Ventilatory Care of Critically ill Patient and

Weaning from Mechanical Ventilation

Dr Priyanka

University College of Medical Sciences & GTB Hospital,

Delhi
 Contents
Introduction
Goals of mechanical ventilation
Indications of mechanical ventilation
Criteria for initiating mechanical
ventilation
Effects of mechanical ventilation
Modes of mechanical ventilation
Ventilatory care bundles
Weaning from mechanical ventilation
 Mechanical ventilation
Cornerstone of intensive care medicine

“Ventilate” is derived from the Latin

word “Ventus” meaning “Wind”

Ventilation is the movement of air into

and out of the lungs
 Mechanical ventilation

Use of a machine to take over active

breathing for a patient

Used for patients who are unable to sustain

the level of ventilation necessary to
maintain the gas exchange functions -
oxygenation and carbon dioxide
elimination
Goals of mechanical ventilation
 
Increase efficiency of breathing

 Increase oxygenation

 Improve ventilation/perfusion
relationship

Decrease work of breathing

 Indications of Mechanical
Ventilation
A. Established acute respiratory failure

B. Incipient respiratory failure

C. Low output states

D. Purposeful hyperventilation
 Indications ….
A) Established Acute Respiratory Failure
 Primary ventilatory failure
 Poisonings which depress the CNS
 CNS and neuromuscular disorders
( poliomyelitis, infective polyneuritis,
myasthenia)
 Snake bites
 Severe tetanus
 Hypoventilating comatose patients
 Indications…
 Acute pulmonary disorders e.g. fulminant
pneumonia, acute lung injury (ARDS)
 Fulminant pulmonary oedema
 Major or massive pulmonary embolism
 Major or massive atelectasis
 Patients with COPD in acute crisis,
unresponsive to conventional therapy
 Patients with acute severe asthma ,
unresponsive to conventional therapy
 Indications…
B) Incipient Respiratory Failure
 Obese patients who have undergone upper
abdominal surgery, or poor risk surgical patients
 Respiratory muscle fatigue in critical illnesses
 Patients with excessive ventilatory demands
 Patients with acute fulminant parenchymal lung
disease with rapidly progressive impairment of
pulmonary function and reserve
 Indications…
C) Low output states
 Shock of any etiology

D) Purposeful hyperventilation
 To decrease intracranial tension in patients
with head injury
 To reduce cerebral edema after CPR or
massive CVA
 Criteria for initiating ventilatory
support in adults

 On the basis of pulmonary

function

 On the basis of blood gas analysis

 On the basis of clinical

parameters
 Criteria….

A) On the basis of pulmonary function

 Respiratory rate > 35/ min
 VC<10 -15mL/kg
 MV> 10-12L /min
 Maximum Inspiratory Force < -20 cm
H2O
 Vd/Vt ratio > 0.6
 Criteria for initiating ventilatory
support in adults
On the basis of blood gas analysis
PaO2 < 50 mmHg on room air
PaO2 < 60 mmHg on O2 support ( fiO2 >
0.5)
PaCO2 > 50 mmHg
pH < 7.25
PaO2/fiO2< 250
P(A-a) O2>350 mmHg on fiO2 of 1
 Criteria for initiating ventilatory
support in adults
On the basis of clinical parameters

Visible excessive work of breathing in

critically ill or debilitated patients
Clinical evidence of respiratory muscle
fatigue
Poor chest excursions
Tachypnea
Respiratory muscle paradox

 Effects of Mechanical
Ventilation
Cardiovascular
Respiratory
Renal
Hepatic
Gastrointestinal
Central nervous system
 Spontaneous breathing
Contraction of the diaphragm and respiratory
muscles

Lowers the pleural, alveolar and airway pressures

below atmospheric pressure

Air flows into lungs

Spontaneous breathing
 Positive pessure ventilation
Gas flows into the lungs under a positive pressure gradient
generated by the ventilator

Increases the pleural, alveolar and airway pressures

above atmospheric pressure

Tidal volume delivered to lungs is directly related to the positive

pressure when a pressure limited ventilator is used . In volume
limited ventilators, the level of positive pressure is dependent on
the mechanical tidal volume and on lung compliance and
airway resistance
 Effects of Mechanical
Ventilation
Cardiovascular
Respiratory
Renal
Hepatic
Abdominal
Gastrointestinal
Central nervous system
 Cardiovascular system
Decreased Preload
Positive alveolar pressure ↑ lung volume
compression of the heart by the inflated lungs
the intramural pressure of the heart cavities rises
(e.g., ↑ RAP ) venous return decreases
preload is reduced stroke volume decreases
cardiac output and blood pressure may drop
Fall in cardiac output is generally compensated
by increase in peripheral venous tone
 Cardiovascular Effects of PPV

Spontaneous ventilation PPV

 Cardiovascular system

Reduced Afterload
Positive intrathoracic pressure
compression of heart
facilitates ventricular emptying
during systole
Increases stroke volume
Blood pressure changes during
mechanical ventilation
Cardiovascular system

Degree of circulatory tolerance is

dependent on
• inspiratory inflation pressures
• time duration of lung inflation
• integrity of vascular reflexes
• circulatory blood volume
Effects of PPV on hemodynamic
measurements
Increase in intrathoracic
pressure
Decrease in pulmonary blood
volume and increase in systemic
blood volume
Decrease in venous return
(CVP)
Decrease in right ventricular
stroke volume
Decrease in pulmonary artery
 Respiratory system

Excessive airway pressure and tidal

volume

Ventilator induced lung injury

Alteration in V/Q ratio

Ventilator associated lung injury
 Neurologic Changes during
Mechanical Ventilation
 Decrease cerebral blood flow
 Increase CSF pressure
 Decrease CSF absorption
 Increase CSF volume
Effect of PPV on other body systems
Cardiovascular considerations
Positive pressure ventilation

Increase in intrathoracic pressure

Compression of pulmonary vessels

Reduction in stroke volume

Cardiovascular considerations
Reduction of cardiac output and pulmonary
blood volume

High V/Q mismatch

Hypoxemia

Decrease in o2 content

Decrease in o2 delivery
Dead space
Anatomic Dead space
- conducting airways
Estimated to be about 1ml per pound of ideal body weight
Alveolar Dead space
- normal lung volume that has become unable to take part in
gas exchange because of reduction in pulmonary blood flow
Pulmonary embolism
Physiologic Dead space
Sum of anatomic and alveolar dead space volumes
Effects of PEEP on hemodynamic
measurements
Increase in pulmonary artery pressures(PAP)
Increase in central venous pressure (CVP)
Decrease in aortic pressure
Decrease in cardiac output
Mechanical ventilation
Neurologic Changes during mechannical
ventilation
 Respiratory alkalosis decreased cerebral blood
flow
(<24hrs) reduced intracranial tension

 Respiratory alkalosis leftward shift of HbO2

(>24hrs) dissociation curve
affinity for hemoglobin
O2 release to tissues
cerebral tissue hypoxia
neurologic dysfunction
hypophophatemia
 Continuous
background of noise
and activity
Disturbed normal
Catheterisation diurinal sleep
rhythm and sleep
deprivation

Treatment in ICU
Insertion of a --a frightening experience !!!
chest drain

Turning the
Changing surgical
patient
dressings