MECHANICAL VENTILATION

MVA

OBJECTIVES
Describe types of breaths and modes of mechanical ventilation
Describe interactions between ventilatory parameters and
modifications needed to avoid harmful effects

MVA

INDICATIONS FOR
MECHANICAL VENTILATION
Ventilation abnormalities
Respiratory muscle dysfunction
Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular disease

Decreased ventilatory drive

Increased airway resistance and/or obstruction

MVA

INDICATIONS FOR
MECHANICAL VENTILATION
Oxygenation abnormalities
Refractory hypoxemia
Need for positive end-expiratory pressure
(PEEP)
Excessive work of breathing

MVA

TYPES OF VENTILATOR BREATHS

Volume-cycled breath
Volume breath
Preset tidal volume

Time-cycled breath
Pressure control breath
Constant pressure for preset time

Flow-cycled breath
Pressure support breath
Constant pressure during inspiration

MVA

MODES OF MECHANICAL
VENTILATION
Consider trial of NIPPV
Determine patient needs
Goals of mechanical ventilation
Adequate ventilation and oxygenation
Decreased work of breathing
Patient comfort and synchrony

MVA

MODES OF MECHANICAL VENTILATION

POINT OF REFERENCE:
SPONTANEOUS VENTILATION

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CONTINUOUS POSITIVE AIRWAY

PRESSURE (CPAP)
No machine breaths delivered
Allows spontaneous breathing at
elevated baseline pressure
Patient controls rate and tidal volume

MVA

ASSIST-CONTROL VENTILATION
Volume or time-cycled breaths + minimal ventilator
rate
Additional breaths delivered with inspiratory effort
Advantages: reduced work of breathing; allows
patient to modify minute ventilation
Disadvantages: potential adverse hemodynamic
effects or inappropriate hyperventilation

MVA

ASSIST-CONTROL VENTILATION
Parameters set:
VT
RR
FiO2
PEEP
The ventilator will deliver the set VT for all mandatory and
spontaneous breaths. Some patients may tend to
hyperventilate on this mode.

MVA

PRESSURE-SUPPORT VENTILATION
Pressure assist during spontaneous inspiration with
flow-cycled breath
Pressure assist continues until inspiratory effort
decreases
Delivered tidal volume dependent on inspiratory
effort and resistance/compliance of lung/thorax

MVA

PRESSURE-SUPPORT VENTILATION
Initial settings:
set PS at the pressure required to generate VT of 8-10 ml/kg
(this will usually be about the same as the plateau pressure)
FiO2 = 1.0
PEEP
Spontaneous mode of ventilation.
Can be used alone or in combination with mandatory modes. Mode used to
wean patients from VTR.
VT is variable, dependant on PS level set above PEEP, patient effort, chest
compliance, resistance to flow.

MVA

PRESSURE-SUPPORT VENTILATION
Potential advantages
Patient comfort
Decreased work of breathing
May enhance patient-ventilator synchrony
Used with SIMV to support spontaneous breaths

MVA

PRESSURE-SUPPORT
VENTILATION
Potential disadvantages
Variable tidal volume if pulmonary
resistance/compliance changes rapidly
If sole mode of ventilation, apnea alarm mode may
be only backup
Gas leak from circuit may interfere with cycling

MVA

SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION (SIMV)
Volume or time-cycled breaths at a
preset rate
Additional spontaneous breaths at
tidal volume and rate determined by
patient
Used with pressure support

MVA

SIMV / (PS): SYNCHRONIZED INTERMITTENT MANDATORY

VENTILATION (WITH/WITHOUT PRESSURE SUPPORT)
Parameters set:
VT (8-12 ml/kg)
RR
FiO2
PEEP
PSV
Synchronized : the VTR will sets up a window of opportunity for the patient to
trigger a breath spontaneously and if they dont or the time window elapses a
mandatory breath will be delivered. The mandatory rate set (at VT set) is
guaranteed. Spontaneous breaths greater then the rate set can be supported
with a pressure support to decrease the work of breathing imposed by the
VTR, circuit, ETT.
MVA

SYNCHRONIZED INTERMITTENT MANDATORY

VENTILATION (SIMV)
Potential advantages
More comfortable for some patients
Less hemodynamic effects

Potential disadvantages
Increased work of breathing

MVA

CONTROLLED MECHANICAL VENTILATION

Preset rate with volume or time-cycled breaths
No patient interaction with ventilator
Advantages: rests muscles of respiration
Disadvantages: requires sedation/neuro-muscular
blockade, potential adverse hemodynamic effects

MVA

PCV: PRESSURE CONTROL

VENTILATION.
Parameters set: (Mode: Either SIMV or A/C)
PC (Inspiratory pressure above PEEP)
PEEP
FIO2
RR & (I:E) Ratio & Ti

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PCV:(CONTD)
Background:
the breath is pressure limited rather than volume limited
best reserved for patients with ARDS
Advantages:
in ARDS, pO2 may increase 10-15%
Disadvantages:
there is no guaranteed tidal volume and thus there is no guaranteed minute
ventilation
air trapping can be a problem
CO2 retention frequently occurs (although this may be acceptable in
"permissive hypercapnia" strategies for ventilation of some patients with acute
respiratory failure)
in general, patients must be heavily sedated since this is an uncomfortable
mode for most patients
MVA

INSPIRATORY PLATEAU PRESSURE (IPP)

Airway pressure measured at end of inspiration with
no gas flow present
Estimates alveolar pressure at end-inspiration
Indirect indicator of alveolar distension
PIP
Plateau pressure

Inspiration

Peak pressure

Expiration
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Plateau pressure

INSPIRATORY PLATEAU PRESSURE

High inspiratory plateau pressure
Barotrauma
Volutrauma
Decreased cardiac output
Methods to decrease IPP
Decrease PEEP
Decrease tidal volume

MVA

INSPIRATORY TIME: EXPIRATORY TIME

RELATIONSHIP (I:E RATIO)
Spontaneous breathing I:E = 1:2
Inspiratory time determinants with volume
breaths
Tidal volume
Gas flow rate
Respiratory rate
Inspiratory pause

Expiratory time passively determined

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I:E RATIO DURING MECHANICAL

VENTILATION
Expiratory time too short for exhalation
Breath stacking
Auto-PEEP

Reduce auto-PEEP by shortening

inspiratory time
Decrease respiratory rate
Decrease tidal volume
Increase gas flow rate

MVA

AUTO-PEEP
Can be measured on some ventilators
Increases peak, plateau, and mean airway
pressures
Potential harmful physiologic effects

MVA

AUTO-PEEP
Can be measured on some ventilators
Increases peak, plateau, and mean airway
pressures
Potential harmful physiologic effects

MVA

WEANING FROM MECHANICAL

VENTILATION:
Factors to consider:
Awake, and off sedation (as much as possible).
Adequate nutrition, fluid status.
Free of infection.
Hemodynamically stable (preferably off pressors, angina controlled, no active
bleeding)
Normal acid-base status
Bronchospasm controlled
Normal electrolyte balance
Oxygenation (O2 requirements <0.5 and PEEP <5 cmH20)
Weaning Parameters:
RR<30
Vt >6-8 ml/Kg
MVA

CAUSES OF FAILURE TO WEAN:

1. Hypoxemia
Diffuse pulmonary disease
Focal pulmonary disease (Pneumonia)
Pulmonary edema (removal of positive pressure can increase preload and lead to
worsening heart failure)
2.Insufficient Ventilatory Drive:
response to metabolic alkalosis
Inadequate function of CNS drive (Ex: sedatives, malnutrition)
3. Excessive Ventilatory Drive:
Excessive CO2 production (sepsis, agitation, fever, high carbohydrate intake)
4. Respiratory Muscle Weakness:
Neuromuscular disease
Malnutrition
Drugs (Neuromuscular blocking agents, Corticosteroids,aminoglycosides)

MVA

CAUSES OF FAILURE TO WEAN: (CONTD)

5. Excessive Work of Breathing:
Airway obstruction
Bronchospasm
Secretions
ETT too small
Chest motion restriction (pain, bandages)
6. Acid base disorders
7. Phrenic nerve Injury
(especially with contralateral pulmonary disease)
MVA

TROUBLESHOOTING:
RULE OF THUMB: If your not sure if the Ventilator is working
properly, you must manually ventilate the patient with the Ambubag & 100% O2 until the RT is present.

MVA

COMPLICATIONS ASSOCIATED WITH

MECHANICAL VENTILATION:
Ventilation-related complications:
Malfunction
hemodynamic effects:
a) decreased cardiac output due to impaired venous return to the right heart and
increased pulmonary venous resistance due to positive pressure alveolar distension
b) autoPEEP

Barotrauma or Atelectasis
Oxygen toxicity
Respiratory alkalosis
Increased intracranial pressure

MVA

COMPLICATIONS ASSOCIATED WITH

MECHANICAL VENTILATION: (CONTD)
Suctioning-related complications:
Hypoxemia
a) patients should always be pre-oxygenated with 100%
oxygen prior to suctioning
b) suction time should be limited
Arrhythmias
Nosocomial infections

MVA