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HISTORY OF MECHANICAL VENTILATION

MECHANICAL VENTILATION Modes of Ventilatory Support


Corrado P. Marini, MD Director of Surgical Education
Geisinger Health System Danville, Pennsylvania

But that life may be restored an opening must be attempted inthe trachea, in which a tube or reed should be put; you will then blow into this, so that the lung may rise againAnd as I do this, and take care that the lung is inflated in intervals, the motion of the heart and arteries does not stop

AtlantiCare Regional Medical Center May 5, 2009

Andreas Wesele Vesalius, 1543

HISTORY OF MECHANICAL VENTILATION


The 1947-1948 polio epidemic
resulted in breakthroughs in the treatment of patients with respiratory paralysis

HISTORY OF MECHANICAL VENTILATION


Stephen Hales
Used a manual bellows to inflate the lungs (1743) first mechanical ventilator Treatise on Ventilators (1751) Also identified Blood pressure Treatment for bladder stones Carbon dioxide

Endotracheal intubation and


mechanical ventilation was pioneered in Denmark

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MODERN VENTILATORS
Mechanical ventilation evolved significantly in
the 1970s and 80s with the introduction of microprocessors

Indications for Mechanical Ventilation

Our understanding of acute lung injury also


evolved greatly Volutrauma (VILI) Barotrauma Atelectotrauma Biotrauma Permissive hypercapnia Lung protective strategies Alveolar recruitment

Airway Instability

Respiratory Failure

RESPIRATORY FAILURE
The etiology of patient respiratory failure can be
divided into two categories Failure to oxygenate Failure to ventilate

RESPIRATORY FAILURE
Failure to oxygenate
Characterized by decreased PaO2 Causes Decreased arterial O2 tension Reduced O2 diffusion capacity Increased intrapulmonary shunt Treatment Increase inspired oxygen fraction (FiO2) Recruit alveoli and restore lung volumes Tidal volume Positive end-expiratory pressure (PEEP)

Each category requires different interventions to


correct the failure

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RESPIRATORY FAILURE

MECHANICAL VENTILATION
Failure to ventilate
Characterized by increased PaCO2 Causes Airway obstruction Decreased ventilatory drive Treatment Control airway Increase patients alveolar ventilation Increase rate Increase tidal volume

OXYGENATION
FiO2 PEEP Alveolar recruitment

VENTILATION
Elimination of CO2 VE = VT x RR

MECHANICAL VENTILATION

MECHANICAL VENTILATION
The goal of mechanical ventilation is to optimize pulmonary gas exchange Existing Controversies Controlled vs. spontaneous ventilation Large vs. small tidal volume PEEP vs. no PEEP Recruitment vs. no recruitment maneuvers Wet vs. dry lungs Invasive vs. noninvasive ventilation

OXYGENATION PaO2 SaO2

VENTILATION PaCO2 PetCO2

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Goals of Ventilator Modes


1. Maintain adequate oxygenation 2. Maintain adequate ventilation 3. Reduce work of breathing 4. Improve patient comfort

MECHANICAL VENTILATION Support of Adequate Oxygenation


Oxygen responsive hypoxemias Pneumonia Sepsis Inhalation injury Oxygen refractory hypoxemias Atelectasis Aspiration / Drowning ALI/ARDS

MECHANICAL VENTILATION Support of Adequate Ventilation

MECHANICAL VENTILATION Goals

Airway compromise Muscle fatigue / weakness Paralysis / spinal cord injury Neuromuscular disease Chest wall injury

Maintain patient comfort Allow a normal, spontaneous breathing pattern


whenever possible

Maintain a PaCO2 between 35 - 45 mmHg Maintain a PaO2 sufficient to meet cellular oxygen
demands but avoid oxygen toxicity

Avoid respiratory muscle fatigue and atrophy

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MECHANICAL VENTILATION Breath Types

MECHANICAL VENTILATION Breath Types

There are two basic breath types


Spontaneous or demand Initiated by the patient Ventilator or mandatory Initiated by the ventilator (time triggered)

Mandatory
Ventilator does the work Ventilator controls start and stop

Spontaneous
Patient takes on work Patient controls start and stop

Breaths are defined by three variables


Trigger: initiates the inspiratory phase Limit: maximal set inspiratory pressure or flow Cycling (the factor that terminates the I cycle)

The Control Variable Inspiratory Breath Delivery

Flow (volume) controlled


- pressure may vary

Trigger Variable Start of a Breath

Pressure controlled
- flow and volume may vary

Time controlled (HFOV)


- pressure, flow, volume may vary

Time - control ventilation Pressure - patient assisted Flow - patient assisted Volume - patient assisted Manual - operator control

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Inspiratory - delivery limits


Maximum value that can be reached but will not end the breathVolume Flow Pressure

End of Inspiratory Phase Cycling mechanisms


The phase variable used to terminate inspiration Volume Pressure Flow Time

TRIGGER VARIABLE

MODES OF VENTILATION

Volume controlled
Controlled by inspiratory flow Limited by a preset volume or maximal inspiratory pressure Cycled by volume or time

Pressure controlled
Controlled by pressure (inspiratory + PEEP) Limited by pressure (inspiratory + PEEP) Cycled by time or flow

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Volume/Flow Control
Inspiration
20

Pressure Control
Inspiration
20

Expiration

Expiration

Volume Control Breath Types


60

Paw

Pressure
0 20 1

Paw
2 0 20 2

Paw
cmH20 -20 120

SEC

6
INSP

Volume
0 0 3 1 2 3 0 0 1 2

Flow
L/min

SEC

6
EXH

120

Flow

Time (s)

Time (s)

If compliance decreases the pressure increases to maintain the same Vt


-3 -3

BASIC MODES OF SUPPORT

PATIENT COMFORT LEVEL Modes of Mechanical Ventilation

Demand breaths
Spontaneous breathing Pressure Support Ventilation (PSV)

Mandatory breaths
Controlled Mechanical Ventilation (CMV) Assist Control Ventilation (ACV) Synchronized Intermittent Mandatory Ventilation (SIMV) Pressure Control Ventilation (PCV)

Ideal comfort level

Absent comfort

10

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SPONTANEOUS VENTILATION
Volume limited - Time cycled - Patient triggered

SPONTANEOUS VENTILATION
The optimal breathing pattern Allows patient to choose rate and volume Provides greatest patient comfort Utilizes physiologically optimal lung segments Less intrapulmonary shunt Less dead space ventilation Minimizes respiratory muscle atrophy

Inspiration initiated by
Negative pressure change (patient)

Expiration initiated by
Respiratory muscle stretch receptors that sense volume change (patient)

PATIENT COMFORT LEVEL

PRESSURE SUPPORT VENTILATION


Pressure limited - Flow cycled - Patient triggered

Spontaneous Breathing

Inspiration initiated by 0
Negative pressure / flow change (patient)

10

Expiration initiated by
Decreasing flow (patient)

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PRESSURE SUPPORT VENTILATION

PRESSURE SUPPORT VENTILATION

Created as a technique to reduce ventilator imposed


work of breathing Patient determines rate, volume, and flow widely used to improve patient comfort Advantages over traditional modes improves patient - ventilator synchrony reduces work of breathing decreases dead-space to tidal volume ratio prevents respiratory muscle fatigue Commonly used in conjunction with SIMV

Uses high gas flow (up to 250 L/min) Reduces work of breathing by overcoming the
resistance of the ventilator and endotracheal tubes

Useful in patient weaning Does not have a back-up rate should apnea
develop

PATIENT COMFORT LEVEL

CONTROLLED MECHANICAL VENTILATION


Volume limited - Time cycled - Ventilator triggered

Spontaneous Breathing

Inspiration initiated by
Time (ventilator)

10
Pressure Support Ventilation

Expiration initiated by
Volume (ventilator) Pressure (ventilator) Time (ventilator) Note absence of patient effort

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CONTROLLED MECHANICAL VENTILATION

PATIENT COMFORT LEVEL


Controlled Mechanical Ventilation

Most common mode of mechanical ventilation Allows no interaction between patient and ventilator Very uncomfortable if patient is awake
almost always requires pharmacologic paralysis

Spontaneous Breathing

Allows no patient work of breathing Can result in high peak inspiratory pressures

10
Pressure Support Ventilation

ASSIST CONTROL VENTILATION

PATIENT COMFORT LEVEL


Controlled Mechanical Ventilation

Patient determines respiratory rate, but not volume Attempts to improve patient comfort by allowing
patient - ventilator interaction

Patient receives full preset tidal volume each breath


results in hyperventilation, hypocarbia, and respiratory alkalosis if patient is tachypneic

Spontaneous Breathing

10
Pressure Support Ventilation Assist Control Ventilation

can result in high peak inspiratory pressures

Requires minimal patient work of breathing


leads to respiratory muscle atrophy and weakness

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SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION


Volume limited - Time cycled - Patient / ventilator triggered

SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION

Inspiration initiated by
Negative pressure change (patient) Time (ventilator)

Different tidal volumes

Originally intended as a method of weaning Most common mode of ventilation in the SICU
setting

Allows patient to choose rate and tidal volume


more natural, physiologic breathing pattern more comfortable for patient requires less patient sedation

Expiration initiated by
Volume (patient) Volume (ventilator) Pressure (patient) Time (patient) Patient Patient

Allows spontaneous breathing while still providing


larger tidal volume breaths to prevent atelectasis

Can result in high peak inspiratory pressures on


mechanical breaths

PATIENT COMFORT LEVEL


Synchronized Intermittent Spontaneous Mechanical Ventilation Breathing Controlled Mechanical Ventilation

ASSIST CONTROL VENTILATION


Volume limited - Time cycled Patient / ventilator triggered

Inspiration initiated by
Negative pressure change (patient) Time (ventilator)

Same tidal volume

10
Pressure Support Ventilation Assist Control Ventilation

time

Expiration initiated by
Volume (ventilator) Pressure (ventilator) Time (ventilator) Ventilator Patient

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PRESSURE CONTROL VENTILATION


Pressure limited - Time cycled - Patient / ventilator triggered

PRESSURE CONTROL VENTILATION

Limits peak inspiratory pressures


used as part of a lung protective strategy smaller tidal volumes increased respiratory rates can lead to hypercapnia, inadequate ventilation

Inspiration initiated by
Negative pressure change (patient) Time (ventilator)

Same pressure

May require pharmacologic paralysis to prevent


patient-ventilator disynchrony

Expiration initiated by
Pressure (ventilator) Time (ventilator) Ventilator Patient

May be used with prolonged/reversed


inspiratory:expiratory times as inverse ratio ventilation
Inspiration occurs before complete exhalation leading to air-trapping or auto-PEEP

INVERSE RATIO VENTILATION

PATIENT COMFORT LEVEL


Synchronized Intermittent Spontaneous Mechanical Ventilation Breathing Controlled Mechanical Ventilation

T I / TE < 1 TI Paw T
E

T I / TE > 1

10
time Pressure Support Ventilation Assist Control Ventilation Pressure Control Ventilation

Flow

Incomplete lung emptying before next breath results in air trapping and intrinsic PEEP

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New Modes of Ventilation


Dual-Controlled Modes
Type
Dual control within a breath

Dual Control within a Breath


Volume-assured pressure support

Manufacturer; ventilator
VIASYS Healthcare; Bird 8400Sti and Tbird VIASYS Healthcare; Bear 1000

Name
Volume-assured pressure support Pressure augmentation

Dual control breath to breath: Pressure-limited flow-cycled ventilation Dual control breath to breath: Pressure-limited time-cycled ventilation

Siemens; servo 300 Cardiopulmonary corporation; Venturi Siemens; servo 300

Volume support Variable pressure support

Pressure-regulated volume control Adaptive pressure ventilation

Hamilton; Galileo Drager; Evita 4 Cardiopulmonary corporation; Venturi

Autoflow Variable pressure control

The Respiratory Therapist sets : pressure limit = plateau seen during VC respiratory rate peak flow rate (the flow if TV < target) PEEP FiO2 trigger sensitivity minimum tidal volume

Dual control breath to breath: SIMV

Hamilton; Galileo

Adaptive support ventilation

Dual Control Breath-to-Breath


Pressure-limited time-cycled ventilation
Pressure Regulated Volume Control

Dual Control Breath-to-Breath


Pressure-limited time-cycled ventilation
Pressure Regulated Volume Control

Delivers patient or timed triggered, pressure-targeted (controlled) and timecycled breaths Ventilator measures VT delivered with VT set on the controls. If delivered VT is less or more, ventilator increases or decreases pressure delivered until set VT and delivered VT are equal

Servo 300

Maquet Servo-i

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Dual Control Breath-to-Breath


Pressure-limited time-cycled ventilation
Pressure Regulated Volume Control

Pressure Regulated Volume Control

The ventilator will not allow delivered pressure to rise higher than 5 cm H2O below set upper pressure limit Example: If upper pressure limit is set to 35 cm
H2O and the ventilator requires more than 30 cm H2O to deliver a targeted VT of 500 mL, an alarm will sound alerting the clinician that too much pressure is being required to deliver set volume
PRVC. (1), Test breath (5 cm H2O); (2) pressure is increased to deliver set volume; (3), maximum available pressure; (4), breath delivered at preset E, at preset f, and during preset TI; (5), when VT corresponds to set value, pressure remains constant; (6), if preset volume increases, pressure decreases; the ventilator continually monitors and adapts to the patients needs

yes

Pressure Regulated Volume Control


Disadvantages and Risks
calculate compliance

Calculate new Pressure limit

no

Volume from Ventilator= Set tidal volume

trigger

Pressure limit Based on VT/C

time= set Inspiratory time

yes

cycle off

no

Varying mean airway pressure May cause or worsen auto-PEEP When patient demand is increased, pressure level may diminish when support is needed May be tolerated poorly in awake nonsedated patients A sudden increase in respiratory rate and demand may result in a decrease in ventilator support

Control logic for pressure-regulated volume control and autoflow

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Pressure Regulated Volume Control


Indications 1. Patient who require the lowest possible pressure and a guaranteed consistent VT 2. ALI/ARDS 3. Patient with the possibility of CL or Raw changes

Pressure Regulated Volume Control


Advantages
Maintains a minimum PIP Guaranteed VT and VE Patient has very little WOB requirement Allows patient control of respiratory rate and VE Variable VE to meet patient demand Decelerating flow waveform for improved gas distribution Breath by breath analysis

VOLUME TARGETED
60 60

Volume Targeted (Pressure Controlled)


Paw
cmH20
SEC SEC

Paw
cmH20 -20 120

6
INSP

-20 120

6
INSP

Flow Flow
L/min

SEC

SEC

L/min

6
EXH

6
EXH

120

120

Many Dual Modes start out looking like PCV

As compliance changes - flow and volumes change

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New Volume Targeted Breath Pressure Variability is Controlled


60

40

Pressure limit overridden Set pressure limit

Paw
cmH20

Paw
cmH20 -20 120

SEC

-20 0.6

6
INSP

Volume
L

Set tidal volume cycle threshold Tidal volume Tidal volume not met met

Flow
L/min

SEC

0 60 Inspiratory flow greater than set flow

6
EXH

120

Flow cycle

Set flow limit

Inspiratory flow equals set flow

Pressure then rises to assure that the set tidal volume is delivered

Flow
L/min

60

Switch from Pressure control to Volume/flow control

trigger

Dual Control within a Breath


Pressure at Pressure support

Volume-assured pressure support

no
flow= 25% peak

yes

delivered VT set VT


yes

This mode allows a feedback loop based on the volume Switches even within a single breath from pressure control to volume control if minimum tidal volume has not been achieved

yes
Cycle off inspiration

no
Insp flow > Set flow

no
Switch to flow control at peak flow setting

no yes
delivered VT = set VT

no

PAW <PSV setting

yes Bird 8400Sti Tbird

Control logic for volume-assured pressure-support mode

Bear 1000

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Dual Control within a Breath


Volume-assured pressure support

Dual Control Breath-to-Breath


Pressure-limited flow-cycled ventilation Volume Support

If pressure is too high, all breaths are pressure-limited. If the peak flow setting is too high , all breaths will be
volume-controlled

Tidal volume is used as feedback control to adjust


the pressure support level

If the pressure is set too high or the minimum tidal volume


is set too low; the volume guarantee is negated

All breaths are patient triggered, pressure limited,


and flow-cycled.

If peak flow is set too low, the switch from pressure to


volume is late in the breath, inspiratory time is too long.

Automatic weaning of pressure support as long as


tidal volume matches minimum required VT (VT set in a feedback loop to adjust pressure).

Dual Control Breath-to-Breath


Pressure-limited flow-cycled ventilation Volume Support

Volume Support versus Volume Assured Pressure Support


How does volume support differ from VAPS? In volume support, we are trying to adjust pressure so that, within a few breaths, desired VT is reached. In VAPS, we are aiming for desired VT tacked on to the end of a breath if a pressure-limited breath is going to fail to achieve VT

Servo 300

Maquet Servo-i

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Volume Support

Entirely a spontaneous mode Delivers a patient triggered (pressure or flow), pressure targeted, flow cycled breath Can also be timed cycled (if Ti is extended for some reason) or pressure cycled (if pressure rises too high). Similar to pressure support except VS also targets set VT. It adjusts pressure (up or down) to achieve the set volume (the maximum pressure change is < 3 cm H2O and ranges from 0 cm H2O to 5 cm H2O below the high pressure alarm setting Used for patients ready to be weaned from the ventilator and for patients who cannot do all the WOB but who are breathing spontaneously

Volume Support

(1), VS test breath (5 cm H2O); (2), pressure is increased slowly until target volume is achieved; (3), maximum available pressure is 5 cm H2O below upper pressure limit; (4), VT higher than set VT delivered results in lower pressure; (5), patient can trigger breath; (6) if apnea alarm is detected, ventilator switches to PRVC

Dual Control Breath-to-Breath


yes

Pressure-limited flow-cycled ventilation Volume Support

Calculate new Pressure limit

no

Volume from Ventilator= Set tidal volume

calculate compliance

Little data to show it actually works. If pressure support level increases to maintain TV in
pt with increased airways resistance, PEEPi may increase.

trigger

Pressure limit Based on VT/C

Flow= 5% of Peak flow

yes

cycle off

If minimum TV set too high, weaning may be delayed.

no

Control logic for volume support mode of the servo 300

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Volume Support
Indications
Spontaneous breathing patient who require minimum VE Patients who have inspiratory effort who need adaptive support Patients who are asynchronous with the ventilator Used for patient who are ready to wean

Volume Support
Advantages
Guaranteed VT and VE Pressure supported breaths using the lowest required pressure Decreases the patients spontaneous respiratory rate Decreases patient WOB Allows patient control of I:E time Breath by breath analysis Variable VI to meet the patients demand

Volume Support
Disadvantages
Spontaneous ventilation required VT selected may be too large or small for patient Varying mean airway pressure Auto-PEEP may affect proper functioning A sudden increase in respiratory rate and demand may result in a decrease in ventilator support

Dual Control Breath-to-Breath


Adaptive Support Ventilation

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Adaptive Support Ventilation

Adaptive Support Ventilation

A dual control mode that uses pressure ventilation (both PC and PSV) to maintain a set minimum VE (volume target) using the least required settings for minimal WOB depending on the patients condition and effort
It automatically adapts to patient demand by increasing or decreasing support, depending on the patients elastic and resistive loads

The clinician sets patients IBW, % desired VE . The ventilator then delivers 100 mL/min/kg. A series of test breaths measures the system C, resistance and auto-PEEP If no spontaneous effort occurs, the ventilator determines the appropriate respiratory rate, VT, and pressure limit delivered for the mandatory breaths I:E ratio and TI of the mandatory breaths are continually being optimized by the ventilator to prevent auto-PEEP If the patient begins having spontaneous breaths, the number of mandatory breaths decrease and the ventilator switches to PS at the same pressure level Pressure limits for both mandatory and spontaneous breaths are always being automatically adjusted to meet the E target

Adaptive Support Ventilation


Indications
Full or partial ventilatory support Patients requiring a lowest possible PIP and a guaranteed VT ALI/ARDS Patient requiring high and/or variable Patients not breathing spontaneously and not triggering the ventilator Patient with the possibility of work land changes (CL and Raw) Facilitates weaning

Adaptive Support Ventilation


Advantages
Guaranteed VT and VE Minimal patient WOB Ventilator adapts to the patient Weaning is done automatically and continuously Variable to meet patient demand Decelerating flow waveform for improved gas distribution Breath by breath analysis

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Adaptive Support Ventilation


Disadvantages and Risks
Inability to recognize and adjust to changes in alveolar VD Possible respiratory muscle atrophy Varying mean airway pressure In patients with COPD, a longer TE may be required A sudden increase in respiratory rate and demand may result in a decrease in ventilator support

Automode

The ventilator switch between mandatory and


spontaneous breathing modes

Combines volume support (VS) and pressureregulated volume control (PRVC)

If patient is paralyzed; the ventilator will provide If the patient breathes spontaneously for two

PRVC. All breaths are mandatory that are ventilator triggered, pressure controlled and time cycled; the pressure is adjusted to maintain the set tidal volume. consecutive breaths, the ventilator switches to VS. All breaths are patient triggered, pressure limited, and flow cycled. ventilator switches back to PRVC

If the patient becomes apneic for 12 seconds; the

What is BiLevel Ventilation? BILEVEL VENTILATION

Is a spontaneous breathing mode in which two levels of pressure and hi/low are set Enabled utilizing an active exhalation valve Substantial improvements for spontaneous breathing better synchronization, more options for supporting spontaneous breathing, and potential for improved monitoring

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BiLevel Ventilation

What is BiLevel Ventilation?


At either pressure level the patient can breathe spontaneously spontaneous breaths may be supported by PS if PS is set higher than PEEPH, PS supports spontaneous breath at upper pressure

Spontaneous Breaths 60

Synchronized Transitions

Spontaneous Breaths

Paw
cmH20 -20

BiLevel Ventilation

Then What Is APRV?

60 PEEPH PEEPHigh + PS Pressure Support

Is a Bi-level form of ventilation with sudden short releases in pressure to rapidly reduce FRC and allow for ventilation Can work in spontaneous or apneic patients APRV is similar but utilizes a very short expiratory time for pressure release and a prolonged time on Phigh This short time at low pressure allows for ventilation


6 7

Paw
cmH20 -20

PEEPL

APRV always implies an inverse I:E ratio

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Airway Pressure Release Ventilation



Provides two levels of CPAP and allows spontaneous breathing at both levels when spontaneous effort is present Both pressure levels are time triggered and time cycled

Airway Pressure Release Ventilation



Allows spontaneously breathing patients to breathe at a high CPAP level, but drops briefly (approximately 1 second) and periodically to allow CPAP level for extra CO2 elimination (airway pressure release) Mandatory breaths occur when the pressure limit rises from the lower CPAP to the higher CPAP level

Airway Pressure Release Ventilation


Indications
1. Partial to full ventilatory support 2. Patients with ALI/ARDS 3. Patients with refractory hypoxemia due to collapsed alveoli 4. Patients with massive atelectasis 5. May use with mild or no lung disease

Airway Pressure Release Ventilation


Advantages
1. Allows inverse ratio ventilation with or without spontaneous breathing (less need for sedation or paralysis) 2. Improves patient-ventilator synchrony if spontaneous breathing is present 3. Increases mean airway pressure 4. Improves oxygenation by stabilizing collapsed alveoli 5. Allows patients to breath spontaneously while continuing lung recruitment 6. Lowers PIP 7. May decrease physiologic deadspace

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Airway Pressure Release Ventilation


Disadvantages and Risks
1. Variable VT 2. Could be harmful to patients with high expiratory resistance (i.e., COPD or asthma) 3. Auto-PEEP is usually present 4. Caution should be used with hemodynamically unstable patients 5. Asynchrony can occur if spontaneous breaths are out of sync with release time 6. Requires the presence of an active exhalation valve

Airway Pressure Release Ventilation

Comparison of three different modes of ventilation


Mechanisms Frequency Exhalation CPD Control Humidity ET tube

HFOV HFJV What is different?


Oscillator 3-15 Hz (180-900) Active Direct setting; No gas trapping Standard humidifier Standard Jet 1-10 Hz (60-600) Passive Gas trapping by increased f and set PEEP Vaporizer, nebulizer, humidity entrainment Modified ET tube

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High Frequency Oscillatory Ventilation


Principles of gas exchange
1. Convection (Bulk Flow) Ventilation 2. Asymetrical Velocity Profile 3. Taylor Dispersion 4. Molecular Diffusion 5. Pendelluft 6. Cardiogenic Mixing

Oscillator

HFOV
CDP Adjust Valve

Taylor Dispersion

Low flow
ET Tube Oscillator

High flow
Patient BIAS Flow

Decrease TVs to physiological dead space and increase frequency

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Gas Profile

Pendelluft Effect

CO2 Elimination

Variables of Oscillator Breaths

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HFOV Principle:
Pressure curves CMV / HFOV

Control Variables of HFVO

CO2 Elimination

Oscillatory volume versus frequency and amplitude

CO2 Elimination = VT2 x f VT = oscillatory volume F = oscillatory frequency


Amplitude

Frequency

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WHAT WE DO KNOW

THE COMPLIANT LUNG


1000

Lungs are heterogeneous; alveoli are not all alike Injured alveoli are non-compliant; normal distention
Volume (mL)

Expiration
800

of injured alveoli results in overdistention of the truly normal alveoli

600

Cyclical inflation and deflation of alveoli using large


tidal volumes and low PEEP injures lung parenchyma and can cause both atelectrauma and volutrauma

A small change in pressure results in a large change in volume

400

Optimal mechanical ventilation ensures adequate


oxygenation while minimizing the detrimental effects of alveolar overdistention

200

Inspiration

0 0 10 20 30 40 50 60 Pressure (cm H2O)

Optimized longvolume : safe window window


Overdistension Edema fluid accumulation Surfactant degradation High oxygen exposure Mechanical disruption Zone of Overdistention

CT 1

CT 2 CT 3

Injury Safe Window


Zone of Derecruitment and Atelectasis

Volume Derecruitment, Atelectasis Repeated closure / re-expansion Stimulation inflammatory response Inhibition surfactant Local hypoxemia Compensatory overexpansion

Paw = CDP Continuous Distending Pressure


Pressure

CDP = Lung volume

Injury

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THE NONCOMPLIANT LUNG


1000

VENTILATOR-INDUCED ALVEOLAR DAMAGE


High peak pressures damage compliant alveoli

800

Volume
Volume (mL) 600

400

200

A large change in pressure is necessary to achieve the same change in volume

A T E L E C T R A U M A
Pressure

V O L U T R A U M A

0 0 10 20 30 40 50 60 Pressure (cm H2O)

Cyclical opening and closing of collapsed alveoli results in shearing forces

VENTILATOR-INDUCED ALVEOLAR DAMAGE


Avoid overdistention

VENTILATOR-INDUCED ALVEOLAR DAMAGE

Volume

A T E L E C T R A U M A

Avoid alveolar collapse


Pressure

V O L U T R A U M A

Volume

A T E L E C T R A U M A
Pressure

V O L U T R A U M A

Increase PEEP to reduce risk of atelectrauma

Decrease TV to reduce risk of volutrauma

Lower respiratory rate to allow spontaneous, small tidal volume breaths and reduce shearing forces

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Alveolar Recruitment

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