Mechanical Ventilation -

Initial Settings
Abdallah Adel Farah
 Learning Objectives
• By the end of this session all learners, must be
able to :
• Discuss the choice of mode initially.
• Outline the initial ventilator settings.
• Know the different values of each mode.
• The proper adjustments to initial settings
• Able to start immediate ventilatory support.
DETERMINING INITIAL
VENTILATOR SETTINGS
 PROBLEM: A 52-year-old man, 5 ft (178 cm) tall and
weighing 200 lb (90 kg),
• is being returned from the operating room after
coronary artery bypass surgery.
• He is being manually(bag-tube) ventilated with
supplemental O2 by the anesthesiologist on the route to
the ICU. He is apneic at this time.
• The patient has no history of lung disease and has never
smoked cigarettes.
• Heart rate and blood pressure are stable, and SpO2
during manual ventilation is 99%.
• What initial mode, VT, rate, and FiO2 appropriate for
this patient ?.
Choice of Mode
• The question of which mode is the right
mode of ventilation for respiratory failure of a
particular cause has no simple answer.
• Initial ventilator settings are chosen based on
the patient’s clinical presentation, the need to
provide full or partial ventilator support and
the patient’s work of breathing .
• The first step in selecting the ventilator mode
is to decide whether the patient should
receive full ventilatory support or partial
ventilatory support.
• The majority of ventilating patients initially
require full support, with the control mode or
the assist/control mode.
• The synchronized intermittent mandatory
ventilation (SIMV) mode also provides full
ventilatory support if the patient is not
breathing spontaneously between mechanical
breaths, and the mandatory frequency is set at
12/min or higher.
• However, there is no evidence suggesting any
of the modes are more beneficial in terms of
patient outcomes except that weaning is
delayed with SIMV.
• Assist/control volume ventilation is the most
common ventilator mode used throughout the
world as the primary initial mode of
ventilatory support.
Choose What You
Know Best
 Volume assist/ Controlled Ventilation

• Appropriate in patients with no respiratory

effort because of depressed neurologic status.
• When sedation and paralysis is indicated to
prevent respiratory effort or other
movements.
• When negative inspiratory effort is
contraindicated as in some cases of severe flail
chest.
Pressure Assist/Controlled Ventilation

• in patients with non-compliant lungs who

exhibit high airway pressure and poor
oxygenation while supported by volume-
controlled ventilation.
• is postulated to reduce pulmonary
barotrauma associated with high ventilatory
pressures and uneven gas distribution.
• Pressure control is also useful in patients
whose airway cannot be fully sealed –
children, and patient with bronchopleural
fistula .
 settings V P PS SIMV & PS
assist/control assist/control
FiO2
RESP Rate
Tidal Vo
Inspiratory
P
Inspiratory
F
I:E Ratio
Inspi pause
PEEP
Trigger
 Tidal Volume and Rate
• The two major determinants of minute
ventilation.
• initial VT of 6 to 8 ml/kg IBW.
Males: Predicted body wt =
50 + 0.91 (ht in cm-152.4)
Females : Predicted body wt =
45.5 + 0.91 (ht in cm-152.4)
• The initial Frequency/respiratory rate, to
eucapneic ventilation (PaCO2 at patient’s
normal) is usually set between 10 and 12/min.
• Normal minute ventilation 7 to 8 L/Min.
 Fraction of inspired oxygen
• The initial fraction of inspired oxygen (Fio2),
should be 1.0 to ensure maximal amount of
available oxygen during the ventilator
adjustments and attempts to stabilize the
patient’s condition.
• It should be adjusted accordingly to maintain a
PaO2 between 80 and 100 mm Hg (lower for
patients with chronic CO2 retention).
• After stabilization of the patient, the FIO2 is
best kept below 50% (titrated over time) to
avoid oxygen induced lung injuries.
• For patients with mild hypoxemia or patients
with normal cardiopulmonary functions (e.g.,
drug overdose, uncomplicated postoperative
recovery), the initial FIO2 may be set at 40% or
at the patient’s FIO2 prior to mechanical
ventilation.
• After placing the patient on a ventilator, blood
gases should be obtained within 15 to 30 min
after the patient has stabilized, to assess both
ventilation , oxygenation and metabolic
components.
Inspiratory-to-Expiratory Ratio I:E
• Generally the ratio is set at 1:2, that’s means
one third of respiratory cycle time is for
inspiration and the rest two thirds is for
expiration.
• initial inspiratory time of approximately 0.8
second (0.6 to 1.0 sec).
• This setting is believed to mimic spontaneous
respiration when lung function is normal .
 Flow Rate
• Flow rate is the speed with which the tidal
volume is delivered; it is measured in liters per
minute.
• The inspiratory flow rate is the chief
determinant of inspiratory time and thus of
the I:E ratio.
• The tidal volume must be delivered within an
appropriate, comfortable time, and the flow
must meet or exceed the patients inspiratory
flow demand.
• If not, the patient will experience “air hunger”,
the work of breathing will be increased, and
patient-ventilator asynchrony will result .
 Relationship of VT, Flow Rate, RR and I:E
ratio
• Understanding of the interrelation of these
variables will help the practitioner to ventilate
a patient regardless of the type of equipment
in use.
 Using Flow to Change the I:E Ratio
Given: Minute Volume = 12 L/min
Desired I:E Ratio = 1: 3
Calculate: The flow rate for an I:E ratio of 1: 3
• Solution: Flow = Minute Volume x Sum of I:E
Ratio
= 12 L/min x (1 + 3)
= 12 L/min x 4
= 48 L/min
• Question :
• Tidal volume : 500 ml
• Rate : 20/minute
• I:E : 1:2
• Flow rate ?
• Duration of respiratory cycle : 3 seconds
• Inspiratory time : 1.0 second
• 500 ml : 1.0 second
• Flow rate L/min
• 500 X 60 = 30000 ml = 30 L/min
• Higher flow rates (>60L/min) shorten inspiratory
time, thereby lengthening expiratory time
(decreased I:E ratio), which may be desired in
patients with COPD and air trapping.
• Increasing the flow rate may have the negative
consequences of increasing the peak
inspiratory pressure and adversely affecting the
distribution of gases because flow becomes
more turbulent.
• Slower inspiratory flow rates will prolong
inspiratoy time, improve the distribution of
gases, and reduce PIP as a result of a more
laminar flow.
 Flow Wave Patterns
• Modern ventilators are capable of delivering
the flow of gases in variable configurations
known as flow wave patterns.
 There are four categories of waveforms :
• Square
• Sinusoidal
• Decelerating
• Accelerating
Square (Constant)

• Peak flow rate is delivered immediately at the

onset of inspiration, maintained throughout the
inspiratory phase, and abruptly terminated at
the onset of expiration .
SQUARE : -------------
Sinusoidal

• Inspiratory flow rate gradually accelerates to

peak flow and then tapers off.
• Believed to mimic spontaneous inspiratory
pattern.
SINUSOIDAL : -------------
Decelerating
(Descending Ramp)

• Flow is at peak at onset of inspiration and

gradually decelerates throughout inspiratory
phase.
• This waveform occurs naturally in pressure-
cycled ventilation.
• In pressure-cycled ventilation flow is always
delivered with the decelerating flow-wave
pattern
DECELERATING : --------------
Accelerating
(Ascending Ramp)

• Flow gradually accelerates in a linear fashion to

set peak flow rate.

• At present time, no studies support the use of

the ascending flow ramp .
• SQUARE: -------------

• SINUSOIDAL : -------------

• DECELERATING : --------------

• ACCELERATING : --------------
• In volume control ventilation a variety of
different wave patterns can be used
• In clinical practice, constant and decelerating
flow patterns are used; the latter is preferred.
• The descending ramp wave may distribute
ventilation more evenly than other patterns of
flow, particularly when airway obstruction is
present .
• This decreases the peak airway pressure,
physiologic dead space, and PaCO2, while
leaving oxygenation unaltered
• In constant, decelerating and sinusoidal flow
patterns, the inspiratory flow rate is equal to
the peak flow rate, but the mean flow rate is
higher in constant flow patterns rather than
the other two.
• This suggests that this pattern will cause more
shearing injury to the lung parenchyma.
• Therefore a decelerating flow pattern is
probably the most effective flow pattern – it
ensures peak flow early in inspiration, while
simultaneously minimizing flow during the
phase of the inspiratory cycle in which the
patient is least likely to need it.
Maximum inspiratory pressure

• An initial cycling pressure is chosen while the

exhaled tidal volume is monitored .
• Pressure is then adjusted until an acceptable
tidal volume is achieved .
• Inspiratory pressure is usually, but not
invariably, set as pressure above PEEP.
• Sum of PEEP and IP should be < 30 cmH2O.
Inspiratory time

• Is adjusted according to the rate and I:E ratio .

• If the rate is 10/min; and I:E ratio is 1:2; then
the inspiratory time is 2.0 seconds .
 PEEP
• Positive end-expiratory pressure (PEEP)
increases the functional residual capacity and
is useful to treat refractory hypoxemia (low
PaO2 not responding to high FIO2).
• The initial PEEP level may be set at 5 cm H2O.
Subsequent changes of PEEP should be based
on the patient’s blood gas results, FIO2
requirement, tolerance of PEEP, and
cardiovascular responses.
 Trigger sensitivity
Triggering by the patient is either :

• Pressure triggering
• Flow triggering
Pressure triggering
• When pressure is the trigger the patients
spontaneous respiratory effort decreases the
pressure within the inspiratory circuit, this
activates the demand valve and inspiration
begins (pressure-triggered) .
• A trigger sensitivity of -1 to -3 cmH2O is
typically set.
Flow triggering
• In flow-triggered ventilation, the patients
activate the demand valve by influencing the
gas flow .
Sensitivity

• Flow-triggering : 1-5L/min
• Pressure-triggering : -1 to -3 cmH2O
 Whenever a change is made to a
ventilator (even initially):
• The effect on the patient is assessed through:
1- is the chest moving ?
2- is the movement symmetrical ?
3- is the patient cyanosed ?
4- is he/she haemodynamically stable ?
5- are the breath sounds audible and equal
bilaterally ?
 Remember …
‘’We’re Treating Patients, NOT
Ventilators’’
Questions
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