INDICATIONS FOR VENTILATORY

SUPPORT
Acute Respiratory Failure (ARF)
Inability of a patient to maintain
adequate PaO2, PaCO2, and potentially
pH.
Impending Respiratory Failure
Respiratory failure is imminent in spite
of the therapies.
Commonly defined as: patient barely
maintaining of normal blood gases at
the expense of significant WOB.
Prophylactic Ventilatory Support
Clinical conditions in which there is high
risk of future respiratory failure.
Ventilator support is instituted to WOB
minimize O2 consumption and
hypoxemia, reduce cardiopulmonary
stress, and/ control airway with
sedation.
Eg. Brain injury, heart muscle injury,
major surgery, shock (prolonged),
smoke injury
Hyperventilation Therapy
Ventilator support is instituted to control
and manipulate PaCO2 to lower than
normal levels.
Eg. Acute head injury

CONTRAINDICATIONS TO VENTILATORY
SUPPORT
Absolute Contraindications
Untreated tension pneumothorax (PPV)
Patients informed refusal
Relative Contraindications
Medical futility
Patient pain and suffering
TWO TYPES OF ACUTE RESPIRATORY
FAILURE
Hypoxemic Respiratory Failure
Known as:
Type 1 ARF, Lung Failure
Oxygenation Failure
Respiratory Insufficiency
Definition:
The failure of lungs and heart to provide
adequate O2 to meet metabolic needs.
Criteria:
PaO2 <60mmHg on FIO2 >50 or PaO2
<40mmHg on any FIO2
SaO2 <90
Basic Causes:
Right-left shunt
Ventilation/perfusion mismatch
Alveolar hypoventilation
Diffusion defect
Inadequate FIO2
Hypercapnic Respiratory Failure
Known as:
Type 2 ARF, Pump Failure
Ventilatory Failure
Definition:
The failure of the lungs to eliminate
CO2
Criteria:
Acute in PaCO2 >50mmHg or Acute above
normal baseline in COPD with concurrent
in pH <7.30
Basic Causes:
Pump failure (drive muscles WOB)
CO2 production
R-L shunt
deadspace





PARAMETERS COMMONLY USED TO
DETERMINE VENTILATORY NEED
PARAMETER NV MV
Ventilation
PaCO2
pH
VD/VT

Oxygenation
PaO2






SaO2
Pa-aO2
PaO2/PAO2
PaO2/FIO2
Qs/Qt shunt

35-45mmHg
7.35-7.45
25-40%


75-100mmHg
(air)





>95%
10-25mmHg
0.8-0.9
350-400 mmHg
<5%

50-55mmHg
<7.25
>60%


<50mmHg
(air)
60mmHg
(50% O2)
<200mmHg
(100% O2)

<75%





TYPES OF MECHANICAL VENTILATION
Full Ventilatory Support
Ventilator does all the WOB necessary
to maintain effective alveolar ventilation.
Goal:





Indications:




Clinical Note:




Partial Ventilatory Support
Patient and ventilator share the WOB
necessary to maintain effective alveolar
ventilation.
Goal:
Achieve only partial control of the
patients ventilatory pattern, allow the
patient to breathe either spontaneously
or trigger the ventilator
Indications:
Allow patients to maintain respiratory
muscle tone, improve patient comfort
Weaning
Clinical Note:
In the majority of ventilation modes the
clinician decides on the balance of
WOB provided by the patient vs the
ventilator.
The exception is A/C, where the
ventilator provides most of the WOB.
VENTILATOR PARAMETERS
Volumes
Minute Volume (VE)
5-10L/m
The amount of air moved in and out
of the lungs in a minute period.
Too small VE hypoventilation &
possible hypoxemia
To large VE hyperventilation
Tidal Volume (VT)
5-12mL/kg
Volume of air delivered to the
patient for a single inspiratory
breath.
Rate changes, rather than VT
changes, are more commonly
employed to regulate PaCO2.
Small VT may result in atelectasis,
hypoventilation, & hypoxemia
Large VT, result in volutrauma,
hyperventilation and decrease CC.
VT inspired by the patient is usually
less than the VT delivered by the
ventilator d/t compressible volume
loss.
Rate
Ventilator Rate (f)
8-12 bpm
Number of breaths per minute delivered
by the ventilator.
Rate is the main parameter adjusted to
change VE & PaCO2
Faster rates used in restrictive disease
(short TC)
Slower rates used in obstructive
disease (long TC)
Slow rates, lead to hypoventilation,
hypoxemia, & patient ventilator
asynchrony
Fast rates, lead to hyperventilation or
inadequate TI/TE, resulting in air-
trapping (auto-PEEP)
Pressures
Peak Inspiratory Pressure (PIP or Ppeak)
<35 cm H2O
Highest (peak) proximal airway
pressure reached during inspiration.
Too low PIP, result in hypoventilation &
atelectasis
Too high PIP, risk of barotraumas


Mean Airway Pressure (Paw)
The mean (average) proximal airway
pressure during the entire respiratory
cycle.
Is the function of PIP, PEEP, TI, TE, VI,
and VI waveform
It may be a set parameter on never
ventilators.
Paw is the major determinant of
oxygenation.
Too low, may result in hypoventilation
and atelectasis
Too high, can increase risk of
barotraumas, compromise both
ventilation and oxygenation effects,
compromise hemodynamics
Plateau Pressure (Alveolar Pressure)
(Pplat/Palv)
<30cm H2O
The average alveolar pressure during
the inspiratory phase.
Is the proximal airway pressure
measured during and inspiratory hold.
PEEP
2-10 cm H2O
Positive end expiratory pressure applied
during MV
Increases FRC by stabilizing open
alveoli to prevent collapse.
FRC leads to:
o atelectasis - shunt - V/Q
o CL - WOB
o minimizes shear force lung injury
PEEP also Paw - gas exchange
Too low, may lead to alveolar collapse
and FRC
Too high, may lead to over-distention
TYPES OF PEEP
PEEPE (extrinsic or applied PEEP)
Purposely applied by the mechanical
ventilator
PEEPI (intrinsic, inadvertent, occult, auto-
peep)
Advertently applied by the mechanical
ventilator
Fast rates/short TE
Total PEEP
PEEPE + PEEPI
Optimal PEEP
PEEP level at which obtain maximal
oxygenation (increased CaO2) with
minimal hemodynamic compromise
Time
Inspiratory Time (TI)
0.5-1.2 sec
The duration of the inspiratory phase.
In VV, TI is commonly the result of
VT/VI
In PV, TI is commonly a set parameter
Short TIs, are commonly used in
patients with decrease CLT (short TC)
Longer TIs, are commonly used in
patients with Raw (long TC)
Long TIs are used to Paw ( TI -
Paw - PaO2)
The longer the TI, the more time
available to deliver the VT, hence ^
alveolar distention and gas exchange.
Expiratory Time (TE)
1.0-1.2 sec
Time duration of the expiratory
phase.
Short TE, faster rate and larger I:E
ratio
TE, may be set parameter but is
more commonly the result of a set TI
(PV), VT (VV) and rate (F)
Longer the TE the more time
available for lung emptying
Short TE, may result in adequate
emptying of the lung resulting in
auto-PEEP
Long TE, may result in
hypoventilation and hypoxemia
I:E Ratio (I/E; Duty Cycle)
1:1.5-1:4
Ratio of inspiratory time to expiratory
time
I:E ratio may be determined by:
o TI and F
o VT, VI, and F
o Set I:E
Inspiratory Pause (Inflation Hold or Plateau)
0.5-3 sec
A delay in the onset of expiration after
inspiration is complete.
Its primary use is to measure static lung
compliance or Pplat.
Expiratory Hold (End Expiratory Pause)
0.5-2.0 sec
A delay in the onset of inspiration and
the prevention exhalation.
The primary use of the expiratory hold is
to measure auto-PEEP, but is only
accurate if no spontaneous efforts by
the patient.
Flow
Inspiratory Flow (VI)
40-100 L/m
The rate st which gas is delivered to the
patient during the inspiratory phase.
Used to provide the desired TI, I:E ratio,
and inspiratory pattern
Goal: VI > peak inspiratory demand
Slower VI, used in patients with Raw
and/ poor gas distribution.
Slow VI, may PIP and risk
barotraumas in certain disease states
Fast VI, may WOB and improve
patient comfort in patients with high
inspiratory demand.
Slow VI, flow-starvation, resulting in
WOB, patient discomfort, and possibly
hypoventilation.
Slow VI, results in long TI and short TE,
leading to patient discomfort and/air
trapping (auto-PEEP)
Fast VI, may cause Raw, PIP, and/
distribution of ventilation.
Inspiratory Flow Waveform (VI waveform)
The flow pattern in which inspiratory
flow is delivered.
Rise Time
The time required to reach the pressure
target (PIP) in PV.
the rise time by VI
the rise time by VI
Rise time is generally adjusted to soften
(slow) the initial rapid VI.
Patient may need a slower rise time for
patient-ventilator synchrony
Oxygen
FIO2
Whatever is necessary to maintain
PaO2
60-100mmHg / SaO2 >90%
The fraction of inspired oxygen
delivered to the patient by the ventilator
Low FIO2, leads to hypoxemia and
hypoxia
High FIO2, may cause O2 toxicity (lung
damage) and intrapulmonary shunting
(absorption atelectasis)
Adjuncts
Sensitivity (Inspiratory Trigger Sensitivity)
The level of spontaneous effort
(pressure/flow) needed to trigger a
machine inspiratory.
Too sensitive, leads to self-cycling
(auto-triggering), air-trapping
Too insensitive, promotes increased
WOB, atelectasis, patient discomfort,
and patient-ventilator asynchrony
Sigh (Periodic Hyperinflation)
The periodic delivery of a larger normal
VT.
Are not recommended when using large
VT, when Pplat is >35cm H2O / for
spontaneous breathing patients on
CPAP.
Humidification
100% humidity at body
The delivery of heated humidified gas to
the patient
Prevents water loss from the airway.
HMEs may be used except when:
o secretions are thick, copious
and/ bloody
HYPERVENTILATION ALKALOSIS
HYPOVENTILATION ACIDOSIS