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Basic mechanical ventilation

Manee Raksakietisak, MD, FRCA
Mechanical ventilation has evolved since the days of the polio epidemics. The
advanced in technology have created several modes and models. Despite major advances,
the basic principles of mechanical ventilation have remained the same. This chapter
focuses on the four topics that are important about mechanical ventilation
I.
Indication of mechanical ventilation
II.
Complications related to mechanical ventilation
III.
Basic modes of mechanical ventilation
IV.
Monitor during mechanical ventilation
V.
Discontinuation of mechanical ventilation
I Indication of mechanical ventilation
There are several indications for mechanical ventilation such as
1. Airway protection e.g. stroke, drug overdose, airway surgery, head injury
patient
2. Moderate to severe hypoxemia (oxygenation failure) e. g. severe pneumonia,
sepsis/ARDS, cardiogenic pulmonary edema, pulmonary embolism
3. Moderate to severe hypercarbia/hypercapnia (ventilation failure) e.g. COPD,
drug overdose, neuromuscular disease
4. Decreased work of breathing (mechanical failure) e.g. severe pneumonia,
COPD, asthma
5. General anesthesia and controlled ventilation
6. Support organ function e.g. CPR
II Complications related to mechanical ventilation
CNS: high positive pressure ventilation can obstruct venous drainage from the
brain and increase ICP. Hypo or hyperventilation affect cerebral blood flow
CVS: positive pressure ventilation reduces venous return and cardiac preload and
can cause hypotension
RS: volu-trauma, pressure-trauma
GI: stress ulcer
KUB: water and Na retention
Psychic trauma
Infection (ventilator associated pneumonia
III Basic modes of mechanical ventilation
One needs to understand ventilatory cycle very well and then learn about the
modes.
Ventlatory cycle has four phases
1. trigger or breath initiation
time trigger e.g. set 10 breaths/min, every 6 seconds ventilator deliver one breath
(ventilator in the operating room)
pressure trigger or pressure sensor e.g. patient initiates and creates negative pressure
(normally set negative threshold 0.5-2.0 cmH2 O)
flow trigger or flow sensor e.g. patient initiates and draws flow from the circuit
(normally set 1-3 L/min)
2. deliver (inspiratory valve opened and esxpiratory valve closed)
Flow is delivered and governed by a target or limit set
flow target which is fixed and tidal volume is constant but the airway pressure varies
pressure target which is a limit set, flow and volume vary

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3. Cycle or clying (machine terminates the breath)
volume e.g. 500 ml
time e.g. 1.5 sec.
flow (ETS, expiratory time sensitivity) e.g.flow decreases to 25% of peak flow
pressure e.g. 20cmH2 O
4. expiration (passive lung recoil)
We usually apply PEEP (positive end expioratory pressure) or CPAC (continuous
positive airway pressure) at the end of expiration to prevent lung atelectasis and
improve oxygenation
Basic modes
There are four modes commonly used:
1. volume assist-control mode (VAC or assist-control ventilation, ACV) or
controlled mechanical ventilation (CMV)
Delivers VT that is machine or patient triggered, flow target and at a frequency that at
least equals the preset rate, each breath terminated by a preset VT

Figure 1. VAC mode1

2. pressure assist-control mode (PAC) or pressure controlled ventilation (PCV)
Delivers VT that is machine or patient triggered, pressure target and at a frequency
that at least equals the preset rate, each breath terminated by a preset T i

Figure 2. PAC mode1

3. pressure support ventilation (PSV)

Delivers VT that is patient triggered, pressure target; each breath terminated by a
inspiratory flow decrease to preset % (ETS) of the peak flow; tidal volume, Ti and
frequency (f) are determined by the patient

Figure 3. PS mode1

4. synchronized intermittent mechanical ventilation (SIMV)

Delivers synchronized breath at preset VT that is machine triggered, flow or pressure
target and at a preset frequency ; patient can breath spontaneously with or without
PSV between machine breaths

Figure 4. SIMV mode1

Table 1. Characteristics of four commonly used modes 1

mode
trigger
deliver
cycle
advantages
VAC/CMV time or
fixed flow
volume
guaranteed
patient
rate
VE
PAC/PCV
PSV

SIMV

time or
patient
patient

fixed
pressure
fixed
pressure

time (Ti)

time or
patient

fixed flow
or pressure

volume

flow
(ETS)

patient
comfort
patient
comfort

guaranteed
VE

disadvantages
uncomfortable in
patients who
require high flow
No guaranteed VE
No guaranteed VE
Inadequate for
patients with
unreliable drive
Increased work of
breathing

Setting a ventilator
1. mode
2. FiO2
3. Tidal volume or pressure limit
4. rate
5. I:E, peak flow rate or inspired time
6. PEEP/CPAC

Modes (volume versus pressure)

Volume target modes, we set the tidal volume, inspiratory flow and respiratory
rate and guarantee minute ventilation. The peak airway pressure is variable. The pressure
target modes, we set the pressure limit, inspiratory time or I:E ratio and respiratory rate.
The peak airway pressure or plateau pressure is constant but tidal volume is variable and
also minute ventilation. The patient is more comfortable.
The clinician also has to choose total (VAC or PAC) or partial support modes
(SIMV or PS) which depend on the patient condition e.g. heavy sedated or after general
anesthesia, patient needs totally support from the ventilator.
FiO2
1.0 or 100% oxygen during unstable hemodynamic, CPR or initially put on ventilator
0.4-0.5 to prevent hypoxemia (PaO 2 100-150 mmHg)
0.3-0.4 to keep PaO 2 60-80 mmHg or SpO 2 90-92% for patient with high risk for
oxygen toxicity e.g. preterm

Tidal volume or pressure limit

Normally we set 6-8 cc/kg of ideal body weight e.g. patient who weighs 70 kg, the tidal
volume 7x70=490 cc and look for PIP which is not too high (not more than 50 cmH2 O
and Ppla <35 cmH2 O)

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For pressure limit, normally we set 15-20 cmH2 O and look for exhaled tidal volume
which depends on patient lung compliance and resistance. If the exhaled tidal volume is
too low or too high, you need to increase or decrease pressure limit.
I:E, peak flow rate or inspired time
I:E ratio is 1:2 in normal patients, 1:3 in COPD or asthmatic patient who need
longer expired time or reverse I:E ratio for severe ARDS patients
Peak flow rate inversely correlate with inspired time and also affects I:E VAC or
SIMV, the inspiratory flow rate is usually set 40-90 L/min
Respiratory rate 8-25/min to keep normocarbia or permissive hypercarbia
Inspired time 1-2 seconds depends to respiratory rate. If higher respiratory rate,
lower inspired time to keep constant I:E ratio.
PEEP/CPAC
The benefits are redistribution of (1) lung water, (the redistribution of extravascular
water leads to improved oxygenation, lung compliance, and ventilation-perfusion
matching) (2) increasing FRC (expanding atelectatic alveoli, the proportion of alveoli that
is perfused but not ventilated is decreasedthat is, shunt is decreased and thus
oxygenation improved) (3) decreasing work of breathing. The candidates for PEEP
1. CVS stable.
2. No increase ICP
3. Lung can be expanded by PEEP
4. Bilateral lung lesion
PEEP can cause hypotension due to excessive positive pressure. At lower level of
PEEP (3-10 cmH2 O) prevents the alveolar collapse, at higher levels reopen or recruit
collapsed alveolar unit (alveolar recruitment). Studies have demonstrated that there is a
critical airway pressure necessary to reopen or recruit collapsed alveolar units. This
critical pressure is referred to as the inflection point
An FIO2 greater than 0.5 is toxic to the lungs, and the first and compelling goal
is to reduce FIO2 to less than 0.5 while maintaining an acceptable Pa O2 . The decrease
in F IO2 below 50% is achieved by performing a dose PEEP-response (PaO2 ) titration.
PEEP should be raised in increments of 2.5 to 5.0 cm H2 O. The patient should be
allowed to stabilize with regard to respiratory mechanics (peak inspiratory pressure
and compliance), hemodynamics (pulse rate and rhythm, systemic and central filling
pressures, and cardiac and urine output), and gas exchange (arterial blood gases).
Usually, each PEEP increment requires 0.5 to 1 hour to complete. Consequently,
performance of a PEEP-FIO2 /PaO2 titration may take several hours. Of course, as the
PEEP titration is being performed, other respiratory care modalities such as
suctioning, turning, and administration of antibiotics, are instituted. The advent of
fiberoptic bronchoscopy has eliminated the need for the use of "super-PEEP" (PEEP
>20 to 25 cm H2 O) because regions of collapsed lung are usually obvious on chest
radiographs and can be suctioned and lavaged open under direct vision with a
bronchoscope.
IV Monitor during mechanical ventilation
The patient should be monitored closely during mechanical ventilation to
ensure appropriate ventilator setting such as
1. respiratory mechanics

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2. hemodynamics
3. gas exchanges
Respiratory mechanics
The changes in peak airway pressure (related to airways resistance and thoracic
compliance) and the plateau pressure (related only to compliance) may quickly identify
pulmonary mechanical abnormalities in ventilated patients (see figure below). An
empirically defined measurement, tidal volume divided by peak inspiratory pressure
change, is defined as dynamic compliance (Cdyn):
Cdyn= VT/ PIP-PEEP
VT is the tidal volume, PIP is the peak inspiratory pressure, and PEEP is the positive endexpiratory pressure. The normal value is 40 to 80 mL/cm H2 O.
Static compliance (Cstat) can be calculated by measuring the plateau pressure and
using the following equation:
Cstat= VT / Ppla-PEEP
The normal value for static compliance is 50 to 100 mL/cm H2 O.

Figure 5. Normal and abnormal respiratory mechanics. 2

Hemodynamics
The ventilated patient should be monitored pulse rate, rhythm and blood pressure
(non- invasive or invasive) in every cases and central filling pressures (CVP or PCWP),
cardiac and urine output in some cases because positive ventilation can affect venous
return and impair cardiac output and tissue perfusion.
Gas exchanges
The major function of the lung is gas exchange: the elimination of CO 2 from
blood. The goal is maintenance of arterial CO 2 within an appropriate physiologic
range. Adequate O 2 delivery must also be maintained. In clinical practice dictates
that arterial O 2 content (PaO2 ) should be sufficient. It is common practice to attempt
to maintain arterial hemoglobin (Hb) O 2 saturation (SpO 2 ) level above 90%, a
reasonable and practical goal for two reasons. First, clinical experience supports the
notion that maintenance of hemoglobin at 90% saturation with O 2 in the presence of
adequate cardiac output can provide sufficient O 2 delivery to the tissues. Second,
because the Hb-O2 dissociation curve becomes abruptly steeper at O 2 saturation
levels below 90% (typical PO2 of 55 to 60 mm Hg), further decreases in PaO2 may
result in sharp diminution of arterial O 2 content.
Inappropriate setting, patient can be hyperventilated (too much support) or
hypoventilated (too little support). Normally ABGs should be checked after
changing the ventilator setting but we can also use SpO 2 and ET CO 2 to estimate
PaO 2 and PaCO 2 respectively. PaO2 /FIO2 ratio is very important to estimate the
shunt effect and is a screening criteria for discontinuation of mechanical ventilation.
PaO2/FIO2 ratio

V Discontinuation of mechanical ventilation

The most common reason for mechanical ventilation during and after anesthesia
is impaired respiratory drive. However, components of increased mechanical load and
impaired neuromuscular function may contribute to an abnormally low ventilatory
function. Patients with severe chronic obstructive pulmonary disease usually are
mechanically ventilated because of transient increases in mechanical load
superimposed on a chronic increase in airways resistance. However, impaired
respiratory drive and abnormal respiratory muscle mechanics may also play a role.
Abnormal arterial oxygenation may exist despite what appears to be adequate
ventilatory effort. Ventilatory support may be required mainly to aid arterial
oxygenation or CO 2 elimination. Assessment of the patient with regard to possible
discontinuation of mechanical ventilation may therefore vary considerably, depending
on the reason for mechanical ventilatory support.
Discontinuation of ventilatory support (i.e., weaning) from a patient whose only
reason for mechanical ventilation is residual anesthesia is generally straightforward.
The ventilator can be stopped when the patient is fully awake and breaths
spontaneously on his own (T piece) for a period of time (30 minutes to 2 hours) and

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can be extubated afterward. A different approach is often required for a patient who
has had prolonged ventilatory support for chronic respiratory disease. Screening
criteria are listed in the table. Commonly used discontinuation criteria include
hemodynamic stability, a vital capacity not less than 10 mL/kg, maximum inspiratory
pressure less than (i.e., more negative) -25 cm H2 O, respiratory rate not above 20
breaths/min, and
E not more than 10 to 20 L/min in the face of normal Pa CO2 , and
adequate arterial oxygenation (e.g., PaO2 /FIO2 ratio > 150 to 200) maintained with an
inspired O 2 concentration not above 40% to 50%, with less than 5 to 8 cm H2 O of
PEEP. An extremely useful, easily measured variable is the ratio of ventilatory
frequency to tidal volume (f/VT) during a 1- to 2-minute trial of spontaneous
ventilation.] An f/VT ratio greater than 100 predicts unsuccessful weaning.
Table 2. -- Screening crite ria used in weaning trials to determine whether patients
receiving high levels of ventilatory support can be considered for discontinuation2
Crite ria
Description
Objective

Adequate oxygenation (e.g., P O2 60 mm Hg on FIO2 4;

PEEP 510 cm H2 O; PaO2 /FIO2 150300 mm Hg)
Stable cardiovascular system (e.g., HR 140 beats/min, stable
BP; no [or minimal] vasopressors)
Afebrile (temperature < 38C)
No significant respiratory acidosis
Adequate hemoglobin (e.g., Hb 810 g/dL)
Adequate mentation (e.g., arousable, GCS 13, no continuous
sedative infusions)
Stable metabolic status (e.g., acceptable electrolytes)

Subjective clinical
assessments

Resolution of disease acute phase; physician believes

discontinuation possible; adequate cough

BP, blood pressure; GCS, Glasgow Coma Scale; Hb, hemoglobin; HR, heart rate;
PaO2 /FIO2 (P/F ratio), arterial oxygen tension/fractional inspired oxygen concentration;
PEEP, positive end-expiratory pressure; PO2 , partial pressure of oxygen.

Suggested readings
1. Huang YCT, Singh J. Basic modes of mechanical ventilation. In: Papadakos PJ,
Lachmann B, editors. Mechanical ventilation: Clinical applications and pathophysiology.
Philadelphia: Saunders: Elsevier 2008. p. 247-55.
2. Moon RE, Camporesi EM. Respiratory monitoring. In: Miller RD, editor. Millers
anesthesia. 6th ed. Philadelphia: Elsevier Churchill livingstone 2005. p. 1437-82.

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MCQ for mechanical ventilation
1. Which one of the following is an indication for mechanical ventilation?
a. a postoperative patient with mild hypoxemia
b. a postoperative patient with head and neck surgery
c. a stroke patient with left hemiparesis and good consciousness
d. a pneumonia patient with dyspnea and hypoxemia despite oxygen therapy
2.
a.
b.
c.
d.

Which one of the following is a complication related to mechanical ventilation?

diuresis
hypertension
pneumothorax
decrease intracranial pressure

3. Which mode of mechanical ventilation gives LEAST support compared with

others?
a. volume assist-control mode (VAC or assist-control ventilation, ACV) or
controlled mechanical ventilation (CMV), TV 500 ml, rate 12/min
b. pressure assist-control mode (PAC) or pressure controlled ventilation (PCV)
20 cmH2 O, rate 12/min
c. pressure support ventilation (PSV) 15 cmH2 O
d. synchronized intermittent mechanical ventilation (SIMV), TV 500 ml, rate 4/min
4. An aspirated pneumonia patient received mechnical ventilation for 2 days, he is
now on SIMV TV 500 ml, rate 2/min, PEEP 5 cmH2 O, no pressure support, FiO 2
0.4 his saturation 99%. Which one of the following criteria is used for
extubation?
a. high fever
b. adequate cough
c. respiratory scidosis with PaCO 2 55 mmHg
d. stable hemodynamics with dobutamine 10 mcg/kg/min
5.
a.
b
c
d.

After extubation, What should be given to all of the patients?

oxygen
analgesics
sedative
breathing exercise