Introduction to

Mechanical Ventilation
Postgraduate students

CEDU
2016
CEDU Learning Outcomes
At the end of the session, the student is expected to:
•Discuss the indications for mechanical ventilation
•Identify the complications associated with
mechanical ventilation
•Explain compliance and resistance
•Describe the different modes of mechanical
ventilation
•Explain common terms and values used
mechanical ventilation
•Identify basic waveforms
•Describe the nursing care associated with a
ventilated patient
CEDU Spontaneous Breathing Review
4 Phases1
•Inspiration
o Active process
o Muscles contract
o Air flows in
•Expiration
o Passive process
o Muscles relax
o Air flows out

Breathing Movements - You Tube

CEDU
Spontaneous Breathing
Inspiration Expiration
• Lung pressure < • Lung pressure >
atmosphere pressure atmosphere pressure

• Air move from • Air move out from

atmosphere to
lung/ alveoli
lung/alveoli
CEDU Mechanical Breathing
• Ventilators deliver a breath by forcing air
into the lungs
• Positive pressure2
• Expiration remains a passive process
• Ventilator ceases to deliver the breath
and allows for the breath to be passively
exhaled2
 Why do we breathe?
CEDU
What is the role of the upper airways?
CEDU Aim of Mechanical Ventilation
• The aim of mechanical ventilation is to
ensure the patient has optimal
oxygenation and ventilation
• Thereby maintaining2
o Gas exchange (O2 and CO2)
o Controlling the elimination of CO2
o Reduce work of breathing (WOB)
CEDU Indications
• Inadequate oxygenation2 (O2)
Examples

• Inadequate ventilation2 (CO2)

Examples

• Protection of the airway

 Type 1 and Type 2 Respiratory
CEDU
Failure
• Type 1 respiratory failure
o Hypoxemic
o Inadequate oxygenation

• Type 2 respiratory failure

o Hypercapnic
o Inadequate ventilation
CEDU Complications/Risks
Ventilator Associated
Lung Injury (ALI)
•Barotrauma • Biotrauma
o Increased airway o Inflammatory
pressures mediators
•Volutrauma • Infection-Ventilator
o Overdistension associated
pneumonia
•Atelectasis/ Atelectrauma
•Stress/Delirium • Oxygen toxicity
References 3,4,5
CEDU Physiological Changes
• The effect of positive pressure ventilation3
o Decreased venous return, therefore reduced
cardiac output
o Increased pulmonary vascular resistance
o Decreased urine output, secondary to the
reduced cardiac output
o Fluid retention
CEDU Compliance/Resistance
• Compliance
o The ease at which the lungs distend
o Elastance is the recoiling ability of the lungs
after being stretched
o COPD, Fibrosis (6)
• Resistance
o Refers to the forces that oppose airflow1,6
o Affected by diameter and length of airways6
o Mucosal Oedema/Secretions/Bronchospasm
CEDU Definitions
• Tidal volume (Tv)
• Peak Inspiratory Pressure (PIP)
• Flow
• Minute Volume (MV)
• PEEP
• Pressure Support
• I:E ratio
• RR – mandatory vs spontaneous
• FiO2
• Trigger
CEDU
PIP
• Peak Inspiratory Pressure
o Highest pressure reading during mechanical
inspiration
o Increased PIP increases risk of barotrauma
o Caused by
o Biting on tube
o Sputum
o Coughing
o Asthma
o Not documented for Spontaneous modes6
CEDU HighPIP
High PIP
•Circuit
o Kinking

•Endotracheal tube
o Displacement, e.g. endobronchial intubation
o Kinking
o Obstruction with foreign material

•Patient
o Bronchospasm (e.g. asthma)
o Lung  (e.g. collapse, consolidation, pulmonary edema)
o Pleural  (e.g. pneumothorax, pleural effusion)
o Patient-ventilator dysynchrony, coughing

o If in doubt manually ventilate and call for help

CEDU Flow
• Known as Peak flow /“SPEED” 2,6
• Maximum flow/speed delivered by the
ventilator during inspiration2
• Is required to deliver adequate tidal volumes
within the set time
• Normal 40-60L/min4
• Required to be set for Volume control modes
• Altering flow rates will alter the I:E
o Flow determines inspiratory time
CEDU Pressure Support
• P/S
o Ventilator provides a constant P once it
senses the patient has made inspiratory effort
(6)
o Spontaneous breaths only
o Supports the pt and enables them to achieve
a suitable Vt without excessive work of
breathing
o Increase P/S = Increase Vt (if compliance and
resistance remain the same)6
o Normal range 10 – 20 cmH2O
 PEEP
CEDU

• PEEP – Positive End Expiratory Pressure

• PEEP holds the alveoli open at the end of
a breath allowing gas exchange to
continue to occur6
• Enables recruitment of alveoli which are
collapsed2,6
• Improves V/Q match6
• Reduces sheering forces on alveoli6
• Normal range 5 – 10 cmH20, can be set up
to 20 cmH20
CEDU I:E
• Time spent in inspiration versus expiration4
• Total time available is determined by the set
RR6
• Expressed as ratio6
• Normal is 1:2
• Can see 1:4 or 1:5
o Which patients might require this ratio?

• Can you have a I:E for PSV?

CEDU Trigger
• Initiates the change from expiration to
inspiration4
• By either the ventilator or patient2
• Can be flow (flow-by), pressure or time1
o Time = ventilator
o Pressure/flow = patient
• Determines the amount of effort the patient
must generate to initiate a breath6
• Too low 6
• Too high
CEDU Control of ventilation
• The variable used to control ventilation
• Most common are:
o Volume
o Pressure
CEDU Volume Control
• Volume
o A set Vt (tidal volume) is chosen on the
ventilator by the clinician2
o Ventilator initiated breaths inspiration stops
once Vt reached2
o Provides consistent Vt
o Flow is constant
o The airway pressures are variable based
upon the pts lung compliance
o Usually set at 6-8mls/kg (6)
CEDU Pressure Control
• Pressure
o A set pressure is chosen on the ventilator by
the clinician2
o Ventilator initiated breaths inspiration stops
once the set inspiratory time has elapsed 2
o Pressure is the same for every breath
o Vt is variable based upon the pts lung
compliance (6)
CEDU Modes of Ventilation
• The breath type and pattern of breath
delivery constitutes the mode of ventilation
• The mode is determined by:
o Control variable (Pressure or volume)
o Type of breath (Mandatory, spontaneous,
assisted)
o Time of breath delivery
CEDU Type of breath
• Mandatory - ventilator controls the timing
and Tv or Inspiratory pressure
• Spontaneous - the patient controls the
timing and the Tv. The clinician does not
set the PIP or volume
• Assisted - patient triggers or initiates the
breath, the ventilator then delivers the set
pressure or volume to assist them
CEDU Breath Delivery - CMV
• Controlled Mandatory Ventilation

• Continuous Mandatory Ventilation

o Also know as IPPV or Assist Control (A/C)
o Volume or pressure control4
o Set minimum respiratory rate (RR)
o Set Tv or Pressure
o Set sensitivity
o Patient can trigger breaths at a faster rate
then the set mandatory rate
o Both mandatory and patient initiated breaths
receive set Tv or Pressure(6)
CEDU
Breath Delivery - SIMV
• Synchronized Intermittent Mandatory
Ventilation
o Volume or pressure control4
o Set mandatory RR4
o The pt is able to breath spontaneously
between the mandatory breaths4
o The ventilator is able to synchronize the
mandatory breaths with the pts respiratory
effort/spontaneous breaths
o Spontaneous breaths require pressure
support (P/S)

• AC, SIMV, and Pressure Support - YouTube

 Breath Delivery - Pressure
CEDU
Support Ventilation
• PSV
• Patient must be able to breath
spontaneously
• Pt initiates and cycles all breaths6
• Pt controls RR, inspiratory flow and Vt4
• Ventilator provides pressure support on
each spontaneous breath with PEEP
• Weaning mode, allows pt to exercise their
respiratory muscles and synchrony with
ventilator4
CEDU Esens / ETS
• Esens = expiratory value sensitivity (Puritan)
• Insp cycle off (Servo-i)
• ETS - Hamilton

o Ensures the ventilator knows when to open to

expiratory valve to allow the patient to breath out
o Only needed on spontaneous breaths
o Normally set at 25% - higher shortens inspiratory
time, lower increases/lengthens inspiratory time
(Servo-i default 30%)
CEDU Esens
CEDU
Rise Time
• %P (Puritan) or T insp. rise (Servo-i)
• How quickly the ventilator reaches the
clinician-determined inspiratory pressure,
for mandatory breaths and P/S for
spontaneous breaths6
• Higher % or shorter T insp. rise means the
pressure level is reached faster
• Look to increase the % (PB) or decrease
the T insp.(servo) Rise if patients
“breath/flow hungry”
CEDU Assessing Rise Time

Completed on the Pressure – Time waveform

•Breath B is an example of a desirable pressure waveform
•Breath A depicts slow rise time: the rise to pressure was so slow that there
is no plateau pressure
•Breath C depicts fast rise time: high PIP, prior to dropping to the pPlt.
CEDU Common Symbols
•
•V = flow (L/min) • PS = pressure support
•f = resp. rate (min) • PEEP = positive end
•Vt = tidal volume (mls) expiratory pressure
•FiO2 = fraction of inspired • Pmean = mean
oxygen inspiratory pressure
•Ti = inspiratory time (sec) • PIP = peak inspiratory
pressure
•MV = minute ventilation
(L/min) • Rise Time – time to
achieve maximal flow at
the onset of inspiration
for pressure related
breaths (Pressure
control or P/S)6
CEDU Ventilator Waveforms
• Ventilator waveforms are a graphical
representation of breath delivery
• They can be used to
o Identify breath types
o Assist in manipulating parameters for specific patients
o Assist in identifying and troubleshooting problems
• Waveforms available:
o Pressure - Time
o Flow – Time
o Volume – Time
o Pressure – Volume Loop
CEDU Ventilator waveforms
CEDU Ventilator loops
CEDU Ventilator Waveforms
Flow versus time waveform
Flow
LPM Peak flow
End inspiration
Increase
in flow

Time

End
expiration
Patient
triggered Passive
effort expiration
begins
CEDU Flow - Time
CEDU Ventilator Waveforms
Pressure versus time waveform

Peak
inspiratory
pressure

End
Pressure
expiration
rises with Time
ventilator
delivered Passive
breath expiration
begins
CEDU Pressure - Time

A – B = Inspiratory Time
B = Peak Inspiratory Pressure
B – C = Expiratory Time
Area beneath the curve = mean airway pressure
CEDU
Pressure – Time
Mandatory breath

Patient initiated,
synchronised breath:
note the negative deflection
prior to inspiration

Spontaneous
breath with no pressure
support
CEDU Ventilator Waveforms
• Volume versus time waveform
Volume Tidal
increases as volume
ventilator breath
is delivered

Time

Inspiration Expiration
CEDU Alteration in PIP
• Low PIP
• Disconnection
• Cuff leak
• Oesophageal intubation

• If in doubt manually ventilate and call for

help
CEDU Volume – Time

Normal: begins at,

and returns to zero.

Abnormal: the
volume delivered is
not completely
exhaled. This could
be due to gas
trapping or a leak.
Nursing a Ventilated
Patient
CEDU Safety
• NUMBER 1 priority
• Must be visualised at all times
• BVM must reach patient
• Portable O2
• Suction attached and on
• Ventilator plugged into BLUE plug
• Check all alarms monitor and ventilator
• IF IN DOUBT MANUALLY BAG
CEDU
Alarms
• Monitor alarms
• Ventilator alarms

Alarm Setting
PIP alarm VC 20%>Pinsp or <40mmH2O
PC <35mmH2O
PEEP 2-3cmH2O above/below preset amount
Vt 20% above and below optimal
MV 20% above and below optimal
f <30
CEDU Patient assessment
• Primary and secondary assessment must
be completed at the commencement of
shift
• Observations documented minimum of 1
hourly, including vital signs and ventilator
• Zero all lines
• Check cuff pressure
CEDU Caring for Ventilated Patient
• Monitoring
o Continuous monitoring of SaO2, HR, RR,
End tidal CO2, +/- BP

o Regular ABGs
o How often? When?
o Why do we assess ABGs?

o Medications
o Interventions
CEDU Caring for Ventilated Patient
• Sedation
o Minimal sedation to enable the patient to be
comfortable on the ventilator
o Reduce metabolic demand for patients,
important of patients with severe hypoxia
o Common drugs – morphine, midazolam &
propofol
o In ICU doctor will give you a RASS score to
aim for
CEDU RASS Score
CEDU
Caring for Ventilated Patient
• Suction
o Open or closed suction4
o Clearance of secretions when clinically indicated, not
routinely4
o Coughing
o Secretions
o Decreased O2 Sats
o Pre-oxygenate before suction if on a high Fi02
o Suction catheter should be half the diameter of the ETT
or tracheostomy
o Suction applied as catheter is removed
o Process of insertion and withdrawal of catheter should
not take longer than 30 secs
CEDU Caring for Ventilated Patient
• Humidification
o Essential at all times
o Prevents the drying and thickening of
secretions6
o HME – Heat and Moisture Exchange
o Picks up moisture and heat from the patients
exhaled breath and then transferred back to the
patient in the next inhaled breath6
o Hot water bath – (Fisher & Pykel)
o The inspired air passes over a bath of heated
sterile water. This enables the warm moist air to be
carried to the lungs
CEDU Caring for Ventilated Patient
• Communication
o The presence of a ETT or tracheostomy limits
conversation to yes or no answers
o Use of writing boards, communication boards
o Non-verbal communication

• Why can’t patient’s talk?

CEDU Caring for Ventilated Patient
• Nutrition
o Important to establish feeding early to provide
energy for respiratory muscles
o ICU Dietitian will order the correct NG
feeds/TPN
o Prevent overfeeding of carbohydrate, this will
produce excess CO2 and the patient will then
have to increase their MV to “blow off” CO2
CEDU Observations of concern
Notify doctor or senior staff:
•SaO2 low or decreasing
•EntCO2 high or increasing
•Tachycardia or bradycardia
•Increased RR
•Patient agitated , tears
•Hypotension or hypertension
•High or low PIP
CEDU Scenario
• Mr Jone is a 62 year old male admitted to
ICU intubated with exacerbation of COPD.
You note that his PIP is alarming and the
reading is now 45cmH2O.

• What are your actions?

CEDU Weaning
• After longer period of ventilation
o Wean to spontaneous mode ASAP
o PS or CPAP maybe required if respiratory
muscles wasted
o Pt can be ventilated for weeks or months as
PS is gradually decreased as pt regains
muscle strength
o Trachy used if long term ventilation required
o Sitting out of bed and even walking should be
encouraged as tolerated
CEDU Questions
CEDU
References
1. Pierce. L. Management of the mechanically ventilated patient. 2 nd edition. St. Louis:
Saunders Elsevier; 2007
2. Courey. A and Hyzy. R. Overview of mechanical ventilation. Uptodate – 2014,Jul,02
http://www.uptodate.com/contents/overview-of-mechanical-ventilation
3. Hyzy. R. Physiologic and pathophysiologic consequences of mechanical ventilation.
Uptodate – 2014, Jul, 27
http://www.uptodate.com/contents/physiologic-and-pathophysiologic-consequences-of
-mechanical-ventilation
4. Urden. L, Stacy. K and Lough. M. Critical Care Nursing – Diagnosis and Management.
7th edition. St. Louis: Mosby Elsevier; 2014
5. Hyzy. R. Ventilator-associated lung injury. Uptodate – 2014,Mar,21 http://
www.uptodate.com/contents/ventilator-associated-lung-injury
6. Cairo J., 2016, PILBEAM’s Mechanical Ventilation Physiological and Clinical
Applications, 6th Edition, Elsevier, USA
7. Elliot. D, Aitken. L and Chaboyer. W. ACCCN’s Critical Care Nursing. 2 nd edition.
Australia: Mosby Elsevier; 2012
8. Gentile. M. Cycling of the Mechanical Ventilator Breath. Respiratory Care – 2011,Jan;
56(1):52-57
9. Mechanical Ventilation in Critical Care http://www.ccmtutorials.com/rs/mv/index.htm
CEDU Diagrams
Diagrams:
• Rittner, F. & Doring, M., Curves and Loops in
Mechanical Ventilation, Draeger Medical, 2005.
• Tyco Healthcare, Ventilator Waveforms, Graphical
Presentation of Ventilator Data, 2003.
• Inspiration and Expiration pic Slide 3 -http://
blm1128.blogspot.com.au/2011/04/objective-49-cont
rast-inspiration-and.html
• Upper airway pic slide 6 -
http://what-when-how.com/paramedic-care/airway-a
natomy-and-physiology-clinical-essentials-paramedi
c-care-part-1
/
• Expiratory sensitivity pic slide 26 -
http://www.medscape.org/viewarticle/528367_9
CEDU You Tube videos
• Breathing Movements
o https://www.youtube.com/watch?v=Mf8xTqfspp4
• AC, SIMV and Pressure Support
o https://www.youtube.com/watch?v=wx6Dkjri0bc
• Respiratory waveforms
o https://www.youtube.com/watch?v=E8aqMNMgCV8
• Mechanical Ventilators in ICU
o https://www.youtube.com/watch?v=N3aSuNTaVBY
• Mechanical Ventilation graphics: Pressure
Volume
o https://www.youtube.com/watch?v=tFZ26GW2pWc
CEDU Weaning
• Following short-term ventilation i.e. post
surgery
o Regain consciousness
o Making respiratory effort
o Adequate pain relief
o Minimal ventilator support – CPAP/PS with
CPAP of 5 cmH20 and PS of 10 cmH20 and
FiO2 < 0.4.
o Normal ABGs
o Able to obey commands – cough on command
CEDU Extubation
• Medical order
Indications:
• Conscious and return of spontaneous ventilation
• Minimal ventilator support – FiO2 <50%, PEEP <
5cmH2O & PS 8cmH20
• Initial reason for intubation is reversed
• Cough present and obey commands
• Optimal CXR
• ABG satisfactory
• All other body systems stable
• Withdrawal of treatment
CEDU Extubation
• Preferably performed early in the day

• Refer to PH CPG Endotracheal Intubation and

Extubation
CEDU Post Extubation
o Possible post extubation complications:
o Stridor
o Laryngeal oedema
o Hoarseness and sore throat
o Sputum retention