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Ventilator Basics

This document provides an overview of fundamentals of mechanical ventilation. It discusses normal respiratory physiology and causes of acute respiratory failure. It then describes different modes of non-invasive respiratory support including low and high flow options. The basics of mechanical ventilation are reviewed including variables that can be adjusted and the 5 basic types of breaths. Common ventilator modes such as ACV, PCV, SIMV, PSV and advanced modes like APRV, biphasic ventilation, and HFOV are explained. Adjuncts to mechanical ventilation like prone positioning are mentioned. Finally, the document reviews the process of liberating a patient from the ventilator.

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326 views38 pages

Ventilator Basics

This document provides an overview of fundamentals of mechanical ventilation. It discusses normal respiratory physiology and causes of acute respiratory failure. It then describes different modes of non-invasive respiratory support including low and high flow options. The basics of mechanical ventilation are reviewed including variables that can be adjusted and the 5 basic types of breaths. Common ventilator modes such as ACV, PCV, SIMV, PSV and advanced modes like APRV, biphasic ventilation, and HFOV are explained. Adjuncts to mechanical ventilation like prone positioning are mentioned. Finally, the document reviews the process of liberating a patient from the ventilator.

Uploaded by

gina contreras
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Fundamentals of

Mechanical Ventilation
Junior Resident Conference
December 22, 2016
Objectives
Learner will be able to describe normal respiration.

LWBAT describe the differences between the


different modes of non-invasive respiratory support

LWBAT describe the differences between the


different modes of mechanical ventillation

LWBAT choose the appropriate changes in


ventillator support
Review of pulmonary
physiology
Minute ventilation (VE) =
Tidal volume (VT) x
respiratory rate (f)
- Normal VE = 5-8L/min
- Controlled by PaCO2 and
medullary pH

VT = dead-space (VD) +
alveolar ventilation (VA)
Normal Inspiration
Acute Respiratory Failure
Hypoxemia:
1) Shunt (V/Q<1)
2) Ventilation-Perfusion
Mismatch
3) Diffusion limitation
4) Dead space
5) Low FiO2
6) Low barometric
pressure
7) Alveolar
hypoventilation

Hypercarbic
Acute Respiratory Failure
Hypoxemia:
1) Shunt (V/Q<1)
2) Ventilation-Perfusion
Mismatch
3) Diffusion limitation
4) Dead space (V/Q>1)
5) Low FiO2
6) Low barometric
pressure
7) Alveolar
hypoventilation

Hypercarbic
Non-invasive techniques:
Low Flow
Nasal Cannula:
FiO2 range: 24-44%
FiO2=20% + (4%x
LO2/min)
Ex: 2L NC = 28% FiO2

* FiO2 influenced by
inspiratory flow rate > if
patient is tachypneic they
recieve less FiO2
Non-invasive techniques:
Low Flow
Non-rebreathing facemask
non-rebreather:
FiO2 range: >40% (can
deliver up to 90% FiO2)
Can set O2 at 8-15L/min

* Good for an acute


desaturation
* Risk of CO2 retention if bag
collapses on inspiration
* Drying!
* Should not be used more
than 4 hours
Non-invasive techniques:
High Flow
Venturi mask:
FiO2 range: 24-44%

* Provides consistent FiO2


regardless of rate or tidal
volumes
* Useful in COPD (concern re:
suppression of respiratory
drive)
Non-invasive techniques:
High Flow

High Flow Nasal Cannula:


10-60 LPM
Humidified air
Each 10L O2 adds
1cm/H2O positive pressure
Non-invasive techniques:
Positive Pressure

Continuous positive airway


pressure (CPAP): increases
alveolar recruitment

BiPAP: inspiratory PS +
PEEP
Mechanical Ventilation:
The Basics
Goals of mechanical ventilation:
Provide adequate oxygenation
Provide CO2 clearance
Decrease work of breathing

Variables:
1) Breath trigger: what initiates the vent?
Change in pressure or flow (patient-initiated)
Set time (ie. rate) (ventilator-initated)
2) Target: what controls gas delivery during the breath?
Set flow
Set inspiratory pressure
3) Cycle termination: what terminates the breath?
Set volume
Set flow
Set time (I:E ratio)
4) End-expiratory pressure (PEEP)
5 Basic Types of Breaths
Breath Type Trigger Target Cycle Termination

Volume Assist Patient Inspiratory flow Set Volume

Volume Control Vent Inspiratory flow Set Volume

Inspiratory
Pressure Assist Patient Inspiratory time
pressure
Pressure Inspiratory
Vent Inspiratory time
Control pressure
Pressure Inspiratory % decrease in
Patient
Support pressure inspiratory flow
5 Basic Types of Breaths
Ventilator Modes
Volume-limited v. Pressure-
limited
Volume-limited
Clinician sets:
peak flow rate Increased Decreased Increased
tidal lung flow
flow pattern volume compliance rate
respiratory rate
PEEP
FiO2

Inspiration ends after set tidal volume

I:E ratio set by flow rate (increase flow


rate>decrease I time, decrease I:E
ratio)

Airway pressures determined by set


volume, lung compliance, airway
resistance
Volume-limited v. Pressure-
limited
Pressure-limited
Clinician sets:
inspiratory pressure
I:E ratio
respiratory rate
PEEP
FiO2

Inspiration ends after delivery of set


inspiratory pressure

Tidal volume is determined by


inspiratory pressure, lung compliance,
airway/tubing resistance

Peak airway pressure is constant


(inspiratory pressure + PEEP)
Volume Assist Control
Ventilation (ACV)
* Requires the least effort from the patient

Volume Assist-control Ventilation


Settings: Rate, Inspiratory volume
* Patient may initiate spontaneous breaths, given same volume as
mandatory breaths

Minute ventilation = (mandatory + spontaneous breaths) x volume

Limitations:
Risk of volutrauma (safe plateau P=30-35 cmH2O)
Increasing rate > decreased expiratory time > may result in
incomplete exhalation (AutoPEEP)
Assist Control Ventilation
(ACV)
Pressure Assist-controlled
Ventilation (PCV)
Volume Assist-control Ventilation
Settings: Rate, Inspiratory pressure, I:E ratio (ie: 1:3)
* Patient may initiate spontaneous breaths, given
same pressure as mandatory breaths

Tidal volume limited by compliance

Limitations:
Lack of guaranteed tidal volume
Synchronized Intermittent
Mandatory Ventilation
(SIMV)
Settings: Rate, Inspiratory volume (volume SIMV) +/- PS
* Ventilator breaths synchronized with patient breaths
* Patient may initiate spontaneous breaths> not
supported, may have variable gas flow

Limitations: increases WOB, may fatigue weak respiratory


muscles
* May augment spontaneous breaths with pressure support
Pressure Support Ventilation
(PSV)
Settings: Inspiratory pressure (PS), PEEP
* Tidal volume dependent on compliance and
respiratory muscle strength
* PS may be weaned as compliance increases
* No set inspiratory time (time depends on flow-cycle-
usually 25%)

Limitations:
Cannot be used in patients without spontaneous
respirations
Unreliable tidal volumes
Comparisons of waveforms
Advanced Modes
Airway Pressure Release
Ventilation (APRV)
High continuous pressure (CPAP)
with intermittent release
Allows for spontaneous breathing
(+/- PS)

Advantage: maximizes alveolar


recruitment while allowing CO2
exchange during release

*Tidal volume related to driving


pressure and compliance

Limitations:
hyperinflation/barotrauma in COPD
Biphasic Ventilation (Bilevel)

Similar to APRV except


has longer lower P
phase> allows for
more spontaneous
breaths during release
phase
High Frequency Oscillatory
Ventilation (HFOV)
Ultra-fast (120-900
breaths/min) with low tidal
volumes
* Rescue mode for severe
ARDSkeeps alveoli open
while reducing barotrauma
* Improves hypoxemia

Limitations: very
uncomfortable (requires
sedation/neuromuscular
blockade), cant clear
secretions
Adjuncts

Prone positioning: may improve V/Q mismatch in


severe hypoxemia
Liberation
1. Reason for intubation needs to be
corrected (ie. MS, etc)
2. Maintain gas exchange without
support
FiO2<=50%
PEEP<=8
Able to maintain normocapnia
3. CV reserve

*Initiate a spontaneous breathing


trial (T-piece or CPAP)
Rapid shallow breathing index
RR/tidal volume(L) (<105 predictive of
successful extubation)
Review Questions
An artificial airway like an endotracheal tube is
used in the following type of ventilation

Positive Pressure
Negative pressure
One of the following modes of ventilation has the
risk of patient getting respiratory alkalosis

High Frequency Oscillatory Ventilation


Synchronous Intermittent Mandatory Ventilation
Assist Control Mode
Pressure Control Mode
The mode of ventilation which allows the patient
to breathe spontaneously at his or her own
respiratory rate and depth between the ventilator
breaths is

High Frequency Oscillatory Ventilation


Synchronous Intermittent Mandatory Ventilation
Assist Control Mode
Pressure Control Mode
Which one of the following modes of ventilation is
triggered by time, limited by pressure and affects
inspiration only?

High Frequency Oscillatory Ventilation


Synchronous Intermittent Mandatory Ventilation
Assist Control Mode
Pressure Assist Control Mode
There can be variations in the minute ventilation
in one of the following modes of ventilation as the
respiratory rate and tidal volume is determined by
patient

High Frequency Oscillatory Ventilation


Synchronous Intermittent Mandatory Ventilation
Pressure Support Mode
Pressure Assist Control Mode
Mrs. L is ventilated on pressure support with the
following settings:
Pressure support: 8
PEEP: 5
FiO2: 40%
Her respiratory rate is 14 breaths/min.
Her most recent blood gas is 7.42/40/52/26

What is the problem?


What should you do next?
Mr. R is ventilated on pressure support with the
following settings:
Pressure support: 8
PEEP: 5
FiO2: 40%
His respiratory rate is 11 breaths/min.
His most recent blood gas is 7.28/62/72/27

What is the problem?


What should you do next?
Thank you!

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