Mechanical Ventilation

Overview
• Intro
• NIV
• Basic Modes
• Settings
• Specific Conditions
• Ventilators
• Other modes
 Acute respiratory failure
• Hypoxia (PO2 < 60mmHg)
– Low inspired O2
– Hypoventilation – CNS, peripheral neuro, muscles, chest wall
– V/Q mismatch
• Shunt – pneumonia, APO, collapse, contusions
– Alveoli perfused but not ventilated
– Venous admixture
• Anatomical shunt – cardiac anomaly
• Increased dead space (hypercapnia) – hypovolaemia, PE, poor cardiac
function
– Diffusion abnormality – severe destructive disease of the lung – fibrosis,
severe APO, ARDS
• Hypercapnia (PCO2 >50mmHg)
– Hypoventilation
– Dead space ventilation
– Increased CO2 production
 Shunt

450 0
mmHg mmHg

100% 70%
70
0% 85% %
7
 Mechanical Ventilation
• Pump gas in and letting it flow out
• Function
– Gas exchange
– Manage work of breathing
– Avoid lung injury
• Physics
– Flow needs a pressure gradient
– Pressure to overcome airway resistance and inflate lung
– Pressure (to overcome resistance) = Flow x Resistance
– Alveolar pressure = (Volume/Compliance) + PEEP
– Airway pressure = (Flow x Resistance) + (V/C) + PEEP
 Gas Exchange
• Oxygenation – get O2 in
– FiO2
– Ventilation (minor effect) – alveolar gas equation, CO2 effect
– Mean alveolar pressure
• Mean airway pressure – surrogate marker, affected by airway
resistance
• Pressure over inspiration + expiration
• Set Vt or inspiratory pressure
• Inspiratory time
• PEEP
– Reduce shunt
• Re-open alveoli – PEEP
• Prolonging inspiration – improve ventilation of less compliant alveoli
• Ventilation – get CO2 out
– Alveolar ventilation = RR x (Tidal volume – Dead space)
 Adverse Effects
• Barotrauma
– High alveolar pressure
– High tidal volume
– Shear injury –
• Repetitive collapse + re-expansion of alveoli
• Tension at interface between open + collapsed alveoli
– Pneumothorax, pneumomediastinum, surgical emphysema, acute lung injury
• Gas trapping
– Insufficient time for alveoli to empty
– Increase risk
• Airflow obstruction – asthma, COPD
• Long inspiratory time
• High respiratory rate
– Progressive
• Hyperinflation
• Rise in end-expiratory pressure – intrinsic-PEEP, auto-PEEP
– Result – Barotrauma, Cardiovascular compromise (high intrathoracic pressure)
• Oxygen toxicity
– Acute lung injury due to high O2 concentrations
• Cardiovascular effects
– Preload – positive intrathoracic pressure reduces venous return
– Afterload - positive intrathoracic pressure reduces afterload
– Cardiac Output – depends on LV contractility
• Normal – IPPV decreases CO
• Reduced – IPPV increases CO
– Myocardial O2 consumption - reduced
Gas Trapping
 NIV
• CPAP
– Similar to PEEP
– Splint alveoli open – reduce shunt
– Spontaneous breathing at elevated baseline
pressure
• BiPAP
– Ventilatory assistance without invasive
artificial airway
– Fitted face/nasal mask
– Initial settings 10/5
NIV
 NIV
• Indicator of success • Contraindications
– Known benefits – Cardiac/Resp arrest
– Younger age – Non-respiratory organ failure
– Lower APACHE score – Encephalopathy GCS <10
– Cooperative – GIH
– Intact dentition – Haemodynamically unstable
– Moderate hypercarbia – Facial or neurological surgery,
(pH<7.35, >7.10) trauma or deformity
– Improvement within first 2 hrs – High aspiration risk
– Prolonged ventilation
anticipated
– Recent oesophageal
anastamosis
 NIV Benefits
• General
• COPD
• Cardiogenic pulmonary oedema
• Hypoxaemic respiratory failure
• Asthma
• Post-extubation
• Immunocompromised
• Other diseases
 What is a Mode?
• 3 components
• Control variable
– Pressure or volume
• Breath sequence
– Continuous mandatory
– Intermittent mandatory
– Continuous spontaneous
• Targeting scheme (settings)
– Vt, inspiratory time, frequency, FiO2, PEEP, flow
trigger
 Volume Control Ventilation
• Set tidal volume
• Minimum respiratory rate
• Assist mode – both ventilator and patient can initiate
breaths
• Advantage
– Simple, guaranteed ventilation, rests respiratory muscle
• Disadvantages
– Not synchronised – ventilator breath on top of patient breath
– Inadequate flow – patient sucks gas out of ventilator
– Inappropriate triggering
– Decreased compliance – high airway pressure
– Requires sedation for synchrony
VCV
 Pressure Control Ventilation
• Set inspiratory pressure
• Constant pressure during inspiration
• High initial flow
• Inspiratory pause – built in
• Advantages
– Simple, avoids high inspiratory pressures, improved
oxygenation
• Disadvantages
– Not synchronised
– Inappropriate triggers
– Decreased compliance – reduced tidal volume
PCV
 Pressure Support
• Set inspiratory pressure
• Patient initiates breath
• Back-up mode – apnoea
• Cycle from inspiration to expiration
– Inspiratory flow falls below set proportion of peak
inspiratory flow
• Advantages
– Simple, avoids high inspiratory pressure, synchrony,
less sedation, better haemodynamics
• Disadvantages
– Dependent on patient breaths
– Affected by changes in lung compliance
PS
 Synchronised Intermittent
Mandatory Ventilation
• Mandatory breaths – VCV, PCV
• Patient breaths – depends on SIMV cycle
– Synchronised mandatory breath
– Pressure support breath
• Advantages
– Synchrony, guaranteed minute ventilation
• Disadvantages
– Sometimes complicated to set
SIMV
VCV vs PCV
VCV vs PCV
 VCV vs PCV - Advantages
• PCV + PS • VCV
– Variable flow – Consistent TV
– Reduced WOB • changing
– Max Palveolar = Max impedance
Pairway (or less) • Auto-PEEP
– Palveolar controlled – Minimum min. vent.
– Variable I-time & (f x TV) set
pattern (PS) – Variety of flow waves
– Better with leaks
VCV vs PCV - Disadvantages

• PCV + PS • VCV
– Variable tidal volume – Variable pressures
• Too large or too • airway
small • alveolar
• No alarm/limit for – Fixed flow pattern
excessive TV (except – Variable effort = variable
some new gen. work/breath
vents) – Compressible vol.
– Some variablity in – Leaks = vol. loss
max pressures (PC,
expir. effort)
 Settings
• FiO2 – start at 1.0
• RR – average 12, higher for those with sepsis/acidosis
• Tidal volume – 500ml, 8ml/kg, smaller volumes in ARDS
• Inspiratory pressure - <30cmH2O, sum of PEEP + Pinsp
• Inspiratory time
– I:E – normally 1:2, simulates normal breathing – synchrony
– PCV – easy to set
– VCV – complicated, Time = Volume/Flow
• PEEP
– Start at 5cmH2O
– Higher – APO, ARDS
– Lower – asthma, COPD
• Triggering
– Flow triggering – more sensitive, synchrony, -2cmH2O
– Pressure triggering
– Inappropriate triggering – triggering when no patient effort
• Oxygenation
 FiO2, PEEP, Insp Time, InspP, Insp pause
– Problems – CVS effects, gas trapping, barotrauma
• Ventilation
 Tidal volume, RR, eliminate dead space
– Problems – barotrauma, gas trapping (reduced minute ventilation)
 Troubleshooting
• Airway pressure
– Ventilator – settings, malfunction
– Circuit – kinking, water pooling, wet filter
– ETT – kinked, obstructed, endobronchial intubation
– Patient – bronchospasm, compliance (lungm, pleura, chest wall), dysynchrony, coughing
– Inspiratory pause pressure - Estimate of alveolar pressure
• Tidal volume
– Reduced – respiratory acidosis
– Monitor in PCV/PS
– Changes in compliance – anywhere in system
– Expired Vt – more accurate
• Minute ventilation – determined by RR + Vt
• Apnoea – important in PS
• Intrinsic PEEP (gas trapping)
– Expiratory pause hold
Total PEEP

Pressure
• Hypotension – after initiating IPPV
– Hypovolaemia/Reduced VR

PEEPe
– Drugs
– Gas trapping – disconnect PEEPi
– Tension pneumothorax
• Dysynchrony
–
Time
Patient factors
– Ventilator – settings, eg I:E
– PS > SIMV > PCV/VCV
 Troubleshooting

• Desaturation
– Patient causes
• All causes of hypoxic respiratory failure
• Endobronchial intubation, PTx, collapse, APO,
bronchospasm, PE
– Equipment causes
– FIO2 1.0
– Sat O2 waveform
– Chest moving?
• Yes – Examine patient, treat cause
• No – Manually ventilate
– No – ETT/Patient problem
– Yes – Ventilator problem – setting, failure, O2 failure
 Ventilators
• Maquet • Evita
– VCV – PS
– PCV – PCV+
– PRVC – SIMV
– PS/CPAP – PCV+A
– SIMV (VC) + PS – Autoflow
– SIMV (PC) + PS
– SIMV (PRVC) + PS
– MMV
– NAVA
 Adaptive Modes - PRVC
• PCV unable to deliver guaranteed minimum
minute ventilation
• Changing lung mechanics + patient effort
• Pressure controlled breaths with target tidal
volume
• Inspiratory pressure adjusted to deliver minimum
target volume
• Not VCV - average minimum tidal volume
guaranteed
• Like PCV – constant airway pressure, variable
flow (flow as demanded by patient)
 Adaptive Modes - PRVC
• Consistent tidal volumes
• Promotes inspiratory flow synchrony
• Automatic weaning
• Inappropriate – increased respiratory drive, eg severe
metabolic acidosis
• Evidence – lower peak inspiratory pressures
VCV vs PRVC
 Adaptive Modes - Autoflow
• First breath uses set TV & I-time
– Pplateau measured
• Pplateau then used
• V/P measured each breath
• Press. changed if needed (+/- 3)
• Dual mode similar to PRVC
– Targets vol., applies variable press. based on mechanics
measurements
– Allows highly variable inspiratory flows
– Time ends mandatory breaths
• Adds ability to freely exhale during mandatory inspiration
(maintains pressure)
 PCV + Assist
• Like PCV, flow varies automatically to
varying patient demands
• Constant press. during each breath -
variable press. from breath to breath
• Mandatory + patient breaths the same
 Inverse Ratio Ventilation
• Increased mean airway pressure
• Prolonged I:E ratio
• Improved oxygenation
– Reduced shunting
– Improved V/Q matching
– Decreased dead space
• Heavy sedation, paralysis
• Preferred PCV
• Benefit – no effect in mortality in ARDS
 Other Modes
• Adaptive support ventilation
– Mandatory minute ventilation
– Adaptive pressure control
• Proportional assist ventilation
– Pressure support (spontaneous breaths)
– Pressure applied function of patient effort
• Automatic tube compensation
– adjusts its pressure output in accordance with flow,
theoretically giving an appropriate amount of
pressure support
 Airway Pressure-Release
Ventilation
• High constant PEEP + intermittent
releases
• Unrestricted spontaneous breaths –
reduced sedation
• Extreme form of inverse ratio ventilation
• E:I – 1:4
• Spontaneous breaths – 10-40% total
minute ventilation
 APRV
• Settings – 2 pressure levels, 2 time
durations
• Uses – ALI, ARDS
• Caution – COPD, increased respiratory
drive
 APRV
• Increase mean airway pressure
– Alveolar recruitment, improve oxygenation
• Promote spontaneous breathing
– Improved V/Q match, haemodynamics
• Improved synchrony
• Evidence – no difference in mortality,
decreased duration of ventilation
 High-Frequency Ventilation
• 4 types
– High frequency jet ventilation
• Ventilation by jet of gas
• 14-16G cannula, specialised ventilator
• 35 psi, RR100-150, Insp 40%
– High frequency oscillatory ventilation
– High frequency percussive ventilation
• HFV + PCV
• HFOV – oscillating around 2 pressure levels
• Less sedation, better clearance of secretions
– High frequency positive pressure ventilation
• Conventional ventilation at setting limits
 High Frequency Oscillatory
Ventilation
• Ventilator delivers a constant flow (bias flow)
• Valve creates resistance – maintain airway
pressure
• Piston pump oscillates 3-15Hz (RR160-900)
• “Chest wiggle” – assess amplitude
• Tidal volumes – less than dead space
• Ventilation – achieved by laminar flow
• Deep sedation, paralysis
 HFOV
• CO2 clearance
– Decrease oscillation frequency, increase amplitude,
increase inspiratory time, increase bias flow (with ETT
cuff leak)
• Oxygenation
– Mean airway pressure, FiO2
• Settings
– Airway pressure amplitude
– Mean airway pressure
– % inspiration
– Inspiratory bias flow
– FiO2
 HFOV
• Applications
– ARDS
– Lung protection – highest mean airway pressure + lowest tidal
volumes
– Ventilatory failure – FiO2>0.7, PEEP>14, pH <7.25, Vt >6ml/kg,
plateau pressure >30)
• Contraindicated
– Severe airflow obstruction
– Intracranial hypertension
• Evidence
– Animal models – less histologic damage + lung inflammation
– Better oxygenation as rescure therapy in ARDS
– No difference in mortality
 Mean Airway Pressure
• Main factor in recruitment and oxygenation
• Increased surface area for O2 diffusion
• Problems
– Barotrauma
– Haemodynamic instability
– Contraindicated patients
– Deep sedation, paralysis
 Specific Conditions
• ARDS
– Definition
• Diffuse bilateral pulmonary infiltrates
• No clinical evidence of Left Atrial Hypertension (CWP<18mmHg)
• PaO2/FiO2 of 300 or less
– Exclusions
• Unilateral lung disease
• Children (wt less than 25kg)
• Severe obstructive lung disease (asthma, COPD)
• Raised intracranial pressure
– High PEEP, low volumes + pressure
– SIMV(PRVC) + PS
– Vt 6ml/gk – check plateau pressure
– Pins >30cmH2O – reduce Vt
– Lowest plateau pressure possible
– RR 6-35, aim pH 7.3-7.45
– Evidence – improved mortality
FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
PEEP 5 5-8 8-10 10 10-14 14 14-18 18-22
 Ventilator Induced Lung Injury
• Excessive inflation pressure
• Mechanical tissue damage
• Inflammation – mechano-signaling due to
tensile forces
• Overstretching of lung units
• Shear force at junction of open and collapsed
tissue
• Repeated opening and closing of small
airways under high pressure
 End-Expiration Pathways to VILI

Extreme Stress/Strain Tidal Forces Moderate Stress/Strain

(Transpulmonary and
Microvascular
Pressures)

Rupture Signaling

Mechano signaling via

integrins, cytoskeleton, ion channels

inflammatory cascade

Cellular Infiltration and Inflammation

Marini / Gattinoni CCM 2004

 Spectrum of Regional Opening Pressures
(Supine Position)
Opening
Pressure
Superimposed
Pressure Inflated 0

Small Airway 10-20 cmH2O

Collapse

Alveolar Collapse
(Reabsorption) 20-60 cmH2O

Consolidation 
= Lung Units at Risk for Tidal
Opening & Closure
 Lung Protection Strategies
• Heterogenous lung units
• PEEP
• Tidal volume
• Keep the lung as open as possible without
generating excessive regional tissue
stresses is a major goal of modern
practice
 Prone Ventilation
• Homogenise transpleural pressure
• Compression – reduced compression from heart
+ abdomen
• Improved recruitment
• Increase in FRC
• Decreased shunt
• Benefit
– Improved oxygenation in 60-80% patient, even on
return to supine position
– No change mortality
 Recruitment Manoeuvres
• Open collapsed lung tissue so it can remain open during
tidal ventilation with lower pressures and PEEP, thereby
improving gas exchange and helping to eliminate high
stress interfaces
• Although applying high pressure is fundamental to
recruitment, sustaining high pressure is also important
• Methods of performing a recruiting maneuver include
single sustained inflations and ventilation with high PEEP
Three Types of Recruitment Maneuvers
 Specific Conditions
• Unilateral lung disease
– Similar approach to ARDS
– Increase Insp time – improve gas distribution
– Lateral position – normal lung down
• Reduce shunt
• Reduce normal lung compliance
• Risk of contamination
– Independent lung ventilator
• Asthma
– Maximise expiratory time, low RR – permissive hypercarbia
– Short inspiratory time
– High airway pressure - ?significance
– Expiratory hold
– Aim – PEEPi < 10cmH20, Pplat <20cmH2O
• COPD
– Similar to asthma
– Bronchospasm not as great, reduced lung compliance
 Airway Obstruction
• Aim – relieve work of breathing, minimise auto-PEEP
• Gas trapping
– Increases work of breathing
– Haemodynamic compromise
– Predisposes to barotrauma
– Decreases ventilation
• PEEP
– Effects Depend on Type and Severity of Airflow Obstruction
– Generally Helpful if PEEP  Original Auto-PEEP
– Potential Benefits
• Decreased Work of Breathing
• Increased VT
• Improved Distribution of Ventilation
 NAVA
• Neurally adjusted ventilatory assist
• Controls ventilator output by measuring the
neural traffic to the diaphragm
• NAVA senses the desired assist using an
array of esophageal EMG electrodes
positioned to detect the diaphragm’s
contraction signal
• Flexible response to effort
• Improves synchrony and weaning
Neural Control of Ventilatory Assist (NAVA)

Ideal
Central Nervous System
Neuro-Ventilatory Coupling

Technology

Phrenic Nerve

New
Diaphragm Excitation Ventilator
 Technology Unit
Diaphragm Contraction

Chest Wall and Lung
Expansion
 Current
Airway Pressure, Flow and Technology
Volume
• References
– Cleveland clinic journal of medicine 2009; 76(7): 417-430
– UpToDate
– BASIC course notes
– Wests Respiratory Essentials

• Links
– http://emedicine.medscape.com/
– http://www.anaesthetist.com/anaes/vent/Findex.htm#index.htm
– http://en.wikipedia.org/wiki/Mechanical_ventilation
– http://www.merck.com/mmpe/sec06/ch065/ch065b.html
– http://www.ccmtutorials.com/rs/index.htm
– http://www.aic.cuhk.edu.hk/web8/mechanical_ventilation.htm