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    Introduction To Mechanical Ventilation

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    Ary Waileruny
    Mechanical ventilation involves using a machine to support or replace spontaneous breathing. This document provides an overview of the history and types of mechanical ventilation, including negative pressure ventilation such as iron lungs, and modern positive pressure ventilation. Key aspects covered include the components of lung ventilation, indications for mechanical ventilation, modes of ventilation such as controlled mandatory ventilation and pressure support ventilation, and monitoring parameters like plateau pressure and auto-PEEP. Settings and considerations are discussed for different clinical scenarios like asthma, COPD, and ARDS.

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    Introduction To Mechanical Ventilation

    Uploaded by

    Ary Waileruny
    105 views43 pages
    Mechanical ventilation involves using a machine to support or replace spontaneous breathing. This document provides an overview of the history and types of mechanical ventilation, including negative pressure ventilation such as iron lungs, and modern positive pressure ventilation. Key aspects covered include the components of lung ventilation, indications for mechanical ventilation, modes of ventilation such as controlled mandatory ventilation and pressure support ventilation, and monitoring parameters like plateau pressure and auto-PEEP. Settings and considerations are discussed for different clinical scenarios like asthma, COPD, and ARDS.

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    Mechanical ventilation involves using a machine to support or replace spontaneous breathing. This document provides an overview of the history and types of mechanical ventilation, including negative pressure ventilation such as iron lungs, and modern positive pressure ventilation. Key aspects covered include the components of lung ventilation, indications for mechanical ventilation, modes of ventilation such as controlled mandatory ventilation and pressure support ventilation, and monitoring parameters like plateau pressure and auto-PEEP. Settings and considerations are discussed for different clinical scenarios like asthma, COPD, and ARDS.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    105 views43 pages

    Introduction To Mechanical Ventilation

    Uploaded by

    Ary Waileruny
    Mechanical ventilation involves using a machine to support or replace spontaneous breathing. This document provides an overview of the history and types of mechanical ventilation, including negative pressure ventilation such as iron lungs, and modern positive pressure ventilation. Key aspects covered include the components of lung ventilation, indications for mechanical ventilation, modes of ventilation such as controlled mandatory ventilation and pressure support ventilation, and monitoring parameters like plateau pressure and auto-PEEP. Settings and considerations are discussed for different clinical scenarios like asthma, COPD, and ARDS.

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    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

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