MECHANIC

VENTILATION
.
VENTILATIO
NADVANCED AIRWAY.
WHAT IS MECHANICAL VENTILATION?

Artificial respiration process that uses an apparatus or

device located in the trachea, connected to a source of
oxygen to help or replace respiratory function.

Inflated
cuff

Red blood cells carry oxygen to

the rest of the body
G=Gas source; S=separator; H=humidifier; P=manometer
VE=flow sensor (measurement C=gas system

General diagram of a respirator.

 Airway management
• Devices Head
extension.
Elevation of
• Non-invasive: the
Nasal Tips Vá Mask
Mask
Venturi
Mask Valve Bag

• Invasive

• Temporary: Oropharyngeal and nasal cannulas, masks and

nasal tips

• Definitive: Orotracheal intubation. Tracheostomy.

 MECHANIC
VENTILATION
Ventilation Criteria ➢ -Burn of the airway.
Neurological deficit ➢ -Anesthesia.
Respiratory difficulty ➢ RR -Asthma.
>36 <8
➢ PaO2 <50 and PaCO2 >50
➢ pH < 7.2
➢ Chest wall instability
➢ > ICP
VENTILATIO
N
Neck Thorax Burns

NEUROLOGICAL EVC TCE HSA

RESPIRATORY

Primary: Pneumonia, ARDS

Secondary: Drugs, Medullary
 VENTILATIO
N of
Sequence Moment • Pass
I ntubation ed
fast
• 0 < 10 min
Method that Preparation

involves the use

of a blocker • 0 < 5 min
neuromuscular and P reoxygenation
sedative agents
and hypnotics, which • 0 < 2 min

limit the P retreatment

Adverse effects
to laryngoscopy paralysis
and intubation . •0

• 0+30-45 sec Passage of

TET
VENTILATIO
N
CLASSIFICATION: VOLUME.
- Controlled VM.
➢ Pressure cycled
- Assisted VM.
➢ Volume cycled ➢
- Positive pressure at
Controlled. the end of expiration.

➢ -Mandatory intermittent
Assisted. ventilation.
VENTILATIO
N
FIO 2

BREATHING FREQUENCY
TIDAL VOLUME (VT) PEEP
PEAK FLOW SENSITIVITY
INSPIRATORY TIME (I:E RATIO)
ALARMS
VENTILATIO
N
REQUIREMENTS OF
VENTILATION

CURRENT VOLUME VcHighs >10

VmclM/kegdios . . . 8 - 10ml/kg
Low Vc .......... 6 – 7
ml/kg

RESPIRATORY RATE 12 – 16 c/min **

Restrictive pathology:
Fcias. high
VENTILATIO
N
FiO2 ......... < 60% Ideal
•
R O E 2 QUERIMENTS
OF
FiO2 ............ 100 %

Emergencies

REQUIREMENTS OF
SECURITY
VENTILATIO
N
ALARMS. . . Depression
 VENTILATIO
N
PULMONARY MECHANICS REQUIREMENTS

RESPIRATORY PRESSURES

P plateau : < 35 cmH2O

P peak : < 45 cmH2O

I/E RATIO
VENTILATIO
N
Insp Time 25%. .
 MECHANICAL
VENTILATION
MODALITIES
MEDIUM
TOTAL VENTILATORY
VENTILATIO
N
VMC: Controlled VM

VMAC: Controlled Assisted VM

IRV: VM with Inverted I/E

 MECHANIC VENTILATION

CONTROLLED.
CONTROLLED MECHANICAL V ENTILATION.
Introduction.
- Total ventilatory support.
- According to the patient's respiratory ■
pattern.

-Programmed respirations: Yeah

The patient does not start the
ventilator.

- It is programmed: duration, amount,

morphology, gas delivered.
 MECHANIC VENTILATION

CONTROLLED.
CONCEPTS.
- VC with positive pressure.
- Scheduled flows.
-Independent of the patient.
- The patient's ventilatory
impulse is suppressed.
-VC ventilation.
Scheduled.
-VP ventilation.
Pressure interacts with
 MECHANIC VENTILATION

CONTROLLED.
Key points.
VMC- gas delivery is scheduled.
- The patient has no ventilatory
impulse.
- The atrophy
respiratory muscle.
-Complete breathing control: FiO2,
VC, FR, TI.
-Maintain the patient with FIO2>
90%.
-Gasometric control.
-Program volume and pressure
pressures.
 MECHANIC VENTILATION

CONTROLLED.
GOALS.
-SO2 >90%.
-Adequate alveolar
ventilation.
-Comfortable patient.
-Plateau pressure >35 cmH2O.
Normal parameters.
FIo2-.4-1
VC 8-12 ml/Kg.
FR12-14.
 MECHANIC VENTILATION

CONTROLLED.
Physiopathological bases.
-Full support.
- Automatic respiratory start. 60/FR.
- Scheduled gas provision, according to treatment objectives.
- Indications: Absence of ventilatory impulse or suppression
thereof.

Complications.
- Muscular dystrophy, 24-48 hrs.
 MECHANIC VENTILATION

CONTRO
MONITORING.
-Clinical: rib cage expansion.
Synchrony of muscles with
ventilation.

Lung auscultation.

Alarms.
 VENTILATIO
•

• N
CONTROLLED MECHANICAL VENTILATION
INDICATIONS
•
Respiratory faliure
•
CNS depressant poisoning
•
Brain death - Eat
•
General anesthesia
•
TCE.

•
DISADVANTAGES
•
Sedation necessary Atrophy
•
respiratory muscles
 MECHANIC VENTILATION

ASSISTED.
Introduction.

-The patient's ventilatory impulse is not

suppressed.

-Programming of supply pattern according

to patient requirements.

-Initial ventilation in patients with

respiratory failure
VENTILATIO
N
VENTILATION
ASSISTED MECHANICAL

INSPIRATORY FLOW
Peak Tidal Volume Flow

TRIGGER LEVEL
- 0.5 a - 1.5
cmH2O
 MECHANIC VENTILATION

ASSISTED. Trigger: activates

inspiratory gas flow with
Key points.
programmed response
-The respirator is sensitive to time.
the patient's inspiratory
efforts

- If the effort is not detected -Careful programming of

within a programmed time, the
ventilator will start the TRIGGER sensitivity.
programmed cycle (controlled
MV assist).
- Gas provision is programmed -Continuous monitoring.
and not modified by the
patient's needs.
 MECHANIC VENTILATION

-Frequency of combined
ASSISTED. mechanical ventilation.
Concepts.

-Mechanical ventilation with - Scheduled gas delivery

positive pressure: programmed pattern.
gas flow in response to the
patient's inspiratory effort.
- Almost complete level of
-If no inspiratory effort occurs
ventilatory support
within a programmed time0 (60
sec./ FR): control period
.........................
programmed gas flow is
activated.
 MECHANIC VENTILATION
ASSISTED.
Trigger and Demand Valve.

-Ventilator sensitive to inspiratory effort.

-Sensors that activate when a pressure drop is detected
in the respiratory circuit.
The sensitivity level is programmed according to the
patient's needs.
-More sensitive trigger with less
negative pressure.
-Trigger sensitivity higher than self-
trigger -.5
-1.5 cmH2O.
-Trigger: acts on PEEP level.
Inspiratory valve opening.
-Long response times require
 ASSISTED MECHANICAL VENTILATION.
Respiratory work in VMA.
-The patient can trigger breathing by overcoming additional loads.
-Resistance imposed by tracheal tube, humidification systems and
inspiratory valve.
-Can lead to muscle fatigue.
-Adjust flow to patient needs.
-Correct factors that increase trigger sensitivity: adequate tube,
airway obstruction, pulmonary edema, PEEP,
 VENTILATIO
N
PARTIAL VENTILATORY SUPPORT
•
IMV: Vent. Intermittent Mandatory

PS: Pressure Support

CPAP: Positive Pressure

Continue on the airway
 ASSISTED MECHANICAL VENTILATION.
Basic monitoring.
-Clinical chart.
-Assess adaptability- synchrony.
-FR, expired MV.
-Blood gases.
-Ventilatory mechanics: ventilation curves
flow, airway pressure, pressure
esophageal,
-Airway pressure alarms,
Exhaled minute volume.
 MECHANIC VENTILATION

ASSIST CONTROLLED.
VMAC programming.
-Patients maintain ventilatory impulse.
-Gas delivery according to demands.
-Gas flow programmed according to needs.
-Variables: trigger sensitivity and peak inspiratory
flow.
-Trigger .5- 1 cmH2O, 1.3
l/m, PF > 60 l/m.
 MECHANIC VENTILATION

ASSIST CONTROLLED.
Clinical and pathophysiological bases.

-ADVANTAGES: Security or sensitivity is not

of VMC synchronized adequate.
with patient -In awake patients:
respiratory effort. asynchrony.
-Ensures ventilatory -Exertion can cause
support. alkalosis
-Reduces sedation
needs.
-Prevents muscle
atrophy.
DISADVANTAGES:
excessive work if
respiratory drive is
high and peak flow
 VENTILATIO
N
INTERMITTENT
MANDATORY
VENTILATION
ADVANTAGES
Lower Barotrauma Risk
Increase IC

DISADVANTAGES
Hyper – Hypo ventilation
Increased work Resp
“ WEANING
VENTILATION
MECHANICS
VENTILATIO
N VM
ALTERNATIVE
SEDATION.
RESPIRATORY ACTIVITY DEPRESSION

ANALGESIA. .Opioids

REDUCE ANXIETY

SUSPEND ACTIVITY
MUSCULAR
 SEDATION.
Paralysis with induction

BNM
• They produce paralysis
• They relax the airway muscles
• Priming Principale Receptor Priming

• Avoid undesirable physiological and psychological

effects
• They produce unconsciousness
• Synergy between BNM and inductors
 SEDATION.
RAMSAY SEDATION LEVELS

LEVEL 1: Agitated and anxious patient. Cooperator,

LEVEL 2: oriented and don't worry
LEVEL 3: Asleep with response to commands
LEVEL 4 : Asleep with brief responses to light and sound
LEVEL 5: Asleep with response only to pain
LEVEL 6: Does not respond
SEDATION.
LIPOSOLUBLE. . . BARRIER
HEMATOENC

DOSE. . . 1. – 2.5 MG/KG

1 – 6 MG/K/H

HALF LIFE. . . 2 TO 8 MIN

DO NOT USE IN: vasoactive drugs, pancreatitis,

COMPLICATIONS.
BAROTRAUMA

HEMODYNAMICS

KIDNEYS

GASTROINTESTINAL

NEUROLOGICAL
VENTILATION NO • I

IPERCAPNICA S I P V IRA TO .

POC Ag S udized ESTUARY

R
Postextubation MODALITIES
No intubation candidates
o BPAP: PS + PEEP
RESPIRATORY INSUFF o CPAP: Continuous PEEP
HYPOXIC
Pulmonary edema
PEEP.
DEFINITION.

Positive pressure at the end of

expiration.
-Zero atmospheric pressure.
-Two types: external and
intrinsic.
-External PEEP: fan circuit.
-Intrinsic PEEP: system
patient's respiratory, airflow
limitation (short expiratory
time or high volumes).
 PEEP
. points.
Key
-Increased PaO2 in
patients with acute lung
damage and severe
hypoxia.
-Decrease in respiratory
work.
-Disadvantages: decreases
IC, barotrauma.
-Limitations: barotrauma,
shock, asthma, COPD,
HIC.
 PEEP
. Indications.
PEEP.
-Acute lung injury PaO2
<60mmHg or SaO2
<90% with FIo2 greater than
50%.
-Acute Pulmonary Edema.
-SIRA.

-Dynamic pulmonary
hyperinflation with
elevated PEEPi.
Work decreases
 PEEP
.
respiratory (asthma and
COPD).
 PEEP
. PEEP.
PATHOPHYSIOLOGY.

Benefits: > PaO2 in acute lung

injury.
recruitment of alveoli.
-Increase in lung volume.
-Improved static compliance.
-Decreases perfusion of non-
ventilated air.
-V/Q improvement reduces short
circuits.
-Decreases inspiratory work in
patients with hyperinflation
PEEP
In case of Shock: IV
.
Programming.
fluids without Left
Acute lung injury: achieve Ventricular failure,
PaO2 greater than 60, Inotropics, reduction
SaO2 90% with FIO2 of PEEP.
>50%, PH < 7.25.

-Do not exceed 15 -Continuous monitoring:

cmHO2. pulse oximetry,
gasometry, vital signs, hourly diuresis, graphic
recording, Suaw Ganz catheter
Dynamic hyperinflation and
elevated PEEPi.
PEEP
Disadvantages:
-< IC,> intrathoracic
pressure < venous return
(< preload).
-Barotrauma: > alveolar
pressure and volume.
-> dynamic
hyperinflation: excessive
flattening of
PEEP.
Limitations.

-Barotrauma.
-Shock.
--Unilateral neupathies.
-HIC
 CONTINUOUS POSITIVE LINE PRESSURE
CPAP . CONTINUOUS POSITIVE AIRWAY PRESSURE .

Definition: Use of PEEP

with spontaneous ventilation (Continuous positive
airway pressure).

-Through an endotra eal tube or nasal or facial mask.

 POSITIVE PRESSURE
C
IND O IC N AC T IO I N N E U S. TO DE

-Initial phases of VIA acute respiratory

failure applied with a mask avoiding
IOT.
-Weaning of patients with COPD
without exceeding PEEPi.
-Weaning of patients with left
ventricular failure.
 POSITIVE PRESSURE
CONTINUOUS OF THE ROAD
Pathophysiology.
As there is spontaneous ventilation,
the intrathoracic pressure is lower.
- < decrease in IC.
- Lower risk of barotrauma.
 POSITIVE PRESSURE
CONTINUOUS
CPAP.
OF THE ROAD
Limitations.

-Same as for PEEP.

-Discomfort with putting on and maintaining the mask.

-Aerophagia and vomiting.

 INTERMITTENT MANDATORY VENTILATION.
Definition. Intermittent mandatory ventilation.

Mechanical ventilation modality that combines spontaneous reactions of

the patient with mandatory ones.

Two types: Asynchronous

synchronized.
 MANDATORY VENTILATION
INTERMITTENT.
IVM.
Indications.
-Ventilation weaning
mechanics: support
mechanics and breathing
spontaneous

-Partial ventilatory support: interspersing

spontaneous breaths.
 MANDATORY VENTILATION
INTERMITTENT -Limitation: inadequate
Key points. IM V. ventilatory capacity.

-< barotrauma and -Requires volume and

pressure alarms
decreased IC compared
to VMA and VMC.
-Harmful effects: Hyper or
hypoventilation,
increased respiratory
work, hyperinflation,
respiratory asynchrony.

.asItsa main indication is

weaning method.
 MANDATORY VENTILATION
INTERMITTENT. (pressure support).
Synchronized IVM. SIMV.
-Breaths triggered by the
patient as in the assisted
one.
-The currently
incorporated fans.
-Fan gas mixture intake
with less work
-Respiratory cycles triggered
by flow and pressure.

-Inspiratory support for

spontaneous breathing
 INTERMITTENT MANDATORY VENTILATION.

IVM. Asynchronized.

-Mandatory mechanical ventilations asynchronized with the patient's

inspiratory efforts.
 MANDATORY VENTILATION
INTERMITTENT.
IVM.
Pathophysiology.

-Benefits: in breaths
spontaneous pressure drops
intrathoracic, increasing venous return.

-Damages: Hyper-hiccup
ventilation, increased work
I breathe.

-Asynchronous respiratory.
 MANDATORY VENTILATION
INTERMITTENT.
IVM.
Programming.
-FR, trigger sensitivity, VC, Inspiratory flow.

Monitoring.

Basic: Clinical, spontaneous and total RR, pulse oximetry, airway

pressure, tidal volume and V. Minute expired.
Advanced: Flow, pressure, volume and work of breathing curves,
capnometry.
 Respiratory criteria.
WEANING. -
RR < 38.
Criteria.
-
vt > 4 ml/hr.
-Good muscle activity. -
v L 15 ml/min.

-Hemodynamic stability. - . P > aO 90 2 % > 75

- Sat

--OGapstoimmoetnriivaeOl mmHg
dpetimcoan.ciencia. -PO2 < 50 mmHg.
-Absence of infectious -FiO2 < 60%
process. -Inspiratory pressure
-Absence of sedation and -15cmH2O.
relaxation.
-Absence of spirits
pressors.
 WEANING.
a Fteclencarespuatona>5formore than 500
)| Arterial saturation of 0 less than 90 times more than 10 *2 with F0, < 40%
Reduce heart failure by 10% for more than 5 minutes
d Systolic blood pressure > ISO mmHg or < 90 mHg for 1 minute in continuous monitoring or by metiaesthesia
The presence of agitation, anxiety, or diaphoresis confirms how changes occur according to the patient's state for more
than 5 / -
min