MECHANICAL

VENTILATION
ARMALYN S. ANDRES, RTRP
GOALS OF MECHANICAL
VENTILATION
INDICATIONS OF
MECHANICAL VENTILATION
 The clinical conditions leading to mechanical ventilation can be grouped into four areas:
 (1) acute ventilatory failure
 (2) impending ventilatory failure
 (3) severe hypoxemia; and
 (4) prophylactic ventilatory support
CONTRAINDICATIONS
Untreated tension pneumothorax is is an absolute contraindication for mechanical ventilation.

There are three considerations in which mechanical ventilation should be terminated or should
not be started.
(1) patient’s informed request
(2) medical futility
(3) reduction or termination of patient pain and suffering.
INITIAL SETTINGS
 Mode
 Frequency
 Tidal volume
 FIO2
 inspiratory:expiratory ratio
 inspiratory flow pattern
 Various alarm limits.
MODE
 The majority of ventilator 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.
 Partial support would be inappropriate initially for patients with ventilatory failure, and it is
more commonly used during the weaning process.
FREQUENCY
 The initial ventilator frequency is the number of breaths per minute that is intended to provide
eucapneic ventilation (PaCO2 at patient’s normal).
 The initial ventilator frequency should be set between 10 and 12/min.
 This frequency, coupled with a 10 to 12 mL/kg tidal volume, usually produces a minute
volume that is sufficient to normalize the patient’s PaCO2.
 Ventilator frequency is the primary control to regulate the PaCO2.
 frequency if the PaCO2 is too high; frequency if the PaCO2 is too low.
TIDAL VOLUME
 The initial tidal volume is usually set between 10 and 12 mL/kg of predicted body weight.
 Tidal volumes as low as 6 mL per kg of predicted body weight have been recommended for
ARDS patients.
 COPD patients may also benefit from a reduced tidal volume setting.
 Decreasing the tidal volume by 100 to 200 mL in COPD patients reduces the expiratory time
requirements and helps to prevent air trapping. A higher flow rate may also be used to shorten
the inspiratory time and lengthen the expiratory time.
PRESSURE SUPPORT
 Pressure support ventilation (PSV) is used to augment a patient’s breathing effort by reducing
the airflow resistance during spontaneous breathing.

 For weaning from mechanical ventilation with a spontaneous breathing trial, PS is titrated
until achieving a spontaneous frequency of 20 to 25/min or a spontaneous tidal volume of 8 to
10 mL/kg predicted body weight (PBW).
 For further weaning, the PS level is reduced by 2 to 4 cm H2O increments as tolerated.
 Extubation can be considered when the PS level reaches 5 to 8 cm H2O for 2 hours with no
signs of respiratory distress.
FIO2
 For patients with severe hypoxemia or abnormal cardiopulmonary functions (e.g., post-
resuscitation, smoke inhalation, ARDS), the initial FIO2 may be set at 100%.
 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% 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.
PEEP
 Set the initial PEEP at 5 cm H2O and make changes based on the patient’s blood gas results,
FIO2 requirement, tolerance of PEEP, and cardiovascular responses.
I:E RATIO
 A time ratio comparing the inspiratory time and expiratory time, normally between 1:2 and 1:4 in
mechanical ventilation.
 This ratio is regulated by the inspiratory flow rate, I time, or E time and is affected by the tidal
volume and respiratory rate.
 Inverse I:E ratios have been used to correct refractory hypoxemia in ARDS patients with very
low compliance. But it should not be the initial I:E setting since reverse I:E ratio has its inherent
cardiovascular complications.
 Depending on the features available on the ventilator, the I:E ratio may be altered by
manipulating any one or a combination of the following controls:
 (1) flow rate
 (2) inspiratory time
 (3) inspiratory time %
 (4) frequency, and
 (5) minute volume (tidal volume and frequency).
FLOW PATTERN
Most modern ventilators offer different inspiratory flow patterns. Although there are subtle
variations, the principal flow patterns are
 (1) square (constant) flow pattern- may be used initially upon setting up the ventilator.
 (2) accelerating (ascending) flow pattern
 (3) decelerating (descending) flow pattern, and
 (4) sine wave flow pattern.
VENTILATOR ALARM
SETTINGS
The following alarms should be basic to any ventilator:
1. low exhaled volume alarm
2. low inspiratory pressure alarm
3. high inspiratory pressure alarm
4. apnea alarm
5. high frequency alarm
6. FIO2 alarm.
LOW EXHALED VOLUME
ALARM
 The low exhaled volume alarm (low volume alarm) should be set at about 100 mL lower than
the expired mechanical tidal volume.
 This alarm is triggered if the patient does not exhale an adequate tidal volume.
 This alarm is typically used to detect a system leak or circuit disconnection.
LOW INSPIRATORY PRESSURE
ALARM
 The low inspiratory pressure alarm (low pressure alarm) should be set at 10 to 15 cm H2O
below the observed peak inspiratory pressure.
 This alarm is triggered if the peak inspiratory pressure is less than the alarm setting.
 The low inspiratory pressure alarm complements the low exhaled volume alarm and is also
used to detect system leaks or circuit disconnection.
HIGH INSPIRATORY PRESSURE
ALARM
 The high inspiratory pressure alarm (high pressure limit alarm) should be set at 10 to 15 cm
H2O above the observed peak inspiratory pressure.
 This alarm is triggered when the peak inspiratory pressure is equal to or higher than the high
pressure limit.
 Once the alarm is triggered by airflow obstruction, inspiration is immediately terminated and
the ventilator goes into expiratory cycle.
APNEA ALARM
 The apnea low volume and low pressure alarms are triggered in apnea and circuit
disconnection (i.e., inadvertent disconnection or during endotracheal suctioning).
 The apnea alarm should be set with a 15- to 20-sec time delay, with less time delay at higher
frequency.
 On some ventilators, the apnea alarm also triggers an apnea backup ventilation mode in which
the ventilator provides ventilatory support until the alarm condition no longer exists.
HIGH FREQUENCY ALARM
 The high frequency alarm should be set at 10/min over the observed frequency.
 Triggering of the high frequency alarm may indicate that the patient is experiencing
respiratory distress.
HIGH AND LOW FIO2 ALARMS
 The high FIO2 alarm should be set at 5% to 10% over the analyzed FIO2 and the low FIO2
alarm should be set at 5% to 10% below the analyzed FIO2.
HAZARDS AND COMPLICATIONS
MALFUNCTION AND MISUSE
OF ALARMS
 Sixty-five percent of the deaths or injuries were related to the malfunction or misuse of
ventilator alarms.
 A breakdown of the causes revealed that the alarms were either turned off or set incorrectly, no
alarm was available for certain disconnections, testing of alarms was not performed, or
response to alarm was delayed or absent
BAROTRAUMA
Risk of barotrauma is high when:
 PIP >50 cm H2O
 Plateau pressure >35 cm H2O
 mPaw >30 cm H2O
 PEEP >10 cm H2O

The risk of barotrauma also increases with the duration of positive pressure ventilation.
Other lung injuries that may occur as a result of positive pressure ventilation include
 pulmonary interstitial emphysema
 Pneumomediastinum
 Pneumoperitoneum
 Pneumothorax
 tension pneumothorax
 subcutaneous emphysema.
DECREASE IN CARDIAC
OUTPUT AND BLOOD
PRESSURE
 Positive pressure ventilation has been implicated in the development of decreased cardiac
output and arterial blood pressure.
 A competent cardiovascular system can compensate for a small drop in venous return by an
increased heart rate and arterial vasoconstriction.
 The two primary compensatory mechanisms include an increased heart rate and arterial
vasoconstriction initiated by the cardiac baroreceptors.
 High airway pressures are more detrimental to the cardiac output in patients with high lung
compliance than those with low compliance.
PRACTICE
QUESTIONS
Which of the following is not an indication for
mechanical ventilation?
a. acute ventilatory failure
b. impending ventilatory failure
c. severe hypoxemia
d. airway obstruction
A patient has an admitting diagnosis of acute
ventilatory failure. This condition is
characterized by a PaCO2 of _______ mm Hg
or greater with an accompanying respiratory
_______.
a. 20, acidosis
b. 50, acidosis
c. 20, alkalosis
d. 50, alkalosis
Impending ventilatory failure may be evaluated
by trending a patient’s:

a. respiratory parameters and mechanics.

b. arterial PO2.
c. vital signs.
d. hemodynamic parameters.
Among other criteria of assessment, impending
ventilatory failure may be present when the patient’s
minute ventilation is _______ 10 L/min and maximum
inspiratory pressure is less than _______.
A. more than, 20 cm H2O
B. more than, -20 cm H2O
C. less than, 20 cm H2O
D. less than, -20 cm H2O
The primary purposes of prophylactic mechanical
ventilation include all of the following except:

A. to minimize the risk of pulmonary complications.

B. to reduce prolonged hypoxia of major body organs.
C. to reduce the work of the cardiopulmonary system.
D. to monitor the arterial blood gases and vital signs.
A physician asks the therapist to set up a ventilator using
volume-controlled made for a 35-year-old post-operative
patient who weighs 132 lb (60 kg). The therapist should
use an initial tidal volume of _______ and frequency of
_______.
A. 400 mL, 12/min
B. 400 mL, 20/min
C. 600 mL, 20/min
D. 600 mL, 12/min
Positive end-expiratory pressure (PEEP) may be indicated
in patients with decreased _______ and presence of
_______.

A. tidal volume, chronic hypercapnia

B. functional residual capacity, refractory hypoxemia
C. vital capacity, acute hypercapnia
D. tidal volume, refractory hypoxemia
At constant tidal volume and frequency, increasing the
inspiratory flow rate will lead to a _______ inspiratory
time (I time) and _______ expiratory time (E time).
A. longer, longer
B. shorter, longer
C. longer, shorter
D. shorter, shorter
What should be the minimum flow rate for a minute
volume of 12 L/min and an I:E ratio of 1:4?

A. 40 L/min
B. 50 L/min
C. 60 L/min
D. 70 L/min
The _______ and _______ are two alarms that are to
detect circuit disconnection.

A. low pressure, high pressure

B. high PEEP, high volume
C. low volume, low PEEP
D. low pressure, low volume
Which of the following is not a common potential
complication of positive pressure ventilation?

A. hypertension
B. decrease in cardiac output
C. accidental patient disconnection
D. barotrauma