Technical Training Course

Anesthesia Delivery and Ventilation

Introduction to Ventilation

Casa Plarre, México D.F. – January 24/28th 2011

Ventilator
• The ventilator is the heart of the
anesthesia system.
• The function of the ventilator is to provide
the patient with a measured delivery of gas
at a selected breathing rate.
• All the ventilators designed and
manufactured by Spacelabs meet these
simple parameters, while offering more
advanced options allowing the patient to
take some responsibility for triggering these
breaths via selected modes.
• Oxygen and expired volume are
monitored. Most models offer a choice of
waveforms.
Ventilation
Parameters
TIME

May be divided into inspiratory (I) and expiratory (E)
periods and is expressed in seconds or by the relation
of inspiratory time to expiratory time expressed as an
I/E ratio

Used to define the number of respiratory cycles
within a given period of time

VOLUME

A measure of the Vt delivered by the ventilator
to the patient

Reflects the volume of gas the patient breathes

Is usually expressed in ml for VT and in L
for minute volume
Ventilation
Parameters
PRESSURE

A measure of the impedance to gas flow rate
encountered in the ventilator breathing circuit and the
patient’s airways and lungs

Refers to the amount of pressure generated as a result
of airway resistance and lung-thorax compliance

Is expressed in cm H2O, mmHg, or Kilopascals (kPa)
(1mmHg = 1.36 cmH2O, 7.6mmHg = 1 kPa)

FLOW RATE (this becomes significant in Lo flow ventilation)

A measure of the rate at which the gas volume is
delivered to the patient

Refers to the volume change per unit time

Is expressed as L/sec or L/min
Ventilation
Phases
60
Limit Cycling
Paw
cmH20 SEC
1 2 3 4 5 6
-20 Base
Triggering

120
INSP

Flow SEC
L/min 1 2 3 4 5 6

120 EXP
Ventilation
Phases - Cycling

How the ventilator switches from inspiration to
expiration: the flow has been delivered to the volume
or pressure target
- Time cycled – the ventilator cycles to expiration
once a set time is reached

such as in pressure controlled ventilation
- Flow cycled– the ventilator cycles to expiration once
a set flow is reached

such as in pressure support
- Volume cycled - the ventilator cycles to expiration once
a set tidal volume has been delivered: this occurs in
volume controlled ventilation. If an inspiratory
pause is added, then the breath is both volume
and time cycled
Ventilation
Phases - Triggering
What causes the ventilator to cycle to inspiration.
Ventilators may be time triggered, pressure
triggered or flow triggered.
Time: The ventilator cycles at a set
frequency as determined by the
controlled rate.
Pressure: The ventilator senses the patient's
inspiratory effort by a decrease in
the baseline pressure.
Flow: Modern ventilators deliver a constant
flow around the circuit throughout the
respiratory cycle (flow-by). A
deflection in this flow by patient
inspiration, is monitored by the
ventilator and it delivers a breath.
This mechanism requires less work by
the patient than pressure triggering.
Ventilation
Flow Pattern
Constant V Constant Flow

Decelerating V
Decelerating Flow

T
Ventilation
Flow Pattern
Constant V Constant Flow
Flow continues at a
constant rate until the
set tidal volume is
T
delivered. Can cause
sustained high Paw
Ventilation
Flow Pattern
Decelerating V
Decelerating Flow
The flow pattern seen in
pressure targeted ventilation:
inspiration slows down as
alveolar pressure increases T
(there is a high initial flow).
Most intensivists and
respiratory therapists use this
pattern in pressure targeted
ventilation also, as it results in
a lower peak airway pressure
than constant and
accelerating flow, and better
distribution characteristics
Ventilation
Control
So, how does the ventilator know how much
flow to deliver?

Volume Controlled
(volume limited, volume targeted)
and Pressure Variable

Pressure Controlled
(pressure limited, pressure targeted)
and Volume Variable
Modes of Ventilation
Ventilation
Modes
Modes of ventilation describes the primary
method, how machine generates and
regulates the flow of gas into the lungs
Ventilation
Modes

Spontaneous Breathing

Controlled Modes: Volume Controlled Ventilation:
- Ventilator is active and patient is passive

Ventilator provides all breaths to the patient & does all work
necessary to maintain effective alveolar ventilation
1) VCV
2) PCV

Assisted Modes:
- Patient initiates and may or may not participate
the breath

Ventilator provides partial support while the patient must
do some or most of the work of breathing
1) SIMV - Synchronized Intermittent Mandatory Ventilation
2) Pressure Support Ventilation (PSV)
Ventilation
Types of Breath
What Causes the Ventilator to Cycle
Mandatory (controlled) - which is
determined by the
respiratory rate
Assisted (as in assist control,
synchronized intermittent
mandatory ventilation,
pressure support)
Spontaneous (no additional assistance
in inspiration)
 Ventilation
Modes Pattern
There Are Only A Few Different Modes of Ventilation:

VCV Volume Controlled Ventilation, without allowances for

spontaneous breathing. All anesthesia ventilators
operate in this way
Pressure Control Ventilate to a pressure rather than a
volume
Intermittent Which mixes controlled breaths and spontaneous
Mandatory breaths. Breaths may also be synchronized to
Ventilation prevent "stacking"
Pressure Where the patient has control over all aspects of
Support his/her breath except the pressure level
High Frequency Where mean airway pressure is maintain constant
Ventilation and hundreds of tiny breaths are
delivered per minute
 Modes of Ventilation
Volume Controlled Ventilation
• VCV
• Ventilation mode where the ventilator delivers a SET
tidal volume
• Most commonly used in Anesthesia
• Airway pressure is measured to “see” changes in
patient lungs
• No matter the pressure needed (up to pressure limit)
ventilator will deliver the set volume
• Constant flow is used
• May have an Inspiratory Pause (within I time)
 Modes of Ventilation
Volume Controlled Ventilation

Start of Breath (Trig)  Patient or Ventilator
(controlled or assisted)

Limiting parameter (Lim)  Flow (flow pattern)

End of Breath signal (Cyc)  Set TV delivered

Dependant Variable  Peak Pressure (depends on

patient’s airway and lung condition)
Modes of Ventilation
Volume Controlled Ventilation

Constant Flow Pattern:
- Airway pressure affected by the compliance and
resistance

Advantages:
- Minute Volume is controllable.
- Well-known technique

Disadvantages:
- The constant flow during beginning of inspiration
may cause High Peak Pressure
- Gas distribution is not optimal
- Patients with lung disease
- Pediatrics
Modes of Ventilation
Volume Controlled Ventilation

Tplat

Vmax

Tinsp
Constant Flow

1 Flow Time Section

2 Plateau
3 Expiration Time
Modes of Ventilation
Volume Controlled Ventilation

- Main Parameters - Additional Parameters

Tidal Volume (ml)
Tp% = Inspiratory Pause (0-50% of

Respiratory Rate (BPM) Ti)

I:E Ratio (1:X)
Pressure Limit (cmH2O)

PEEP
Modes of Ventilation
Pressure Control Ventilation

Definition:
- Is a ventilation mode which generates a constant
inspiratory pressure at the airway regardless
respiratory mechanics of the patient.
- Flow delivery from the ventilator mainly depends
on patient’s respiratory mechanics
- Ventilator should reach target pressure as soon
as possible, maintaining that pressure over the
inspiratory time.
 Modes of Ventilation
Pressure Control Ventilation

- Parameters

Target Pressure (Pset) in cmH2O

Inspiratory time (Ti) in secs. or I:E Ratio

Respiratory Rate in breaths/min

PEEP Level in cmH2O
Modes of Ventilation
PCV vs. VCV
PCV VCV
Pressure

Pset + PEEP

PEEP
Flow
Volume

Vt

Ti Te Time
Modes of Ventilation
PCV vs. VCV

With PCV less pressure is required in order to deliver the

same amount of volume to a patient lung

Safer volume delivery without high peak alveolar pressure

Even volume distribution within the lung

Ability to fill “slow” alveolar units increasing inspiratory time.

Auto-PEEP will not increase alveolar peak pressure, less
barotrauma risk.

Leaks don’t diminish volume delivery to the patient (automatic
compensation)

Able to use in every patient (neonate to adult)
Modes of Ventilation
Synchronized Intermittent Mandatory Vent

SIMV is a ventilation mode where there are two different
breath types:
- Mandatory: Usually volume target breaths (may include
other type)
- Spontaneous:

Totally spontaneous: patient breathes on their own

Supported: patient is helped with pressure support

It allows spontaneous breathing while assuring some
mandatory minute volume to the patient

Synchronization of mandatory breaths allow total
ventilator-patient synchrony.
 Modes of Ventilation
Synchronized Intermittent Mandatory Vent

- Parameters

Tidal Volume
PEEP

Respiratory rate (set ≠ meas)
Pressure Support level

Inspiratory time
Trigger level

Pressure Limit
Inspiratory pause
 Modes of Ventilation
Synchronized Intermittent Mandatory Vent
Variables
Mandatory Breath Spontaneous breaths

Trigger:
Trigger:
- Patient: Flow or pressure
- Time

Cycling
- Patient: Flow or pressure - Under pressure support: flow

Cycling:
Control Variable
- volume - Pressure

Control Variable
- Flow
Modes of Ventilation
Synchronized Intermittent Mandatory Vent

Deliver a minimum minute volume

Patient is allowed to breathe spontaneously between mandatory
breaths

Pressure Support can be added

Timing for spontaneous and mandatory breaths is defined through a
time window

Ventilator always deliver a certain amount of mandatory breaths
Modes of Ventilation
SIMV and Pressure Support
SIMV w/o PSV

SIMV w/PSV
PS Breath

Mandatory breath
Modes of Ventilation
Synchronized Intermittent Mandatory Vent

Advantage:
- Patient is able to breath spontaneously
- Can be used as weaning tools

Disadvantage:
- Excessive work of breathing

Resistance of the endotracheal tube and demand valves:
 Solved by Pressure Support ventilation
Modes of Ventilation
Synchronized Intermittent Mandatory Vent

SIMV in ICU
• Known as a Weaning Mode, to overcome fighting ventilation
• Ensures minimum level of ventilation (mandatory breaths)

SIMV in anesthesia
• Ensures Minimum Minute Ventilation in spontaneous breathing
• With or without PSV
• Can be used during maintenance and off-set of anesthesia

When is SIMV Helpful?

• When patients’ spont. rate & tidal volume change due to the
depth of anesthesia
• To have a smooth transition from mechanical to spontaneous
ventilation
 Modes of Ventilation
Pressure Support

Spontaneous ventilation mode where the ventilator supports patient’s

effort.

Work of breathing is “shared” between the patient and the ventilator.

Pressure Support should compensate imposed resistance by an artificial
airway

It requires synchronization with both patient’s inspiration and exhalation.

Once the ventilator “detects” the inspiratory effort, it will deliver a
constant inspiratory pressure over the inspiration time

The flow going into the patient will decelerate until it reaches the
threshold level (25% of peak flow).

Then cycling to expiration occurs until a new inspiratory effort is
detected by the ventilator
Modes of Ventilation
Pressure Support
Pressure

PS + PEEP

PEEP
Trigger

Peak Flow (up to 100 LPM)

Exp. Theshold (25%)
Flow
Volume

Insp. Exp. Time

Modes of Ventilation
Pressure Support
Modes of Ventilation
Assisted Spontaneous Breathing (ASB)

The patient should trigger every respiration.

Once the ventilator “detects” the inspiratory effort, it
delivers a constant inspiratory flow

The pressure in the circuit will increase until it reaches
the PS level set by the user.

Then cycling to expiration occurs until a new inspiratory
effort is detected by the ventilator
Modes of Ventilation
PS vs. ASB

Pressure Support has several advantages
compared with ASB:
- Flow matched with patient’s need.
- Pressure target mode with better volume
delivery
- Better leak compensation (for LMA use)
- Flow cycling with better synchronization of the
expiratory phase
Gas Volume Compensation
Volume Compensation
Introduction

Volume delivery is affected by:
- Compressible volume loss (diminish volume)
- Circuit compliance (diminish volume)
- Fresh Gas Flow (adds volume)
E
G
J L
D

M F

C
N B
I A
Q
P K
R
 Volume Compensation
Compliance Compensation

• The effect of the gas being compressed in the dead space of the
breathing system (Circuit compliance and compression loss) is to
reduce the volume (TV) that is delivered to the patient.
• To calculate this effect it is necessary to measure the capacity or
compliance of the system (Cs). This is done during the pre-use check.
• The system is first pressured to 10cmH20 to check for leaks. Then the
system is raised a further 30cmH20, the volume needed to produce
the pressure rise is recorded.
• Volume in (ml) / Pressure = Dead space compliance (Cs)
• The Total compliance of the system and patient (Ct) is measured
after 2 or 3 stable breaths
• The TV can then be adjusted to compensate for the lost volume due
to compression within the breathing system.
• Set TV x (1+ (Cs / Ct –Cs)) = New TV
 Volume Compensation
Compliance Compensation
Example
• System test measurement using 240ml to give 30cmH20
pressure rise
• Volume in (ml) / Pressure = Dead space compliance Cs
• 240ml / 30cmH20 = 8 = Cs
• Ventilator running on patient with set 500ml TV gave 20cmH20
peak Pressure
• 500ml / 20cmH20 = 25 = Ct
• Set TV x (1+(Cs / Ct –Cs)) = New TV
• 500ml x (1+(8 / 25-8)) = 735ml
• 735ml is the actual ventilator output to give 500ml at the patient
 Volume Compensation
Fresh Gas Compensation
• Fresh gas flow adds to the delivered Tidal Volume TV
during the inspired period
• To compensate for this a reduction in the delivered
volume needs to be made
• Set TV – (Fresh gas flow (ml/Min) x Inspired Time
(sec)/60)
• Example FG 5 LPM, TV 600ml, 10 BPM, I:E 1:2.0
• 600 – (5000 x 2 / 60) = 434ml
• The ventilators effective TV is 434ml to allow for FG of
5LPM to give the patient 600ml

• NOTE: A Vt Bellows < VtFGF condition activates a high

fresh gas flow alarm
 Volume Compensation
Complete Compensation

The complete effect of volume compensation could be described as:

Bellows TV = Set TV x (1+(Cs / Ct –Cs)) - (FGF (ml/Min) x IT (sec)/60)

So the ventilator change TV Bellows on a breath by breath basis to

achieve TVset = Vti

Even if TV set remain unchanged, TV Bellows will change with a
modification in:
- FGF (i.e. Low Flow Anesthesia)
- Respiratory Rate
- I:E Ratio
- PEEP
- Inspiratory Pause
- Respiratory Mechanics (i.e. patient compliance and resistance)
 Volume Compensation
Example of Compensation
During pre-test of the 700/900 the sequence of events are:

1. Switch absorber to Bag This part of the test is to check if a switching

absorber is fitted.
2. Switch absorber to Vent To make sure the absorber is in Vent position so
that the bellows can be filled and the patient circuit
is in circuit.
3. Fresh gas test To check that there is less then 0.5 LPM of fresh
gas flowing. If more than 0.5 LPM is flowing then the
message “Fresh gas too high” will be displayed.
4. Raise the pressure in the This checks that the Patient circuit is occluded and
system to 10cmH20 the bellows is full of gas.
If there is a leak or the above are not correct the
700/900 will continue to try to raise the pressure for
25 seconds then give the message Failed
Compliance or Failed to Raise Pressure.
If all is OK, proceed.
 Volume Compensation
Example of Compensation
5. Raise the pressure a further
30cmH20
6. Hold the pressure at 40cmH20
10 seconds
The 700/900 records the amount of gas needed
to produce this pressure rise.
If the pressure does not rise (usually a leak on the
patient circuit or in the fresh circuit) you will again
have the message Failed Compliance.
If the pressure rises then the 700/900 will proceed
to the next stage.
This is the system leak test. If the pressure falls for
3cmH20 in the 10 seconds then the 700/900 will Fail
Leak Test. The test will also fail if the patient flow
sensor is missing. If the pressure does not fall then
the leak test will be passed.