Definition.

Indications
Ventilator
Settings
Modes of
Ventilation
Weaning
Summary

Use of a mechanical apparatus to provide

the requirements of a patients breathing.

Use of positive pressure to physically

transport gases into and out of lungs
(earlier ventilators used negative pressure)

Usually performed via ETT but not always

(noninvasive ventilation)

A supportive measure not a therapy

Must diagnose and treat underlying

cause

Used to support &/or rest patient until

underlying disorder improved

Acute resp failure:

ARDS
Heart failure.
Pneumonia
Sepsis.
Complication of surgery.
Trauma

Acute exacerbations COPD.

Neuromuscular diseases.

FIO2
Volume (VT)
Rate
Pressure
PEEP
I:E
Flow rate

Fraction of inspired oxygen (FiO2):

Target Sao2 90 % & Pao2< 60mmHg.

Atempt to keep FiO2 <50% to avoid O2 toxicty.

Tidal volume (Vt):

Is constant in volume-cycled modes and variable

with in pressure-limited modes.
In patients without lung disease Vt of 8 - 10 mL/kg .
Lower Vt 6 ml/kg are recommended for ARDS, &
Vt 8 mL/kg is recommended in patients with asthma,
COPD(as long as no increase in plateau presure).

Respiratory rate (RR):

12 and 20 breaths per minute is reasonable.
Determine minute ventilation.

Minute ventilation (VE):

Is the product of the Vt and RR.
V is based on PaCO2 as a marker of ventilatory
requirements.
V of approximately 5 L/min maintain
normocapnea.
Permissive hypercapnia is allowed in ARDS and
status asthmaticus.

Inflation pressure limit:

High inflation pressures cause barotruama.

Increased Pplat, is most injurious, reflecting
alveolar overdistention and not airway resistance.
Pplat > 30 cm H2O is recommended.

Inspiratory Sensitivity :

It is the drop in airway pressure that is required

before the ventilator senses the patient's effort.
0.5 to 1 cm H2O allow very weak patients to
initiate a breath, Higher values make triggering
more difficult.

Inspiratory flow rate:

The ratio of Vt to inspiratory flow rate determines inspiratory time

(Ti).
inspir flow rate
Ti
time for expiration
auto PEEP.
inspir flow rate
PIP & not Pplat.
COPD & asthma the expiratory time should be increased to allow
exhalation of trapped gas.

Positive end-expiratory pressure (PEEP):

PEEP is the maintenance of positive pressure after expiratory

flow is completed.
Useful to treat refractory hypoxemia
Complication:
Hypotension
Diastolic dysfunctions
Barotrauma

MV may be:

Invasive, delivered
through an
endotracheal tube
(ETT) or
tracheostomy tube.

Noninvasive positive
pressure ventilation
(NIPPV) interfaces
the ventilator with
the patient through a
full-face or nasal
mask.

Volume cycled MV:

Pressure-limited MV:

Delivers a preset (Vt) specified

by the operator.

Delivers a flow until a preset

pressure limit that is set by the
operator is reached.

(PIP) are, depending on the

patient's compliance.

PIP is always the same but Vt is

variable, according to the
patient's compliance.

Examples:
Pressure Support Ventilation
(PSV)
Pressure Control Ventilation
(PCV)
CPAP
BiPAP

Examples:
Assist/Control
Intermittent Mandatory
Ventilation (IMV)
Synchronous Intermittent
Mandatory Ventilation
(SIMV)

Every breath is an assisted breath.

The patient determines the inspiratory
flow rate and the RR.
Advantages:
Better patient synchrony
Limits Peak inspiratory Pressure.
Disadvantages:
Inadequate volumes if the ETT is
blocked or decreased lung
compliance.
Apnea backup is less supportive
than that of AC

Controlled breaths are

delivered at a preset time
interval.
RR, maximal pressure limit
are both controlled.
Spontaneous breaths is
allowed between the
mandatory breaths.
Advantades:

Decrease risk of barotrauma

Used in inverse ratio
ventilation.

Disadvantages:

Cannot ensure minimal VE

Used for oxygenation and as a mode of

weaning.
patient assumes most of the work of
breathing & determine RR, Vt & VE.

Ventilator delivers two levels of positive

airway pressure for preset periods of time.

Advantages:
Decreased

requirement for sedation.

Used in Obstructive Sleep Apnea.

Disadvantages:
Theoretical

risk of over-distension of lungs.

Pt RR < preset rate so all

breath will be assisted.
Pt RR > preset rate so all
breath will be controlled.
Advantages:

Ensures a minimum VE.

Better patient synchrony.

Disadvantages:

Induce respiratory alkalosis if

high respiratory drive (i.e.,
liver failure).

Ventilator

will deliver a preset volume at a specific

time intervals.
Different from Controlled mode: pt can initiate
spontaneous breaths.
Different from Assisted mode: spontaneous breaths
are not supported by machine.
Advantages:
Assures a VE
Disadvantages:
Patient asynchrony.

Delivered spontaneous,
assisted, and mandatory
breath.
Most commonly used mode.

Advantages:
Ensures a minimum VE.

Disadvantages:
The worst mode of
weaning.

Avoids intubation and complications.

Can deliver various modes of ventilation
Indications:

Hypercapneic respiratory failure (COPD exac).

Cardiogenic pulmonary edema.
Hypoxic respiratory failure.

Contraindications:

Inability to cooperate (i.e. Confusion).

Inability to clear secretions.
Hemodynamic instability.
Frature skull base as it may cause
pneumoencephaly.

Volume Support.
Pressure-Regulated Volume Control (PRVC).
Volume-Assured Pressure Support.
Automode.
Adaptive support ventilation (ASV).
Proportional Assist Ventilation(PAV).
Mandatory Minute Ventilation.
Airway Pressure Release Ventilation
(APRV).

When:

The underlying pathology improves.

Hemodynamically stable.
Oxygenation:

PaO2/FiO2 >200,
PEEP<7.5 cm H2O,
FiO2<0.5

Indices:

Rapid shallow breathing:

RR/Vt > 105 positive predictive value of 78%.

RR/Vt < 105 negative predictive value of 95 %.

Maximal Inspiratory Pressure(Pmax)

Excellent negative predictive value if less than 20 cm H2O .

Methods:

Spontaneous breathing trials:

complete withdrawal of MV
Only one trial every 24-hour

CPAP:

Allow monitoring of RR, Vt & VE

Pressure support ventilation (PSV)

SIMV:

Gradual reduction in the level of PSV

The worst mode of weaning.

Duration:

Short-term MV (<21 days)

prolonged MV (>21 days)

30 to 120 minutes
at least 24 hours.

Auto-PEEP.

Poor nutritional status.

Overfeeding.

Left heart failure.

Decreased magnesium and phosphate levels.

Infection/fever.

Major organ failure.

Clinical criteria :
Diaphoresis .
Increased respiratory effort .
Paradoxical breathing & use of accessory respiratory.
Cardiac:
HR < 30 beats/min over baseline.
Profound bradycardia.
Ventricular ectopy.
Supraventricular tachyarrhythmias.
Mean arterial blood pressure equal to or greater than
15 mm Hg or equal to or less than 30 mm Hg from
baseline.

Respiratory:

RR < 35 breaths/min .
SaO2> 90%.
PaCO2 50 mmHg or increase >8 mmHg.
pH<7.33 or decrease >0.07.
PaO2 60 mm Hg with FiO2 of 0.5.

Ventilator management algorithim

Modified from Sena et al, ACS
Surgery: Principles and Practice
(2005).

Initial intubation
FiO2

PEEP = 5

=RR = 50%
12 15
VT = 8 10 ml/kg

SaO2 < 90%

SaO2 < 90%

FiO2
(keep
Increase
SaO2>90%)
Increase PEEP to max 20
Identify possible acute lung
injury
Acute lung injury
Identify respiratory failure
causes

No injury

Acute lung injury

TV
(lung-protective)
Low
settings
Reduce TV to 6 ml/kg
Increase RR up to 35 to
keep pH > 7.2, PaCO2 < 50
Adjust PEEP to keep FiO2 <
SaO2 < 90%
SaO2 > 90%
60%

SaO2 < 90%

SaO2 > 90%

Associated conditions (PTX,

hemothorax, hydrothorax)
Consider adjunct measures
(prone positioning, HFOV,
IRV)

Continue lungprotective ventilation

until:
PaO2/FiO2 > 300
Criteria met for

SaO2 > 90%

SaO2 > 90%

Adjust RR to maintain PaCO2 Pass SBT
Extubat
= 40
Reduce FiO2 < 50% as Airway stable e
tolerated
Reduce PEEP < 8 as tolerated
Fail SBT
Assess
criteria for SBT daily
Airway stable

Persistently fail SBT

Consider tracheostomy
Resume daily SBTs with CPAP
or tracheostomy collar

Pass SBT

Intubated > 2
wks

Prolonged ventilator
dependence
Consider PSV wean (gradual
reduction of pressure support)
Consider gradual increases in
SBT duration until endurance
improves

Pass SBT

Mechanical ventilation used to:

1.
2.
3.
4.
5.

Improve oxygenation.
Improve ventilation (CO2 removal).
Unload respiratory muscles.
Neuromuscular diseases.
Decrease intracranial tension.

A support until patients condition

improves

Different modes for ventilation

Differ in how breaths are initiated, ended and
assisted.
No proven advantage of one mode over the other.
Use ventilator strategies to avoid volutrauma
and other adverse effects.

Numerous trials performed to develop criteria for

success weaning, however, not very useful to predict
when to begin the weaning and physicians should
rely on clinical judgement also.

Daily screening may reduce the duration of

MV and ICU cost.
The removal of the artificial airway from a
patient
who
has
successfully
been
discontinued from ventilatory support should
be based on assessment of airway patency
and the ability of the patient to protect the
airway.
Patients receiving MV who fail an SBT should
have the cause determined.

Tracheostomy should be considered after it

becomes apparent that the patient will
require prolonged MV.

Thank you