SMART

VENTILATION
: Mechanical
Ventilation 101 Prof K U Tobi
A Mechanical
Ventilator
• Mechanical ventilation is any method
of breathing assistance in which a
machine supports a patient's
breathing.
• Mechanical ventilatory support is
among the commonest indications for
admission to the intensive care unit
(I.C.U.)
 • Introduction
• Characteristics of an ideal ventilator
• Indications for Mechanical Ventilation
Outline and • SMART Ventilation

Learning
- Setting
- Mode

Objectives -
-
Adjuvants
Release
- Troubleshooting
• Initiation of Mechanical Ventilation
 • The mechanical ventilator can be a life-saving device if
used "smartly" or a death box if otherwise. There is a
need to understand the indication for ventilatory
support, the ventilator workings and patient-ventilator
interaction.
• "SMART" ventilation is an acronym which means:
- Setting
Introduction - Mode
- Adjuvant
- Release or Weaning
- Troubleshooting.
• SMART ventilation aims to target Specific, Measurable,
Achievable, Reproducible and Time-bound goals to
restore normal respiratory physiology.
 • Versatile i.e. tidal volume up to 1500mls and
respiratory rate 60/minute and facilities for
other ventilator modes.
• Economical, simple, portable and robust
Characteristics • Nebulisation of drugs possible.
of an ideal • Inspiration and airway pressure monitoring
ventilator: • Long-lasting
“VENTILATE” • Alarm systems e.g. disconnect alarms, high
airway pressure alarms
• Easy to clean and sterilize.
 Indications for mechanical ventilation

• The primary indication for mechanical ventilation

is a respiratory failure; however, the indication for
respiratory support, the underlying condition must
be reversible, or weaning may be impossible.
Specific indications include: the “4Hs”
Hypoxaemic respiratory failure due to, for example
acute respiratory distress syndrome (ARDS) with
ABG values of PaO2< 8kpa (60mmHg)
Hypercapnic respiratory failure with and PaCO2
>8kpa (60mmHg)
Hypoventilation with respiratory rate
<5cycles/minute, tidal volume <5ml/kg
Hyperventilation with respiratory rate
>35cycles/minute
 • Before initiating mechanical ventilation for a patient, some
settings must be fed into the ventilator. These settings should be
patient- and condition-specific. Appropriate settings must be
ensured for optimal ventilatory output and favourable patient
outcomes. These include:
Respiratory rate: The rate set will depend on the tidal volume,
type of lung pathology, and the target PaCO2. for example, 8-12

SMART: breaths/minute for patients with normal lung physiology, 6-8 for
patients with obstructive lung disease and 12-20 for patients
with restrictive lung disease.
Setting Tidal Volume (T.V.): The appropriate initial tidal volume depends
on numerous factors, most notably the disease for which the
patient requires mechanical ventilation. All tidal volumes are
expressed as ml/kg of ideal or Predicted body weight. For all
adults with normal lungs, tidal volume is set at 6-8 mL/kg (based
on ideal body weight).
Flow rate: The usual setting is 40-100 litres per minute, and the
peak flow rate is the maximum flow the ventilator delivers
during inspiration. The flow rate is adjusted in a specific
condition.
 Inspiratory time (I): The normal I: E ratio is 1:2. Depending on the disease
process, such as ARDS, the I: E ratio can be changed to improve
ventilation. Occasionally, inverse ratio ventilation (IRV) may be desired.
Fractional inspired concentration of oxygen (Fi02): Ranges from 21% to
100%. At the initiation of ventilatory support, it is recommended that the
FiO2 be set at 1.0 (100%). Once the patient is stabilized, the FiO2 can be
reduced based on pulse oximetry and arterial blood gas values. The FiO2
should only be as high as is necessary to keep the PaO2 in the desired

SMART: range.
Positive End Expiratory Pressure (PEEP): Physiological PEEP is 4-5 cmH2O.

Setting The setting of PEEP also depends on the patient's lung pathology. For
instance, you could start 'Z.E.E.P.' or zero PEEP in severe asthma.
However, in pulmonary oedema /ARDS, a much higher PEEP, such as 8-10
cmH2O, may be required.
Pressure Limit: Pressure limit protects against barotrauma; thus, a plateau
pressure not exceeding 35 cm H2O is usually recommended. A higher
pressure generated may be an indication of an obstructed airway which
may be due to mucus or secretion.
Trigger: The triggering setting determines the patient's effort to initiate an
inspiratory breath on the ventilator. Note that flow triggering is a better
setting for patients who can breathe spontaneously because it reduces
the work of breathing.
 SMART: Setting

S.No. SETTING FUNCTION USUAL PARAMETERS

Number of breaths delivered by the

 1. Respiratory Rate (RR) Usually 6-20 breaths per minute
ventilator per minute

Volume of gas delivered during each

 2. Tidal Volume (VT) Usually 6-10ml/kg
ventilator breath

Amount of oxygen delivered by 21% to 100%; usually set to keep

 3. Fractional Inspired Oxygen (FiO2)
ventilator to patient PaO2 > 60 mmHg or SaO2 > 90%

Length of inspiration compared to Usually 1:2 or 1:1.5 unless inverse

 4. Inspiratory:Expiratory (I:E) Ratio
length of expiration ratio ventilation is required

Maximum amount of pressure the 10-20 cm H2O above peak inspiratory

 5. Pressure Limit
 SMART: Modes of Ventilation

• Broadly classified into controlled and assisted mode

ventilation.
 Assisted mode ventilation is the most commonly
employed in the I.C.U. This is designed to work with the
patient's respiratory effort. The patient's inspiratory effort
is detected, triggering the ventilator to boost the
inspiratory breath.
 Controlled mandatory ventilation: CMV completely
controls the patient's ventilation, and the patient CANNOT
generate spontaneous breaths, volumes, or flow rates in
this mode, which can either be volume-controlled or
pressure controlled.
- The volume-controlled ventilation (CMV) indications
include patient bucking or fighting the ventilator, tetanus,
convulsive disorders, and crushed chest injury.
- With Pressure Controlled Ventilation (PCV), the ventilator
delivers pressure-limited, time-cycled breaths with a
preset inspiratory pressure.
 •Assist-Controlled mode (A/C): All
delivered breaths, whether
mandatory or patient-triggered,
will be delivered by the ventilator
according to the set parameters.
SMART: This mode is used for patients
who can initiate a breath but
have weakened respiratory
Modes of muscles.
•Intermittent Mandatory
Ventilation ventilation: The ventilator
delivers a preset number of time-
cycle mandatory breaths and
allows the patient to breathe
spontaneously in between
•Synchronized Intermittent
Mandatory Ventilation (S.I.M.V.):
Prevents breath stacking, as
mandatory breaths are
synchronized with spontaneous
breaths.
•Mandatory Minute Ventilation
(MMV): The ventilator measures
patient’s minute volume and,
delivers it as mandatory breaths
in btw spont breaths..
•Pressure support ventilation
(P.S.V.): Supports spontaneous
breathing of patients by
augmenting each inspiratory
effort at a preset inspiratory
pressure level. It applies pressure
plateau to the patient airway
during spontaneous breathing.
•Adaptive Support Ventilation
(ASV): Patient's data, e.g. body
weight and percentage minute
volume, are fed into the
ventilator. The ventilator selects
and provides the frequency,
inspiratory time, I:E and sets the
high-pressure limit for mandatory
and spontaneous breaths.
•Proportional Assisted Ventilation
(PAV): Assists patient’s ventilation
in proportion to the patient's
effort inspiratory flow, volume
and pressure are variable, and
pressure support changes
according to elastance, airflow
resistance, and patient demand.
 SMART: Modes of
Ventilation
• Volume Assured Pressure Support Ventilation (VAPS): Incorporates
inspiratory pressure support ventilation and conventional volume-assisted
cycles to provide optimal inspiratory flow during assisted or controlled
ventilation. Desired tidal vol and pressure support are preset.
• Pressure Regulated Volume Control Ventilation (P.R.V.C.): Achieves volume
support while keeping P.I.P. at the lowest level. This is achieved by altering
peak and inspiratory time in response to changing airway or compliance
characteristics. At constant flow, P.I.P. increases, which increases airflow
resistance; thus, decreasing flow reduces airflow resistance. To compensate
for lower flow, inspiratory time is prolonged.
• Airway Pressure Release Ventilation (APRV): Similar to CPAP as the patient
can breathe spontaneously. Airway pressure is maintained at moderately high
levels (15-20cmH2O) throughout most of the respiratory cycle, with brief
periods of low pressure to allow lung deflation. Increased pressure ensures
alveolar recruitment and oxygenation, and brief deflation allows CO2
excretion without alveolar collapse.
 • The following mnemonic
facilitates recollection of some of
these adjuvants, "P.H.I. L.I.P.E.":.
 Positive End Expiratory Pressure
(PEEP): Basically, PEEP does not
allow airway pressure to return to
SMART: zero at the end of expiration.
Therapeutic PEEP usually ranges
Adjuvants of from 10-30cm H2O in adults.
 High-frequency ventilation (HFV)
Ventilation delivers a small volume of gas
between 1-3ml/kg tidal volume at
a very rapid rate which may range
from 60-180 breaths/minute.
There are three types of HFV,
namely: H.F.P.P.V.: 60-
110breaths/min, H.F.J.V.: 110-
600breaths/min and H.F.O.V.: 600-
3000breaths/min
 Inverse Ratio Ventilation (IRV):
reverses the typical inspiratory:
expiratory ratio. IRV intends to
improve oxygenation by increasing
the mean airway pressure (M.A.P.)
and inspiratory time. Normal I: E is
1:1.5 to 1:3. But in IRV, I: E may
range from 2:1 to 4:1
 Low Volume Ventilation: Lower
Tidal Volume ventilation reduces
ventilator-induced lung injury
(V.I.L.I), barotrauma, volutrauma,
atelectrauma, and biotrauma.
 Prone Ventilation: Typically
reserved as a rescue treatment
option for severe acute respiratory
distress syndrome (ARDS). This
method of ventilation requires
adequate sedation and muscle
paralysis. Regular arterial blood gas
must be done to assess the degree
of oxygenation. Attention must be
paid to the pressure areas to
prevent pressure ulcers.
 Extracorporeal membrane
oxygenation (ECMO): This external
artificial circuit carries venous blood
from the patient to a gas exchange
device where the blood is
oxygenated, and carbon dioxide
removed. The oxygenated blood is
then returned to the patient via a
central vessel.
 • Weaning off the ventilator is
gradual withdrawal of
machine support to allow
the patient resume
spontaneous breathing. The
SMART: framework for a safe
weaning process in our units
Release or is: When the patient is no
longer a GHOST, i.e.
Weaning G.C.S.>13/15
Haemodynamic stability:
M.A.P.>65mmHg and no
longer on inotrope
Oxygenation is improved: RR
<35/min; FiO2 <0.5,
SPO2>90% and
PEEP<10cmh2O; tidal
volume>5ml/kg, vital
capacity >10ml/kg.
Spontaneous breathing
adequate with intact
reflexes (gag and cough
reflexes)
Temperature <37.5o C
• The process of weaning
From Full Control to SIMV: SIMV-
PSV reduces the need for sedation
during the weaning process and it
facilitates the process of weaning.
From SIMV-PSV to CPAP: It reduces
the mandatory breaths and allows
consistent pressure support, which
encourages each spontaneous
breathing with adequate ventilation.
The success of this step determines
a successful pass to a more
supportive mode like CPAP.
From CPAP to Extubation: evaluate
Spontaneous Breathing Trial (SBT) by
determining the Rapid Shallow
Breath Index, aka Tobin's index.
Disconnect the patient from the
ventilator and attach a Wright
spirometer to obtain this index. A
result greater than 105 virtually
rules out readiness for weaning. In
the absence of a Wright Spirometer,
determine Tobi’s index with the
patient on CPAP with low-pressure
support (below 10), physiological
PEEP and FiO2 < 50%.
 • Failure to wean off the ventilator is the failure to pass a
spontaneous breathing trial (S.B.T.). It also means the
requirement for endotracheal intubation within 48 hours
following extubation for a patient on a mechanical
ventilator.
• Some of the reversible causes of failure to wean have
been grouped into a mnemonic "WHEANS NOT":
Wheezing
Failure to Heart diseases, e.g. L.V.H.
wean off the Electrolyte deraignment, e.g. hypokalaemia
Anxiety
ventilator Nutritional insufficiency
Sepsis, e.g. ventilator-associated pneumonia
Opioids use (prolonged)Thyroid disease
 Patient assessment: This
includes assessing the need
for urgent resuscitation,
SMART: the patient's airway,
Troubleshooting adequate and bilateral
chest movement and the
patient's level of
oxygenation,
haemodynamic status or
agitation.
Hypoxia: In assessing the
patient's hypoxia, follow
this mnemonic, "DOPE”, i.e.
-Displaced ETT
-Obstructed (kinked or
bitten tube, mucous plug,
etc.)
-Pneumothorax,
-Esophageal intubation.
Haemodynamic instability:
Some causes are
hypovolaemia secondary
to a reduction in venous
return exacerbated by
positive intrathoracic
pressure, drug-induced
vasodilation and
myocardial depression and
tension pneumothorax.
Agitation: An increase in
patient agitation and dis-
synchrony on the
ventilator could be
secondary to overall
patient discomfort or
secondary to feelings of air
hunger.
  The Ventilators Alarms: These are
various alarm systems, including
high or low-pressure alarms.
- High Airways Pressure Alarm
SMART: (HAPA): Some causes include
Troubleshooting inappropriate setting on the
ventilator, displaced or
obstructed tubes and circuits.
Others are increased airway
resistance due to bronchospasm,
and reduced chest or lung
compliance, e.g. abnormal chest
wall or pneumothorax
- Low-pressure or low-exhaled tidal
volume alarm (LAPA.) indicates
tubing disconnection or air leak.
First, verify that the ventilator
tubing is intact and the
connections are tight; reconnect
and tighten tubing at
connections, drainage, and access
points..
- High Respiratory Rate Alarm
(HRRA.): evaluate the patient
for anxiety, pain, respiratory
distress and
confusion/agitation. Verbal
communication is essential in
I.C.U. even if the patient
doesn't speak: Reassure the
patient.
- Apnoea Alarm (AA): The A.A.
can be triggered by three
factors viz: Patient,
Endotracheal tube or
Ventilator Circuit. If the patient
is not breathing, the alarm will
be triggered by exceeding the
apnea interval. There may be
an accidental extubation, or
the ventilator circuit might be
disconnected from the patient.
 • Ensure the indication • Enter initial ventilator setting
for ventilatory support (“SMART”) e.g.
is reversible FiO2=1.0 initially then reduce
Initiating • Obtain consent from gradually.
Mechanical relatives or patients if PEEP=5cmH2O
conscious
Ventilation • Obtain baseline ABG
Tidal volume=7-10ml/kg
Inspiratory
before initiating MV pressure=20cmH2O,
• Ensure adequate Frequency =10-15 cycles /min
supply of gas /oxygen,
proper working of the PSV/ASB=20cmH2O
ventilator. I:E ratio=1:2
• Select mode of Flow trigger=2l/min
ventilation: assist or Pressure trigger=-1 to-
control mode 3cmH2O.
Conclusion and
Questions
 • Karin Deden , Ventilation modes in intensive care,
HEADQUARTERS Dräger Medical GmbH Moislinger
Allee 53–55 23558 Lübeck, Germany www.draeger.com
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• Dean R, Hess R M, Kacmarek. Essentials of Mechanical
Ventilation McGraw-Hill Medical; 2nd edition 2002.
• Lynelle NB, Pierce. Guide Mechanical Ventilation and

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