Introduction to Mechanical

Ventilation

R. Steven Tharratt, MD, MPVM

But that life maybe restored to the

animal, an opening must be attempted in
the trunk of the trachea, in which a
tube of reed or cane should be put; you
will then blow into this, so that the lung
may rise again and the animal take in
air and take care that the lung is
inflated in intervals [and] the motion of
the heart and arteries does not stop.

Andreas Wessele Vesalus 1543

Mechanical Ventilation
History

Sporadically used in early 20th

century
Initially used postoperatively
Polio Units 1958
Milestone in the development of
modern intensive care.

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Mechanical Ventilation - Uses

Support of ventilation Polio

Support of oxygenation
Development of PEEP 1967
Protection of the airway
Delivery of medication - anesthetics

Indications for Mechanical

Ventilation

Failure of oxygenation.
Failure of ventilation.
To facilitate diagnostic, surgical and
therapeutic procedures.
Failure to protect the airway.

Modern Mechanical Ventilators

Source of oxygen and air.

Gas warming and humidification systems.
Valves, solenoids, and pneumotachographs
for shaping, control and monitoring of gas
flow.
User interface.
Patient monitoring, safety, and alarm
systems.

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 General Principles of
Mechanical Ventilation

Gas flows only down pressure gradients.

Exhalation is a passive process.
Mechanical ventilation depends only on the
interaction of 5 parameters.
3 decision points are required to classify
mechanical ventilation.
Ventilator modes are tools designed to
accomplish specific goals.

Mechanical Ventilation One

Classification Scheme

1. Means of pressure generation.

2. Parameter that sets the respiratory
cycle.
3. Parameter determining the end of
inspiration.

Mechanical Ventilation
Means of Pressure Generation

Negative pressure ventilation.

Positive pressure ventilation.

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Negative Pressure Ventilation

Negative intrathoracic pressure produced.

Encasement of the thorax in a closed space
Advantages:
Noninvasive
Avoidance of baro-, volu-, hemo-, trauma
Disadvantages:
Ventilation only cant oxygenate
Little application in acute disease processes

Positive Pressure Ventilation

Intrathoracic pressure is positive.

Usually requires endotrachael
intubation
Advantages:
Widely available, can improve oxygenation
Disadvantages:
Baro-, volu -, hemo-, trauma, infectious
complications.

Parameters of Mechanical
Ventilation

TIME
Volume
Pressure
Inspiratory:Expiratory (I:E)
Ratio
Flow

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Mechanical Ventilation
Setting the Respiratory Cycle

The total respiratory cycle(Ttot) is

set by one parameter.
For practical purposes all mechanical
is time cycles.
If respiratory rate is 10
breaths/minute:
Ttot = 60 seconds / 10 breaths = 6 seconds

Mechanical Ventilation
Setting the End of Inspiration

Since time determines Ttot and

exhalation is passive:
One parameter must limit inspiration.
Often [inappropriately] called cycle
or control.
3 limiting parameters are commonly
encountered:
Volume, pressure, I:E ratio

Volume Limited Ventilation

Gas flows until a desired tidal volume is

reached.
Tidal volume and minute ventilation is
constant.
Inspiratory pressures and I:E ratios will be
variable.
Most common limited parameter
encountered in adult mechanical ventilation.

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Pressure Limited Ventilation

Gas flows until a desired inspiratory

pressure is reached.
Pressure will be constant.
Tidal volumes and minute ventilation
variable.
Dependant on compliance and resistance of the
lungs.
Often used in settings of acute lung injury
(ARDS).

Time Limited Ventilation

Gas flows until an inspiratory time is

reached.
Pressure, volume may be variable.
Usually encountered in high frequency
ventilatory techniques (mostly
pediatric).

Inspiratory:Expiratory Ratio
Limited Ventilation

Really a variation of time limited

ventilation.
Gas flows until a set I:E ratio is reached.
Tidal volumes and pressures are variable.
May require sedation and paralysis.
Encountered in adults with severe
obstructive disease processes or acute lung
injury.

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Flow Limited Ventilation

Gas flow for a fixed time determines

inspiration.
Ability of gas pressure (potential
energy) to drive the ventilator logic.
fluidic logic obviates the need for
electrical power.
Battlefield and aero medical
applications.

Modes of Mechanical
Ventilation

Simply tools to achieve ventilatory goals.

Each have advantages and disadvantages.
3 general classes of modes.
Control, assisted, and spontaneous
Conscientious total patient care is more
important than specific ventilator mode.

Controlled Modes

What you set is what you get

Ventilator completely controls all
aspects of ventilation.
Used when PaCO2 needs precise
control infrequently encountered.
Often requires sedation.

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Assisted Modes

2 forms of assisted modes:

Assist control mode
Intermittent mandatory ventilation
(SIMV)
These forms differ in their handling
of a patient breath.

Breath Definitions

Machine Breath:
Initiated by the ventilator.
Delivers set pressure, volume, or flow.
Does not require (or expect) patient cooperation.
Patient Breath:
Initiated by the patient.
Patient set volume, flow, time.
May be ignored, allowed, or assisted by the
ventilator.

Assist Control Mode

Ventilator delivers machine breaths at rate
set by the user.
Additional patient breaths are assisted by
the ventilator.
The ventilator delivers a full machine breath in
response to the patient initiation.
A doubling of the patients respiratory rate
will double minute ventilation.
Useful in crisis situations or in diseases
with high minute ventilation requirements.

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Intermittent Mandatory
Ventilation

Ventilator delivers machine breaths at rate

set by the user.
Additional patient breaths are allowed by
the ventilator but not assisted.
Patient set volume, flow and time
Less dramatic swings in minute ventilation.
More patient comfort and a commonly used
mode.

Spontaneous Modes

No machine breaths only patient breaths.

Used ONLY in patients with spontaneous
breathing.
Patient breaths may be supported by the
ventilator to a set pressure or volume (but
no machine breaths are delivered).
Usually encountered in weaning from
mechanical ventilation.

Continuous Positive Airway

Pressure (CPAP)

A spontaneous mode.
Patients spontaneously breath around
a fixed positive airway pressure.
Essentially a combination of PS and
PEEP.
May have a high work of breathing
associated with this mode.

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Pressure Support Mode
Initially developed to overcome airway
resistance in a particular brand of
ventilator.
Used as a weaning adjunct.
Particularly useful in deconditioned patients.
Pressure augmentation of patient breaths.
Exhalation is against atmospheric (or PEEP)
pressure.
Similar to a SCUBA regulator.
Can be combined with IMV modes.

Positive End Expiratory

Pressure (PEEP)

Not a mode.
Developed from CPAP ARDS.
Increases FRC improves
oxygenation.
Potential hemodynamic and
barotraumatic consequences.

Mechanical Ventilation -
Complications

Barotrauma
Hemodynamic effects
Infections complications nosocomial
pneumonias.
Pulmonary thromboembolism.
Airway complications.
Gastrointestinal/Hepatic/Renal effects.
Ventilator malfunctions.

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Discontinuance of Mechanical
Ventilation
Is the patient getting better or worse?
Is the FiO2 < 0.6
PEEP < 5 cm. H2O for adequate
oxygenation.
Resting minute ventilation usually < 10
liters/minute.
Negative inspiratory force < -25 cm. H2O
Minimal secretions and ability to protect
the airway.
Successful completion of a spontaneous
breathing trial (SBT).

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