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Ventilator:
A machine used to assist or replace the
work generated by the ventilatory
muscles.
Mechanical Ventilation:
Use of a ventilator to move gas into and
out of the pulmonary system.
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Mechanical Ventilation
Ventilators deliver gas to the lungs using
positive pressure at a certain rate.
The amount of gas delivered can be
limited by time, pressure or volume.
The duration can be cycled by time,
pressure or flow.
Indications
Respiratory Failure
Apnea / Respiratory Arrest
inadequate ventilation (acute vs. chronic)
inadequate oxygenation
chronic respiratory insufficiency with FTT
Cardiac Insufficiency
eliminate work of breathing
reduce oxygen consumption
Neurologic dysfunction
central hypoventilation/ frequent apnea
comatose patient, GCS < 8
inability to protect airway
Closed Loop vs Open Loop
Control of Ventilator
control controlled
circuit controller system
(patient)
+
inspiratory
limit control
ventilator
setting signal
-
feedback signal
(pressure, volume, or flow)
Closed Loop
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Flow sensitivity
Types of Ventilator Breaths
Volume-Cycled Breath (Volume Breath)
Time-Cycled Breath (Pressure Control Breath)
Flow-Cycled Breath (Pressure Support Breath)
20 20
Paw
Pressure Paw
0 0
1 2 0 1 2
20 20 20 20
Volume
0 0
0 0
0 1 2 0 1 2
3 3
-3 -3
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Open Lung Strategy
Zone of Overdistension
Zone of Atelectasis
Volume control mode Pressure control mode
VENTILATOR INITIATION
(CONVENTIONAL VENTILATOR)
In the beginning, one must choose :
appropriate device
mode of ventilation
initial ventilator settings
The goal of initial settings :
To optimize the patients oxygenation,
ventilation and acid base balance
To avoid harmful side effects:
hemodynamics, barotrauma,
volutrauma & oxygen toxicity
SELECTION OF A VENTILATOR
Airway Pressures
Peak Inspiratory Pressure (PIP)
Positive End Expiratory Pressure (PEEP)
Pressure above PEEP (PAP or P)
Mean airway pressure (MAP)
Continuous Positive Airway Pressure (CPAP)
Inspiratory Time or I:E ratio
Tidal Volume: amount of gas delivered with
each breath
Ventilatory Parameters
Tidal volume (V T):
8 ml/kg
Peak Inspiratory Pressure (PIP) or
Inspiratory Pressure Limitation (IPL):
Should not > 20 25 cm H2O
Changes in inspiratory pressure should be undertaken in
2 cm H2O
Frequency :
Babies : 30 40 x/min
Infants : 20 25 x/min
Older children : 15 20 x/min
Changes in the ventilatory frequency are made in steps
of 3 5 /min
Ventilatory Parameter
Inspiratory/Expiratory Ratio (I/E Ratio) :
RR = 60/ (TI + TE)
Severe restrictive ventilatory disorders (ARDS)
TI
Obstructive ventilatory disorders (asthma)
TI and TE
TI normal : 0.4 1.0
TE should not < 0.25 to avoid air trapping
Normal I:E ratio 1:1 and 1:2
Ventilatory Parameter
Flow:
Babies : 4 10 L/minute
PIP Flow
CPAP flow rate in constant flow ventilator
2.5 3 times MV (VT x RR).
Minimum of a 3-4 L/m
PEEP:
4 8 cm H2O
Changes in PEEP level should be undertaken in
steps of 1 or 2 cm H2O
Ventilatory Parameter
I E
Airway Pressure and Flow Tracing
AC+PEEP CMV
Time
CPAP
Lung
Volume
Airway
M M M M
Pressure
Time
Assist Control
Lung
Volume
Airway
Pressure M M P P
Time
Assist-control, volume
Lung
Volume
Airway
Pressure M M
P P
Time
SIMV Mode
Synchronised Intermittent Mandatory Ventilation
Combination of machine ventilation and spontaneous breathing
Patient can breath spontaneously in prescribed cycles
Mechanical mandatory ventilation synchronise with patient
Pressure Support
Preset pressure boost on inspiration
Delivery of a variable tidal volume based
on lung, chest wall, ventilator system
compliance and patient effort
Requires a spontaneously breathing
patient
SIMV with Pressure Support
Lung
Volume
Airway
Pressure M M P P
Time
CPAP + PSV
Lung
Volume
Airway
Pressure P P P P
Time
Tidal Volume
Good Bad
U
g
l
y
Lung
Volume
Peak Airway Pressure
Time
Troubleshooting
Is it working ?
Look at the patient !!
Listen to the patient !!
Pulse Ox, ABG, EtCO2
Chest X ray
Look at the vent
(PIP; expired TV; alarms)
Troubleshooting
When in doubt, DISCONNECT THE
PATIENT FROM THE VENT, and begin
bag ventilation.
Ensure you are bagging with 100% O2.
This eliminates the vent circuit as the source
of the problem.
Bagging by hand can also help you gauge
patients compliance
Troubleshooting
Airway first: is the tube still in? (may need
DL/EtCO2 to confirm) Is it patent? Is it in the
right position?
Breathing next: is the chest rising? Breath
sounds present and equal? Changes in exam?
Atelectasis, bronchospasm, pneumothorax,
pneumonia? (Consider needle thoracentesis)
Circulation: shock? Sepsis?
Trouble Shooting
Dont be a DOPE
Disconnect the patient from the vent and
bag the patient with 100% oxygen
Confirm ETT placement-Airway
Auscultate the lungs-Breathing
Consider other causes of circulatory
compromise-Circulation
Keep needle and tube thoracostomy kit handy
Common Problems: DOPE
Dislodge: Extubation,
Obstructed: Plug, mainstem, kink
Pneumothorax - Tension
Equipment failure etc.: Ventilator, suction,
oxygen delivery, nebulizer, agitation, dynamic
hyperinflation
Troubleshooting
Improving Ventilation and/or Oxygenation
can increase respiratory rate (or decrease rate if
air trapping is an issue)
can increase tidal volume/PAP to increase tidal
volume
can increase PEEP to help recruit collapsed
areas
can increase pressure support and/or decrease
sedation to improve patients spontaneous effort
Trouble Shooting
Adjusting PaO2:
To decrease :
FiO2 should be decreased of 10-20%.
Rule of 7 : there will be a 7 mmHg decrease in
PaO2 to each 1% decrease in FiO2
To increase:
Correction of the respiratory acidosis will
improve oxygenation
PEEP can be added in increments
from 2-4 cm H2O
Increase I:E ratio
Trouble Shooting
Adjusting PaCO2:
To decrease:
Increase the rate
Increase the tidal volume
To increase:
Check the leaks in the systems
Decrease the rate
Decrease the tidal volume
Determine the cause of hyperventilation
Rule out artificial causes of increased
respiratory rate
Weaning Off
Steps for reducing mechanical vent support :
Reduction of the FiO2 concentration
Normalization of the I:E ratio
Reduction of the PEEP
Alternate ventilatory modes allowing spontaneous
respiratory effort (SIMV, ASB, BIPAP, CPAP)
Reduction or adjustment of the analgesic and
sedation
Weaning Criteria
Stable clinical situation
Adequate ventilatory situation
Adequate cerebral functions
Stable cardiovascular situation
Adequate fluid balance
Stable gastrointestinal function
Good balanced metabolic situation
No extreme catabolism
Extubation Criteria
Extubation (minimum value)
Gas exchange :
PaO2 with FIO2 < 0.4 > 8 kPa
PaO2/FiO2 > 200
PaCO2 < 6 kPa
pH > 7.35
Breathing mechanics :
RR < 35 x/m
VT > 5 ml/BW
Vital capacity > 10-15 ml/BW
Inspiratory effort > 25 cm H2O
Symptoms of weaning failure
Increasing tachypnea
Reduced tidal volume
Thoraco-abdominal discoordination
Secretion retention
Restlessness
Tachycardia
Hipertension
Weaning Algorithm
Special situations I
Obstructive Diseases
Asthma and RSV Bronchiolitis
Watch for air trapping / breath stacking
Low rate, larger Tidal volume, long
Expiratory time
check Autopeep
preserve I-time
Consider Heliox, Ketamine, Halothane
Special situations II
Restrictive disease (ARDS)
Limit Tv accept hypercapnia
Increase PEEP for FRC
Prone positioning
CaO2 and tolerate lower Sat %
consider High Frequency Oscillatory
(HFO) Ventilation>>> Surfactant>>>
Nitric Oxide
Adverse effects of
mechanical ventilation :
Increase in intra-thoracic pressure
Decreased venous return
Increased pulmonary vascular resistance
Reduction in cardiac output
Decreased perfusion of kidneys, liver and
viscera
Reduced venous return from the brain and
consequent increased intra-cerebral pressure
Barotrauma
Complications
Ventilator Induced Lung Injury (VILI)
Oxygen toxicity
Barotrauma / Volutrauma
Peak Pressure
Plateau Pressure
Shear Injury (tidal volume)
PEEP
Complications
Cardiovascular Complications
Impaired venous return to RH
Bowing of the Interventricular Septum
Decreased left sided afterload (good)
Altered right sided afterload
Sum Effect..decreased cardiac output
(usually, not always and often we dont
even notice)
Complications
Other Complications
Ventilator Associated Pneumonia
Sinusitis
Sedation
Risks from associated devices
(CVLs, A-lines)
Unplanned Extubation
Getting Started (Parameters)
PEEP Rate
FIO2
Getting Started (Mode)
Volume Pressure
Pros Preserve MV Avoid PP
Easy Familiar (NICU)
Decelerating Flow
Cons PP ?? MV??
Constant flow
Control vs. SIMV
Control Modes SIMV Modes
Every breath is Vent tries to synchronize
supported regardless of with pts effort
trigger
Cant wean by Patient takes own breaths
decreasing rate in between (+/- PS)
Patient may Potential increased work of
hyperventilate if agitated breathing
Patient / vent
Can have patient / vent
asynchrony possible and
may need sedation +/- asynchrony
paralysis
Pressure vs. Volume
Pressure Limited Volume Limited
Control FiO2 and Control minute
MAP (oxygenation) ventilation
Still can influence Still can influence
ventilation oxygenation
somewhat somewhat (FiO2,
(respiratory rate,
PAP)
PEEP, I-time)
Decelerating flow Square wave flow
pattern (lower PIP pattern
for same TV)
Pressure vs. Volume
Pressure Pitfalls Volume Vitriol
tidal volume by change no limit per se on PIP
suddenly as patients (usually vent will have
compliance changes upper pressure limit)
this can lead to square wave(constant)
hypoventilation or
overexpansion of the flow pattern results in
lung higher PIP for same
if ETT is obstructed tidal volume as
acutely, delivered tidal compared to Pressure
volume will decrease modes
Trigger
How does the vent know when to give a
breath? - Trigger
patient effort
elapsed time