Essentials of MV

(Basic level)

Abdelrhman Ali Aboshady

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

 Lung Mechanics & Graphics in ARDS

 Lung Protective Ventilation Strategy … ARDS Network Protocol

Optimal/Best PEEP

 Advanced TTT for moderate to severe ARDS

- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive /Salvage Therapies in ARDS

Severity of ARDS & TTT options
 Three Compartments of ARDS
A) Airspaces that are filled with exudates and Not
Recruitable Lung. Usually in the dependent regions.

B) Aerated normal lung

 susceptible to barotrauma induced by inappropriate
ventilation.
 Usually located in the nondependent regions.

C) Areas that are collapsed due to interstitial infiltration and

are Potentially Recruitable
Contents:
 Introduction

 Lung Mechanics & Graphics in ARDS

 Lung Protective Ventilation Strategy … ARDS Network Protocol

Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive /Salvage Therapies in ARDS

Compliance:
The relative ease of structure distension

ΔV
C=
ΔP
tidal volume Normal :
Cs = Spont. 50-100-170 mL/cm H2O
Pplat - PEEP Total PEEP
MV: 40 - 50 -100 mL/cm H2O

Decreased with:
• Mainstem Intubation
• Tension Pneumothorax
• Congestive Heart Failure
• Pleural Effusion
• ARDS
• Atelectasis
• Abdominal Distension
• Consolidation
• Chest Wall Edema
• Fibrosis
• Thoracic Deformity
• Hyperinflation
 Respiratory System Compliance

=
the compliances of both

Lung parenchyma
+
Thoracic structures.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
Changes In Compliance
Changes In Compliance during VCV
Lung Compliance Decreased

Set Tidal Volume

Maintained
Contents:
 Introduction

 Lung Mechanics & Graphics in ARDS

 Lung Protective Ventilation Strategy … ARDS Network Protocol

Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive /Salvage Therapies in ARDS

 Lung Protective Ventilation Strategy

- Choose PC-CMV, VC-CMV or PRVC for supporting oxygenation and

ventilation

- No evidence to date that PC-CMV is superior to VC-CMV, or vice versa.

- Start at 100% oxygen. Maintain SaO2 at 88% to 95% or greater.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
Lung Protective Ventilation Strategy

1) Low Tidal Volume (Vt).

& Limit Plateau Pressure (Pplat).
“ To prevent Lung OVERDISTENSION” “Volutrauma & Barotrauma”

2) Optimal PEEP
“ To keep the lung open and prevent ALVEOLAR COLLAPSE” “Atelectrauma”

3) Limit FiO2
“ To prevent Oxygen Toxicity”
 Lung Protective Ventilation Strategy
1) Low VT & Limit Pplat
- Lower VT to 4-6 ml/Kg of IBW.

- Keep P plateau < 30 cm H2O (In obese patients & stiff chest walls < 35 cm
H2O). By :
- ↓ Vt,
- Adequate sedation,
- Adjusting PEEP to optimal levels,
- Ruling out “Auto-PEEP”
- Ruling out pneumothorax or mucous plugging

- Increase RR to maintain VE esp. if muscle relaxant & heavy sedation are

used …… Auto PEEP may develop with ↑ RR.
J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Lung Protective Ventilation Strategy
1) Low VT & Limit Pplat

- Consider “Permissive Hypercapnia”

- Allow PaCO2 to rise above normal (but pH > 7.3) if necessary,
- Contraindications:
↓ COP – ↑ ICP – Epilepsy - Hyperkalemia.
- If pH became < 7.15 → consider NaHCO3.
- As patient clinically improves, Change Ventilation settings to correct
hypercapnia.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
ARDS Network Protocol
ARDS Network Protocol: Initial settings
ARDS Network Protocol: Initial settings
a. Calculate PBW
 Males: 50 + 0.9 [ht in cm –152.4]
 Females: 45.5 + 0.9 [ht in cm –152.4]
 Thepredicted body weight is calculated based on height and is
usually lower than the actual body weight.

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
ARDS Network Protocol: Initial settings
b. Select mode:
 PCV or ACV are preferred as initial modes.

c. Set initial Vt
 6ml/kg PBW (if current Vt > 8ml/kg PBW).

d. Set initial FiO2

1 even if no refractory hypoxemia.
ARDS Network Protocol: Initial settings

e. Set respiratory rate

 16-20 bpm

f. Set moderate to high PEEP

 8-10 cmH2o.

g. Set inspiratory flow rate

 above patient demand (usually > 80L/min)
 This is an extremely important step to prevent patient ventilator
dyssynchrony. These patients usually have a very high minute
ventilation, as high as 15-20 L/min.
ARDS Network Protocol: Initial settings
Initial PEEP settings
• PEEP is used to reverse hypoxemia and atelectasis .
• Goal of PEEP is to recruit (or maintain recruitment of ) atelectatic or flooded
lung.
• Three large multicenter randomized trails have tested higher versus lower
PEEP while limiting tidal volumes in all patients:
– ALVEOLI Trial (Assessment of Low tidal Volume and elevated End-expiratory volume to
Obviate Lung Injury).
– ExPress Trial (Expiratory Pressure),
– LOVS Trial (Lung Open Ventilation Study).
ARDS Network Protocol: Initial settings
Initial PEEP settings

• No significant improvement in mortality .

• Express trial found an improvement in ventilator free days.

• Meta-analysis of the trials:

– Modest reduction in mortality for patients with moderate and severe ARDS
in the higher PEEP arms
ARDS Network Protocol: Initial settings
Monitoring
 Every 4 hours and or after any change in PEEP and Vt check:
 Plateua pressure (0.5 second inspiratory pause)
 pH (if available)
 SpO2
 RR
 Vt

 Monitoring lung mechanics, RR and pH is fundamental until goals are achieved

and maintained.
ARDS Network Protocol: Initial settings
Goals and targets
A) OXYGENTATION Goal:
PaO2 55 – 80 mmhg or SpO2 88-95%;

B) PLATEAU PRESSURE Goal:

</= 30 cm H2O

C) pH Goal:
7.30-7.45
ARDS Network Protocol: Initial settings
Goals and targets
A) OXYGENTATION GOAL:
 PaO2 55 – 80 mmhg or SpO2 88-95%; Use incremental FiO2/PEEP combinations below to
achieve goal
ARDS Network Protocol: Initial settings
Goals and targets
B) PLATEAU PRESSURE GOAL:
 </= 30 cm H2O
 If Pplat > 30 cm H2O :
 decrease Vt by 1ml/kg steps (minimum = 4ml/kg).
 If Pplat < 25 cm H2O :
 Vt < 6ml/kg, increase Vt by 1ml/kg until Pplat > 25 or Vt = 6 ml/kg.
 If Pplat 25-30 cm H2O :
 keep same Vt
 If Pplat < 20 cm H2O & breath stacking occurs:
 may increase Vt in 1ml/kg increments (maximum =8ml/kg), sedation and paralysis might be
considered
ARDS Network Protocol: Initial settings
Goals and targets
C) pH goal:
 7.30-7.45

 Acidosis management: (pH < 7.30)

 If pH 7.15 – 7.30: Increase RR until pH > 7.30
 If pH < 7.15: Increase RR to 35. If pH remains < 7.15 & NaHCO3 might be
considered .

 Alkalosis management: (pH > 7.45)

 Decrease ventilator rate if possible.
ARDS Network Protocol: Initial settings
Goals and targets

 Permissive hypercapnia
 A Limitation of low VT or inspiratory pressure used to protect the lungs
against excessive mechanical stretch.
 the PaCO2 was allowed to become elevated.

 it was considered thatmoderate hypercapnia was not necessarily a harmful

entity but was worth tolerating in order to spare physical ventilator-induced
lung injury (VILI) .
 Lung Protective Ventilation Strategy
2) Optimal PEEP

- Use PEEPe at a level that prevents alveolar collapse but minimizes

overdistention to prevent lung damage. High PEEP levels >15 cm H2O
may be required in ARDS. “Open Lung Approach”

- When oxygenation is inadequate, sedate, paralyze, and change patient

position. Cardiac output and hemoglobin levels should be optimized.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
Lung Protective Ventilation Strategy
2) Optimal PEEP
1) Using the PEEP table provided by ARDSNet:
(High-PEEP or low-PEEP strategy).
Lung Protective Ventilation Strategy
2) Optimal PEEP
1) Using the PEEP table provided by ARDSNet:
(High-PEEP or low-PEEP strategy).

-No difference in terms of survival, but a high-PEEP strategy is associated with

improved oxygenation.

- If ↑ PEEP failed to correct or worsened oxygenation → Cardiac shunts or

unilateral Lung disease ………. Those patients are managed by: limiting PEEP,
prone positioning, and pulmonary vasodilators.
Lung Protective Ventilation Strategy
2) Optimal PEEP
2) The lowest level of PEEP that results in the Maximum Recruitment
of alveoli without overdistension (Highest Static Compliance).
▪ Measured by adding/reducing PEEP in small increments and calc. of Cst.
VT
▪ Cst = Pplat - PEEP
Optimally distended

Over distended

Cst

PEEP
5 10 15 20 (cmH2O)
P-V relationship curve…..loop
Contents:
 Introduction
 Lung Mechanics & Graphics in ARDS
 Lung Protective Ventilation Strategy … ARDS Network Protocol
Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive /Salvage Therapies in ARDS

Contents:
 Introduction
 Lung Mechanics & Graphics in ARDS
 Lung Protective Ventilation Strategy … ARDS Network Protocol
Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive Therapies in ARDS

Adjunctive Therapies in ARDS
Neuromuscular Blocking Agents:
▪ Early (1st 24-48 hours)
▪ Moderate to Severe ARDS
▪ Short duration (24-48 hours)
▪ Especially in Asynchrony patients

▪ Effects:
Improved Mortality,
same ICU myopathy.
Contents:
 Introduction
 Lung Mechanics & Graphics in ARDS
 Lung Protective Ventilation Strategy … ARDS Network Protocol
Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive /Salvage Therapies in ARDS

Prone Positioning
Prone Positioning

Indications
 Moderate to severe ARDS with P:F ratio < 150 mmHg and FiO2 ≥ 0.6

 Early (ideally < 48 hours) following 12-24 hours of MV allowing for TTT optimization.

 for 16 or more hours per day

 Best outcomes achieved using tidal volumes of 6ml/kg predicted body weight and
consider the use of neuromuscular blocking drugs if there is evidence of ventilator
dys-synchrony.
Prone Positioning
Contraindications
Absolute:

• Spinal instability

• Open chest post cardiac surgery/trauma

• <24 hrs post cardiac surgery

• Central cannulation for VA ECMO or BiVAD support

Prone Positioning
Contraindications
Relative:
• CVS instability despite resuscitation with fluids and inotropes
• Morbid obesity
• Pregnancy 2nd/3rd trimester
• Multiple Trauma e.g. Pelvic or Chest fractures, Pelvic fixation device
• Severe facial fractures
• Head injury/Raised intracranial pressure
• Frequent seizures
• Raised intraocular pressure
• Recent tracheostomy <24hrs
• Previously poor tolerance of prone position
Prone Positioning
Procedures .. Supine to Prone
Contents:
 Introduction
 Lung Mechanics & Graphics in ARDS
 Lung Protective Ventilation Strategy … ARDS Network Protocol
Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive /Salvage Therapies in ARDS

Lung Recruitment Maneuvers
 Definition:

A Recruitment Maneuver is a procedure where a sustained positive pressure

is applied, to an injured lung, over an increment of time, to recruit, keep
open closed alveoli.

 Importance:
 Improve oxygenation and improve shunts.
 Help to improve ventilation,
 To try and determine the “Optimal PEEP” to keep the lung from dynamic
collapse and alveolar de-recruitment...
Lung Recruitment Maneuvers
Indications:
 Moderate-Severe ARDS
 Early in ARDS (before the onset of fibro-proliferation)
 More benefit in 2ry > 1ry ARDS
 Patients with Alveolar Collapse/consistent Atelectasis.

Contraindications:
 Hemodynamic instability
 Emphysematous bullae
 Pneumothorax
 Unilateral lung dis.
Contents:
 Introduction
 Lung Mechanics & Graphics in ARDS
 Lung Protective Ventilation Strategy … ARDS Network Protocol
Optimal/Best PEEP
 Advanced TTT for moderate to severe ARDS
- Muscle relaxation

- Prone Position

- Recruitment Maneuvers

- Adjunctive/Salvage Therapies in ARDS

Adjunctive/Salvage Therapies in ARDS

▪ Airway Pressure Release Ventilation (APRV)

▪ Inhaled Pulmonary Vasodilators: …. Salvage

Improved O2, same Mortality.

▪ Extracorporeal Membrane Oxygenation (ECMO):

uncertain
Thank You
Dr.abderhmanali@gmail.com
Abdelrhman.aboshady@med.menofia.edu.eg