Ventilators Made Easy

Jason Waechter 2010 Revised 2011

To begin understanding ventilators, lets start with the 2 most basic components of ventilation: respiratory rate and tidal volume. For each of these parameters, there are 2 different options: Respiratory rate can be determined by the: o ventilator o patient Tidal volume can be delivered as a fixed: o volume o pressure

Given these 4 variables, we can create 4 different modes:

Resp. rate Ventilator Ventilator Patient Patient
VCV = CMV = PCV = PSV =

+ + + +

Tidal Volume Volume Pressure Volume Pressure

= = = =

Mode VCV (CMV) PCV (not used) PSV

volume controlled ventilation (not a commonly used name) controlled mandatory ventilation (commonly used name) pressure controlled ventilation pressure support ventilation

Tidal Volume settings: If the ventilator is set to deliver a volume (lets say 500 cc), then no matter what (within reason), the ventilator will push 500 cc through its tubing into the patient. This is good because can be sure that you know how much air is going into the patient with each breath and you therefore have control over the tidal volume. The downside of this mode is that the cost is high airway pressure. If you have a set of stiff lungs, the ventilator will slam the air in and potentially generate very high pressures (called peak pressures or plateau pressures). High ventilator pressures are bad. This type of tidal volume is called volume regulated. If the ventilator is set to deliver a pressure (lets say 20 cmH20), then no matter what (within reason), the ventilator will maintain a pressure within the tubing of 20 cmH20 during inspiration. This is good because you can be guaranteed that the airway pressure will never be greater than 20. The downside of this mode is that you dont actually know how much air is getting pushed out of the ventilator. Maybe it is 100 cc (just enough to fill the trachea) or maybe it is 1400 cc (way too much for most anyone). This type of tidal volume is called pressure regulated.

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Respiratory rate: The breaths can be triggered by either time (you set a rate into the ventilator and when the next breath is due, the ventilator delivers it) or alternatively, if the patient tries to take a breath, the breath can be triggered by the patients inspiratory effort. The ventilator can detect these efforts because the inspiratory effort of the patient will transiently lower the airway pressure and can also cause some air flow into the patient. The ventilator can detect either the change in pressure or change in flow and once detected, deliver a breath. The good thing about patient triggered breaths is that they occur when the patient wants them and therefore are more comfortable for the patient and possibly more physiological. However, if the patient loses their respiratory effort (from sedation for example), then the patient will hypoventilate or possibly become apneic if 100% of the breaths depend on patient triggering. Flow rate: The flow rate is how fast the air enters the patient. In a volume regulated mode the ventilator controls how fast the breath is delivered. In other words, the flow is controlled by the ventilator. In a pressure regulated mode, the flow depends primarily on the patient because all the ventilator can do is provide a fixed pressure without controlling the delivered flows or volumes. When you breathe normally (try it), early in the respiratory cycle your flow rates are fast. As you fill up (or empty) your lungs, your flow rates quickly decrease to a rate of zero. In a volume regulated mode, we set the ventilator to a constant flow rate through all of inspiration, but this is non-physiological way to breathe. An alternative to the constant flow rate is something called decelerating ramp, which simply means that at the start of inspiration, the flow rate is fast and then gradually declines through to the end of inspiration which is closer (but not identical to) physiological breathing. Which mode to use? To help decide which mode is best, there are 2 fundamental principles: control and comfort. In patients who are really sick, a mode that offers the most control is best. For patients who are awake and trying to breathe synchronously with the ventilator, maximum comfort is best. To determine which modes have control vs. comfort, analyze which factors (rate, tidal volume, and flow rates) are primarily patient determined (P) vs. ventilator determined (V). Ventilator controlled modes offer more control; patient controlled modes offer more comfort. Mode RR TV Flow Comfort Control CMV V V V + +++ PCV V P P ++ ++ PSV P P P +++ + Therefore, for sickest patients, CMV offers the most control and for breathing synchronously with the ventilator, PSV offers the most comfort.

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Mixtures of modes and names: Virtually all commonly used ventilator modes are actually combinations of 2 of the modes described on page 1. This is because modes should have some ability to allow extra patient triggered breaths if the patient wants to take extra breaths. Now we have a combination of ventilator timed breaths and patient triggered breaths. The following table shows some common ventilator modes that are combinations: A/C SIMV MMV PCV + Ventilator Timed Volume regulated (CMV) Volume regulated (CMV) Pressure regulated (PCV) Pressure regulated (PCV) Patient Triggered Volume regulated Pressure regulated (PSV) Pressure regulated (PSV) Pressure regulated (PSV)

A/C = assist control SIMV = synchronized intermittent mandatory ventilation MMV = mandatory minute ventilation PCV + = pressure control ventilation plus

Fancy Modes: By adding a little something extra to the basic modes, we can create some fancy modes. For example, if you start with PCV and ask the computer target a given tidal volume (for example, 500 cc) the ventilator can titrate (in real time) inspiratory pressures to obtain the desired tidal volume. If the tidal volumes fall below 500 cc, the inspiration pressures will increase and vice versa. Remember that in a simple pressure regulated mode, the ventilator gives a fixed pressure, so the volume delivered is not guaranteed. In this mode, the ventilator measures the tidal volume and responds appropriately! This mode is called PRVC or pressure regulated, volume controlled since the main mode is a pressure regulated mode. Therefore, if the patients compliance changes, the amount of inspiratory pressure will change accordingly to maintain the desired tidal volume. A very similar mode is called volume control with autoflow. Another fancy mode is MMV (mandatory minute ventilation). If the patient is breathing less than a preset minute ventilation (remember that MV = RR x TV), then the ventilator mode is PCV. If the patient breathes more than the set minute ventilation, then the mode switches over to PSV. In other words, the ventilator timed breaths can be inhibited by the patient if the patient is breathing enough. In most other mixed modes, the ventilator timed breaths occur regardless of the patients breathing.

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PEEP, BiPAP and CPAP: PEEP (positive end expiratory pressure) and CPAP (continuous positive airway pressure) are the same thing. The only difference is that we refer to PEEP when the patient is receiving additional inspiratory pressure and CPAP when not. In my opinion, PEEP really should be called PEP (positive expiratory pressure) since it is constant throughout all of expiration and is not simply present at the end of expiration. Pressure CPAP

Time

PCV (black part) with PEEP (the grey part)

Time Notes: CPAP and PEEP really are the same thing as you can see in the images above. The only difference is that we call it PEEP when there are additional inspiratory breaths (black areas on graph) being delivered to the patient. CPAP (i.e. no extra inspiratory support) can be delivered through an endotracheal tube (not common) or with a facemask (common) with PCV, the pressure is constant throughout inspiration: this illustrates the concept of a pressure regulated tidal volume Another mode used is BiPAP which is two level (bi) ventilatory support with a facemask. One level of support is during inspiration and the other level during expiration (PEEP). It is the same as PSV except that the patient is not intubated. PSV (if intubated) or BiPAP (if using facemask)

Time Note: an inspiratory effort (small dip) can be seen before each inspiration. This is what the ventilator detects as a patient effort and knows when to supply the extra pressure. Compare PSV with previous PCV graph. The only difference is the little dip.

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For completeness, below is a graph of CMV (a volume regulated mode). Note that as the tidal volume is delivered, the pressure in the lungs increases throughout inspiration as the lungs become more and more full. CMV with PEEP

Time

Ok. Back to our original topic, which was PEEP Why do we use PEEP on the ventilator? Simply put, it is believed to: keep the alveoli open during expiration (this avoids atalectasis) help push fluid out of the alveoli stent open airways that are obstructive (like in asthma or COPD) and potentially reduce air trapping (also called autoPEEP or intrinsic PEEP) possibly improve V/Q matching reduce ventricular preload by pressurizing the thorax and reducing venous return However, PEEP is not always good. The down sides to PEEP include: it increases overall airway pressure and increases risk of barotrauma possibly reduced V/Q matching (note this is the opposite of one of the benefits) reduced venous return leading to hypotension reduce respiratory compliance by overinflating the lungs (only at high levels) impede exhalation (the patient has to exhale against this pressure) Titrating the level of PEEP requires some trial and error and should always be individualized to each patients endpoints of oxygenation, airway pressures, blood pressure, lung water, and overall ventilatory mechanics.

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Ventilator settings for different lung diseases: The main diseases that you will be faced with ventilating are: restrictive lungs obstructive lungs wet lungs ARDS There are different strategies for each disease process. Restrictive lungs: Restrictive lungs are small and stiff. Therefore, the problem encountered is high airway pressures during inspiration. The best solution is to use small tidal volumes. However, the consequence of small tidal volumes is a reduced minute ventilation and so to compensate, the respiratory rate needs to be increased. High levels of PEEP can further increase airway pressures, so PEEP is usually not set very high. Obstructive lungs: The main problem with obstructive lungs is expiratory flow. It is easier to get air in because with inspiration, the airways are enlarged but in expiration, the airways shrink and the resistance to flow increases, causing air trapping. Thus, the best solution is to allow long expiratory times. There are 2 main ways to do this: reduce the respiratory rate and change the inspiratory to expiratory (I:E) ratio for longer E times. Reducing the respiratory rate generally results in bigger gains in expiratory time. The consequence of low respiratory rates however, is a reduced minutes ventilation and so to compensate, the tidal volumes need to be higher. High PEEP levels can sometimes help and sometimes make things worse and need to be titrated individually. Wet Lungs: The main problem is water in the lungs which makes them stiff. High PEEP will help with that. Tidal volumes sometimes need to be reduced because the lungs can become stiff when wet and therefore, airway pressures can be high. ARDS: The main problem is ventilator induced lung injury (superimposed on existing lung injury) and wet, stiff lungs. Thus, small tidal volumes and high PEEP is usually the strategy. When a patient has ARDS and has stiff lungs, mortality is reduced when using tidal volumes in the range of 6-8 ml/kg. Note that in all strategies, either a low RR or low tidal volume is used. This will reduce minute ventilation and raise pCO2. Sometimes, we cant fully compensate for the ventilation strategy with really sick lungs and so we allow the pCO2 to remain elevated and this is called permissive hypercapnea. This is used when the risk of increasing RR or tidal volume is believed to outweigh the risk of having an elevated pCO2.

Waechter. Ventilators 2011.

teachingmedicine.com