Mechanical Ventilation

Mechanical Ventilation
Definition:

Positive pressure ventilation provides

PRESSURE and FLOW to the airway
. affect Oxygen and CO2 transport
between environment & pulmonary capillary

 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

Goals of Mechanical Ventilation

. appropriate OXYGEN supplementation

.. adequate alveolar VENTILATION
Reduce WORK OF BREATHING..
Increase patient COMFORTduring respiration

 Mechanical Ventilation
Types:
Total:
Ventilator completely
UNLOAD ventilatory muscles
& provides ALL work of breathing.
Partial:
The mechanical device partially unloads
the ventilatory muscles requiring the patient
to provide the remainder of work of breathing.

 Mechanical Ventilation
Use:
Total:
Respiratory failure with patient ms. clearly
overloaded or fatigued.
Gas exchange is very unstable or unreliable.
Partial:
Respiratory failure less severe & / or during
recovery or weaning phase.

 Device Features for total
ventilatory support
What INITIATES.breath?

Trigger variable

Patient effort Machine timer

 Device Features for ventilatory
support
What CONTROLS gas delivery during
breath?
Target variable

Flow target Pressure target

 Device Features for ventilatory
support
What TERMINATES.. breath?

Cycle variable

Volume Pressure limits Inspiratory time

 Modes Of Mechanical Ventilation
Controlled Mechanical Ventilation
Assist-Control Ventilation
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Pressure-Support Ventilation (PSV)
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure
(CPAP)

 Point of Reference:
Spontaneous Ventilation

Controlled Mechanical Ventilation
Preset ..
- RESPIRATORY RATE -TIDAL VOLUME

NO patient interaction with ventilator..

Advantages: rests muscles of respiration

Disadvantages: requires sedation/neuro-
muscular blockade, potential Hemodynamic
effects


 Modes Of Mechanical Ventilation
Controlled Mechanical Ventilation
Assist-Control Ventilation
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Pressure-Support Ventilation (PSV)
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure
(CPAP)

 Assist-Control Ventilation
Preset
- RESPIRATORY RATE (minimal) -TIDAL VOLUME

Additional patient-initiated breaths receive.

preset tidal volume
Advantages: reduced work of breathing; allows
patient to modify minute ventilation
Disadvantages: potential adverse hemodynamic
effects or inappropriate hyperventilation


 Modes Of Mechanical Ventilation
Controlled Mechanical Ventilation
Assist-Control Ventilation
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Pressure-Support Ventilation (PSV)
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure
(CPAP)

 Synchronized Intermittent
Mandatory Ventilation (SIMV)
Preset
- RESPIRATORY RATE -TIDAL VOLUME

Additional spontaneous breaths at tidal

volume and rate determined by patient

 Synchronized Intermittent
Mandatory Ventilation (SIMV)
Potential advantages
Better patient-ventilator interaction!!!!!
Less hemodynamic effects
Potential disadvantages
Higher work of breathing than CMV, AC

 Modes Of Mechanical Ventilation
Controlled Mechanical Ventilation
Assist-Control Ventilation
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Pressure-Support Ventilation (PSV)
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure
(CPAP)

 Pressure-Support Ventilation (PSV)
Pressure assist during spontaneous
inspiration
Pressure assist continues till ..
inspiratory effort decreases
Delivered TIDAL VOLUMEdepend on
-Inspiratory Effort
-Resistance / Compliance of lung/thorax

Pressure-Support Ventilation
Potential advantages
Patient comfort
Less WOB than spontaneous 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
is only backup
Gas leak from circuit may interfere with
cycling

 Modes Of Mechanical Ventilation
Controlled Mechanical Ventilation
Assist-Control Ventilation
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Pressure-Support Ventilation (PSV)
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure
(CPAP)

Pressure-Controlled Ventilation
Used to LIMIT INFLATION PRESSURE
Allows setting of Tinsp.
Complexity of interacting ventilatory variables
necessitates critical care consultation

 Modes Of Mechanical Ventilation
Controlled Mechanical Ventilation
Assist-Control Ventilation
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Pressure-Support Ventilation (PSV)
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure
(CPAP)

1. Continuous Positive Airway
Pressure (CPAP)
No machine breaths delivered
Allows spontaneous breathing
at elevated baseline pressure
PATIENT CONTROL.. RATE & T.VOLIUME

Inspiratory Time: Expiratory Time
Relationship (I:E ratio)
Spontaneous breathing I:E = 1:2
Inspiratory time determinants
(preset 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
Increase gas flow rate
Decrease tidal volume
Decrease respiratory rate

 Auto-PEEP
Can be measured on some ventilators
Increases peak, plateau, and mean airway
pressures
Potential harmful physiologic effects

 Physiopathology of Respiratory Failure30
ResistanceAW ComplianceR
D VA/Q

VO2
Work of Breathing VE VCO2
pH

Fatigue Neuromuscular
disorders

Hypoxemia Hypercapnia
AW=Airrway; R=respiratroy system; VE = minute ventilation, VO2 = Oxygen consumption, VCO2=carbon dioxide production

 Alveolar Pressure and Gas Exchange

Dead space

Intensity of the effects

PaO2

Oxygen transport

Alveolar Pressure

Note that as airway pressure increases above a certain level (e.g., high
PEEP [positive end-expiratory pressure]):
Oxygen transport start to decline despite the rising PaO2 as cardiac output starts falling.
Dead space also tends to increase due to compression of alveolar capillaries by high alveolar
pressure, creating ventilated but poorly perfused alveolar units.

Adapted from: Marini, et al. Crit Care Med. 1992.

 Positive Pressure Ventilation:
The Equation of Motion
In a passive subject, airway pressure represents the entire pressure (P)
applied across the respiratory system.
The work required to deliver a tidal breath (Wb) = tidal volume (VT) x
airway pressure
The pressure (P) associated with the delivery of a tidal breath is defined
by the simplified equation of motion of the respiratory system (lungs &
chest wall):
P = VT/CR+ VT/Ti x RR + PEEP total

P elastic P resistive P elastic

Where CR = compliance of the respiratory system, Ti = inspiratory time and VT/Ti = Flow, RR = resistance of the respiratory system and
PEEP total = the alveolar pressure at the end of expiration = external PEEP + auto (or intrinsic) PEEP, if any. Auto PEEP = PEEP total P
extrinsic (PEEP dialed in the ventilator) adds to the inspiratory pressure one needs to generate a tidal breath.

 Peak Alveolar and Transpulmonary Pressures
P(t) = VT/CR+ Flow x RR + PEEP
tot
Peak Airway Pressure
+ Alveolar Pressure
Plateau pressure
_ _

meanPaw
Palveolar
+ +
_ + _ + _
Ppleural
Intrinsic PEEP
External PEEP

Ptranspulmonary = Palveolar - Ppleural Pplat = Maximum Palveolar

Transpulmonary pressure is a key determinant of alveolar distension.

 Other Potentially Adverse Effects of Mechanical
Ventilation
Excessive airway pressure and tidal volume can lead to lung injury
(ventilatorinduced lung injury) and contribute to increased
mortality.

Lungs of dogs ventilated for a few hours with large The Acute Respiratory Distress Syndrome Network.
tidal volume demonstrate extensive hemorrhagic N Engl J Med. 2000;342:1301-1308.
injury.

The Pressure and Work of Breathing can be
Entirely Provided by the Ventilator (Passive
Patient)
Ventilator

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