

– If Pplat < 25 cm H2O and VT< 6 ml/kg, increase VT by 1 ml/kg

until Pplat > 25 cm H2O or VT = 6 ml/kg.
– If Pplat < 30 and breath stacking or dyssynchrony occurs: may
increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat
remains < 30 cm H2O.
Goals in Mechanical Ventilation: ARDS
• pH Goal: 7.30 – 7.45
– Acidosis Management: (pH < 7.30)
• If pH 7.15-7.30: Increase RR until pH > 7.30 or
PaCO2 < 25 (Maximum set RR = 35).

• If pH < 7.15: Increase RR to 35.

• If pH remains < 7.15, VT may be increased in 1 ml/kg
steps until pH > 7.15 (Pplat target of 30 may be
exceeded). May give NaHCO3

– Alkalosis Management: (pH > 7.45) Decrease vent rate if

possible.
 Weaning for ARDS
(based from ARDSNET)

A. Conduct a SPONTANEOUS BREATHING TRIAL

daily when:
1.FiO2 ≤ 0.40 and PEEP ≤ 8 OR FiO2 < 0.50 and
PEEP < 5 cmH2O

2.PEEP and FiO2 ≤ values of previous day.

3.Patient has acceptable spontaneous breathing

efforts.
4.Systolic BP ≥ 90 mmHg without vasopressor
support.

5.No neuromuscular blocking agents or blockade

 Weaning for ARDS
A. SPONTANEOUS BREATHING TRIAL (SBT):
SBT of UP TO 120 minutes of with FiO2 < 0.5 and PEEP < 5:
1. Place on T-piece, trach collar, or CPAP ≤ 5 cm H2O with PS < 5
2. Assess for tolerance as below for up to two hours.
a. SpO2 ≥ 90: and/or PaO2 ≥ 60 mmHg
b. Spontaneous VT ≥ 4 ml/kg PBW
c. RR ≤ 35/min
d. pH ≥ 7.3
e. No respiratory distress (distress= 2 or more)
HR > 120% of baseline
Marked accessory muscle use
Abdominal paradox
Diaphoresis
Marked dyspnea
3. If tolerated for at least 30 minutes, consider extubation
4. If not tolerated, resume pre-weaning strategies
 COPD/Asthma and Mechanical
Ventilation
• Expiratory flow Limitation

• Dynamic Hyperinflation

• Auto-PEEP
 Ventilation Strategy in
COPD/Asthma
Volume Controlled Ventilation
• Increase flowrate (peak inspiratory flow rate)
– Monitor for PIP vs Plateau Pressure
• Decrease tidal volume*
– Decrease I time and increase E time
• Decrease respiratory rate*
– Extend respiratory cycle time and Increase Expiratory time
• Decrease percent inspiratory time (I time %)
• Application of PEEP to reduce Auto-PEEP effects
Note: *Decreases minute ventilation

Pressure-Controlled Ventilation
• Shorten Inspiratory Time
 Ventilator Strategy in COPD patient
Parameter Change I Time E Time I:E ratio
Increase flow rate Decrease Increase Increase
Decrease tidal volume Decrease Increase Increase
Decrease f Minimal Increase Increase
change

I Time % and I:E ratio Equivalent

I time % I:E ratio
14.3% 1:6
16.7% 1:5
20% 1:4
25% 1:3
33.3% 1:2
50% 1:1
60% 1.5:1
66.7% 2:1
 Initial Settings for COPD

1. Volume-controlled ventilation
2. Assist/Control Mode
3. Tidal Volume: 6-8 ml/kg of PBW
4. Set initial rate: 10-12/min
5. Set Peak Inspiratory Flow Rate: 60 – 120 L/min
6. Set PEEP: 85% below the level of auto-PEEP if
needed
Weaning From Mechanical Ventilation
• Steps to liberate
– Readiness for ventilation discontinuation
– SBTs
– Evaluation of SBTs
– Extubation

• Strategies to quickly and safely liberate patient from

mechanical ventilator
– Fluid Status
– Weaning protocols
– Choice of Sedatives
– Physical Therapy and occupational therapy
– NIV adjunct to early liberation
Weaning From Mechanical Ventilation
• Two reasons patients are not withdrawn from the
ventilator
– Patient is too sick
– Clinician is not attempting to get patient off the ventilator

• Failure to recognize ventilator withdrawal process

– Longer stay
– Higher cost
– Excessive sedation
– Longer exposure to high airway pressures/volumes
– Increased infection risk
Weaning From Mechanical Ventilation
Steps To Liberate
Steps To Liberate
Steps To Liberate
Steps To Liberate
Steps To Liberate
Steps To Liberate
 Steps To Liberate

Readiness for ventilation discontinuation

Parameter Threshold
Respiratory Rate <30/min
Minute Ventilation <10 L/min
Vital Capacity > 10 ml/kg
Maximum inspiratory pressure < - 25 cmH2O
(MIP)
Rapid Shallow Breathing index <100 breaths/min/L
Steps to Liberate
Steps to Liberate
Steps to Liberate
Steps to Liberate
Steps to Liberate
Steps to Liberate
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation
Weaning from mechanical Ventilation