Introduction to

Mechanical Ventilation
Postgraduate students

ICU Educator
2014
CEDU Learning outcomes
At the end of the session, the student is expected to:
•Discuss the indications for mechanical ventilation
•Identify the complications associated with
mechanical ventilation
•Explain compliance and resistance
•Explain the different modes of mechanical
ventilation
•Explain common terms and values used
mechanical ventilation
•Discuss basic waveforms
•Discuss the nursing care associated with a
ventilated patient
CEDU Spontaneous breathing review

Richardson, 2007

4 Phases:
Inspiration (active process)
• muscles contract
• air flow in
Expiration (passive process)
• muscles relax
• air flows out
CEDU
Spontaneous breathing
Inspiration Expiration
• Lung pressure < • Lung pressure >
atmosphere pressure atmosphere pressure

• Air move from • Air move out from

atmosphere to
lung/ alveoli
lung/alveoli
CEDU Mechanical breathing
• Ventilators deliver a breath by forcing air
into the lungs to inflate them and
therefore causing a positive pressure.
• Expiration remains a passive process
and occurs when the ventilator cease to
deliver the breath and allows for the
breath to be passively exhaled
• The ventilator dose not “suck” the gas
out of the lungs
• Why do we breathe?
• What is the role of the upper airways?
CEDU Aims of mechanical ventilation
• The main aim of MV is to ensure the
patient has optimal oxygenation and
ventilation. Thereby maintaining gas
exchange (O2 and CO2), controlling the
elimination of CO2 and reduce work of
breathing (WOB).
CEDU Indications
• Inadequate oxygenation (O2)
o Hypoxia
o Pulmonary oedema
o Pneumonia
• Inadequate ventilation (CO2)
o Decreased consciousness
o Cardiopulmonary arrest
CEDU Type 1 and type 2 failure
• Type 1 respiratory failure
o Hypoxemic
o Inadequate oxygenation

• Type 2 respiratory failure

o Hypercapnic
o Inadequate ventilation
CEDU Complications/risks
• Barotrauma • Biotrauma
o Increased airway o Activation of both
pressures local and systemic
inflammatory
• Volumtrauma mediators
o Overdistension
• Infection-Ventilator
• Atelectasis associated
• Stress/ Delium pneumonia
• Oxygen toxicity
CEDU Physiological changes
• The effect of positive pressure ventilation
o Decreased venous return, therefore reduced
cardiac output.
o Increased pulmonary vascular resistance.
o Decreased urine output, secondary to the
reduced cardiac output.
o Increased risk of pneumothorax.
CEDU Lung changes
• Atelectasis –
o Collapse of part or all of a lung by blockage of
the air passages. Common causes are
prolonged bed rest with few changes in
position, shallow breathing, accumulation of
secretions and underlying lung diseases
• Reduction in surfactant
o The surfactant reduces the surface tension of
alveoli and eases the opening of the alveoli.
• Reduction in lung compliance
CEDU Other changes
• Reduces the oxygen consumption of the
patient which required for the work of
breathing.
• Water and sodium changes due to the
effect of positive pressure in the lungs on
the secretion of antidiuretic hormone.
CEDU Compliance/resistance
• Compliance
o Elastance and recoil of the lung tissue and
chest wall
o ARDS/Pneumonia/Pulmonary
fibrosis/Pneumothorax/Crush injury
• Resistance
o Measurement of the opposition to the flow of
gas
o Inflammation/Swelling/Bronchospasm/Asthma
CEDU Pressure or Volume
• Volume
o A set Vt is chosen on the ventilator to
deliver a set volume for each ventilator
breath.
o The airway pressures are variable based
upon the pts lung compliance.
o 6-10mls/kg
• Pressure
o A set pressure is chosen on the ventilator to
deliver air flow until the pressure is reached.
o The tidal volume is variable based upon the
pts lung compliance.
CEDU Modes of Ventilation

• CMV – Continuous Mandatory

Ventilation
o Used when the pt is not expected to
breath for themselves.
o Mandatory mode so has a set RR
o Either a set volume or set pressure can be
used.
o Also know as IPPV
o Our Assist Control (A/C)
CEDU SIMV

• Synchronized Intermittent Mandatory

Ventilation
o The pt is able to breath spontaneously
between the mandatory breaths.
o Mandatory mode so has a set RR
o The ventilator is able to synchronize the
mandatory breaths with the pts respiratory
effort. If no resp effort is made the ventilator
will deliver the set breath rate at RR.
o Either a set volume or set pressure can be
used.
CEDU P/S
• Pressure Support
o When the pt “triggers” a breath the ventilator
provides support. This augments the pts effort.
o The amount of support chosen should support
the pt and enable them to achieve a suitable
tidal volume without excessive work of
breathing.
o Can be used in different modes of ventilation
whenever the patient will take spontaneous
breaths (i.e. SIMV, CPAP, BiLevel)
o Normal range 10 – 20 cmH2O
 CPAP / PEEP
CEDU

• These terms are often used interchangeably

• CPAP – Continuous Positive Airway Pressure
• PEEP – Positive End Expiratory Pressure
• The pressure holds the alveoli open at the end of
a breath allowing gas exchange to continue to
occur.
• Enables recruitment of alveoli which are
collapsed.
• Normal range 5 – 10 cmH20, can be set up to 20
cmH20.
CEDU CPAP/Pressure Support
• Written as PSV
• Most common spontaneous mode of
ventilation.
• Provides pressure support on each
spontaneous breath with CPAP at the end of
expiration.
• Level of support set to provide minimal
support for patient to achieve adequate
ventilation.
• Weaning mode, allows pt to exercise their
respiratory muscles.
CEDU Flow
• Known as Peak flow
• Like a big flow meter on the wall
• Is required to deliver adequate tidal
volumes within the set time
• Normal 40-60L/min
• Required to be set for Volume control
modes
(SIMV VC, A/C VC)
 %P (Puritan)
CEDU
T insp. rise (Servo-i)

• Determines how quickly the pressure is

delivered during the inspiratory breath
• Higher % or shorter T insp. rise means the
pressure level is reached faster providing
the patient with an easier sensation of
breathing
• Look to increase the % (or decrease the T
insp. Rise if patients “breath/flow hungry”
CEDU PIP
• Peak inspiratory pressure
o Highest pressure reading during mechanical
inspiration
o Detecting an increased risk of barotrauma
o Caused by
o Biting on tube
o Sputum
o Coughing
o Asthma
CEDU I:E
• Time (seconds) spent in inspiration versus
expiration
• Expressed as ratio
• Normal is 1:2
• Can see 1:4 or 1:5
o Which patients might require this ratio?
CEDU Trigger

• Ensure that the ventilator is able to

detect patient’s respiratory effort
• Determines the amount of effort the
patient must generate to initiate a breath
• Can be flow (flow-by) or pressure
• Too low = self triggering
• Too high = causes distress and
uncomfortable for patient
CEDU Esens
• Esens = expiratory value sensitivity (Puritan)
• Insp cycle off (Servo-i)
o Ensures the ventilator knows when to open to
expiratory valve to allow the patient to breath
out
o Only needed on spontaneous breaths
o Normally set at 25% - higher shortens
inspiratory time, lower increases/lengthens
inspiratory time (Servo-i default 30%)
CEDU Esens
CEDU Common symbols
• V = flow (L/min) • PS = pressure
• f = resp rate (min) support
• Vt = tidal volume • PEEP = positive end
(mls) expiratory pressure
• FiO2 = fraction of • Pmean = mean
inspired oxygen inspiratory pressure
• Ti = inspiratory time • PIP = peak
(sec) inspiratory pressure
• MV = minute
ventilation (L/min)
CEDU Ventilator waveforms
Ventilator waveforms are a graphical
representation of breath delivery
They can be used to:
o Identify breath types
o Assist in manipulating parameters for specific
patients
o Assist in identifying and troubleshooting problems
Waveforms available:
o Pressure - Time
o Flow – Time
o Volume – Time
o Pressure – Volume Loop
CEDU Ventilator waveforms
Flow versus time waveform
Flow
LPM Peak flow
End inspiration
Increase
in flow

Time

End
expiration
Patient Passive
triggered expiration
effort begins
 Flow - time

Square: constant flow, results in higher PIP and shorter pPlt time (and therefore less
time for gas exchange)
Sine: normal spontaneous breath
Decelerating: flow initially fast to reach a given pressure, then slows to maintain a
pPlt. This is the most desirable flow pattern as it allows for larger tidal volume delivery
with lower airway pressures (reducing the risk of volutrauma and VIL) and it results in
a longer pPlt and hence better gas exchange.
 Flow - time

Assessing Inspiratory time:

If flow does not return to zero prior to the end of inspiration, then the
inspiratory time is too short to deliver the desired tidal volume.
 Flow - time

Assessing efficacy of bronchodilators:

As well as listening to a patient’s chest pre and post administration of
bronchodilators to assess for wheeze, examining the flow – time waveform can also
be useful. If bronchospasm is reduced, expiratory flow will be faster and the
expiratory time will be shorter.
 Flow - time

Assessing for leaks (when a flow trigger is used):

Leaks can occur in the circuit, around the cuff of an artificial airway, or if a
bronchopleural fistula is present.
Note that when the expiratory flow ceases, the flow rate has become positive. The
continued ventilator flow rate compensates for the leak to ensure maintenance of
PEEP.
CEDU
Ventilator waveforms

Pressure versus time waveform

Pressure

Peak
inspiratory
pressure

End
Pressure
expiration
rises with Time
ventilator
delivered Passive
breath expiration
begins
 Pressure - time

A – B = Inspiratory Time
B = Peak Inspiratory Pressure
B – C = Expiratory Time
Area beneath the curve = mean airway pressure
 Pressure – time
Mandatory breath

Patient initiated, synchronised

breath: note the negative
deflection prior to inspiration

Spontaneous breath with

no pressure support
 Pressure – time
Pressure support
breaths: varying
inspiratory times

Pressure control
breaths: patient initiated,
synchronised. Note the
plateau pressure and
absence of a PIP
 Pressure - time

Assessing the Flow Rate:

• a long, sloping increase in pressure indicates that the flow rate is too low
• a rapid, steep rise to pressure indicates that the flow rate is too high
 Pressure - time

Assessing the Rise Time (time to reach the set pressure):

• Breath B is an example of a desirable pressure waveform
• Breath A depicts slow rise time: the rise to pressure was so slow that there is no
plateau pressure.
•Breath C depicts fast rise time: high PIP, prior to dropping to the pPlt.
CEDU Ventilator waveforms
• Volume versus time waveform
Volume
Volume Tidal
increases as volume
ventilator breath
is delivered

Time

Inspiration Expiration
 Volume – time

Normal: begins at, and

returns to zero.

Abnormal: the volume

delivered is not
completely exhaled.
This could be due to gas
trapping or a leak.
NURSING A VENTILATED
PATIENT
CEDU Safety
• NUMBER 1 priority
• Must be visualised at all times
• BVM must reach patient
• Portable O2
• Suction attached and on
• Ventilator plugged into BLUE plug
• Check alarms
CEDU
Alarms
• Ventilator alarms
• Monitor alarms

Alarm Setting
PIP alarm VC 20%>Pinsp or <40mmH2O
PC <35mmH2O
PEEP 2-3cmH2O above preset amount
Vt 20% above and below optimal
MV 20% above and below optimal
f <30
CEDU Caring for ventilated patient
• Sedation
o Minimal sedation to enable the patient to be comfortable
on the ventilator
o Reduce metabolic demand for patients, important of
patients with severe hypoxia
o Common drugs – morphine, midazolam & propofol.
• Nutrition
o Important to establish feeding early to provide energy for
respiratory muscles
o Do not want to allow overfeeding of carbohydrate, this will
produce excess CO2. The patient will then have to
increase their MV to “blow off” CO2.
CEDU

• Suction
o Open or closed suction
o Clearance of secretions when clinically indicated.
o Pre-oxygenate before suction
o No evidence to support instillation of saline down ETT.
o Suction catheter should be half the diameter of the ETT or
tracheostomy
o Suction applied as catheter is removed
o Process of insertion and withdrawal of catheter should not
take longer than 30 secs.
CEDU

• Humidification
o Essential at all times
o Prevents the drying and thickening of
secretions
o HME – Heat and Moisture Exchange
o Picks up moisture and heat from the patients
exhaled breath and then transferred back to the
patient in the next inhaled breath.
o Hot water bath – (Fisher & Pykel)
o The inspired air passes over a bath of heated
sterile water. This enables the warm moist air to
be carried to the lungs.
CEDU

• Communication
o The presence of a ETT or Trachy limits
conversation to yes or no answers.
o Use of writing boards, communication boards.
o Non-verbal communication.

• Why can’t patient’s talk?

CEDU
• Monitoring
o Continuous monitoring of O2 Sats.
o Regular ABGs
o How often? When?
o Why do we even do ABGs?
o End tidal CO2
o Documentation of ventilator settings and
patient observations
o RR, Vt, MV, FiO2, I:E, Vent Mode,O2Sats,
Airway Pressures,
o Alarms set – airway pressures, MV, Vt, RR,
CEDU Weaning
• Following short-term ventilation i.e. post
surgery
o Regain consciousness
o Making respiratory effort
o Adequate pain relief
o Minimal ventilator support – CPAP/PS with
CPAP of 5 cmH20 and PS of 10 cmH20 and
FiO2 < 0.4.
o Normal ABGs
o Able to obey commands – cough on
command
CEDU

• After longer period of ventilation

o Wean to spontaneous mode ASAP, however
the patient may require additional PS or CPAP
if respiratory muscles wasted.
o Pt can be ventilated for weeks or months as
PS is gradually decreased as pt regains
muscle strength.
o Trachy used if long term ventilation required.
o Sitting out of bed and even walking should be
encouraged as tolerated.
CEDU Extubation
• Minimal ventilatory support – FiO2 <50%,
CPAP 5cmH2O & PS 8cmH20.
• Conscious state – obey commands
• Minimal sputum
• No airway obstruction
CEDU

• Process
o Stop NG feeds > 4 hours previously
o Explain procedure to patient
o Prepare equipment – scissors, syringe, suction, O2 mask,
emergency equipment
o Ensure medical staff aware.
o O2 mask with O2 flowing
o Suction down ETT and in oropharynx
o Cut tapes
o Suction down the tube
o Then deflate the ETT cuff while suction catheter insitu
o Pull up suction catheter and ETT simultaneously.
CEDU

• Suction mouth
• Encourage pt to cough
• Apply O2
• Observe for resp distress
o Stridor
o APO
o Wheeze
o Hypoxia
• Observe for >4 hours before discharge to the ward
CEDU Questions
CEDU References
• Arthur, S, S. (1999). Lung Injury Caused by
Mechanical Ventilation. Chest, 116. (95-115)
• Dekeer, F. (2003). Psychoneuroimmunology in
critically ill patients. ACCCN Clinical Issues, 14 (1).
25-32
• Jin Xiong Lian. (2008). Know thefacts of mechanical
ventliation. Men in Nursing. Go to
• http://www.Mechanical ventilation ppt 2012\Know the
facts of mechanical ventilation.mht
• http://www.ccmtutorials.com/rs/mv/index.htm
CEDU

• http://en.wikipedia.org/wiki/Ventilator-
associated_pneumonia
• Mazen Kherallah. (2009). Advanced Mode of
Mechanical Ventilation. Middle East Critical Care
Assembly. Go to
• http://www.mecriticalcare.net/downloads/mv/Adva
ncedVentilatoryModes.pdf
• E, W. Ely., S, K. Inouye., G, R. Bernard., S,
Gordon., etc. (2001). Delirium in Mechanically
Ventilated patients. Caring for the critically ill
patient. JAMA. 286 (21). 2703-2710
CEDU

• Deshpande, V., Clinical Utility of Ventilator Waveforms,

http://www.vsrc.org/HandoutVentGraphics.doc
• Neligan, P., A System for Analysing Ventilator
Waveforms, Critical Care Medicine Tutorials,
http://www.ccmtutorials.com/rs/mv/page15.htm
• Op’t Holt, T. B., Understanding the essentials of
waveform analysis, AARC Times, 1999, pp7-12.
• Rittner, F. & Doring, M., Curves and Loops in
Mechanical Ventilation, Draeger Medical, 2005.
• Tyco Healthcare, Ventilator Waveforms, Graphical
Presentation of Ventilator Data, 2003.
CEDU

Diagrams:
• Deshpande, V., Clinical Utility of Ventilator
Waveforms,
http://www.vsrc.org/HandoutVentGraphics.doc

• Rittner, F. & Doring, M., Curves and Loops in

Mechanical Ventilation, Draeger Medical, 2005.

• Tyco Healthcare, Ventilator Waveforms, Graphical

Presentation of Ventilator Data, 2003.