Skills Day - Mechanical Ventilation

Ventilator Anxiety
Airing Out Our Concerns
Goals of mechanical ventilation

Outline
Ventilation (removal of carbon dioxide from the blood) Provide adequate oxygenation

Robert L. Joyner, Jr., Ph.D., RRT

Associate Professor of Health Sciences Director, Respiratory Therapy Program Salisbury University

Modes of mechanical ventilation Ventilator alarms Case study

Ventilation
Tidal volume
Volume of gas inspired or expired during a breath. Can be spontaneous or mechanical Dead space
Gas in the lung that does not participate in gas exchange Ventilator circuit and endotracheal tube Anatomic (conducting airways) Airway anatomy down to the respiratory zone Alveolar Alveoli that are ventilated but not perfused

Ventilation Cont.
Physiologic Anatomic + alveolar

Respiratory rate/frequency
The number of breaths over the period of one minute

Minute ventilation (generic overall goal)

Respiratory rate x tidal volume. This is the amount of gas that passes into or out of the lung during one minute

Ventilation with

Little or no blood flow

Ventilation Cont.
Alveolar minute ventilation (overall goal)
Respiratory rate x (tidal volume - physiologic deadspace) Responsible for elimination of CO2

Oxygenation
During mechanical ventilation, oxygenation is determined by two factors:
FiO2
> 60% may be toxic to tissues and induce lung injury

When examining an arterial blood gas, thought must be given to the work of breathing required to maintain a certain PaCO2

Mean airway pressure (restoring FRC)

The average pressure exerted on the airway across a breath Good estimate of alveolar pressure

Skills Day - Mechanical Ventilation

Mean Airway Pressure Oxygenation

Changes in mean airway pressure are induced by changes in
PEEP
Positive end expiratory pressure

PEEP Effects

Inspiratory time
The amount of time during a single breath that is spent during inspiration is affected by:
Tidal volume Respiratory rate I/E ratio
Macintyre, 1991

Diseased alveoli without PEEP may collapse during exhalation. PEEP provides stability at the end of exhalation.

Mean Airway Pressure

Inspiratory Time Effects
Volume limited Pressure limited Dual Control

Types of Ventilation

Macintyre, 1991

Volume Limited
The ventilator delivers a preset tidal volume with a constant flow pattern at the preset respiratory rate
Main advantage
Minute ventilation guarantee

Volume Limited Cont.

Suggestions for use
The gold standard
To date clinicians/physicians are most comfortable with this type of ventilation Guaranteed minute ventilation For most patients if no leak is present
Cuffed endotracheal tube Bronchopleural fistula

Main disadvantage
High peak airway pressures can be exerted depending on the setting of the high pressure limit alarm, set tidal volume, and patients respiratory mechanics

Skills Day - Mechanical Ventilation

PCV Pressure Control

The ventilator will deliver breaths with a constant preset pressure (pressure control level above peep) with a decelerating flow pattern for a preset inspiratory time with a preset respiratory rate.
Main advantage. Pressures will never exceed settings. At normal I/E ratios can be more comfortable for patients because of variable inspiratory flow. Main disadvantage. There is no minute ventilation guarantee / tidal volume. Alarms must be set appropriately.

(Pressure-controlled Ventilation)

Volume Flow Pressure

Macintyre, 1991

Pressure constant, flow and volume vary.

Pressure Control Cont.

Suggestions for use.
Patients with reduced compliance.
That is, provides an functional way of controlling I:E ratio and inspiratory:expiratory time.

Modes of Ventilation
Definition: The pattern in which volume or pressure used to provide ventilation is delivered. Most common modes of mechanical ventilation.
Control. Assist control. SIMV. CPAP. Pressure support.

In patients with a gas leak problems or syndromes (uncuffed tubes & bronchopleural fistulas. When high peak airway pressures are of high concern? Primary mode in infants and children.
Neonatologist and Pediatric Intensivists are most comfortable with this type of ventilation.

Control
Volume Flow Pressure

Assist Control

Volume Flow Pressure

Macintyre, 1991 Macintyre, 1991

Skills Day - Mechanical Ventilation

IMV
(Intermittent Mandatory Ventilation)

SIMV
(Synchronous Intermittent Mandatory Ventilation)

Volume Flow Pressure

Volume Flow Pressure

Macintyre, 1991

Macintyre, 1991

Ventilator is not sensitive to patient efforts. Can cause breath stacking leading to barotrauma or cardiovascular compromise.

Ventilator only cycles to inspiration during a patient inspiration or during apnea.

CPAP SIMV Cont.

Volume Flow Pressure

(Continuous Positive Airway Pressure)

Volume Flow Pressure

Macintyre, 1991

Macintyre, 1991

If no breath is detected during the window of opportunity, the ventilator cycles to inspiration and delivers a mandatory breath.

No respiratory rate, just an average pressure exerted across a respiratory cycle.

PSV Pressure Support / CPAP

The ventilator will deliver a breath with the preset pressure (pressure support level above PEEP) kept constant during inspiration
Major advantage
Provides support during a spontaneous breath Pressures will not exceed settings Pressure

(Pressure Support Ventilation)

Volume Flow

Major disadvantage
No minute ventilation guarantee

Macintyre, 1991

Flow progressively decreases over the course of a breath. Once the flow is reduced to a preset value inspiration is terminated.

Skills Day - Mechanical Ventilation

Pressure Support / CPAP Cont.

Suggestions for use
Reduce imposed resistance by the ventilator system
Et-tube

SIMV With Pressure Support

Volume Flow Pressure

As a support mode in patients with intact respiratory drive Weaning

Macintyre, 1991

Pressure support is often used in conjunction with SIMV to provide support during spontaneous breaths.

Triggering a Mechanical Breath

Pressure triggering Flow triggering Which is Better?

Triggering a Mechanical Breath

Pressure triggering.
Inspiratory effort reduces pressure within the ventilator circuit. Once the circuit pressure drops a preset amount, inspiration is detected by the ventilator.

Pressure Triggering
Controlled Breath and Assisted Breaths

Triggering a Mechanical Breath

Flow trigger (on the PBT 7200 this is known as flow-by)
A preset flow of gas is constantly traveling through the ventilator circuit (bias flow) During a spontaneous patient inspiration, the flow of gas going through the expiratory side of the ventilator circuit is reduced Once the flow through the expiratory side of the ventilator circuit is reduced by a predetermined flowrate, inspiration is detected by the ventilator

Skills Day - Mechanical Ventilation

Flow Trigger (No Effort) (On PBT 7200 also called Flow-By)
Expiratory Limb Inspiratory Limb

Flow Trigger (Patient Effort) (On PBT 7200 also called Flow-By)
Expiratory Limb Inspiratory Limb

(Base Flow Pts Inspiratory Flow)

Base Flow (e.g. 10 l/m)

(Base Flow Pts Inspiratory Flow)

Base Flow (e.g. 10 l/m)

Sensitivity based on variance of flow entering the inspiratory limb compared to flow exiting the expiratory limb

No Patient Effort

Sensitivity based on variance of flow entering the inspiratory limb compared to flow exiting the expiratory limb

Patient Inspiration

Flow Triggering (Setting the Base Flow Using Graphics)

Pressure vs. Flow Triggering

Overall, smaller is better.

Variations in pressure can be attributed to patient work.

Banner MJ, Blanch, PB, Kirby, RR. Imposed work of breathing and methods of triggering a demand-flow, continuous positive airway pressure system Crit Care Med 1993; 21: 183-90.

Case Studies
#1 congestive heart failure
Ventilation not an issue Needs help oxygenating

Case Study #1 (Congestive Heart

Failure)
A 63 y/o mildly obese male arrives to the emergency room from a local seafood restaurant. He is complaining of severe shortness of breath and moderate chest pain. Upon physical exam you find a patient in severe respiratory distress tachycardic and mildly hypotensive. The patient is wearing a non re-breathing mask and has an SpO2 = 79%. Initial ABG on 100% NRB
pH = 7.24 PCO2 = 27 mmHg PO2 = 50 mmHg

#2 drug overdose
Hypoventilation Needs help oxygenating

Skills Day - Mechanical Ventilation

Case Study #1 (Congestive Heart

Failure)
Non-invasive ventilation initiated via CPAP mask @ 7.5 cmh2o with an fio2 = 1.00, 100 mg Lasix given 1 hour post treatment, arterial blood gas was repeated:
Ph = 7.37 PCO2 = 38 mmHg PO2 = 100 mmHg

Case Study #2 (Comatose Overdose)

A 34 y/o woman entered the emergency room comatose. She was suspected of taking an overdose of an unknown drug. Initial arterial blood gases on room air are as follows:
Ph = 7.15 PCO2 = 80 mmHg PO2 = 42 mmHg HCO3 = 28 mEq/l BE = 0 mEq/l Spo2 = 80%

Case Study #2 (comatose overdose)

The patient is intubated and placed on a mechanical ventilator with the following settings:
Tidal volume = 700cc (70 kg pt - 10cc/kg) Respiratory rate = 12/min PEEP = 5 cmh2o Fio2 = 1.0 Arterial blood gas 30 minutes post institution of mechanical ventilation
Ph = 7.39 PCO2 = 43 mmHg PO2 = 312 mmHg