Mechanical Ventilation

Imtiyaz Ali
Lecturer, UTAR
Objectives
 Discuss goals of MV
 List indications of MV
 State uses of tracheal tubes and its drawbacks
 Understand principles of MV
 Describe common modes and advanced
modes of MV
 Discuss complications of MV
Goals of MV
 Maintain ABG’s
 Optimize V/Q
 Decrease Myocardial Workload
Indications
 Respiratory Failure
◦ Apnea / Respiratory Arrest
◦ Inadequate ventilation (acute vs. Chronic)
◦ Inadequate oxygenation
◦ Chronic respiratory insufficiency
Indications
 Cardiac Insufficiency
◦ Eliminate work of breathing
◦ Reduce oxygen consumption

 Neurologic dysfunction
◦ Central hypoventilation/ frequent apnea
◦ Patient comatose, GCS < 8
◦ Inability to protect airway
“8” Sets of Indications

1 Airway Airway protection

2 Breathing Apnea, Distress
3 Circulation Shock
4 Disability Low GCS
5 Arterial BloodGas PaO2<55mmHg,PaCO2< 50mmHg &
PH<7.32
6 Volume VC <10ml/Kg
7 Pressure Neg.Insp.Pr < 25cmH2O
8 Flow FEV1<10ml/Kg
Pearls
 No absolute contraindications exist to mechanical ventilation
 The need for mechanical ventilation is best made early on
clinical grounds
 A good rule of thumb - if the practitioner is thinking that
mechanical ventilation is needed, then it probably yes
 Waiting for return of laboratory values can result in
unnecessary morbidity or mortality
 ETT/Tracheostomy
 Patient and ventilator are connected
through a sealed tracheal tube (ETT
or tracheostomy tube)
 ETT through mouth or nose less
tolerable and may be used for upto 2
weeks
 Ttracheostomy tube is more
comfortable than ETT, but signifies
extra care for a newly created
tracheostomy
 Cuff of tracheal tubes are inflated to
prevent escape of ventilating gas,
and inhibits large volume aspirations
Drawbacks of tracheal tubes
 Communication disruption
 Swallowing dysfunction
 Risk of chest infection
 Tracheostomy complications
 Discomfort, over salivation, airflow
resistance, and damage to the trachea
& larynx (using ETT)
 Humidification of airway is required
Principles
 Triggering -The mechanism that starts the inspiratory phase
◦ How does the vent know when to give a breath? - “Trigger”
◦ Either the patient or ventilator can trigger inspiration
 Patient triggered (Patient effort)
◦ The patient’s effort can be “sensed” as a change in pressure
or a change in flow in circuit
 Ventilator triggered (Elapsed time)
◦ when a certain amount of time has elapsed
◦ e.g., 5 seconds if the rate is 12 [60 sec/12 b/m = 5 sec
Principles
 Cycling - How the ventilator ends the inspiratory phase of the
breath (inspiration cycles into expiration)
◦ Volume cycling – inspiration ends when a preset tidal
volume is delivered
◦ Pressure cycling – inspiration ends when a preset
pressure is reached on the airway
◦ Time cycling – inspiration ends when a preset
inspiratory time has elapsed
◦ Flow cycling – inspiration ends when a preset flow
has been reached
“8” Methods of Support
1. CMV

2. ACV

3. IMV

4. SIMV
5. PSV

6. PEEP

7. CPAP

8. BiPAP
Modes
 Control mode (CMV)
◦ Every breath is fully supported by the ventilator
Modes
 Assisted control mode (ACM)
◦ In newer control modes, machines may act in assist-control
◦ Ventilator supports with a minimum set rate and all triggered
breaths above that rate are also fully supported
Modes
 IMV mode
◦ IMV modes support breaths only at the set rate and interval
◦ If the set rate is 5, then every 12 seconds the patient will
receive a machine triggered breath
◦ In between those 5 breaths, the patient is free to breathe but
those breaths are not supported
Modes
Modes
 SIMV mode
◦ ventilator synchronizes IMV “breath” with patient’s effort
◦ Deliver preset breaths and volume in coordination with pt
respiratory efforts
◦ Limits barotrauma
Modes
Modes
 Pressure support
◦ ventilator supplies pressure support but no set rate i.e.,
ventilator may not give any breaths at all but support the
patient’s spontaneous efforts
◦ Can decrease work of breathing by providing flow during
inspiration for patient triggered breaths
◦ Can be given with spontaneous breaths in IMV modes or as
stand alone mode without set rate
Modes
Modes
 PEEP
◦ Boosts SaO2
◦ Prevents alveolar collapse
◦ Does not require patient to breathe
Advanced Modes
 Pressure-regulated volume control (PRVC)
 Volume support
 Inverse ratio ventilation (IRV)
 BiPAP/CPAP
Advanced Modes
 PRVC
◦ A control mode which delivers a set tidal volume
with each breath at the lowest possible peak
pressure
◦ Delivers the breath with a decelerating flow pattern
that is thought to be less injurious to the lung……
“the guided hand”
Advanced Modes
Advanced Modes
 Volume Support
◦ set a “goal” tidal volume
◦ the machine watches the delivered volumes and
adjusts the pressure support to meet desired “goal”
within limits set
Advanced Modes
 Inverse Ratio Ventilation
◦ Pressure Control Mode
◦ I:E > 1
◦ improves oxygenation
◦ Significant risk for air trapping
◦ Patient will need to be deeply sedated and perhaps
paralyzed as well
Advanced Modes
Advanced Modes
 Non invasive positive pressure
ventilation
◦ CPAP/BiPAP via tight fitting mask
◦ Decreased need for sedation and the ability
to avoid intubation
◦ NIPPV
 patients with obstructive sleep apnea at night
 As a bridge from mechanical ventilation
 patients with ARDS as a primary mode of support
Advanced Modes
Settings
 Ventilation & oxygenation matched to
patient according to PaCO2 & PaO2
values
 Adequate ventilation – Vt 450-600ml; RR
10-15pm; minute volume approx. 5-9L
 Minute volume adjusted according to
PaCO2
◦ Vt for small change
◦ RR for large change
 Inspired O2 concentration (FiO2) adjusted
according to PaO2
Settings
 Inspiratory flow rate related to I:E ratio
◦ 1:2 allows adequate CO2 clearance & venous return
◦ 1:4 prevents intrinsic PEEP
◦ 4:1 can prevent atelectasis by recruiting more alveoli
 PEEP
◦ 3-5 CmH2O
Complications
 Impaired cardiac  Breathlessness
output  GIT dysfunction
 Barotrauma  Excess secretions
 Increased dead  Gas trapping
space  Weakness of
 V/Q mismatch inspiratory muscles
 Fluid imbalance
 Discomfort
References
 Alexandra Hough. (3rd edition). Physiotherapy
in respiratory care: an evidence based
approach to respiratory and cardiac
management