Mechanical Ventilators and

Ventilation Basics

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 What is Mechanical Ventilation?
Mechanical ventilation is a modality of applying positive
pressure for patients who are unable to sustain the level of
ventilation mainly for gas exchange functions - oxygenation and
carbon dioxide elimination.

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 Goals of MV
1. Ventilation and Oxygenation,
2. Minimize the risk of lung injury,
3. Reduce patient work of breathing (WOB),
4. Optimize patient comfort

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 Ventilator Machines - Types
• FACILITY
– Home care , Portable/Transport, ICU ventilators

• AGE GROUP
– Neonatal, pedi, Adult ventilators

• MODE
– CPAP, BiPAP, HFNC, Conventional ventilators

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 Functional Anatomy of a Ventilator
General components.
•Graphic User Interface
•Breath Delivery unit
•Battery, Compressor
•Circuits : tube, filters, humidifiers, EtCo2 monitorsPatient Interface:
Mask, ET tube, Trach Collars
•Power, Air and Oxygen cables and Sources

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 Ventilator Peripherals
• Monitors vital signs +/- EtCo2
• Suction Machines with Catheters
• Ambu bag
• O2 concentrator
• External battery
• Oxygen cylinder with regulator
• Heater humidifier
• Filters
• Nebulization kits
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 MV Operation Principles
• A typical ventilator system consists of three main
sub-systems:
• The “Inspiratory Flow Delivery System” is responsible
for generating and manipulating the oxygen-enriched
air that is sent into the patient’s lungs.
• The “Expiratory Path” that provides an appropriate
path for the exhalation.
• A microcontroller (MCU) is used to control the
operation of the whole system based on the
information obtained from different sensors and the
parameters that the clinician specifies.
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Ventilator machine

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Block diagram of a ventilator

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Electronically controlled gas valve

An example electronically-controlled valve.MSc

Mechanical Ventilation- Image
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Principles,,,ctd

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 Additional Ventilatror parts
• Also a pressure sensor and a CO2 sensor are
required to monitor the airway and provide the
patient with sophisticated output waveforms and
features.
• Moreover, we need a humidifier to add moisture to
the oxygen-enriched air that is delivered to the
patient (the humidifier is not shown in our block
diagram).
• In addition, a ventilator need to have a graphical
display to show appropriate settings,
measurements, calculations, and alarms.
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Basics of mechanical ventilation

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 Normal breath
Normal breath inspiration animation, awake

Lung @ FRC= balance

Diaghram contracts
-2cm H20

­Chest volume

¯Pleural pressure

-7cm H20

Alveolar
Air moves down pressure falls
pressure gradient
to fill lungs
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 Normal breath
Normal breath expiration animation, awake

Diaghram relaxes

Pleural /
Chest volume ¯

Pleural pressure
rises
Alveolar
pressure rises

Air moves down

pressure gradient
out of lungs

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 Normal breath
Pressure

Expiration
+3
+2
+1
0
-1
-2
-5

Inspiration

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 Pressure Normal breath

Expiration
+3
+2
+1
0
-1
-2
-5

Inspiration
volume

Time Mechanical Ventilation- MSc RT-

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 Normal breath

Expiration
FLOW

Inspiration

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 Expiration
Pressure +3 Normal breath
+2
+1
0
-1
-2
-5

Inspiration
volume

Inspiration
FLOW

Expiration
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 Ventilator breath inspiration animation

Air blown in
0 cm H20

­ lung pressure Air moves down

pressure gradient
to fill lungs

+5 to+10 cm H20
­ Pleural
pressure
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 Ventilator breath expiration animation
Similar to spontaneous…ie passive

Ventilator stops
Pressure gradient
blowing air in
Alveolus-trachea

Air moves out

Down gradient ¯ Lung volume

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 +
3
+ Normal breath Mechanical breath
2
+
Pressure

0
-
1
-
2
-
5
volume
FLOW

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Origins of mechanical ventilation

•Negative-pressure ventilators
(“iron lungs”)
• Non-invasive ventilation first
used in Boston Children’s Hospital
in 1928
• Used extensively during polio
outbreaks in 1940s – 1950s The iron lung created negative pressure in abdomen
as well as the chest, decreasing cardiac output.

•Positive-pressure ventilators
• Invasive ventilation first used at
Massachusetts General Hospital
in 1955
• Now the modern standard of
mechanical ventilation

Iron lung polio ward at Rancho Los Amigos Hospital

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 Several ways to ..connect the
machine to Pt
• Oro / Naso - tracheal Intubation
• Tracheostomy
• Non-Invasive
Ventilation

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Ventilation = Inspiration + Expiration
Inspiration = 1) Start or Triggering
2) inspiratory motive force or control or Mode
3) termination of inspiration or Cycling
Expiratory Phase Maneuvers Mechanical Ventilation- MSc RT-
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 Classification (the Basic
Questions)
A. Trigger mechanism
– What causes the breath
to begin? B C
B. Limit variable
– What regulates gas
flow during the breath?
C. Cycle mechanism A
– What causes the breath
to end?

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 1 2 3 4

The four phases of each ventilatory

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cycle
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 Inspiration
Expiration
volume

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 Cycling

e
od
volume

rM
lo
tro
n
co
or
e
rc
fo
ive
ot

Start
ym
r
to
ira
sp
in

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 Cycling Vs. Limiting

Pressure Pressure

Limited Cycled

Time Time
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Triggering the Ventilator
q flow trigger

q pressure trigger

q volume Trigger

q Time Trigger

q Other techniques: Neurally Adjusted Ventilatory Assist (NAVA)

Chest impedance
Abdominal movement

Flow triggering is considered to be more comfortable,

Increasing the trigger sensitivity: decreases the work of breathing

accidental triggering and unwanted breaths

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 Trigger

Which Trigger is correct?

flow trigger

pressure trigger

volume Trigger

Time Trigger Mandatory

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 all the breaths with
mandatory
inspiratory cycling

Spontaneous
Mandatory
Unsupported
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 Trigger

Which Trigger is correct?

flow trigger

pressure trigger

volume Trigger

Time Trigger

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 Trigger

Which Trigger is correct?

flow trigger

pressure trigger supported

volume Trigger

Time Trigger
Mandatory
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 Trigger

Which Trigger is correct?

flow trigger

pressure trigger supported

volume Trigger

Time Trigger Mandatory

Synchronized
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 Mandatory
Triggered (VCV)
(PSV)

spontaneous
spontaneous
and mandatory
and
inspiratory
cycling
mandatory
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No mandatory inspiratory cycling
all the breaths are pressure-
targeted and trigger inspiratory-
cycled

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Which Trigger?
flow trigger

pressure trigger

volume Trigger

Time Trigger

Non of the above

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 Vent Parameters or Variables
Vent Setting Vent Outcome Others (mechanics)
• Mode Vti, Vte, MV, Compliance
• Tidal Volume Peak pressure, Resistance
• Pressure insp Plateu pressure, PV loop
• Rate (f) MAP, PEEPe, Slow Vital
• Insp Time RR, flow, I:E, capacity
• PEEP SPO2, BP, HR, etc Time Constant
• FiO2 MIP
• Triggor Po.1
• Pattern

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Expiration Inspiration

Air OUT Air IN

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 Time Constant = C X R

A certain amount of time is necessary for pressure equilibration (and therefore completion of delivery of
gas) to occur between proximal airway and alveoli. TC, a reflection of time required for pressure
equilibratlon, is a product of compliance and resistance. In diseases of decreased lung compliance, less
time is needed for pressure equilibration to occur, whereas in diseases of increased airway reslstance,
more time is required. Expiratory TC is increased much more than inspiratory TC in obstructive airway
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diseases, because airway narrowing is exaggerated duringK expiration.
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 3-5 time constant

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C = 100 cc/ Cm H2O Time Constant
R = 1 Cm H2O / L / Sec

Time Constant = ?
= R.C
=100 cc/ Cm H2O X 1 Cm H2O / L / Sec
= 0.1 Sec
C = 50 cc/ Cm H2O
R = 1 Cm H2O / L / Sec

TC= ?
= R.C
=50 CC / Cm H2O X 1 Cm H2O / L / Sec
= 0.05 Sec
C = 100 cc/ Cm H2O
R = 2 Cm H2O / L / Sec

Time Constant = ?
= R.C
=100 CC/ Cm H2Mechanical
O X 1 Cm H2O /MSc
Ventilation- L /RT-
Sec
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 Selection of Appropriate Inspiratory Time
TI too long
TI too short
T E = 3-5 time constant Tc = C x R

TI is usually initiated at: 0.5-0.7 sec for neonates,

0.8-1 sec in older children,
1-1.2 sec for adolescents and adults
need to be adjusted through : individual patient observations
and according to the type of lung disease.

T I + T E = Time Cycle
F ( RR ) = 60/TC IT ET

F= 60/ TI +TE

T I = 3-5 time constant Tc = C x R

Many ventilators ask the user to set the I:E ratio and respiratory rate

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V T = 100 cc TI = 0.8 sec
Inspiratory Flow = ?
Inspiratory Flow = 100 / 0.8 = 125 cc/sec (7.5 L/ Min )

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• RR = 60 I:E = ½ • IT= 0.8 ET= 1.2Sec
IT = ? ET = ? • RR=?
F= 60/ TI +TE
60 = 60 / TI + 2TI = 60/ 3TI F= 60/ TI +TE
IT = 0.33 ET = 0.66 RR = 60 / 0.8+1.2 = 30

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Inspiratory Flow/Pressure/Volume Pattern

Decelerating
Square
Accelerating
Sinusoidal

Inspiratory Rise Time

time
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 Pressure-controlled inflation
Pmax = Pinf + PEE

Inspiratory Rise Time

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Effect of a pressure-limit on a volume-controlled breath

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 Cycling
Termination of Inspiration (Cycle)

1)Time-cycled

2)Volume-cycled

3) flow-cycled

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 Pressure Controlled Ventilation

Cycling at 25% Flow

VT

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 Pressure Controlled Ventilation

respiratory resistance and both the resistance and compliance of

compliance are both lower the respiratory system are higher
Cycling at 25% Flow

IT>
IT<

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 ET ET
10%

50%
Over inflation Improve
Over inflation

(high resistance),
prolonged inspiration
a large tidal volume.
the next inspiratory phase startsMechanical
before expiratory gas flow has reached zero
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inspiratory motive force or control or Mode

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Mechanical Ventilation- MSc RT-Critical Opening Pressure
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 Volume Controlled Ventilator

The desired tidal volume is set on the ventilator, and the resulting airway
pressure excursion is merely observed.
Inspiratory volume is thus the primary, or independent, variable (V) and the
change in airway pressure (P) resulting from this is the secondary, or
dependent, variable.
The value of P is determined by the compliance of the respiratory system,
which is given by V/P.
If the compliance of the respiratory system falls, V remains constant but P
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 Pressure Controlled Ventilator

The desired inflating pressure is set on the ventilator, and the tidal volume that this delivers
is merely observed.
The change in airway pressure is thus the primary, or independent, variable (P) and the
volume change (V) resulting from this is the secondary, or dependent, variable.
The value of V is determined by the compliance of the respiratory system, which is given
by (V/P).
If the compliance of the respiratory system falls, P remains constant but V falls

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 volume-controlled inspiration

A: Volume/time curve for a volume-controlled inspiration with

a tidal volume of VT1 litres and an inspiratory time of TIa
seconds. The inspiratory flow ( ˙VI ) is the slope of the volume/time :
˙VI = VT 1 / TI a

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 volume-controlled inspiration

High Flow

High VT

Low VT

I time Low Flow

instant

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PRESSURE

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Time
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 H ig
hF
low

VT
Constant

Low Flow
I time
variable

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PRESSURE

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Inspiration sometimes have two phases,
1) an active ‘flow’ (TI f low) phase during which gas is being delivered to the patient,
2) end-inspiratory pause (TI pause )
TI = TI fVentilation-
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 end-inspiratory
pause

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 Changes in
End-inspiratory
Pause

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Pressure profile of a volume-controlled breath with an end-inspiratory pause

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PRESSURE

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Volume-controlled inflation

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 Comparison of ‘volume-controlled’
and ‘pressure-controlled’ breaths

Volume Pressure

Tidal volume Fixed Variable

Airway pressure Variable Fixed

Minute volume Set Measured

Inspiratory flow Constant Decelerating

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 Comparison of ‘volume-controlled’
and ‘pressure-controlled’ breaths

VCV PCV
Tidal volume Fixed Variable

Airway pressure Variable Fixed

Minute Volume Set Measured

Inspiratory Flow Constant/Square Decelerating

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 IPPV PSV CPAP

Trigger Inspiratory cycling Inspiratory support Breath type Example

Time Time Yes Mandatory IPPV

Patient Patient Yes Triggered Pressure

support

Patient Patient No Spontaneous CPAP

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CONVENTIONAL VENTILATOR SETTINGS
FI02
Is the patient adequately oxygenated?
2 Question
1: ‘how well are this patient’s lungs able to take up the oxygen I am
supplying?’
2: ‘is enough oxygen being supplied to the patient’s vital organs?’

The clinical assessment of the adequacy of oxygenation is deceptively difficult

Measurement of PaO2 or
(SaO2), or
both

The PaO2 and SaO2 are not equivalent and provide different information

PaO2/ FiO2
A-a Gradient
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CaO2 = ( Hb × 1.34 × SaO2/100 ) + (0.0225 × PaO2 )
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A-a Gradient = PAO2 − PaO2

PAO2 = FIO2 × (Pb − 47) − PaCO2/0.8

PAO2=F IO2 × (Pb + { PEEP/75} − 47) − PaCO2/0.8

oxygenation index OI = 100 × FIO2 × Paw/ PaO2

PAO2/ PaO2 more indicative of V/ Q mismatch and alveolar capillary integrity.

VI = (PIP x ventilator rate/min x Paco2) / 1000
==================================================================

extra-pulmonary

CaO2 = ( Hb × 1.34 × SaO2/100 ) + (0.0225 × PaO2 )

oxygen delivery D ˙ O2 = ˙Qt × CaO2/ 100

oxygen consumption
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 FiO2
Pa O2 SaO2 = 95

Pa02 value of 70-75 torr is a reasonable goal

Fi O2 values should be decreased to a level ~0.4 as long as SaO2 remains 90% or above

Rate of diffusion = Area × K × PAO2− PaO2 / d

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 IT / Plateau

RR by ET
CPAP

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 Positive end-expiratory pressure (PEEP)

What is PEEP?
Positive pressure measured at the end of expiration.

)
PHYSIOLOGICAL PEEP
PEEP (3 to 5 cm H2O)
to overcome the decrease in FRC that results from the bypassing of the glottic
apparatus by the ETT

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 Positive End-expiratory Pressure
(PEEP)
What is the goal of PEEP?
PEEP FOR HYPOXAEMIA
• ‘to open the lungs and keep them open’
• To improve respiratory mechanics,
• To reduce intrapulmonary shunt,
• To stabilize unstable lung units
• To reduce the risks of ventilator-induced lung injury (VILI
• Recruit lung in ARDS
• Prevent collapse of alveoli
• Diminish the work of breathing

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Mechanical Ventilation- MSc RT-Critical Opening Pressure
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 PEEP- Indications.
• If a PaO2 of 60 mmHg cannot be achieved
with a FiO2 of 60%
• If the initial shunt estimation is greater than
25%
• Pulmonary edema
• ARDS/ALI
• Atelectosis

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 Complications of positive end-expiratory pressure (PEEP)
Pulmonary over-distension
Barotrauma
Ventilator-induced lung injury (VILI)
Increased dead space
Impaired carbon dioxide elimination
Reduced diaphragmatic force-generating capacity
Reduced cardiac output and oxygen delivery
Impaired renal perfusion
Reduced splanchnic blood flow
Hepatic congestion
Reduced lymphatic drainage
Diminish cardiac output
Regional hypoperfusion
Augmentation of I.C.P.?
Paradoxal hypoxemia
Hypercapnoea and respiratory acidosis
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 Prolongation of inspiratory time

INVERSE RATIO VENTILATION

first described in the early 1970s in infants with ARDS

the inspiratory period extends beyond 50% of the total cycle time

IRV can be applied in either volume- (VC) or pressure-controlled (PC) mod.

To maintaining an open lung in ALI/ARDS

requires profound sedation and frequently the use of neuromuscular blockade.

adverse consequences to cardiac output; any perceived benefits to oxygenation may

well be offset by consequent reductions in oxygen delivery.

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 AIRWAY PRESSURE RELEASE VENTILATION (APRV)
first described in 1987.
is a form of bi-level assisted ventilation
utilizing continuous positive airway pressure (CPAP) with periodic pressure releases,
either to a lower CPAP pressure or
to atmospheric pressure
The ventilator settings for APRV do not usually include the respiratory frequency but
instead :
the duration of Phigh, Thigh in seconds;
the duration of Plow, Tlow in seconds;
absolute value of Phigh and Plow.
the patient is able to breathe spontaneously during both of these phases.

Bi-level ventilation
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Bi-level ventilation.
the airway pressure cycles between two levels of CPAP.
The patient can breath spontaneously during both Phigh and Plow phases, and only
receives inspiratory assistance during the low–high transition.

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High-frequency oscillatory ventilation.
(HFOV) A system of ventilation which uses respiratory rates between 300 and 900 breaths
per minute

Segmental bronchi
ET tube

Carina

Alveoli
Oscillator

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Prone Positioning as a Recruitment maneuvers

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 Ventilation

at rest 200 mL.min−1

1) volume of dead space,

2) tidal volume,
3) respiratory frequency
4) Positive end-expiratory pressure (PEEP

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 Influences on the production of carbon dioxide
• Factors associated with increased carbon dioxide production
– Systemic inflammation
– Sepsis
– Burnt patients
– Hyperpyrexia
– Thyrotoxic crisis
– Muscular activity (seizures, excessive respiratory work)
– Predominance of glucose as metabolic substrate
– Administration of exogenous bicarbonate

• Factors associated with reduced carbon dioxide production

– Hypothermia
– Hypothyroidism
– Sedation and neuromuscular blockade
– Predominance of fatty acids as metabolic substrate
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 P CO2 = K X ( V CO2 / MV)

MV = RR X VT

VT = Alveolar Space + Dead Space

Dead Space
Physiological dead space (VD) = Alveolar (VDA) + Anatomical (VDanat)

VD = Alveolar (VDA) + Anatomical (VDanat) +Equipment (VDequip)

Vd/Vt = 0.3

VD / VT = PaCO2 − PE TCO2 / PaCO2

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 Tidal Volume and Rate
VT and rate depends on the time constant.
In normal lungs :
age-appropriate ventilator rate
tidal volume of 6-8 mL/kg
Diseases associated with decreased time constants
(decreased static compliance, are best treated with :
small (6 mLlkg) tidal volume
and relatively rapid rates
Diseases associated with prolonged time constants
(increased airway resistance, e.g., asthma,
bronchiolitis)
are best treated with:
relatively slow rates
and higher (8-10 mLlkg) tidal volume
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 Positive end-expiratory pressure (PEEP)
effects on CO2
Low levels of PEEP (3 to 5 cmH2O) have little effect
Higher levels of PEEP (8 to 15 cmH2O)
may increase the Vd/Vt ( mostly with low VT) CO2

in recruitable lung CO2

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 General techniques to lower carbon
dioxide production
Avoidance of pyrexia
induced hypothermia
Lowering the respiratory quotient (use of fatty acids)
Sedation and neuromuscular blockade reduce metabolic rate by around 9%

Conventional mechanical ventilation alveolar ventilation

Adjunctive pulmonary therapies

Bronchodilators
Physiotherapy
Tracheal gas insufflation

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 Permissive hypercapnia
potential advantage of permissive hypercapnia:
deliberate hypoventilation
reduction in tidal volumes
reduction transpulmonary pressures
limit pulmonary injury.
In vitro,
hypercapnia reduces the activation of:
NF-kB,
intercellular adhesion molecule-1 (ICAM-1)
interleukin-8 (IL-8)
in human pulmonary endothelial cells
NF-kB is a key regulatory molecule in the activation of many pro-inflammatory genes,
including those that produce ICAM-1 and IL-8, molecules that trigger the movement
of leukocytes into the inflamed lung.
In vivo,
Hypercapnia may reduce inflammation in experimental lung injury.

Finally, hypercapnia may improve ventilation perfusion matching and intestinal and
subcutaneous tissue oxygenation

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Increase in: pCO2 pO2 MAP
FiO2 no change increase no change
usually no
Rate decrease increase
change
PIP/TV decrease increase increase
Inspiratory usually no
increase increase
time change
usually no
PEEP increase increase
change

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MONITORING RESPIRATORY MECHANICS
Exhaled Tidal Volume
leak out
decrease in VTE ( PCV) : decrease in compliance
or increase in resistance

increase in VTE is indicative of improvement and

may require weaning of inflation pressures to adjust the VTE.
Peak Inspiratory Pressure
In VCV and PRVC, the PIP is determined by compliance and resistance.

increase in PIP decreased compliance (atelectasis, pulmonary edema, pneumothorax)

or increased resistance (bronchospasm, obstructed ET).

decreasing the respiratory rate

lower PIP in patients with prolonged TC
or prolonging the TI

In such patients, a decrease in PIP suggests increased compliance

or decreased resistance of the respiratory system.

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 Respiratory System Dynamic Compliance
and Static Compliance

CSTAT= VTE/ (Pplat - PEEP)

CDYN= VTE / ( PIP - PEEP)

PCV

CDYN= VTE / ( PIP - PEEP)

VCV and PRVC
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 Assessment of Auto-PEEP

Auto-PEEP is assessed with the use of an expiratory pause maneuver

-have adverse effects on ventilation and hemodynamic status.

Management : decreasing RR
or decreasing inspiratory time
increasing the set PEEP ("extrinsic" PEEP),
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 Ventilator settings
1. Ventilator mode
2. Respiratory rate
3. Tidal volume or pressure inspiratory
4. Inspiratory flow
5. I:E ratio
6. PEEP
7. FiO2
8. Inspiratory trigger

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 Assist – Control AC
Trigger window
Spont breath sensed
Can be set
Sensitivity can be set

Vent breath Vent breath Synch Vent breath Vent breath

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 AC
• Patient only gets ventilator breaths
• These are just delivered at different times to
coincide with patient spontaneous effort
• Can help keep lungs recruited

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 SIMV
Trigger window 1 Spont breath sensed
for Vent breath Trigger window 2 for
supported breath

Vent breath Vent breath Synch Vent Supported Vent breath

breath breath
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 Pressure Support
• Because it is difficult to breathe through a
ventilator, the vent can help
• It supports spontaneous effort
• Pressure support
– No background rate
– Patient determines resp rate & I:E
– Usually apnoea backup

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 Pressure Support

Spontaneous Pressure is applied

breath sensed throughout
by ventilator inspiratory effort

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 CPAP & PEEP

The constant bit

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 CPAP and PEEP

• What do they do for your lungs?

• What about your cardiovascular system?

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 BiLevel/APRV

• Bi-Level Positive Airway Pressure

• 2 PEEPs basically
• Patient can breathe at any point
– Easier for patient to tolerate
– Less sedation?
• Pressure support can be added if required

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 Tidal Volume or Pressure setting
• Optimum volume/pressure to achieve good
ventilation and oxygenation without
producing alveolar overdistention

• Max = 6-8 cc/kg

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 Inspiratory Trigger
• Normally, it is set automaticaly

• 2 modes:

– Airway pressure triggering

– Flow triggering

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 I:E Ratio

• Normaly 1:2

• Asthma/COPD 1:3, 1:4, …

• Severe hypoxia
ARDS/ALI
Pul.Edema 1:1 , 2:1

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 FIO2
• Goal – to achive PaO2 > 60mmHg or a sat
>90%

• Start at 100% and aim 40% [ titre down before

PEEP titration]

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Vent settings to improve <oxygenation>
PEEP and FiO2 are adjusted in tandem
• FIO2
• Simplest maneuver to quickly increase PaO2
• Long-term toxicity at >60%
• Free radical damage
• Inadequate oxygenation despite 100% FiO2 usually
due to pulmonary shunting
• Collapse – Atelectasis
• Pus-filled alveoli – Pneumonia
• Water/Protein – ARDS
• Water – CHF
• Blood - Hemorrhage

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 Pulmonary edema
Translocation of fluid to peribroncheal region – helps in oxygenation

PEEP

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 Commonly Used Initial Ventilator Set-up

• Mode: CMV/AC/SIMV / PRVC/PSV. Pressure/Volume

• VT : 6 - 8 ml/kg IBW (maintain Pplat < 30cmh2o)
• f/RR : 12 - 20 bpm, minimize autoPEEP
• FiO2: 0.4 - 1.0
• PEEP: 5 - 10cmH20….> Recruitment maneuver in
ARDS
• PS: 10 - 15cmH20
• I-time -à (I:E) Ratio: (1: >2 ).
• Flowrate 30 - 70 lpm, to achieve optimal I time [I:E ratio]
• Trigger/ Sensitivity-[pressure/flow] – 2- 4 cmh2o. OR
1- 3 L/m
• Flow pattern – use it as a minor tune
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 General Approach of a Patient on MV
• Always start from the
patient à Ventilator
GAS
• Think of first Ventilation
EXCHANGE
and then Oxygenation
• Beware pressure, volume
Lung Hemodyn
and time are interrelated!
Protection amic
• Check patient synchrony -
-- there are many causes
of dys-synchrony!

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 Ventilation: Refers Co2 Elimination from the body

• Minute Ventilation (VE) = RR X VT ( 4 -10 lpm)

• What matters is alveolar ventilation (VE – VD)
• High rate may increase VE but reduces alveolar ventilation
• f = 10-25 bpm (average)
• Vt = 6 - 8 ml / kg (IBW)
• PaCO2 = 35-45 mmHg [Co2 elimination and production]
• pH = 7.35-7.45, ? compensatory or respiratory cause
• Dead Space ventilation: 1/3 of the normal Tv

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 Oxygenation
• FIO2 : 40 – 60 % is safe

• PEEP: Recruits alveoli, Improve V/Q, push fluid

away, reduce asynchrony & reduce WoB, etc

• I-time. : longer I-time improves contact time

• Optimal volume : no oxygenation without ventilation

• Target Saturation > 88 %

• Pmean – key factor for pressure effect of

oxygenation

• Beware of oxygen toxicity and nitrogen washout

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 Oxygen Delivery
DO = 1.34 x Hgb x SaO2 x CO (L)x 10

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 “The Synchrony Tools”
When there is dissynchrony problem, please check the following but
not limited to: Flow, Pattern, Volume, Oxygentaion, Sensitivity, Pain,
Anxiety, Leak, Pressure support term, I:E ratio,etc

30
3. Pressure
Support Term.
2. Slope/Rise Adjust
Adjustment

Pa 4. Return to Baseline
cmH
w 2
O
Sec
1 2 3 4 5 6
-10
1. Leak Compensation

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 Physiologic Effect of PPV
• Increase alveolar ventilation
• Alveolar expansion, decrease WoB, improve O2 delivery
• Increase V/Q ratio / mismatch
• Decrease venous return/ CO,,, decrease perfusion
• Tissue damage and barotrauma
• Reduce surfactant, Atelectasis, Auto-PEEP
• ICP? Either way
• Atelectrauma / increased sheer force
• Biotrauma, Volume trauma, biochemcal injury – Stretch /Hyper
O2
• Disuse atrophy – respiratory muscles

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 Ventilator Chart
Ventilator Settings Ventilator /Patient Outcomes
• Mode • Volumes (Vti,Vte, VE)
• Tidal Volume/ Pinsp • Pressures (Peak, Plateu,
• Rate Mean and PEEPe)
• Flow, Insp Time • Time (Rate, I:E, flow, Ti)
• PEEP • SpO2, HR, EtCO2,
• FiO2 • WoB, Synchrony
• Sensitivity • Compliance
• Pattern • Resistance
• Plimit • Time Constant

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 REPORTING / COMMUNICATING

Setting Outcome day 3

Mode- AC-V Peak - 26
Tidal Vol- 420 Plateu- 20
Rate- 14 bpm I:E- 1:2
Tinsp– 1.4se SPO2 ---91%
FiO2- 60% Total RR--14
PEEP- 10 cmh20 Bp –110/70
Sensitivity- 2cmh20 MV– 5.0
Rise time- 4 Compliance-20

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 Troubleshooting
• Sudden deterioration
• SPO2 below the goal (too low)
• Frequently high peak pressure
• Pplateu over 30cmh2o
• Evidence of air-trapping
• Patient is not in synchrony with the machine
• Repeated failure for weaning

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 Sudden high PIP alarm!!!
Consider DOPE
• D- Disposition of ETT (migration of the tube)
• O- Obstruction / kinking
• P- Pneumothorax
• E- Equipment failure

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Common Alarms,,, classwork on the possible causes
• Low Minute Volume or Tidal volume
• Increased Minute Volume
• Change in respiratory rate
• Sudden increase in peak pressure
• Gradual increase in Peak pressure
• Drift in FiO2, drift in set Vt and Vti
• I:E ratio too high or too low
• Inspired gas temp too high
• Ventilator autocycling
• Increased gap between Pplat and Ppeak
• Air / oxygen pressure low

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 Weaning from Mechanical Ventilation
Factors to consider:
• Awake, and off sedation (as much as possible).
• Psychological readiness
• Ventilatory muscle function
• Free of infection.
• Hemodynamically stable (preferably off vaso-pressors)
• Normal electrolyte balance
• Optimal oxygenation (FiO2 < 0.5 and PEEP < 5 cmH20)
• Acceptable ventilation
– RR/Vt [RSBI] <105breaths/min /L
– RR<30, and no anxiety or confusion during SBT
– Vt > 5ml/Kg with minimal support

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 Weaning – Pressure Support

• Ventilator Criteria to Consider for COVID19

– Meeting oxygenation goals with FIO2 < 0.5, PEEP < 8
on PSV < 10 (Tan, et. al)
– Minimal secretions
• Set your inspiratory pressure above the Peep
setting to provide a tidal volume spontaneously
(CPAP+5).
• The goal would be to reach a pressure support of
10 or less to move to extubation.

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 Weaning----M-O-V-E

➤ M—Mentation (Awake, Alert, follows simple commands

➤ O----Oxygenation (FIO2</= .5 with SPO2 greater than 90%)
➤ V---Ventilation ( MV< 10 L/M with adequate acid base.)
➤ E----Expectoration (Good Gag and effective cough. Able to
clear secretions on own.)

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 Criteria for Extubation
➤ Reversibility of the underlying disease
➤ Spontaneous TV > 5 ml/kg
➤ Resp. Rate < 35/min
➤ Minute Volume < 10 l/min
➤ Vital Capacity > 15 ml/kg
➤ NIF or MIP > 20 cwp
➤ Good gag reflex and effective cough
➤ If you suspect Airway Edema, do a cuff leak test.

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 Weaning Failure Criteria
1. f > 35/min for > 5minutes
2. HR> 140 bpm
3. SBP > 180 or < 90 mmHg
4. SpO2 < 90%
5. Anxiety or Agitation
6. Diaphoresis
7. PaCO2/ETCO2 increase >/= 10 mmhg if available.
8.If Pt. fails SBT, place back on ventilator and document the time and
reason for failure.
PSV as tolerated with goal of providing a comfortable mode of ventilation
until next day’s Screen.

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 Causes of failure to wean:
Hypoxemia
• Diffuse pulmonary disease
• Focal pulmonary disease (Pneumonia)
• Pulmonary edema
Insufficient Ventilatory Drive:
• response to metabolic alkalosis
• Inadequate function of CNS drive (Ex: sedatives, malnutrition)
Excessive Ventilatory Drive:
• Excessive CO2 production (sepsis, agitation, fever, high
carbohydrate intake)
Respiratory Muscle Weakness:
• Neuromuscular disease
• Malnutrition
• Drugs (Neuromuscular blocking agents, Corticosteroids,
aminoglycosides)
Excessive work of breathing

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 Extubation
• Check airway patency– Do Cuff Leak Test
• Position the patinet (Fowler’s or semi-Fowler’s)

• Pre-oxygenation with 100% O2

• The mouth and throat are thoroughly suctioned

• The patient is instructed to cough

• The ET cuff is completely deflated

• Withdraw tube in a single swift during expiratory phase
• Oxygen is administered through a facemask

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Corona Virus Infectious Disease (COVID-
19)

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 COVID19- Signs of Deterioration
• Increased O2 needs (suggesting V/Q imbalance)
• Increased A-a gradient with ABG, decreased P/F ratio
• Tachypnea (RR > 30) is quite common
• Usually with significant hypoxia (deeper than the level of distress)
• Dyspnea, Indications of shortness-of-breath
• Diaphoresis - indicates potential for near-respiratory- arrest)
• Lack of improvement on noninvasive strategies (HFNC, noninvasive
CPAP or ?NPPV),
• Hemodynamic instability seen as a concerning sign (consider
intubation)

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 COVID19 – Observations
Phenotypes (Gattinoni, etal.)
Phenotype L
• Hypoxia-driven disregulation
of pulmonary perfusion
• Low elastance, Low V/Q, Low
recruitability, Low PEEP
response. [L]
• These patients often have
good lung compliances
(>50ml/cmh2o), lower plateau
pressure (<22cmh2o), and
lower driving pressures
(<15cmh20).
Phenotype H
• Pulmonary edema/collapse -
ARDS-like features
• High lung elastance, Higher
recruitability, High Right-to-
Left shunt, Higher PEEP
response
• These patients have lower lung
compliance (<40cmh2o), higher
driving pressures (>15cmh20).

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 SARS-COVID19- Ventilation in General
• Try to differentiate Phenotype L (V/Q problem) or H(shunt
problem)
• Worth trying O2 supply including high flow nasal cannula
(HFNC) --- caution!
• Closely watch for P/F ratio and WOB for immediate decision to
intubate. Beware of P-SILI
• Prone Positioning showed good result
• Target SP02: 88% -94%; Use ARDSNet approach of 4-8 ml/kg IBW
• Target plateau pressure < 30 cm H2O
• Maintain the driving pressure (Pplat - PEEP) to under 12-15
• Early APRV could be very useful especially for Phenotype H

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 SARS-COVID19 – Ventilator Settings
• Mode- No preference except APRV in some patients
• Tidal Volume (target tidal volume): start at around 6 mL/kg Ideal
Body Weight (IBW).
• If Compliance is normal (Phenotype L), consider going up to 8
mL/kg IBW to reduce asynchrony
• If Plateau is 30 or greater, drop tidal volume by 1 mL/kg IBW at a
time until Pplat under 30 or at 4 mL/kg IBW (ARDSnet)
• As you decrease VT, you will likely need to increase RR. Consider
increasing 5/min for each 1 mL/kg drop in tidal volume.
• Deep Sedation may also be required. Reduce the driving pressure
and body oxygen consumption

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 COVID19-SARS-2 Vent Setting, ctd
Rate
– Start at 16-20bpm and to be titrated based on MV need
• Inspiratory Time:
– Typically around 0.8-1.5 second, may need to adjust it later.
– Ensure adequate exhalation (flow scalar should return to
baseline) unless APRV where "therapeutic air-trapping" is
employed AND
– Ensure adequate inhalation time to improve gas distribution
and then oxygenation
– Ensure optimal I:E ratio or need to heavily sedate the patient

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 COVID19-SARS-2 Vent Setting, ctd
• PEEP
– Phenotype L doesn’t benefit from high PEEP.
– Higher PEEP is suggested for H. If PEEP is too high:
P/V Loop with beaking; cardiac output will decrease;
BP will drop - this indicates over-distension of alveoli,
DECREASE PEEP
– Try to maintain a driving pressure (Pplat-PEEP) of
under 15 by adjusting VT and PEEP) if no spontaneous
breaths (Meng, et. al)

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 COVID19-SARS-2 Vent Setting, ctd
FIO2
• Prioritize use of PEEP over FIO2 when possible.
• Increasing FIO2 without adequately recruiting alveoli (PEEP)
will result in only minimal increases in PaO2.
• High FIO2s (1.0 or 100%) may result in further atelectasis from
nitrogen washout
• PEEP usually follows FiO2 during weaning
Proning
• Creates redistribution of blood and improves V/Q
• Early, with deep sedation, for about 6hrs at a time
• Proning is an aerosol-generating procedure

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 APRV MODE
• Phigh- 20-30cmh2o
• Plow- 0-5cmh2o
• Thigh- 5sec (COPDers may require a bit less time)
• Tlow- 0.5sec
• Avoid Sedation
• Usually recruitment will be successful in 6-12hrs
• Aggressively titrate down the FiO2 down to safer
mode
• Make sure to avoid hypercapnia or atelectrauma
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Adapting NIV Equipment for Invasive
Ventilation
VIDEO

https://www.youtube.com/watch?v=w-NZeaEKRng

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 Case 0

50 yo male pt with IBW of 60 with CC of Cough

and fever, ?COVID19 , fails to saturate non-invasive
O2 supplement, Need to place him on MV

Initially : BP- 120/75

SPO2- 72% with 15lpm

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 Case 1
• 35, m, 9th, TBi, diffuse axonal injury,
pneumonia
• ceftr, metri, manitol, heparinn, morphine,
becodyl, Phenytoin
• 160/100, spo2 -100, rr 23, GCS-8,
• PSV, 65kg, PS- 15, 40%, PEEP-5,
• PIP-21, TV-649, I:E- 1:3.3, I-time-1.4, RR-23,
SP02-100, HR-93,
• laetral decubitous, ETT-6.0, P/E
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 Case 2
• 24, F, 6th post OP lap for peritonitis, septic, TypeI DM, AKI,
• HypoK, Hypo Na,
• AKI - working dx
• antibiotics- vanco, meropenium, GI and DVT prophy,
Hydrocortison, Vassopressor, Besacodyl, Dexa, Diazepam
(sedation)
• AC-P, Pi-15, Rate-14, Ti- 1.1, PEEP-5, 40% fio2, sens-3
• SPO2-97, Hr-99, BP-110/90, RR-27
• PIP-26, PEEP-3, Pla-21, Tve-360, MV-9, RR-27, IE- 1:1
• visible secretion, lateral position, gasping type of ventilation,

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 Case 2- MCC
• 57yo, M, cough, fatigublity, headache, fever--- 5days
duration
• BP-147/86, PR-98, RR-32, SPO2- 80% on 20 LPM,
Crepitation, post 1/3rd bilateral, COVID, HPT, pulm
edema? Ceftaz, vanco, Dexa, lasix, Anti HPTN, heparin
• Stayed in ICU2 for 4hrs on 15lPM, BP-140/90, SPO2-86% -
-- ICU1
• HFOT---6hrs, RR-22, SPO2-90,
• Intubated 3 days ago and placed on PRVC, PEEP-6, Tv-
430, Ti-, RR-15?
• Outcome- SPO2-97, RR-19, BP-164/68, PR-96
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 Current setting and outcome
• PRVC, Fio2-80%, Tv-350, RR-14, Ti-1.4, PEEP-
12
• Outcome- Peak-23, plate-22, Mean-16, Tve-
309, Tvi-384, RR-25, I:E-1.4:1, heavily sedated,
Cdyn-71, Cstat-32, Spo2- 90, PR-91, BP-127/81
• Medication- Ceftaz, Vanco, Amilodipine,
anagesia, Vancuronium, Dexa, Atrovastatin,
Ketamin, propofoll

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ommendation

01–212. Mechanical Ventilation- MSc RT-

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Resolution

• Wear a surgical mask for

patients during HFNC therapy
• Connect nasal cannula tightly
Respiratory care committee of Chinese Thoracic Society.
Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 20;17(0):E020

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Open Source for ventilator Training
https://www.openpediatrics.org

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