Gian Carlo T.

Rabago RN MD
Tondo Medical Center
Department of Surgery
 Part of supportive care; Never curative.
 Goals:
 To normalize ABGs
 to correct Acid-base imbalance
 to correct Ventilation side of ABG (paCO2)
 Failure to ventilate results to Hypercapnia (ventilation is the result of adequate air exchange
between atmosphere and lungs)
 to correct Oxygenation side of ABG (paO2)
 To achieve 90% SpO2 on the lowest FiO2 concentration possible
 To remove/reduce work of breathing
 to unload respiratory muscles from work in a synchronize manner as possible.
 Hypoxemic Respiratory Failure (Type 1 RF) - difficulty in oxygenation; low O2
 example: CHF, Pulmonary embolism, V/Q mismatch, ARDS etc

 Hypercapnic Respiratory Failure (Type 2 RF) - elevated CO2

 Example: Neuromuscular diseases, COPD, Drugs, etc

 Airway protection - protect airway

 Example: airway swelling
 Low Tidal volume (6-8ml/kg)
 Previously 12-15ml/kg causes hyperinflation of lung tissue leading alveolar rupture either d/t
excessive alveolar pressure (barotrauma) or alveolar volume (volutrauma)
 Alveolar rupture can lead to Acute lung injury, Biotrauma, accumulation of alveolar in pleural space
(pneumothorax), mediastinum (pneumomediastinum), lung parenchyma (pulmonary interstitial
emphysema)
 Low tidal volume was associated with 9% reduced mortality

 Adding PEEP
 As Low TV can cause collapse of airways, adding PEEP can prevent airway collapse. PEEP
keeps airway open (NV: 5-20cmH20)
 Permissive Hypercapnia
 Allowing hypercapnia to persist in favor of maintaining a low tidal volume.

 FiO2 lowest as possible

 To prevent cell damage from ROS generated. Usually reduce FIO2 <50% within 24hrs of
intubation or ASAP.
 1. PROXIMAL AIRWAY PRESSURE
 A. End-Inspiratory Peak Pressure
 The pressure at the end of inspiration generated by airways as air flows into lungs.
 Determined by airway resistance and recoil force of airway
 High Peak Pressure: Mucus plug, airway secretions, bronchospasm, tip of ET tube occluded
 Low Peak Pressure: Air leak (Tubing disconnection)
 B. End-Inspiratory Plateau Pressure
 The pressure at the end of inspiration generated when air flow stops (during a breath hold or
manual occlusion of expiratory end of tubing to allow pressure to equalize)
 Determined by Lung compliance (ability of lungs to distend)
 High Plateau Pressure: Decreased Lung Compliance - PNX, Edema, ARDS, Atelectasis, Abd
Distention
 Phases of breathing in mechanically ventilated patient
 Start of inspiration
 Inspiratory phase
 End-inspiration
 Baseline/Expiration

 4 types of breathing (in MV patients)

 A. Control breath (Mandatory Breath)
 Breathing is controlled by MV by setting up Tidal Volume and RR; TRIGGERED by time. It means, the
patient on MV will breathe based on time set.
 B. Spontaneous or Pressure support breath
 Patient triggers a spontaneous breath and MV will support it by pressure. If this spontaneous breath is
given a mandatory breath it is otherwise called assisted breath.
 C. Assisted breath (Synchronized breath)
 Not mandatory nor spontaneous breath. This happens when mandatory breath triggered by time
overlaps or occurs at the same time of patient spontaneous breath. Thus, its a mandatory breath
triggered by the patient.
 Volume-Cycled Breath (Volume Breath)
 Delivery of preset Tidal volume regardless of other factors. MV allows you to exhale when
preset volume is achieved.
 Disadvantage: Pts with worsening airway resistance can have volutrauma as preset TV will be
delivered regardless how high the pressure is in the alveoli.
 Time-Cycled Breath (Pressure Control Breath)
 Delivery of air with a preset pressure. TV will be automatically adjusted by MV based on the
pressure limited/allowed by MV. MV allows you to exhale when preset airway pressure is
achieved.
 Changes in airway resistance will alter TV delivered to patient (Inc Airway resistance  Low
tidal volume delivered)
 Flow-Cycled Breath (Pressure Support Breath)
 Same as Time-Cycled Breath, only that pressure control terminated when airflow is <25% of
initial pressure. MV allows you to exhale when flow rate becomes <25% of initial flow rate and
not when a certain pressure is achieved
 1. Assist-Control (AC)
 Full ventilatory support bec patient cant breathe efficiently even if can breathe spontaneously
 Delivers volume-cycled breath or time-cycled breath
 Control: Breathing is controlled by MV by setting up Tidal Volume and RR; TRIGGERED by time.
It means, the patient on MV will breathe based on time set.
 Example: 500mL and 10cpm (means TCT is 6seconds); MV will deliver breathing of 500mL TV every
6seconds thus time triggered.
 Assist: Patient can trigger spontaneous breath but cant sustain it unless assisted by a MV. ;
TRIGGERED by patient
 Usually in a MV, AC is a mode where patient's breathing is controlled by MV and when patient triggers
his own breathing the MV will deliver the controlled breath.
 Example: 500ml and 10cpm; MV will deliver breathing of 500mL TV every 6seconds but if patient breaths
spontaneously it will be assisted by MV by giving 500mL TV
 Problematic in patients who are tachypneic or have reduced expiratory airflow bec there may
not be enough time to exale the inflation volume thus can lead to breath-stacking --> auto-
PEEP  increased intra-thoracic pressure --> low VR  Low CO  Low BP --> Arrest
 2. SIMV (Synchronized Intermittent Mandatory Ventilation)
 Partial ventilatory support
 Delivers mandatory volume-cycled breath or time-cycled breath at a preset rate
 Optimizes patient-ventilator interaction by delivering preset mechanical breaths in
conjunction with patient’s inspiratory efforts. Patient can breathe spontaneously and can
sustain that cycle of breathing without pressure support.
 Periods of spontaneous breathing can prevent auto-PEEP and progressive hyperinflation
of lungs in patients who are tachypneic.
 Prevents atrophy of respiratory muscles from prolonged periods of MV
 3. Pressure Support Ventilation
 Partial Ventilatory support
 Patient breathes spontaneously with preset inspiratory pressure during that spontaneous
breath, thus, support ventilation
 No mandatory breaths are given unline AC and SIMV
 May be used with SIMV in patients with episodes of apnea.
 No spontaneous breathing thus no PSV --> Apnea
 Continuous Positive Airway Pressure
 Patient’s inspiration is initiated at an elevated baseline system pressure and airway
pressure returns to that level at the end of expiration.
 Application of PEEP in a spontaneously breathing patient
 Has non-invasive form through a specialized tight-fitting face mask
 Can be used to postpone intubation in patients with ARF
 Nasal CPAP in OSA
 Acts as stent that prevents upper airway collapse
 Pressure within alveoli after end-expiration
 Keeps small airways open to prevent atelectasis and impaired gas exchange.
 Improves Oxygenation, improves lung compliance, increases Functional Residual
Capacity (amount of air present in lungs after exhalation)
 Can be set 5-10cmH20
 >10 cmH20 is not associated with better outcomes and may lead to cardiac compromise
 Readiness Criteria for Spontaneous Breathing Trial
 1. Respiratory
 PaO2 >60mmHg on FiO2 <40-505 and PEEP 5-8cmH20
 PaCO2 normal or same as baseline
 Patient can initiate inspiratory effort

 2. Cardiovascular
 No evidence of myocardial ischemia
 HR <140bpm
 Normal BP without vasopressors

 Neurologic
 GCS >13
 Awake, alert, arousable, no seizures
 Spontaneous Breathing Trial (SBT)
 A. Rapid shallow breathing index (RSBI)
 RR/Vt = NV 40-50/Liter
 >100/Liter wont tolerate SBT; <80 = 95% probability of weaning success
 Example: 20/0.5L
 B. Maximum Inspiratory Pressure (Pimax)
 Evaluation of inspiratory muscle strength
 Exhale to residual lung volume then inhale forcefully
 NV Pimax > -20 cmH20
 30-120 minutes trial of spontaneous breathing
 Success:
 Comfortable vs labored breathing
 Gas Exchange (>90% SaO2, normal or constant PCO2

 CPAP
 Can help facilitate weaning. Can be continued after extubation