Professional Documents
Culture Documents
Ventilation
John J. Marini
Alain F. Broccard
University of Minnesota
Regions Hospital
Minneapolis / St. Paul
USA
Advanced Mechanical Ventilation Outline
…and
Dimensions of a fully
Collapsed Normal Lung
Tension Cysts
Tidally Phasic Systemic Gas Embolism
End-Expiration End-Inspiration
Consequences of Elevated Alveolar Pressure--2
In recent years there has been intense interest in another and perhaps
common consequence of excessive inflation pressure--Ventilator-Induced
Lung Injury (VILI).
VILI appears to develop either as a result of structural breakdown of the
tissue by mechanical forces or by mechano-signaling of inflammation due
to repeated application of excessive tensile forces.
Although still controversial, it is generally agreed that damage can result
from overstretching of lung units that are already open or from shearing
forces generated at the junction of open and collapsed tissue.
Tidally recurrent opening and closure of small airways under high
pressure is thought to be important in the generation of VILI.
Prevention of VILI is among the highest priorities of the ICU clinician
caring for the ventilated patient and is the purpose motivating adoption of
“Lung Protective” ventilation strategies.
Translocation of inflammatory products, bacteria, and even gas may
contribute to remote damage in systemic organs and help explain why
lung protective strategies are associated with lower risk for morbidity and
death.
Recognized Mechanisms of Airspace Injury
Airway Trauma
“Stretch”
“Shear”
Mechanisms of Ventilator-Induced Lung Injury (VILI)
High airway pressures may injure the lungs by repeated overstretching
of open alveoli, by exposing delicate terminal airways to high pressure,
or by generating shearing forces that tear fragile tissues.
These latter shearing forces tend to occur as small lung units open and
close with each tidal cycle and are amplified when the unit opens only
after high pressures are reached.
To avoid VILI, end-inspiratory lung pressure (“plateau”) should be kept
from rising too high, and when high plateau pressures are required,
sufficient PEEP should be applied to keep unstable lung units from
opening and closing with each tidal cycle.
Independent of opening and closure, tissue strain is dramatically
amplified at the junctions of open and closed lung units when high
alveolar pressures are reached.
Extremely high tissue strains may rip the alveolar gas-blood interface.
Repeated application of more moderate strains incite inflammation.
Such factors as breath frequency, micro-vascular pressure,
temperature, and body position modify VILI expression.
End-Expiration Pathways to VILI
Rupture Signaling
inflammatory cascade
A Portal for
Gas & Bacteria?
1µ
Hotchkiss et al
Crit Care Med 2002;
The Problem of Heterogeneity
Finding just the right balance of tidal volume and PEEP to keep the lung as
open as possible without generating excessive regional tissue stresses is a
major goal of modern practice.
Alveolar Collapse
(Reabsorption) 20-60 cmH2O
Consolidation ∞
= Lung Units at Risk for Tidal
Opening & Closure
(from Gattinoni)
Different lung regions may be overstretched or underinflated, even as
measures of total lung mechanics appear within normal limits.
UPPER LUNG
TOTAL LUNG
Lung Volume
Alveolar Pressure
LOWER LUNG
Recruitment Parallels Volume As A
Function of Airway Pressure
Recruitment and
Inflation (%)
Frequency
Distribution of
Opening Pressures
(%)
20 pressure
From Crotti et al
10 AJRCCM 2001.
0
0 5 10 15 20 25 30 35 40 45 50
Paw
[cmH2O]
Zone of
↑ Risk
Dependent to Non-dependent
Progression of Injury
Histopathology of VILI
Supine
Prone
Proning May Benefit the Most Seriously Ill
ARDS Subset
0.5 Supine
Mortality Rate
Prone
0.4
* p<0.05 vs
0.3 Supine
*
0.2
0.1
0.0
> 49 40- 49 31- 40 0 - 31
SAPS
Quartiles II II
of SAPS
Proning Helped Most in High VT Subgroup At
Risk For VILI
0.5
Mortality Rate Supine
0.4 Prone
* p<0.05 vs
0.3 Supine
0.2 *
0.1
0.0
< 8.2 8.2- 9.79.7- 12 > 12
V /Kg
Quartiles of VT /Predicted
T
body weight
How Much Collapse Is Dangerous
Depends on the Plateau
S-C Lim, et al
Crit Care Med 2004
How is the Injured Lung Best Recruited?
• Prone positioning
• Adequate PEEP
• Adequate tidal volume (and/or intermittent ‘sighs’?)
• Recruiting maneuvers
• Minimize edema (?)
• Lowest acceptable FiO2 (?)
• Spontaneous breathing efforts (?)
Severe Airflow Obstruction
Varies with body position and from site to site within the lung
Volume Losses in Recumbent Positions
No PEEP PEEP10
Normal
COPD
Flow Limitation “Waterfall”
PEEP
Adding PEEP that approximates auto-PEEP may reduce the difference
in pressure between alveolus (Palv) and airway opening, thereby
lowering the negative pleural (Pes) pressure needed to begin
inspiration and trigger ventilation.
Adding PEEP Lessens the Heterogeneity of End-expiratory Alveolar
Pressures and Even the Distribution of Subsequent Inspiratory Flow.
PEEP may offset
COPD ASTHMA (COPD) or add to
auto-PEEP
(Asthma),
depending on flow
limitation.
Dependent
Variable
Set Variable
Set Variable
Dependent
Variable
Decelerating flow profile is an option in flow controlled
ventilation but a dependent variable in pressure control.
Peak pressure is a function of flow;
plateau pressure is not
Pressure Controlled
breaths (PCV) do not
restrict flow.
In PCV, tidal volume can be reduced if the inspiratory time or the expiratory time
is too brief to allow the airway and alveolar pressures to equilibrate.
The development of auto-PEEP reduces the gradient for inspiratory flow and
curtails the potential tidal volume available with any given set inspiratory airway
pressure.
These conditions are most likely to arise in the setting of severe airflow
obstruction. Therefore, modifications of the breathing frequency and inspiratory
cycle period (‘duty cycle’) may powerfully impact ventilation efficiency.
Airway
Alveolar Pressure
Pressure
Residual Flows
Paw Reflects Effort and Dys-Synchrony During
Constant Flow Ventilation
Deformed Airway Pressure Waveforms
High Pressure Alarm
Physician Settings
Ideal body weight
% Minute Volume
Maximal Allowed Pressure
Neural Control of Ventilatory Assist
(NAVA)
• Although still in its development phase, the possibility of
controlling ventilator output by sensing the neural traffic flowing
to the diaphragm promises to further enhance synchrony.
• NAVA senses the desired assist using an array of esophageal
EMG electrodes positioned to detect the diaphragm’s
contraction signal.
• The reliability of neurally-controlled ventilator assistance needs
to be determined before its deployment in the clinical setting.
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
Electrode Array in Neurally Adjusted
Ventilatory Assist (NAVA)
Volume
PAW
DGM
EMG
ATC ATC
Postop
Critically Ill
Discontinuation of Mechanical Ventilation
Even when the mechanical requirements of the respiratory system can be met by
adequate ventilation reserve, congestive heart failure, arrhythmia or ischemia may cause
failure of spontaneous breathing.
Integrative Indices Predicting Success
Measured Indices Must Be Combined With
Clinical Observations
Three Methods for Gradually
Withdrawing Ventilator Support
Although the majority of patients do not require gradual withdrawal of ventilation, those
that do tend to do better with graded pressure supported weaning than with abrupt
transitions from Assist/Control to CPAP or with SIMV used with only minimal pressure
support.
Extubation Criteria
Ability to protect upper airway
Effective cough
Alertness
Improving clinical condition
Adequate lumen of trachea and larynx
“Leak test” during airway pressurization with the
cuff deflated