Sonali & Rachana 2

Mechanical Ventilation

Prepared By-
Sonali Koiri
Rachana Shrestha
BNS 3rd Year
 Introduction
Mechanical Ventilator:
• A mechanical ventilator is a positive or
negative pressure breathing device that can
maintain ventilation and oxygen delivery for a
prolong period.
• It is a machine that generates a controlled flow
of gas into a patient’s airway.

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Sonali & Rachana 5
 PARTS OF
VENTILATOR
Monitor/ Screen
Heat & Moisture Exchanger (HME) Filter
 Contd…
Advantages:

• Easy to use in breathing circuits

• Cheap and disposable
• 60-70% relative humidity achieved
• Temperature achieved ranges from 29-34ºC
• Can be incorporated as a microbial filter.
Contd…
Humidifier
Flow Sensor
Y- Piece/ Connector
Catheter Mount
 Contd…
• Use to add ‘ extra length’ to the breathing
system when needed
• Provides mobility and flexibility to the patient
end of the circuit.
• Used as an intermediary connection between
the patient and the breathing system.
 Introduction
Mechanical Ventilation:
The mechanical ventilation is the process by
which gas is moved into the lungs by creating
a pressure gradient artificially.

Respiratory support is needed to correct

hypoxemia and hypercapnia and to reduce
work of breathing.

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 Goals
• Treat hypoxemia.
• Treat acute respiratory acidosis.
• Relief of respiratory distress.
• Prevention or reversal of atelectasis.
• Resting of ventilatory muscles.

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 Indications
• Neurological impairment (drugs, poisions ,
snake bite, trauma) with “Glasgow Coma Scale
“ (GCS) ≤ 8.
• Respiratory Failure
a. Arterial PaO2 <60 mm Hg (on supplemental
Oxygen).
b. Arterial PaCO2 >50 mm Hg (in the absence of
chronic airway disease)

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 Contd
c. Evidence of elevated work of breathing:
Respiratory rate > 35 breaths/minute.
Tidal volume < 5ml/kg.
Vital Capacity < 15ml/kg.
Presence of retraction or nasal flaring.
Paradoxical or divergent chest motion.
• Cardiopulmonary arrest.
• Neuromuscular disorders.
• Lung Diseases.
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Criteria for institution of ventilatory support:

Normal Ventilation Parameters

range indicated
A- Pulmonary function
:studies
10-20 35 > • Respiratory rate
(breaths/min).
5-7 5< • Tidal volume (ml/kg
body wt)
65-75 15 < • Vital capacity (ml/kg
body wt)
75-100 20-< • Maximum Inspiratory
Force (cm HO2)
 Cont..

Normal Ventilation Parameters

range indicated
B- Arterial blood
Gases

7.35-7.45 7.25 < • PH

75-100 60 < • PaO2 (mmHg)
35-45 50 > • PaCO2 (mmHg)
 Ventilator Setting
• Setting regulates the rate ,depth, and others
characteristics of ventilation which are based on the
patient status
 ABGs
 Body weight
 Level of consciousness
 Muscles strength
 Common Ventilator Settings
parameters/ controls

• Fraction of inspired oxygen (FIO2)

• Tidal Volume (VT)
• Peak Flow/ Flow Rate
• Respiratory Rate/ Breath Rate / Frequency ( F)
• I:E Ratio (Inspiration to Expiration Ratio)
• PEEP
 Fraction of inspired oxygen
(FIO2)
• The percent of oxygen concentration that the patient
is receiving from the ventilator. (Between 21% &
100%)
• Initially a patient is placed on a high level of FIO2
(60% or higher).
• Subsequent changes in FIO2 are based on ABGs and
the SaO2.
• The lowest possible fraction of inspired oxygen
(FiO2) necessary to meet oxygenation goals should
be used.
• In adult patients the initial FiO2 may be set at 100% until
arterial blood gases can document adequate oxygenation.

• An FiO2 of 100% for an extended period of time can be

dangerous ( oxygen toxicity) but it can protect against
hypoxemia

• For infants, and especially in premature infants, high levels of

FiO2 (>60%) should be avoided.

• Usually the FIO2 is adjusted to maintain an SaO2 of greater

than 90% (roughly equivalent to a PaO2 >60 mm Hg).

• Oxygen toxicity is a concern when an FIO2 of greater than

60% is required for more than 25 hours
 Tidal Volume (VT)
• The volume of air delivered to a patient during a
ventilator breath.
• The amount of air inspired and expired with each
breath.
• Usual volume selected is between 5 to 15 ml/ kg body
weight)
• In the volume ventilator, Tidal volumes of 10 to 15
mL/kg of body weight were traditionally used.
• the large tidal volumes may lead to (volutrauma)
aggravate the damage inflicted on the lungs
• For this reason, lower tidal volume targets (6 to 8
mL/kg) are now recommended.
 Respiratory Rate/ Breath
Rate / Frequency ( F)
• The number of breaths the ventilator will
deliver/minute (10-16 b/m).
• Total respiratory rate equals patient rate plus
ventilator rate.
• An optimal method for setting the respiratory rate has
not been established. For most patients, an initial
respiratory rate between 12 and 16 breaths per minute
is reasonable
• The nurse double-checks the functioning of the
ventilator by observing the patient’s respiratory rate.
Positive End-Expiratory Pressure
(PEEP)
• PEEP is the pressure in the lungs (alveolar pressure)
above atmospheric pressure (the pressure outside of
the body) that exists at the end of expiration.
• Applied PEEP is generally added to mitigate end-
expiratory alveolar collapse. A typical initial applied
PEEP is 5 cmH2O. However, up to 20 cmH2O may
be used in patients undergoing low tidal volume
ventilation for acute respiratory distress syndrome
(ARDS)
 Peak Flow/ Flow Rate
• The velocity of gas flow or volume of gas delivered
by the ventilator per minute (L/min).
• The speed of delivering air per unit of time, and is
expressed in liters per minute.
• The higher the flow rate, the faster peak airway
pressure is reached and the shorter the inspiration;
• The lower the flow rate, the longer the inspiration.
• The peak flow rate is the maximum flow delivered by
the ventilator during inspiration. Peak flow rates of
60 L per minute may be sufficient, although higher
rates are frequently necessary.
 I:E Ratio (Inspiration to
Expiration Ratio):-
• During spontaneous breathing, the normal I:E ratio is
1:2, indicating that for normal patients the exhalation
time is about twice as long as inhalation time.
• If exhalation time is too short “breath stacking”
occurs resulting in an increase in end-expiratory
pressure also called auto-PEEP.
• Depending on the disease process, such as in ARDS,
the I:E ratio can be changed to improve ventilation
 CLASSIFICATION
• Negative Pressure Ventilation
• Positive Pressure Ventilation
Volume Controlled
Pressure Controlled

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 Negative Pressure Ventilation
• These exert negative pressure on external
chest decreasing the intra-thoracic pressure
during inspiration, allows air to flow into the
lungs, filling its volume.
• These are simple to use and do not require
intubations of the airways; consequently, they
are especially adaptable for home use.
• It is used mainly in chronic respiratory failure
associated with neuromuscular conditions.

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 Contd…

• Examples: Iron lung, body

wrap and chest cuirass

• Dis-advantages
 Limited access for patient care
 Inability to properly monitor
pulmonary mechanics
 Patient discomfort
 Positive Pressure Ventilation
• A positive pressure ventilation inflate the lungs
by exerting positive pressure in the airway
forcing the alveoli to expand during inspiration.
Expiration occurs passively.
• It requires an artificial airway (endotracheal or
tracheostomy tube) and use positive pressure
to force gas into patient’s lungs.
• Inspiration can be triggered either by the
patient or machine.
Positive Pressure Ventilation
  
Classification of Positive Pressure Ventilation

1. Volume controlled
 Deliver a preset tidal volume
 Allows pressure to vary with changes in resistance and
compliance
 Volume delivery remains constant

2. Pressure controlled
 Deliver a preset inspiratory pressure during each
inspiration
 Volume delivery may vary 39
 Pressure and Gradients
• Peak inspiratory pressure (Ppeak)
• Plateau pressure (Pplateau)
• Baseline pressure
• Mean airway pressure (Pmean)

40
 Peak Inspiratory Pressure (Ppeak):

• Highest pressure reached at opening of the airway during inspiration.

• In mechanical ventilation, the number reflects a positive pressure in
centimeters of water pressure (cmH2O)
• In pressure controlled, it is set on ventilator.
• In volume controlled, it is determined by volume and flow settings ,
compliance and resistance.
•  PIP should never be chronically higher than 40 cmH 2O unless the
patient has Acute Respiratory Distress Syndrome
• Things that may increase PIP could be increased secretions,
bronchospasm, biting down on ventilation tubing, and decreased
lung compliance.
41
Peak Pressure (PPeak)

42
 Plateau pressure (Pplateau):
• The plateau pressure is the pressure applied
to small airways and alveoli.
• It is measured during an inspiratory pause on
the ventilator.
• Exhalation is prevented by the ventilator for a
brief moment(0.5-1.5sec)
• The plateau pressure <30cmH2O

43
 Baseline pressure
• Pressure in the ventilator circuit at the end of exhalation.
• Normally, the baseline pressure is zero(or atmospheric), which
indicates that no additional pressure is applied at the airway opening
during expiration and before inspiration.
• Sometimes the baseline pressure is higher than zero, such as when
the ventilator operator selects a higher pressure to be present during
exhalation. This is called Positive End Expiratory Pressure (PEEP).
• When PEEP is set, the ventilator prevents the patient from exhaling
to zero(atmospheric pressure).
• PEEP increases the volume of gas left in the lungs at the end of a
normal exhalation; that is, PEEP increases the functional residual
capacity (FRC)
44
 Mean Airway Pressure (Pmean):
 Average pressure over the entire respiratory
cycle
 Affected by PEEP, Inspiratory time (TI).
 Has significant affect on oxygenation.

45
PHASES OF VENTILATORY CYCLES CONTROL VARIABLE
1. TRIGGERING (Initiation of 1. PRESSURE (cm H2O)
inspiration) 2. FLOW (L/min)
1. INSPIRATION 3. VOLUME (ml)
2. CYCLING (Change over 4. TIME (sec)
from inspiration to
expiration)
3. EXPIRATION
 Modes of Mechanical Ventilation
 Defined as a set of operating characteristics that
control how the ventilator functions, in what way
a ventilator is triggered into inspiration and cycled
into exhalation, what variables are limited during
inspiration and whether or not the mode allows
mandatory breaths, intermittent breaths, or
spontaneous breaths.

48
 Selection of Modes of Ventilation
Regardless of which operating mode is selected, it
should achieve four main goals:
• Provide adequate ventilation and oxygenation.

• Avoid ventilator-induced lung injury.

• Provide patient-ventilator synchrony.

• Allow successful weaning from mechanical

ventilation. 49
 Modes
• Continuous mandatory mode
– Control (CMV)
– Assist control (AC)
• Intermittent Mandatory mode
– IMV (Intermittent Mandatory Ventilation)
– SIMV ( synchronized Intermittent Mandatory Ventilation)
• Spontaneous mode
– Continuous Positive Airway Pressure (CPAP)
– BiLevel Positive Airway Pressure (BiPAP)
– Pressure support (PS)
50
 Controlled Mandatory Ventilation
(CMV)
 The ventilator initiates and controls both the volume
delivered and the frequency of breaths. Patient cannot
trigger ventilation. If set on a rate of 12, ventilator will
deliver 1 breath every 5 seconds. No more, no less.
Patient should be sedate and possibly paralyzed.
 This mode is used for the patient who is unable to
initiate breath.
 Not often used in ICU as it does not allow any
synchronisation with the patient's own breathing 51
CMV

52
 Contd…
Advantages
• Guaranteed volume(or pressure ) with each
breath
• Low patient workload
 Disadvantages
• Spontaneous breath not allowed
• Needs deep sedation & Paralysis
• Apnea & Hypoxia if accidentally disconnected
• Ventilator dependence
53
 Assist Control mode (AC)

 Assist-control ventilation allows the patient to initiate a

ventilator breath (assisted or patient-triggered ventilation),
but if this is not possible, ventilator breaths are delivered at
a preselected rate (controlled or time-triggered ventilation).
 The ventilator breaths during ACV can be volume-
controlled or pressure-controlled.
 Used for the patients who can initiate a breath but who
have weakened respiratory muscles such as Gullain Barre
Syndrome, post cardiac or respiratory arrest, pulmonary
oedema, ARDS etc. 54
AC mode

55
 Contd…
Advantages  
• Increase Patients comfort
• Patients work of breathing is low
• Patient can control the frequency
 
Disadvantages
• Risk of Hyperventilation

56
  
Intermittent Mandatory Ventilation
 Intermittent mandatory ventilation provides a
combination of mechanical breaths and spontaneous
breaths .
 Mechanical breaths are delivered at preset intervals
and a preselected tidal volume, regardless of patient’s
efforts.
 Although the patient can increase the respiratory rate
by initiating inspiration between ventilator delivered
breaths, these spontaneous breaths are limited to the
tidal volume generated by the patient.
57
IMV

58
 Contd…
Advantages
• Allows spontaneous breath of any tidal
volume

Disadvantages
• Increase work of breathing
• Asynchrony leading to Breath Stacking

59
 Synchronized Intermittent Mandatory
Ventilation (SIMV)
 SIMV also delivers a preset tidal volume and number of
breaths per minute .
 Between ventilator delivered breaths the patient can
breath spontaneously with no assistance from the
ventilator on those extra breaths.
 Mandatory breaths are synchronised with the patient's
own inspiratory effort which is more comfortable for the
patient
 Machine-delivered breaths are initiated only after patient
exhales, preventing breath stacking
60
Contd…
 Contd…
Advantages
• The mandatory breath is delivered in synchrony with patient
effort. This makes greater comfort during breathing.
• The patients respiratory muscles remain active, and so disuse
atrophy is less common.
• Prevents breath stacking
 
Disadvantages
• Hypoventilation is possible if the patient is not capable of
spontaneous breathing
• Excessive work of breathing is possible during spontaneous
breaths unless an adequate level of pressure support is applied.

62
 Pressure Support Ventilation
 PSV can be used in conjunction with spontaneous
breathing in any ventilator mode. ( eg.SIMV +
PSV).
 Pressure support ventilation (PSV) is pressure-
augmented spontaneous breathing.
 Pressure support ventilation applies a pressure to
the airway throughout the patient triggered
inspiration to decrease resistance within the
tracheal tube and ventilator tubing.
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 Contd…
Pressure support is typically used in the SIMV
mode to facilitate weaning
• Increases the patient’s spontaneous tidal
volume
• Decreases the patient’s spontaneous
frequency.
• Decreases the work of breathing

64
 PSV

PSV applies a preset pressure plateau to the patient’s airway for the duration of a
spontaneous breath 65
 Contd…
Advantages
• The patient can control the depth, the length
and the flow of each breath.
• Allows flexibility in ventilatory support.
Disadvantages
• Excessive levels of support can result in:
Respiratory alkalosis, Hyperinflation,
Ineffective triggering, Apneic spells

66
TO BE CONTINUED…….

Sonali & Rachana 67

 References

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Kluwer: Philadelphia
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in Intensive Care Medicine (2nd Edition).
 Contd…
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