PEDIATRIC MECHANICAL

VENTILATION: THE BASIC

SAPTADI YULIARTO
 NORMAL RESPIRATION vs.
PPV

- - - - + +
- - + + +
- + +
- - +
- - -
Positive pressure
Normal respiration
ventilation
LUNG MECHANICS

Compliance (C)

Resistance (R)

Time constant (Tc)

COMPLIANCE

C = △V /△P

Low lung compliance:

• Pneumonia

• Lung edema

• Pulmonary haemorrhage

• Atelectasis
COMPLIANCE
RESISTANCE

.
R = △P /△V
RESISTANCE

High airway resistance

• Spasm

• Small tube

• Mucus plug

TIME CONSTANT

Tc = C * R
TIME CONSTANT
 VENTILATOR PHASE
Volume

Pressure Time

Flow

Time

Flow

Pressure
 EXPIRATORY VALVE INSPIRATORY VALVE

TRIGGER

CYCLE

PATIENT LIMIT
 VENTILATOR MODES

VOLUME PRESSURE
CONTROLLED CONTROLLED

LIMIT Volume Pressure

DEPENDENT
Pressure Volume
VARIABLE
 VENTILATOR MODES
FULLY ASISSTED PARTIALLY
SPONTAN
CONTROLLED CONTROLLED CONTROLLED

V-CMV
VC-SIMV
PSV

NAME A/C
P-CMV P-SIMV CPAP

Time OR
Time AND

Patient (flow,
TRIGGER Time Patient (flow, Patient (flow,
pressure)
pressure) pressure)

Volume OR
Volume OR
Volume AND

LIMIT Pressure
Pressure Pressure Pressure

Time AND
CYCLE Time Time Flow
Flow
HOW TO MAKE INITIAL
SETTING
Set MODES : Fully controlled (CMV or P-CMV)

set RR : according to the AGE

set △P : according to the predicted TIDAL

VOLUME (4-6 ml/kg OR 6-8 ml/kg)

set PEEP : 3-5 cmH2O or higher in ARDS

set Ti to achieve I:E = 1:1.5 - 1:2

set FiO2

set Trigger if the patient has spontaneous

breath
 HOW TO ADJUST?
Adjust the TRIGGER if the patient has adequate
spontaneous breath, switch to the SIMV or
spontaneous mode if needed

Adjust △P to achieve appropriate TV

Adjust Ti : according to the inspiratory Tc (look

the flow graphic)

Adjust FiO2 to the minimum level to achieve SpO2

>94%

Increase PEEP if necessary to achieve SpO2 >94%

 of flow during volume control modes with a descending ramp Fig. 3. (i-iii) Scalar waveforms typica
profile, which has several potential benefits. The inspiratory hold pressure, flow, and volume scalar
pressure-control modes of ventilatio
also results in a prominent plateau in the volume waveform as is

SCALAR WAVEFORMS OF
of the scalars in volume modes (Fi
shown in Fig 3; the characteristic shape of the waveforms seen constant during inspiration (i) whe
with pressure-control modes (pressure-ACV [P-ACV] and SIMV-PC) decay form. An inspiratory hold ma
and support modes are shown. In pressure-control modes, the plateau of the volume scalar (iii). T

VOLUME-CONTROL MV
pressure waveform is now the one with the characteristic shape pressure support modes of ventilati
improve clarity. In the pressure supp
whereas the flow waveform typically assumes the shape of an a target flow rate is reached (e.g., 30
not reaching zero before exhalation
scalar plateau is no longer observed

exponential decay.14 The volu

able from those observed wi
of waveforms to the right in
pressure support modes (e.
inspiratory flow is not expe
begins. In these instances, th
CONSTANT FLOW once a preset percentage of
peak). This point is reached w
figure. Because the terminat
the flow is low but not ze
minimal plateau (lower dash
The use of synchronized
(SIMV) as mode of ventilatio
settings; however, it represe
when it comes to ventilator
typal sorts of SIMV breaths ar
The vertical series labeled
associated with a mandator
the shark fin pressure tracin
evident. No inspiratory hold
begins once the target tid
initiation of inspiratory flow,
Fig. 2. (i-iii) Scalar waveforms typical of volume control modes of ventilation. The (triggering). The second bre
 SCALAR WAVEFORMS OF
PRESSURE-CONTROL MV
M.S. Mellema / Topics in Companion An Med 28 (2013) 112–123 113

CONSTANT PRESSURE
orms. The 6 basic forms that make
n. Ascending ramp and descending
tial rise and exponential decay,
ated with spontaneous breathing

livered breaths are shown

eous breaths. The pressure
onential rise shape (“shark
period of inspiratory hold,
redistribution of gas (“pen-
cline from peak inspiratory
pressure (Pplat).13 If the
his concavity would not be
nce the preset tidal volume
that the flow profile in this
inspiration. The delivery of
ingful assessment of airway
lators allow for the delivery
s with a descending ramp Fig. 3. (i-iii) Scalar waveforms typical of pressure-control modes of ventilation. The
pressure, flow, and volume scalars are shown as they typically appear when
114 VC? PC? ?? ?? ??
M.S. Mellema / Topics in Companion An Med 28 (2

(pressure co
an exponent
appears as l
ously, when
form takes o
PEEP is bein
baseline, but
pressure bet
this level ind
When an
pressure wav
ing the patie
and plateau
pressures ca
respectively.
dynamic co
estimate sta
than static
required in
Fig. 4. (i-iii) Scalar waveforms typical of SIMV breaths. The pressure, flow, and
reflected by
volume scalars are shown as they typically appear when SIMV modes of ventilation
are employed. The first 3 breaths shown (A-C) are depicted as they would appear static compl
 PRESSURE WAVEFORMS M.S. Mellema / Topics in Companion An Med 28 (2013) 112–123 115

Fig. 5. (i-iii) The pressure waveform. Waveforms iA and iB are typical of volume control without and with an inspiratory hold, respectively. In pressure-control modes,
inspiratory pressure remains constant (iC) and the pressure scalar assumes a square conformation. The presence of PEEP raises baseline pressure above atmospheric (dashed
 the flow USING PRESSURE
selected, unless WAVEFORMS
an inspiratory hold is put in place. Thus, TO
if the
pearance clinician opts for a volume control mode of ventilation, the
ve) does selectionASSESS CHANGE
of a decelerating IN LUNG
ramp flow pattern may allow for a
be made
pressure MECHANICS
ever, the
a given
uld result
proach is
use of a
spiratory
andatory
e far left,
s for the
sen. The
m when
o before
and this
I-time is
ow state”
t risk for
looks at Fig. 6. (i-ii) Using the pressure waveform to assess changes in lung mechanics.
(i) The characteristic changes in the pressure waveform, PIP, Pplat, or both are
does not shown for instances of increased airway resistance and decreased compliance.
116
FLOW WAVEFORMS M.S. Mellema / Topics in Companion An Med 28 (2013) 11

negative deflectio
decreasing volum
determined from
this same figure. L
inspection is in th
As shown in Fig
plunge straight to
phase indicates th
than ultimately ca
the circuit or th
remained within
flow into the pleu

Pressure-Volume Lo

Pressure-volum
of the dynamic in
sure and circuit vo
in the assessment
the last 2 decades
important role in
support of patien
Fig 11i shows a
Fig. 7. (i-ii) The flow waveform. (i) The flow waveforms typically seen when delivered breath
resistances. The slope of this line is a measure of pulmonary
compliance. As intrapulmonary flows have not been given enough
time to cease,USING
this formFLOW WAVEFORMS
of compliance would be termedTO dynamic
compliance (Cdyn) rather than static compliance.
OPTIMIZE INSPIRATORY TIME
Fig 11ii shows a patient-triggered PV loop for comparison. This
“figure 8 ” type of loop is typical of patient effort.29 In this case, the

Fig. 8. Using the flow scalar to optimize inspiratory time. The flow waveform for
4 different volume control mandatory breaths with 2 different flow profiles are
depicted. For breath (a), a constant (square) flow delivery was selected whereas for
the remaining 3 (b-d) a decelerating ramp flow pattern was chosen. The third
breath (c) shows the appearance of the waveform when I-time is optimal. Flow
returns all the way to zero before exhalation begins. In breath “b,” the I-time is too
 USING FLOW WAVEFORMS TO
DETECT AUTO-PEEP
M.S. Mellema / Topics in Companion An Med 28 (2013) 112–123

e flow scalar to detect auto-PEEP. The pressure tracing from 2 successive breaths delivered in volume control mode with descending
xample, expiratory flow fails to return to zero before the next breath is delivered, indicating that auto-PEEP is present.

triggering or initiating activity and thus the small the changes expected to occur with an increase in
 sensitivity is altered, then the patient would need to do more or
less work to trigger the ventilator and the size of this area would
change.
Changes in the orientation and area of PV loops can indicate
alterations in the mechanical properties of the patient's lungs,
obstructed, heat-moisture exchanger occlusion has occurre
airway suctioning or bronchodilator administration is nee
Compliance changes also alter the shape and position of PV lo
As shown in Fig 12 ii, a reduction in compliance (e.g., pulmo
edema develops) caused the PV loop to rotate (labeled “A”) as

VOLUME WAVEFORMS
the circuit, or both.29 Fig 12i shows 2 loops from the same patient. starting point was anchored and the loop rotated toward
The gray loop is the initial tracing whereas the black loop shows x-axis. Conversely, if compliance increases (e.g., edema resolve

Fig. 10. (i-ii) The volume waveform. The volume waveforms from 2 successive breaths are represented. One cannot typically discern the ventilation mode employed fro
nspection of the volume waveform alone. (i) Tidal volume can be determined as the peak volume attained. The slope of the volume tracing at any point is equal to t
118
P-V LOOP
M.S. Mellema / Topics in Companion An Med 28 (2013) 112–123

The recognition of the mechanisms underlying ventilator-

induced lung injury has lead to a greater role for PV loop
inspection in optimizing ventilator settings. In this setting, the
clinician is advised to inspect the loop in search of 2 important
inflection points (Fig 14i). The lower inflection point reflects a
point at which pulmonary compliance significantly increases. This
is thought to be the point at which a number of collapsed
conducting or gas exchange units or both open. The cyclic opening
and closing of these areas can lead to significant pulmonary
damage (atelectrauma).30 This atelectrauma can be minimized
by increasing PEEP to a value greater or equal to the value at which

PATIENT EFFORT Fig. 11. (i-ii) Pressure-volume (PV) loops. Typical PV loops for machine-triggered
(i) and patient-triggered (ii) breaths are depicted. PEEP is present in both examples
(dotted line and arrow). The shaded area in loop (ii) is reflective of the degree of
patient effort exerted during the triggering phase. A line can be drawn between the
2 points where minimal flow occurs (end exhalation and end inspiration) and the
slope of this line is an estimate of dynamic compliance.

if its starting point was anchored and the loop rotated toward the
Companion An Med 28 (2013) 112–123

The recognition of the mechanisms underlying ventilator-

induced lung injury has lead to a greater role for PV loop

USING P-V LOOPS TO ASSESS

inspection in optimizing ventilator settings. In this setting, the
clinician is advised to inspect the loop in search of 2 important
inflection points (Fig 14i). The lower inflection point reflects a

CHANGE IN LUNG MECHANICS

point at which pulmonary compliance significantly increases. This
is thought to be the point at which a number of collapsed
conducting or gas exchange units or both open. The cyclic opening
and closing of these areas can lead to significant pulmonary
damage (atelectrauma).30 This atelectrauma can be minimized
by increasing PEEP to a value greater or equal to the value at which

Fig. 11. (i-ii) Pressure-volume (PV) loops. Typical PV loops for machine-triggered
(i) and patient-triggered (ii) breaths are depicted. PEEP is present in both examples
(dotted line and arrow). The shaded area in loop (ii) is reflective of the degree of
patient effort exerted during the triggering phase. A line can be drawn between the
2 points where minimal flow occurs (end exhalation and end inspiration) and the
slope of this line is an estimate of dynamic compliance.

if its starting point was anchored and the loop rotated toward the
y-axis (labeled “B”). The change in compliance can be appreciated
by the significant alteration in the slopes of the Cdyn lines.
One must keep in mind that the shape of the PV loops is not
entirely independent of the ventilator settings. Providing the same Fig. 12. (i-ii) Pressure-volume loop changes seen with alterations in pulmonary
tidal volume with more rapid flow rates would result in increased mechanics. (i) Two PV loops from the same patient are depicted. The gray loop is
bowing of the loop away from the compliance line. Moreover, in the initial tracing whereas the black loop shows the changes expected to occur
with an increase in airway or circuit resistances or both. The loop bows out farther
pressure-control modes, the latter portion of the inspiratory limb
from the dynamic compliance line indicating that relatively greater applied
can appear nearly vertical as constant inspiratory pressure is pressure is required to overcome resistance and reach a given volume. Note that
maintained (Fig 13i). Excessively large tidal volumes can lead to the Cdyn decreased (as indicated by the slope of line “a” vs. line “b”). (ii) A
 USING P-V LOOPS TO ASSESS
OVERDISTENSION
M.S. Mellema / Topics in Companion An Medthe starting
the lower inflection point is observed. In contrast, the upper
inflection point reflects the point at which pulmonary compliance
significantly decreases owing to alveolar overdistension and the
risk of alveolar injury (volutrauma) is increased.31 It is generally
advised to keep PIP below the pressure at which the upper
inflection point is noted. It must be noted that in small patients
(o 2 kg), the flow signal (and thus volume changes) may be
difficult to acquire using all but the most sensitive equipment.
When the monitoring equipment cannot acquire the signal, many
models continue to plot the last recorded value. The plot of a rising
pressure with an absolutely constant volume results in a sharp,
narrow horizontal beak at end inspiration where flow is lowest.
This signal acquisition artifact can mimic true beaking in these
small patients. The clinician should remember that biological
processes rarely result in biophysical relationships that are abso-
lutely linear in nature.
A leak in the ventilator circuit can also be reflected by
changes in the PV loop. Fig 14 ii shows an open, broken,
incomplete loop that is typical of a circuit leak. Monitoring for
leaks is important for ensuring proper cuff inflation, ensuring
Fig. 13. (i-ii) Pressure control and overdistension effects on PV loops. (i) The
delivery of targeted tidal volume, and alerting the clinician to the
constant pressure applied during inspiration can lead to a more square-shaped PV
possibility of air leakage from the respiratory tract to the
loop. (ii) Overdistension of the alveoli by excessively large tidal volumes can result
inpleural space.
a beaklike extension of the portion of the PV loop found near end inspiration.
Fig. 14. (i-ii) Upper or lower inflection points and circuit leaks on PV loop
some (but not all) PV loops, an upper or lower inflection point, or both,
identified. Maintaining airway pressures between the pressures at whic
inflections occur can help to reduce ventilator-induced lung injury. (ii) Circ
result in broken, open PV loops in which the expiratory limb fails to return
28 (2013) point.
112–123 119
Flow-Volume Loops
Flow-volume loops are related to the flow scalar an
inspiratory and expiratory limbs should roughly match the
of the flow scalar portions above and below the x-axis, r
tively (Fig 15i and ii).29 The morphology of the waveform
not match precisely as one is plotting flow against time a
other against volume, but the waveforms should be qualit
similar. Flow-volume loops are particularly important
assessment of excessive Raw and in alerting the clinician
presence of copious airway secretions or circuit leaks.
asynchrony can also be detected via flow-volume loops
been discussed in the PVD section later.10
In ventilator waveform presentation, the flow-volume l
typically presented with the inspiratory limb above the
(Fig 16). In pulmonary function testing, the flow-volume loo
more typically presented with the expiratory limb above the
and end inspiration closest to the y-axis (i.e., upside dow
inverted; picture the loop in Fig 16 rotated clockwise 18
Fig 16, “a” denotes the start of inspiration. Inspiration contin
ue beaking in these
ber that biological
ships that are abso-

USING P-V LOOPS TO ASSESS AIR

so be reflected by
an open, broken,
eak. Monitoring for LEAK
inflation, ensuring
the clinician to the
atory tract to the

Fig. 14. (i-ii) Upper or lower inflection points and circuit leaks on PV loops. (i) On
some (but not all) PV loops, an upper or lower inflection point, or both, may be
lema / Topics in Companion An Med 28 (2013) 112–123

the inspiratory V-F LOOP

control mode is
mb begins with
xpiratory flow is
fort dependent
on full assist-
the expiratory
t portion of the
d” is the most
ugh peak flow is
cant increase in
o late portion of
ng reduction in
ould prompt the
g or bronchodi-

e loops (Fig 17 ii).

and expiratory
ith the PV loop,
p is to create a

via flow-volume
Fig. 16. Typical appearance of a flow-volume loop. For ventilator graphics, the
ow-volume loop inspiratory limb (point “a” to “b”) is generally depicted above the x-axis. Peak
ndent portion of inspiratory flow is achieved in early expiration (c). As expiratory flow progresses
concurrently. The first (phase 1) is the “initiation of inspiration,”
which is also called “the trigger mechanism.” PVD during phase
1 is often referred to as “trigger asynchrony.” Trigger asynchrony
V-F LOOP IN VOLUME AND
has been shown to be by far the most common form of PVD in

PRESSURE CONTROL

Fig. 17. (
secretion
to the ex
circuit le
Fig. 15. (i-ii) The flow-volume loop. The general profile of the flow tracing should secretion
 ous increase in airflow without triggering a machine-delivered
breath. This form of PVD is often the result of an inappropriately
or
an
erm

can V-F LOOP IN MANY CONDITIONS

ring
cted
on,”
hase
ony
D in

Fig. 17. (i-iii) Flow-volume loops with increased Raw, circuit leaks, and excessive
secretions. (i) Increased airway resistance can result in a scooped-out appearance
to the expiratory limb of a flow-volume loop. (ii) Much as is seen with PV loops,
PATIENT MONITORING

Synchrony

Work of breathing

Oxygenation : PaO2 OR SpO2, OI or OSI

Ventilation : PaCO2 OR ETCO2

DOPE
PATIENT MONITORING

OI = (FiO2 * MAP * 100) / PaO2

OSI = (FiO2 * MAP * 100) / SpO2

 WEANING

PREREQUISITE :

Improvement of disease

Stable respiratory and hemodynamic status

Spontaneous mode, regular-adequate breath,

low pressure, low FiO2
 STEP OF WEANING
Change mode: from fully to partially to
spontaneous mode

Decrease △P while maintain appropriate TV

Decrease FiO2 to minimum level while maintain

SpO2 >94%

CPAP or T-piece :

Normal work of breathing, oxygenation,

ventilation in 1 hour then extubation

Prior steroid administration?

THANK YOU