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Introduction to


Charles S. Williams RRT, AE-C

Learning Objectives:

 Indications for intubation and

mechanical ventilation.
 Review the different modes of
ventilation and complications.
 Case study.
 Ventilator weaning and indicators.
 Short-term vs. Long-term weaning.
Key Terms:
 Tidal Volume, (Vt)
−The volume of air inhaled and exhaled
each breath.
 Respiratory rate, (RR,f)
−Number of breaths per minute, also
known as frequency.
 Minute Ventilation, (VE)
−The total amount of air moving in and
out of the lungs in 1 minute, (Vt x RR).
Key Terms:
 PEEP (Positive End Expiratory Pressure)
−Positive pressure applied at the alveoli at the
end of exhalation.
 FIO2 (Fractional Inspired Oxygen)
−Amount of oxygen. Expressed as a percentage,
 I:E ratio, (Inspiration/Expiratoy ratio)
−Normal I:E ratio = 1:2, 1:3
When do we intubate?

 To facilitate mechanical
 To maintain an open pathway
between the upper and lower
 To protect the lower airway
from aspiration.
 Assist with pulmonary
Indications for Mechanical
 Apnea or Impending Respiratory Failure:
(ARDS, CHF, Status Asthmaticus, Neuromuscular disease)

 Acute Respiratory Failure:

– Hypoxemic (Type I failure; oxygenation)
– Hypercapnic (Type II failure; CO2 elimination)
 Prophylactic Support:
(Post-op, Post MI, Brain injury, etc.)
 Hyperventilation Therapy:
(Acute head injury)
Modes of Ventilation
Modes of Ventilation:
 BiPAP (Non-invasive
 Pressure Support /
Volume Support
 Volume Control
 Pressure Control
 PRVC Servo-I ventilator from Maquet, Inc.
Modes of Ventilation:

Pressure / Support
Describes the type of breath Control = Set mandatory rate on
being delivered: ventilator
Pressure or volume Support = Spontaneous breaths
Modes of Ventilation:

Spontaneous Breathing



 No ventilator support
 Produces a sinusoidal pressure waveform on
graphics display.
Modes of Ventilation:
Continuous Positive Airway Pressure Positive End Expiratory Pressure

15 spontaneous Ventilator
breaths breath

Positive pressure applied to Positive pressure applied at the

spontaneous breathing patients. end of exhalation on ventilator
Can be used to treat Obstructive breaths.
Sleep Apnea

• CPAP/PEEP can improve oxygenation by “holding” the alveoli open.

• May decrease venous blood return if too much positive pressure is
applied. This can effect blood pressure and cardiac output
Modes of Ventilation:
Creates a pocket of air
that “splints” open the
upper airway to help treat
obstructive sleep apnea

bronchioles and
smaller airways

Keeps alveoli “dry” Helps oxygen to

in patients with move across the
CHF, fluid overload alveolar-capillary
Modes of Ventilation:

Inspiratory Positive
Airway Pressure (IPAP)
Expiratory Positive
Airway Pressure (EPAP)
Bipap Vision® from Respironics, Inc.
Modes of Ventilation:


• A form of non-invasive ventilation (NIV)

• Adds a second pressure setting (insp.)
Inspiratory Positive • EPAP = CPAP
Airway Pressure (IPAP) • BiPAP has same benefits as CPAP plus:
+ a) Reduces WOB
Expiratory Positive
Airway Pressure (EPAP) b) Improves ventilation (CO2
Modes of Ventilation:
PS - Adds pressure to spontaneous breaths to enhance
inspiratory tidal volume.
VS - Automatically adjusts the amount of pressure
needed to obtain a desired tidal volume.
15 Pressure Support

 Weaning modes
 PS may be used alone or in
combination with other modes.
Modes of Ventilation:


5 Spontaneous breaths

 Weaning mode
 Allows for combined ventilator
assisted and spontaneous breaths.
 Pressure support is usually added
for spontaneous breaths.
Modes of Ventilation:
Breaths are delivered at a preset volume.
Pressure is variable, Flow remains constant during

Ventilator Spontaneous
breath breath

• Guarantees delivery of desired tidal volume

• Increased risk of barotrauma due to potentially high peak pressures.
• Fixed flowrate may not meet patient’s inspiratory demand.
Modes of Ventilation:
Breaths are delivered at a preset pressure.
Pressure remains constant during inspiration, Flow is variable.
Usually used for stiff, non-compliant lungs (ARDS).

Pressure setting

Ventilator Spontaneous
breath breath

• Less risk of lung injury due to high peak pressures
• Variable flow rate can better meet patient’s demand

• Delivery of tidal volume will vary depending on lung compliance, etc.
Modes of Ventilation:
 Considered a “dual” ventilator mode.

 Combines the advantages of both

Volume Control (guaranteed tidal volume)
and Pressure Control Ventilation. (lower
peak pressures, variable flow).

 Attempts to deliver the desired tidal

volume, using the lowest possible

 Use clinically as you would “standard”

Volume Control.
Modes of Ventilation:

Control Modes

• Not used for weaning.

• Usually requires sedation.
• Does allow for spontaneous breathing.
• Patient triggered breaths and ventilator
breaths will be identical.
What Mode is Best for my Patient?

Patients that are apneic or require lots of

sedation, generally should be on a Control
mode like Volume Control, PRVC, etc.
What Mode is Best for my Patient?

Pressure Control
mode is usually
indicated when peak
inspiratory pressures
are high.
Patients with ARDS,
Adult Respiratory
Distress Syndrome,
and patients with
stiff, non-compliant
What Mode is Best for my Patient?

Spontaneous breathing patients

generally do well in SIMV mode. The
patient may feel more “in control” of
their breathing.

Adding Pressure Support to SIMV can

reduce muscle fatigue and may allow for
more synchronous breathing efforts with
the ventilator.
What Makes a Complete Order for ventilation?
Case Study:

36 yr. old female,

admitted to SJRMC,
with respiratory
distress due to
bacterial pneumonia.
Case Study:
 Laboratory Results:
− WBC: 24,000
− ABG: pH 7.12, PaCO2 74, PaO2 45,
HCO3 24 on 100% O2
(hypoxic and hypercapnic respiratory failure)

 Chest x-ray:
− Extensive Bilateral Pneumonia.
 Patient is intubated and place
on the ventilator.
 Vent settings:
Tidal volume: 600 ml
Resp Rate: 20
FiO2: 100%
Pressure Support: 10, PEEP: 5
Case Study: cont…
 ABGs after 30 minutes on ventilator:
pH 7.22, PaCO2 64, PaO2 74, HCO3 24.
 Peak airway pressures are measuring *50 cm H2O.
 IV steroids and antibiotics are started.
 She is very agitated. IV sedation is increased.
(Peak airway pressures continue to be 50cm H2O
or higher).
 Decision is made to switch to Pressure control
ventilation mode due to high peak pressures.

*In general, keeping peak pressures < 30cm H2O is desirable.

Case Study: cont…
 Vent settings:
Mode: Pressure Control
Inspiratory Pressure: 26
Resp Rate: 24
FiO2: 100%

 Insp. Pressure is adjusted to maintain exhaled tidal volume

of 550-600 ml
 After switching to PCV, Her peak airway pressure is now
measuring 31cm H2O (26+5), instead of 50cm H2O.
(Much lower risk of developing a pneumothorax due to barotrauma.)

 ABG’s eventually improve to normal range:

pH 7.42, PaCo2 44, PaO2 110, HCO3 24.
Case Study: conclusion
 As the patient began to oxygenate better,
sedation was weaned and she returned to
SIMV/PS mode.

 Within 5 days of intubation she was

extubated. And was soon discharged
Complications to Mechanical Ventilation:

Ventilator Induced Lung Injury, (VILI)

 Barotrauma
Caused by excessive pressure
 Volutrauma
Caused by excessive volume
 Oxygen Toxicity
to Mechanical Ventilation:

Complications from ventilator-induced lung injury

Complications to Mechanical Ventilation:

Ventilator Associated Pneumonia, (VAP)

 A sub-type of Hospital Acquired

Pneumonia, (HAP).
 Usually occurs within 48 hours of being
Complications to Mechanical Ventilation:

Decreased Cardiac Output and Blood Pressure

 Increased intrathoraic pressures can

increase the pressure surrounding the
heart and major blood vessels.
 This can impede blood flow to the heart
causing a decreased CO/BP.
Ventilator Weaning
Ventilator Weaning

Control modes Combined Support modes

Pressure Control Pressure Support
Volume Control SIMV Volume Support
Indications for Weaning
 Resolution of acute phase of
 FIO2 of 40% or less, Peep 5-10
 Stable vital signs
 Stable ABG’s (minimal acidosis)
 No continuous IV sedation
 Adequate cough
 RSBI less than 100
Indications for Weaning
• Reliable predictor of weaning
• Pt is allowed to breath
without vent support for 1
RSBI minute, RR is then divided by
Rapid Shallow exhaled tidal volume.
Breathing Index
• Normal value is < 100.
• Performed every a.m. in
conjunction with RN sedation
Approaches to weaning:

• Decreasing SIMV rate

• Decreasing levels of Pressure Support
• Spontaneous Breathing Trials
Approaches to weaning:

Decreasing SIMV rate

The SIMV rate is decreased by 2 breaths/min every 4-6

hours as tolerated.

When the SIMV rate is down to 4, and is tolerated for 2-4

hours , the patient is then considered for extubation or
changing to pressure support mode.

Example order: Wean IMV rate by 2, every 4-6 hours as

tolerated. Maintain RR < 30 w/ no respiratory distress.
Approaches to weaning:

Decreasing Levels of Pressure Support

Pressure Support level is slowly decreased over time.

When the patient has tolerated a pressure support level of

5 -7, for 2-4 hours, the patient is considered weaned.

Example order: Wean pressure support by 2 every 6-8 as

tolerated. Maintain RSBI < 100. Lowest pressure 5cm

*PS 5 is maintained to overcome airway resistance from breathing tube

Approaches to weaning:

Spontaneous Breathing Trials

The patient is removed from the vent and placed
on T-Bar or left attached to the ventilator and
placed on Flow-By mode.

The patient’s vital signs are monitored during

the trial, usually for 30-120 mins.

Example order: May attempt SBT x 30 min as

tolerated BID.
Short-term weaning
Long-term weaning
Short-term weaning:
 Example: post-op open
heart patient.
 The FiO2 is weaned to a
stop point of 40%. The
RR is weaned by 2
breaths with a stop
point of 2-4 breaths
 The patient is then
placed on CPAP and
weaning parameters are
obtained along with
ABG’s. Respiratory Therapist obtaining weaning parameters
Short-term weaning:

 The patient is then extubated with physician


 Most open heart patients meet a goal

extubation time of 6 hours or less.
Long-term weaning:

 Some patients may take longer to wean

due to MSOF, poor nutritional status,
 Even though it can be a slow and long
process, the most complex patient can
be weaned.
 PS weaning proves to be an effective
tool to help wean long-term patients.
Thank You!