Mechanical ventilation & Respiratory support therapy

DR.REZWANUL HOQUE BULBUL

MBBS, MS, FCPS, FRCSG, FRCS Ed

ASSOCIATE PROFESSOR DEPARTMENT OF CARDIAC SURGERY BSMMU, DHAKA, BANGLADESH

DEFINITION
It refers to the gamut of artificial means used to support ventilation and oxygenation. They encompass all forms of Positive Pressure Ventilation and those modes used to increase airway pressure above atmospheric during spontaneous ventilation

GOALS OF VENTILATION Increase efficiency of breathing Increase oxygenation Improve ventilation/perfusion relationships Decrease work of breathing

Types of Systems
Negative Pressure Ventilator Iron lung Allows long-term ventilation without artificial airway Maintains normal intrathoracic hemodynamics Uncomfortable, limits access to patient

Types of Systems Positive Pressure Ventilator Uses pressures above atmospheric pressure to push air into lungs Requires use of artificial airway Types Pressure cycled Time cycled Volume cycled

Positive Pressure Ventilators Pressure Cycled Terminates inspiration at preset pressure Small, portable, inexpensive Ventilation volume can vary with changes in airway resistance, pulmonary compliance Used for short-term support of patients with no pre-existing thoracic or pulmonary problems

Positive Pressure Ventilators Volume cycled

Most widely used system Terminates inspiration at preset volume Delivers volume at whatever pressure is required up to specified peak pressure May produce dangerously high intrathoracic pressures

Positive Pressure Ventilators Time cycled

Terminates inspiration at preset time Volume determined by Length of inspiratory time Pressure limit set Patient airway resistance Patient lung compliance Common in neonatal units

CLASSIFICATION / On the basis of three functions INITIATION CONTROL

Initiation triggered by machine at a predetermined time set regardless of patient effort

ASSIST

Supported breath is triggered when patient initiates a breath that develops negative pressure below a threshold termed sensitivity
Tidal volume is preset while peak airway pressure is variable Airway pressure is preset while tidal volume is variable Tidal volume delivered then converted to expiration May be prolonged by inspiratory pause declines to predetermined level

LIMIT

VOLUME
PRESSURE

CYCLE OFF

VOLUME TIME

FLOW RATE Converted to expiration when flow rate

VENTILATOR MODES
Defined by inspiratory events while expiration is treated as independent entity

CONTROLLED MECHANICAL VENTILATION(CMV)

Initiation is time dependent with a fixed rate Tidal volume is delivered along with inspiratory pause Tidal volume is delivered regardless of airway pressure If pressure limit is set delivery will stop once the limit is reached Eliminates patients work of breathing Requires an anaesthetized and paralyzed patient Useful when inspiratory effort contraindicated (flail chest) Patient must be incapable of initiating breaths Rarely used

 ASSISTED MECHANICAL VENTILATION

Initiation is assisted when sensitivity is reached

Otherwise similar to CMV Better tolerated in light sedation Cannot be used in sedated or paralyzed Work of breathing is greater Can predispose to alkalosis if resp. rate is high

Assist Mode
Assist/Control (A/C)
Patient triggers machine to deliver breaths but machine has preset backup rate Patient initiates breath--machine delivers tidal volume If patient does not breathe fast enough, machine takes over at preset rate Tachypnea patients may hyperventilate dangerously

A/C mode

 Assist Mode
INTERMITTENT MANDATORY VENTILATION (IMV) Combination of CMV and Spontaneous modified circuit allows continuous flow that allows patient to breathe between machine delivered breath with minimal work of breathing Delivery is regardless of the stage of respiration
Patient breathes on own Machine delivers breaths at preset intervals Patient determines tidal volume of spontaneous breaths Used to wean patients from ventilators patient machine dyssynchrony may lead to lung over distension or fighting with the ventilator Patients with weak respiratory muscles may tire from breathing against machines resistance Largely abandoned in favor of SIMV

 Assist mode SYNCHRONISED INTERMITTENT MANDATORENTILATION (SIMV)

IMV in assist mode
Machine timed to delay ventilations until end of spontaneous patient breaths Avoids over-distension of lungs Decreases barotrauma risk

However if patient does not breathe then IMV delivers Relative work of breathing is less Does not contribute to central hyperventilation syndrome Does not require sedation or paralysis In COPD patients, hypercarbia is preserved Popular mode for weaning of patients

SIMV mode

PRESSURE SUPPORT VENTILATION Applicable in spontaneous ventilation Initiation of respiration cause rapid flow of gas until selected pressure is crossed and continues until inspiration drive is stopped Advantage over SIMV being support is provided for each breath Requires spontaneous ventilation but spontaneous breath in SIMV mode are also supported Cannot be used in low pulmonary compliance Central hyperventilation syndrome along with resp.alkalosis may develop Monitoring of tidal volume is required

Pressure support ventilation

Volume control vs. pressure control

There are, effectively, two ways of assisting inspiration by using positive pressure to deliver a certain amount of volume (volume control ventilation), or by delivering a certain amount of pressure (pressure control ventilation). Volume control means volume constant and pressure variable. Pressure control means pressure constant (or limited) volume variable ventilation. The mode of ventilation, is the way in which the ventilator uses volume or pressure to bump the patient up the pressure-volume curve. Patients may be given mandatory breaths (controlled ventilation) or may have their spontaneous breaths assisted (assist control ventilation). An alternative mode (which is often used with controlled modes) is pressure support, which allows a patient breath spontaneously, start and finish breaths and determine the tidal volume. Mechanical ventilation that is achieved regardless of the patient's spontaneous breathing, but that uses pressure as the major determining variable, along with rate and time, of how much air the patient receives.

High Frequency Ventilation (HFV)

Small volumes, high rates Allows gas exchange at low peak pressures Mechanism not completely understood
High frequency positive pressure ventilation--60-120 breaths/min High frequency jet ventilation--up to 400 breaths/min High frequency oscillation--up to 3000 breaths/min

High Frequency Ventilation (HFV)

Useful in managing:
Tracheobronchial or bronchopleural fistulas Severe obstructive airway disease Patients who develop barotrauma or decreased cardiac output with more conventional methods Patients with head trauma who develop increased ICP with conventional methods Patients under general anesthesia in whom ventilator movement would be undesirable

Alternative modes of ventilation

Non-invasive positive pressure ventilation using specialized face or nasal mask Negative pressure ventilation using special apparatus in COPD patient Airway pressure release ventilation- Lung is kept inflated at constant pre-set pressure to achieve alveolar recruitment and inflation, intermittent release of pressure to allow exhalation Mandatory minute ventilation- Pre-set minute ventilation either by spontaneous or by supplemental breath by machine Inverse ratio ventilation- normal I:E ratio is reversed from 1:2/1:3 to 1:1-3:1 Partial liquid ventilation- Perfluorocarbon liquid instilled into lung followed by standard mechanical ventilation ECMO

 POSITIVE END EXPIRATORY PRESSURE commonly kept at 3 5 cm of water as a substitute for physiological PEEP provided by closed glottis primary goals include: 1. increase functional Residual Capacity 2. distends patent alveoli 3. recruits previously collapsed alveoli 4. In pulmonary edema, may redistribute extra vascular lung water from alveolar capillary interstitium to peribronchial and perihilar interstitium

Disadvantages 1. Alveolar distention and pulmonary dead space increases air trapping, CO2 retention and hypercapnia 2. Not useful in diseased lung 3. Not tolerated in awake patients 4. Increased work of breathing 5. Increased chances of barotrauma Contraindications 1. Severe hemodynamic instability 2. Acute bronchospasm 3. Severe Emphysema 4. Pneumothorax Suspected or present

Continuous Positive Airway Pressure (CPAP)

PEEP without preset ventilator rate or volume Physiologically similar to PEEP May be applied with or without use of a ventilator or artificial airway Requires patient to be breathing spontaneously Does not require a ventilator but can be performed with some ventilators

RATIONALE FOR MECHANICAL VENT.

Provides the time to reverse the adverse effects on lung function induced by anaesthesia and surgery Allows aggressive pain control without concern for respiratory depression Reduces the work of breathing and saves energy at the critical period

In patients who are hemodynamically unstable, ensures effective ventilation reducing the number of variables in management

INDICATION OF MECHANICAL VENTILATION

PLANNED POST OPERATIVE Based on Surgical procedures 1. Cardiac Surgery 2. Major Vascular Surgeries 3. Procedures with major blood loss 4. High risk Surgical Incisions Planned- other diseases 1. Neuromuscular and Mechanical dysfunction 2. Parenchymal lung diseases 3. Acute lung injury 4. Multi System Organ Failure Unplanned 1. Depressed CNS response to hypoxia and hypercapnia
upper abdominal reduces FRC by 60% thoracotomy reduces FRC by 40%

INDICATION (CONTD CARDIO PULMONARY COMPLICATION

Acute Myocardial Infarction Arrhythmias Pulmonary edema Severe bronchospasm Lobar Atelectasis

SURGICAL COMPLICATIONS
Hemorrhage Cardiac contusion following TEE, Phrenic Nerve injury

OPERATIVE CATASTROPHE
Cardiac arrest, Malignant hyperthermia, ABO mismatch Gastric Acid aspiration, Major anaphylactic reaction

INADEQUATE REVERSAL OF ANAESTHESIA

inadequate elimination of anaesthetic agents inadequate reversal of opioid analgesics inadequate reversal of muscle relaxants

Ventilator Settings
Tidal volume--10 to 15ml/kg (std = 12 ml/kg) Respiratory rate--initially 10 to 16/minute FiO2--0.21 to 1.0 depending on disease process 100% causes oxygen toxicity and atelectasis in less than 24 hours 40% is safe indefinitely PEEP can be added to stay below 40% Goal is to achieve a PaO2 >60 I:E Ratio--1:2 is good starting point Obstructive disease requires longer expirations Restrictive disease requires longer inspirations

Changes are made according to Arterial Blood Gas reports Maintain with ACV, use sedatives & muscle relaxants if needed Switch to Synchronized Intermittent Mandatory Ventilation (SIMV) mode, reduce respiratory rate gradually and finally switch to Spontaneous mode Extubate the patients when the criteria's are met.

Ventilator Settings
Ancillary adjustments

Inspiratory flow time Temperature adjustments Humidity Trigger sensitivity Peak airway pressure limits Sighs

Quick Guide to Setup

Self check and/or Calibration as needed Check circuit and connections Set Mode: Usually Assist/Control Adjust I time: Usually 1 second Set tidal volume: 10-12 ml/kg is standard May need to set Flow based on I time Set ventilatory rate: Adult 12-16/min

 WEANING FROM VENTILATOR Criteria

1. Mental Alertness 2. No active bleeding 3. Haemodynamic stability 4. Normothermic 5. Satisfactory Arterial Blood Gas report PaO2 > 70 mm of Hg on an FIO2 <50% PaCO2 < 45 mm of Hg pH 7.35 7.45

For Extubation
Vital Capacity > 10 15ml / kg Negative Inspiratory Force > 25 cm water Spontaneous Respiratory Rate < 30 / min D(A-a)O2 <350 TORR ON 100% O2

Ventilator Complications Mechanical malfunction

Keep all alarms activated at all times BVM must always be available If malfunction occurs, disconnect ventilator and ventilate manually

Ventilator Complications Airway malfunction

Suction patient as needed Keep condensation build-up out of connecting tubes Auscultate chest frequently End tidal CO2 monitoring Maintain desired end-tidal CO2 Assess tube placement

Ventilator Complications Pulmonary barotrauma

Avoid high-pressure settings for high-risk patients (COPD) Monitor for pneumothorax Anticipate need to decompress tension pneumothorax

low chance with peak airway pressure < 45 cm of water high tidal volume may injure alveolar capillary membrane

Oxygen toxicity
incidence and rapidity of oxygen related injury increases with FIO2 > 60%

Ventilator Complications
Renal malfunction Gastric hemorrhage Pulmonary atelectasis Infection Oxygen toxicity Loss of respiratory muscle tone increased intra cranial pressure

Ventilator complications Acute Respiratory Insufficiency present when there is evidence of inadequate oxygenation (PaO2 <60 mm Hg on FIO2 0.5) or Ventilation (PCO2 >50 mm Hg) during mechanical ventilatory support.

Causes: -Ventilator malfunction, improper setting - Endotracheal tube malfunction - Pulmonary Problems Atelectasis, Pulmonary edema, Pneumonia, Pneumothorax, Haemothorax - Low cardiac output states - Aspiration Pneumonia

Management: - Examine the ventilator setting and function, ET Tube, ABGs, CXR - Hand ventilate with 100% O2, increase FIO2 in ventilator until problem is corrected - May require repositioning of ET tube, insertion of Intra thoracic tube - Asses and optimise hemodyanmics - Add Inverse Ratio Ventilation with PEEP increment - Consider sedation and Paralysis in patient Ventilator synchronicity - Treat identifiable causes

Chronic Respiratory insufficiency

inability to wean from ventilator within 48-72 hours caused by problems that primarily impair oxygenation or produce primary Ventilatory insufficiency Causes: Hypoxia, ARDS, Sepsis, Metabolic Abnormalities, Phrenic nerve paralysis Management: Treat the primary cause Patients may even require Tracheostomy for further airway management

Thank you