Ventilators 2

Ventilators
Dr Ankit shahi
• Short term for few hours
Ventilators • Prolong for few days

• Has to be weaned off
Rationale for Using Mechanical Ventilation
• To decrease the work of breathing

• To maintain normal oxygenation
• To maintain normal levels of ventilation and acid-base balance
• The use of ventilators allows for mechanical ventilatory support so as to:

• Meet physiologic needs in acute respiratory failure indicated by failure of the respiratory system to maintain an adequate
balance of pH, PaO2, and/or PaCO2
• Protect the airway and lung parenchyma (drug overdose, cerebrovascular accident, head or spinal cord injury)
• Relieve upper airway obstruction (tumor, allergic reaction, edema)
• Improve pulmonary toilet in patients with excessive secretions or inability to successfully clear secretions by coughing
Potential Adverse Effects of Positive Mechanical
Ventilation
• Hemodynamic Effects
• • Decreased venous return
• • Decreased cardiac output
• • Decreased renal perfusion
• • Decreased blood pressure
• Pulmonary Effects
• • Increased ventilation/perfusion ratio and dead space/tidal volume ratio
• • Air trapping
• • Barotrauma can cause
• o Release of proinflammatory cytokines, which can lead to multi-system failure
• o Pneumothorax, subcutaneous emphysema
• • Increased work of breathing and respiratory distress (eg, narrow diameter ET tube, discomfort
• associated with mechanical ventilation, incoordination with ventilator)
• • Respiratory muscle weakness
• • Infection—nocosomial or aspiration pneumonia
• Other Effects
• • Increased use of narcotics or sedative agents
• • Use of other invasive measures (eg, arterial lines, feeding tube)
• • Increased intracranial pressure
• Positive-pressure ventilators are used almost exclusively for mechanical ventilatory assistance in critical care units. The
positive pressure from the ventilator provides the force that delivers gas into the patient’s lungs by increasing intrathoracic
pressure to expand the chest wall. The termination of gas flow allows the chest wall to recoil to the resting position, thus
exhaling the gas
• AutoPEEP or intrinsic PEEP (PEEPi): When alveolar pressure remains positive at the end of expiration causing a dynamic
hyperinflation or air trapping. This occurs when the time available for expiration is shorter than the time required for
passive emptying to individual’s functional residual capacity (FRC).
Several parameters should be noted on the ventilator screen:
(1) Mode of ventilation,

(2) FIO2,
(3) PEEP (positive end-expiratory pressure [mm of H2O]),
(4) respiratory rate (breaths per minute),
(5) tidal volume (milliliters),
(6) minute volume (mL/min), and
(7) alarm settings.
Modes
• Continuous positive airway pressure (CPAP)

• Spontaneous mode of ventilation
• Weaning mode
• CPAP maintains positive pressure continuously in the airways
• Pressure support is be added to augment patient’s tidal volume
• When used with a mask is considered noninvasive ventilation
• CPAP provides continuous positive airway pressure during both the inspiratory and expiratory phases.
• During CPAP, the patient is breathing spontaneously and has to generate all the inspiratory effort.
• CPAP is frequently used to wean patients off the ventilator.
• Positive end-expiratory pressure (PEEP)

• Positive pressure applied at the end of expiration during ventilation
Side effects of high Fio2 and PEEP
• Oxygenation
• A high fraction of inspired oxygen (FiO2) and positive end expiratory pressure (PEEP) are used to
maintain adequate oxygenation.
• Both of these parameters, however, can have adverse effects.
• High FiO2 can induce oxygen toxicity and cause reabsorption atelectasis.
• High PEEP can impede venous return, decrease cardiac output, decrease systemic blood pressure, and increase the risk
of overdistending alveoli.
• FiO2 is the abbreviation for the fractional concentration of inspired oxygen. It is a measure of the proportion of inspired
oxygen. For example, an FiO2 of 21% or 0.21 means that 21% of the inspired air is oxygen.
• FiO2 is typically maintained below 0.5 even with mechanical ventilation, to avoid oxygen toxicity, but there are
applications when up to 100% is routinely used.
• Absorption Atelectasis—About 80% of the gas in the alveoli is nitrogen. If high concentrations of oxygen are administered, the
nitrogen is displaced. When the oxygen diffuses across the alveolar-capillary membrane into the blood stream, the nitrogen is
no longer present to distend the alveoli contributing to their collapse and atelectasis.
• Oxygen Toxicity—High levels of oxygen administration for 24 hours usually results in some lung damage because of oxygen
radical production. Oxygen radical production occurs because of incomplete reduction of oxygen to water. Oxygen radicals are
very reactive molecules that can damage membranes, proteins, and many cell structures in the lungs.
• resolution or relative resolution of the initial event or disease that led to acute respiratory failure.
• patient’s status should be maximized in regard to nutrition, metabolic stability, fluid and electrolyte balance,
hemodynamic stability, and cardiac function
• afebrile and must demonstrate an improving or stable chest x-ray, and respiratory secretions should be
manageable
• Adequate gas exchange with FIO2 less than 50% and SaO2 greater than 90% with a positive end-expiratory
pressure (PEEP) of less than 5 cm H2O.
• • Negative inspiratory force of 20 to 30 cm H2O.
• • The ratio of respiratory rate to tidal volume (RR/VT) less than 105, with respiratory rate less than 35 breaths
per minute. This ratio is an indicator of rapid shallow breathing and has been found to be the most accurate
predictor of weaning failure
• Minute ventilation (VE = respiratory rate × tidal volume) less than 15 L/minute.
• • During the wean, the patient will be monitored for respiratory rate, depth and pattern, ABG (arterial blood
gas) values, pulse oximetry, cardiac rate and rhythm, and mental status changes
• Respiratory rate greater than 35 breaths per minute
• Appearance of paradoxical breathing pattern, use of
accessory muscles of respiration, or dyspnea
• Desaturation with SaO2 less than 90%, any decrease of
Terminate PaO2, or increase in PaCO2 of 5 mm Hg as monitored
by ABG values, especially in the presence of acidosis
weaning with a pH less than 7.30
• Change in heart rate greater than 20 beats per minute,
a change in blood pressure more than 20 mm Hg,
angina, cyanosis, or cardiac arrhythmias
• Change in level of consciousness
During weaning
• Simplest method for assessment is a yes–no question: Are you short of breath? This can be
further qualified by using a numerical scale, similar to a pain scale, rating dyspnea from 0
to 10, with 0 indicating no shortness of breath and 10 indicating the worst imaginable
shortness of breath
IMP
• In pulmonary shunting , ventilators may be ineffective because o2 cannot reach to alveoli.

Indications and Common Conditions for Using Noninvasive Positive Pressure
Ventilation
• Signs of respiratory failure as defined by:

• PaCO2
• > 50 mmHg and PaO2/FiO2 < 200
• Moderate to severe dyspnea with RR > 24/min or paradoxical breathing
• Common conditions that noninvasive positive pressure ventilation (NPPV) is used in the event of
respiratory failure are:
• restrictive chest wall disease, sleep apnea, neuromuscular disorders, COPD, and acute
• pulmonary edema.
• Patients need upper airway control and an intact cough to be suitable for NPPV, otherwise intubation
and
• positive pressure invasive mechanical ventilation will be used.
Negative Pressure Ventilation
• Negative pressure ventilation (NPV) expands the lungs by pulling out the chest wall.
Each of the NPV devices provides an airtight enclosure around the thorax.
• The negative pressure applied to the chest wall mimics normal ventilation during
which the inspiratory muscles pull out the chest wall. Examples of NPV are iron
lungs, body wrap, or cuirass ventilators.
Ventilator Modes Frequently Used With Noninvasive Positive Pressure Ventilation
• Ventilators frequently use a bilevel of continuous positive airway pressure (BiPAP) that provide
positive airway pressure during inspiration (IPAP) and expiration (EPAP).
• Patients with spontaneous breathing needing some ventilatory support are prime candidates for
the use of BiPAP ventilation .
• People with sleep apnea often benefit from the use of CPAP or BiPAP for nocturnal ventilation.
• For the more disabled patients,

• assisted control or full ventilation in either volume- or pressure-controlled ventilation are
available
Subjective assessment
Adequate cough
No neuromuscular blocking agents
Absence of excessive trachea-bronchial secretion
Reversal of the underlying cause for respiratory failure
No continuous sedation infusion or adequate mentation on sedation
Objective measurements
Stable cardiovascular status
Heart rate ≤ 140 beat/minute
No active myocardial ischemia
Criteria's for
Adequate hemoglobin level ( ≥ 8 g/dl)
Systolic blood pressure 90–160 mmHg
Afebrile (36° C < temperature < 38° C)
weaning No or minimal vasopressor or inotrope (< 5 µg/kg/minute dopamine or dobutamine)

Adequate oxygenation
patient off Tidal volume > 5 mL/kg

Vital capacity >10 mL/kg
ventilator
Proper inspiratory effort
Respiratory rate ≤ 35/minute
PaO2 ≥ 60 and PaCO2 ≤ 60 mmHg
Positive end expiratory pressure ≤ 8 cmH2O
No significant respiratory acidosis (pH ≥ 7.30)
Maximal inspiratory pressure (MIP) ≤ -20 – -25 cmH2O
O2 saturation > 90% on FIO2 ≤ 0.4 (or PaO2/FIO2 ≥ 200)
Rapid Shallow Breathing Index (respiratory Frequency/Tidal Volume) < 105
ARDS
• Severe hypoxemia occurs that is characteristically not responsive to increasing FiO2,

which is indicative of pulmonary shunting.
• The lungs have a decreased compliance; high pressures and a high FiO2 are required in an
attempt to obtain adequate oxygenation.
• Approximately 50% of patients with ARDS develop multisystem failure. The cause of
death is not usually due to hypoxemia but rather multisystem failure and hemodynamic
instability. The mortality rate is approximately 30% to 40%, which may vary in different
centers

Ventilators 2

Uploaded by

Copyright:

Available Formats

Ventilators 2

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ventilators 2

Uploaded by

Copyright:

Available Formats

Ventilators

Ventilators • Prolong for few days

• To decrease the work of breathing

• The use of ventilators allows for mechanical ventilatory support so as to:

(1) Mode of ventilation,

• Continuous positive airway pressure (CPAP)

• Positive end-expiratory pressure (PEEP)

• In pulmonary shunting , ventilators may be ineffective because o2 cannot reach to alveoli.

• Signs of respiratory failure as defined by:

• For the more disabled patients,

weaning No or minimal vasopressor or inotrope (< 5 µg/kg/minute dopamine or dobutamine)

patient off Tidal volume > 5 mL/kg

• Severe hypoxemia occurs that is characteristically not responsive to increasing FiO2,

You might also like