Essentials of MV

(Basic level)

Abdelrhman Ali Aboshady

Assistant Lecturer of Critical Care Medicine
Menoufia University
Contents:
 Indications

 Goals of MV

 Selecting the patient interface (Invasive Vs NIV)

 Mode selection (Full Vs partial ventilatory support, Control variable)

 Initial Settings for Normal Lung

 Initial Settings for Abnormal Lung

Initiation of MV

You must answer these questions:

Indications Goals

Interface Lung Pathology Duration Support level

Location Staff training

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
Indications
Of MV
Indications Of MV
1) Apnea or Respiratory Arrest ( e.g. General Anesthesia, post cardiac arrest)
2) Acute hypercapnic respiratory failure (Type II)
(Can’t ventilate = high PaCO2 > 50 mm Hg and rising
…… despite initial TTT lines)
3) Acute hypoxemic respiratory failure (Type I)
(Can’t oxygenate = low PaO2 below the predicted normal range for the
patient’s age ……. despite initial TTT lines)
4) Unacceptably high WOB “Impending ventilatory failure”
5) +/- Hemodynamic compromise ; Refractory shock
6) +/- Can’t protect airway (e.g. GCS < 8)
Indications Of MV

Although ventilators have been used for more

than half a century,

surprisingly

little evidence and few precise criteria

are available to guide clinicians about when to

initiate ventilatory support.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
Indications Of MV

If you’re not sure

whether or not the patient needs a ventilator,

the patient needs a ventilator.

Goals
of MV
 Goals of Mechanical Ventilation
Minimize the risk of
Lung Injury
Faster
Weaning
Adequate pulmonary
Gas Exchange

Reduce patient
WOB
Maintain
Spontaneous
Breathing Optimize patient
Comfort
Invasive VS NIV
Choice of Interface
Full Vs. Partial
Ventilatory Support
( FVS Vs. PVS )
 Full Vs. Partial
Ventilatory Support
( FVS Vs. PVS )
 FVS ; ventilator provides all
the energy necessary for
alveolar ventilation

 PVS; the patient must

actively participate in
ventilation
Mode Selection …. Control Variable

VCV PCV
is based on whether
Consistency Limiting of
of TV pressure
delivery is or delivery is
important important.

Advantages Vs. Disadvantages

Initiation of MV

You must answer these questions:

Indications Goals
6 6

Interface Lung Pathology Duration Support level

3
Location Staff training

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
 Initial
Ventilator Settings
of Normal Lung
Initial Ventilator Settings 1) During VCV
1) Minute Ventilation ( VE )
Men VE = 4 × body surface area (BSA) 100 ml/Kg/minute
Women VE = 3.5 × BSA
BSA = 0.007184 × Ht in cm 0.725 × Wt in Kg 0.425
BSA is usually around 2.1

Increase This by
10% /°C above 37° C
20% for metabolic acidosis

Decrease This by
10% /°C between 35° C and 37° C

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
Initial Ventilator Settings 1) During VCV
2) Tidal Volume (TV)
- Minimum of 6 mL/kg IBW
- Maximum of 8 mL/kg IBW
Predicted BW in: Male = 50 + 2.3 (ht [in] – 60) kg
Female = 45.5 + 2.3 (ht [in] – 60) kg
Height Male Female
150 cm 50 Kg 46 Kg
155 cm 52 Kg 48 Kg
160 cm 57 Kg 52 Kg
165 cm 61 Kg 57 Kg
170 cm 66 Kg 61 Kg
175 cm 70 Kg 66 Kg
J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
 Initial Ventilator Settings 1) During VCV
3) Respiratory Frequency (f)
f = VE/ VT

Typically 12 - 18 breaths / minute

4) Flow, Inspiratory Time & I-E ratio

 Flow : 30-45 L/Min
 Inspiratory time : around 1 sec
 I:E : 1:2-3

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
Initial Ventilator Settings 1) During VCV
5) Flow Patterns:
Initial Ventilator Settings 1) During VCV
6) Inspiratory Pause:

- To obtain measurements of P plateau >> for C static calculation

- To improve the distribution of air throughout the lungs regardless of the type
of flow pattern used
- Provides a longer TI >> optimum V /Q matching and reduces VD/VT ratios

- Must be used with care, or not at all, in patients with COPD and flow
limitation.
- Not commonly used with each breath in clinical practice because it may
significantly increase Paw and reduce pulmonary blood flow.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
Initial Ventilator Settings 2) During PCV
1) Determine VE & VT as described for VC-CMV.

2) Set pressure to achieve target VT ( 2 methods )

1 - Start at a low pressure (10-15 cm H2O) and
check the VT before readjusting pressure
or 2 - VCV breath .. P plateu (or PIP-5) = P ins

3) Set frequency to achieve the same VE.

f = VE / VT

4) Set I : E ratio of greater than or equal to 1 : 2.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
 Initial Ventilator Settings 3) During PSV
Level of Ps :
- Set pressure to achieve a target VT as described for VC-CMV.
- Levels of 8 to 14 cm H2O are typically used

Baseline Pressure ….. PEEP

Use minimum levels of PEEP (3 to 5 cm H2O) (Physiological PEEP)to :

- Preserve a patient’s normal FRC.

- Avoid atelectasis.

- Compensate for AutoPEEP in COPD with spontaneous breathing

Backup Mode Settings

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
 Initial Ventilator Settings 3) During PSV
Setting Rise Time & Expiratory Trigger
It is advisable to use graphic monitoring to help making adjustments
- Rise time ….. mostly 50-200 mSec
- Expiratory trigger ….. mostly 25%

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
 Setting FIO2
- Many practitioners start with an FiO2 of 1.0
and then reduce it as quickly as possible.

- If PaO2 is within the desired range before beginning ventilatory support on

specific FIO2, use same FiO2 to initiate MV.

- Titrating …… pulse oximetry and ABG

- FIO2 > 0.50 ……. Consider PEEP.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth)
 Initial
Ventilator Settings
of Abnormal Lung
 Obstructive Vs Restrictive
Air trapping/AutoPEEP Barotrauma

 RR …. Decrease  RR …. Increase
 Tv …. 6-8 ml/kg  Tv …. 6-8 ml/kg
 Ti …. Decrease  Ti …. Increase
 Flow … Increase  Flow … Decrease
 T pause …. Decrease/No  T pause .. Increase
 I:E …. Decrease  I:E …. Increase
Thank You