Mechanical Ventilation for Dummies

Keep It Simple Stupid

Indications
Airway Ventilation failure (CO2) Hypoxia Combination

Airway obstruction Inability to protect airway Hypoxia (PaO2 < 50) Hypercapnia (PaCO2 > 50) Respiratory distress (RR > 30, use of accessory muscles)

Ventilator Management
Scalar
CMV ACV IMV SIMV SIMV + PS PCV IRV PRVC APRV CPAP

Control Mode- Scalars

(Volume- Targeted Ventilation) (Volume- Targeted Ventilation)
Preset Peak Flow Preset Peak Flow

(L/min) (L/min)

F llo w F ow

Dependent on Dependent on CLL & Raw C & Raw

P rre s s u rre P eH O)u e ss (cm

(cm H2 O) 2

Preset Vtt Preset V

VVoollluum ee V o (ml)m ee V o (ml) um lu m T iim e (s e c ) T m e (s e c )

2000 RespiMedu 2000 RespiMedu

Essentials of Ventilator Graphics Essentials of Ventilator Graphics

CLINICAL UTILITY OF VENTILATOR GRAPHICS Vijay Deshpande, MS, RRT, FAARC

Ventilator Management
Loops

Pressure-Volume Loops Pressure-Volume

VT VT
Ex Ex p piir ra t a tiio on n

Flow-Volume Loop Flow-Volume Loop

Inspiration Inspiration
Flow Flow (L/min) (L/min)

1 1 4 4 3 3

IIns ns p piir ra t a t iio on n

Volume Volume ((mL)) mL) mL) mL

Volume (ml) Volume (ml)

FRC FRC
PIP PIP

Paw (cm H2O) Paw (cm H2O)

Essentials of Ventilator Graphics Essentials of Ventilator Graphics

2 2 Expiration Expiration
2000 RespiMedu 2000 RespiMedu

Essentials of Ventilator Graphics Essentials of Ventilator Graphics

2000 RespiMedu 2000 RespiMedu

CLINICAL UTILITY OF VENTILATOR GRAPHICS Vijay Deshpande, MS, RRT, FAARC

Ventilator Management
This really is all there is to it

Time (RR) Volume (Vt) Pressure (PIP, Pplat) Flow

Volume vs Time Scalar Volume vs Time Scalar

Inspiratory Tidal Volume Inspiratory Tidal Volume

Volume Volume (ml) (ml)

Inspiration Inspiration Expiration Expiration

TI TI

Time (sec) Time (sec)

Ventilator Management
Control Mechanical Ventilation
Time Set respiratory rate Independent Volume Set Vt Variables Flow Set to deliver the Vt Airway Pressure Dependent on the interaction of the above and on the respiratory system compliance and airflow resistance

Ventilator Management
Pressure Control Ventilation Time Set respiratory rate Independent Pressure Set pressure Variables Flow Set to deliver pressure Volume Dependent on the interaction of the above and on the respiratory system compliance and airflow resistance

Ventilator Management
Dual Control Modes - PRVC
Time Set RR Independent Volume Set VT Variables Flow Set Pressure increases or decreases to maintain the set VT (Dependent variable), but this is Limited (i.e. controlled)

Airway Pressure Release Ventilation

APRV-BILEVEL SIMV
Advantages 1. Lower Paw for a given VT 2. Lower VE, i.e., less dead space 3. Limited adverse effects on cardiac function 4. Spontaneous breathing 5. Decreased sedation Potential Disadvantages 1. Volumes change with changes in compliance and resistance 2. New technology 3. Limited access to technology 4. Limited research and clinical experience

CPAP is transiently decreased or released to a lower level during expiration.

Ventilator Management
Peak Insp Pressure (PIP) vs. Plateau airway Components of Inflation Pressure pressure (P plat) Transairway pressure
PIP-Pplat
Obstruction Secretions RAD
Paw Paw (cm H22O) (cm H O) 1 1 2 2 1. PIP 1. PIP 2. Pplat/Alveolar Pressure 2. Pplat/Alveolar Pressure A. Airway Resistance A. Airway Resistance B. Distending Pressure B. Distending Pressure

A A

B B Time (sec) Time (sec)

Begin Inspiration Begin Inspiration

Begin Expiration Begin Expiration

CLINICAL UTILITY OF VENTILATOR GRAPHICS Vijay Deshpande, MS, RRT, FAARC

Ventilator Management
Compliance
Relationship of volume to pressure Dynamic vs static
Lung Compliance Changes Lung Changes in the P-V Loop in P-V Loop
VT VT
Volume Targeted Ventilation Volume Targeted Ventilation

COMPLIANCE COMPLIANCE COMPLIANCE COMPLIANCE Volume (mL)) mL) Volume ((mL) (mL

Normal Normal Increased Increased Decreased Decreased

PIP levels PIP levels

Essentials of Ventilator Graphics Essentials of Ventilator Graphics

Paw (cm H22O) Paw (cm H O)

2000 RespiMedu 2000 RespiMedu

CLINICAL UTILITY OF VENTILATOR GRAPHICS Vijay Deshpande, MS, RRT, FAARC

History of Mechanical Ventilation

Poliomyelitis
Negative pressure (iron lung)

WW II
Positive pressure cycled (Bennett and Bird)

Volume cycle (Emerson) VT 6-8 ml/kg, Sigh 12-18 ml/kg VT 10-15ml/kg without sighs ARDS & PEEP
Ashbaugh Bigelow and Petty UCHSC 1967

Ventilator Induced Lung Injury VILI is due to volume (Overdistension)

Ventilation 45 cm H2O

Baseline

5 min

20 min

Dreyfuss Am. Rev. Respir. Dis. 1998; 137: 1159-1164

ARDS is Not Homogeneous

Gattinoni L. Milan Italy

Inflection Points
Paw increases with little change in the volume

Lower
Lung Compliance Changes Lung Compliance Changes in the P-V Loop in the P-V Loop
VTT V
Volume Targeted Ventilation Volume Targeted Ventilation

Upper
Overdistension Overdistension
Paw rises with little or no change in VT Paw rises with little or no change in VT

COMPLIANCE COMPLIANCE COMPLIANCE COMPLIANCE Volume (mL)) mL) Volume ((mL (mL)

Normal Normal Normal Normal Increased Increased Increased Increased Decreased Decreased Decreased Decreased

Paw Paw (cm H22O) (cm H O)

PIP levels PIP levels

Essentials of Ventilator Graphics Essentials of Ventilator Graphics

Pressure (cm H22O) Pressure (cm H O)

2000 RespiMedu 2000 RespiMedu

Paw (cm H2O) Paw (cm H2O)

Essentials of Ventilator Graphics Essentials of Ventilator Graphics

2000 RespiMedu 2000 RespiMedu

CLINICAL UTILITY OF VENTILATOR GRAPHICS Vijay Deshpande, MS, RRT, FAARC

ARDSnet
NIH NHLBI ARDS Clinical Trials Network

ARDS Network: ARMA

Respiratory Management in ARDS 6 vs. 12 ml/kg Tidal Volume
Mode: Volume Assist / Control Rate: Set rate < 35; adjust for pH goal = 7.30-7.45 Oxygenation PaO2 = 55-80 mmHg SaO2 = 88-95% PEEP FiO2 5 5 .3 .4 8 .4 8 .5 10 .5 10 .6 10 .... 20 .7 .... 1.0

I:E = 1:1.8-1.3 Weaning by Pressure Support when PEEP/FiO2 < 8/.40

New Eng J Med 2000; 342: 1301

ARDS Network: ARMA

Respiratory Management in ARDS 6 vs. 12 ml/kg Tidal Volume 12 ml/kg Group 6 ml/kg Group
Initial Vt = 12 ml/kg IBW If Pplat > 50 cmH20, reduce Vt by 1 ml/kg. Minimum Vt = 4 ml/kg If Pplat < 45 cmH20 and Vt < 11 ml/kg, increase Vt by 1 ml/kg. Initial Vt = 6 ml/kg IBW. If Pplat > 30 cmH20, reduce Vt by 1 ml/kg. Minimum Vt = 4 ml/kg. If Pplat < 25 cmH20 and Vt < 5 ml/kg, increase Vt by 1 ml/kg.

New Eng J Med 2000; 342: 1301

ARDS Network: ARMA

Respiratory Management in ARDS 6 vs. 12 ml/kg Tidal Volume
45 40
cm water

6 ml/kg 12 ml/kg

Plateau Pressure

35 30 25

*
33 + 8

25 + 6
20 0 1 2 Study Day 3 4

New Eng J Med 2000; 342: 1301

ARDS Network: ARMA

Respiratory Management in ARDS 6 vs. 12 ml/kg Tidal Volume

200 180

10

* *

6 ml/kg 12 ml/kg

*
PEEP (cm water)

8 6 4 2 0

P/F 160
140 120 6 ml/kg 12 ml/kg

2 Study Day

3 4 Study Day

14

21

New Eng J Med 2000; 342: 1301

ARDS Network: ARMA

Respiratory Management in ARDS 6 vs. 12 ml/kg Tidal Volume Vt 6 vs. 12 ml/kg Mortality 31.0 vs 39.8%

New Eng J Med 2000; 342: 1301

ARDS Network: ALVEOLI

High vs. Low PEEP
Ventilator management the same as ARMA except PEEP
Lower PEEP/ Higher FiO2 Treatment Group FiO2 30 40 40 50 50 60 70 70 70 80 90 90 90 100 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24

Higher - PEEP/Lower FiO2 Treatment Group FiO2 30 30 30 30 30 40 40 50 50 50-80 80 90 100 100 PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24
N Engl J Med 351:327, July 22, 2004

ARDS Network: ALVEOLI

High vs. Low PEEP
Variable Day 1 Low High PEEP P/F 8.9 14.7 Low 8.5 169 Day 3 High 12.9 206 Low 8.4 181 Day 7 High 12.9 218

168 220

N Engl J Med 351:327, July 22, 2004

ARDS Network: ALVEOLI

High vs. Low PEEP

Conclusions VT goal 6 ml/kg Pplat limit of 30 cm H2O, Outcomes are similar whether lower or higher PEEP levels are used.

N Engl J Med 351:327, July 22, 2004

ARDS Network: FACTT

Fluids and Catheter Treatment Trial PAC vs. CVP

N Engl J Med 354:2213, May 25, 2006

ARDS Network: FACTT Conservative vs. Liberal Fluid

N Engl J Med 354:2564, June 15, 2006

ARDS Network: FACTT Conservative vs. Liberal Fluid

D Furosemide mg/d Liberal 1 2 3 4 5 6 7 74 72 65 80 73 58 51 Conserve 148 157 166 154 164 158 127 Intake ml/d Liberal Conserve 5029 4467 3997 3752 3825 3782 3639 4230 3590 3390 3430 3201 3159 3226 Output ml/d Liberal Conserve 2501 2824 3060 3188 3358 3334 3216 3043 3966 3797 3606 3444 3316 3143 Balance ml/d Liberal Conserve 2529 1642 936 563 483 508 458 6992+502 1186 -376 -408 -165 -226 -144 130 -136+491

7 day fluid balance N Engl J Med 354:2564, June 15, 2006

ARDS Network: FACTT Conservative vs. Liberal Fluid

N Engl J Med 354:2564, June 15, 2006

ARDS Network: FACTT Conservative vs. Liberal Fluid

Outcome Death
(60d)

Liberal 28.4% 12.1 11.2 14

Conserve 25.5% 14.6 13.4 10

P 0.30 .001 .001 .06

VFD
(28d)

ICU-FD
(28d)

Dialysis
(60d)

N Engl J Med 354:2564, June 15, 2006

ARDS Network: LASRS

Late ARDS Steroid Rescue Study
Methylprednisolone 2 mg/kg load 0.5 mg / kg q 6 for 14d, 0.5 mg / kg q 12 for 7d, Taper over 4 days Taper over a 2 days if septic shock Intensive infection surveillance

28.6 v 29.2%

New Eng J Med Volume 2006; 354:1671-1684

ARDS Network: LASRS

Late ARDS Steroid Rescue Study
Placebo (91) Mortality (60d) 28.6% VFD (28d) 6.8 + 8.5 ICU FD (28d) 6.2 + 7.8 Myopathy (no.) 0 Infections / pts 43/30 Amylase (D7) 73 +50 Glucose (D7) 144.0 + 61.8 MP (89) 29.2% 11.2 + 9.4 8.9 + 8.2 9 25/20 125 + 131 158.7 + 64.4 p 1.0 .001 .02 .001 .14 .003 .14

New Eng J Med Volume 2006; 354:1671-1684

Institute for Healthcare Improvement (IHI)

Ventilator Bundle

HOB > 30o DVT prophylaxis PUD Prophylaxis Daily sedative vacation and assessment of readiness to extubate

http://www.ihi.org/IHI/

Mechanical Ventilation Weaning

What was the reason for intubation? Has that reason been resolved? Can patient protect airway? Can patient handle secretions? Oxygenation? Ventilation? (CO2) Others: Cardiac function, acid base, abdomen, renal function 35% prediction
You will never find a fever if you do not measure a temperature?

Nonphysicain Directed Weaning

Ordered Protocol

Ely AmJRCCM 1999; 159: 439

Kollef CCM 1997; 25: 567

Daily Sedative Vacation

Control

Vacation

Kress New Eng J Med 2000

Mechanical Ventilation Weaning

Pressure Support
Gradual reduction in ventilator work is assumed by the patient
PSV

SIMV + PS
Some breaths are ventilator work and some are patient work
Brochard AJRCCM 1994; 150: 896 SBT q d

T-piece
Discontinuation of ventilator work is assumed by patient.

Esteban NEJM 1995; 332: 345

Mechanical Ventilation Failure to Wean

Increase in demands
Abnormal respiratory mechanics
RAD Decrease C

Unresolved infection
Fever = Me = work

Decrease in patient capability

Sedation Weakness
Malnutrition Neuro- or Myo-pathy

Demands Total Support Deleterious work

Capability Ventilator Independence Tolerable load

Chest wall mechanics

Weaning Guidelines
Daily assessment of potential Spontaneous breathing trials (30-120 min) Stable support between SBTs Ability to protect airway Reverse causes of failure Weaning protocols for nonphysician Prolonged ventilation=slow gradual lengthening of SBTs
Chest 2001; 120: 375S

Mechanical Ventilation Weaning

Withdrawl of the ventilator Test for successful extubation
Vt 5-7 ml/kg RR < 30 Me < 15 L RR/Vt < 105 NIF < 20 FVC 10-15 ml/kg

10% Failure

Questions?
KISS