Ventilation Techniques - A practical workshop

Presented at ANZCA 2015 by

Dr Chris Thompson, Senior Staff Specialist
Royal Prince Alfred Hospital

Goals of the workshop Loss of ventilation skills

• Improve ventilation awareness and skills
• Learn how to use a modern ventilator to
fix ventilation problems.
Skills
• Mask and bagging skills
• Can’t intubate, can’t ventilate skills
Questions
• Are you, as an anaesthetist, comfortable dealing
with sick patients who have unique challenges?
• Can anaesthetists do as good a job as Intensivists
in looking after patient’ lungs?
• Anaesthetists have lost some of their ventilation
skills as the ventilators used
in some anaesthetic machines are 20 years behind
those in ICU. However, other machines have
ventilators that are better than ever
• Most patients are healthy and so anaesthetists
have become deskilled in mask and bagging
ventilation
• Anaesthetists use high inspired oxygen to mask
poor ventilation in the patient
• The advent of the LMA has meant that it is not
necessary to intubate if it is too hard to introduce
an ETT
• The failure in the CICO is actually a failure in
ventilation on the most part
• Breathing is required for control of carbon dioxide
• Oxygen given in recovery is to deal with the failure
to return the patient to normal
oxygenation and breathing after the anaesthetic

Ordinary respiratory care in the anaesthesia

Improve environment

Ventilation •
•
100% oxygen on induction and emergence
Apnoea on induction

Awareness •
•
ETT paralysis
Patient lying flat
• If there are respiratory problems, the patient is
sent to ICU
• Opioid analgesia
• High flow Hudson mask
 VENTILATION TECHNIQUES - A practical workshop | 2

• If the patient has a low SpO2 then increase the the APL valve, which increases the work of
FiO2 breathing
• High FiO2/I:E ratio of 1:2/5cmH2O PEEP • Dräger machines – same as an ICU circuit,
• IPPV – 700mls TV and 10 breaths per minute whereby on inspiration the gas comes
• These contribute to lung collapse and bad directly from the ventilator and in expiration the
outcomes patient only needs to blow off against the PEEP
• Instead of increasing oxygen to solve ventilation valve
problems, anaesthetists should deal with the root • The lung itself has a normal respiratory rate of 15.
cause The elastic work is used to overcome lung
• Results in trying to establish ventilation after the stiffness, while the air flow work overcomes
patient has become apnoeic and the tongue has resistance. The respiratory rate should be
caused obstruction. increased for stiff lungs and decreased for airway
resistance
Multi-modal solution • Lung collapse makes the lung smaller and
resistance is increased. Stiffer lungs increase the
• Lung recruitment
pressure within the lung which can result in the
• Reduced tidal volume
anaesthetist ventilating the stomach by accident
• Reasonable amount of PEEP
while bagging the patient. The anaesthetic
• Results in
machine is able to provide ventilation with
o Decrease in atelectasis/ARDS
accuracy if Pressure support is used
o Wound infection
• In pressure support mode, the inspiratory effort is
o Decrease days in ICU
detected by looking at a flow trigger. The machine
o Decrease need for non-invasive ventilation
sees air going in and when using Dräger
machines, an arrow is shown on the flow curve.
Total lung care
The machine increases airway pressure and gas
• Plan ahead flows into the lungs. The airway pressure increase
• Less than 70% oxygen on induction and is set by the anaesthetist as the pressure support
emergence value. The machine watches the air flow curve
• Sit the patient up on induction and emergence until it is 25% of peak air flow. Once it has fallen
• Pressure support on induction and emergence to 25% the pressure support is released. The
• Non-invasive ventilation through a mask to pressure support is dynamically adjusting the
decrease obstruction during induction duration of the increase to match what the patient
• Avoid ETT/paralysis requires. It adapts to the patient’s lung mechanics
• Small tidal volumes at a quicker rate e.g. 500mls x and breathing pattern
13 breaths Settings
• PEEP 5- 10cmH2O (optimised) o Inspired pressure delta of 5-8cmH2O with a
• I:E ratio at 1:1 (individualised) to lower airway Dräger machine, may need more
pressure for better distribution of with a GE machine. It should be adjusted to
ventilation the desired tidal volume
• FiO2 of 30-40% o Flow trigger should be 5L/min for adults and 2-
• Recruitment ventilation 3L/min for children or tachypnoeic adults
• Full reversal o Rise time – 0.3 seconds for an adult, however,
• Early extubation for gasping adults or children it should be
• Minimise lung soiling by removing the ETT with brought down
the cuff inflated o PEEP/CPAP – 5-8 cmH2O
• Minimise post-operative FiO2 o Apnoea response time- dependent upon the
• Don’t blow off all the patient’s CO2 resting respiratory rate, is self-triggering in
Dräger’s pressure support mode. If the
Pressure Support respiratory rate is set a 15 breaths per minute
then the trigger will be at 6 seconds
• Most anaesthetic ventilators can be used to recruit o I:E ratio – should be 1:1, inspiration must follow
and use Pressure Support straight on from expiration togive the lowest
• GE machines – patient must breath through the CO2. Inspiration and expiration should be
soda lime and the bag and must exhale through

symmetrical in time. There should be constant
air flow.
o Compliance – with a normal compliance curve,
10cmH2O of PEEP will get approximately
800mls of tidal volume. In a collapsed lung,
anaesthetist will need to recruit to try and fix
the altered compliance. Optimal mechanical
PEEP is where compliance is best. This is
where there is the best tidal volume increase
for the smallest pressure change
o PEEP optimisation
 Step PEEP up in a constant manner and
look at the tidal volume change
 The tidal volume will get bigger until the
lung is overstretched, then the tidal
volume will decrease. Optimal PEEP has
the maximum tidal volume.
Method
 Pressure control mode
 Slow rate
 I:E ratio of 1:1
 Step PEEP up to around 20cmH2O
(30cmH2O for obese patients)
 Hold for 30 seconds
 Maintain ventilation
 Treat hypotension
 Step PEEP up and back gradually
 Result is that the lungs become more
elastic and can be recruited as this
method is implemented
 Tidal volume increase relates to extent of
lung collapse
Minimising airway pressure
• Great for laparoscopy to decrease carbon
dioxide
• Low tidal volume, high rate
• Recruit the lung by optimising PEEP
• Optimise inspiratory and expiratory time (1:1
ratio)
• Monitor compliance over time and recruit prn
• Use volume-preset pressure modes if available
Preventing lung collapse
• Avoid apnoeic episodes in 100% oxygen and
consider inducing with pressure support and
CPAP
• Perform recruitment manoeuvers
o 30-40cmH2O over 15-20 cmH2O of PEEP
o Hold for 10 breaths or 30 seconds
• Monitor compliance and re-recruit if needed
VENTILATION TECHNIQUES - A practical workshop | 3
• Optimise PEEP/CPAP to best lung compliance or
best PaO2
• Use pressure based ventilation modes
• Extubate sitting up with PEEP and the ETT cuff
inflated
Improving Oxygenation
• Recruit lungs
• Optimise PEEP
• Monitor compliance
• Re-recruit prn
• I:E ratio 1:1 with optimal inspiratory and expiratory
times
• Give inotropes, if needed, to give optimal PEEP
Extubation Strategies
• Maintain PEEP/CPAP at all times
o Wean using pressure support with PEEP
o Don’t bag and leave apnoeic to induce
respiration
• Recruit lung just before extubation
• Extubate sitting up with PEEP
o As little oxygen as possible
o ETT cuff inflated
o Awake as possible
o Good analgesia
o Fully reversed
• Minimise opioid, use blocks/ketamine
• Patient should be able to breath well in air
Summary
• Lung collapse and increased work of breathing
is normal during anaesthesia but need not be
• Pressure support makes breathing easier
• Recruitment, optimal PEEP and other open
lung strategies improve lung function,
reduce work of breathing and improve
outcomes
• Great ventilation skills are not difficult to learn