Physiology of Mechanical Ventilation

Physiology of Mechanical
Ventilation
Dr Baswaraj T
 To know the basics of pulmonary
mechanics and initiation of
breathing
 Application of the knowledge of
physiology to clinical situations and
planning ventilatory strategies
Lung Mechanics : A
Balance between two
forces
Compliance : Distensibility
(stretchability):
Ease with which the lungs can expand
Responsible for inspiration
Elasticity :
Tendency to return to initial size after
distension
Recoil ability
Elasticity : Stroma of lungs and respiratory
muscles
Lung Compliance
 Volume change per unit change in
pressure
Volume Change (V)
Compliance (C) =
Pressure Change (∆
P)
 Low or High – Inefficient gas

exchange
Compliance curve is
sigmoidal
Low Compliance (High
elastance)
 Stiff / Non-compliant
 Work of breathing – ↑
 ↓FRC
 ↓LV, ↓ MV, Restrictive lung defect
 Refractory hypoxemia
 Eg:
 Atelectasis, ARDS, Tension pneumothorax, Retained
secretions
 Bronchospsam, Kinked ETT, Airway obst
High Compliance
 Incomplete exhalation & CO2
elimination
 ↑FRC, Obst lung defect
 Eg:
 Emphysema
Compliance & Work of
Breathing
 Compliance is inversely related to
pressure change (Work of
breathing)
 Hypoventilation: Unable to
compensate for ↓ compliance by ↑ and
maintaining a higher level of work of
breathing
Surface Tension and
Surfactant…
 Force exerted by fluid in alveoli to
resist distension
 Lungs secrete and absorb fluid,
leaving a very thin film of fluid which
causes surface tension
 Surfactant lowers surface tension by
reducing attractive forces of
hydrogen bonding by becoming
interspersed between H20 molecules
Law of Laplace…
 Pressure in alveoli is directly
proportional to surface
tension; and inversely
proportional to radius of
alveoli
 Higher Pressures required to
keep open the smaller alveoli
of preterm neonates with high
surface tension
Pressure : Volume Loops…
Normal lungs Slope = Compliance
Volume
RAD
Pressure
Airway Resistance
 Airflow obstruction in the airways
 Length, Size & Patency of Airways,
ETT & Vent circuits
 Factors affecting:
 Inside - Secretions
 Wall – Neoplasm
 Outside - Lymphnodes
Airway Resistance
 Simplified form of Poiseuille’s Law:
∆P= V
r4
 Normal Raw : 0.6 & 2.4 cm H20/L/sec
at a flow rate of 30 L/min
 Varies directly with length & inversely
with the diameter of the ETT
 Vent Circuit – Condensed water
Increased airway
resistance
TYPE CLINICAL CONDITION
COPD Emphysema
Chronic bronchitis
Asthma
Bronchiectasis
Mechanical Obstruction Post intubation obst
FB aspiration
ET Tube
Condensatation in vent circuit
Infection LTB
Epiglottitis
Bronchiolitis
Raw & Work of Breathing
Pressure (∆ P)
Raw =
Flow (V)
 Pressure change (Peak – Pleatu) =

Work of breathing
 Ventilatory & Oxygenation failure
Time Constant
 Kt = CL X R (sec)
 Time taken for transthoracic pressure

change to be transmitted as volume change
in the lungs
 Measure of how quickly the lungs can inflate
or deflate or how long it takes for alveolar &
proximal air way pressures to equilibrate
Time Constant
 1 TC : The it takes the

alveoli to discharge 63% of 95% 98% 99%
100
its VT through the airway to 86%
Change in pressure (%)

80
mouth or vent circuit 63%
60
 3 to 5 time constants : 40
requires for near-total 20
inflation or deflation of the 0
lungs 0 1 2 3 4 5 Time
Time Constants
Time Constant
 3 to 5 Kt = 0.36 to 0.6 sec – should be
the inspiratory / expiratory phase
 Very short Ti : Incomplete delivery of
tidal volume
 Very short Te : Inadvertent PEEP, Gas
trapping
Time Constant
 Restrictive diseases (eg., Atelactesis):
 Low compliance
Shorter
 Shorter time constant Ti
 Inflation/deflation faster than normal lungs
 Tolerate rapid rates without compromising minute ventilation
 Obstructive diseases (eg., Asthma) :

 High resistance
Longer Te
 longer time constants – & Low
 To avoid gas trapping PEEP
What is Mechanical
Ventilator
 Complex system
consisting:
 Power supply,
 Compressed air and oxygen,
 A drive mechanism to provide
motive force to push oxygen
into the patient’s lungs and
 A control mechanism to
manage the gas flow, volume,
pressure and timing
What is Mechanical
Ventilator
 Simply, any machine to push or pull gas
mixer ( air & oxygen) into the lungs.
 By applying positive pressure at the airway
either invasively or non invasively ( positive
pressure ventilation)
 Negative pressure around the chest
( negative pressure ventilation)
21
Anatomy of ventilator
O2
Air
Blender
Expiratory valve
Inspiratory limb Expiratory limb
To Patient
22
Ventilator : Terminologies
 Tidal Volume : Volume of gas that flow in and out of the chest during
quiet breathing (7-10 ml/Kg).
 Respiratory Rate (RR): The frequency of breaths delivered by

the ventilator
 Peak Inspiratory Pressure (PIP): Highest pressure that is met

during inspiration
 Positive End Expiratory Pressure (PEEP) : Pressure at the end of

expiration to prevent alveolar atelectasis
23
Ventilator : Terminologies
 Inspiratory Time : Time of inspiration : 0.45 – 0.60
 I:E Ratio: Relationship between inspiratory time (I) and

expiration time (E). The normal ratio 1:1.5 to 1:2.
 Sensitivity: Used to determine the patient’s effort to

initiate an assisted breath (inspiration)
 Minute Volume (MV): Determines alveolar ventilation

(RR x VT = MV)
Typical vent settings
 FIO2
 Rate
 Volume
 PIP and PEEP
 Flowrate, I-time, I:E Ratio
 Mode ???
Different brands of ventilators have different

control layouts, but they all accomplish
essentially the same functions.
Guidelines for Initiating Positive
Pressure Ventilation
 Select Rate – physiologic norm for age.

 Select tidal volume: 10 – 15 ml/kg (volume controlled)
 Select PIP:15 – 25 cm H2o (pressure controlled).
 Select inspiratory time: 0.40 to 0.50 Secs.
 I:E Ratio: 1:1.2 or 1:1.3
 FiO2: 60 to 100%
 PEEP: 3 cm or higher as needed
26
Summary
 Compliance is reduced at both high and low lung
volumes : Do not overstretch a spring
 Resistance is higher in narrower and longer airways
(Poiseuille’s law ) : Select appropriate ETT Size &
Cut short any extra lengths of ET
 Normal time constant is 0.12 sec : Min Ti or Te
should be 0.36 sec
 Restrictive diseases : Shorter Ti
 Obstructive diseases : Longer Te

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Physiology of Mechanical

 Low or High – Inefficient gas

 Pressure change (Peak – Pleatu) =

 Time taken for transthoracic pressure

 1 TC : The it takes the

Change in pressure (%)

 Obstructive diseases (eg., Asthma) :

Inspiratory limb Expiratory limb

 Respiratory Rate (RR): The frequency of breaths delivered by

 Peak Inspiratory Pressure (PIP): Highest pressure that is met

 Positive End Expiratory Pressure (PEEP) : Pressure at the end of

 I:E Ratio: Relationship between inspiratory time (I) and

 Sensitivity: Used to determine the patient’s effort to

 Minute Volume (MV): Determines alveolar ventilation

Different brands of ventilators have different

 Select Rate – physiologic norm for age.

 PEEP: 3 cm or higher as needed

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