GOOD MORNING

Mechanical
 RESPIRATORY FAILURE

Inability of the lungs to provide O2 and excrete CO2

Patient in Acute
Respiratory
Distress

Failure of CO2 Failure of Oxygenation

Homoeostasis/ ventilation (LUNG FAILURE)
(PUMP FAILURE)

HYPERCAPNEIC RESP HYPOXEMIC RESP.

FAILURE FAILURE
 ventilatory Failure
• - > failure of the lungs to excrete CO2
• -> PaCO2 > 45 – 50 mmHg
• - > often accompanied by hypoxemia corrected by
supplemental oxygen
• -> decrease alveolar minute ventilation
• -> increase deadspace ventilation
 Oxygenation Failure
• - > a severe hypoxemia that does not respond to moderate to
high level of supplemental oxygen (PaO2 of < 40 mmHg with FiO2
of > 60%)
• - > CAUSES:
• Hypoventilation
• Ventilation/Perfusion Mismatch
• Intrapulmonary Shunting
Intrapulmonary shunting (low v/q)
• - > Refers to perfusion in excess of ventilation
• - > shunted blood is not useful in gas exchange because it does
not come in contact with ventilated and oxygenated alveoli
• - > causes refractory hypoxemia
• - low oxygen in the blood that responds poorly with oxygen
therapy alone
INTERPRETATION of SHUNT

< 10% Normal

10 – 20% Mild shunt
20 – 30% Significant Shunt
> 30% Critical and Severe Shunt
INTERPRETATION of Oxygenation Status
• HYPOXEMIA STATUS • PaO2

Normal 80 – 100 mm Hg
Mild 60 – 79 mm Hg
Moderate 40 – 59 mm Hg
Severe <40 mm Hg
Clinical conditions leading to mechanical
ventilation
• 1. Depressed respiratory drive
• - pts may have normal pulmonary function but the respiratory
muscles do not have adequate neuromuscular impulse to function
properly.
• - may lead to HYPOVENTILATION due to decreased in alveolar
ventilation
Causes of Depressed Respiratory Drive
Drug overdose
Acute spinal cord injury
Neurologic dysfunction or coma
Sleep disorders
Metabolic alkalosis
 Clinical conditions leading to
mechanical ventilation
• 2. Excessive ventilatory workload
• - increased work of breathing
• - leads to fatigue of respiratory muscles, eventually leading to
ventilatory failure and subsequently oxygenation failure
Causes of Excessive Ventilatory
Workload
Acute airflow obstruction
Congenital heart disease
Increased metabolic rate
Decreased compliance
 Clinical conditions leading to
mechanical ventilation
• 3. Ventilatory pump failure
• - is the structural dysfunction of the respiratory system to
include:
• a. lung parenchyma
• b. respiratory muscles
• c. chest wall compliance
• - may lead to:ventilatory and subsequently oxygenation failure
Causes of Ventilatory Pump Failure
Chest trauma
Premature birth
Electrolyte Imbalance
Geriatric patients
 Indications of Mechanical Ventilation
INDICATION
1. Acute Ventilatory Failure
2. Impending Ventilatory Failure
PARAMETERS
Apnea
PaCO2: > 45 mmHg, 50 mmHg ( higher in COPD)
pH: < 7.30
Tidal Volume: < 5 ml / kg
Frequency: > 35 / min
Minute Volume: > 10 L / min
Vital Capacity: < 10 ml / kg
MIP: < - 20 cmH20
Rising PaCO2 > 50 mmHg
VD/Vt > 60%
 Indications of Mechanical Ventilation
INDICATION
3. Severe hypoxemia or
Oxygenation failure
4. Prophylactic vent. support
PARAMETERS
PaO2: < 60 mmHg at FiO2 > 50 % or
PaO2: < 40 mmHg at any FiO2
PaO2/FiO2 (P/F ratio): < 300 mmHg for ALI
PaO2/FiO2 (P/F ratio): < 200 mmHg for ARDS
P (A-a) O2 > 450 mmHg at 100 %
Reduce Pulmonary Complications
Reduce hypoxia of major body organs
Reduce cardiopulmonary stress
example
• Which of the following is NOT an indication for continuous
mechanical ventilation?
• A. MIP -20 cmH2O
• B. acute ventilatory failure
• C. Vt < 5 mL/kg
• D. VC < 10 mL/kg
• A need for some form of ventilatory support is usually indicated
when an adult’s rate of breathing rises above what level?
• a. 35/min
• b. 30/min
• c. 25/min
• d. 20/min
• Which of the following measures taken on adult patients indicate
unacceptably high ventilatory demands or work of breathing?
• a. VE of 17 L/min
• b. breathing rate of 22/min
• c. VD/VT of 0.45
• d. MIP of –40 cm H2O
• Which of the following measures taken on adult patients indicative
of mechanical ventilation?
• a. PaO2 of 65 mmHg at FiO2 of 50 %
• b. P (A-a) O2 of 257 mmHg at FiO2 of 100 %
• c. P / F ratio of 150 mmHg
• d. Respiratory Rate of 12 bpm
• Ventilatory support may be indicated when the VC falls below what
level?
• a. 45 ml/kg
• b. 65 ml/kg
• c. 10 ml/kg
• d. 30 ml/kg
• Which of the following MIP measures taken on an adult patient
indicates inadequate respiratory muscle strength?
• a. –90 cm H2O
• b. –70 cm H2O
• c. –40 cm H2O
• d. –15 cm H2O
Complications of
 complications
• 1. Barotrauma
• -> hyperinflation of alveoli past rupture point.
• a. pneumothorax : characterized by subcutaneous emphysema
• b. Pneumomediastinum
• c. Pneumopericardium
-> Airway pressures that could lead to barotrauma:
a. PEEP > 10 mmHg
b. PAP > 50mmHg
c. Pplat > 35mmHm
d. mPaw > 30mmHg
complications
• 2. Pulmonary infection
• 3. Atelectasis
• 4. Pulmonary Oxygen toxicity
• 5. Tracheal damage
• 6. Decrease cardiac output
• 7. Decrease urine output
• 8. Lack of nutrition
example
• 5. Prolonged ventilation has been associated with the following
except:
• a. increased incidence of ventilator associated pneumonia
• b. increased multi organ failure
• c. decreased used of hospital resources
• d. increased mortality
• . A mechanically ventilated patient has a pH 7.48, Paco2 22 mm Hg,
Pao2 84 mm Hg. Tidal volume is set at 700 mL (12 mL/kg) and the
respiratory rate is set at 15 breaths/min. PEEP is 8 cm H2O and Fio2
is 0.4. The plateau pressure is 36 cm H2O. Which of the following
would you recommend?
a. Decrease the tidal volume
b. increase the respiratory rate
c. Decrease the PEEP
d. Increase the Fio2
 MECHANICAL VENTILATION

NEGATIVE PRESSURE VENTILATION POSITIVE PRESSURE VENTILATION

NON INVASIVE
ADVANCE MODES
VOLUME PRESSURE (COMBINATION OF P AND V)

INVASIVE VENTILATION NON - INVASIVE

 STRATEGY IN MECHANICAL VENTILATION

NON - INVASIVE

INVASIVE

VOLUME VENTILATION

PRESSURE VENTILATION

PRESSURE CONTROL – INVERSE RATIO VENTILATION

ADVANCE MODES
Classification of
 Classification
• I. Negative Pressure Ventilation
• II. Positive Pressure Ventilation
Negative pressure ventilation
• Uses negative pressure to bring air into the lungs
• It is a non - invasive type of ventilation
• Ex ample of which is the chest cultrass also called the “iron lung”
Positive pressure ventilation
• Uses positive pressure to bring air into the lungs
• Can be used for both invasive and non invasive ventilation
• Also has 3 types:
• 1. Volume type
• 2. Pressure Type
• 3. Pressure and Volume (Advance modes)
Characteristics of mechanical ventilators
• 1. Limits:
• a. Pressure limited
• b. volume limited
• 2. Breath delivered:
• a. mandatory breath
• b. assisted breath
• c. spontaneous breath
Characteristics of mechanical ventilators

• 3. Triggering: to inspiration
• a. Pressure triggered
• b. Flow triggered
• c. Time triggered
Characteristics of mechanical ventilators

• 4. Cycling: to expiration
• a. volume cycled
• b. pressure cycled
• c. flow cycled
• d. time cycled
Characteristics of mechanical ventilators

• 5. Variability:
• a. Pressure variable
• b. Volume variable
Volume ventilation
Volume ventilation
• CHARACTERISTICS:
• > Volume limited or volume pre – set
• > volume cycled or time cycled
• > pressure variable
Volume ventilation
SET PARAMETERS:

MODE: Full or Partial ventilator support Vt: 8 – 10 kg/PBW

RR: 1o - 16 bpm FiO2: 21% - 100 %
PFR: 40 - 60 lpm PEEP: 5 cmH2O
FLOW PATTERN: Square wave SENSITIVITY: - 2 cmH2O
or 1 L
Modes of volume
 Different Modes ON VOLUME
VENTILATION
FULL VENTILATORY SUPPORT PARTIAL VENTILATORY SUPPORT
• 1. Controlled Mandatory • 1. Intermittent Mandatory
Ventilation (CMV) Ventilation (IMV)
• 2. Assist Ventilation • 2. Synchronized Intermitent
• 3. Assist/Control Mandatory Ventilation (SIMV)
 Controlled mandatory ventilation
CHARACTERISTICS:
> volume limited, Time cycled
> pressure variable
> machine triggered
> purely mechanical breath
> correction of PaCO2 level can be done through changing Tidal
Volume and RR settings
CONTROLLED MANDATORY VENTILATION(CMV)
 assisted ventilation
• CHARACTERISTICS:
• > Volume limited, volume cycled
• > pressure variable
• > patient triggered
• > purely mechanical breath
• > correction of PaCO2 level can be done through changing Tidal
Volume and RR settings
 Assist/control ventilation
• CHARACTERISTICS:
• > Volume limited, volume cycled and or Time cycled
• > pressure variable
• > patient or machine triggered
• > purely machine breath
• > correction of PaCO2 level can be done through changing Tidal
Volume and RR settings
Control and assist control mode
Intermittent mandatory ventilation
• CHARACTERISTICS:
• > volume limited and volume cycled for mechanical breaths
• > pressure variable
• > patient and machine triggered
• > machine breath and spontaneous breaths
• > correction of PaCO2 level can be done through changing Tidal
Volume and RR settings
• > NO LONGER USE due to breath stacking
 Synchronized Intermittent mandatory
ventilation
• CHARACTERISTICS:
• > volume limited and volume cycled for mechanical breaths
• > pressure variable
• > patient and machine triggered
• > machine breath and spontaneous breaths
• > correction of PaCO2 level can be done through changing Tidal
Volume and RR settings
• > Use as a weaning method
IMV and SIMV mode
example
• . Which of the following modes of ventilation delivers a set pressure
or volume and a set rate?
• a. controlled mandatory ventilation
• b. continuous positive airway pressure
• c. assist control ventilation
• d. SIMV
• Which of the following modes delivers a controlled breaths and
allows the patient to breath spontaneously between controlled
breaths preventing breath stacking:
• a. assist b. Assist/Control
• c. control d. SIMV
• Which of the following modes can prevent respiratory muscle
atrophy:
• a. assist b. Assist/Control
• c. control d. SIMV
• In an A/C mode with a back up rate of 12 bpm, if the patient has a
total of 16 triggered breaths, how many breaths did the patient
receive from the ventilator?
• a. 12
• b. 28
• c. 16
• d. 4
• In SIMV mode, if the back up rate is 12 bpm and the patient had a
total of 8 spontaneous breaths, how many breaths did the patient
receive in all?
• a. 12
• b. 8
• c. 20
• d. 4
Other settings
of volume
ventilation
Respiratory rate
• > set at 12 – 16 bpm
• > usual parameter that is manipulated to correct PaCO2 level
• > affects the I:E ratio
• > ↑ RR leads to ↓ I:E ratio or shorter E time
• > ↓ RR leads to ↑ I:E ratio or longer E time
Tidal volume
• > set parameter under volume ventilation, 8 – 10 ml/kg of PBW
• > also manipulated to correct PaCO2 level
• > affects I:E ratio
• > ↑ Vt leads to ↑ I time or ↓ E time or ↓ I:E ratio
• > ↓ Vt leads to decrease ↓ I time or ↑ E time or ↑ I:E ratio
• > computed by obtaining Predicted Body Weight
• 1. Male PBW in kg = 106 + [6 x (Height in inches – 60)] ÷ 2.2
• 2. Female PBW in kg = 105 + [5 x (Height in inches – 60)] ÷ 2.2
Volume time waveform
• > can be use to assess for air trapping or leak
Volume/
Air-Trapping or Leak

Loss of volume

•If the exhalation side of the waveform doesn’t return to baseline,

it could be from air-trapping or there could be a leak (ETT, vent
circuit, chest tube, etc.)
Peak flow rate
• > initially set from 40 – 60 lpm
• > determines how fast the set Vt is delivered
• > affects I:E ratio
• > ↑ PFR leads to ↓ I time or ↑ E time or ↑ I:E ratio
• > ↓ PFR leads to ↑ I time or ↓ E time ↓ I:E ratio
• > can cause dyssynchrony
example
• A 44 year old male patient is being mechanically ventilated with a
volume cycled ventilator. You observe that there is insufficient time
for the patient to exhale completely. You would now do which of
the following to correct the problem?
• A. increase the flow
• B. decrease the minute volume
• C. add PEEP
• D. none of the above
Using flow rates to change I:E ratio
• A patient in a volume limited ventilator has minute volume of 12 L/min.
What should be your minimum PFR if you want an I:E ratio of 1:4?

Solution: Flow = minute volume × sum of I:E

= 12 L/min × (1+4)
= 12L/min × 5
= 60 L/min

• a. 40 LPM b. 60 LPM c. 50 LPM d. 70 LPM

• A patient in a volume limited ventilator has minute volume of 10
L/min. What should be your minimum PFR if you want an I:E ratio
of 1:3?

• a. 40 LPM b. 60 LPM c. 50 LPM d. 70 LPM

Peak flow pattern
• > determines the manner of delivery of set Vt
• > use to assess or monitor :
• 1. dyssynchrony
• 2. auto PEEP
• 3. changes in expiratory flow
Peak flow pattern

• > has 4 available waveforms:

• 1. square wave – maximum flow is throughout inspiration
• 2. decelerating – maximum flow at start and diminishes as
inspiration ends
• 3. sine wave – maximum flow at mid inspiration, resembles
spontaneous breath
• 4. accelerating – maximum flow at end inspiration
• 5. decay – has some similarity with decelerating
Flow patterns
most commonly use flow patterns

Volume Pressure
examples
Flow/Tim
Auto-Peep (air trapping)

Expiratory flow
doesn’t return to
baseline

Start of next breath

•If expiratory flow doesn’t return to baseline before the next breath starts,
there’s auto-PEEP (air trapping) present , e.g. emphysema.
Recognizing prolonged expiration (air trapping)

Recognize
airway obstruction
when

Expiratory flow quickly tapers off

and then enters a prolonged
low-flow state without returning to
baseline (auto- PEEP)

This is classic for the flow

limitation and decreased lung
elastance characteristic of COPD
or status asthmaticus
Flow/Time Scalar

Bronchodilator Response
Pre-Bronchodilator Post-Bronchodilator

Longer Shorter
E-time E-time

Peak Exp. Flow

Improved Peak Exp. Flow

•To assess response to bronchodilator therapy, you should see an increase in

peak expiratory flow rate.

•The expiratory curve should return to baseline sooner.

Recognizing ineffective/wasted patient effort

Patient inspiratory effort

fails to trigger vent
resulting in a wasted effort
fio2
• > set from .21 to 1.0 or 21% to 100%
• > the usual parameter manipulated to correct oxygenation
• > causes oxygen toxicity
example
 Mode: control ABG:  
Rate: 12 bpm pH 7.44
Vt: 700 ml PaCO2 36 mmHg
FiO2: 35 % PaO2 55 mmHg

The following data are obtained from a patient receiving mechanical ventilation with a
volume ventilator. To increase the PaO2 to 80 mmHg, what must be your FiO2?

a. 35 % b. 40 % c. 45 % d. 50%

Solution: Desired FiO2 = PaO2 (desired) x FiO2 current PaO2 current

= 80 x .4 ÷ 55
= .50 or 50 %
 Mode: control ABG:  
Rate: 12 bpm pH 7.44
Vt: 700 ml PaCO2 36 mmHg
FiO2: 30 % PaO2 53 mmHg

The following data are obtained from a patient receiving mechanical ventilation with a
volume ventilator. To increase the PaO2 to 80 mmHg, what must be your FiO2?

a. 35 % b. 40 % c. 45 % d. 50%
Mode: A/C pH 7.52
Vt: 750 ml PaCO2 27 mmHg
BUR: 12 bpm PaO2 57 mmHg
FiO2: 40% HCO3 23 mEq
PEEP: 5 cmH2O    

The following data’s are collected from a patient receiving mechanical ventilation with a volume
ventilator. Based on the following data’s, which of the following changes would you recommend?

a. increased PEEP to 7 cmH2O

b. decreased Vt to 650 ml
c. decreased BUR to 8 bpm
d. increased FiO2 to 50 %
sensitivity
• > senses patient breathing effort
• > has two types:

• 1. Pressure sensitivity
• - set from – 0.5 to – 5.0 cm H20

• 2. Flow sensitivity
• - more sensitive to patient breathing effort compared to pressure
• - set from 1 to 5 liters
Positive end expiratory pressure
• > use in lung recruitment
• > prevents collapse of alveoli
• > prevents alveolar injury due to shearing effect of opening and
closing of alveoli
• > used to correct refractory hypoxemia caused by
intrapulmonary shunting
• > a PEEP of 5 cmH2O is used as a physiologic PEEP
Indications of peep
• 1. Intrapulmonary shunt and refractory hypoxemia
- a. PaO2 < 60mmHg with FiO2 of 50% and above
b. PaO2/FiO2 (P/F) ratio < 200mmHg
2. Decrease FRC and lung compliance
3. auto PEEP not responsive to adjustments in ventilator
settings
4. Pulmonary edema
Complications/hazards of peep
• 1. Barotrauma
• 2. Decrease venous return
• 3. Decrease cardiac output
• 4. Decrease urinary output
Complications/Hazards of PEEP
↑PEEP

↑mPaw, ↑PIP

Increase pleural pressures

↓ venous return

Decrease cardiac output

Decrease O2 delivery
example
• . For a patient on mechanical ventilation, total collapse of the
alveoli can be prevented by:
• a. low tidal volumes
• b. PEEP
• c. High FiO2
• d. low peak flow rates
Pressure
Characteristics PRESSURE VENTILATION
• > Pressure pre – set
• > Pressure limited
• > Time cycled, Flow cycled or Pressure cycled
• > Volume variable
• > use for invasive and non invasive ventilation
PRESSURE VENTILATION
• SETTINGS:
•
• Mode: FVS, PVS PIP: 20 cmH2O
• RR: 12 - 16 bpm FiO2: 21 - 100 %
• PEEP: 5 cmH2O I time: .5 sec to 1 sec
• I:E ratio: 1:3
Modes ON pressure VENTILATION
FULL VENTILATORY SUPPORT PARTIAL VENTILATORY SUPPORT
• 1. PCV • 1. PSV
• 2. Assist/Control • 2. CPAP
• 3. PC - IRV • 3. BiPAP
 Modes
of pressure ventilation
PRESSURE CONTROLLED VENTILATION
CHARACTERISTICS:
> Pressure limited
> Time cycled
> Time Triggered
> Volume variable
 Assist/Control
CHARACTERISTICS:
> Pressure limited
> Time cycled and or Pressure cycled
> Time Triggered or Patient triggered
> Volume variable
PRESSURE CONTROLLED – inverse ratio
VENTILATION
CHARACTERISTICS:
> Pressure limited
> Time cycled
> Time Triggered
> Volume variable
PRESSURE support VENTILATION
CHARACTERISTICS:
> Pressure limited
> Flow cycled
> Patient Triggered
> Volume variable
> use as a weaning method
 Continuous positive airway pressure
ventilation
CHARACTERISTICS:
> Pressure limited
> use as a weaning method especially in infants
> use during non invasive ventilation (NIPPV)
 Bi level positive airway pressure
CHARACTERISTICS:
> Pressure limited
> Time or flow cycled
> Time or patient Triggered
> Volume variable
> use for non invasive ventilation
 Other settings of
pressure ventilation
Respiratory rate
• > set at 10 – 16 bpm
• > usual parameter that is manipulated to correct PaCO2 level
• > affects the I:E ratio
• ` > affects mean airway pressure
• > ↑ RR leads to ↓ I:E ratio or shorter E time
• > ↓ RR leads to ↑ I:E ratio or longer E time
Peak Inspiratory pressure (PIP)
• > set parameter under pressure ventilation
• > manipulated to correct PaCO2 level
• > affects mean airway pressure (mPaw)
fio2
• > set from .21 to 1.0 or 21% to 100%
• > the usual parameter manipulated to correct oxygenation
• > can cause oxygen toxicity
sensitivity
• > senses patient breathing effort
• > has two types:

• 1. Pressure sensitivity
• - set from – 0.5 to – 5.0 cm H20

• 2. Flow sensitivity
• - more sensitive to patient breathing effort compared to pressure
• - set from 1 to 5 liters
I time
• > set from 1 sec to 1.5 seconds
• > affects mean airway pressure
 i:e ratio
• > ratio of inspiration to expiration
• > normally set at 1:2 to 1: 4
• > mean airway pressure
• > use inversely in conjunction with pressure ventilation (PCV-
IRV) during:
• severe hypoxemia not responsive to conventional ventilation
Positive end expiratory pressure
• > use in lung recruitment
• > prevents collapse of alveoli
• > prevents alveolar injury due to shearing effect of opening and
closing of alveoli
• > used to correct refractory hypoxemia caused by
intrapulmonary shunting
• > a PEEP of 5 cmH2O is used as a physiologic PEEP
• > affects mean airway pressure
Points to remember in pressure ventilation
• Increase in: pCO2 pO2 MAP

FiO2 no change increase no change

usually no
Rate decrease increase
change

PIP decrease increase increase

Inspiratory usually no
increase increase
time change
usually no
PEEP increase increase
change
terminologies
• Peak Inspiratory Pressure (PIP) or Peak Airway Pressure
-> pressure used to deliver the tidal volume to the lung

• Plateau Pressure (Pplat)

->pressure that maintains lung inflation in the absence of airflow

• Mean airway Pressure (mPaw)

- > average pressure within the airway during one complete
respiratory cycle
Mean airway Pressure (mPaw)
• Normal value: < 30 cmH20 in adult
• Equation:
• mPaw = (f x I time) x (PiP – PEEP) + PEEP
• 60
• Where:
• mPaw – mean airway pressure (cmH20)
• f – respiratory in 1 minute
• I time – inspiratory time in 1 sec
• PIP – Peak inspiratory Pressure (cmH20)
• PEEP – Positive end expiratory Pressure
Example
• A patient is currently ventilated in pressure type ventilator under a
control mode. The ventilator settings are:
• RR: 45/min
I time: 0.5 sec
PIP: 35 cmH20
PEEP: 5 cmH2O
FiO2: 100 %
Compute for the mPaw:
Solution
• mPaw = (45 x 0.5) x (35 – 5) + 5
• 60
• = 16.25 cmH2O
example
• Which ventilator mode delivers gas at a preset rate and tidal
volume or pressure regardless of inspiratory effort?
• a. assist-control ventilation
• b. control ventilation
• c. CPAP
• d. SIMV
• Mean airway pressure may be increased by all of the following
adjustments, except increasing the:
• a. inspiratory time
• b. frequency
• c. positive end-expiratory pressure level
• d. FIO2
• During pressure-targeted modes of ventilatory support, the volume
delivered depends on which of the following?
• 1. set pressure limit
• 2. patient lung mechanics
• 3. patient effort
• a. 1 and 2
• b. 1 and 3
• c. 2 and 3
• d. 1, 2, and 3
• The doctor wants to increase the mean airway of the pressure limited
ventilator currently use by the patient. Which of the following could be
increased to accomplish this?
• 1. PEEP
• 2. PIP
• 3. Inspiratory Time
• a. 1 and 2
• b. 1 and 3
• c. 2 and 3
• d. 1, 2, and 3
Non invasive
 nippv
• > intended to avoid complications of invasive ventilation.
• > first type of ventilation to consider to a patient in acute
respiratory failure
MODES UNDER
 CPAP
> may be set initially at 5 cmH2O
> may be achieved with the use :
a. nasal prongs
b. CPAP mask
> Indications:
1. Treatment of postoperative atelectasis
2. obstructive sleep apnea
3. cardiogenic pulmonary edema
4. weaning
•
 Bipap
> is a bi - level positive airway pressure ventilation
> settings are:
IPAP: 10 cmH2O
EPAP: 4 cmH2O
> Indications :
1. acute respiratory failure
2. obstructive sleep apnea
3. other conditions that result in hypoventilation
Common Interfaces for CPAP and BiPAP
• 1. nasal mask
• 2. oronasal mask
• 3. Full face mask
• 4. nasal pillows ( nasal prongs)
Adjustments of Bipap to improve
ventilation

1. Increasing IPAP level

2. decreasing EPAP level
3. improving compliance
4. reducing air flow resistance
Adjustments Of bipap to improve
oxygenation

1. increasing EPAP level

 contraindications

1. hemodynamically unstable
2. hypoventilation
3. nausea
4. facial trauma
5. untreated pneumothorax
6. elevated intracranial pressure (ICP).
example
• Which statement is correct about NIMV?
• a. It can't be used with PEEP.
• b. Available modes include bilevel positive airway pressure and
CPAP.
• c. Inspiration is initiated only by the ventilator.
• d. It's contraindicated in patients with obstructive sleep apnea.
• Which of the following would the respiratory therapist select to
treat a patient who has obstructive sleep apnea?
• A. BiPAP®
• B. Nasal cannula
• C. Chest cuirass ventilator
• D. simple oxygen mask
• A patient with COPD is extubated after receiving mechanical
ventilation for 2 weeks. Several hours after extubation, the patient
complains of progressively worsening while on 2lpm cannula. His
RR increase from 16 to 26 bpm. Which of the following is the
appropriate recommendation?
• A. initiate noninvasive positive pressure ventilation
• B. reintubate and begin mechanical ventilation
• C. give the patient a non rebreathing mask
• D. begin postural drainage and percussion every 4 hours
Difference between
pressure and volume
Assuming that the right and left lung are the same in size, shape and patency, and
we are to ventilate them separately. One with volume and the other with pressure.
What changes would take place if there is an increase in airway resistance or
bronchospasm?

VOLUME VENTILATION PRESSURE VENTILATION

• Settings before bronchospasm • Settings before bronchospasm
• 1. Tidal Volume: 500ml • 1. PIP: 25 cmH2O
• 2. Observed PIP: 25 cmH2O • 2. Observed Tidal Volume: 500
• CHANGES ml
• A. constant Vt • CHANGES
• B. increased PIP • A. constant PIP
• B. decrease Vt
What changes would take place if there is a decrease in compliance or
ARDS?

VOLUME VENTILATION PRESSURE VENTILATION

• Settings before ARDS • Settings before ARDS
• 1. Tidal Volume: 500ml • 1. PIP: 25 cmH2O
• 2. Observed PIP: 25 cmH2O • 2. Observed Tidal Volume: 500
• CHANGES ml
• A. constant Vt • CHANGES
• B. increased PIP • A. constant PIP
• B. decrease Vt
 Lung Compliance Changes and
the P-V Loop…. (Volume mode)

↑C C ↓C
Preset VT

Volume

Pressure PIP levels

Constant VT………. Variable Pressure

 Lung Compliance Changing in P-V Loop (pressure mode)
………….

1.With surfactant
2. Emphysematous L

VT levels
RDS…lung

Volume

Pressure Preset PIP

Constant PIP……… variable VT

What changes would take place if there is an increase in compliance or
resolve pulmonary edema?

VOLUME VENTILATION PRESSURE VENTILATION

• Settings during presence of • Settings during presence of
pulmonary edema pulmonary edema
• 1. Tidal Volume: 500ml • 1. PIP: 40 cmH2O
• 2. Observed PIP: 40 cmH2O • 2. observed Tidal Volume: 500
ml
• CHANGES
• CHANGES
• A. constant Vt
• A. constant PIP
• B. decreased PIP
• B. increase Vt
 Lung Compliance Changes and
the P-V Loop…. (Volume mode)

↑C C ↓C
Preset VT

Volume

Pressure PIP levels

Constant VT………. Variable Pressure

 Lung Compliance Changing in P-V Loop (pressure mode)
………….

1.With surfactant
2. Emphysematous L

VT levels
RDS…lung

Volume

Pressure Preset PIP

Constant PIP……… variable VT

example
• . Which of the following types of ventilation would deliver a
constant tidal volume during an increase in airway resistance?
• a. Pressure controlled ventilation
• b. Volume controlled ventilation
• c. both
• d. None of the above
• . Which of these airway changes will affect the delivered tidal
volume on a pressure limited ventilator?

• 1. decrease lung compliance

• 2. increase lung compliance
• 3. increase airway resistance
• a. 1 only
• b. 1 and 2 only
• c. 2 and 3 only
• d. 1, 2 and 3
• . Which of these airway changes will affect the delivered tidal
volume on a volume limited ventilator?

• 1. decrease lung compliance

• 2. increase lung compliance
• 3. increase airway resistance
• a. 1 only
• b. 1 and 2 only
• c. 1, 2 and 3
• d. none of the above
 Monitoring and
management of mechanically ventilated patient
What do we
monitor?
1. Ventilation
2. Oxygenation
3. Airway Pressures :
a. Peak Airway
Pressure b. Plateau
Pressure c. Mean
Airway Pressure d.
PEEP
4. Lung compliance and Airway resistance
5. Vital signs
Monitoring ventilation
• > the most reliable monitoring tool to check for ventilation is
ABG analysis
• > check for level of level of PaCO2: 35 – 45 mmHg and pH: 7.35 –
7.45
Strategy to improve ventilation on volume
limited ventilators
• > Respiratory Rate and tidal Volume are the 2 parameters that
can improve ventilation
• > Respiratory Rate is the first parameter to consider in
improving ventilation
• > adjusting RR to improve ventilation is more beneficial in
control and SIMV modes
• > Adjusting tidal volumes to improve ventilation can be done in
situations where a patient has atelectasis or the set tidal volume is
beyond Predicted Body Weight
example
• To most effectively increase a patients alveolar minute ventilation
while the patient is using a volume ventilator in a control mode,
you would recommend increasing which of the following?

• a. FiO2
• b. Vt
• c. RR
• d. Peak flow rate
When a patient is receiving ventilation in a control mode, how may
the PaCO2 best be raised?

• a. increase Vt
• b. increase FiO2
• c. decrease RR
• d. increase Peak flow rate
Other strategies
• > If Airway pressures are indicative of baraotrauma:
a. PEEP > 10 mmHg
b. PAP > 50mmHg
c. Pplat > 35mmHg
> you can use:
• a. Permissive hypercapnia
• b. shift to Pressure Control Ventilation
•
Permissive Hypercapnia
• -> strategy to minimize barotrauma
- > Vt of 4-7 ml / kg to keep plateau pressure lower
than 35 cmH20
 LOW TIDAL VOLUME

PEAK AIRWAY ATELECTASI RESPIRATORY

S ACIDOSIS
HYPOXEMIA PaCO2
PRESSURE

MEAN
AIRWAY MAY BE MAY BE
NORMALIZED
PRESSURE WITH
CORRECTED
BICARBONATE BY USING A
LIKELIHOOD ON HIGHER FIO2
OF THROMETHAMIN
BAROTHRAUM E
A

Mechanism and physiological changes of permissive hypercapnia

example
• A 50 kg (110 lb) patient is being mechanically ventilated with the
following settings: Mode - Assist/control, FI02 - 1.0, Rate - 12bpm,
• PEEP - 10 cm H20 , VT - 650 mL, Peak airway pressure - 80 cm H20

• Sp02 - 85% :
A current chest x-ray shows diffuse bilateral infiltrates. To reduce peak
airway pressure which of the following is the most appropriate action?
• A. Increase the frequency.
• B. Change to PCV
• C. increase the FI02.
• D. Increase PEEP to 15 cm H20.
• A 50 kg (110 lb) patient is being mechanically ventilated with the
following settings: Mode - Assist/control, FI02 - 1.0, Rate - 12bpm,
• PEEP - 10 cm H20 , VT - 650 mL, Peak airway pressure - 80 cm H20

• Sp02 - 85% :
A current chest x-ray shows diffuse bilateral infiltrates. To reduce peak
airway pressure which of the following is the most appropriate action?
• A. Increase the frequency.
• B. decrease Vt
• C. increase the FI02.
• D. Increase PEEP to 15 cm H20.
• A 50 kg (110 lb) patient is being mechanically ventilated with the
following settings: Mode - Assist/control, FI02 - 1.0, Rate - 12bpm,
• PEEP - 10 cm H20 , VT - 650 mL, Peak airway pressure - 80 cm H20

• Sp02 - 85% :
A current chest x-ray shows diffuse bilateral infiltrates. To reduce peak
airway pressure which of the following is the most appropriate action?
• A. Increase the frequency.
• B. use permissive hypercapnia
• C. increase the FI02.
• D. Increase PEEP to 15 cm H20.
• Which of the following conditions does not require high
mechanical respiratory rates?
• a. metabolic alkalosis
• b. ARDS
• c. increased intracranial pressure
• d. metabolic acidosis
 Mode: A/C ABG:  
Rate: 18 bpm pH 7.35
Vt: 800 ml PaCO2 47 mmHg
FiO2: 90% PaO2 53 mmHg
PEEP 15 cmH20 HCO3 26 mEQ/L
PAP 53 cm H20 BE +2

The following data are collected from an 80 kg (176-lb) patient with ARDS receiving volume-
controlled ventilation;

Which of the following is the most appropriate recommendation?

a. Increase PEEP to 20 cm H2O

b. Switch to pressure-control ventilation
c. Increase the FiO2 to 1.0
d. Increase the tidal volume to 900 ml
Strategy to improve ventilation on pressure
limited ventilators
• > Respiratory Rate and PIP are the 2 parameters that can
improve
Ventilation
> Respiratory Rate is the first parameter to consider in improving
ventilation
• > as long as the set rate is not below normal spontaneous rate,
the PIP level is adjusted to improve ventilation
Themosteffectivewaytoimproveventilationistoincreasetidalvolumenot
VentilatorRate
computation
 Mode: Control ABG:  
Rate: 15 bpm pH: 7.50
Vt: 800 ml PaCO2: 30 mmHg
    PaO2: 98 mmHg

These data have been collected from a patient in a mechanical ventilator. To

increase this patients PaCO2 to 40 mmHg, the ventilator rate should be adjusted to
what level?
a. 10/min
b. 11/min
c. 12/min
d. 13/min

Solution: Desired Rate = Rate (current) x PaCO2 (current) ÷ PaCO2 (desired)

= 15 x 30 ÷ 40
= 11 bpm
 Mode: Control ABG:  
Rate: 10 bpm pH: 7.30
Vt: 800 ml PaCO2: 50 mmHg
    PaO2: 98 mmHg

These data have been collected from a patient in a mechanical ventilator. To

increase this patients PaCO2 to 40 mmHg, the ventilator rate should be adjusted to
what level?
a. 10/min
b. 11/min
c. 12/min
d. 13/min
Monitoring Oxygenation
• > the most reliable monitoring tool to check for oxygenation is
ABG analysis
• > check for level of level of PaO2: 80 – 100 mmHg
Strategy to improve Oxygenation on
volume limited ventilators
• > adjust FiO2 level which is from 21% to 100%
• > In moderate to severe hypoxemia due to refractory
hypoxemia brought about by intrapulmonary shunting, PEEP level
is titrated
a. PaO2 < 60mmHg with FiO2 of 50% and above
b. PaO2/FiO2 (P/F) ratio < 200mmHg
> Titrate PEEP to attain OPTIMAL PEEP
> Shift to PC-IRV
EXAMPLE
• A 50 kg (110 lb) patient is being mechanically ventilated with the
following settings: Mode - Assist/control, FI02 - 1.0, Rate - 12bpm,
• PEEP - 10 cm H20 , VT - 650 mL, Peak airway pressure - 80 cm H20
• Sp02 - 85% :
A current chest x-ray shows diffuse bilateral infiltrates. To reduce peak
airway pressure and improve oxygenation, which of the following is the most
appropriate action?
• A. Increase the frequency.
• B. Change to PC-IRV
• C. Decrease the FI02.
• D. Increase PEEP to 15 cm H20.
 OPTIMAL PEEP
• > a PEEP level that improves oxygenation and compliance
without decreasing cardiac output.
• > can be determined by:
• 1. PaO2
• 2. PvO2
• 3. compliance
• 4. Oxygen Saturation
example
Which of the following is the optimum peep
using compliance

PEEP(cmH2O) PAP(cmH2O) PPLAT(cmH2O) Vt (ml)

4 36 20 500
6 39 22 500
8 42 23 500
10 45 27 500
WHICH OF THE FOLLOWING IS THE OPTIMUM PEEP USING PaO2 AND
COMPLIANCE AS INDICATOR?

Titration of Optimal PEEP using PaO2 and Compliance as

Indicator
PEEP (cmH20) PaO2 (mmHg) Compliance
(ml/cmH20)
0 43 26
5 67 33
8 77 37
10 83 43
12 79 41
WHICH OF THE FOLLOWING IS THE OPTIMUM PEEP USING PaO2 AND
COMPLIANCE AS INDICATOR?

Titration of Optimal PEEP using PaO2 and Compliance as

Indicator
PEEP (cmH20) PaO2 (mmHg) compliance
0 43 35
5 67 37
8 77 45
10 83 32
12 79 30
WHICH OF THE FOLLOWING IS THE OPTIMUM
PEEP?
Titration of Optimal PEEP using PaO2 and Compliance as Indicator
PEEP (cmH20) FiO2 % PaO2 (mmHg) Compliance (ml/cmH20)
5 100 47 21
7 100 60 23
9 100 67 27
11 100 78 29
13 100 87 32
15 100 78 28
PvO2 :
> partial pressure of venous oxygen
tension
> normal range is 35 – 45 mmHg
> obtained from Pul. Art. Catheter
> reflects cardiac output

Titration of Optimal PEEP using PaO2 and PvO2 as

Indicator
PEEP (cmH20) PaO2 (mmHg) PvO2
4 68 34
6 74 37
8 78 33
10 82 32
Weaning from PEEP and high Fi02
• Maintain PEEP and decrease
Fi02 to 40%.
• Maintain Fi02 and decrease
PEEP to about 5cmH20 (2-3
cmH20 increments)
• Maintain or Discontinue PEEP
of 5 cmH2O
• Keep Pa02 >60mmHg or Sa02 >
90%
Monitor V/S for acute changes
• Keep Pa02 >60mmHg or Sa02 >
90%
Monitor V/S for acute changes
• Monitor V/S for hypoxia and
increased WOB
Weaning of FiO2 using O2Sat, PaO2 and vital
signs as Indicator
PEEP (cmH20) FiO2 % O2Sat PaO2 (mmHg) Vital Signs
15 100 99 110 normal
15 90 98 98 normal
15 80 98 92 normal
15 70 98 85 normal
15 60 96 82 normal
15 40 95 80 normal
 Weaning of PEEP using PaO2 and vital signs as
Indicator
PEEP (cmH20) FiO2 % O2Sat PaO2 (mmHg) Vital Signs
15 40 99 110 normal
13 40 95 95 normal
11 40 97 88 normal
9 40 96 85 normal
7 40 95 83 normal
5 40 95 78 normal
EXAMPLE
• To manage a mechanically ventilated patient with ARDS, which
of the following would best decrease intrapulmonary shunting?
• A. increasing the PEEP
• B. increasing the tidal volume
• C. increasing the expiratory time
• D. increasing the respiratory rate
• A 6 year old child who weighs 20 kg (44 lbs) is intubated and being
mechanically ventilated on the following settings:
• Mode: A/C , FIO2: 0.80, Set rate: 12 br/min., Total rate: 15 br/min.
• Tidal volume: 200 ml
Arterial blood gas results:
• pH: 7.48
• PaCO2: 31 torr
• PaO2: 54 torr
• HCO3: 22 mEq/L
• The respiratory care practitioner should recommend which of the
following?
• A. initiate 6 cmH2O PEEP
• B. decrease the rate to 10
• C. increase the tidal volume to 300 ml
• D. increase the FIO2 to 0.85
• Which of the following indicate severely impaired oxygenation
requiring high FIO2s and positive end-expiratory pressure?
• 1. PaO2–PaO2 greater than 350 mm Hg on 100% O2
• 2. VC less than 10 ml/kg
• 3. PaO2/FIO2 less than 200
• a. 1 and 2
• b. 1 and 3
• c. 2 and 3
• d. 1,2, and 3
• Which of the following conditions is associated with a lack of
response to increased FIO2 in patients receiving positive-pressure
ventilation?
• a. dead space
• b. shunt
• c. hypoxemia
• d. hypoventilation
• A patient with ARDS is receiving mechanical ventilation with PEEP. The
PEEP level is increased from 5 cmH2O to 10 cmH2O. Which of the
following should be monitored by the respiratory therapist to evaluate
the patient response.
• 1. blood pressure
• 2. heart rate
• 3. body temperature
• 4. fluid intake and output
• a. 1 and 2
• b. 1, 2 and 3
• c. 1, 2 and 4
• d. 2, 3 and 4
• e. 1, 2, 3 and 4
• After a ventilator patient’s PEEP level is increased from 8 cmH2O
to 12 cmH2O, the PvO2 drops from 37 mmHg to 33 mmHg. This
indicates which of the following?
• a. venous return has increased
• b. tissue oxygenation has increased
• c. static compliance has increased
• d. cardiac output has decreased
• A mechanically ventilated patient needs to be titrated with PEEP
to improve oxygenation: All of the following are used to assess
optimal PEEP except:

• a. PaO2
• b. static compliance
• c. PvO2
d. FiO2
Airway pressures
Pressure level that would most likely lead to
barotrauma
• 1. Peak Airway Pressure: > 50 cmH2O
• 2. PEEP: > 1o cmH2O
• 3. Plateau Pressure: > 35 cmH2O
• 4. Mean Airway Pressure: > 30 cmH2O
 Airway resistance, Dynamic
compliance and static compliance
 Airway resistance
• > airflow obstruction in the airway
• > Normal Value (intubated patient): 5 cmH2O/L/sec
• > can be monitored on the pressure wave form and P-V loop
• > can be computed by:

• Raw = (PIP – Plateau P)

• PFR
 example
• The following data have been collected from a patient using a
volume ventilator: Compute for the Raw:
• Peak Inspiratory pressure: 35 cmH2O
• Plateau pressure: 20 cmH2O
• Peak Flow rate: 60 L/min or 1 L/sec

• Raw = 35 cmH2O – 20 cmH2O

• 1 L/sec
• = 15 cmH2O/L/sec
 example
• The following data have been collected from a patient using a
volume ventilator: Compute for the Raw:
• Peak Inspiratory pressure: 12 cmH2O
• Plateau pressure: 10 cmH2O
• Peak Flow rate: 50 L/min
 PRESSURE TIME CURVE

pressure Paw(peak)

Pres

Pplat
Pres

time

flow
This is a normal pressure-time waveform time
With normal peak pressures ( Ppeak) ;
plateau pressures (Pplat )and
‘Square wave’
airway resistance pressures (Pres) flow pattern
 HIGH AIRWAY RESISTANCE

pressure

Ppeak Normal

Pres e.g. ET tube

blockage

Pplat
Pres

time

flow
The increase in the peak airway pressure is driven time
entirely
This isby
anan
abnormal
increasepressure-time
in the airwayswaveform
resistance
pressure. Note the normal plateau pressure. ‘Square wave’
flow pattern
 Clinical Conditions that increases
Airway Resistance
Type Clinical Conditions
 1. COPD  Emphysema, Asthma
 Chronic bronchitis
 Bronchitis

 2. Mechanical Obstruction  Post intubation obstruction

 Foreign body aspiration
 ET tube
 Condensation in the circuit

 3. Infection  Croup
 Epiglottitis
 Bronchiolitis
compliance
Why the need for Compliance Measurement
• -> because abnormally high or low compliance impairs patients
ability to maintain efficient gas exchange.

• LUNG COMPLIANCE
• > defined as the ease with which the lung expands
• > normal value is 80 – 100 ml/cmH2O
• > can be computed by:

• Compliance = Volume/pressure
 Dynamic Compliance
-> is a measurement of airway resistance and lung compliance
- > not an accurate measurement of lung compliance
- > can be computed:

• Dynamic Compliance = Corrected Vt______

• Peak Pressure – PEEP
 Clinical Ranges
• For critically ill patients:

• DYNAMIC COMPLIANCE: 30 -40 ml/cmH2O

• Note: much lower in intubated patients

example
• Given the following data, calculate the patients dynamic
compliance.
• Vt: 600 ml
• PIP: 35 cmH2O
• PEEP: 5 cmH2O
• Dynamic Compliance = Corrected Vt______
• Peak Pressure – PEEP
• Dynamic CL = 600 ml
• 30 cmH2O
• = 20 ml/cmH2O
• Given the following data, calculate the patients dynamic
compliance.
• Vt: 500 ml
• PIP: 25 cmH2O
• PEEP: 5 cmH2O
 HIGH AIRWAY RESISTANCE

pressure

Ppeak Normal

Pres e.g. ET tube

blockage

Pplat
Pres

time

The increase in the peak airway pressure is driven

entirely
This isby
anan
abnormal
increasepressure-time
in the airwayswaveform
resistance
pressure. Note the normal plateau pressure.
 Static Compliance
• > more accurate measurement of lung compliance
• > measured with no air flowing through airways
• > use in determining optimal PEEP
• > can be computed by:

• Static CL = Corrected Vt
• Plateau Pressure – PEEP
 Clinical Ranges
• For critically ill patients:

• STATIC COMPLIANCE: 40 – 60 ml/cmH2O

• Note: much lower in intubated patients

example
 example
• Given the following data, calculate the patients static compliance.
• Vt: 800 ml PPlat: 25 cmH2O
• PEEP: 5 cmH2OPeak P: 45 cmH2O

• Static CL = Corrected Vt
• Plateau Pressure – PEEP

• Static CL = 800 ml
• 20 cmH2O
• = 40 ml/cmH2O
 example
• Given the following data, calculate the patients static compliance.
• Vt: 700 ml PPlat: 20 cmH2O
• PEEP: 5 cmH2O Peak P: 35 cmH2O
• Tubing compression Factor (TCF): 3 ml/cmH2O

Corrected Vt = Vt – (Peak P X TCF)

= 700 ml – (35 cmH2O x 3 ml/cmH2O)
= 700 ml – 105 ml = 595 ml
 example
SOLUTION:

• Static CL = 595 ml
• 15 cmH2O
• = 39.6 ml/cmH2O
 example
• Given the following data, calculate the patients static compliance.
• Vt: 500 ml PPlat: 15 cmH2O
• PEEP: 5 cmH2O Peak P: 25 cmH2O
• Tubing compression Factor (TCF): 3 ml/cmH2O
 DECREASE COMPLIANCE
The increase in the peak airway pressure is driven
by the decrease in the lung compliance.
Increased airways resistance is often
also a part of this scenario.
Paw(peak)
pressure

Normal

Pres
e.g. ARDS

Pplat

Pres
time

flow
time
This is an abnormal pressure-time waveform
‘Square wave’
flow pattern
Clinical conditions that decrease Compliance
Type of Compliance Clinical Condition
 Static Compliance  ARDS
 Atelectasis
 Tension Pneumothorax
 Obesity
 Retained Secretions in the lungs

 Dynamic Compliance  Bronchospasm

 Kinking of ET tube
 Airway Obstruction
 Retained secretions in the airways
 Points to remember
• - conditions causing changes in plateau pressure and static
compliance invoke similar changes in peak inspiratory pressure and
dynamic compliance

• - conditions where airflow resistance is increased, the peak

inspiratory pressure is increased, while the plateau pressure stays
unchanged.
examples
• TIME PEAK PRESSURE PLATEAU PRESSURE
• 6: 00 am 28 cmH2O 10 cmH20
• 700 am 34 cmH2O 10 cmH2O
• 8:00 am 42 cmH2O 10 cmH20
• What does it indicate:
• a. an increasing in airway resistance
• b. a decreasing in dynamic compliance
• TIME PEAK PRESSURE PLATEAU PRESSURE
• 6: 00 am 28 cmH2O 10 cmH20
• 700 am 34 cmH2O 10 cmH2O
• 8:00 am 42 cmH2O 10 cmH20
• Which of the following conditions could manifest these changes:
• a. kink ET tube
• b. patient biting the ET tube
• c. bronchospasm
• d. airway obstruction
• TIME PEAK PRESSURE PLATEAU PRESSURE
• 6: 00 am 42 cmH2O 10 cmH20
• 700 am 34 cmH2O 10 cmH2O
• 8:00 am 28 cmH2O 10 cmH20
• What does it indicate:
• a. a decreasing in airway resistance
• b. an increasing in dynamic compliance
• TIME PEAK PRESSURE PLATEAU PRESSURE
• 6: 00 am 28 cmH2O 10 cmH20
• 700 am 34 cmH2O 20 cmH2O
• 8:00 am 42 cmH2O 30 cmH20
• What does it indicate:
• a. a decreasing static compliance
• b. a decreasing dynamic compliance
• TIME PEAK PRESSURE PLATEAU PRESSURE
• 6: 00 am 28 cmH2O 10 cmH20
• 700 am 34 cmH2O 20 cmH2O
• 8:00 am 42 cmH2O 30 cmH20
• Which of the following conditions could manifest these changes:
• 1. obesity
• 2. retained secretions in the lungs
• 3. ARDS
• 4. atelectasis
• TIME PEAK PRESSURE PLATEAU PRESSURE
• 6: 00 am 42 cmH2O 30 cmH20
• 700 am 34 cmH2O 20 cmH2O
• 8:00 am 28 cmH2O 10 cmH20
• What does it indicate:
• a. an increasing or improving static compliance
• b. an increasing or improving dynamic compliance
• A 58-year-old man is being mechanically ventilated. During a
routine ventilator check, the respiratory therapist notices that the
static lung compliance has remained constant, while the dynamic
lung compliance has decreased over 2 hours. The most likely
reason for this change is:
• A. Increased airway resistance.
• B. Noncardiogenic pulmonary edema.
• C. Decreased tidal volume.
• D. Development of atelectasis.
• It is important to monitor airway pressure in a patient receiving
mechanical ventilation because it best reflects:
• A. lung compliance
• B. PaO2
• C. PaCO2
• D. ICP
• A respiratory care practitioner reviews a ventilator parameter sheet and
finds that the peak inspiratory pressure has been gradually rising for the past
several hours. Which of the following could be the cause for this change?
• I. Bronchospasm
• II. Increasing pulmonary compliance
• III. Accumulation of secretions
• IV. Increasing airway resistance
• A. III only
• B. I & III only
• C. I, III & IV
• D. I, II, III &IV
Calculation of compliance is also important
in the determination of optimal peep level

PEEP(cmH2O) PAP(cmH2O) PPLAT(cmH2O) Vt (ml)

5 36 21 500
7 40 23 500
11 43 26 500
12 48 29 500

Which of the following is the best PEEP?

WHICH OF THE FOLLOWING IS THE
BEST PEEP
PEEP (cmH20) PaO2 (mmHg) Compliance
(ml/cmH20)
0 43 26
5 67 33
8 77 37
10 83 43
12 79 41
• Which of the following could cause an increase in Peak
Inspiratory Pressure on a volume ventilator?
• 1. decrease compliance
• 2. decrease Raw
• 3. Partially occluded ET
• 4. High Inspiratory Flow setting
• a. 1 and 2
• b. 2 and 3
• c. 1, 3 and 4
• d. 1, 2, 3 and 4
weaning
• > is the process of abruptly or gradually widrawing ventilator
support when the cause of respiratory failure is under resolution.
Weaning Success
• -> is able to maintain normal spontaneous breathing 48 hours
following extubation
Weaning Failure
• - means failure of the patient to sustain normal spontaneous
breathing 48 hours after extubation.
Weaning in Progress
• -> patients who are extubated but continue to receive
ventilatory support by Non Invasive Ventilation.
• -> purposely to prevent complications of long term mechanical
ventilation
signs of Weaning Failure
• CLINICAL SIGNS
• 1. tachypnea
• 2. Tachycardia
• 3. Hypertension
• 4. Hypotension
• 5. Hypoxemia
• 6. acidosis
• 7. arrhytmias
signs of Weaning Failure
• PHYSICAL SIGNS
• 1. agitation
• 2. distress
• 3. diminished mental status
• 4. diaphoresis
• 5. increased work of breathing
Patient Condition Prior to Weaning

• Two (2) important points pertaining to the patients clinical

condition:
1. Recovery from the acute phase of the disease or injury that
prompted the need for MV .
2. Absence of clinical conditions that may interfere with the
patients ability to maintain work of breathing.
Weaning Criteria
• -> evaluate readiness for weaning trial and the likelihood of
weaning success.
 Common Weaning Criteria
CATEGORY EXAMPLE Note
Clinical Criteria Resolution of acute phase of disease
Adequate cough
Absence of excessive secretions
Cardiovascular and hemodynamic stability
no anemia, fever or electrolytes imbalance
Ventilatory Criteria Spontaneous breathing Trial Tolerates 20 – 30 minutes
PaCO2 < 50 mmHg w/ normal ph
Vital Capacity > 10 ml/kg
Spontaneous Vt > 5 ml/kg
Spontaneous f (RR) < 25 / min
f / Vt (RSBI) < 105 breaths / min / L
Minute Ventilation < 10 L with satisfactory ABG
Occlusion Pressure in 0.1 sec (PO.1) < 6 cmH2O
 Common Weaning Criteria
CATEGORY EXAMPLE Note
Oxygenation Criteria PaO2 without PEEP > 60 mmHg @ Fio2 up to 0.40
PaO2 with PEEP (< 8 cm H2O) > 100 mmHg @ Fi02 up to 0.40
SaO2 > 90% @ Fi02 up to 0.40
Qs/Qt < 20%
P(A-a)O2 < 350 mmHg @ Fi02 of 1.0
PaO2/FiO2 (P/F) > 200 mmHg

Pulmonary Reserve Vital Capacity > 10 ml / kg

MIP > – 20 cmH20 in 20 sec

Pulmonary Static Compliance > 30 ml/cmH20

Measurements
Airway Resistance Stable or improving
VD/Vt < 60% while intubated
Respiratory to Tidal Volume Ratio
(RSBi)
• -> Evaluates the presence and severity of a spontaneous
breathing that is rapid (High RR) and shallow (low Vt)
• - > most reliable among all other weaning criterias
• Equation:
RSBi = f/Vt
example
Respiratory to Tidal Volume Ratio (RSBi)

• Example:
Calculate the RSBi given the spontaneous respiratory rate of 14
bpm and Vt of 0.5 L (500ml). Does this index indicate a
successful weaning?

Solution:
RSBi = f/Vt
= 14 bpm/0.5 L
= 28 breaths/min/L
Calculate the RSBi of a patient whose spontaneous respiratory
rate is 20 bpm and Vt of 500 ml. Does this index indicate a
successful weaning?
Weaning modes
T – piece weaning
- an abrupt discontinuation of MV and resumption of
spontaneous breathing through a T – tube system.
- > SIMPLEST weaning method
- > single trial lasting up to 2 hours if tolerated
SIMV
• -> A pre set number of volume controlled breaths are set while
allowing spontaneous breaths without assistance
• -> Gradual decrease in mandatory breaths until such time that
the back up rate of 4 or less is achieved.
• - > When used in conjunction with Pressure Support Ventilation,
decrease Pressure Support level first at 5 – 10 cmH2O before
decreasing back up rate.
Pressure Support Ventilation
- > Gradual reduction of PSV level until a minimum of 5 cmH2O
is reached
- > prevents activation of accessory muscles
- > Has the highest weaning outcome in weaning trials
Signs of Weaning Failure
• - tachypnea
• - use of accessory muscles
• - paradoxical abdominal movements
• - dyspnea
• - chest pain
• - diaphoresis
• - delirium
Terminal Weaning
- Withdrawal of MV that results in the death of the patient
- Due to the following Reasons:
1. patients informed request
2. medical futility
3. reduction of pain and suffering
4. Fear and distress
examples
• 1. A 60 y/o COPD patient who was confined due to acute
myocardial infarction is on mechanical ventilator, if weaning is to
consider, which of the following would be your first consideration?
• a. Primary medical problem
• b. COPD issues
• c. Fluid status of the patient
• d. oxygenation
• 2. Which of the following indicates that weaning should not be
attempted?
• a. cessation of use of sedatives and neuromuscular blocking
agents
• b. continuous use of dopamine and dobutamine drip
• c. normal potassium level
• d. PaO2 of >60 mmHg at FiO2 of < .40
• 3. A method of weaning that imposes abrupt discontinuation of
respiratory support.
• a. Pressure support weaning
• b. SIMV weaning
• c. Non Invasive Ventilation
• d. T piece weaning
• 5. A patient is currently ventilated on volume ventilator on an A/C mode with
the following settings. RR: 12 , FiO2: 40%, PEEP of 5 cmH2O. His vital signs are
normal and all other lab results are within normal limits: His ABG are as follows:
• pH: 7.37, PaCO2: 45 mmHg, PaO2: 78 mmHg, HCO3: 23 mEq

• Which of the following would you recommend?

• a. Decrease FiO2 to 30%
• b. Decrease PEEP to 3 cmH2O
• c. recommend for weaning trial
• d. Extubate the patient
 Mode: SIMV ABG:  
Rate: 6 bpm pH 7.35
Vt: 700 ml PaCO2 43 mmHg
FiO2: 40% PaO2 98 mmHg
Pressure 25 cmH20    
Support

A postoperative patient is to be weaned from mechanical ventilation. The following ventilator settings
are being used

Which of the following should the respiratory therapist recommend to begin weaning this patient?
a. Decrease the FiO2
b. Decrease pressure support
c. Decrease VT
d. Increase inspiratory flow
 Mode: SIMV ABG:  
Rate: 10 bpm pH 7.24
Vt: 700 ml PaCO2 57 mmHg
Total rate 28 bpm PaO2 66 mmHg
FiO2 35 %  HCO3 23 mEq/l 
Peak Flow Rate 25 LPM
Pressure Support 10 cmH2O

The patient is tachypneic and agitated and the high pressure alarm is triggering with each breath.
On the basis of these information:

Which of the following should the respiratory therapist recommend?

a. increase peak flow rate

b. increase FiO2
c. increase pressure support
d. Increase tidal volume
• For successful weaning, a patient generally needs a vital capacity of
at least
• a. 5 ml/kg.
• b. 7 ml/kg.
• c. 10 ml/kg.
• d. 15 ml/kg.
• Which of the following values are not indicative of weaning?
• a. PaO2 of 83 mmHg
• b. PEEP of 5 cmH2O
• c. FiO2 of 40%
• d. none of the above
• For successful weaning, your patient's negative inspiratory
pressure should be at least
• a. -10 cm H2O.
• b. -15 cm H2O.
• c. -20 cm H2O.
• d. -30 cm H2O.
• Which weaning method provides a gradual transition from
ventilatory support to spontaneous breathing while maintaining a
patent airway with an ET tube?
• a. T-piece
• b. PSV
• c. CPAP
• d. SIMV
• A mechanically ventilated patient is recovering from a drug
overdose has a PaO2 of 76 mmHg on 30% oxygen. What is the
PaO2/FiO2 (P/F) index:
• a. 350
• b. 253
• c. 479
• d. 135
• A physician wants to wean a patient from a ventilator. Which of the following
measurements obtained by an RT indicative of a successful weaning?

• 1. MIP of – 41 cmH2O
• 2. P (A-a) O2 190 mmHg at 1oo% FiO2
• 3. Vital capacity of 14 ml/kg

• A. 1 only
• B. 1 & 3 only
• C. 2 and 3 only
• D. 1, 2 and 3
• Which of the following weaning parameters is the most reliable
indicator of a successful weaning:
• a. MIP
• b. RSBi
• c. P/F ratio
• d. PaCO2
• Which is most likely a sign of weaning intolerance in your patient?
• a. heart rate of 90 beats/minute
• b. BP of 185/104
• c. respiratory rate of 24 breaths/minute
• d. Spo2 of 92%
• Which of the following indicates that the patient should not be
extubated?
• a. VC: 18 ml/kg, MIP: - 40 cmH2O, VD/Vt: 30 %
• b. VC: 16 ml/kg, MIP: - 80 cmH2O, VD/Vt: 40%
• c. VC: 14 ml/kg, MIP: - 16 cmH2O, VD/Vt: 50%
• d. VC: 16 ml/kg, MIP: - 80 cmH2O, VD/Vt: 55%
 Mode: SIMV ABG:  
Rate: 6 bpm pH 7.44
Vt: 700 ml PaCO2 34 mmHg
FiO2: 35 % PaO2 89 mmHg
 HCO3 24 mEq/l 

Based on the following data, the therapists should recommend which of the following?

a. administer NaHCO3
b. extubate the patient
c. Decrease VT to 600ml
d. decrease Rate to 4/min
Ventilator alarms
Alarms that signal leak in the system
• 1. Low Pressure alarm : set at 5 to 10 cmH2O below PIP
• 2. Low PEEP alarm: set 2 to 4 cmh2O below baseline level
• 3. Low Tidal volume alarm: set approximately 10% below the set
Tidal volume
Apnea alarm
• -> set between 10 to 15 seconds
• -> signals that no breath is being taken or delivered to the
patient
High pressure alarm
• -> should be set 5 to 10 cmH2O above PIP
• -> signals the presence of increasing airway resistance or
decrease in compliance.
• -> activation in volume ventilator will lead to premature cycling
to expiration delivering a decrease Vt.
EXAMPLE
• A patients low pressure alarm is triggered persistently. The likely
causes of this condition include all of the following except:
• a. Disconnection of the ventilator circuit
• b. Kinking of the endotracheal tube
• c. leak in the humidifier
• d. Leakage of the ET cuff tub
• A patients high pressure alarm is triggered persistently. The likely
causes of this condition include all of the following except:
• a. bronchospasm
• b. coughing
• c. high pressure alarm set too high
• d. mucus plug
• A patient was given a paralyzing drug and is receiving mechanical
ventilation. Which of the following ventilator alarms would be the
most important?

• A. low pressure
• B. high pressure
• C. High RR
• D. High minute ventilation
examples
• Venous return is least impaired by which of the following ventilator
settings?

• A. SIMV mode, rate of 12bpm

• B. Control mode, rate of 10bpm
• C. A/C mode, rate of 10 bpm
• D. SIMV mode, rate 8 bpm
A 75 kg male patient is using a volume ventilator in the control mode.
Appropriate data from his chart are as follows:

ABG:
Vt: 700mlPFR: 60LPM pH: 7.28
Rate: 12/min PCO2: 54 mmHg
FiO2: 50% PaO2: 74 mmHg
PEEP: 5 cmH2O HCO3: 25 mEq

What changes would you recommend base on ABG?

1. Increase PEEP
2. increase rate
3. increase FiO2 to 70%
4. Increase Vt to 750 ml
A patient weighing 80kg is using a volume ventilator in the control
mode. Pertinent data as follows:

ABG:
Vt: 800ml PFR: 60LPMpH: 7.41
Rate: 12/min PaCO2: 37 mmHg
FiO2: 60% PaO2: 137 mmHg
PEEP: 8 cmH2O HCO3: 26 mEq

What changes would you recommend base on ABG?

1. Decrease FiO2 to 50%
2. decrease Vt to 700ml
3. decrease rate to 10
4. Decrease PEEP to 6 cmH2O
A 46 y/o 50 kg male is mechanically ventilated with a volume ventilator
in A/C mode with data as follows:

ABG:
Vt: 500mlpH: 7.48
Rate: 12/min PaCO2: 27 mmHg
FiO2: 30% PaO2: 53 mmHg

What changes would you recommend base on ABG?

1. Decrease rate to 8
2. Decrease Vt to 450 ml
3. Increase FiO2 to 50%
4. Begin PEEP at 8 cmH2O
A patient is using a Pressure ventilator in control mode with the
following settings:

ABG:
PIP: 30 cmH2O pH: 7.50
Rate: 10/min PaCO2: 29 mmHg
FiO2: 35% PaO2: 97 mmHg
I:E Ratio: 1:3 HCO3: 25 mEq

What changes would you recommend base on ABG?

1. Change I:E ratio
2. Decrease FiO2
3. Decrease PIP
4. Decrease RR
A 60 kg (132lbs) female patient is using a volume ventilator in a control
mode with the following settings:

ABG:
Vt: 800ml pH: 7.52
Rate: 12/min PaCO2: 28 mmHg
FiO2: 40% PaO2: 92 mmHg

What changes would you recommend base on ABG?

1. decrease FIO2 to 50%
2. Add PEEP of 5 cmH2O
3. decrease rate to 6/min
4. Decrease Vt to 600 ml
A patient is currently hook on a volume ventilator in assist control
mode with the following settings. What would be your
recommendation based on the abg?
ABG:
Vt: 750ml pH: 7.52
Rate: 12/min PaCO2: 28 mmHg
FiO2: 40% PaO2: 92 mmHg

What changes would you recommend base on ABG?

1. decrease FIO2
2. Add PEEP
3. decrease rate
4. Decrease Vt
 THANK YOU
AND
GOODLUCK!!!