MECHANICAL

VENTILATION

R. Duncan Hite, M.D.

Associate Professor of Internal Medicine
Section on Pulmonary and Critical Care Medicine
 OBJECTIVES

Mechanics of Ventilators

Weaning (“Liberation”) from

Mechanical Ventilation

Non Invasive Mechanical Ventilation

(NIPPV)
 Respiratory Failure

Hypoxic Respiratory Failure

 Hypercarbic Respiratory Failure

 VENTILATION

Physical Parameters of Ventilation

Pressure
Volume
Flow
VENTILATION

Negative Pressure
• Spontaneous
• Mechanical

Positive Pressure
• Mechanical
­ Invasive
­ Non Invasive (CPAP, BiPAP)
MECHANICAL VENTILATION
Ventilation Modes

Volume-Cycled (Vt fixed, P variable)

Assist Control (AC, CMV)
Intermittent Mandatory Ventilation (IMV, SIMV)

Pressure-Cycled (P fixed, Vt variable)

Pressure Support (PSV)
Pressure Control (PCV)
Airway Pressure Release (APRV)
MECHANICAL VENTILATION
Ventilation Modes

MacIntyre, Chest, 1993, 104, 560.

 COMPLIANCE

Compliance = V/P

Dynamic = Vt/PIP-PEEP
Key physiologic variables:
Lung Compliance
Chest Wall Compliance
Airway Resistance

Static = Vt/Pplat-PEEP
MECHANICAL VENTILATION
Nomenclature
MECHANICAL VENTILATION
Triggering
MECHANICAL VENTILATION
Respiratory Rate
Assist Control
Set rate = sets time duration for ventilator to give breath if not
triggered by patient. Possible for no breath to be
given without patient triggering
All breaths are preset tidal volume
SIMV
Set rate = sets time interval during which assisted breath must
be given with or without patient triggering
Preset tidal volume only provided during assisted breaths. Vt
for other breaths are spontaneous or PSV-assisted.
PSV
NO set rate. Preset pressure provided during all breaths.
PCV
Able to set rate, same as AC. Preset pressure provided for all.
MECHANICAL VENTILATION
SIMV
 Terminology of PEEP

Extrinsic (i.e. Machine generated)

 Terminology of PEEP

Extrinsic (i.e. Machine generated)

PEEP = CPAP

Intrinsic = autoPEEP
Obstructive lung disease - “air trapping”
Mechanical (Inverse Ratio Ventilation)
Prolonged Inspiration/Intrinsic PEEP
 Terminology of PEEP

Extrinsic (i.e. Machine generated)

PEEP = CPAP

Intrinsic = autoPEEP
Obstructive lung disease - “air trapping”
Mechanical (Inverse Ratio Ventilation)

“Physiologic” (?)
Amato, etal. Am J Respir Crit
Care Med, 1995, 152, 1835.
Low Volume Ventilation Strategy
ARDS

ARDS Network, NEJM, 2000,342,1301.

 Low Volume Ventilation Strategy
ARDS

190 50
180
45
170
PaO2/FiO2 Ratio

160 40

PaCO2
150 Lower Lower
35
140 Traditional Traditional
130 30

120
25
110

100 20

Day 0 Day 1 Day 3 Day 7 Day 1 Day 3 Day 7

ARDS Network,
NEJM,2000,342,1301.
 Permissive Hypercapnea
• Management Issues
– Cardiovascular
• Reduced Myocardial Contractility
• Pulmonary Vasoconstriction
• Systemic Vasoconstriction
(increased afterload)
– Central Nervous System
• Anesthetic
• Increased Intracranial Pressure
• Cerebral Vasodilation
– Musculoskeletal
Hickling, etal. Crit Care Med, 1994,22,1568.
• Reduced Contractility
– Endocrine
Weaning Guidelines
“Weaning” (Extubation)
Parameters
Parameters:
• Strength
• MIP (< -20 cmH2O)
• VC (> 10 cc/kg)
• Vt (> 5 cc/kg)
• Demand
• Ve (< 10 Lpm)
• RR (> 30 bpm)
• Combined
• f/Vt (< 105 bpm/L)
 “Weaning” (Extubation)
Parameters

Hilberman, etal. J Thor Cardiovasc Surg, 1976, 71, 711.

“Weaning” (Extubation)
Parameters

Yang, Tobin. NEJM, 1991, 324, 1445.

Modes of Ventilation for
Weaning
Volume-Cycled (Vt fixed, P variable)
Assist Control (AC, CMV)
Synchronized Intermittent Mandatory
Ventilation (SIMV)

Pressure-Cycled (P fixed, Vt variable)

Pressure Support (PSV)
Pressure Control (PCV)
Airway Pressure Release (APRV)
 Comparison of Weaning Modes

SIMV v. PSV??
PSV - more patient
comfort, requires more
observation
SIMV - less apnea
alarms!

Esteban,etal. NEJM,
1995, 332, 345.
Impact of Daily Screen at NCBH

Ely, etal. N Engl J

Med, 1996, 335, 1864.
MECHANICAL VENTILATION
Spontaneous Breathing Trials

Modes:
AutoFlow or Flowby
PSV = 5
T-Piece Trial

Duration:
30 - 120 min

Esteban,etal. Am J Resp Crit Care

Med, 1999, 159, 512.
Non Invasive Ventilation

• PEEP = CPAP
• BiPAP = CPAP + PSV modes
• ePAP = CPAP
• iPAP = CPAP + PSV
Non Invasive Ventilation

• Clinical Indications:
• Hypercarbic Respiratory Failure
• COPD Exacerbation
• BiPAP
• OSA / Obesity Hypoventilation
• Neuromuscular Disease
• Hypoxic Respiratory Failure
• Cardiogenic Pulmonary Edema
• CPAP (?BiPAP)
• Other ??
Mehta, Hill. Am J Respir Crit Care
Med, 2001, 163, 540.
 Non Invasive Ventilation
Patient Selection

Predictors of Success Mehta, Hill. AJRCCM, 2001, 163,

540.
• Younger Age
• Lower acuity of illness
• Better Neurologic score
• Cooperative and able to coordinate breathing with
ventilator
• Less air leaking; intact dentition
• Hypercarbia; not too severe (PaCO2 > 45 and < 92 mm
Hg)
• Acidemia, but not too severe (pH < 7.35, > 7.10)
• Improvements in gas exchange, HR and RR within
first 2 h
 Non Invasive Ventilation
Delivery Issues

Post Extubation Resp Failure

• Likely Improves Reintubation rate in COPD
patients
• No change in other etiologies
• May increase mortality (?)

Staff Requirements
• No increase in nursing time
• Significant increase in RT time in first 8 – 48
hours
• Requires MD re-evaluation after first 2 hours
Mehta, Hill. AJRCCM, 2001, 163, 540.
• Results not as favorable when performed outside
of ICU