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MECHANICAL VENTILATION

In Infant and Children


Introduction
Indications
Basic anatomy and physiology
Modes of ventilation
Selection of mode and settings
Common problems
Complications
Weaning and extubation
Mechanical Ventilator

Ventilator:
A machine used to assist or replace the
work generated by the ventilatory
muscles.
Mechanical Ventilation:
Use of a ventilator to move gas into and
out of the pulmonary system.

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Mechanical Ventilation
Ventilators deliver gas to the lungs using
positive pressure at a certain rate.
The amount of gas delivered can be
limited by time, pressure or volume.
The duration can be cycled by time,
pressure or flow.
Indications
Respiratory Failure
Apnea / Respiratory Arrest
inadequate ventilation (acute vs. chronic)
inadequate oxygenation
chronic respiratory insufficiency with FTT
Cardiac Insufficiency
eliminate work of breathing
reduce oxygen consumption
Neurologic dysfunction
central hypoventilation/ frequent apnea
comatose patient, GCS < 8
inability to protect airway
Closed Loop vs Open Loop
Control of Ventilator

control controlled
circuit controller system
(patient)
+
inspiratory
limit control
ventilator
setting signal
-
feedback signal
(pressure, volume, or flow)

Closed Loop
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Flow sensitivity
Types of Ventilator Breaths
Volume-Cycled Breath (Volume Breath)
Time-Cycled Breath (Pressure Control Breath)
Flow-Cycled Breath (Pressure Support Breath)

Modes of Mechanical Ventilation


(How a ventilator ventilate a patient i.e., breath type given)
Volume or Pressure ?
Assist-Control (AC) Ventilation
Pressure-Support Ventilation (PSV)
Synchronized Intermittent Mandatory Ventilation (SIMV)
Controlled Mechanical Ventilation (CMV)
Basic Ventilator Type
Volume Control Pressure Control
Controls Controls
-Rate -Rate
-PEEP -PEEP
-FiO2 -FiO2
-Inspiratory Time -Inspiratory Time
-Tidal Volume -Peak Inspiratory Pressure
Relative Advantages/Disadvantages Relative Advantages/Disadvantages
-Known TV -No guarantee of TV
-Risk for barotrauma -pressure limited
decreases risk of barotrauma
Uses Uses
-Most ventilated patients -Neonates
-Patients in OR (including neonates) -patients where pressure is a concern
ARDS, asthmatics sometimes
MODES MECHANICAL VENTILATION
CONTROL CMV and IMV Control modes deliver a set breath, the
MODES (Rarely) size and duration determined by the
VC, PC and physician, each part of the respiratory
PRVC cycle. If the patient is breathing
spontaneously above the set rate, he or
she will generally receive a full set
breath, regardless of how much effort
they are generating

SUPPORT VS, PS, CPAP, The ventilator mode determines both


MODES BiPAP and when a patient gets a breath and what
SIMV with PS kind of breath they receive. The goal is
(partly control to select a mode that is both comfortable
and partly for the patient and allows adequate
support) ventilation and oxygenation with
minimal trauma.
Volume/Flow Control Pressure Control
Inspiration Expiration Inspiration Expiration

20 20

Paw
Pressure Paw

0 0
1 2 0 1 2
20 20 20 20

Volume
0 0
0 0
0 1 2 0 1 2

3 3

Flow 0 Time (s) 0 Time (s)

-3 -3
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Open Lung Strategy

Zone of Overdistension

Zone of Atelectasis
Volume control mode Pressure control mode
VENTILATOR INITIATION
(CONVENTIONAL VENTILATOR)
In the beginning, one must choose :
appropriate device
mode of ventilation
initial ventilator settings
The goal of initial settings :
To optimize the patients oxygenation,
ventilation and acid base balance
To avoid harmful side effects:
hemodynamics, barotrauma,
volutrauma & oxygen toxicity
SELECTION OF A VENTILATOR

Familiar with the ventilator equipment


Power source of ventilator :
Electrically powered: electric wall outlet or battery
Pneumatically powered: compressed gas 50-psi
Combined powered + microprocessor controlled

Adjust vent setting to the test lung before vent


connecting to the patient
GENERAL CHECK LIST PROCEDURE
FOR VENTILATOR SET UP
Vent assembled correctly
Humidifier filled, heater plugged in, thermostat set
Electrical connection made
Power disconnect alarm functional
Oxygen hose connected to 50psi source
Oxygen blender/analyzer/O2 concentration accurate
Low/high pressure alarm & relief valve functional
All indicator & selector knobs and other alarm system
(audibly & visually) in control panel functional
Leaks absent in all circuit connections
Resuscitation bag, suction apparatus & other accessories
available
SETTING ALARM LIMITS

Apnea < 15 - 20 sec


High/low Ve 10 - 15% above/below
High/low Vt 10 - 15% above/below
High/low PIP 5 - 10 cmH2O above/below
High/low PEEP 3 - 5 cmH2O above/below
High/low FiO2 5% above/below
High/low Rate 10 - 15 bpm above/below
I:E ratio When I > E

Note: If too sensitive, its constantly being triggered


INITIAL ASSESSMENT OF
VENTILATORY SUPPORT

Inspection, palpation, and auscultation


position of the artificial airway and cuff inflation
pulse, blood pressure, and ECG
patient-ventilator system synchrony,
breathing circuit, humidifier,
ventilator settings and findings
ABG
Chest X-ray
Nomenclature
(Ventilatory Parameters)

Airway Pressures
Peak Inspiratory Pressure (PIP)
Positive End Expiratory Pressure (PEEP)
Pressure above PEEP (PAP or P)
Mean airway pressure (MAP)
Continuous Positive Airway Pressure (CPAP)
Inspiratory Time or I:E ratio
Tidal Volume: amount of gas delivered with
each breath
Ventilatory Parameters
Tidal volume (V T):
8 ml/kg
Peak Inspiratory Pressure (PIP) or
Inspiratory Pressure Limitation (IPL):
Should not > 20 25 cm H2O
Changes in inspiratory pressure should be undertaken in
2 cm H2O
Frequency :
Babies : 30 40 x/min
Infants : 20 25 x/min
Older children : 15 20 x/min
Changes in the ventilatory frequency are made in steps
of 3 5 /min
Ventilatory Parameter
Inspiratory/Expiratory Ratio (I/E Ratio) :
RR = 60/ (TI + TE)
Severe restrictive ventilatory disorders (ARDS)
TI
Obstructive ventilatory disorders (asthma)
TI and TE
TI normal : 0.4 1.0
TE should not < 0.25 to avoid air trapping
Normal I:E ratio 1:1 and 1:2
Ventilatory Parameter
Flow:
Babies : 4 10 L/minute
PIP Flow
CPAP flow rate in constant flow ventilator
2.5 3 times MV (VT x RR).
Minimum of a 3-4 L/m
PEEP:
4 8 cm H2O
Changes in PEEP level should be undertaken in
steps of 1 or 2 cm H2O
Ventilatory Parameter

Mean Airway Pressure (MAP):


MAP is determined by inspiratory flow, PIP, I:E ratio and
PEEP and is about 5-10 cm H2O
MAP should be as low as possible to minimize the danger
of barotrauma
FiO2 :
Keep FiO2 as high required but as low as possible
Set to achieve PaO2 between 8-12 kPa for neonates and
about 13 kPa for babies and infants
Guidelines for the initiation of
mechanical ventilation

Choose the most popular ventilator mode


The initial FiO2 level should be 1.0.
Titrated downward to maintain the SpO2 at 92% to 94%
Initial VT 8-10 ml/kg.
Patients with ARF from neuromuscular disease often
require VT levels of 10 to 12 ml/kg to satisfy air hunger
Patient with ARDS, a VT of 5-8 ml/kg is recommended to
avoid high inspiratory plateau pressures
Choose a respiratory rate and minute ventilation as require
Target pH, not PaCO2
Basic ventilator setting for babies
(Constant-flow ventilator):
BW 5 kg
TI : 0.6 0.8
TE: 1.0 1.2
RR: 30 40x/m
I:E between 1:1 and 1:2
Flow: 5
PEEP: 3
FIO2: 50%
(or high enough for within normal limits)
Basic ventilator setting for most children

RR: 20 25x/m for infants


15 20 x/min for older children
I:E 1:2
VT : 10 15ml/kg
IPL: < 20 mbar
PEEP: 3-5 mbar
FIO2: 50%
(or high enough for within normal limits)
Use PEEP in diffuse lung injury
to support oxygenation and reduce the FiO2
Set the trigger sensitivity to allow a minimal patient
effort to initiate the inspiration
Sedation, analgesia, and neuromuscular
blockade, when poor oxygenation, inadequate ventilation or
excessively high PIP are thought to be related to intolerance of
vent setting
Initial Settings
Pressure Limited Volume Limited
FiO2 FiO2
Rate Rate
I-time or I:E ratio I-time or I:E ratio
PEEP PEEP
PIP or PAP Tidal Volume

These choices are with time - cycled ventilators.


Flow cycled vents are available but not commonly
used in pediatrics.
Initial Settings
Settings
Rate: start with a rate that is somewhat
normal; i.e., 15 for adolescent/child,
20-30 for infant/small child
FiO2: 100% and wean down
PEEP: 3-5
Control every breath (A/C) or some (SIMV)
Mode ?
Which is your choice?
Pressure Limited or Volume Limited
FiO2 FiO2
Rate Rate
Tidal Volume MV
I-time
PEEP PEEP
MAP I time
PIP
T V ( & MV) PIP ( & MAP)
Varies Varies
Adjustments
To affect To affect
oxygenation, ventilation,
adjust: adjust:
FiO2 Respiratory
PEEP Rate
I time MV
PIP MAP Tidal Volume
Pressure vs. Volume: I generally choose Volume to start.
(The others choose pressure).
Why? generally a more straightforward in terms of meeting
goals of ventilation.
Mode: PRVC, (new mode, if available), otherwise SIMV with or
without PS.
Why? PRVC has the advantages of guaranteed tidal volume
AND limiting the peak pressure. The decelerating wave
pattern on the flow is also generally more friendly.
Rate: 20
Why? A good place to start. You can always adjust later.
- large children < 15
- small infants or neonates > 30
PEEP: 5mm Hg
Why? a little above physiologic.
Not so high as to cause problems.
FiO2: 100%
Why? You can start to wean once you are certain
everything is stable. Allows maximal preoxygenation in
case anything happens.
Tidal Volume: 8-10ml/kg
Why? Above physiologic, gives good distention without
significant barotrauma. 10-12ml/kg used to be the standard
range, but people are generally using PEEP to maintain
lung volume and smaller tidal volumes to avoid baro or
volutrauma.
Inspiratory Time: somewhere from 0.5 to 1 second
Why? physiologic. Longer for bigger kids. But this will
vary on the situation. Asthmatics for example merit very
short I-times to allow maximal time for exhalation.
Blood Gases
The simplest way to look at mechanical ventilation
is as a way to keep the blood gases normal.

pH hydrogen Ion concentration


pCO2 partial pressure of Carbon dioxide
pO2 partial pressure of oxygen
To control Manipulate Adjust

pH Minute ventilation - Respiratory rate


PaCO2 - Tidal volume

PaO2 - Oxygen delivery - FiO2


- V/Q match - Mean airway pressure
(PEEP and PIP)
Adjusting ventilator setting according to BGA changes
PIP increased
PaO2 low PaCO2 high If spontaneous breathing present,
increase frequency.
FiO2 increased
PaO2 low PaCO2 normal Mean airway pressure increased
PEEP increased
TI prolonged
PaO2 low PaCO2 low Consider diagnosis of other abnormalities.
PaO2 normal PaCO2 high PEEP decreased
Frequency increased
Mean airway pressure maintained
PaO2 normal PaCO2 low Frequency decreased
Mean airway pressure maintained
PaO2 high PaCO2 normal Mean airway pressure decreased
PIP decreased
FiO2 decreased
PaO2 high PaCO2 low Pressure decreased
Frequency decreased.
FiO2 decreased
PaO2 normal PaCO2 normal -
Respiratory Rate

RR = 20 (resp cycle 3 seconds)


I E

RR = 12 (resp cycle 5 seconds)

I E
Airway Pressure and Flow Tracing

Spontaneous Vent PSV


P
r
e
CPAP SIMV
Ps
s
s
u
AC
r
e SIMV+PS

AC+PEEP CMV
Time
CPAP

Decreases the work of breathing by


reducing inspiratory work
Increases total lung volume
Offers no back up rate
Variable tidal volume dictated by effort
CPAP Mode
Continuous Positive Airway Pressure
The maintenance of a pressure above atmospheric at the
airway opening throughout a spontaneous breathing cycle
BIPAP Mode
Biphasic Positive Airway Pressure

Pressure-controlled ventilation combined with free


spontaneous breathing during the complete breathing cycle.
Control
Every breath is machine initiated and
dictated
Fixed tidal volume with each breath
No utility outside of the operating room
Control Mode

Lung
Volume

Airway
M M M M
Pressure

Time
Assist Control

Preset rate and tidal volume


For each additional triggered attempt
the ventilator will deliver a standard
tidal volume breath
Initial mode of choice for respiratory
failure
Assist Control Mode

Lung
Volume

Airway
Pressure M M P P

Time
Assist-control, volume

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB,


Scmidt GA, & Wood LDH(eds.): Principles of Critical Care
SIMV
Synchronized intermittent mandatory
ventilation
Preset rate and tidal volume synchronized
to the patients efforts
For each additional triggered attempt the
ventilator will deliver a variable tidal
volume breath dictated by patient effort
and not ventilator supported
SIMV Mode

Lung
Volume

Airway
Pressure M M
P P

Time
SIMV Mode
Synchronised Intermittent Mandatory Ventilation
Combination of machine ventilation and spontaneous breathing
Patient can breath spontaneously in prescribed cycles
Mechanical mandatory ventilation synchronise with patient
Pressure Support
Preset pressure boost on inspiration
Delivery of a variable tidal volume based
on lung, chest wall, ventilator system
compliance and patient effort
Requires a spontaneously breathing
patient
SIMV with Pressure Support

Offers the benefits of pressure support


with the security of a back-up rate
Pressure support is delivered each time
the patient generates a negative
inspiratory effort
SIMV + PSV

Lung
Volume

Airway
Pressure M M P P

Time
CPAP + PSV

Lung
Volume

Airway
Pressure P P P P

Time
Tidal Volume

8-10 cc/kg ideal body weight


Factors together with respiratory rate to
produce minute ventilation
Consider reductions in patients with
reactive airways disease or multilobar
infiltrates to 6-8 cc/kg
PEEP
Positive end expiratory pressure
Increases residual volumes and total lung
volumes
5 cm H2O is considered physiologic by
some and unnecessary by others
High levels may limit venous return and
potentially injure the lung
Alveolar Distention
PEEP 6 cc/kg 10-15 cc/kg

Good Bad
U
g
l
y

Increasing Tidal Volume and Plateau Pressure


Overdistending healthy alveoli
Peak Flow

The speed that a tidal volume is delivered


Typically preset at 60 L/min ?
Increased from 80-120 L/min in those
patients with reactive airways disease
May increase PIP but not plateau
pressures
Flow: 4-10 L/min in babies (3 x MV)
Flow time waveform
FIO2
Positive pressure ventilation alters
the normal pulmonary physiology
Start with 100% FIO2 and
titrate to pulse oximetry
Lung injury due to high levels of oxygen
occurs at prolonged time greater than 24 hours
at FIO2 greater than 70%
Sensitivity
The ventilators ability to sense
the patients inspiratory efforts
Measured in negative pressure cm H2O
Typically set at -2 cm H2O
The more negative the pressure setting,
the greater the work of breathing
Settings Summary
Mode ? (Assist Control)
Respiratory rate ? < 20 >
Tidal volume ? (8-10 cc/kg BW)
PEEP ? (5 cm H2O)
FIO2 ? (100%)
Peak flow ? 60 L/min
Lung Pressures

Peak Inspiratory Pressure (PIP)- the


highest inflection point reached during
delivery of a breath
Dictated by system and patient
compliance
No correlation with risk of lung injury
Lung Pressures

Plateau Pressure - if an inspiratory pause


is placed at the end of inspiration,
the needle comes to rest at a point
the plateau pressure
Reflects the pressure witnessed by the
alveolus and correlates with the risk of
lung injury > 30 cm H2O
Plateau Pressure

Lung
Volume
Peak Airway Pressure

Airway Plateau Pressure


Pressure

Time
Troubleshooting
Is it working ?
Look at the patient !!
Listen to the patient !!
Pulse Ox, ABG, EtCO2
Chest X ray
Look at the vent
(PIP; expired TV; alarms)
Troubleshooting
When in doubt, DISCONNECT THE
PATIENT FROM THE VENT, and begin
bag ventilation.
Ensure you are bagging with 100% O2.
This eliminates the vent circuit as the source
of the problem.
Bagging by hand can also help you gauge
patients compliance
Troubleshooting
Airway first: is the tube still in? (may need
DL/EtCO2 to confirm) Is it patent? Is it in the
right position?
Breathing next: is the chest rising? Breath
sounds present and equal? Changes in exam?
Atelectasis, bronchospasm, pneumothorax,
pneumonia? (Consider needle thoracentesis)
Circulation: shock? Sepsis?
Trouble Shooting
Dont be a DOPE
Disconnect the patient from the vent and
bag the patient with 100% oxygen
Confirm ETT placement-Airway
Auscultate the lungs-Breathing
Consider other causes of circulatory
compromise-Circulation
Keep needle and tube thoracostomy kit handy
Common Problems: DOPE
Dislodge: Extubation,
Obstructed: Plug, mainstem, kink
Pneumothorax - Tension
Equipment failure etc.: Ventilator, suction,
oxygen delivery, nebulizer, agitation, dynamic
hyperinflation
Troubleshooting
Improving Ventilation and/or Oxygenation
can increase respiratory rate (or decrease rate if
air trapping is an issue)
can increase tidal volume/PAP to increase tidal
volume
can increase PEEP to help recruit collapsed
areas
can increase pressure support and/or decrease
sedation to improve patients spontaneous effort
Trouble Shooting
Adjusting PaO2:
To decrease :
FiO2 should be decreased of 10-20%.
Rule of 7 : there will be a 7 mmHg decrease in
PaO2 to each 1% decrease in FiO2
To increase:
Correction of the respiratory acidosis will
improve oxygenation
PEEP can be added in increments
from 2-4 cm H2O
Increase I:E ratio
Trouble Shooting
Adjusting PaCO2:
To decrease:
Increase the rate
Increase the tidal volume
To increase:
Check the leaks in the systems
Decrease the rate
Decrease the tidal volume
Determine the cause of hyperventilation
Rule out artificial causes of increased
respiratory rate
Weaning Off
Steps for reducing mechanical vent support :
Reduction of the FiO2 concentration
Normalization of the I:E ratio
Reduction of the PEEP
Alternate ventilatory modes allowing spontaneous
respiratory effort (SIMV, ASB, BIPAP, CPAP)
Reduction or adjustment of the analgesic and
sedation
Weaning Criteria
Stable clinical situation
Adequate ventilatory situation
Adequate cerebral functions
Stable cardiovascular situation
Adequate fluid balance
Stable gastrointestinal function
Good balanced metabolic situation
No extreme catabolism
Extubation Criteria
Extubation (minimum value)
Gas exchange :
PaO2 with FIO2 < 0.4 > 8 kPa
PaO2/FiO2 > 200
PaCO2 < 6 kPa
pH > 7.35
Breathing mechanics :
RR < 35 x/m
VT > 5 ml/BW
Vital capacity > 10-15 ml/BW
Inspiratory effort > 25 cm H2O
Symptoms of weaning failure
Increasing tachypnea
Reduced tidal volume
Thoraco-abdominal discoordination
Secretion retention
Restlessness
Tachycardia
Hipertension
Weaning Algorithm
Special situations I

Obstructive Diseases
Asthma and RSV Bronchiolitis
Watch for air trapping / breath stacking
Low rate, larger Tidal volume, long
Expiratory time
check Autopeep
preserve I-time
Consider Heliox, Ketamine, Halothane
Special situations II
Restrictive disease (ARDS)
Limit Tv accept hypercapnia
Increase PEEP for FRC
Prone positioning
CaO2 and tolerate lower Sat %
consider High Frequency Oscillatory
(HFO) Ventilation>>> Surfactant>>>
Nitric Oxide
Adverse effects of
mechanical ventilation :
Increase in intra-thoracic pressure
Decreased venous return
Increased pulmonary vascular resistance
Reduction in cardiac output
Decreased perfusion of kidneys, liver and
viscera
Reduced venous return from the brain and
consequent increased intra-cerebral pressure
Barotrauma
Complications
Ventilator Induced Lung Injury (VILI)
Oxygen toxicity
Barotrauma / Volutrauma
Peak Pressure
Plateau Pressure
Shear Injury (tidal volume)
PEEP
Complications
Cardiovascular Complications
Impaired venous return to RH
Bowing of the Interventricular Septum
Decreased left sided afterload (good)
Altered right sided afterload
Sum Effect..decreased cardiac output
(usually, not always and often we dont
even notice)
Complications
Other Complications
Ventilator Associated Pneumonia
Sinusitis
Sedation
Risks from associated devices
(CVLs, A-lines)
Unplanned Extubation
Getting Started (Parameters)

Oxygenation Ventilation (MV)

PEEP Rate

I-time (flow) Tidal Volume (P)

FIO2
Getting Started (Mode)
Volume Pressure
Pros Preserve MV Avoid PP
Easy Familiar (NICU)
Decelerating Flow

Cons PP ?? MV??
Constant flow
Control vs. SIMV
Control Modes SIMV Modes
Every breath is Vent tries to synchronize
supported regardless of with pts effort
trigger
Cant wean by Patient takes own breaths
decreasing rate in between (+/- PS)
Patient may Potential increased work of
hyperventilate if agitated breathing
Patient / vent
Can have patient / vent
asynchrony possible and
may need sedation +/- asynchrony
paralysis
Pressure vs. Volume
Pressure Limited Volume Limited
Control FiO2 and Control minute
MAP (oxygenation) ventilation
Still can influence Still can influence
ventilation oxygenation
somewhat somewhat (FiO2,
(respiratory rate,
PAP)
PEEP, I-time)
Decelerating flow Square wave flow
pattern (lower PIP pattern
for same TV)
Pressure vs. Volume
Pressure Pitfalls Volume Vitriol
tidal volume by change no limit per se on PIP
suddenly as patients (usually vent will have
compliance changes upper pressure limit)
this can lead to square wave(constant)
hypoventilation or
overexpansion of the flow pattern results in
lung higher PIP for same
if ETT is obstructed tidal volume as
acutely, delivered tidal compared to Pressure
volume will decrease modes
Trigger
How does the vent know when to give a
breath? - Trigger
patient effort
elapsed time

The patients effort can be sensed as a


change in pressure or a change in flow
(in the circuit)
Troubleshooting
Well, it isnt working..
Right settings ? Right Mode ?
Does the vent need to do more work ?
Patient unable to do so
Underlying process worsening (or new problem?)
Air leaks?
Does the patient need to be more sedated ?
Does the patient need to be extubated ?
Vent is only human..(is it working ?)
Troubleshooting
Patient - Ventilator Interaction
Vent must recognize patients
respiratory efforts (trigger)
Vent must be able to meet patients
demands (response)
Vent must not interfere with patients
efforts (synchrony)
Need a hand??
Pressure Support
Triggering vent requires certain amount of
work by patient
Can decrease work of breathing by providing
flow during inspiration for patient triggered
breaths
Can be given with spontaneous breaths in IMV
modes or as stand alone mode without set rate
Flow-cycled
Advanced Modes
Pressure-regulated volume control
(PRVC)
Volume support
Inverse ratio (IRV) or airway-pressure
release ventilation (APRV)
Bilevel (BIPAP)
High-frequency
Advanced Modes
PRVC
A control mode, which delivers a set
tidal volume with each breath at the
lowest possible peak pressure. Delivers
the breath with a decelerating flow
pattern that is thought to be less injurious
to the lung the guided hand.
Advanced Modes
Volume Support
equivalent to smart pressure support
set a goal tidal volume
the machine watches the delivered
volumes and adjusts the pressure support
to meet desired goal within limits set
by you.
Advanced Modes
Airway Pressure Release Ventilation
Can be thought of as giving a patient two
different levels of CPAP
Set high and low pressures with release
time
Length of time at high pressure generally
greater than length of time at low pressure
By releasing to lower pressure, allow lung
volume to decrease to FRC
Advanced Modes
Inverse Ratio Ventilation
Pressure Control Mode
I:E > 1
Can increase MAP without increasing PIP:
improve oxygenation but limit barotrauma
Significant risk for air trapping
Patient will need to be deeply sedated and
perhaps paralyzed as well
Advanced Modes
High Frequency Oscillatory Ventilation
extremely high rates (Hz = 60/min)
tidal volumes < anatomic dead space
set & titrate Mean Airway Pressure
amplitude equivalent to tidal volume
mechanism of gas exchange unclear
traditionally rescue therapy
active expiration
Advanced Modes
High Frequency Oscillatory Ventilation
patient must be paralyzed
cannot suction frequently as disconnecting the
patient from the oscillator can result in volume
loss in the lung
likewise, patient cannot be turned frequently so
decubiti can be an issue
turn and suction patient 1-2x/day if they can
tolerate it
Advanced Modes
Non Invasive Positive Pressure Ventilation
Deliver PS and CPAP via tight fitting mask
(BiPAP: bi-level positive airway pressure)
Can set back up rate
May still need sedation
How do you
trouble shoot
mechanical
ventilators??
Lowered Expectations
Permissive Hypercapnia
accept higher PaCO2s in exchange for limiting
peak airway pressures
can titrate pH as desired with sodium
bicarbonate or other buffer
Permissive Hypoxemia
accept PaO2 of 55-65; SaO2 88-90% in
exchange for limiting FiO2 (<.60) and PEEP
can maintain oxygen content by keeping
hematocrit > 30%
Adjunctive Therapies
Proning
re-expand collapsed dorsal areas of the lung
chest wall has more favorable compliance curve
in prone position
heart moves away from the lungs
net result is usually improved oxygenation
care of patient (suctioning, lines, decubiti)
trickier but not impossible
not everyone maintains their response or even
responds in the first place
Adjunctive Therapies
Inhaled Nitric Oxide
vasodilator with very short half life that can be
delivered via ETT
vasodilate blood vessels that supply ventilated
alveoli and thus improve V/Q
no systemic effects due to rapid inactivation by
binding to hemoglobin
improves oxygenation but does not improve
outcome
Extubation
Weaning
Is the cause of respiratory failure gone or
getting better ?
Is the patient well oxygenated and
ventilated ?
Can the heart tolerate the increased work
of breathing ?
Extubation
Weaning (cont.)
decrease the PEEP (4-5)
decrease the rate
decrease the PIP (as needed)
What you want to do is decrease what
the vent does and see if the patient can
make up the difference.
Extubation
Extubation
Control of airway reflexes
Patent upper airway (air leak around tube?)
Minimal oxygen requirement
Minimal rate
Minimize pressure support (0-10)
Awake patient
Compliance

Burton SL & Hubmayr RD: Determinants of Patient-Ventilator Interactions:


Bedside Waveform Analysis, in Tobin MJ (ed): Principles & Practice of Intensive
Care Monitoring