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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
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MODERN VENTILATORS
Mechanical ventilation evolved significantly in
the 1970s and 80s with the introduction of microprocessors
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)
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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
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Airway compromise Muscle fatigue / weakness Paralysis / spinal cord injury Neuromuscular disease Chest wall injury
Maintain a PaCO2 between 35 - 45 mmHg Maintain a PaO2 sufficient to meet cellular oxygen
demands but avoid oxygen toxicity
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Mandatory
Ventilator does the work Ventilator controls start and stop
Spontaneous
Patient takes on work Patient controls start and stop
Pressure controlled
- flow and volume may vary
Time - control ventilation Pressure - patient assisted Flow - patient assisted Volume - patient assisted Manual - operator control
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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
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)
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)
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)
Spontaneous Breathing
Inspiration initiated by 0
Negative pressure / flow change (patient)
10
Expiration initiated by
Decreasing flow (patient)
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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
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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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
Patient determines respiratory rate, but not volume Attempts to improve patient comfort by allowing
patient - ventilator interaction
Spontaneous Breathing
10
Pressure Support Ventilation Assist Control Ventilation
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Inspiration initiated by
Negative pressure change (patient) Time (ventilator)
Originally intended as a method of weaning Most common mode of ventilation in the SICU
setting
Expiration initiated by
Volume (patient) Volume (ventilator) Pressure (patient) Time (patient) Patient Patient
Inspiration initiated by
Negative pressure change (patient) Time (ventilator)
10
Pressure Support Ventilation Assist Control Ventilation
time
Expiration initiated by
Volume (ventilator) Pressure (ventilator) Time (ventilator) Ventilator Patient
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Inspiration initiated by
Negative pressure change (patient) Time (ventilator)
Same pressure
Expiration initiated by
Pressure (ventilator) Time (ventilator) Ventilator Patient
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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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
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
Hamilton; Galileo
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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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
no
trigger
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
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VOLUME TARGETED
60 60
Paw
cmH20 -20 120
6
INSP
-20 120
6
INSP
Flow Flow
L/min
SEC
SEC
L/min
6
EXH
6
EXH
120
120
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40
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
6
EXH
120
Flow cycle
Pressure then rises to assure that the set tidal volume is delivered
Flow
L/min
60
trigger
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
Bear 1000
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If pressure is too high, all breaths are pressure-limited. If the peak flow setting is too high , all breaths will be
volume-controlled
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
no
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
yes
cycle off
no
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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
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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
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Automode
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
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
Spontaneous Breaths 60
Synchronized Transitions
Spontaneous Breaths
Paw
cmH20 -20
BiLevel Ventilation
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
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Oscillator
HFOV
CDP Adjust Valve
Taylor Dispersion
Low flow
ET Tube Oscillator
High flow
Patient BIAS Flow
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Gas Profile
Pendelluft Effect
CO2 Elimination
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HFOV Principle:
Pressure curves CMV / HFOV
CO2 Elimination
Frequency
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WHAT WE DO KNOW
Lungs are heterogeneous; alveoli are not all alike Injured alveoli are non-compliant; normal distention
Volume (mL)
Expiration
800
600
400
200
Inspiration
CT 1
CT 2 CT 3
Volume Derecruitment, Atelectasis Repeated closure / re-expansion Stimulation inflammatory response Inhibition surfactant Local hypoxemia Compensatory overexpansion
Injury
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800
Volume
Volume (mL) 600
400
200
A T E L E C T R A U M A
Pressure
V O L U T R A U M A
Volume
A T E L E C T R A U M A
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
Lower respiratory rate to allow spontaneous, small tidal volume breaths and reduce shearing forces
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Alveolar Recruitment
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