Absolute Basics of Mechanical Ventilation

Dr David Howell
Consultant in Intensive Care, Respiratory and Acute Medicine

Aims and Objectives

Define Positive Pressure Mechanical Ventilation Explain Continuous Mandatory Ventilation (CMV) Explain Synchronised Mandatory Ventilation (SIMV) Explain Pressure Support Ventilation (PSV) Explain Basic Ventilator Settings

Not a Talk on Physiology of Mechanical Ventilation

What you Encounter

Positive Pressure Mechanical Ventilator

Lots of Monitors and Knobs to Turn

Some are More Complicated than Others

Invasive support
Advanced Ventilation

Tracheostomy
Prone Position Nitric Oxide
Long Term Weaning/Individual plan

Standard Ventilation

Weaning
Optimising the Pt for weaning

Suctioning Intubation

Weaning Screen/standard protocol

Humidification
Wake, Warm & Wean Non-Invasive Ventilation

Oxygen Therapy

Mask CPAP

Extubation Decannulation

Non-invasive support

NIV vs. Invasive Mechanical Ventilation

NIV is defined as ventilatory support provided via a tight fitting mask or similar interface as opposed to invasive support, which is provided via a laryngeal mask, endotracheal tube or tracheostomy tube. Tight fitting masks deliver can CPAP, BIPAP or NIV via the mechanical ventilator.

Indications for Mechanical Ventilation

The work of breathing usually accounts for 5% of oxygen consumption (V02).
In the critically ill patient this may rise to 30%. Invasive mechanical ventilation eliminates the metabolic cost of breathing.

Indications for Mechanical Ventilation

Inadequate oxygenation (not corrected by supplemental O2 by mask). Inadequate ventilation (increased PaCO2). Retention of pulmonary secretions (bronchial toilet). Airway protection (obtunded patient, depressed gag reflex).

Intubation

Bare Essentials for Intubation ALSOBLEED

1 Airway: oral Guedel airway to lift tongue off posterior pharynx to facilitate mask ventilation during pre-intubation phase. 2 Liquids: stop feed and aspirate ng tube. 3 Suction: extremely important to avoid pulmonary aspiration. 4 Oxygen: preoxygenate patient and ensure a source of O2 with a delivery mechanism (ambu-bag and mask) is available.

Bare Essentials for Intubation ALSOBLEED

5 Bougie: to facilitate tube insertion in more difficult airway.

6 Laryngoscope: have a long and short blade available.

7 Endotracheal tube: for average adult, cuffed oral endotracheal tube 7.0 for women and 8.0 for men. 8 End tidal CO2: to confirm correct position of tube. 9 Drugs: an induction agent, muscle relaxant, sedative are usually required.

Principles of Mechanical Ventilation

PEEP

ET tube Ventilator Tubing Major Airways

Alveoli

Principles of Mechanical Ventilation

Positive pressure ventilation involves delivering a mechanically generated breath to get O2 in and CO2 out. Gas is pumped in during inspiration (Ti) and the patient passively expires during expiration (Te). The sum of Ti and Te is the respiratory cycle or breath.

Principles of Mechanical Ventilation

Flow

Pressure

Ti

Te

Ti

Te

Principles of Mechanical Ventilation

In the fully ventilated patient, positive pressure breaths are delivered either as preset volume or pressure continuous mandatory breaths (CMV) breaths.
The mechanical ventilator triggers the breath and switches from inspiration to expiration when the preset volume, pressure (or time) is achieved/delivered.

During CMV the patient takes no spontaneous breaths.

CMV is usually used in theatre and in very unwell ICU patients.

Principles of Mechanical Ventilation

Volume control Tidal volume is preset Usually 500 mls Airway Pressure is Variable Pressure control Inspiratory Pressure is preset Usually 15-20 cm H20 Tidal Volume is Variable

Principles of Mechanical Ventilation

Mandatory breaths are delivered during inspiration, to generate a tidal volume (Vt), at a set rate (f), the quotient of which is the minute volume (MV). Minute Volume = Tidal Volume x frequency In volume control ventilation, an inspiratory flow rate is also set. The ratio of the time spent in inspiration:expiration (I:E ratio) is usually 1:2.

Principles of Mechanical Ventilation

Volume Control Breath
Pressure

Pressure Control Breath

Flow

Ti

Te

Ti

Te

Principles of Mechanical Ventilation

Mechanically ventilated patients usually receive positive end-expiratory pressure (PEEP), to overcome the loss of physiological PEEP provided by the larynx and vocal cords. PEEP is delivered throughout the respiratory cycle and is synonymous to CPAP, but in the intubated patient. Standard PEEP setting is 5 cm H20.
Sedation is often required to prevent ventilator-patient asynchrony.

Basic Settings on the Ventilator

Tidal Volume Pressure controlled breath (15-20 cm H20) Volume controlled breath (500 mls) Rate (frequency) (10-12 breaths/minute)

Positive end expiratory pressure (PEEP) (5 cm H20)

FiO2 (0.21-1) Peak airway pressure (PAP)

Principles of Mechanical Ventilation

Why is the peak airway pressure (PAP) important? Ventilator Induced Lung Injury (VILI).

Mechanical ventilation is injurious to the lung.

Aim PAP< 35 cm H20.

Principles of Mechanical Ventilation

Volume Breath
35 cm H20
Pressure

Pressure Breath

Flow

Ti

Te

Ti

Te

Pneumothorax

Principles of Mechanical Ventilation

Dont forget that the peak airway pressure will also include the PEEP that is added

Principles of Mechanical Ventilation

Once stabilised on CMV, the level of ventilatory support may be reduced (weaning). This can be done by providing a mixture of synchronised intermittent mandatory breaths (SIMV) and spontaneously triggered pressure supported breaths (PSV).

Principles of Mechanical Ventilation

Ventilator assisted breaths are synchronized with the patients breathing to prevent the possibility of a mechanical breath on top of a spontaneous breath. However, the patients attempt at a breath would not be enough to generate an adequate tidal volume on its own, hence the term pressure support.

Principles of Mechanical Ventilation

Pressure support is only delivered during inspiration and the patients attempt at breathing triggers the breath rather than the ventilator. A standard level of pressure support delivered in inspiration is 20 cm H20

SIMV and Pressure Support Ventilation

Ventilator

Patient

Principles of Mechanical Ventilation

As patients improve, mandatory breaths are withdrawn and receive pressure-supported breaths alone. Finally, as tidal volumes improve, the level of pressure support is reduced and then withdrawn so patients breathe spontaneously with PEEP alone. Extubation can now be contemplated.

Spontaneous modes of breathing should always be encouraged as respiratory muscle function is maintained

Pressure Support Ventilation

Patient

Patient

Successful Weaning and Extubation

To succeed, the initiating cause of respiratory failure, sepsis, fluid and electrolyte imbalance and nutritional status should all be treated or optimised. Failure to wean is associated with:

Ongoing high V02.

Muscle fatigue.

Inadequate drive.
Inadequate cardiac reserve.

Successful Weaning and Extubation

Weaning screens exist to help select patients for extubation. In the unsupported patient, if f/Vt is >100, extubation is likely to be unsuccessful. There is some evidence to support extubation to NIV, particularly in patients with COPD.

Basic Ventilatory Modes: Summary

Continuous Mandatory Ventilation (CMV) Pressure control Volume control No spontaneous breathing Ventilator triggers breath Synchronised intermittent mandatory ventilation (SIMV)/Pressure Support Ventilation (PSV) Pressure control (SIMV) Volume control (SIMV) Some spontaneous breathing is allowed (PSV) Mixture of ventilator and patient triggered breaths

Basic Ventilatory Modes: Summary

Pressure Support Ventilation (PSV) Spontaneous breathing with inspiratory support All patient triggered breaths

PEEP/CPAP (5 cm H20) Entirely spontaneous breathing Consider extubation

Basic Ventilatory Modes: Summary

CMV

PSV PEEP SIMV PSV

Mandatory

Overlap

Spontaneous

Standard Ventilator Settings MORITE

Mode O2

Respiratory Rate
Inspiratory Action Inspiratory Time Expiratory Action

Standard Ventilator Settings MORITE

Mode
O2 Respiratory Rate Inspiratory Action Inspiratory Time

CMV, Volume Control

0.5 (50% 02) 12/minute Set Vt at 500 mls Set I:E ratio 1:2

Expiratory Action
Be Aware

Set PEEP at 5 cm H20

PAP 35 cm H2O

Spontaneously Ventilating Patient Failing Conventional Therapy

Consider

Optimise

CPAP on Ward BIPAP on Ward

NIV on ICU BIPAP

Patient Position

Humidification

Patient Requiring Basic Invasive Mechanical Ventilation

CMV (VCV or PCV)

IMV (VCV or PCV)

PSV

PEEP/CPAP

Escalation

De-escalation