Mechanical Ventilation –

Monitoring & Troubleshooting

Abdallah Adel Farah

 Learning Objectives
• By the end of this session the learner, should be
able to :
• Monitor the different values and settings of
ventilator.
• Detect and response properly to ventilator’s
alarms.
• Know the proper troubleshooting for each alarm
and how to response.
• Provide immediate and suitable management.
Monitoring the ventilator
• The ventilator should be checked systemically
on a scheduled, institution-specific basis, but
usually no less often than every 4 hours .
 A check should also be performed
• Before ABG values
• Bedside pulmonary function data are obtained
• After any change in ventilator setting
• After an event of patient deterioration
• At any time when the function of the
ventilator is questionable .
• Monitor information found on control panel
– Mode
– VT
– Set rate
– FIO2
– I:E ratio
– Level of PS
– Level PEEP
– Sensitivity
• Monitor the following information found on
the display panel :
– Peak airway pressure
– Plateau pressure
– Mean airway pressure
– RR, Vt of the patient
– Exhaled tidal volume ( mandatory and
spontaneous breath).
• Adequacy of oxygenation and ventilation can
be monitored by arterial blood gases and
pulse oximetry, while patient-ventilator
synchrony is best monitored by clinical
observation.
 Response to ventilator alarms
• In the ICU there are many alarms
• A ventilator alarm, however may be the one
with the highest priority.
• When it sounds, it may indicate a problem
with the patients airway or breathing, the two
highest priorities in the ABCs .
• When any ventilator alarm sounds, the first
thing to do is look at the patient .
• If the patient is disconnected from the
ventilator, then reconnect the patient to the
machine.
 If the patient is connected :
• Is the patient in distress ?
• Not in distress .
Identifying the patient in distress ?
• When patients are described as fighting the
ventilator, this means that they were doing
well, but suddenly developed distress
The sudden onset of dyspnea can be visually
recognized by the following physical signs .
• Tachypnea
• Nasal flaring
• Diaphoresis
• Accessory muscle use
• Retraction of the intercostal spaces
• Paradoxical or abnormal movement of the
thorax and abdomen .
• If the patient is connected to the ventilator
and is in distress and you can not readily
identify the cause, then disconnect the patient
from the machine and provide manual
ventilation .
• If the patients distress immediately goes away,
the problem is with the ventilator .
• If the distress does not go away, then the
problem is with the patient .
 Ventilator-related problems
• Leaks
• Inadequate oxygen supply.
• Inadequate ventilatory support
• Inappropriate Trigger sensitivity
• Inadequate flow setting
 Trigger sensitivity
The lack of ventilator response to a patients
inspiratory effeorts may be because of
• Inadequate sensitivity settings
• Poorly responsive internal demand valve
• The use of an external nebulizer that is
blocking the machine ability to sense a
patients breath
• Water in the inspiratory line
• The presence of auto-PEEP .
• Inappropriate sensitivity is easy to adjust;
simply increase the sensitivity setting .
 Inadequate flow setting
• A low inspiratory gas flow can be corrected by
increasing the flow setting or by changing flow
pattern by using a descending ramp instead of
a rectangular wave .
 Patient-related problems
• Airway problems : secretions, bronchospasm,
• ETT related problems .
• Dynamic hyperinfaltion (auto-PEEP) .
• Pneumothorax
• Pulmonary edema
• Atelectasis
• Pulmonary embolism .
 Pressure Alarms
• High pressure alarm
• Low pressure alarm
• High minute volume
Remember:
Airway pressure = flow x resistance + alveolar
pressure
 High Pressure Limit
• The high pressure limit is usually set 10 cm
above the patients average PIP
• Normal PIP for a patient on a ventilator is
between 20 and 30 cmH2O
• Usual pressure set alarm : 40 cmH2O
• When this alarm is activated, the ventilator
terminates the inspiratory phase.
 Peak and plateau pressures
• When the inflation volume is constant, an
increase in the PIP is due to changes in
pulmonary compliance or airway resistance or
both .
• Because no flow is present when the plateau
pressure is created, this pressure is not a
function of flow resistance in the airways .
• Instead, the plateau pressure is directly
proportional to the elastance of the lungs and
chest wall .
• If the peak pressure is increased but the
plateau pressure is unchanged, the problem is
an increase in airway resistance .
 In this situation, the major concerns are
• Obstruction of the endotracheal tube
• Migration and displacement of ETT
• Airway obstruction from secretions
• Acute bronchspasm .
• Kinks or water in tubing (circuit)
• Biting of ETT by patient
• If the peak and plateau pressures are both
increased, the problem is a decrease in
distensibility of the lungs and chest
wall(decreased compliance) .
 In this situation, the major concerns are
• Pneumothorax,
• Lobar atelectasis
• Auto-PEEP
• Acute pulmonary edema
• Worsening pneumonia
• ARDS .
 Extrapulmonary restriction as may arise from :
• Abdominal distension (abdominal
compartment syndrome, ascitis)
• Tidal volume too large for the amount of lung
being ventilated (eg, a normal tidal volume
being delivered to a single lung because of
malpositioning of the ETT.
• Asynchronus breathing, increases both peak
and plateau pressures .
 Response (management) to high PIP

• Suction airway secretions

• Straighten airway and other tubing to
eliminate links,
• Drain water from circuit tubing
• Place bite block (mouth gage) or sedate
patient
• Checking the centimeter markings of the tube
can show if a tube is too deep or too far out of
the airway .
• Auscultate for equal air-entry
• Auscultate breath sounds for wheeze, and
administer bronchodilator .
• Checking for signs of ETT obstruction.
 Acute obstruction of endotracheal tubes
(ETT)
• Increases peak airway pressure
• Decreases tidal volume (during pressure
ventilation)
• Hypercapia
• Rapid decrease of end-tidal CO2
• Oxygen desaturation that may have lagged
behind the decrease of end-tidal CO2
• DON’T DEPEND ON PIP TO DETECT ETT
OBSTRUCTION
• Peak airway pressure increase is a late
warning sign of partial endotracheal tube
obstruction whereas change in expiratory flow
is an early warning sign (decelerating effect on
the high expiratory is pronounced) .
 Evaluation
• Evaluation of an obstruction problem should
include :
• Disconnect and manually bagging the patient
• passage of a suction catheter through the ETT
to confirm its patency and then making
deflation and re-inflation of the cuff to see the
difference upon ventilation.
 Endotracheal tube cuff inflated with 20 ml of air after
removal from the patient. Note herniation of the cuff on the
Murphy eye's side.
 Estimation of auto-PEEP
• It’s PEEP above the preset level on the
ventilator
• Result from the short expiratory time, and not
completely allowing full exhalation, resulting
in air trapping
• Expiratory hold (End Expiratory Pause)
Expiratory Hold : End Expiratory Pause

• Is a procedure performed to estimate pressure

in the patients lung and circuit from trapped
air (auto-PEEP) .
• It is performed at the end of exhalation,
following a mandatory breath.
Causes
There are three common situations during
which auto-PEEP develops:
• High minute ventilation
• Expiratory flow limitation, and
• Expiratory resistance.
lack of return of flow to baseline at the end
of the breath
• When a high minute ventilation is the
presumed cause of auto-PEEP, the minute
ventilation should be decreased by lowering
the tidal volume or respiratory rate.
• This frequently requires a strategy of
permissive hypercapnia
• When an expiratory flow limitation due to
obstructive airways disease is the presumed
cause of auto-PEEP, the duration of expiration
should be prolonged.
• This can be accomplished by increasing the
inspiratory flow, decreasing the tidal volume,
or decreasing the respiratory rate.
• Treatment with bronchodilators, steroids, and
antibiotics may also be beneficial.
• When increased expiratory resistance is the
presumed cause of auto-PEEP, the source of
increased resistance should be identified and
corrected.
• This may require sedation, pharmacologic
paralysis, or replacement of the endotracheal
tube or ventilator tubing.
• If the cause is airflow limitation, intrinsic PEEP
can be reduced by shortening inspiratory time
or reducing the respiratory rate, thereby
allowing a greater fraction of the respiratory
cycle to be spent in exhalation.
 Low pressure alarm
• Alarm will be activated if pressure in system
has fallen and is not reaching the level that
has generally been required for adequate
ventilation in a particular patient .
• The low inspiratory pressure alarm is usually
set 5 to 10 cmH2O pressure below the
patients average PIP.
 The cause is :
• Patient-ventilator disconnection, or
• Leak in the system (ETT or ventilator-related) .
• If the leak is not obvious (not related to ETT),
then the patient must be manually ventilated
with a resuscitation bag while the machine
leak is checked .
 High minute ventilation
Cause :
• increase in respiratory rate or tidal volume
• Ventilator self-cycling because of incorrect set
sensetivity .
• Assessment and treatment : anxiety, pain,
hypoxemia, or metabolic acidosis
• Treat the underline cause.
• Don’t jump to sedation and paralysis (unless
it’s compromising the patient), figure out
what’s wrong
 Expiratory Tidal Volume
• Regardless of mode of ventilation, the most
accurate measure of the volume received by
the patient is the exhaled tidal volume (EVT).
• The volume actually received by the patient,
in any mode of ventilation, must be confirmed
by monitoring the EVT on the display panel of
the ventilator .
• Generally the low exhaled tidal volume alarm
is set 100 mL less than the prescribed tidal
volume .
 Low Oxygen Pressure
• The low oxygen pressure alarm warns of
inadequate pressure in the oxygen lines
supplying the ventilator .

• Due to loss of oxygen source or loss of

adequate pressure within oxygen source .
 Low Air Pressure
• The low air pressure alarm warns of
inadequate pressure in the air lines supplying
the ventilator.
• If the air source is lost, most ventilators will
provide 100% oxygen in an attempt to
maintain an adequate source of fresh gas to
the patient .
Patient-ventilator dysynchrony
• Detect the cause first before sedate the
patient more heavily.
• Causes :
• Inappropriate mode
• I:E ratio
• Mode of triggering and trigger sensitivity
• Inappropriate sedation
 Hypotension
• Hypotension immediately after initiation of
positive ventilation is usually due to :
• Hypovolemia
• Drugs used for induction of anaesthesia
• Gas trapping
• Tension pneumothorax (less common)
 management
• If the cause hypovolemia give a fluid chelleng
and check.
• Immediately disconnect the patient from the
ventilator, if the causes is trapping 10 – 30 sec
the BP will rise.
• Neither the disconnection or fluids helped,
consider other causes (tension pneu)
 Apnea/Low Frequency Alarm
• The apnea or low frequency alarm is triggered
when the total frequency drops below the low
frequency limit.
• Disconnection of the ventilator
• patient under respiratory depressants or
muscle-paralyzing agents, and respiratory
muscle fatigue, cardiopulmonary arrest.
• Always set a backup ventilation mode.
poor oxygenation and ventilation
• If the patient is desaturating, and Pao2 is
decreased, it can be improved by (in this
order) :
• Increase FiO2.
• Increase PEEP.
• Increase inspiratory time.
• Increase tidal volume or respiratory rate.
Remember the effect of each change you make
• Poor ventilation and high CO2 level, can
improve the elimination by (in this order):
• Increase respiratory rate.
• Increase tidal volume.
• Increase the expiratory time.
• Decreasing dead space.
Remember the effect of each change you make
 Detect

Manage Monitor

Remember …
‘’We’re Treating Patients, Not Ventilators’’
Questions
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