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MECHANICAL VENTILATION

Types of ventilator Systems

Negative Pressure Ventilator

Positive Pressure Ventilator


Negative Pressure Ventilator
Physiological processes with

ve insp. Pressure
+ve exp. Pressure
0 at end of insp. And exp.

Iron lung
Allows long-term ventilation without artificial airway
Maintains normal intrathoracic hemodynamics
Uncomfortable, limits access to patient

Positive Pressure Ventilator


Uses pressures above atmospheric pressure to push air into
lungs
Requires use of artificial airway
Types
Pressure cycled
Time cycled
Volume cycled

Positive Pressure Ventilator


Manual
non-invasive (bag and mask)
invasive (E. intubation)
Mechanical
constant (CPAP)

intermittent
o partially
(IMV)
o

complete (CMV)

combine (CPAP with IMV OR CMV)

Mechanical ventilation
Mechanical ventilation follows on from emergency airway management
and intubation and is needed to support the breathing of a patient in the
emergency situations .

Indications

For impending or established upper airway obstruction.


In acute respiratory failure

for oxygenation (hypoxaemia)


a PaO 2 <11 kPa (<85%) on 40% oxygen or higher
(PaO 2 < 8 kPa (<60mmHg) on FiO 2 >60%)
pneumonia including aspiration pneumonitis
pulmonary edema
asthma
chest trauma

for CO2 control ( hypercapnia)

PaCO 2 > 8 kPa (>60 mmHg) and pH <7.25


ICP control in head injury
hypercapenia respiratory failure.

For airway protection in the unconscious patient

overdose

intracranial problems.
For provision of anaesthesia before urgent surgery in the multiply
injured trauma patient.

Virtually all patients who have been intubated will be ventilated mechanically as
unassisted spontaneous breathing through an ETT is not appropriate

when is ventilation inappropriate?


Background of chronic severe respiratory disease with very poor
exercise tolerance (i.e. end-stage disease)

Progressive irreversible neuromuscular diseases (e.g. motor


neurone disease)

Underlying advanced or disseminated malignancy

Extensive stroke or intracranial haemorrhage (some of these


patients may be appropriate for consideration of organ donation at a
later stage).

The patient's wishes (if known) are taken into account along with
background detail including previous admissions to ICU, exercise
capacity and pre-existing quality of life.

In practice, for many patients the required information is not immediately


available and urgent ventilation is undertaken on empirical clinical
appearances.
For some patients, non-invasive ventilation or CPAP may be the first
intervention or can be made a ceiling of support.
In some hospitals, as part of the do not resuscitate policy there is also a
do not intubate decision.

Basic principles of ventilation


The principles of safe ventilation apply in resuscitation room practice, as
elsewhere:

The inspiratory phase is under positive pressure, whereas expiration is

passive

This reversal of intrathoracic pressure can have a major impact

on the circulation by reducing venous return and can lead to severe


hypotension and cardiac arrest.

Excessively high airway pressures should be avoided to minimize the risk

of barotrauma and hypotension

Adjustments to settings after starting ventilation are made gradually in

response to adequacy of gas exchange

Pulse oximetry indicates oxygenation continuously

Capnography indirectly reflects the arterial CO 2 level and clearance as

well as breath by breath monitoring of airway patency and disconnection

Arterial blood gas sampling more accurately indicates these gas

exchange parameters and needs to be done regularly when a patient is


first ventilated

Phases of intermittent gas flow with a mechanical ventilator

Inspiratory phase:
pressure generated (constant pressure)
flow generated (constant flow rate)
Inspiratory to expiratory change over cycling:

Time (I.T) (0.5-0.7 sec.)

Pressure (I.P) (15-20 CM H 2O ) (PIP 20-25 CM H 2O)

volume (T.V) (8-10 ml per kg) = flow rate (ml per sec) mutably insp.Time (sec.)

flow cycled (F.R) (40-80 l per min.)

Expiratory phase: passive

Expiratory to inspiratory change over cycling:


patient cycling
patient triggering

time cycling

The physiological inspiratory: expiratory ratio is 1:2.

Inspiratory to expiratory change


Time cycled
Terminates inspiration at preset inspiratory Time (0.5-0.7 sec.)

Volume cycled

Terminates inspiration at preset Tidal volume (8-10ml/kg)


Delivers volume at whatever pressure is required up t o
specified peak pressure (PIP 20-25 CM H O)
2

Volume setting by

Length of IT (0.5-0.7 sec.)

Pressure limit set (15-25 cmH2o).

Tidal volume(8-10 ml/kg) (that increased with increase flow


rate and insp.Time)

Pressure Cycled
Terminates inspiration at preset pressure(15-25 cmH2o)
(tidal volume) increase with increase preselected airway
Pressure and decrease with increase flow rate because early
high pressure occurrence.
Tidal volume(8-10 ml/kg)
(that increased with increase flow rate and insp.Time)

Types of mechanical ventilators


Both assist the patient by delivering compressed gases with positive
pressure.

pressure ventilators
Pressure ventilators terminate inspiration when a preset
Pressure is reached and therefore avoid excessive inflating pressures.
The usual pressure in an infant or child is (15-20 cm H2O)
They do not compensate for changes in lung compliance and deliver a
variable amount of gas with each breath
Currently are used predominantly in neonates and young infants.

A volume ventilator
Is delivers a preset volume of gas during each mechanical
inspiration.
This type of ventilator compensates for all changes in resistance.
The danger of volume ventilators is that they generate high airway
pressures, which can result in barotrauma.
The usual tidal volume in an infant or child is (8-10mL/kg)
The rate depends on the patient's age and the clinical condition.
Currently, they are used for children and older infants.

Both volume and pressure ventilators have the ability to


provide positive end-expiratory pressure (PEEP), which is
especially important in situations in which there is decreased
lung compliance.

The major side effect of excessive PEEP is


decreased venous return to the right side of the heart
and decreased cardiac output.

In the emergency department setting, PEEP is usually set at (3


to 5 cmH2O)

preemie

infant

child

adolescent

RR/min

40

30

20

12

IT sec.

0.4

0.6

0.7

0.9

PIP
cmH2o

16

20

20

20

TV ml/kg

5-10

5-10

5-10

5-10

PEEP
cmH2o

4-5

4-5

4-5

4-5

Fio2

titrate

down

As
tolerate

WHAT I:E RATIO (INSPIRATORY:EXPIRATORY RATIO)

1:2 typically used in a patient without severe lung problems


1:3-1:4 may be needed in asthma
1:1-2:1 used to aid lung recruitment in severe hypoxaemia.
Safe adjustment of I:E ratio
Inspiratory time is usually adjustable
Inspiratory pause time may be added on some machines.
The relationship between inspiratory time and set breath rate
can cause the I:E ratio to vary especially when using
pressure control. Example
10 breaths/min each breath is 6s long Insp. time= 2 sec. ,
Expi. time = 4 sec. , I:E = 1:2
Rate changes to 20 breaths/min each breath is now only 3s I
= 2s E is now only 1s I:E ratio 2:1.

characteristics of ventilation modes


control modes (VC, PC )

Patient does not participate in ventilations and must be incapable of

initiating breaths.

should be reserved for patients who are apneic.

A patient who is breathing spontaneously would be uncomfortable on

this mode of ventilation.

It deliver a set breath which is set by the physician.

If the patient breathes over the set rate, he or she will receive a fully

supported breath, regardless of how much effort is generated.

pressure control ventilation (pcv)

the machine generates the volume necessary to achieve the this


set pressure.

Here, the inspiratory time (0.5-0.7 sec.) and an inspiratory


pressure PIP (15-20 cmH2o) are set.

Also set Fio2 and PEEP


PCO2 is controlled by adjusting the respiratory rate and TV.
TV is directly proportional to P (PIP-PEEP).
As in Volume Control, you can adjust the FiO2, PEEP, and
inspiratory time to affect the pO2.
The delivered tidal volume is determined by the compliance of the
chest and airways resistance.
Setting the rate also determines the I:E ratio as the inspiration
time has been fixed
The I:E ratio may be set at 1:1 or inversely by at 2:1 if oxygenation is
poor .
the I:E ratio is kept at 1:3 used in situations such as asthma
where air trapping is a danger. Here,

A careful watch needs to be kept on tidal volume as it can


either go up or down very rapidly so Tidal volume alarms
must be set appropriately at (10 ml per kg).

Uses:
In neonates or patients with high airway pressures (ARDS) to
avoid barotrauma
.
Contraindications:
Not a friendly mode in the awake patient.

Advantages:
Pressure limited, decreases barotrauma risk.

Disadvantages:
No guaranteed TV.

volume control ventilation


Machine initiates inspiration, does work of breathing, controls
tidal volume and rate.

Theses ventilators work by delivering whatever pressure is


necessary to achieve a set volume.
Here, You can set the respiratory rate(15/min) , inspiratory time
(0.5-0.7 sec.) and and tidial volume (8-10 cmH2o) . Also set Fio2 and
PEEP
To control the pO2 you can adjust the FiO2, the PEEP, and the
inspiratory time.

PCO2 is controlled by adjusting the tidal volume and the rate.

Useful in children and older infants whose apneic or heavily


sedated Or neuromuscular paralysis and when inspiratory effort
contraindicated (flail chest)

Intermittent mandatory ventilation


was initially developed as a means of weaning patients from CMV back
to total spontaneous respiration.
pressure or volume modes.
During IMV, mechanical breaths are delivered at a preset frequency
(time triggered) No patient interaction.
In between mechanical breaths, the patient is allowed to breathe
spontaneously but The ventilator does not deliver a controlled breath
during spontaneous breathing.
IMV is thought to have a number of benefits.
First, it decreases the amount of positive pressure to which the lung is
subjected.
It has been suggested that this will decrease the impedance of venous
return to the right heart associated with positive pressure ventilation.
Uses:
Commonly for neonates.
Contraindications:
uncomfortable
Advantages:
Regular breaths guaranteed.
Disadvantages:
Patient is not allowed to breathe with the ventilator, i.e. doesn't work
with the patient.

Assist mode ventilation

mechanical breaths are initiated by the patient's spontaneous

respiratory effort.

The ventilator accomplishes this by sensing a change in


circuit pressure or gas flow (pressure or flow triggered).

This mode allows the patient to interact ventilator.

That is, the ventilator is responsive to the patient's needs in a

synchronous fashion. with the It may be used for fully awake


intubated patients.
The assist mode should not be used with apneic patients
because no respiratory support would be afforded.

Assist/control mode ventilation

The ventilator will deliver a controlled breath at a preset


time interval or when it detects a patient-initiated breath.

This combination of assisted and controlled breaths offers the

advantages of both modes.

It allows the patient to interact with the ventilator, thereby serving

the patient's respiratory needs.

Should the patient become apneic or too weak to initiate


a mechanical breath, the ventilator would continue to provide
support in the form of controlled breaths triggered by a period of
apnea.

synchronized intermittent mandatory ventilation


Synchronized intermittent mandatory ventilation (SIMV) is similar to IMV
except that mechanical breaths are triggered by the

patient's respiratory effort instead of being time triggered.


If no effort is detected during a preset time interval, a controlled breath is
delivered.
usually used with pressure support Like IMV, the patient breathes
spontaneously between ventilator breaths with advantage that it allows the
patient to interact with the ventilator to a greater degree and thus allows
the patient to be more comfortable while on the ventilator.
If a high enough rate is selected, this mode is similar to the assist/control
mode.
Can be used as a weaning mode .

Disadvantages:
Any other breaths during cycle are not supplemented.

Synchronized intermittent mandatory ventilation (SIMV). At set intervals, the


ventilator's timing circuit becomes activated and a timing "window" appears
(shaded area). If the patient initiates a breath in the timing window, then the
ventilator will deliver a mandatory breath.
If no spontaneous effort occurs,then the ventilator will deliver a mandatory breath a fixed time
after the timing window.

pressure support ventilation


Pressure support ventilation (PSV) is pressure triggered, pressure
limited, and flow cycled.
This means that mechanical breaths are initiated by the patient's
spontaneous effort. The ventilator then delivers a preset pressure
into the circuit.
This pressure can be set to provide any fraction of the total
respiratory support needed by the patient.
The ventilator cycles to exhalation when the flow in the circuit decreases
below some preset level 25% less than peak.
This allows the patient to determine the length and volume of the
delivered breath.
used to support spontaneous breathing and a weaning mode
Contraindications: Patient who is not spontaneously breathing.
Advantages: Helps overcome resistance of the ET tube, making
spontaneous breathing easier.
Disadvantages: Can be uncomfortable for small patients, need to have
appropriate sensing.

Typical support pressure is 10-15 cm H 2O to achieve a tidal


volume of 8-10 mL/kg

PEEP is also usually set: 5cm H 2O typical

Peak inspiratory pressure (PIP) (15-20cm H 2O)

= pressure support (10-15cm H 2O) + PEEP (5cm H 2O)

The breath is terminated when the inspiratory flow drops (usually to


25% of peak).

All breaths are patient triggered if patient breathing is not detected after

a set time interval (usually 20-30s), the machine alarms and a backup
apnoea mandatory ventilation kicks in.

When used with SIMV , the patient receives mandatory breaths but

spontaneous breaths in between are augmented by pressure support

Components of a pressure-support breath.


Point A is the patient's effort indicated by anegative deflection.
When the ventilator senses this trigger (change in pressure or flow), it will
deliver flow to reach the desired pressure-support level
(Point B) as rapidly as possible.Ventilator-delivered flow is then servo-adjusted to
patient demand to maintain this pressure plateau
(Point C). Inspiration is terminated when a minimal flow criterion is reached (25%

of peak)
(PointD ) and airway pressure returns to baseline.

PEEP
5cm H O is typical
10cm H O for lung recruitment as described above, can be
2

higher in

specialized situations

In asthma and COPD, PEEP is set at zero or worsening air trapping

can occur.

Effects of positive end-expiratory pressure

Increased alveolar recruitment


Increased functional residual capacity
Minimizes intrapulmonary shunt
Redistribution of pulmonary blood flow
Redistributes lung water from alveoli to interstitium: increased
extra-vascular lung water

Reduced cardiac output


Pulmonary barotrauma.

relative contraindications to peep

Hypotension

Right heart failure


Raised intracranial pressure
Right to left intracardiac shunts
Asymmetrical or focal lung disease
Bronchopleural fistula

VENTILATOR SETTINGS
WHERE TO START: INITIAL VENTILATOR SETTINGS
Obviously, the individual patient and clinical setting will determine
the mechanical ventilation needs, but the following is a good place
to start, realizing that the settings will most likely require adjusting
to achieve the desired effect

Safety checks
Most machines will be left ready to switch on and go but preliminary
checks are always needed before connecting to the patient

Oxygen (and possibly air) hose connected to wall socket outlets or

oxygen cylinder with Schrader valve socket.

Mains electricity cable connected?


Battery charged?
Patient breathing circuit connected and leak tested?

(some are permanently fitted, others are disposable single use)

Bacterial filter connected to circuit?


Alarms working and correctly set?
Monitoring equipment available and working?
Capnograph for paco2
Oxygen analyzer
Pulse Oximetry and ECG and blood pressure device connected
to the patient

VENTILATOR-USER INTERFACE
Primary controls
Mode
Rate
Tidal volume or pressure
Flow or inspiratory time
PEEP

FiO2

Secondary controls
Pause: in volume mode (0.25-2 sec.)
Sigh.: in volume mode that increase volume to tidial volume

Alarms

Monitored parameters
Pressure
Volume
Waveforms.

INITIAL VENTILATOR SETTINGS

Set "Assist/SIMV with Trigger Sensitivity": (-2 cm H 0)


2

Insp. Time (0.5sec.)


Obstructive disease requires longer expirations( 1:3)
Restrictive disease requires longer inspirations (2:1)

I:E Ratio 1:2 is good starting point

Respiratory rate--initially (10 to 16/minute)


Tidal volume 8-10 ml/kg (std = 12 ml/kg)
Peak airway pressure limits (20-25 cm H2o)
Insp. Flow rate (40-80 l per min)

FiO 2 (0.4 - 0.6) depending on disease process


100% causes toxicity and atelectasis in less than 24 hr
40% is safe indefinitely
PEEP(5 CM H2O) can be added to stay below 40%
Goal is to achieve a (PaO 2 >60%)

PEEP 24 cm H2O
Temperature ,Humidity and Sighs adjustments

QUICK GUIDE TO SETUP

Self check and/or Calibration as needed

Check circuit and connections

Set Mode and Assist/SIMV Sensitivity"

Adjust "I" time

Set tidal volume

May need to set "Flow" based on "I" time

Set ventilatory rate

Set PEEP

Set "Set pressure alarms

Assess patient to confirm ventilation function

Monitor vital signs

Pulse oximetry (waveform)

Capnography (waveform)

CAUSES OF VENTILATOR ALARMS

Disconnection
Pressure development outside the pre-set range
Leakage
Reducing compliance
Partial airway obstruction
Gas supply failure
Power failure

Reduction of FiO
Apnoea

CONNECTING THE PATIENT TO THE MACHINE

Ventilation after intubation will initially by hand with abreathing


circuit or a self-inflating bag;

With appropriate settings, and after confirming correct operation,


the ventilator circuit is attached to the catheter mount from the ETT.

The capnograph must be in the patient circuit.


Watch for chest movement and the appropriate capnograph
waveform and end-tidal CO level.
2

The ventilator should display appropriate exhaled tidal volume


and airway pressures

SUBSEQUENT VENTILATORY SETTING


Assesse oxygenation
Look colour and pso2 and pao2
If poor oxygen with( pso2< 90%) and (pao2 < 60mmHg) So increase
oxygen concentration And CPAP (PEEP) (but not > 7)

Assesse ventilation

By look chest expansion and paco2

If poor with high paco2 so increase RR mainly if with lower chest


expansion Or increase tidal volume (insp. Time and flow rate ) mainly if
with high chest expansion

Asses work of breathing


Must be normally with absent retraction and normal resp.rate and good
coordination

WEANING FROM VENTILATION

Mean Gradual withdrawal of mechanical ventilation

May be within few days as in pneumonia or bronchiolitis

Or for several weeks in BPD and resp. muscle paralysis


When start

If improve condition and stable oxygen saturation and ABG


stable cardiovascular system (may be on low dose inotropes
however)
normal electrolytes and haemoglobin concentration
free from infection
free from pain

How

Gradually one parameter change with clinical and lab.


evaluation If normal then next change

WEANING CRITERIA

normal Pa CO2 (for that child)

PaO2 >8 kPa (>60mmHg) on FiO2 0.4

pH >7.3

vital capacity 10-15 ml/kg

tidal volume 4-5 ml/kg

peak negative pressure >20 cm H2O

spontaneous minute ventilation <10 l/min

GUIDELINE OF WEANING
Change mode (CMV TO IMV or SIMV or SMV)
Stop sedition
Decrease vent. rate

Decrease minute ventilation ( T.V X R.R) (to <10 l/min)


lower insp. Time ,flow rate and lower vent. Rate by 3-4 rate per min.

Lower oxygen

By lower PEEP to 3-4 cmHg

Lower oxygen concentration to 40-50%

Switch ventilator to CPAP with (3-4 cmHg) and oxygen to 40-50% in older
children

Extubation
hyper oxygenation with bag through tube immediately before remove tube by
applying pressure and give oxygen with concentration 10% higher than that of
CPAP (50-60%)
And be already for reintubation if detoriatiated

COMPLICATIONS OF INTUBATION AND MECHANICAL VENTILATION


Equipment

Malfunction or disconnection

Incorrectly set or prescribed

Contamination

Pulmonary

Airway intubation (e.g. damage to teeth, vocal cords, trachea)

Ventilator-associated pneumonia (reduced lung defense)

Ventilator-associated lung injury (e.g. diffuse lung injury due to


regional overdistension or tidal recruitment of alveoli)

Overt barotrauma (e.g. pneumothorax)

O2 toxicity

Patient-ventilator asynchrony

Circulation

Low Right ventricular preload and cardiac output

High Right ventricular afterload (if the lung is overdistended)

Low Splanchnic blood flow with high levels of positive end


expiratory pressure (PEEP) or mean Paw

High Intracranial pressure with high levels of PEEP or mean Paw

Fluid retention due to low cardiac output low renal blood flow

Other

Gut distension (air swallowing, hyomotility)

Mucosal ulceration and bleeding

Peripheral and respiratory muscle weakness

Sleep disturbance, agitation and fear (which may be prolonged


after recovery)

Neuropsychiatric complications

MANAGEMENT VENTILATOR COMPLICATIONS

Airway malfunction

Suction patient as needed

Keep condensation build-up out of connecting tubes

Auscultate chest frequently

End tidal CO monitoring

Maintain desired end-tidal CO2

Assess tube placement

Mechanical malfunction

Keep all alarms activated at all times

BVM must always be available

If malfunction occurs, disconnect ventilator and


ventilate manually

Pulmonary barotrauma

Avoid high-pressure settings for high-risk patients (COPD)

Monitor for pneumothorax

Anticipate need to decompress tension pneumothorax

Hemodynamic alterations

Decreased cardiac output, decreased venous return

Observe for:

Decreased BP

Restlessness, decreased LOC

Decreased urine output

Decreased peripheral pulses

Slow capillary refill

Pallor

Increasing Tachycardia