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Ventilator Anxiety
Airing Out Our Concerns
Goals of mechanical ventilation
Outline
Ventilation (removal of carbon dioxide from the blood) Provide adequate oxygenation
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
Ventilation with
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
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.
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
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
(Pressure-controlled Ventilation)
Macintyre, 1991
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
IMV
(Intermittent Mandatory Ventilation)
SIMV
(Synchronous Intermittent Mandatory Ventilation)
Macintyre, 1991
Macintyre, 1991
Ventilator is not sensitive to patient efforts. Can cause breath stacking leading to barotrauma or cardiovascular compromise.
Macintyre, 1991
Macintyre, 1991
If no breath is detected during the window of opportunity, the ventilator cycles to inspiration and delivers a mandatory breath.
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.
Macintyre, 1991
Pressure support is often used in conjunction with SIMV to provide support during spontaneous breaths.
Pressure Triggering
Controlled Breath and Assisted Breaths
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
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
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
#2 drug overdose
Hypoventilation Needs help oxygenating