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‫بسم اهلل الرمحن الرحيم‬

MECHANICAL VENTILATION

Dr. rasha mohamed yousif abadi

Anasethesia and Icu specialist
 Mechanical Ventilation
1. Indications for Intubation and Ventilation.
2. Principles of Mechanical Ventilation.
3. Patterns of Assisted Ventilation.
4. Ventilator Dependence: Complications
5. Liberation from Mechanical Ventilation:
Weaning.
6. Troubleshooting.
7. Arterial Blood Gases.
 Indications for Mechanical
Ventilation

1. “Thinking” of Intubation:
elective v/s emergent.
2. “Act of weakness?”.
3. Endotracheal tubes are not a disease
and ventilators are not an addiction.
4. And the usual elective and emergent
indications that you all know!
 Who needs a ventilator?
 Can’t oxygenate (low PaO2/SPO2)
 Can’t ventilate (high PaCO2)
 Can’t participate or protect airway (low GCS)
 If you’re not sure whether or not the patient needs
a ventilator, the patient needs a ventilator.
 Ventilators at OSU
Puritan-Bennett Servo

7200

840
 Indication for mechanical
ventilatory support
 Ventilation abnormalities:-
 Oxygenation abnormalities:-
Resp. muscle dysfunction
- Muscle fatigue.
- Chest wall abnormalities.
- Neuromuscular disease.
Decreased ventilatory drive
Increased airway resistance
and/or obstruction.
- Refractory hypoxemmia.
- Need for PEEP.
- Excessive work of breathing
 Objectives of Mechanical
Ventilation
1. Improve pulmonary gas exchange
Reverse hypoxemia and Relieve acute respiratory acidosis.
2. Relieve respiratory Distress
Decrease oxygen cost of breathing and reverse respiratory
muscle fatigue.
3. Alter pressure-volume relations
Prevent and reverse atelectasis.
Improve Compliance.
Prevent further injury.
4. Permit lung and airway healing.
5. Avoid complications.
 Strategies for Mechanical
Ventilation
Ventilatory Traditional Lung-Protective
Parameter
Inflation Volume 10-15 ml/kg 5-10 ml/kg

End-insp. Peak Pr<50cm Plateau Pr<35

pressure water
PEEP PRN to keep 5-15 cm of water
FiO2<0.6
ABG Normal, pH 7.36- Hypercapnia
7.44 allowed, pH 7.2-
7.4
 Monitoring Lung Mechanics
Proximal Airway Pressures (end-inspiratory)
1. Peak Pressure Pk
Function of: Inflation volume, recoil force of
lungs and chest wall, airway resistance.
2. Plateau Pressure Pl
Occlude expiratory tubing at end-inspiration.
Function of elastance alone.
 Use of Airway Pressures
Pk increased Pl unchanged:

1. Tracheal tube obstruction.

2. Airway obstruction from secretions.
3. Acute bronchospasm.

Rx: Suctioning and Bronchodilators.

 Use of Airway Pressures
Pk and Pl are both increased:
1. Pneumothorax.
2. Lobar atelectasis.
3. Acute pulmonary edema.
4. Worsening pneumonia.
5. ARDS.
6. COPD with tachypnea and Auto-PEEP.
7. Increased abdominal pressure.
8. Asynchronous breathing.
 Use of Airway Pressures
Decreased Pk:

1. System air leak: Tubing disconnection, cuff leak.

Rx: Manual inflation, listen for leak.

2. Hyperventilation: Enough negative intrathoracic

pressure to pull air into lungs may drop Pk.
 sitting of ventilation
1. Assist Control.
2. Intermittent Mandatory Ventilation.
3. Pressure Controlled Ventilation.
4. Pressure Support Ventilati
5. Continuous Positive Airway Pressure.
 Assist Control Ventilation
Volume-cycled lung inflation:
1. Patient can initiate each mechanical breath or
Ventilator provides machine breaths at a preselected
rate.
2. Maintain I:E ratio to 1:2 to 1:4. An increase in Peak
flow decreases the time for lung inflation and increases
the I:E Ratio.
3. I:E ratio of <1:2 can cause hyperinflation by air
trapping.
4. Diaphragmatic contraction continues during ACV and
increases the work of breathing.
There are two ways to give a
breath

Volume Controlled Pressure Controlled

EITHER CAN BE USED WITH A/C OR SIMV!

Ventilator Settings - MODE
 What do you set?
You set:
Volume Controlled Tidal volume
Peak flow
Rate
VC Monitor
 Assist Control Ventilation
Adverse effects:
1. In a tachypneic patient →Lead to
overventilation and severe respiratory
alkalosis.
2. Hyperinflation and Auto-PEEP→ Lead to
Electromechanical dissociation.
 Intermittent Mandatory Ventilation

1. Delivers volume cycled breaths at a

preselected rate with spontaneous breathing
between machine breaths.
2. Less Alkalosis and Hyperinflation.
3. Synchronized IMV (SIMV).
 SIMV

SIMV divides Tb into Mandatory periods (Tm)

and Spontaneous periods (Ts)
 Intermittent Mandatory Ventilation

Disadvantages:
1. Increased work of Breathing:
 Spontaneous breathing through a high resistance
circuit.
 Solution: Add Pressure support.

2. Cardiac Output Changes:

 C O decreased by decreasing ventricular filling.
 C O increased by reducing ventricular afterload.
 More significant decrease in patients with LV
dysfunction.
 IMV vs. ACV
1. Switch to IMV for:
Rapid breathers with alkalosis and over-
Inflation.
2. Switch to ACV for:
Patients with respiratory muscle weakness
and LV dysfunction.
 Pressure Controlled Ventilation

1. Pressure cycled breathing, fully ventilator controlled.

2. Inspiratory flow rate decreases exponentially during
lung inflation.
3. (+)Reduces peak airway pressure and improves gas
exchange.
4. (-)Inflation volume varies with changes in mechanical
properties of the lungs.
5. Suited for patients with neuromuscular diseases and
normal lung mechanics.
 What do you set in PC?

Pressure Controlled

You set:
Pressure limit You set:
Time spent in Pressure limit
inspiration I:E ratio
(Itime) Rate
Rate
 Where are those?

 Pi = Inspiratory pressure above PEEP = (Pressure limit = Pi +

PEEP)
 Ti = time for inspiration
 Rate – Breaths/minute
– 16 breaths/minute = 3.75s/breath = 0.95/(3.75 – 0.95) = I:E = 1:2.9
**Different ventilators do PCV set-up differently**
 Inverse ratio Ventilation
1. PCV combined with prolonged inflation time.
2. Inspiratory flow rate is decreased.
3. I:E ratio reversed to 2:1.
4. Helps prevent alveolar collapse.
5. (-) Hyperinflation, Auto-PEEP and decreased
cardiac output.
6. Use: ARDS with refractory hypoxemia or
hypercapnia.
 Correcting Hypoxemia
 Increase FiO2
 Increase PEEP
 Increase Inspiratory time
 Increase VE
 Pressure Support Ventilation
1. Pressure augmented breathing.
2. Allows patient to determine the inflation
volume and respiratory cycle duration.
3. Uses: augment inflation during spontaneous
breathing or overcome resistance of
breathing through ventilator circuits (during
weaning).
4. Popular an a non-invasive mode of ventilation
via nasal or face masks.
PS can also be used with SIMV

MECHANICAL
P SPONTANEOUS
R
E
S
S
U
R
E

TIME
 Noninvasive positive pressure
vent.

A. Continuous positive Airway

Pressure
1. Spontaneous breathing.
2. Patient does not need to generate negative
pressure to receive inhaled gas.
3. CPAP replaced spontaneous PEEP.
4. Use: Non-intubated patients (COPD).
Continue
 CPAP = (Expiratory positive airway
pressure).
 BIPAP = (Bilevel positive airway pressure).
= insp. positive Airway pressure + exp. Positive airway pressure(CPAP)

 Given to alert, cooperative pt. whose

respiratory condition is expected to improve
in 48 – 72 hours.
Patient on CPAP
 Complications of Mechanical
Ventilation

1. Toxic effects of Oxygen.

2. Decreased cardiac output.
3. Pneumonia and sepsis.
4. Psychological problems.
5. Ventilator dependence.
 Complications of Mechanical
Ventilation
1. Purulent sinusitis.
2. Laryngeal Damage.
3. Aspiration :Value of routine tracheal suctioning.
4. Tracheal Necrosis (pressure below 20mm water).
5. Alveolar rupture: Pneumothorax,
pneumomediastinum, subQ emphysema,
pneumoperitoneum.
6. Basilar and sub-pulmonic air collections in the supine
position, as seen on X-ray.
 Liberation from Mechanical Ventilation:
Weaning
 Weaning: Gradual withdrawal of mechanical ventilation.
1. Misconceptions:
 Duration- longer duration, harder to wean.
 Method of weaning determines ability to wean.
 Diaphragm weakness is a common cause of failed
weaning.
 Aggressive nutrition support improves ability to
wean.
 Removal of ET tube reduces work of breathing.
Bedside Weaning Parameters
Parameter Normal Adult Threshold for
range weaning
PaO2/FiO2 >400 200
Tidal Volume 5-7ml/kg 5ml/kg
Resp. Rate 14-18/min <40/min
Minute Ventl. 5-7L/min <10L/min
Vital capacity 65-75ml/kg 10ml/kg
Bedside Weaning Parameters
Maximal >-90 cm Water (F) -25cm of water
Inspiratory >-120 cm water
Pressure (M)
Rate/Tidal Volume <50/min/L <100/min/L
 Maximal Inspiratory Pressure
1. Pmax: Excellent negative predictive value if
less than –20 (in one study 100% failure to
wean at this value).
2. An acceptable Pmax however has a poor
positive predictive value (40% failure to wean
in this study with a Pmax more than –20).
 Frequency/Volume ratio
 Index of rapid and shallow breathing RR/Vt.
 Single study results:
- RR/Vt>105, 95% wean attempts unsuccessful.
- RR/Vt<105, 80% successful.
• One of the most predictive bedside parameters.
 T-Piece Weaning
1. On-off toggle switch that circulates between on and
off the ventilator.
2. Inhaled gas is delivered at a high flow rate.
3. Varied protocols: like 30min-2hr on and off, or keep
as long as possible and if tolerated for >2-4hr….
Deemed successsful (RR, TV, HR, diaphoresis, sat).
4. Failed T piece: Resume Vent support till
comfortable, 24h.
vent Airflow with CPAP

patient
 T-Piece with Ventilator
1. Drawback: increased resistance due to vent tubing
and actuator valve in circuit.
2. Provide minimum pressure support (PSV) :Pmin.
3. Pmin= PIFR X R.
4. PIFR is during spontaneous breathing.
5. R is airflow resistance during mech ventilation.
6. R= Pk-Pl/Vinsp.
7. (Vinsp:inspiratory flow rate delivered by the vent).
 IMV Weaning
1. Gradual decrease in no of machine breaths in
between the spontaneous breaths.
2. False security: It does not adjust to patient’s
ventilatory demands to maintain constant
MV.
3. End point in IMV weaning is the T-piece
trial.
4. Most important to recognize when a patient is
capable of spontaneous unassisted breathing.
5. T-piece more rapid than IMV.
 Complicating Factors
1. DYSPNEA.
2. Anxiety and dyspnea are detrimental (low dose
haloperidol or morphine).
3. CARDIAC OUTPUT.
4. Increased LV afterload can reduce CO, impair
diaphragm function, promote pulmonary edema.
5. (Use Swan to monitor CO, may use dobutamine).
6. ELECTROLYTE DEPLETION.
7. OVERFEEDING.
 The Problem Wean
1. RAPID BREATHING: Check TV.
2. Low TV>> Resume vent support.
3. TV not low…….. Check arterial pCO2.
4. Arterial Pco2 decreased>sedate
(anxiety).
5. Arterial pCO2 not decreased> Resume
vent.
 The Problem Wean
1. ABDOMINAL PARADOX.
2. Inward displacement of the diaphragm during
inspiration is a sign of diaphragmatic muscle fatigue.
3. HYPOXEMIA.
May be due to low CO and MVO2.
4. HYPERCAPNIA.
- Increase in PaCO2-PetCO2: increase dead space
ventilation.
- Unchanged gradient: Respiratory muscle fatigue or
enhanced CO2 production.
 Tracheal Decannulation
1. Successful weaning is not synonymous with
tracheal decannulation.
2. If weaned and not fully awake or unable to
clear secretions, leave ETT in place.
3. Contrary to popular belief, tracheal
decannulation increases the work of
breathing due to laryngeal edema and
secretions.
4. Do not perform tracheal decannulation to
reduce work of breathing.
 Inspiratory Stridor
1. Post extubation inspiratory stridor is a sign of
severe obstruction and should prompt
reintubation.
2. Laryngeal edema (post-ext) may respond to
aerosolized epinephrine in children.
3. Steroids have no role.
4. Most need reintubation followed by
tracheostomy.
 ARDS and Low Volume Ventilation
1. ARDS Network trial :
2. Traditional: TV 10-15ml/kg, keep plateau<50cm
water.
3. Low TV ventilation: TV 6ml/kg, keep plateau<30cm
water.
4. Need high RR in Low TV group to prevent acidosis.
5. Permissive hypercapnia tolerated well, if needed, use
IV bicarb to maintain pH.
6. May add PEEP in addition to the low TV group to
prevent atelectrauma (open-close alveoli>> alveolar
fracture).
7. Results: Lower mortality in the Low TV group (31%
v/s 39.8%).