Mechanical Ventilator

Shahzaib
MECHANICAL VENTILATION

 Goals
 Maintain patient comfort
 Allow a normal, spontaneous breathing pattern whenever possible
 Maintain a PaCO2 between 35-45 mmHg
 Maintain a PaO2 sufficient to meet cellular oxygen demands but avoid oxygen
toxicity
 Avoid respiratory muscle fatigue and atrophy
 Indications for Mechanical ventilation

 Airway Instability
 Respiratory failure
RESPIRATORY FAILURE

 The etiology of patient respiratory failure can be divided into two categories
1.Failure to oxygenate
2.Failure to ventilate
RESPIRATORY FAILURE

 Failure to oxygenate
-Characterized by decreased Pa02
 Failure to ventilate
-Characterized by increased PaCO2
MECHANICAL VENTILATION

 Breath Types
 There are two basic breath types
1-Spontaneous or demand
Initiated by the patient
2- Ventilator or mandatory
Initiated by the ventilator (time triggered)
Variables

 Breaths are defined by these variables

 Control: Constant throughout inspiration, regardless of changes in respiratory
impedance
 Trigger: Initiates the inspiratory phase
 Limit: Maximal set inspiratory pressure or flow
 Cycling: The factor that terminates the inspiratory cycle
Control Variable

 Flow (volume) controlled

-pressure may vary
 Pressure controlled
-flow and volume may vary
 Time controlled
- pressure, flow, volume may vary
Trigger Variable

 Time -control ventilation

 Pressure -patient assisted
 Flow -patient assisted
 Volume -patient assisted
Limit Variable

 Inspiratory - delivery limits Maximum value that can be reached but will not end
the breath
 Volume
 Flow
 Pressure
Cycling Variable

 The phase variable used to terminate inspiration

 Volume
 Pressure
 Flow
 Time
Goals of Ventilator Modes

1 Maintain adequate oxygenation

2. Maintain adequate ventilation
3. Reduce work of breathing
4. Improve patient comfort
Goals of Ventilator Modes Cont...

 Support of Adequate Oxygenation

1.Oxygen responsive hypoxemias
 Pneumonia
 Sepsis
 Inhalation injury
2.Oxygen refractory hypoxemias
 Atelectasis
 Aspiration
 ALI/ARDS
Goals of Ventilator Modes Cont...

3. Support of Adequate Ventilation

 Airway compromise
 Muscle fatigue / weakness
 Paralysis/spinal cord injury
 Neuromuscular disease
 Chest wall injury
Why new modes?

 Regardless of the mode used, the goals are:

 To avoid lung injury
 Keep the patient comfortable
 Wean the patient from mechanical ventilation as soon as possible.
MODES OF MECHANICAL
VENTILATION
Volume Control Ventilation

 The ventilator delivers a pre-determined VT at a preset frequency

 Advantages
 Guaranteed minute ventilation
 Disadvantages
 No patient interaction. The patient can not initiate a breath
Assist/Control Ventilation

 The ventilator delivers a pre-determined VT with each inspiratory effort generated

by the patient. A back-up frequency is set to insure a minimum VE Assisted
breath, the patient must lower the airway pressure by a preset amount, called the
trigger sensitivity
 Advantages
 Patient can increase VE by increasing respiratory rate
 Disadvantages
 Dys-synchrony
 Respiratory alkalosis
 Dynamic hyperinflation
Intermittent Mandatory Ventilation(IMV)

 Intermittent mandatory ventilation (IMV) is a type of ventilatory support in which

mandatory positive pressure breaths are delivered at preset time intervals.
 Between these breaths, the patient may breathe spontaneously.
 IMV is associated with patient-ventilator dys synchrony because the mandatory
breaths are not delivered in concert with the patient's inspiratory effort.
 A mechanical breath could therefore be delivered during a spontaneous
inspiration, leading to lung overdistention,
Synchronized Intermittent Mandatory
Ventilation (SIMV).
 The ventilator delivers a predetermined VT at a preset frequency and allows the
patient to take spontaneous breaths between ventilator breaths Spontaneous
breaths may be augmented with pressure support.
 Advantages
 Improved venous return
 Disadvantages
 Increased oxygen consumption
 Increased work of breathing
Pressure Control Ventilation (PCV)

 The practitioner sets the maximal pressure obtained by the ventilator (preset
Pressure), frequency and time the pressure is sustained (inspiratory time).
Inspiratory time is set as a percent of the total cycle or absolute time in seconds.
Pressure Control Ventilation (PCV)

 Advantages
 Tidal volume variable with constant peak airway pressure
 Full ventilatory support
 Decreased mean airway pressure
 Control frequency
• Disadvantages
 Requires sedation or paralysis
 Ventilation does not change in response to clinical changing needs
Pressure Support Ventilation (PSV)

 The ventilator delivers a predetermined level of positive pressure each time the
patient initiates a breath. A plateau pressure is maintained until inspiratory flow
rate decreases to a specified level
Pressure Support Ventilation (PSV)

 Advantages
 The flow rate, inspiratory time, and frequency are variable and determined by the
patient
 Decreased inspiratory work
 Enhanced muscle reconditioning
 Disadvantages
 Requires spontaneous respiratory effort
 Delivered volumes affected by changes in compliance
Positive End Expiratory Pressure (PEEP)

 PEEP is the application of positive pressure to change baseline variable during CMV, SIMV, IMV
and PCV. PEEP is primarily used to improve oxygenation in patients with severe hypoxemia.
 Advantages
 Improves oxygenation by increasing FRC
 Decreases physiological shunting
 Improved oxygenation will allow the FIO2 to be lowered
 Increased lung compliance
 Decreased work of breathing
 Disadvantages
 Increased incidence of pulmonary barotrauma
 Potential decrease in venous return
 Increased intracranial pressure
Inverse Ratio Ventilation (IRV)

 During normal spontaneous breathing, the ratio of inspiratory to expiratory time is

1:2 to 1:3.
 During inverse ratio ventilation, the inspiratory time is prolonged, lasting up to
50% to 75% of the respiratory cycle, which yields an inspiratory to expiratory
time ratio of 1:1 to 3:1
 IRV ventilation may be accomplished in a pressure controlled, time cycled mode
(PCV-IRV) or a volume cycled mode (VCV-IRV)
Inverse Ratio Ventilation (IRV)

 Advantages
 Maintains elevated mean airway pressure, while maintaining safe peak alveolar
pressures
 Recruitment of lung units with decreased compliance
 Disadvantages
 Auto-PEEP
 Exacerbation of hemo-dynamic instability
 Barotrauma
 Requires deep sedation and paralysis
Adaptive support ventilation (ASV)

 Adaptive support ventilation (ASV) evolved as a form of mandatory minute

ventilation implemented with adaptive pressure control.
 ASV automatically selects the appropriate tidal volume and frequency for
mandatory breaths and the appropriate tidal volume for spontaneous breaths on
the basis of the respiratory system mechanics and target minute alveolar
ventilation.
Ventilator settings in adaptive support
ventilation
 Ventilator settings in ASV are:
 Patient height
 Sex
 Percent of normal predicted minute ventilation
 Fio2
 PEEP
 Clinical applications of adaptive support ventilation
ASV is intended as a sole mode of ventilation, from initial
support to weaning.
 Theoretical benefits of adaptive support ventilation
In theory, ASV offers automatic selection of ventilator settings, automatic
adaptation to changing patient lung mechanics, less need for human manipulation of
the machine, improved synchrony, and automatic weaning.