Presented by : Dr.
Himanshu Jangid
Patients requiring mechanical ventilation :
1. Ventilatory Failure : Pt Minute ventilation cannot
keep up with CO2 production.
2. Oxygenation Failure : Pt’s pulmonary system cannot
provide adequate oxygen for metabolism.
1. ed Airway Resistance
2. Changes in Lung Compliance
3. Hypoventilation
4. V/Q Mismatch
5. Intrapulmonary Shunting
6. Diffusion Defect
In Mechanical Ventilation it Depends upon:
Length Airway
Size ET Tube
Patency Ventilator Circuit
Obstrution in airway:
1. Inside the Airway( e.g. Retained secretions)
2. In the Wall of Airway( e.g. Bronchial muscle
Neoplasm)
3.Outside the Airway(e.g. Tumour Compression)
Poiseuille’s Law : P= V
r4
Resistance in ET Tube:
Directly Proportional to: Length.
Inversely Proportional to : Diameter and Patency.
Resistance by Ventilator Circuit:
Amount of water in circuit due to condensation
Clinical conditions:
1. COPD : Emphysema
Chronic Bronchitis
Asthma
Bronchiectasis
2. Mechanical obstruction : Postintubation Obstruction
Foreign Body Aspiration
Endotracheal Tube
Condensation in Ventilator
3. Infection : Laryngotracheobronchitis
Epiglottitis
Broncholitis
Airway Resistance(Raw) = ∆P
V
∆P = Pressure change(Peak Inspiratory Pressure – Plateau
Pressure)
V = Flow
Increased Raw = Increased work of breathing.
Obstructive Disorders = Deeper and Slower
Breathing.
Restrictive Disorders = Shallow and Faster
Breathing.
Defination: Degree of lung expansion per unit pressure
change.
C = ∆P
∆V
Low Compliance(high elastance) :
Stiff or Noncompliant lungs.
High amount of work of breathing.
Can be responsible for Refractory Hypoxemia.
Occurs in Restrictive Lung diseases.
Low lung volumes and Low minute ventilation.
Increased Respiratory Rate.
High Compliance :
Increased FRC.
Occurs in Obstructive Lung diseases.
Incomplete Exhalation.
Lack of elastic recoil.
Emphysema: Chronic air trapping
Destruction of lung tissue
Enlargement of terminal and respiratory bronchioles
Impaired gas exchange
VT
LITERS
0.6
0.4
0.2
Paw
cmH2O -60 40 20 0 20 40 60
Mandatory Breath
VT
LITERS
0.6
0.4
Inspiration
0.2
Paw
cmH2O -60 40 20 0 20 40 60
Mandatory Breath
VT Counterclockwise
LITERS
0.6
Expiration
0.4
Inspiration
0.2
Paw
cmH2O -60 40 20 0 20 40 60
Pressure-Volume Loop Changes
VT
LITERS
0.6
0.4
0.2
Paw
-60 -40 -20 0 20 40 60
cmH2O
Changes in Compliances
Indicates a drop in compliance
VT (higher pressure for the same
LITERS volume)
0.6
0.4
0.2
Paw
-60 40 20 0 20 40 60
cmH2O
Static Compliance:
Measured when there is no air flow.
Airway resistance is not a determing factor.
Reflects the elastic resistance of lungs and chest wall.
Dynamic Compliance:
Measured when air flow is present.
Airway resistance is a critical factor.
Shows both the airway resistance and elastic
resistance.
1.Obtain corrected expired tidal volume.
2.Obtain Plateau Pressure by applying inspiratory hold
or occluding the Exhalation port at end expiration.
3.Obtain Peak Inspiratory Pressure.
4.Obtain Positive End Expiratory Pressure(PEEP) level.
Static Compliance :
Corrected Tidal Volumae
(PleateuPressure – PEEP)
Dynamic Compliance :
Corrected Tidal Volume
(peak Inspiratory Pressure – PEEP)
Static Compliance : Atelectasis
ARDS
Tension pnemothorax
Obesity
Retained Secretions
Dyanamic Compliance: Bronchospasm
Kinking of ET Tube
Airway Obstruction
Anatomical Dead space:
The volume of conducting airways which doesn’t take
part in gas exchange.
About 1ml/lb in ideal body weight.
ed Tidal volume = Increase in anatomic dead space %
Example: 150/500 = 0.3 or 30%
150/300 = 0.5 or 50%
Aleoolar Deadspace :
When a % of alveoli ventilated are not adequately
perfused.
Causes:
Decreased Cardiac Output
Obstruction of pulmonary vessels
Physiologic Deadspace :
Anatomic + Alveolar Deadspace
In Normally , PhysioDS = Anatomic Deadspace
Physiologic Deadspace to tidal volume ratio can be
calculated by :
V(d) = PaCO2 – PeCO2
V(t) PaCO2
PaCO2 = Arterial CO2, PeCO2 = Mixed expired sample
V(d)/V(t) < 60% predicts normal ventilatory function
upon weaning from mechanical ventilation.
Inability to maintain proper removal of CO2 from
lungs.
Five mechanisms:
1. Hypoventilation
2. Persistent V/Q mismatch
3. Persistent Intrapulmonary Shunting
4. Persistent Diffusion Defect
5. Persistent reduction of inspired oxygen tension.
Causes:
CNS Depression
Neuromuscular diseases
Airway obstruction
Characterized by :
Decreased Alveolar Ventilation
Increased Arterial CO2 Tension
Alveolar Volume:
Volume of tidal volume that takes part in gas
exchange.
Va = V(t) – V(d)
Proportional to Tidal volume
Inversely proportional to Deadspace volume
Minute Alveolar Ventilation:
Va = (Vt – Vd) x RR
Amount of Ventilation
Amount of Perfusion
V/Q Ratio = 0.4 ( in lower lung zone) Because of Gravity
= 0.3 ( in upper lung zone)
V/Q Ratio Pulmonary Embolism
V/Q Ratio Airway Obstruction
ILD
Hypoxemia due to mismatch can be corrected by :
Increasing the Rate , Tidal volume and FiO2 on ventilator.
Shunting refers to perfusion in excess of ventilation.
Causes Refractory Hypoxemia
Poor response to O2 Therapy
Normally;
Physiologic Shunt = Anatomic Shunt < 5%
NonCritical Patients = < 10%
Critical Patients = > 30%
Estimated Physiologic Shunt Equation :
NonCritical pts :
Estimated Qsp = ( CcO2 – CaO2)
Qt 5 + ( CcO2 – CaO2)
Critical pts : Estimated Qsp = ( CcO2 – CaO2)
Qt 3.5 + (CcO2 – CaO2)
Classical PS Equation:
Classic Qsp = CcO2 – CaO2
Qt CcO2 – CvO2
Decrease P(A-a) gradient High Altitude
Fire Combustion
Thickening of A-C membrane Pul. Edema
Retained secretions
Decrease surface area of A-C Emphysema
membrane Pul. Fibrosis
Insufficient time for diffusion Tachycardia
Hypoxemia :
Reduced O2 in blood.
PaO2 :
Reflects the dissolved O2 in blood not that carried by
hemoglobin.
Precise measurement by Oxygen Content ( CaO2).
Hypoxemia Levels in term of PaO2
Normal 80 – 100 mmHg
Mild 60 – 79 mmHg
Moderate 40 – 59 mmHg
Severe < 40 mmHg
Hypoxia :
Reduced O2 in Organs and tissues.
Can occur with a normal PaO2.
Four types :
1. Hypoxic Hypoxia
2. Histotoxic Hypoxia
3. Stagnant Hypoxia
4. Anemic Hypoxia
Three Distinct Groups:
1.Depressed Respiratory Drive
2.Excessive Ventilatory Work load
3.Failure of Ventilatory pump
Depressed Respiratory Drive :
Drug Overdose
Acute Spinal cord injury
Head trauma
Neurological Dysfunction
Sleep Disorders
Metabolic Alkalosis
Excessive Ventilatory Work load :
Acute Airflow Obstruction
Deadspace ventilation
Acute Lung Injury
Congenital Heart Diseases
Cardiovascular decompensation
Shock
Increased Metabolic Rate
Decreased Compliance
Drugs
Failure of Ventilatory pump:
Chest Trauma
Premature Birth
Electrolyte Imbalance
Geriatric Patients
Thank You
