INTRODUCTION TO

MECHANICAL
VENTILATION

Citra R. Perangin-angin

History

2 Kings 4 : 34
Hippocrates (400 BC): first intubation
Paracelcus (1493-1541): bellow and oral
tube
Pre 1900 : whole-body respirators for
research
- 1930 US poliomyelitis: Emerson Iron
Lung

EARLY VENTILATOR

1937

2 Type of MV

NEGATIVE PRESSURE
VENTILATOR

POSITIVE PRESSURE
VENTILATOR

NEGATIVE PRESSURE
VENTILATOR
1. Negative pressure surrounding the body by big tank
2. Earlier ventilator in endemic polio era
3. IRON LUNG pulls the thorax cavity inspiration
4. Limited acces to the patient

POSITIVE PRESSURE
VENTILATOR (PPV)
1. Push positive pressure to the lung
2. Modern ventilator
3. Air actively push to the lung by higher pressure in ventilator
4. Must overcome the resistance and compliance of lung and
chest wall
5. Postive pressure disturbs venous return to the heart,
increases pulmonary vasculare resistance, decrease cardiac
output NON Physiologic

2 COMPONENTS
LUNG VENTILATION

AIRWAY RESISTANCE
(RAW)

COMPLIANCE
(COMPL)

AIRWAY

LUNG

RAW
CL

Indications for
Mechanical Ventilation

Ventilation abnormalities
Respiratory muscle dysfunction
Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular disease

Decreased ventilatory drive

Increased airway resistance and/or

obstruction

Indications for
Mechanical Ventilation

Oxygenation abnormalities
Refractory hypoxemia
Need for positive end-expiratory pressure

(PEEP)
Excessive work of breathing

Types of Ventilator
Breaths

Volume-cycled breath
Volume breath
Preset tidal volume

Time-cycled breath
Pressure control breath
Constant pressure for preset time

Flow-cycled breath
Pressure support breath
Constant pressure during inspiration

Basic Mode of MV

Controlled Mechanical (Mandatory)

Ventilation (CMV)
Assist-Control Ventilation (A/C)
Synchronized Intermitten Mandatory
Ventilation (SIMV)
Pressure Controled Ventilation (PCV)
Pressure Supported Ventilation (PSV)
Continous Positive Airway Pressure
(CPAP)

Partitioning of the Workload Between

the Ventilator and the Patient

How the work of breathing partitions between the patient and the
ventilator
depends on:

Mode of ventilation (e.g., in assist control most of the work is usually done by the
ventilator)
Patient effort and synchrony with the mode of ventilation
Specific settings of a given mode (e.g., level of pressure in PS and set rate in SIMV)

Modes of Mechanical Ventilation

Point of Reference:
Spontaneous Ventilation

Controlled Mechanical Ventilation

Preset rate with volume-cycled breaths

No patient interaction with ventilator, no
spontaneous breath
Advantages: rests muscles of respiration
Disadvantages: requires sedation/neuromuscular blockade, potential adverse
hemodynamic effects

Controlled Mechanical Ventilation

Fixed TV but pressure variated depends on

Resistance and Compliance of the lung

Volume control
Volume
targeted
Set TV 500 cc

Flow/volume

Volume fixed

Pressure variated
TVe 500 cc
Pres variated

Peak
Pressure

Pressure

Assist-Control Ventilation

Volume or time-cycled breaths + minimal ventilator

rate
Additional breaths delivered with inspiratory effort
Advantages: reduced work of breathing; allows
patient to modify minute ventilation
Disadvantages: potential adverse hemodynamic
effects or inappropriate hyperventilation

Assist-Control Ventilation

Additional breath triggered by the patient

are pushed until preset volume achieved

Synchronized Intermittent
Mandatory Ventilation (SIMV)

Volume or time-cycled breaths at a

preset rate
Additional spontaneous breaths at tidal
volume and rate determined by patient
Used with pressure support

Synchronized Intermittent
Mandatory Ventilation (SIMV)

Potential advantages
More comfortable for some patients
Less hemodynamic effects
Potential disadvantages
Increased work of breathing

PCV

Control mode
Predetermined pressure in predetermined

time (tyme-cycled) and fixed rate

Use to limit the inflation pressure

TV variated depends on resistance and
compliance of the lung
Often called (P) CMV

PCV

Advantages:
Prevent barotrauma
Adjusted I:E ratio

Disadvantages
Potential hyper or hypoventilation
Need sedation and NMB because of

uncomfort
Respiration muscles atrophy

Pressure-Support
Ventilation

Pressure assist during spontaneous

inspiration with flow-cycled breath
Pressure assist continues until inspiratory
effort decreases
Delivered tidal volume dependent on
inspiratory effort and
resistance/compliance of lung/thorax

PSV

Pressure support given must achieves

one or more of the following goals:
Vt 6-10 cc/kg, depending on patien needs
A slowing RR to an acceptable range
The desired minute ventilation

Approriate alarm and backup ventilation

setting are essential

Pressure-Support
Ventilation

Potential advantages
Patient comfort
Decreased work of breathing
May enhance patient-ventilator synchrony
Used with SIMV to support spontaneous
breaths

Pressure-Support
Ventilation

Potential disadvantages
Variable tidal volume if pulmonary

resistance/compliance changes rapidly

If sole mode of ventilation, apnea alarm mode

may be only backup

Gas leak from circuit may interfere with cycling

Continuous Positive Airway

Pressure (CPAP)

No machine breaths delivered

Allows spontaneous breathing at

elevated baseline pressure

Patient controls rate and tidal volume

MONITORING

Inspiratory Plateau Pressure (IPP)

Airway pressure measured at end of

inspiration with no gas flow present
Estimates alveolar pressure at endinspiration -- compliance
Indirect indicator of alveolar distension
Plateau pressure

PIP
Plateau pressure

Inspiratory Plateau
Pressure

High inspiratory plateau pressure

Barotrauma
Volutrauma
Decreased cardiac output

Methods to decrease IPP

Decrease PEEP
Decrease tidal volume

Safe Inspiratory Plataeu Pressure <

30 cmH2O

Pulmonary Mechanics
Peak pressure
Airway Resistance
Plateau pressure
I

Inspiratory Time: Expiratory Time

Relationship (I:E ratio)

Spontaneous breathing I:E = 1:2

Inspiratory time determinants with volume
breaths
Tidal volume
Gas flow rate
Respiratory rate
Inspiratory pause
Expiratory time passively determined

I:E Ratio during Mechanical

Ventilation

Expiratory time too short for exhalation

Breath stacking
Auto-PEEP
Reduce auto-PEEP by shortening
inspiratory time
Decrease respiratory rate
Decrease tidal volume
Increase gas flow rate

Auto-PEEP(intrinsic, inadvertent,
occult)

Can be measured on some ventilators

Increases peak, plateau, and mean
airway pressures
Potential harmful physiologic effects

Auto-PEEP

Can be measured on some ventilators

Increases peak, plateau, and mean
airway pressures
Potential harmful physiologic effects

Suspecting and Measuring AutoPEEP

Suspect AutoPEEP if flow at

the end of expiration does not
return to the zero baseline.

AutoPEEP is commonly measured by performing a pause at the end of

expiration. In a passive patient, flow interruption is associated with
pressure equilibration through the entire system. In such conditions,
proximal airway pressure tracks the mean alveolar pressure caused by
dynamic hyperinflation.

Interventions to reduce auto-PEEP

Decrease RR
Decrease VT
Increase gas flow rate

Permissive Hypercapnia

Acceptance of an elevated paCO2, eg.,

lower tidal volume to reduce peak airway
pressure
Contraindicated in increased ICP
Consider in severe asthma and ARDS
Critical care consultation advised

Normal Lung Mechanics and Gas

Exchange
Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs

CNS depression
NL
NL
NL
NL
NL
None
A/C, SIMV
0.21-0.40
8-12 ml/Kg
12/m
2-5
1/1.5-2
Adjusted for patients comfort
40-50
Desired

Severe Airflow Obstruction

Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs

Asthma
IMP
NL

NL

IMV-A/C
0.30-0.50
5-7 ml/Kg
15-18/m
0
1/4-5
60 L/m
60-75
Undesired

Acute on Chronic Respiratory

Failure
Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs

COPD
IMP
NL-

NL-

SIMV-A/C
0.25-0.40
6-8 ml/Kg
15-18/m
0
1/3-4
60L/m
50-60
Undesired

Acute Hypoxemic Respiratory Failure

Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs

ARDS
-
NL
NL/

None
SIMV-A/C
1
4-6 ml/Kg
24-28 /m
--
1/1.5 - 3/1
40 L/m
50-60
Undesired