Bedside Teaching

On
Mechanical
Ventilation

Submitted To-

Ms. Tarika Sharma

Lecturer, CON ILBS

Submitted By-

Ms. Manisha

2nd year, CON ILBS

Mechanical ventilation
Mechanical ventilation is the medical term for artificial ventilation where mechanical means is
used to assist or replace spontaneous breathing. This may involve a machine called
a ventilator or the breathing may be assisted by an Anesthesiologist, certified registered nurse
anesthetist, physician, physician assistant, respiratory therapist, paramedic,

Mechanical ventilation can be defined as the technique through which gas is moved toward and
from the lungs through an external device connected directly to the patient.

There are two main types: positive pressure ventilation, where air (or another gas mix) is pushed
into the trachea, and negative pressure ventilation, where air is, in essence, sucked into the lungs.
There are many modes of mechanical ventilation, and their nomenclature has been revised over
the decades as the technology has continually developed.

Uses of mechanical ventilation-

 Maintain or improve oxygen/carbon dioxide levels in the blood
 Rest the respiratory muscles
 Improve sleep quality
 Decrease the work of breathing
 Inflate the lungs more fully
 Ease coughing
 Prevent respiratory complications

Common indications for mechanical ventilation include the following:

 Bradypnea or apnea with respiratory arrest
 Acute lung injury and the acute respiratory distress syndrome
 Tachypnea (respiratory rate >30 breaths per minute)
 Vital capacity less than 15 mL/kg
 Minute ventilation greater than 10 L/min
 Arterial partial pressure of oxygen (PaO 2) with a supplemental fraction of inspired oxygen
(FIO 2) of less than 55 mm Hg
 Alveolar-arterial gradient of oxygen tension (A-a DO 2) with 100% oxygenation of greater
than 450 mm Hg
 Clinical deterioration
 Respiratory muscle fatigue
  Obtundation or coma
 Hypotension
 Acute partial pressure of carbon dioxide (PaCO 2) greater than 50 mm Hg with an arterial
pH less than 7.25
 Neuromuscular disease
Classification of ventilators
The two main categories of ventilators include:
Noninvasive ventilators »
 These devices provide breathing support through an external interface, such as a mask or nasal
prongs.
Invasive ventilators »
 Patients on long-term ventilation may require ventilation through an endotracheal tube inserted
through the mouth or nose, or through a tracheostomy tube inserted into an incision in the in the
neck.
Noninvasive ventilators
 These ventilators provide breathing support through an external interface, such as a mask or nasal
prongs. They can be used for several hours a day or just during sleeping hours.
 Noninvasive ventilators are positive airway pressure ventilators that use positive pressure to force
gas or air into a patient's lungs. Breathing can be triggered by either the patient or the machine.
The constant flow permits the patient to easily take spontaneous breaths, making these ventilators
a simple, reliable mechanical design.
There are four types of positive pressure ventilators.
Volume-cycled ventilators
Volume-cycled ventilators deliver a preset volume of gas/air or “tidal” volume and then allow passive
exhalation. This type is ideal for patients with acute respiratory distress syndrome or bronchospasm, since
the same tidal volume is delivered regardless of airway resistance or compliance.
Pressure-cycled ventilators
Pressure-cycled ventilators deliver gases at a preset pressure and allow passive exhalation. The benefit is
a decreased risk of lung damage from high inspiratory pressures. The disadvantage is that the tidal
volume delivered can vary with changes in lung resistance and compliance if the patient has poor lung
compliance and increased airway resistance.
This ventilator is often used for short-term therapy. Some have the capability to provide both volume-
cycled and pressure-cycled ventilation. These combination ventilators are also commonly used in critical
care environments.
Flow-cycled ventilators
Flow-cycled ventilators deliver oxygenation until a preset flow rate is achieved during inhalation.
Time-cycled ventilators
Time-cycled ventilators deliver oxygenation over a preset time period. The ventilators are not used as
frequently as the volume-cycled and pressure-cycled ventilators.
Two other commonly used ventilators include:
Continuous positive airway pressure ventilators
Continuous positive airway pressure ventilators increase the work of breathing by forcing the user to
exhale against resistance. This ventilator provides a continuous flow of air at the same level of pressure
during inhalation and exhalation to help keep the airway open. This is especially helpful for obstructive
sleep apnea. But this is not considered a true ventilator because it doesn’t assist with breathing.
Bi-level positive airway pressure ventilators
Bi-level positive airway pressure ventilators deliver air at two pressures for inhalation and for exhalation.
This type of ventilator helps treat neuromuscular disease with a spontaneous timed mode or backup rate
that initiates breaths, particularly at night.
A variety of nasal or facial masks and attachments are available, and can be customized for the best fit.
Invasive ventilators
Invasive ventilation is delivered through an endotracheal tube inserted into the patient’s nose or mouth, or
through a tracheostomy, a surgical incision in the neck to access the trachea.
Invasive ventilation delivers air on a timed cycle through the tube, and ensures that the patient takes a
minimum number of breaths per minute. Ventilators can be adjusted to respond to the patient’s own
efforts to breathe or to override these efforts.
The decision to start invasive ventilation can often be a permanent one for patients who are unlikely to
recover the ability to breathe on their own.
One drawback of invasive breathing assistance is that it interferes with the body’s normal mechanisms for
clearing the respiratory tract of mucus. In addition, most patients relying on invasive ventilation will need
humidification because the nose and mouth, through which air is normally moisturized, is bypassed.

Modes of ventilator

Volume Modes

Assist-Control Ventilation (ACV)

Also known as continuous mandatory ventilation (CMV). Each breath is either an assist or control breath,
but they are all of the same volume. The larger the volume, the more expiratory time required. If the I:E
ratio is less than 1:2, progressive hyperinflation may result. ACV is particularly undesirable for patients
who breathe rapidly – they may induce both hyperinflation and respiratory alkalosis. Note that
mechanical ventilation does not eliminate the work of breathing, because the diaphragm may still be very
active.

Synchronized Intermittent-Mandatory Ventilation (SIMV)

Guarantees a certain number of breaths, but unlike ACV, patient breaths are partially their own, reducing
the risk of hyperinflation or alkalosis. Mandatory breaths are synchronized to coincide with spontaneous
respirations. Disadvantages of SIMV are increased work of breathing and a tendency to reduce cardiac
output, which may prolong ventilator dependency. The addition of pressure support on top of spontaneous
breaths can reduce some of the work of breathing. SIMV has been shown to decrease cardiac output in
patients with left-ventricular dysfunction [Crit Care Med 10: 423, 1982]
ACV vs. SIMV

Personal preference prevails, except in the following scenarios: 1. Patients who breathe rapidly on ACV
should switch to SIMV 2. Patients who have respiratory muscle weakness and/or left-ventricular
dysfunction should be switched to ACV

Pressure Modes
Pressure-Controlled Ventilation (PCV)

Less risk of barotrauma as compared to ACV and SIMV. Does not allow for patient-initiated breaths. The
inspiratory flow pattern decreases exponentially, reducing peak pressures and improving gas exchange
[Chest 122: 2096, 2002]. The major disadvantage is that there are no guarantees for volume, especially
when lung mechanics are changing. Thus, PCV has traditionally been preferred for patients with
neuromuscular disease but otherwise normal lungs

Pressure Support Ventilation (PSV)

Allows the patient to determine inflation volume and respiratory frequency (but not pressure, as this is
pressure-controlled), thus can only be used to augment spontaneous breathing. Pressure support can be
used to overcome the resistance of ventilator tubing in another cycle (5 – 10 cm H20 are generally used,
especially during weaning), or to augment spontaneous breathing. PSV can be delivered through
specialized face masks.

Pressure Controlled Inverse Ratio Ventilation (PCIRV)

Pressure controlled ventilatory mode in which the majority of time is spent at the higher (inspiratory)
pressure. Early trials were promising, however the risks of auto PEEP and hemodynamic deterioration
due to the decreased expiratory time and increased mean airway pressure generally outweight the small
potential for improved oxygenation

Airway Pressure Release Ventilation (APRV)

Airway pressure release ventilation is similar to PCIRV – instead of being a variation of PCV in which
the I:E ratio is reversed, APRV is a variation of CPAP that releases pressure temporarily on exhalation.
This unique mode of ventilation results in higher average airway pressures. Patients are able to
spontaneously ventilate at both low and high pressures, although typically most (or all) ventilation occurs
at the high pressure. In the absence of attempted breaths, APRV and PCIRV are identical. As in PCIRV,
hemodynamic compromise is a concern in APRV. Additionally, APRV typically requires increased
sedation

Dual Modes
Pressure Regulated Volume Control (PRVC)

A volume target backup is added to a pressure assist-control mode

Neurally Adjusted Ventilatory Assist (NAVA)

Addtional Modes, Strategies, Parameters

Inverse Ratio Ventilation

Inverse Ratio Ventilation (IRV) is a subset of PCV in which inflation time is prolonged (In IRV, 1:1, 2:1,
or 3:1 may be use. Normal I:E is 1:3). This lowers peak airway pressures but increases mean airway
pressures. The result may be improved oxygenation but at the expense of compromised venous return and
cardiac output, thus it is not clear that this mode of ventilation leads to improved survival. IRV’s major
indication is in patients with ARDS with refractory hypoxemia or hypercapnia in other modes of
ventilation

Adaptive Support Ventilation

Calculates the expiratory time constant in order to guarantee sufficient expiratory time and thus minimize
air trapping

Tube Compensation
Positive End Expiratory Pressure (PEEP)

Does not allow alveolar pressure to equilibrate with the atmosphere. PEEP displaces the entire pressure
waveform, thus mean intrathoracic pressure increases and the effects on cardiac output are amplified.
Low levels of PEEP can be very dangerous, even 5 cm H20, especially in patients with hypovolemia or
cardiac dysfunction. When measuring the effectiveness of PEEP, cardiac output must always be
calculated because at high saturations, changes in Q will be more important than SaO2 – never use SaO2
as an endpoint for PEEP. PEEP is indicated clinically for 1) low-volume ventilation cycles 2) FiO2
requirements > 0.60, especially in stiff, diffusely injured lungs such as ARDS and 3) obstructive lung
disease. Do NOT use in pneumonia, which is not diffuse, and where PEEP will adversely affect healthy
tissue and worsen oxygenation. One way to gauge the effect of PEEP is to look at peak inspiratory
pressure (PIP) – if PIP increases less than the added PEEP, then the PEEP improved the compliance of
the lungs.

Continuous Positive Airway Pressure (CPAP)

Positive pressure given throughout the cycle. It can be delivered through a mask and is can be used in
obstructive sleep apnea (esp. with a nasal mask), to postpone intubation, or to treat acute exacerbations of
COPD

Bilevel positive airway pressure

Bilevel positive airway pressure (BPAP) is a mode used during non-invasive ventilation (NIV). First used
in 1988 by Professor Benzer in Austria, it delivers a preset inspiratory positive airway pressure (IPAP)
and expiratory positive airway pressure (EPAP). BPAP can be described as a Continuous Positive Airway
Pressure system with a time-cycled change of the applied CPAP level. CPAP, BPAP and other non-
invasive ventilation modes have been shown to be effective management tools for chronic obstructive
pulmonary disease and acute respiratory failure.
Often BPAP is incorrectly referred to as "BiPAP". BiPAP is the name of a portable ventilator
manufactured by Respironics Corporation; it is just one of many ventilators that can deliver BPAP.
Ventilator Alarms
1. Common Alarms.
a. High pressure limit (set 10 cmH2O above peak airway pressure).
b. Minimum exhaled volume (set 100 mL below exhaled tidal volume).
c. Low pressure limit (set 10 cmH2O below peak airway pressure).
d. Oxygen alarm (set 5% above and below set FrOz).
e. PEEP/CPAP (high and low level).
f. Failure to cycle (check power supply).
g. Loss of power (check power supply).
h. Oxygen failure (check oxygen source).
i. Temperature alarm (set low and high level).

2. Troubleshooting: always provide manual ventilation first.

a. Low pressure alarm - consider:
1. Patient disconnect.
2. Leak in the ventilator circuit.
3. Insufficient flow.
4. Endotracheal/tracheostomy tube cuff leak.
b. High pressure alarm - consider:
1. Patient obstruction (endotracheal tube, pneumothorax, t Raw, secretions, etc).
2. Equipment obstruction (ventilator circuit).
c. Low exhaled volume alarm - consider:
1. Patient disconnect (ventilator circuit).
2. Low spontaneous tidal volume.
d. Temperature alarm.
1. High temperature alarm - check humidifier temperature.
2. Low temperature - check humidifier temperature, may decrease during aerosol
therapy.

Complications of Mechanical Ventilation:

Associated with patient’s response to mechanical ventilation:

1. Decreased Cardiac Output

2. Baotrauma
3. Nosocomial pneumonia
4. Decreased Renal Perfusion
5. Increased Intracranial Pressure (ICP)
6. Hepatic congestion
7. Worsening of intracardiac shunts
Associated with ventilator malfunction:

 Alarms turned off or nonfunctional – may lead to apnea and respiratory arrest
 Troubleshooting Ventilator Alarms
 Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected
 Low oxygen pressure: Oxygen malfunction

Other common potential problems related to mechanical ventilation

Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick

secretions, Patient discomfort due to pulling or jarring of ETT or tracheostomy, High PaO2, Low
PaO2, Anxiety and fear, Dysrhythmias or vagal reactions during or after suctioning, Incorrect
PEEP setting, Inability to tolerate ventilator mode.

Absolute Contraindications:

Shock, Inability to protect the airway, Significant altered mental status, Pneumothorax , Recent
gastric, esophageal, laryngeal surgery, Significant facial fracture, Rapid deterioration

Relative Contraindications:

Nausea and vomiting, Cardiac arrhythmia, Significant chest trauma, Agitation, Myocardial
Infarction

BIBLIOGRAPHY
 Tortora, G.J, Derrickson,B,(2009), Principles Of Anatomy and Physiology (12th ed) John
Willey & Sons, Inc Vol(2),175-337

 Waugh. A, Grant. A(2010), Anatomy and Physiology in Health and Illness(11th ed),
Churchill livingstone elsevier, 379-427

 Smeltzer, S.C, Bare, B.G, Hinkle, J.L(2010), Brunner & Suddarth’s textbook of medical-
surgical nursing(12th ed), wolters kluwer (india) pvt. ltd. Vol (2), 2006-2116

 Longo, D.L, Kasper,D.L, et al. (2012), harrison’s principles of Internal Medicine (18th
ed), McGraw Hill companies (vol.1), 312-322
 http://www.vetfolio.com/monitoring-and-nursing/mechanical-ventilation-ventilator-
settings-patient-management-and-nursing-care
 https://www.utmb.edu/policies_and_procedures/4230151
 https://www.slideshare.net/KylePEdmondsMD/the-procedure-of-mechanical-ventilator-
withdrawal