Non Invasive dan Invasive

Ventilation
Arini Ika Hapsari
Narasumber : dr Hadiki Habib SpPD, SpEM
 Ventilation
• Ventilation (V) refers to the flow of air into and out of the
alveoli
• Air flow from atmosphere to lungs trough pressure gradient

Higher pressure  lower pressure

Trans airway pressure gradient =

airway pressure – alveolar pressure

Oxygen pathway
Air inhales through nostrils  nasal cavity  pharynx 
larynx  traches  mainstem bronchus  conducting
bronchioles  terminal bronchioles  respiratory
bronchioles  alveolar duct  alveoli  capillary  body
Ventilation
Passive inhalation
- Negative pressure inside body generated -> moves air into lungs
- Diaphragm contracts downwards, chest muscle pull ribs outward -> ↑ ↑ ↑ intrathoracic
volume -> ↓ ↓ ↓ intrathoracic pressure -> air moved into lungs (air flows down
pressure gradient)

Passive exhalation
- ↑ ↑ ↑ intrathoracic pressure generated -> moves air out of lungs
- Diaphragm relaxes (returns to resting position), external intercostal muscles relax,
thoracic cage recoils -> elastic lung recoil -> ↓ ↓ ↓ intrathoracic volume -> ↑ ↑ ↑
intrathoracic pressure -> air pushed out of lungs

Boyle’s law: P = 1/V

Mechanical Ventilation
• The technique through which gas is moved toward
and from the lungs through an external device
connected directly to the patient.
• Clinical objectives:
• To maintain gas exchange
• Reduce or substitute respiratory effort
• Diminish the consumption of systemic and/or myocardiac
O2
• Obtain lung expansion
• Allow sedation, anesthesia and muscle relaxation
Mechanical Ventilation Indication
• The most common reasons for instituting MV
are
• Acute respiratory failure with
hypoxemia (ARDS, heart failure with
pulmonary edema, pneumonia, sepsis,
complications of surgery and trauma) 
~65% of all ventilated cases
• Hypercarbic ventilatory failure—e.g.,
due to coma (15%), exacerbations of
chronic obstructive pulmonary disease
(COPD; 13%), and neuromuscular
diseases (5%).
Type of Ventilation

Invasive • Insersi pipa dengan cuff (endotracheal tube/ETT) ke

trakea  pemberian udara langsung ke saluran napas
Ventilation dengan tekanan positif

Non invasive • Pemberian udara langsung ke saluran napas dengan

Ventilation tekanan positif dengan tanpa insersi ETT

(NIV)
Non Invasive Ventilation
Indications vs contraindications NIV
Type of Non Invasive Ventilation
Low-flow High-flow
(variable-performance) (fixed-performance)
• Nasal canula • Optiflow/ HFNC
• Simple mask • CPAP (Continuous positive
• Nonrebreather airway pressure)
• BPAP (Bilevel positive
airway pressure)
 Low Flow NIV
Nasal Cannulas (NC)
• Affected by
• Flow
• respiratory rate
• Factors affecting O2 concentration or air
dilution (open/closed-mouth breathing,
anatomic factors  dead space  the
actual FiO 2 inspired variable between
patients.
• Flow rate 1 to 6 L/min with FiO 2 of 0.22 to
0.24 at 1 L/min up to 0.4 at 5 to 6 L/min
Simple Mask
• Has a 100 to 200 mL reservoir  increase in inspired
O2 concentration.
• Actual delivered FiO 2 is variable and dependent on
mask volume, O2 flow and pattern of ventilation
• Allows for CO2 accumulation during exhalation, so
O2 flow should be high enough to washout the mask
and prevent rebreathing
• Flow rate 5 to 10 L/min. The FiO 2 concentration
ranging from 0.3 to 0.8
Low Flow NIV
Non Rebreather
• A simple mask with an attached 300 to
600 mL reservoir bag with a valve
• This valve prevents exhaled gas from flowing
into the reservoir and flows out of the mask
ports.
• Flow rate up to 15L/min
High Flow NIV
Optiflow
• Allow for blending of 100% O2 and room air to produce
gas with the desired FiO 2 (up to 60 L/min)
• Optiflow Physiologic mechanism : washout of physiologic
dead space, decreased RR, increased tidal volume,
increased end-expiratory volume, and some small degree
of positive end-expiratory pressure
• Allows for the delivery of air volumes that essentially
washes out the pharyngeal dead space  CO2 is
replaced O2  creating greater O2 gradient  improved
breathing efficiency
High Flow NIV
CPAP BPAP
• Continuously applies a constant level • The device alternates delivering
of positive end-expiratory pressure inspiratory positive airway pressure
(PEEP) to a spontaneously breathing (IPAP) and expiratory positive airway
patient pressure (EPAP).
• The delivered PEEP increases the
patient’s functional residual capacity
(FRC), opens underventilated alveoli,
decreases atelectasis, and improves
lung compliance.
Invasive Ventilation
Terminology
• PEEP (Positive end-expiratory pressure)  pressure applied by the ventilator at the end of each
breath to ensure that the alveoli are not so prone to collapse. This 'recruits' the closed alveoli in
the sick lung and improves oxygenation.
• Lung compliance  measure of distensibility of the lungs—it is the change in volume per unit
change in transpulmonary pressure
• Compliance = delta volume/ delta transpulmonary pressure

• Low compliance  the lungs are stiff or noncompliant  lung expansion difficult and increasing the
WOB
• High compliance  incomplete exhalation, air trapping, and reduced CO2 elimination due to a lack of
elastic recoil in the lung (eg emphysema).
• Airway resistance is the obstruction to airflow in the airways, normally 0.5 to 2.5 cm H2O/L/s1 in
health. It is affected by 2 main factors: the velocity of gas flow and the airway radius.
Mechanics of Ventilation
• Gas flows into the lungs down the transairway
pressure gradient:
Trans airway pressure gradient =
airway pressure – alveolar pressure

This gradient can be generated via positive- or negative-pressure ventilation.

• Negative-pressure ventilation (eg iron lungs) creates this pressure by applying a negative
pressure to the chest wall which subsequently decreases alveolar pressure.

• Positive pressure ventilation creates the pressure gradient by applying a positive pressure
at the airways.
 • Pressure at point B ~ alveolar pressure 
Mechanics of Ventilation volume required to inflate the alveoli divided
compliance of the alveoli plus the baseline
PEEP.
• Pressure at point A is ~ airway pressure
measured by the ventilator  is product of
flow and resistance added to the pressure at
point B.

If considering this as an ideal pair of

Alveoli
lungs, then flow, volume, and
pressure are variables whilst
resistance and compliance are
constants.
 Determinant of Mechanical Ventilation
LIMIT: CYCLE
How many When Inspiration
breath? ends?

TRIGGER
What initiate the
breath?

Celli BR. Mechanical Ventilatory Support. In: Loscalzo J, editor. Harrison's Pulmonary and Critical Care Medicine. Philadelphia: McGraw-Hill
Education; 2017.
Trigger : what the ventilator senses to initiate an
assisted breath.
• Triggering variable:

• Time  Breath according to a set respiratory rate, independent of patient

effort. Cth RR 15/min  respiratory cycle last 4 seconds
• Pressure  Spontaneous breath  drop airway pressure below set PEEP 
reach tigger pressure  breath initiated
• Flow  Inspiratory flow of gas during spontaneous breath  initiate
inspiration
• Neural assist  ventilator is able to sense electrical diaphragmatic activity 
initiates an assisted breath
Cycle : What ends inspiration

• Volume: cycling terjadi setelah preset volume diberikan  eg: volume

tidal 500  ekspirasi setelah Vt tercapai
• Time: cycling terjadi setelah preset time tercapai  eg: RR 15; I:E 1:1 
breath tiap 4 detik, inspirasi 2 detik, ekspirasi 2 detik
• Flow: cycling setelah flow turun ke preset inspiratory flow rate tertentu
• Pressure: cycling setelah preset pressure tercapai
Limit : What target or limit is achieved during
inspiration
• A limit is the mechanism that determines how the breath is delivered to the patient rather than
the factor that brings inspiration to an end.

• Flow limited  A fixed flow is delivered over a set time intervals so that a
known tidal volume will be delivered to the patient
• Pressure limited  A fixed pressure is set with a fixed time interval and the
volume delivered varies with patient characteristics such as lung compliance.
Ventilator Breath Types
(1) Controlled breath: initiated by the ventilator
(a) Preset volume
(b) Preset pressure

(2) Assisted breath: initiated by the patient and assisted by the ventilator
Modes of Ventilation
• Continous Mandatory Ventilation
• Ventilation will be controlled if there are no spontaneous breaths but can be assisted if there are spontaneous breaths.
• The breath type is always a mandatory breath (preset volume or pressure).

• Volume Control (VC)

• Trigger is time  depends on the set frequency
• When the patient is making spontaneous efforts, the trigger is either flow or pressure.
• The user sets the tidal volume, respiratory rate, I:E ratio, and PEEP.
• No compensation for leaks and airway pressures may vary with changing lung compliance/resistance which can contribute to barotrauma

• Pressure Control (PC)

• Trigger is time

• Inflation pressure is set by the operator and the ventilator delivers an inspiratory flow in order to reach this set pressure.
• The resultant tidal volume depends upon the compliance and resistance of the respiratory system.
• The user sets the inspiratory airway pressure, respiratory rate, I:E ratio, and PEEP.
• Pressure Regulated Volume Control (PRVC)

• Hybrid volume control – pressure control

• combination of alteration in inspiratory time and peak flow in response to the breath-by-breath changes in airway or compliance
characteristics.
• Synchronous Intermittent Mandatory Ventilation (SIMV)
• SIMV allows spontaneous breathing between ventilator breaths.
• If the patient is apnoeic, the ventilator will deliver these breaths as mandatory breaths.
• The mandatory ventilator breaths during SIMV can be volume controlled or pressure controlled
• the spontaneous breaths will be synchronised to mandatory breath if it falls on the SIMV period or pressure-supported when it falls in
the spontaneous period triggered by pressure or flow.
• This mode can allow for some spontaneous respiratory effort and aid weaning from a ventilator
• Pressure- Support Ventilation
• The operator sets the inspiratory pressure which supports the patient’s effort. A backup ventilation setting is used in case of apnoea.
• The ventilator delivers a high initial flow rate (peak inspiratory flow) until the set airway pressure is reached. Cycling from inspiration
to expiration occurs when the inspiratory flow rate during the deceleration phase of inspiratory flow falls to the set expiration trigger
sensitivity (ETS), which is set as a percentage of peak inspiratory flow.
 Strategi Pemilihan Mode
Controlled/Assist vs Spontaneous?
 No neurological drive of breathing; respiratory
muscle weakness; increased WOB; ARDS

Initiate their own breathe?

 Controlled vs Assist; role of SIMV

Volume vs Pressure?
 No obvious difference (Campbell et al, 2002);
Both may be used in respiratory failure (Rittayamai et
al, 2015); No difference in ARDS (Cochrane Review,
2015)

Chacko, Binila, et al. "Pressure‐controlled versus volume‐controlled ventilation for acute respiratory failure due to acute lung injury (ALI) or acute respiratory distress syndrome (ARDS)." Cochrane
Database of Systematic Reviews 1 (2015).
Putowski Z, Czok M, Liberski PS, Krzych LJ. Basics of mechanical ventilation for non-anaesthetists. Part 1: Theoretical aspects. Adv Respir Med. 2020; 88: 424–432
Protective Alveolar
Ventilation
• Once the patient has been intubated, the basic goals of MV are to
optimize oxygenation while avoiding ventilator­induced lung injury due
to overstretch and collapse/re­recruitment.
• Alveoli tend to close if the distending pressure falls below the lower
inflection point A, whereas they overstretch if the pressure within
them is higher than that of the upper inflection point B.
• Protective ventilation (purple shaded area), using a lower tidal volume
(6 mL/kg of ideal body weight) and maintaining PEEP to prevent
overstretching and collapse/opening of alveoli  improved survival
rates among patients receiving mechanical ventilatory support.
 Kriteria Weaning
Subjektif (Keadaan Umum):
 Perbaikan gagal napas; kesadaran baik; tanpa
sedasi/neuromuskular agent

Objektif (Hemodinamik):
 Hemodinamik stabil

Oksigenasi (AGD):
 PaO2 ≥ 60 mmHg, PaCO2 ≤ 50 mmHg
 No acidosis
 RR ≤ 35x, SpO2 > 90%, FIO2 < 0,4 (P/F Ratio ≥ 200)
 Minimal PEEP (≤ 8 mmHg)

Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. 2016;4(2):65.
 Trial Weaning (SBT: Spontaneous Breathing Test)
Metode SBT:
 T piece: Supplemental O2 diberikan via ETT
 CPAP: Supplemental O2 + PEEP (1-5 cmH20)
 PS: Supplemental O2 + minimal PS (5-8 cmH20)

Durasi SBT: 30-120 menit

Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. 2016;4(2):65.
 Kriteria keberhasilan SBT

Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. 2016;4(2):65.
 Evaluasi Kesiapan Ekstubasi

Gagal ekstubasi: kebutuhan re-intubasi dalam 48

jam pasca ekstubasi

Zein H, Baratloo A, Negida A, Safari S. Ventilator weaning and spontaneous breathing trials; an educational review. Emergency. 2016;4(2):65.