MECHANICAL VENTILATION

Prepared by:
Dr. Nehad Abed
Board anesthesia and intensive care

1
Basic physics related to mechanical ventilation
➢ In simple terms the lung-ventilator unit can be thought of as a tube with a
balloon on the end with the tube representing the ventilator tubing, ET tube
and airways and the balloon the alveoli.

➢ Pressure at point B is equivalent to the alveolar pressure and is determined

by the volume inflating the alveoli divided by the compliance of the alveoli
plus the baseline pressure (PEEP).

➢ Pressure at point A (equivalent to airway pressure measured by the

ventilator) is the sum of the product of flow and resistance due to the tube
and the pressure at point B.

➢ Flow, volume and pressure are variables while resistance and compliance
are constants.

➢ Flow = Volume/time
➢ In volume and flow preset modes pressure becomes
a dependent variable.

➢ It is important to monitor pressure in order to

minimize the risk of barotrauma.

➢ However, in this context it is alveolar pressure not

airway pressure that is important.

➢ By measuring the airway pressure during an end-

inspiratory pause it is possible to eliminate the
component due to resistance because during an end-
inspiratory pause there is no flow and thus
PAW=PALV.
➢ In most circumstances the contribution of the resistance
component to airway pressure is relatively small and constant so it
is reasonable to monitor airway pressure, however in patients with
high resistance (eg patients with obstructive lung disease) it is
important to monitor end-inspiratory pressure.

➢ Measurement of end-inspiratory pressure may also help determine

the cause of a sudden rise in airway pressure.

➢ If both are high then the problem is due to a fall in compliance

eg.
➢ endobronchial intubation,
➢ Pneumothorax,
➢ while if only the airway pressure is high then the problem is due
to increased resistance eg.
➢ partially blocked ETT,
➢ Bronchospasm.
 Factors that increase airway resistance
(increased peak airway pressure “PIP”)
➢ Biting down on tube
Normal
➢ ETT obstructed, narrowed,

➢ Cough

➢ Secretions

➢ Bronchospasm
↑ PIP
➢ Fast respiratory rate

6
 Factors that decrease lung compliance
(increase plateau pressure “PP”)

➢ Pulmonary edema

➢ Pneumonia ↑ PP

➢ Atelectasis

➢ Pneumothorax

➢ Increased abdominal pressure against diaphrag

m (ascites, gas distention)

7
 The era of intensive care medicine
began with positive-pressure ventilation
➢ Negative-pressure ventilators (“iron lungs”)

✓ Non-invasive ventilation first used in Boston Children’s

Hospital in 1928

✓ Used extensively during polio outbreaks in 1940s – 1950s

➢ Positive-pressure ventilators

✓ Invasive ventilation first used at Massachusetts General

Hospital in 1955

✓ Now the modern standard of mechanical ventilation

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Iron Lung circa 1950’s

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10
Modern(ized) Iron Lung

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Drager Evita II

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Servo 900c

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 Mechanical Ventilation
➢ A supportive measure not a therapeutic tool.

➢ Use ventilator to support or rest patient until

underlying disorder improved.

➢ Usually performed via ETT but not always (non-

invasive ventilation).

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 Goals of MV

➢To improve oxygenation

➢To improve ventilation

➢To decrease work of breathing

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 Respiratory Failure
One or more of the following criteria
➢ Tachypnea: RR > 30-40 /minute (according to age)

➢ Hypoxia: PaO2 < 60 mmHg

➢ Hypercarbia: PaCO2 > 50 mmHg

➢ PH < 7.2 (respiratory acidosis)

16
Indications for MV
➢ Respiratory Failure
✓ Apnea / Respiratory Arrest
✓ Inadequate ventilation (acute vs. chronic)
✓ Inadequate oxygenation
➢ Cardiac Insufficiency
✓ Eliminate work of breathing
✓ Reduce oxygen consumption
➢ Neurologic impairment :
✓ Prevention or management of increased ICP
✓ GCS < 8
➢ Airway Protection or Airway obstruction
➢ Need for surgery (esp. on cavities e.g. thoracic or abdominal)

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 Definitions
➢ Tidal Volume (TV): Volume of air in each breath.
➢ Rate: Breaths per minute.
➢ Minute Ventilation (MV): Total ventilation per minute.
MV = TV x Rate.
➢ Flow: Volume of gas per time.
➢ Inspiratory time (TI): Amount of time delegated to inspiration.
➢ Expiratory time (TE): Amount of time delegated to expiration.
➢ Inspiratory/expiratory ratio (I:E ratio): ratio between inspiratory and expiratory
time
➢ Peak inspiratory pressure (PIP): Maximum pressure measured by the
ventilator during inspiration.
➢ Positive end expiratory pressure (PEEP): Pressure present in the airways at
the end of expiration.

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 Breathing Circuit
➢ The setup of the circuit is the same for adults, children or
neonate. The difference is marked by the diameter of the
tubes: 22 mm for adults, 15 mm for pediatric, and 12 mm
for neonates patients.

➢ The breathing circuit is composed of:

✓ Inspiratory limb

✓ Expiratory limb

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The inspiratory limb includes

➢ Oxygen sensor:

➢ Heater humidifier:

➢ Water trap

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 The expiratory limb includes
➢ Expiratory Valve

➢ expiratory flow
sensor:
✓ It transmits the
airway pressure,
expiratory volume
and flow integration.

➢ Water trap

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 Modes of Mechanical
Ventilation
➢ Spontaneous / Assist

➢ Controlled

➢ Dual (Assist Control (AC)

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 Modes of Mechanical Ventilation

➢ Spontaneous ➢ Controlled ➢ Dual

/Assist 1- Volume Control Assist Control (AC)
2- Pressure Control
Volume or pressure controlled
refers to the type of breath
delivered, not the mode of
ventilation
Many different modes are
Volume Control or pressure
controlled
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24
 Volume ventilation Modes vs.
Pressure ventilation Modes
Volume-cycled modes : Pressure-cycled modes:
deliver a fixed volume at variable deliver a fixed pressure at
pressure (adults) variable volume (neonates).

➢ Volume-cycled modes ➢ Pressure-cycled modes

1. Volume Control Vent

1- Pressure Control Ventilation
(PCV)
2- Intermittent Mandatory
Ventilation (IMV)
2- Pressure Support Ventilation
3- Synchronous Intermittent (PSV)
Mandatory Vent (SIMV)
3- BiPAP
4- Volume Guarantee (VG): a
pre-set Tidal Volume is set,
PIP & Insp time adjustment
based on needs of the patient. 25
 MODES OF PPV

3 Categories of PPV

CMV SIMV SPONTANEOUS

A/CVolume SIMVVolume CPAPw/PSV
A/CPressure SIMVPressure CPAPw/o PSV
Other
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 Comparison chart
Volume Pressure Flow I-time

Spontaneous variable variable variable variable

VCV FIXED Variable FIXED FIXED

PCV variable FIXED variable FIXED

variable Variable variable

PSV FIXED
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 VENTILATOR SETTINGS
➢Mode setting
➢Volumes settings: TV, minute vol, peak flow
➢Time settings : rate, I:E ratio, Insp. time, Exp.
Time

➢Pressure settings: PIP, PEEP

➢Fio2: Fraction of inspired oxygen
➢Trigger & sigh
➢Alarms settings
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 VENTILATOR SETTINGS
Mode:
➢ The decision to use a ventilator mode should be
based on an understanding of the physiology ,
clinician bias, institutional preference, and the
capabilities of the ventilators available.
➢ You should put in your mind when you speak about a
mode the following :
➢Trigger : who/what starts a breath (pt/vent)
➢Target : what the vent is trying to achieve
➢Cycle : what causes breath to end
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 Modes of Mechanical Ventilation
You should put in your mind when speak about
mode the following :
➢ Trigger : who/what starts a breath (pt/vent)

➢ Target : what the vent. is trying to achieve

➢ Cycle : what causes the breath to end

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 Modes of Mechanical Ventilation
(Control or Target)

A- Volume Modes

B- Pressure Modes

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 1- Volume Ventilators

➢ The volume ventilator is commonly used in critical care units.

➢ The basic principle of this ventilator is that a selected volume of air is

delivered with each breath.

➢ The amount of pressure required to deliver the set volume depends on :-

✓ Patient’s lung compliance

✓ Patient–ventilator resistance factors.

32
➢ Therefore, peak inspiratory pressure (PIP ) must be
monitored in volume modes because it varies from
breath to breath.
➢ With volume mode of ventilation, we select:

✓Tidal volume (for the mechanical breaths).

✓Respiratory rate.
✓Inspiratory time.

33
 2- Pressure Ventilators
➢ The use of pressure ventilators is increasing in
critical care units.

➢ A typical pressure mode delivers a selected gas

pressure to the patient early in inspiration, and
sustains the pressure throughout the inspiratory
phase.

➢ It usually used if compliance is decreased and the

risk of barotrauma is high(e.g. ARDS) .
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➢ Although pressure is constant with these modes,
volume is not.
➢ Volume will change with changes in airway
resistance or lung compliance,
➢ With pressure modes, we select:
✓The pressure level to be delivered.
✓Respiratory rate
✓Inspiratory time (with some mode options (i.e.,
pressure controlled).
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 Common applicable Modes
1. Controlled Mandatory Ventilation (CMV)
(volume or pressure)

2. Assist-control (A/C) (volume or pressure)

3. Synchronized intermittent mandatory ventilation

(SIMV) (volume or pressure)
4. Pressure-support ventilation (PSV)
5. Continuous positive airway pressure (CPAP)

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 1- Continuous Mandatory Ventilation ( CMV)

➢ Ventilation is completely provided by the mechanical

ventilator with a preset tidal volume, respiratory rate
and oxygen concentration

➢ Ventilator totally controls the patient’s ventilation i.e.

the ventilator initiates and controls both the volume
delivered and the frequency of breath.

➢ Client does not breathe spontaneously.

➢ Client can not initiate breathe

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Continuous Mandatory Ventilation (CMV)

➢ Trigger –Machine initiates all breaths

Patient can not initiate

➢ Target – Volume or Pressure

➢ Cycle : reaching the preset volume or Pressure

e.g. Vent gives 10 bpm @ 500cc each,

pt gets zero extra breaths (even he tries)

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CMV

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 2- Assist Control Mode A/C
➢ The ventilator provides the patient with a pre-set tidal
volume at a pre-set rate .

➢ The patient may initiate a breath on his own, but the

ventilator assists by delivering a specified tidal volume
to the patient. Client can initiate breaths that are
delivered at the preset tidal volume.

➢ Client can breathe at a higher rate than the preset

number of breaths/minute

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 Assist Control Mode A/C

➢ The total respiratory rate is determined by the number of

spontaneous inspiration initiated by the patient plus the
number of breaths set on the ventilator.

➢ In A/C mode, a mandatory (or “control”) rate is selected.

➢ If the patient wishes to breathe faster, he or she can

trigger the ventilator and receive a full-volume breath.

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 Assist Control Mode A/C

➢ Often used as initial mode of ventilation:

✓ Traumatic brain injury (TBI)

✓ Severe poly trauma.

✓ Post cardiopulmonary resuscitation (CPR)

✓ Or need for complete sedation or relaxation of the patient

➢ Disadvantages:
✓ Hyperventilation

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Assist Control Mode A/C

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 Assist Control (Volume Control)

➢ Trigger – machine and patient

➢ Target – volume
➢ Cycle : reaching the preset volume

e.g. Vent. gives 10 bpm @ 500cc each

pt initiates 6 bpm – vent. provides
500cc
 Total: (10 × 500) + (6 × 500) = 8000 cc

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 Assist-Control (pressure Control)
➢ Trigger – ventilator and patient

➢ Target – Pressure (above PEEP)

➢ Settings – Mode: PC
Rate 10; Pressure 24 cm H2O
PEEP 5
e.g. vent gives 10 bpm to a peak Paw = 29
pt takes 6 bpm targeted to peak Paw =29
 Total breaths 16 at fixed pressure & variable volume

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 3- Synchronized Intermittent Mandatory
Ventilation (SIMV)
➢ The ventilator provides the patient with a pre-set
number of breaths/minute at a specified tidal volume
and FiO2.

➢ In between the ventilator-delivered breaths, the patient

is able to breathe spontaneously at his own tidal
volume and rate with no assistance from the ventilator.

➢ However, unlike the A/C mode, any breaths taken

above the set rate are spontaneous breaths taken
through the ventilator circuit.
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➢ The tidal volume of these breaths can vary from
the tidal volume set on the ventilator, because the
tidal volume is determined by the patient’s
spontaneous effort.

➢ Adding pressure support during spontaneous

breaths can minimize the risk of increased work of
breathing.

➢ Ventilators breaths are synchronized with the

patient spontaneous breathe.( no fighting)
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➢Used to start weaning the patient from the
mechanical ventilator ( e.g. after A/C
mode).

➢Weaning is accomplished by gradually

lowering the set rate and allowing the
patient to assume more work

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Synchronized Intermittent Mandatory Ventilation (SIMV)
➢ Trigger – ventilator and patient

➢ Target – ventilator breaths = volume

patient breaths = patient effort

➢ Settings-Mode: SIMV
Rate 10; Vt 500cc
FIO2 0.4; PEEP 5
e.g. vent gives 10 bpm @ 500cc each
patient takes 6 bpm @ 150 cc each
 Total: (10 ×500) + (6 × 150) = 5900 cc
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SIMV

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Revision: Modes of Ventilation

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 4- Pressure Support Ventilation (PSV)

➢ The patient breathes spontaneously while the ventilator

applies a pre-determined amount of positive pressure to the
airways upon inspiration.

➢ Pressure support ventilation augments patient’s

spontaneous breaths with positive pressure boost during
inspiration i.e. assisting each spontaneous inspiration.

➢ Helps to overcome airway resistance and reducing the work

of breathing.

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➢ Indicated for patients with small spontaneous tidal
volume and difficult to wean patients.

➢ Patient must initiate all pressure support breaths.

➢ It is a mode used primarily for weaning from

mechanical ventilation.

➢ Pressure support ventilation may be combined with

other modes such as SIMV or used alone for a
spontaneously breathing patient.

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 Pressure Support Ventilation (PSV)

➢ Trigger – patient only

➢ Target - pressure

➢ Cycle – patient flow decrease

Settings – Mode: PSV = 14 cm H2O

FIO2 0.4; PEEP 5
e.g. pt takes 18 bpm @ Vt = 500cc
machine gives zero breaths

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5- Continuous Positive Airway Pressure
(CPAP)
➢ Constant positive airway pressure during spontaneous breathing

➢ CPAP allows to observe the ability of the patient to breathe

spontaneously while still on the ventilator.

➢ CPAP can be used for intubated and non-intubated patients.

➢ It may be used as advanced weaning mode

➢ Can be used for nocturnal ventilation (nasal or mask CPAP)

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 CPAP
➢Trigger – patient
➢Cycle – patient effort ceases

➢Settings: PEEP 5; FIO2 0.4

e.g. patient takes 24 bpm @ 250 cc each

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 PEEP
Positive End-Expiratory
Pressure

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 Positive End-Exp Pressure PEEP
➢ It is an elevation in alveolar
pressure above atmospheric
pressure at end of exhalation.
➢ improves gas exchange by
opening small airways in the
dependent lung zones & distributing
inspired gas homogeneously.

➢ decreases expiratory flow

limitation & dynamic hyperinflation.

➢ decreases oxygen consumption. with PEEP

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Positive End-Expi Pressure PEEP
Types of PEEP
➢ Extrinsic PEEP (ePEEP): applied through a
mechanical ventilator, it may be :
✓ 1- Physiologic: PEEP (3 - 5 cm H20)
✓ 2- Supraphysiologic OR Theraputic PEEP:> 5
cm H20

➢ Intrinsic PEEP( iPEEP) : occurs because of

incomplete ventilation where Initiating a new breath
prior to complete exhalation leading to air-trapping

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 Positive End-Expiratory Pressure
Extrinsic PEEP (ePEEP):
➢ Physiologic: (3 - 5 cm H20) overcomes the decrease in
functional residual capacity due to Endotracheal intubation (glottis
has been bypassed).
➢ Supraphysiologic OR Theraputic : > 5 cmH20
✓ Offsets auto-PEEP in patients with obstructive lung disease
✓ Improves oxygenation in patients with hypoxemic respiratory
failure
✓ Improves oxygenation and cardiac performance in patients with
cardiogenic pulmonary edema
✓ CAUTION IN : focal lung disease, pulmonary embolism,
hypotension, patients with increased ICP, hypovolemia,
bronchopleural fistula

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 Positive End-Expiratory Pressure
Intrinsic PEEP( iPEEP) :
AutoPEEP
➢ It is ventilation - associated
➢ Occurs because of incomplete ventilation where Initiating
a new breath prior to complete exhalation leading to air-
trapping
➢ Causes : high minute volume ventilation,
expiratory flow limitation or increased
expiratory resistance
➢ Advers effects : Hypoxemia, hypotension and
barotrauma.
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Different levels of PEEP

Best PEEP
Produces the least shunting without a significant
reduction in cardiac output.

Optimum PEEP
Produces the maximal O2 delivery with the lowest
dead space/tidal volume ratio.

Appropriate PEEP
Produces the least dead space.

Intrinsic PEEP
It exists when expiration continues right up to
inspiration. Often seen in airway obstruction, asthma,
COPD, ARDS and in forced expiration. Also known as
'intrinsic PEEP'.
Positive End-Exp Pressure
Best PEEP

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 Positive End-Expi Pressure PEEP
➢INDICATIONS FOR PEEP
✓ARDS
✓Stabilize chest wall
✓Physiologic peep
✓Decrease Auto-peep
➢CONTRAINDICATIONS FOR PEEP
✓Increased intracranial pressure
✓Unilateral pneumonia
✓Bronchoplueral fistulae
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 Positive end expiratory pressure (PEEP)

➢ PEEP: an elevation in alveolar pressure above

atmospheric pressure at the end of exhalation

➢ It differs from CPAP in that:

✓ PEEP is only applied during expiration, whereas
CPAP is applied throughout the entire
respiratory cycle.
✓PEEP is not a mode but a parameter. CPAP is a
mode.
✓PEEP is used in a mandatory ventilator breath,
CPAP is used during spontaneous breath. 65
 Positive End-Expiratory Pressure

➢Physiologic: (3-5 cm H20)

➢Improves gas exchange by opening small
airways in the dependent lung zones and
distributing inspired gas homogeneously
(maximizing the FRC).
➢Decreases oxygen consumption

➢ Adverse effects of PEEP

✓Hypotension (decreased venous return)
✓Barotrauma and pneumothorax
✓Increased ICP (when >10)
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 Gas trapping (Auto-PEEP)

➢ Progressive hyperinflation of alveoli.

➢ Progressive rise in end-expiratory pressure (intrinsic
PEEP)
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 Gas trapping

➢Predisposing factors:
➢Long inspiratory time ( expiratory time
short)
➢High respiratory rate ( absolute expiratory
time short)
➢Large tidal volume
➢Expiratory flow limitation or increased
expiratory resistance (Asthma or COPD)

68
Gas trapping
➢Adverse effects
✓Barotrauma & possible pneumothorax

✓Cardiovascular compromise

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 Time-cycled ventilator
➢ In which inspiration is terminated when a preset
inspiratory time, has elapsed.

➢ TV depends on inspiratory time and inspiratory flow rate.

➢ They are used in neonate intensive care areas and in

OR.

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 High-Frequency Ventilators
➢ High-frequency ventilators use small tidal
volumes (1 to 3 mL/kg) at frequencies greater
than 100 breaths/minute.

➢ The high-frequency ventilator accomplishes

oxygenation by the diffusion of oxygen and
carbon dioxide from high to low gradients of
concentration.
71
 High-Frequency Ventilators

➢ A high-frequency ventilator would be used to

achieve lower peak ventilator pressures, thereby
lowering the risk of barotrauma.

➢ 3 different modes: high-frequency positive-pressure

ventilation (HFPPV), high-frequency jet ventilation
(HFJV), and high-frequency oscillatory ventilation
(HFOV)

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 NEW
MODES
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 Why new modes?
➢ Conventional modes are uncomfortable & Need heavy
sedation & paralysis

➢ Patients should be awake and interacting with the ventilator

➢ To enable patients to take spontaneous breath on inverse ratio

ventilation

➢ New Dual modes : Combining advantages of both volume &

pressure control

➢ Recently developed modes allow ventilator to control V or P

based on a vol feedback 74
 1. (APRV) Airway Pressure Release
Ventilation
➢ Ventilator cycles between two different levels of
CPAP ( an upper pressure level and a lower level
called PEEPH and PEEPL ).
➢ The two levels are required to allow gas move in and
out of the lung.
➢ Baseline airway pressure
is the upper CPAP level &
pressure is intermittently
“released” to a lower level ,
thus eliminating waste gas
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 (APRV) Airway Pressure Release Ventilation cont

➢ If pt paralyzed: pressure control, time triggered

pressure limited, time cycled ventilation (Similar
to PCV with no spont. ventilation)

➢ Spontaneous breathing: is allowed at both levels

of pressure

➢ Time spent at low pressure (short expiratory

time): prevents complete exhalation; maintains
alveolar distension
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 Airway pressure–release ventilation
➢ Bi-level, or biphasic, ventilation is a relatively new mode of ventilation that
has recently gained popularity.

➢ The ventilator is set at 2 pressures (high CPAP, low CPAP), and both levels
are time cycled.

✓ The high pressure is maintained for most of the time while the low
pressure is maintained for short intervals of usually <1 second to allow
exhalation and gas exchange to occur.

✓ The patient can breathe spontaneously during high or low pressure.

✓ This mode has the benefit of alveolar recruitment.

Its disadvantage is that

✓ the tidal volume is variable.
✓ The clinician must be constantly aware of patient's minute
ventilation to prevent severe hypercapnia or hypocapnia.
 2- Dual Control
➢ It switch between PC and VC breaths

➢ Switch within a single breath OR between breaths

➢ Ventilator operates in either the PS or PC modes where

pressure limit ↑ or ↓ in an attempt to maintain selected
TV based on the TV of the previous breath (Analogous to
having a therapist at the bedside who ↑ or ↓ the pressure
limit of each breath based on the TV of the previous
breath)

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3- (VAPS) Volume Assured Pressure Support
➢ Mandatory breaths or PS breaths

➢ Combine high variable flow of a pressure-limited breath with constant

volume delivery of a volume-limited breath

➢ During pressure support: VAPS is a safety net that always supplies a

minimum TV Breath: initiated by the patient or may be time-triggered

➢ Once the breath is triggered, ventilator will attempt to reach PS setting as

quickly as possible

➢ This portion of the breath is pressure control

➢ & is associated with a rapid variable flow (may↓WOB)

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 4- (PRVC) Pressure Regulated Volume Control
➢Dual Control Breath to Breath
➢ Assist-control ventilation

➢ Pressure control is titrated to a set TV

➢ Time cycled

➢ The pressure limit will fluctuate between 0 cm H2O above the

PEEP level to 5 cm H2O below the high-pressure alarm setting

➢ The ventilator will signal if the tidal volume & maximum

pressure limit settings are incompatible
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 5- (ASV) Adaptive Support Ventilation
➢ Based on minimal WOB concept

➢ Automatic adaptation of the ventilator settings to patient's

passive and active respiratory mechanics

➢ Initially designed to reduce episodes of central apnea :

improvement in sleep quality, & decreased daytime
sleepiness

➢ Can be used for pts who are at risk for central apnea like
those with brain damage

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 6- (MMV) Mandatory Minute Ventilation
➢ ventilator changes it’s output based on measured input
variable

➢ If anticipated TV < set (based on MV of past 30 sec):

Mandatory breaths which are VC, time triggered is
given.

➢ In contrast to SIMV: the MMV gives mandatory breaths

only if spontaneous breathing has fallen below a pre-
selected minimum ventilation.
82
 7- (ATC) Automatic Tube Compensation
➢ Single greatest cause of imposed WOB is the ET
➢ This mode Compensates for the resistance of the ET tube by
increasing PS & inspiratory flow levels as ET diameter
decreases
➢ Under static conditions PS can effectively eliminate
endotracheal-tube resistance
➢ Variable inspiratory flow and changing demands: cannot be met
by a single level of PS
➢ ATC attempts to compensate for ET resistance via closed-loop
control of calculated tracheal pressure Measurement of
instantaneous flow to apply pressure proportional to resistance
throughout the total respiratory cycle
83
 8- (VSDC) Volume Support Dual Control:
Breath to Breath
➢ Concept : Closed-loop control of pressure-support ventilation
that uses TV as a feedback control for continuously adjusting
the pressure-support level

➢ Patient-triggered - Pressure-limited - Flow-cycled

➢ Operation : pressure change can range from 0 cm H2O above

PEEP to 5 cm H2O below the high-pressure alarm setting

➢ All breaths are pressure-support breaths

➢ VS will wean the patient from pressure support as patient

effort increases & lung mechanics improve
84
Synonyms Causing Confusion: Drager
➢ IPPV = VC (w Auto Flow OFF)
➢ IPPV = PRVC (w Auto Flow ON)
➢ BiPAP = SIMV-PC
➢ BiPAP / Assist : CMV-PC with an
➢ active exhalation valve

85
KEY POINTS: MECHANICAL VENTILATION
➢ All patients’ should be ventilated with a lung protective
ventilator strategy from the time of intubation to extubation-
✓ Tidal volume 4 to 8 ml/kg PBW
✓ Plateau pressure < 28 cm H2O
✓ Driving pressure < 15 cm H2O
✓ PEEP sufficient to prevent end expiratory alveolar collapse
✓ FiO2 titrated to maintain pO2 55 to 80 and SpO2 88% to 95%.

➢ The greater the control over the process of ventilation the

greater the level of asynchrony.

➢ The forms of asynchrony most likely to cause ventilator

induced lung injury are flow asynchrony and double
triggering.
86
 Main determinants

Oxygenation (Oxygen Ventilation (Carbon

in): dioxide out):
➢  RR
➢ FIO2
➢  tidal volume
➢ PEEP (Re-open
alveoli and  shunt)
➢  Expiratory time
➢↑Insp. time

87
 What mode to be used?
➢ Largely apneic patient:
➢ Control of minute ventilation important

✓ Assist control

➢ Control of peak pressure important

✓ Pressure control

➢ Intermittent spontaneous breaths

✓ SIMV
➢ Regular spontaneous breaths, improving condition
✓ Pressure support

88
 Initial ventilator setting
➢ Mode: (e.g. Full ventilatory support: AC ventilation)
➢ Respiratory rate: start at 10-14 (adjust according to PaCO2).
➢ Tidal volume: 6-8 ml/kg (IBW) (adjust according to PaCO2).
➢ FiO2: initial 1.0 then adjust to maintain PaO2 80-100 mmHg
➢ I : E ratio: 1:2 (Inverse I:E in ARDS, 1:3 in Asthma &COPD)
➢ Various alarm limits (e.g. inspiratory pressure 10-15 cmH2O
below & above expected).

89
 Troubleshooting
➢ Is it working ?
✓ Look at the patient !!
✓ Listen to the patient !!
✓ Vital signs!!
✓ Look at the ventilator/ the alarms
✓ Pulse oximeter, ABG
✓ Chest X ray
➢ When in doubt, DISCONNECT THE PATIENT FROM THE VENTILATOR,
AND BEGIN BAG VENTILATION
✓ Ensure you are bagging with 100% O2
✓ This eliminates the ventilator circuit as the source of the problem
✓ Bagging by hand can also help you gauge patient’s compliance

90
 Non-invasive ventilation
➢ For years, negative pressure ventilators were the only non-
invasive methods of assisting ventilation.

➢ It was later recognized that delivery of continuous positive

airway pressure by close fitting nasal masks for treatment of
obstructive sleep apnoea could also be used to deliver an
intermittent positive pressure.

➢ This was followed by improvements in the interface and

establishment of role of NIV in patients with COPD.

➢ The use of NIV has increased in the last decade in various

conditions to avoid the complications of intubation.
Advantages of NIV

➢ Preservation of airway defense mechanism

➢ Early ventilatory support
➢ Intermittent ventilation
➢ Patient can eat, drink and communicate
➢ Ease of application and removal
➢ Patient can cooperate with physiotherapy
➢ Improved patient comfort
➢ Reduced sedation requirements
➢ Avoidance of complications of intubation
➢ Ventilation outside hospital setting possible

Disadvantages
➢ Mask is uncomfortable/claustrophobic
➢ Time consuming for medical and nursing staff
➢ Airway is not protected
➢ No direct access to bronchial tree for suction
 Mechanism of Action
➢ Improvement in pulmonary mechanics and oxygenation
NIV augments alveolar ventilation and allows oxygenation without raising
the PaCO2.

➢ Partial unloading of respiratory muscles

NIV reduces trans-diaphragmatic pressure, pressure time index of
respiratory muscles and diaphragmatic electromyographic activity. This
leads to an increase in tidal volume, decrease in respiratory rate and
increase in minute ventilation. Also overcomes the effect of intrinsic PEEP.

➢ Resetting of respiratory center ventilatory responses to PaCO2

In patients with COPD, the ventilatory response to raised PaCO 2 is
decreased especially during sleep.

➢ By maintaining lower nocturnal PaCO2 during sleep by administering NIV, it

is possible to reset the respiratory control center to become more
responsive to an increased PaCO2 by increasing the neural output to the
diaphragm and other respiratory muscles.

➢ These patients are then able to maintain a more normal PaCO2 throughout
the daylight hours without the need for mechanical ventilation.
Requirements for successful non-invasive support

➢ A co-operative patient who can control their airway and

secretions with an adequate cough reflex.

➢ The patient should be able to co-ordinate breathing with

the ventilator and breathe unaided for several minutes

➢ Haemodynamically stable

➢ Blood pH>7.1 and PaCO2 <92 mmHg

➢ The patient should ideally show improvement in gas

exchange, heart rate and respiratory rate within first two
hours.
Indications for NIV

➢ Acute respiratory failure

➢ Hypercapnic acute respiratory failure
➢ Acute exacerbation of COPD
➢ Post extubation difficulty
➢ Weaning difficulties
➢ Post surgical respiratory failure
➢ Thoracic wall deformities
➢ Cystic fibrosis
➢ Status asthmaticus
➢ Acute respiratory failure in obesity hypoventilation syndrome
➢ Chronic Respiratory Failure
➢ Immunocompromised Patients
➢ Patients 'not for intubation'.
➢ Hypoxemic acute respiratory failure

The evidence is less convincing to show efficacy of NIV in

hypoxemic respiratory failure.
Possible indications include cardiogenic pulmonary oedema,
community acquired pneumonia, post traumatic respiratory
failure and ARDS.
Selection Criteria
Acute Respiratory Failure
➢ At least two of the following criteria should be present:
➢ Respiratory distress with dyspnoea
➢ Use of accessory muscles of respiration
➢ Abdominal paradox
➢ Respiratory rate >25/min
➢ ABG shows pH <7.35 or PaCO2 >45mmHg or PaO2/FiO2 <200
➢
Chronic respiratory failure (obstructive lung disease)
➢ Fatigue, hypersomnolence, dyspnoea
➢ ABG shows pH <7.35, PaCO2 >55 mmHg, PaCO2 50-54 mmHg
➢ Oxygen saturation <88% for >10% of monitoring time despite O2
supplementation

Thoracic Restrictive/ Cerebral Hypoventilation Diseases

➢ Fatigue, morning headache, hypersomnolance, nightmares, enuresis,
dyspnoea
➢ ABG shows PaCO2 >45mmHg
➢ Nocturnal SaO2 <90% for more than 5 minutes
Contraindications
➢ Respiratory arrest/unstable cardiorespiratory status
➢ Uncooperative patients
➢ Unable to protect airway- impaired swallowing and cough
➢ Facial/oesophageal or gastric surgery
➢ Craniofacial trauma/burns
➢ Anatomic lesions of upper airway

Relative Contraindications
➢ Extreme anxiety
➢ Morbid obesity
➢ Copious secretions
➢ Need for continuous or nearly continuous ventilatory assistance
Modes of Non-invasive Ventilation
All modes of ventilation can be used for applying non-invasive
ventilation

CPAP
➢ CPAP by nasal mask provides a pneumatic splint which holds the
upper airway open in patients with nocturnal hypoxaemia due to
episodes of obstructive sleep apnoea.

➢ It provides positive airway pressure throughout all phases of

spontaneous ventilation.

➢ CPAP increases the FRC and opens collapsed alveoli.

➢ CPAP reduces left ventricular transmural pressure and therefore

increases cardiac output.
➢ Hence it is a very effective for treatment of pulmonary oedema.

➢ Pressures are usually limited to 5-12 cm of H2O,

➢ Since higher pressure tends to result in gastric distension
requiring continual aspiration through a nasogastric tube.
BIPAP Bi-level Positive Airway Pressure

provides two levels of positive pressure of non-invasive ventilation

ventilation, supporting patient’s spontaneous breathing.

During exhalation, pressure is variably positive.

A higher pressure (IPAP) for breath in and a lower pressure

(EPAP) for breath out in order to:
✓ Reduce the work of breathing
✓ Improve oxygenation and ventilation

Cycling between inspiratory and expiratory modes may either be

triggered by the patient's breaths or preset.
101
 Are there benefits for high-flow nasal cannula
(HFNC) beyond oxygen administration.
➢ The major benefit for HFNC is the high flow, which minimizes room
air dilution.
➢ This allows administration of precise high oxygen concentrations.
➢ Because the oxygen administration is by nasal prongs rather than
by face mask, there are fewer interruptions oftherapy due to
removal of the device.
➢ The high flow into the nose effectively flushes the upper
airway,which is a dead-space lowering effect.
➢ This reduction in anatomic dead space reduces the
minuteventilation requirement, and studies have consistently
reported a lower breathing frequency whenHFNC is applied.

102
 high-flow nasal cannula (HFNC)
➢ The high flow into the pharynx opposes expiratory flow,
thus producing a continuous positive airway pressure
(CPAP) effect.

➢ With the mouth closed, there is an increase in CPAP of

about1 cm H2O for each 10 L/min increase in flow. Much of
this CPAP effect might be lost, however, if themouth is
opened.

➢ The high flow provided through the upper airway also

decreases inspiratory resistance,and this may reduce the
work of breathing.
103
 high-flow nasal cannula (HFNC)
➢ The available evidence supports the use of HFNC
for selected patients with acute hypoxemic
respiratory
failure.
➢ It can also be used to prevent hypoxemic
respiratory failure, such as postextubation aduring
intubation.

➢ Current evidence does not support routine

application of HFNC postextubation, suggesting
that the therapy should be reserved for patients
104
with demonstrated hypoxemia.
 high-flow nasal cannula (HFNC)
➢ It can also be used to prevent hypoxemic respiratory failure,
such as postextubation and during intubation.

➢ HFNC should be initiated at a flow of50 L/min.

➢ That flow is maintained and FIO2 is decreased, provided that

SpO2 is more than 90%.

➢ Note that the FIO2 is decreased rather than the flow. If the
FIO2 reaches less than0.4, consideration can be givento a
change to conventional oxygen therapy.

105
high-flow nasal cannula (HFNC)

106
Flow diagram of use of high-flow nasal cannula for
hypoxemic acute respiratory failure
Volume limited ventilation
In this mode, ventilators are usually set in assist-control mode with
high tidal volume (10-15 ml/kg) to compensate for air leaks.

This mode is suitable for patients with

✓ obesity
✓ chest wall deformity (need high inflation pressure) and in
✓ patients with neuromuscular diseases who need high tidal
volumes for ventilation.

Proportional assist ventilation (PAV)

This is a newer mode of ventilation.

In this mode the ventilator has the capacity for responding rapidly
to the patients' ventilatory efforts.
By adjusting the gain on the flow and volume signals, one can
select the proportion of breathing work that is to be assisted.
KEY POINTS:
NONINVASIVE RESPIRATORY SUPPORT
➢ HFNC is used for patients with acute hypoxemic respiratory
failure.

➢ 2. In addition to delivery of precise high oxygen concentration,

HFNC flushes dead space from the upper airway, reduces
inspiratory resistance, and produces a small level of CPAP.

➢ 3. Mask CPAP is used for the treatment of cardiogenic pulmonary

edema, post-operative hypoxemia, and for hypoxemic respiratory
failure in patients with hematologic malignancy.

➢ 4. The primary indications for NIV are COPD exacerbation, acute

cardiogenic pulmonary edema, post-operative respiratory failure,
and prevention of extubation failure.

109
 KEY POINTS:
NONINVASIVE RESPIRATORY SUPPORT
➢ 5. An interface that fits over the nose and mouth is
recommended for application of NIV foracute respiratory
failure.

➢ 6. Skin breakdown is an important avoidable complication of

NIV.

➢ 7. Leak compensation is the most important consideration

when selecting a ventilator for NIV.

➢ 8. Aerosol therapy can be combined with NIV and HFNC.

110
 Summary
➢ The use of NIV has increased during the past few years.

➢ In acute exacerbation of COPD it is now considered the ventilator

mode of first choice.

➢ For treatment of acute pulmonary oedema, CPAP alone is very

effective. NIV reduces the chances of endotracheal intubation in
hypoxaemic respiratory failure.

➢ It is also being used to facilitate weaning from invasive ventilation.

➢ NIV is first choice in patients with neuromuscular diseases and

chest wall deformity.

➢ Central hypoventilation and patients of obstructive sleep

apnoea not responding to CPAP are also acceptable
indications.
 Weaning
There are a number of complications associated with mechanical ventilation,
including barotrauma, pneumonia and decreased cardiac output. For
these reasons, it is essential to discontinue ventilatory support as soon as
the patient improves.

Weaning is indicated when the underlying condition is resolving.

➢ Many patients are ventilated for a short period or time, for example those
recovering from major surgery.

➢ Others undergoing many days of ventilation (eg ARDS);

During long periods of prolonged ventilatory support, the respiratory muscles

weaken and atrophy.
As a consequence, the speed of weaning is often related to the duration and
mode of ventilation.

Assisted modes of ventilation and good nutritional support

are important to prevent atrophy of the respiratory
muscles.
➢ Weaning from mechanical ventilation is intended to shift the work of
breathing from the ventilator back to the patient over time.

➢ An issue separate from discontinuing ventilator support is

determining if the patient can maintain his or her airway and be
extubated safely.

➢ Patients recovering from prolonged critical illness are at risk of

developing 'critical illness polyneuropathy'.
➢ In this condition, there is both respiratory and peripheral muscle
weakness, with reduced tendon reflexes and sensory abnormalities.
➢ Treatment is supportive.

➢ There is evidence that long-term administration of some aminosteroid

muscle relaxants (such as vecuronium) may cause persisting
paralysis.
➢ For this reason, vecuronium should not be used for
prolonged neuromuscular blockade.
When to withdraw mechanical ventilation

Weaning or liberation from mechanical ventilation, is an

important issue.

Unnecessary delays in the withdrawal of mechanical

ventilatory support increases the

➢ patient's risks for complications,

➢ increases the length of ICU stay,
➢ hospital costs.

However, premature withdrawal from the ventilator can also

be deleterious.

Patients who may be able to support their own ventilation

and oxygenation can often be recognized by assessing
objective measurements or by asking the following
questions:
➢ Is the process responsible for the patient's respiratory failure
resolving or improving?

➢ Is the patient hemodynamically stable? Is the patient free of active

cardiac ischemia or unstable arrhythmias, and vasopressor support
absent or minimal?

➢ Is oxygenation adequate with a PaO2 of >60 mm Hg with an FiO2 of <

40% and a PEEP of < 5 cm H2O?

➢ Are mental and neuromuscular statuses appropriate with the patient

on minimal or no sedation? Does the patient have adequate strength
of the respiratory muscles?

➢ Are the acid-base status and electrolyte status optimized?

➢ Is the patient afebrile?

➢ Are the patient's adrenal and thyroid functions adequate to allow for
weaning?
 Numerous weaning parameters that can be used to
help predict successful extubation
➢ However, no weaning protocol is 100% accurate in predicting successful
weaning and extubation. These weaning parameters must be individualized
for each clinical scenario.

➢ For instance, if the rapid shallow breathing index (the respiratory rate/tidal
volume is <105, the patient is likely to be weaned from mechanical
ventilation. The investigators who derived this number examined primarily
middle-aged patients.

➢ However, data from follow-up studies of patients >70 years suggest that a
slightly higher rapid shallow breathing index of <130 may be acceptable.

➢ These parameters give no insight into whether a patient can protect his or
her airway or clear secretions.

➢ Clinical judgment and experience play a large role in the physician's decision
to withdraw mechanical ventilatory support.

➢ If a patient cannot be extubated and/or if the results of rapid, swallow

breathing test are not satisfactory, the reason for the failure must be
evaluated and treated.
 Indications for weaning
The decision to start weaning is often subjective and based on clinical experience.
However, there are some guidelines that may be helpful:

➢ Underlying illness is treated and improving

➢ Respiratory function:
✓ Respiratory rate < 35 breaths/minute
✓ FiO2 < 0.5, SaO2 > 90%
✓ PEEP <10 cmH2O
✓ Tidal volume > 5ml/kg
✓ Vital capacity > 10 ml/kg
✓ Minute volume < 10 l/min

➢ Absence of infection or fever

➢ Cardiovascular stability, optimal fluid balance and electrolyte replacement

➢ Prior to trial of weaning, there should be no residual neuromuscular blockade and

sedation should be minimized so that the patient can be awake, cooperative and in a
semirecumbent position.

➢ Weaning is likely to fail if the patient is confused, agitated or unable to cough.

Parameters Indicating Readiness to Wean
➢ Underlying cause for mechanical ventilation resolved
✓ Improved chest x-ray

✓ Minimal secretions

✓ Normal breath sound

➢ Mental readiness (conscious & can protect his A/W)

➢ Hemodynamic stability:
✓ adequate cardiac output
✓ Absence of hypotension
✓ Minimal vasopressor therapy

118
Parameters Indicating Readiness to Wean
➢ Adequate oxygenation & ventilation:
✓Adequate resp. muscle strength
✓PaO2 >60 mmHg with FiO2 < 0.5
✓PCO2 <50 mmHg
✓RR<30 /min
✓Spontaneous TV > 5ml /kg
✓Minute ventilation < 10 L/min
✓PEEP < 8 cm H2O
✓Pressure support < 8 cm H2O

119
Parameters Indicating Readiness to Wean

➢ Absence of factors that impair weaning

✓Infection
✓Anemia
✓Hypokalemia
✓Sleep deprivation
✓Pain
✓Abdominal distention

120
How to withdraw mechanical ventilation

➢ The 3 general approaches to weaning are:

➢ synchronized intermittent mandatory

ventilation (SIMV)

➢ pressure support ventilation (PSV)

➢ SBT

➢ CPAP
➢In SIMV weaning
➢ Breaths are either a mandatory ventilator-controlled breath or a
spontaneous breath

➢ With or without pressure support

➢ The original intent of SIMV was to let the patient's respiratory

muscles rest

➢ During the mandatory breaths and to work during the spontaneous

breaths.

➢ Weaning is accomplished by decreasing the number of mandatory

breaths

➢ Gradually increasing the workload of the respiratory muscles

➢ Weaning is typically done by 2 breaths every 1–2 hours

➢ The patient's heart rate, respiratory rate, and oxygen saturation

indicate his or her ability to accept the work of breathing
➢ Evidence now suggests that
the respiratory muscles are not able to rest during the
mandatory breaths and that this mode may result in muscle
fatigue and prolong mechanical ventilation.

➢ Findings from randomized trials that suggest that

SIMV weaning delays extubation compared with PSV and SBT
and that it should not be the primary mode of weaning in most
patients.

➢ However,
SIMV weaning does ensure that the patient receives some
ventilatory support, and it may be favored in institutions where
the staffing level of respiratory therapists is not optimal.
➢ In PSV weaning
➢ all breaths are spontaneous and combined with enough pressure support to
ensure that each breath is a reasonable tidal volume.

➢ The pressure support lowers the work of breathing for the patient.

➢ Weaning is performed by gradually decreasing the amount of pressure

support and by transferring an increased proportion of the work to the
patient.

➢ This transfer is continued until the pressure support approaches 5-6 cm

H2O.

➢ When the patient can tolerate this level of ventilatory support, extubation is
usually successful.

➢ Studies have demonstrated that PSV weaning reduces the number of days
on mechanical ventilation compared with SIMV alone.

➢ PSV can be used in conjunction with SIMV when a patient is weaned from
mechanical ventilation. The coupling of these 2 modes is an especially
attractive option in frail patients with underlying chronic illnesses.
➢ In SBT weaning
➢ The preferred method of weaning is the SBT.

➢ This is an attempt to gauge how the patient might do if immediately

removed from the ventilator.

➢ This method is also referred to as the sink-or-swim trial.

➢ The key is to withdraw ventilatory support while oxygenation is

continued.

➢ The simplest form of SBT is the T-piece trial.

➢ The patient is disconnected from the ventilator, and the endotracheal

or tracheostomy tube is hooked to a flow-by oxygen system, usually
from the wall.

➢ The transition from the ventilator tubing to the new tubing attached to
the wall oxygen outlet requires extra work and patient monitoring by
the respiratory therapist.
➢ If the trial is unsuccessful, the extra tubing is wasted.

➢ In some studies, approximately 80% of patients receiving mechanical

ventilation do not require prolong weaning.

➢ This observation explains why SBT is both useful and practical.

This approach has had the most success with weaning in randomized
controlled trials.
Therefore, it is a preferred approach to removing patients from
mechanical ventilation.

➢ At the end of the SBT, the patient should be evaluated for possible
extubation, as his or her blood pressure, respiratory rate, heart rate, and
gas exchange are also considered.
The SBT should last 30-90 minutes.
An SBT should be performed only once a day. Several SBTs a day offer
no benefit.
➢ In Continuous Positive Airway Pressure (CPAP) weaning

➢ The same assessment can be made by using the continuous

positive airway pressure (CPAP) mode while the patient is still
connected to the ventilator.

➢ This is a relatively common method of assessing the patient's

ability to do the work of breathing by himself or herself.

➢ Variations on this theme include adding a small amount of end-

expiratory pressure and using CPAP of 5 cm H20 or a CPAP of
0 but with a PSV of 5-6 cm H2O to offset the resistance from the
artificial airway.

➢ No controlled studies have shown any superiority in assessing

the outcomes of weaning between these approaches.
KEY POINTS:
WEANING FROM MECHANICAL VENTILATION, AND EXTUBATION

➢ Daily systematic assessments of patients receiving

mechanical ventilation for the ability to breathes
pontaneously are important in achieving timely
discontinuation of ventilator support and reducing
complications related to artificial airways and mechanical
ventilation.

➢ A respiratory therapist–driven or nurse-driven protocol for this

daily assessment can safely reduce the duration of
mechanical ventilation and performs better than standard
physician assessments.

➢ Sedation and analgesia should be minimized or interrupted

on a daily basis. 128
KEY POINTS:
WEANING FROM MECHANICAL VENTILATION, AND EXTUBATION

➢ Before removing the artificial airway, patients should be

able to protect their airway, follow commands,should
demonstrate good cough effort, and should not have
copious secretions. (RememberCAALMS.)

➢ Systematic attention to medical conditions that impair

spontaneous breathing, such as left-ventriculardysfunction,
muscle fatigue, and metabolic abnormalities, should be part
of daily patient assessment.
➢ This can guide the medical care for those patients in whom
a spontaneous breathing trial fails or whorequire prolonged
ventilator support.
129
 Failure to wean
➢ During the weaning process, the patient should be observed for early
indications of fatigue or failure to wean.

➢ These signs include distress:

✓ increasing respiratory rate,
✓ falling tidal volume and
✓ hemodynamic compromise, particularly tachycardia and
hypertension.

At this point it may be necessary to increase the level of

respiratory support as, once exhausted, respiratory muscles
may take many hours to recover.

➢ It is sensible to start the weaning process in the morning to allow

close monitoring of the patient throughout the day.

➢ In prolonged weaning, it is common practice to increase ventilatory

support overnight to allow adequate rest for the patient.
➢ The commonest indication of tracheostomy in an ICU setting is to
facilitate prolonged artificial ventilation and the subsequent
weaning process.

➢ Tracheostomy allows a reduction in sedation and thus increased

cooperation to the weaning process.

➢ It also allows effective tracheobronchial suction in patients who ar

e unable to clear pulmonary secretions either due to excessive s
ecretion production or due to weakness following critic
al illness.

➢ prolonged mechanical ventilatory support is defined as requirin

g at least 6 h/day of ventilator support for more than 21 days. Th
ese patients generally require a tracheostomy f
or optimal care.
 Complications of intubation

During laryngoscopy and intubation

➢ Malpositioning
✓ Esophageal intubation
✓ Bronchial intubation
➢ Airway trauma
✓ Dental damage
✓ Lip, tongue, or mucosal laceration
✓ Sore throat

132
 Complications of intubation

During laryngoscopy and intubation

➢ Malpositioning
✓ Esophageal intubation
✓ Bronchial intubation
➢ Airway trauma
✓ Dental damage
✓ Lip, tongue, or mucosal laceration
✓ Sore throat

133
 Complications of intubation

During laryngoscopy and intubation

➢ Physiological reflexes
✓ Hypoxia, hypercarbia
✓ Hypertension, tachycardia
✓ Intracranial hypertension
✓ Intraocular hypertension
✓ Laryngospasm

134
 Complications of intubation

➢ Following extubation
✓Edema and stenosis (glottic, subglottic, or
tracheal)
✓Hoarseness (vocal cord granuloma or
paralysis)
✓Laryngeal malfunction and aspiration
✓Laryngospasm
✓Negative-pressure pulmonary edema

135
 Adverse Effects of Mech. Ventilation
➢ Pulmonary:
✓ Barotrauma(and possible pneumothorax): induced by excessive
pressure
✓ Volutrauma: induced by excessive volume
✓ Ventilator-associated pneumonia
✓ Air trapping (auto-PEEP)
✓ Increase work of breathing (Improper mode or setting)

➢ Cardiovascular:
✓ Decease preload (decreased venous return)
✓ Increase RV afterload

136
 Implementation of the ventilator Bundle

➢ Interventions to be implemented unless contraindicated:

✓ Maintain head of bed elevated at 30 to 45 degree
✓ Interrupt sedation each day to assess readiness to wean from
ventilator

✓ Provide prophylaxis for deep vein thrombosis

✓ Administer medications for peptic ulcer disease prophylaxis

137
 Which Ventilator Mode am I describing?

➢ A composite mode in which the ventilator

delivers a set volume at a set frequency and
allows the patient to take additional spontaneous
breaths

138
SIMV

139
 Which Ventilator Mode am I describing?

➢ A spontaneous mode in which the patient

triggers and cycles every breath and the
ventilator only supports the pressure
during the breath

Pressure Support ventilation

140
 Which Ventilator Mode am I describing?

➢ A mode in which the ventilator delivers a

set volume at a minimum set frequency (it
allows the patient to initiate additional
mandatory breaths of the set volume)

141
Assist Control (Volume Control)

142
 What variables affect ventilation?

➢PEEP
➢Tidal volume
➢Minute ventilation
➢FiO2
➢Respiratory rate

143
 What variables affect ventilation?

➢PEEP
➢Tidal volume
➢Minute ventilation
➢FiO2
➢Respiratory rate
➢minute ventilation = tidal volume x
respiratory rate

144
 What variables affect oxygenation?

➢PEEP
➢Tidal volume
➢Minute ventilation
➢FiO2
➢Respiratory rate

145
 What variables affect oxygenation?

➢PEEP
➢Tidal volume
➢Minute ventilation
➢FiO2
➢Respiratory rate
➢V/Q matching allows the optimal diffusion
of oxygen between the alveoli and the
capillaries
146
Which of the following is not a criteria for extubation?

A. FiO2 < 50%

B. PEEP < 8 cm H2O
C. PaO2 > 75 mm Hg
D. Minute ventilation > 15 L/min
E. pH = 7.30 – 7.50

147
A. FiO2 < 50%
B. PEEP < 8 cm H2O
C. PaO2 > 75 mm Hg
D. Minute ventilation > 15 L/min
E. pH = 7.30 – 7.50

148