Damietta health directorate

Training and schools department

Basics of Mechanical
ventilation
 Damietta health directorate
Training and schools department

Basics of Mechanical ventilation

By

Mahmoud Muhamad shaqria

Clinical research department member
Clinical instructor in technical nursing institute

M.Sc. nursing administration , ACLS , BLS , Leadership NTI, Comprehensive Clinical Research Training
AMS. CPHQ , TOT , Disaster management , Occupational Safety and Health , KPI & ICD-10, Infection Control Practical Program
IRB Members (Basic Course) , Information Privacy Security (IPS)
Learning objectives:-
By the end of this course, learners will:-

1- Identify and differentiate between different types of mechanical ventilation.

2- Recognize signs and symptoms indicative of respiratory distress and failure.

3- Describe the various types of oxygen masks used in respiratory care.

4- Define lung compliance and resistance and their relevance to respiratory function.

5- Identify and explain different modes of mechanical ventilation.

Cont. learning objectives:

6- Apply knowledge of curves to optimize ventilator settings based on patient

condition.

7-Discuss various weaning techniques and strategies.

8- Identify common alarms encountered during mechanical ventilation.

9- Discuss the role of nursing in the care of mechanically ventilated patients.

Outlines:-
• Introduction (Types and definition of mechanical ventilation)
• Assessment of Respiratory Distress & failure
• Oxygen masks
• Lung mechanics
• Modes of mechanical ventilation
• Curves
• Weaning from mechanical ventilation
• Alarms of mechanical ventilation
• Nursing management
Introduction

Mechanical ventilation can be applied as :-

Negative pressure: to the outside of the thorax (e.g., the iron lung)

Positive pressure: to the airway. The desired effect of positive pressure ventilation is

to maintain adequate levels of Pao, and Paco₂ while also unloading the inspiratory

muscles.

Shelledy, D. C., & Peters, J. I. (2019).

negative pressure positive pressure
• Mechanical ventilation is the delivery of gases to support breathing in
patients who are unable to maintain adequate gas exchange on their
own. It can be delivered invasively, through an artificial airway such as
an endotracheal tube or tracheostomy tube, or noninvasively, using a
mask interface.

• Mechanical ventilation is the machine-delivered flow of gases to both

oxygenate and ventilate a patient who is unable to maintain
physiological gas exchange.

Jonathan, Friedman., Seth, Assar. (2022)

Assessment of Respiratory Distress & failure

 Assessment of Respiratory Distress

 Respiratory Failure

 Arterial Blood Gases (Rapid interpretation)

 Indications of MV
Assessment of Respiratory Distress & failure

 Assessment of Respiratory Distress

 Respiratory Failure

 Arterial Blood Gases (Rapid interpretation)

 Indications of MV
Respiratory Distress
How to assess a patient with respiratory distress?

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth). Elsevier.
Respiratory Distress
How to assess a patient with respiratory distress ?

1) Patient COMPLAINT of “Not Getting Enough Air”.

2) Level of CONSCIOUSNESS.

3) Appearance and texture of the SKIN (cyanosis, sweating, pale).

4) Abnormal breath SOUNDS.

Stridor, Wheezes, Crackling & Snoring

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth). Elsevier.
Respiratory Distress
How to assess a patient with respiratory distress ?

5) VITAL signs: ….. Take care of “panic attacks”

- Respiratory Rate …… (>20)

- Heart Rate ……. (>100)

- Blood Pressure ….. (Increase … decrease)

- SpO2 …….(>94% ……. 88-92%)

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth). Elsevier.
 Respiratory Distress
How to assess a patient with respiratory distress ?

6) Chest Auscultation: ….. Cause

7) Using of ACCESSORY MUSCLES of respiration

(e.g. the sternocleidomastoid, scalene, and trapezius muscles).

( e.g. Abdominal wall muscles )

8) PARADOXICAL breathing
(usually indicates increased WOB and the onset of respiratory muscle fatigue).

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth). Elsevier.
Tachycardia and tachypnea
are early indicators of
hypoxia,
But they are nonspecific and
mostly subjective signs that
may provide only limited
help in deciding when to
intubate and ventilate a
patient

J.M. Cairo. (2016). Pilbeam’s mechanical

ventilation: physiological and clinical applications
(sixth). Elsevier.
J.M. Cairo. {2016). Pilbeam’s mechanical ventilation: physiological and clinical applications {sixth). Elsevier.
Assessment of Respiratory Distress & failure

 Assessment of Respiratory Distress

 Respiratory Failure

 Arterial Blood Gases (Rapid interpretation)

 Indications of MV
Respiratory Failure Lab Diagnosis
1) Acute hypoxemic respiratory failure (Type I)
(Can’t oxygenate) (Lung Failure)
= low PaO2 < 60 mm Hg

TTT: Oxygen Therapy ….. Ventilatory support

2) Acute hypercapnic respiratory failure (Type II)

(Can’t ventilate) (Pump Failure)
= high PaCO2 > 50 mm Hg and rising

TTT: Ventilatory support +/- Controlled Oxygen Therapy

N.B Unacceptably high WOB “Impending ventilatory failure”

Assessment of Respiratory Distress & failure

 Assessment of Respiratory Distress

 Respiratory Failure

 Arterial Blood Gases (Rapid interpretation)

 Indications of MV
 Arterial Blood Gases
• Rapid Interpretation of Oxygenation & Ventilation
 Oxygenation vs. Ventilation

• Oxygenation:
– The process of adding oxygen to the body – Occurs at the cellular level
– Process occurs at the Alveolar / Capillary bed
– Oxygen binds to hemoglobin -> dissolves in plasma -> body

• Ventilation:
– A separate physiological process
– Simply -> air moves in and out of the lungs – Can be spontaneous or artificial
– Occurs from the nose/ mouth -> alveoli – Active vs. Passive phase of breathing
Arterial Blood Gases (Rapid interpretation)
Normal Values:
1)pH ………. 7.35 - 7.45
2)PaCO2…… 35 - 45
3)PaO2 …….. >80 (Age <60, on room air)
4)Decreased PaO2 …………………………….. Hypoxemia
60-80 ……. Mild hypoxemia
< 60 ……. Type I Respiratory Failure

2)Decreased pH & Increased PaCO2 …… Hypoventilation

(pH < 7.35) + (PaCO2 > 50) ….. Type II Respiratory Failure

Acute Vs Chronic
N.V. Bhagavan, Chung-Eun Ha, in Essentials of Medical Biochemistry (Second Edition), 2015
Assessment of Respiratory Distress & failure

 Assessment of Respiratory Distress

 Respiratory Failure

 Arterial Blood Gases (Rapid interpretation)

 Indications of MV
Indications Of MV
1) Apnea or Respiratory Arrest ( e.g. General Anesthesia)

2) Acute hypercapnic respiratory failure (Type II)

(Can’t ventilate = high PaCO2 > 50 mm Hg and rising …… despite initial TTT lines)

3) Acute hypoxemic respiratory failure (Type I)

(Can’t oxygenate = low PaO2 below the predicted normal range for the patient’s age

……. despite Oxygen Therapy )

4) Unacceptably high WOB “Impending ventilatory failure”

5) +/- Hemodynamic compromise ; Refractory shock

6) +/- Can’t protect airway (e.g. GCS < 8)

What are values of PaO2, PaCO2, or pH at which we must
invasively ventilate the patient ??

No single value for PaO2, PaCO2, or pH

indicates a need for invasive ventilation

J.M. Cairo. {2016). Pilbeam’s mechanical ventilation: physiological and clinical applications {sixth). Elsevier.
Indications Of MV

Although ventilators have been used for more than half a

century,
surprisingly

little evidence and few precise criteria

are available to guide clinicians about

when to initiate ventilator support.
J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications (sixth). Elsevier.
Lung mechanics
Lung mechanics
 Equation of Motion

 Lung Mechanics

- Compliance (C)

- Resistance (R)

 Heart-Lung interactions

 Air Trapping & Auto-PEEP

Lung mechanics
 Equation of Motion

 Lung Mechanics

- Compliance (C)

- Resistance (R)

 Heart-Lung interactions

 Air Trapping & Auto-PEEP

CONTROL MECHANISM :

Pressure, volume and flow are VARIABLES

Compliance and resistance are CONSTANTS

What is the difference between

VOLUME & FLOW ?

Lung mechanics
 Equation of Motion

 Lung Mechanics

- Compliance (C)

- Resistance (R)

 Heart-Lung interactions

 Air Trapping & Auto-PEEP

 Compliance:
The relative ease of structure distension
Elastance:
The tendency of a structure to return to its original form after being
stretched

C = 1/E or E = 1/C
C=
Δ V
ΔP
May be
- Static Compliance (CS) or - Dynamic Compliance (Cd)

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Respiratory System Compliance
tidal volume
Cs =
Pplat - PEEP

Normal :
Spont. 50-100-170 mL/cm H2O
MV: 40 - 50 -100 mL/cm H2O

Decreased with:
• Mainstem Intubation • Tension Pneumothorax • Abdominal Distension
• Congestive Heart Failure • Pleural Effusion • Chest Wall Edema
• ARDS • Thoracic Deformity
• Atelectasis
• Consolidation
• Fibrosis
• Hyperinflation
Resistance:
measurement of the frictional forces that must be overcome during
breathing.

Airway Resistance:
- The resistance to airflow through the conductive airways

- Measured in cmH2O/[L/s].

- May be

Inspiratory Resistance
or Expiratory Resistance
 Inspiratory Resistance
PIP - Pplat measure with 60
Ri = flow
L/min (1 L/s)
constant flow

Normal:
5 - 10 cm H2O/L/s for intubated ventilated adults

Increased with:
 Secretions
 Bronchospasm
 Small/ obstructed endotracheal tube
Lung mechanics
 Equation of Motion

 Lung Mechanics

- Compliance (C)

- Resistance (R)

 Heart-Lung interactions

 Air Trapping & Auto-PEEP

 Cardiovascular effects
of +ve Pressure
Ventilation
Positive pressure Ventilation causes:
 Rise in pleural pressure

 Rise in intraabdominal pressure

 Increased lung volumes

 Cardiovascular effects
of +ve Pressure Ventilation
Preload:
Positive intra-thoracic pressure reduces venous return
This effect is minimized by (sympathetic tone & increased
intraabdominal pressure) >> sedation & open abdomen exacerbate effect
on venous return
Exacerbated by
 high inspiratory pressure
 prolonged inspiratory time
 PEEP
 Cardiovascular effects
of +ve Pressure Ventilation
Afterload: Controversy !!!!!
 Decreased afterload due to decreased LV transmural pressure

 Overall effect depends on whether ventricular contractility is normal

or abnormal

 Contractility
 cardiac output

 Normal contractility

 cardiac output
Lung mechanics
 Equation of Motion

 Lung Mechanics

- Compliance (C)

- Resistance (R)

 Heart-Lung interactions

 Air Trapping & Auto-PEEP

Air trapping
Air trapping
Air trapping
Air trapping
Air trapping
Air trapping
 Air trapping
Insufficient time for alveoli to empty before the next breath
 Air Trapping .. Auto-PEEP / Intrinsic PEEP
 Predisposing factors:

 Airway obstruction: Asthma or COPD

 High respiratory rate ( absolute expiratory time short)

 Long inspiratory time ( expiratory time short)

 Air Trapping .. Auto-PEEP / Intrinsic PEEP

 Main Adverse effects:

 Progressive rise in end-expiratory pressure (intrinsic PEEP/Auto-PEEP)

• >> Cardiovascular compromise

• >> Increased WOB, Difficulty triggering ventilator

• >> Increased dead space

 Progressive hyperinflation of alveoli >> Increased Pplat

• >>Barotrauma
 Detection of Air Trapping

Inspiration Normal
Flow (L/min) Patient

Time

Air-trapping
AUTO PEEP
Expiration

When expiratory flow doesn’t return to base line………

and inspiration starts before exp ends….
Measuring Auto-PEEP
- Patient is sedated
on Controlled mode

- Look at Pressure
curve during
Expiratory hold
 Intrinsic PEEP (PEEPi)
PEEPi = PEEPtot
OR
PEEPi = PEEPtot - PEEPe
Pressure

PEEPtot
PEEPe

Time
Ventilator management of Auto-PEEP
1) Increase Expiratory time (Adjust I:E ratio):
- Decrease inspiratory time
- Increase inspiratory flow
- Decrease time pause
- Decrease respiratory rate

2) Decrease Minute Ventilation:

- Decrease Tidal Volume
- Decrease respiratory rate

3) External PEEP: (in Spontaneous Breathing patients)

To counteract effect of Auto-PEEP on triggering the ventilator
Introduction to basic moods
of MV
Introduction to basic moods of MV
 Mode - Breath - Phase Variables

 Breath Types: Spontaneous Vs Mechanical

 Basic Modes

 Full Vs. Partial Ventilatory Support

Introduction to basic moods of MV
 Mode - Breath - Phase Variables

 Breath Types: Spontaneous Vs Mechanical

 Basic Modes

 Full Vs. Partial Ventilatory Support

 Modes of Ventilation
 Mode is a combination of Breathes

 Breath is a cycle ( Respiratory Cycle ) formed of

a combination of Phases.
- Change From Expiration To Inspiration (Initiation),

- Inspiration,

- Change From Inspiration To Expiration (Termination),

- Expiration.
 Phase Variables of The Breath
A. Trigger Variable :
What STARTS the inspiration?

• Patient : - Pressure
- Flow
- Volume
A
• Machine: - Time

- Neural

- Manual Triggering:
 Phase Variables of The Breath
A. Trigger Variable :
What STARTS the inspiration?
• Patient : - - Neural
Pressure - Flow / volume

• Machine: - Time - Manual

A
Pressure >> about −1 cm H2O.

Flow >> 2 L/Min

Bias Flow
When set properly, flow triggering has been shown to require
less work of breathing than pressure triggering.
 Phase Variables of The Breath
A. Trigger Variable :
What STARTS the inspiration?
• Patient : - - Neural
Pressure - Flow / volume
B
• Machine: - Time -
Manual
B. Limit (Control) Variable :
A
what REGULATES gas flow during the inspiration?
• Volume
• Flow
• Pressure
 Phase Variables of The Breath
A. Trigger Variable :
What STARTS the inspiration?
• Patient : - - Neural
Pressure - Flow / volume
B C
• Machine: - Time -
Manual
B. Limit (Control) Variable : A
what REGULATES gas flow during the inspiration?
• Volume + Flow
• Pressure
C. Cycle Variable : Flow
What ENDS the inspiration? Time
• Patient : Volume
• Machine : Pressure
 Phase Variables of The Breath
A. Trigger Variable :
What STARTS the inspiration?
• Patient : - - Neural
Pressure - Flow / volume
B C
• Machine: - Time -
Manual
B. Limit (Control) Variable : A
what REGULATES gas flow during the inspiration?
• Volume + Flow
• Pressure
C. Cycle Variable :
What ENDS the inspiration?
• Patient : Flow
• Machine : Time / Pressure
 Phase Variables of The Breath
D. Baseline Variable :

- Control during expiration.

B C

- Pressure control is the most practical >>>

Positive end-expiratory pressure (PEEP). A D

- Indirect control of TIME

Control Variable
The ventilator can

control

ONLY ONE variable at a time

Volume Or Pressure
Introduction to basic moods of MV
 Mode - Breath - Phase Variables

 Breath Types: Spontaneous Vs Mechanical

 Basic Modes

 Full Vs. Partial Ventilatory Support

Supported Breath…

Patient Triggered
Pressure limited
Flow Cycled

Set PS Level
Pressure (cm H2O)

Time (sec)

Starts & ends by patient

 Types of Spontaneous Breaths

Start Limit End

Breath
(trigger) (control) (cycle)

P
Spontaneous

Spontaneous P P
(Flow/Pressure)

Supported P M P
 V (Flow/Pressure) (Pressure/Volume) (Flow)

 M=machine, P=patient
Mechanical Breath:
• Starts by Machine or Patient
• Controlled & Ends by Machine
Pressure Assisted Controlled

Time
 Types of Mechanical Breaths
Start Limit End
Breath
(trigger) (control) (cycle)

Controlled M Volume or pressure M

Mechanical

(Time) (Time)

Assisted P Volume or pressure M

 V (Flow/Pressure) (Time)

 M=machine, P=patient
 Types of Breaths
Start Limit End
Breath
(trigger) (control) (cycle)

Controlled M Volume or pressure M

Mechanical

(Time) (Time)

Assisted P Volume or pressure M

 V (Flow/Pressure) (Time)

P P
Spontaneous

Supported Pressure or Volume

(Flow/Pressure) (Flow)

Spontaneous P ------- P
(Flow/Pressure) (Flow)

M=machine, P=patient
Introduction to basic moods of MV
 Mode - Breath - Phase Variables

 Breath Types: Spontaneous Vs Mechanical

 Basic Modes

 Full Vs. Partial Ventilatory Support

 Mode : Combination of breaths
Breath Mode

Controlled

Assisted

Spontaneous

Supported
 Mode: Combination of breaths
Breath Mode

CMV
Controlled (VC-CMV)
(PC-CMV)

Assisted

Spontaneous

Supported
 Mode: Combination of breaths
Breath Mode

CMV
Controlled ACM
(VC-CMV)
(PC-CMV) (VC-ACM)
(PC-ACM)
Assisted (PRVC)

Spontaneous

Supported

PRVC: pressure regulated volume control

 Mode: Combination of breaths
Breath Mode

CMV
Controlled ACM
(VC-CMV)
(PC-CMV) (VC-ACM)
(PC-ACM)
Assisted (PRVC)

Spontaneous CPAP

Supported
 Mode: Combination of breaths
Breath Mode

CMV
Controlled ACM
(VC-CMV)
(PC-CMV) (VC-ACM)
(PC-ACM)
Assisted (PRVC)

Spontaneous CPAP

Supported PSV
 Mode: Combination of breaths
Breath Mode

CMV
Controlled ACM
(VC-CMV)
(PC-CMV) (VC-ACM) SIMV
(PC-ACM) (VC-SIMV)
Assisted (PRVC) (PC-SIMV)
(PRVC-SIMV)

Spontaneous CPAP

Supported PSV

PRVC: pressure regulated volume control

 Mode: Combination of breaths
Breath Mode

CMV SIMV+PS
Controlled (VC-CMV) ACM
(VC-SIMV)
(PC-CMV) (VC-ACM) SIMV (PC-SIMV)
(PC-ACM)
(VC-SIMV) (PRVC-SIMV)
Assisted (PRVC)
(PC-SIMV)
(PRVC-SIMV)

Spontaneous CPAP

Supported PSV
Introduction to basic moods of MV
 Mode - Breath - Phase Variables

 Breath Types: Spontaneous Vs Mechanical

 Basic Modes

 Full Vs. Partial Ventilatory Support

 Full Vs. Partial
Ventilatory Support
( FVS Vs. PVS )

 FVS ; ventilator
provides all the
energy necessary
for alveolar
ventilation

 PVS; the patient

must actively
participate in
ventilation
Basic Modes of MV
Basic Modes of MV
 Full Vs. Partial Ventilatory Support

 Assist/Control Modes: VCV, PCV

 Combined modes: SIMV (SIMV+PS)

 Spontaneous Modes: PSV, CPAP

 Volume modes Vs Pressure Modes

 Ideal Mode of Ventilation

 Full Vs. Partial
Ventilatory Support
( FVS Vs. PVS )

 FVS ; ventilator
provides all the
energy necessary
for alveolar
ventilation

 PVS; the patient

must actively
participate in
ventilation
Mode
For each mode we will discuss:

 Names

 Parameters
 Advantages
 Disadvantages

 1) Settings + (PEEP , FiO2 , +/- Backup )

 2) Alarms
 3) Management
Settings
 Tidal volume (VT)
 P ins (above PEEP or total ???)
 Ps (above PEEP or total ???)

 RR >>> ( total cycle time = 60/RR )

 Flow rate (+/- Flow pattern)
 Inspiratory time (Ti) T pause (TP) … I:E ratio
…

 PEEP
 FiO2
 Inspiratory Trigger (Sensitivity)
 Expiratory Trigger (Cycling criteria)
 Rise time
Basic Modes of MV
 Full Vs. Partial Ventilatory Support

 Assist/Control Modes: VCV, PCV

 Combined modes: SIMV (SIMV+PS)

 Spontaneous Modes: PSV, CPAP

 Volume modes Vs Pressure Modes

 Ideal Mode of Ventilation

 1) Volume Control MV
Names
CMV - IPPV - VCV - Volume Control

Advantages
Guaranteed preset volume (VT)  Minute Ventilation

Disadvantages
Variable peak inspirt. pressures (PIP)>>Barotrauma Risk ??
Fixed peak inspiratory Flow

Breathes characters
• Triggered by Time (control) , Flow/Pressure
• Limited by (assist) Volume
• Cycled by Time / Alarm pressure
 1) Volume Control MV
Settings
 Tidal volume (VT) ……… ( 6-8 up to 10 ml/kg of IBW)
 RR
2 of these 4
 ± 1) Inspiratory flow rate
 ± 2) Inspiratory time (Ti)
 ± 3) T pause
 ± 4) I:E

 ± Flow pattern (square or decelerating)

 P max / Pressure limit

 PEEP, FiO2, Inspiratory Trigger & Rise time

Alarms
 High Pressure Alarm
 2) Pressure Control MV
Names
PCV - BiPAP Assist - PCV+
Advantages
 Variable flow rate.
 Decelerating Flow waveform
 Avoid barotrauma
Disadvantages
• Frequent adjustments to maintain adequate VE
• Pt with noncompliant lungs may require alterations in
inspiratory
times to achieve adequate TV
Breathes characters
• Triggered By Time , ( Flow / Pressure )
• Limited By Pressure
• Cycled By Time
 2) Pressure Control MV
Settings
 Inspiratory pressure

 RR
 Inspiratory time or I:E
(Ti)
 PEEP, FiO2, Inspiratory Trigger & ± Rise time

Alarms
 Low tidal volume - Minute Ventilation
Basic Modes of MV
 Full Vs. Partial Ventilatory Support

 Assist/Control Modes: VCV, PCV

 Combined modes: SIMV (SIMV+PS)

 Spontaneous Modes: PSV, CPAP

 Volume modes Vs Pressure Modes

 Ideal Mode of Ventilation

 4) Synchronous Intermittent Mandatory Ventilation
(SIMV)
 Deliver a minimum number of mandatory breaths (IMV)
 Triggered window for synchronized mandatory breaths.
 Triggered window for spontaneous/supported breaths
 SIMV-VC (± PS)
Settings:
Guaranteed preset volume (VT)  Minute Ventilation
RR
Inspiratory time (Ti)  I:E
Inspiratory flow rate
Flow waveform characteristics (square or decelerating wave forms)
± Pressure Support

Alarms:
Pressure limit

Disadvantages:
Variable peak inspiratory pressures (PIP)
 SIMV-PC(± PS )
Settings:
Guaranteed PIP  No Barotrauma
RR

Inspiratory time (Ti)  I:E

± Pressure Support

Alarms:
Low tidal volume - Minute Ventilation

Advantages:
Variable flow rate.
Decelerating Flow waveform
Basic Modes of MV
 Full Vs. Partial Ventilatory Support

 Assist/Control Modes: VCV, PCV

 Combined modes: SIMV (SIMV+PS)

 Spontaneous Modes: PSV, CPAP

 Volume modes Vs Pressure Modes

 Ideal Mode of Ventilation

 6) Pressure Support Ventilation
(PSV)
Names
PSV - ASB - Spontaneous -
CPAP(misnomer)

Advantages
 More synchronous with spontaneous breathing
 Variable & Decelerating Flow waveform
 Guaranteed PIP  No Barotrauma
 Mode of SBT & weaning
Parameters
 Triggered By Flow / Pressure
 Limited By Pressure
 Cycled By Flow
Flow cycling in Supported Breath

Flow PIF

Inspiration
T
E Zero
TI Time flow

Expiration

PEF
 6) Pressure Support Ventilation
(PSV)
Settings:
Pressure Support
PEEP

Inspiratory Trigger ± Expiratory Trigger

Rise time
Backup Mode
FiO2

Alarms:
Low tidal volume - Minute
Ventilation
High RR
 Inspiratory Cycle Off
Inspiration ends

pressure
The breath ends when the ventilator detects
inspiratory flow has dropped to a specific
flow value.

flow
 Inspiratory Cycle Off
100% of Patient’s
Peak Inspiratory Flow

100%
75%
Flow cycling in
50% Supported Breath ….
Flow

30% Classically seen in PSV

 Inspiratory Cycle Off
Exhalation
spike
A B

100% 100%

60%
10%
Restrictive lung disease, a
decrease in the total volume of air
that the lungs are able to hold, is
often due to a decrease in the
elasticity of the lungs themselves
or caused by a problem related to
COPD Restricted lung the expansion of the chest wall
during inhalation
6) Pressure Support Ventilation (PSV)
 7) Continuous Positive Airway Pressure (CPAP)
Names
CPAP

Settings:
 PEEP
 FiO2

Parameters
 Triggered by Patient
 Limited by Patient
 Cycled by Patient
 PEEP in baseline phase
7) Continuous Positive Airway Pressure (CPAP)
 7) Continuous Positive Airway Pressure
(CPAP)

It is NOT a mode for VENTILATION

It improves OXYGENATION

It is only for
Noninvasive Interfaces
Basic Modes of MV
 Full Vs. Partial Ventilatory Support

 Assist/Control Modes: VCV, PCV

 Combined modes: SIMV (SIMV+PS)

 Spontaneous Modes: PSV, CPAP

 Volume modes Vs Pressure Modes

 Ideal Mode of Ventilation

Pressure-cycled Modes
- Pressure Control Ventilation (PCV)
- PRVC (pressure regulated volume control)
- SIMV-PC
- BIPAP/ APRV
- Pressure Support Ventilation (PSV)

Volume-cycled Modes
- Volume Control Ventilation (VCV) (Assist/Control)
- SIMV-VC
 VC
V Vs PCV
is based on whether

Consistency Limiting of pressure

of TV delivery is
delivery is important
important Or
“Minute “Prevention of
Ventilation” Barotrauma”
Basic Modes of MV
 Full Vs. Partial Ventilatory Support

 Assist/Control Modes: VCV, PCV

 Combined modes: SIMV (SIMV+PS)

 Spontaneous Modes: PSV, CPAP

 Volume modes Vs Pressure Modes

 Ideal Mode of Ventilation

 Ideal Mode of Ventilation
 Low airway pressures.
Minimize the risk of
Lung Injury
 Adequate minute ventilation.
 Adequate oxygenation Adequate pulmonary
Gas Exchange
 Lowest possible work of breathing (WOB).
Reduce patient


WOB
Responds to rapid changes in patient demand.
Optimize patient
 Synchronized with the patient. Comfort
Ideal Mode of Ventilation
It’s not the ventilator mode that
makes a difference …

It’s the skills of the clinician and

nurses.
Ventilator Curves
Ventilator Curves
 Introduction: Curves & Loops (Why &
What ????)

3 Curves:
* Pressure - Time
* Flow - Time

* Volume - Time
 Introduction
• Graphics are waveforms that reflect the patient-ventilator system
and their interaction.

1- Scalars (Curves):
Plot Pressure, Flow, or Volume against TIME.

Time is the x-axis.

2- Loops:
Plot Pressure or Flow Volume
against
(P/V or F/V).
There is NO TIME component.
Introduction
 Purpose of Graphics

1) Monitor the patient’s disease status (C and Raw)

& response to therapy.

2) Monitor proper ventilator function

3) Allow fine tuning of ventilator to decrease WOB,

optimize ventilation, and maximize patient comfort.
What do we need to learn ?
 How to IDENTIFY different WAVES (and LOOPS) ?
and differentiate between NORMAL AND
ABNORMAL ?

 How it helps to identify the MODE of Vent ?

 How it helps to ADJUST vent settings / vent circuits ?

 How it helps to manage DISEASE PATTERN ?

1. Progression
2. Responding to drugs.
3. Deterioration
Curves
- Pressure - Time Curve

- Flow - Time Curve

- Volume - Time Curve

 Pressure Controlled Volume Controlled
Mode Mode
Pressure
Flow
Volume

Time Time
1) Pressure–Time Curve
Type of Breath in Pressure – Time Curve
 Pressure Controlled "PCV"
The pressure waveform is a plateau

Assisted Controlled
Pressure

Time
 Volume Controlled "VCV"
" with Constant Flow & pause "

Pr. due to elastance

Peak insp pr = Total
pr
P
Pr. due to Plat pr
resistance

EEP

Ti Te
Volume Controlled "VCV"
" with Constant Flow & pause "
Changes In Airway Resistance
Changes In Compliance
Changes In Compliance during VCV
Lung Compliance Decreased

Set Tidal Volume

Maintained
Changes In Compliance during PCV Set Pressure
Maintained
Lung Compliance Decreased

Delivered VT
Decreased
Measuring Auto-PEEP
Assessment of Mechanics

Raw= Peak - Plateau

Auto-PEEP
Pressure – Time Curve
Can be used to assess:
In assist-control Modes ( VCV & PCV):
• Breath Type (Pressure vs. Volume)
• Measuring of plateau pressure ..... Insp.
Hold
• Measuring of auto-PEEP ..... Exp. Hold
In volume control mode:
• Airway Obstruction
• Decreased Compliance
• Asynchrony ------- Inspiratory Flow Sufficiency
2) Flow-Time Curve
Normal Flow Time Curve
Normal Flow Time Curve
Types of Inspiratory Flow Pattern
Types of Inspiratory Flow
Pattern
Exponential-decay Rectangular Ascending-ramp Sinusoidal
Flow Waveform
Pressure / Volume Controlled

Decelerating flow
PIF

Flow
Inspiration
T
E Zero flow
TI Time

Expiration

PEF
Flow Waveform
•Volume Controlled

Constant flow
Flow

Time
 Flow cycling in Supported Breath

Flow PIF

Inspiration
T
E Zero
TI Time flow

Expiration

PEF
 Response To Bronchodilators

Before After

Long TE Shorter TE
Flow

Time

PEFR

Improved PEFR

To assess response to bronchodilator therapy,….

1. An increase in peak expiratory flow rate.
2. The expiratory curve should return to baseline sooner.
Air Trapping
 Air
Trapping………

Inspiration Normal
Patient
Flow (L/min)

Time

Air-trapping
AUTO PEEP
Expiration

When expiratory flow doesn’t return to base line………and

inspiration starts before exp ends….
Measuring Auto-PEEP
Excessive secretions
 Flow Time Curve
Can be used to assess:

• Air trapping (auto-PEEP)

• Airway Obstruction

• Bronchodilator Response

• Breath Type (Pressure vs. Volume, Controlled vs

Supported)

• Airway secretions

• Asynchrony -------- Ineffective inspiratory effort

3) Volume –Time Curve
Normal Volume – Time Curve
Air leaks
or Air trapping
Volume (ml)

Exhalation that does not return to zero

 Volume – Time Curve
Can be used to assess:

• Leaks
• Air trapping (auto-PEEP)

• Tidal Volume

• Active Exhalation
Pressure – Time DD Obstructive
Curve (in VCV) Vs Restrictive

Flow – Time Air Trapping

Curve Auto-PEEP

Volume – Time
Curve
Leaks
Who can
solve ????
Identifying type of Breath/ mode of vent…………..

Pressure

Time
Identifying type of Breath/ mode of vent…………..

Pressure Assisted Controlled

Time

Pressure Assist/Control Ventilation Mode

Is it a Volume or Pressure mode? P
Is it a Control or Support mode?

Mode
Pressure support/CPAP

The pressure waveform has a plateau

The flow waveform doesn't return to baseline

Interpret the mode:
 Interpret the mode:

Is it a Volume or Pressure mode?

Is it a Control or Support mode?
Identify
mode……?

Flow
(L/min)

Set P level
Set P level
Pressure
(cm H2O)
CPAP level

Volume
(ml)
Time (sec)
Identify
mode……?
SIMV-PC + PS

Flow
(L/min)

Set P level
Set P level
Pressure
(cm H2O)
CPAP level

Volume
(ml)
Time (sec)
 Identify mode…..

Flow (L/m)

Pressure
(cm H2O)

Volume
(mL)

Time (sec)
 Identify mode…..
PSV mode
• Patient Triggered, Pressure limited, Flow Cycled Mode
• Flow Cycling
• Flow (L/m)

Pressure support

Pressure
(cm H2O)

Volume
(mL)

Time (sec)
 Summary
Pressure – Time DD Obstructive
Curve (in VCV) Vs Restrictive

Flow – Time Air Trapping

Curve Auto-PEEP

Volume – Time
Curve
Leaks
Weaning of MV
Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
Definitions

Discontinuation
Liberation
Weaning
- The process of withdrawing MV support and transferring the work of breathing
from the ventilator to the patient
- Weaning covers the entire process of liberating the patient from mechanical
support and from the endotracheal tube.
- Can be accomplished
*Abruptly *Gradually
- Weaning (may be used to describe the gradual reduction of ventilatory support)
 Definitions
Weaning Success
Extubation and the absence of ventilatory support 48 h following the
extubation.

Weaning Failure
defined as one of the following:
1)failed SBT;
2)reintubation and/or resumption of ventilatory support following
successful extubation; or
3)death within 48 h following extubation.

Weaning from mechanical ventilation, Task Force: ERS, ATS, ESICM, SCCM. Eur Respir J 2007; 29: 1033–1056
Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
 Stages of Weaning

DELAYED extubation as well as PREMATURE extubation can

lead to many complications
There is much evidence that weaning tends to be delayed
Weaning from mechanical ventilation, Task Force: ERS, ATS, ESICM, SCCM. Eur Respir J 2007;
 Stages of Weaning

Principles & Practice of Mechanical Ventilation: Martin Tobin ,3rd edition, 2013
Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
I) Readiness Criteria

Intubated patients should be assessed

DAILY for extubation potential.
Self-extubation
>>> 50% >>> No reintubation

suggesting that
Many patients are maintained on MV
Longer than necessary.

Physicians frequently underestimate the ability

of patients to be successfully weaned.
Readiness Criteria
1) Reversal of the underlying CAUSE(S) of MV

2 ) Clinical Stability (CARDIOVASCULAR, MENTAL, COMORBID)

3) Adequate Oxygenation & Ventilation

4) Pulmonary Functions ( Indices)
 Readiness Criteria
1) Reversal of the underlying CAUSE of MV
At least significantly

2) Clinical Stability:
A) Stable CARDIOVASCULAR status:
 Heart rate <140 beats/min.
 Systolic BP 90-160 mmHg without or with minimal vasopressors.
 No evidence of Active myocardial ischemia.
B) Adequate MENTAL status with Capability to CLEAR SECRETIONS:
 Patient is arousable or can protect his airway.
C) Absence of correctible COMORBID conditions:
 Fever.

 Electrolyte abnormalities.
Readiness Criteria
3) Adequate Oxygenation & Ventilation:
 PaO2 >60 mm Hg, P/F ratio >200 on FIO2 <40-50 %
and PEEP <5-8 cm H2O.
 PaCO2 normal or baseline, Arterial pH > 7.25.
 Patient is able to initiate an inspiratory effort

4) Pulmonary Functions:
- Rapid-Shallow Breathing Index < 105/L
- RR/VT (B/min/L) with spontaneous breathing during a One Minute T-piece trial.
- Commonly calculated by turning PSV to 0-5, putting PEEP at 5 for one minute.
- Minute ventilation < 10–15 L/min
- Thoracic compliance > 25 ml/cm H2O
- Maximum Inspiratory Pressure (MIP)/NIF < -20 to -25 cm H2O
 Readiness Criteria
N.B
These criteria are to be taken AS
CONSIDERATIONS rather than as rigid
requirements (or strict criteria) that must
all
be met simultaneously.

Weaning from mechanical ventilation, Task Force: ERS, ATS, ESICM, SCCM. Eur Respir J 2007
Case Scenario
Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
 II) Spontaneous Breathing Trial )SBT(

Patients who fulfil readiness criteria

should be assessed by SBT before weaning
 Spontaneous Breathing Trial (SBT)
1) T-Piece Trial:
The patient is removed from the ventilator and humidified supplemental oxygen is
provided to the airway with T-piece.
- For 30 - 120 min
OR
2) SBT with CPAP or PSV:
The patient is kept on the ventilator with:
- low level of PEEP (e.g., 5 cm H2O) and
- low level of PSV ( 0 - 8 cm H2O).
- For 30 - 120 min
- Patients who fail an SBT do so within the first 20 min
- Patients tolerant to SBT 30-120 min were found to have
SUCCESSFUL discontinuation at least 77% of the times
 T-Piece/CPAP Trial Vs PSV SBT ???

In acutely hospitalized patients ventilated more than 24 hours, should the

SBT be conducted with or without inspiratory pressure augmentation?

Recommendation: Initial SBT should be conducted with inspiratory pressure

augmentation (5-8 cm H2O) rather than without (T-piece or CPAP.(
(Conditional recommendation, Moderate quality evidence)

Chest. 2017; 151 (1):166-180. doi:10.1016/j.chest. 2016. 10. 036

 Monitoring During SBT
1) Hemodynamics:
 HR, BP

2) Respiratory:
 RR, respiratory Pattern, Accessory muscles, WOB

3) Gas exchange:
 SpO2, Capno, ABG

4) Mental status
 Consciouness level, Agitation
 Criteria of SBT Tolerance
 1) Hemodynamic stability:
-
HR < 120–140 beats/min; HR not changed > 20%
- SBP < 180–200 & > 90 mm Hg; BP not changed > 20%
- No pressors required

 2) Stable ventilatory pattern:

- RR 30–35 breaths/min; RR not changed by > 50%
& Absence of increased work of breathing
Signs:
- Use of accessory respiratory muscles
- Thoracoabdominal paradox
- Diaphoresis
- Onset or worsening of discomfort
 Criteria of SBT Tolerance
 3) Gas exchange acceptability:
- SpO2 = 85–90%; PO2 50–60 mm Hg
- pH = 7.32; increase in PaCO2 10 mm Hg

 4) Mental status Stability:

- No : somnolence, coma, agitation, anxiety
Patients Who Pass SBT
1) ASSESS readiness for extubation

2) Consider extubation to Preventative NIV in high risk patients

Patients Who Fail SBT

>> Difficult & Prolonged Weaning
3) Was my patient truly Ready for weaning?

4) What are Causes of the SBT Failure?

and What are readily Reversible factors that can be corrected?

3) How should we continue Mechanical Ventilatory support?

 Patients Who Pass SBT

1) ASSESS readiness for extubation

2) Consider extubation to Preventative NIV in high risk

patients
 Patients Who Pass SBT
1) ASSESS readiness for extubation:
Airway Protection /maintainence:
- GCS > 8 , better to obey commands, Alertness

- Acceptable bulbar function …. Adequate swallowing & gag reflex

 Effective Cough/ Clear Secretions:

- Good cough on stimulation ( eg. Post pharynx or tracha) … peak exp flow 60

- Small amount of secretions ( < 2.5 ml/h << suction frequency > 2 hours)

Airway Patency: Adequate lumen of trachea and larynx >> to identify patients who are at risk
for post-extubation stridor (PES )

 “Cuff Leak test” - “Cough test”

 Patients Who Pass SBT
Question #6:
-Should a cuff leak test (CLT) be performed prior to extubation of mechanically
ventilated adults?
-Should systemic steroids be administered to adults who fail a CLT prior to
extubation?

Recommendation: We suggest performing a CLT in mechanically

ventilated adults who meet extubation criteria and are deemed high
risk for PES
)Conditional recommendation, very low certainty in the evidence(

Chest. 2017; 151 (1):166-180. doi:10.1016/j.chest. 2016. 10. 036

 Patients Who Pass SBT
Risk factors for Post-Extubation Stridor (PES):
- Mechanical ventilation >6 days,
- Large ETT
- Female gender,
- Repeated intubation or reintubation after unplanned extubation
- Traumatic intubation

Recommendation: For adults who have failed a cuff leak test but are otherwise ready for
extubation, we suggest administering systemic steroids at least 4 hours before extubation. A
repeat cuff leak test is not required following the administration of systemic steroids
.
(Conditional recommendation, moderate quality evidence)

Chest. 2017; 151 (1):166-180. doi:10.1016/j.chest. 2016. 10. 036

 Patients Who Pass SBT
Cuff leak test:
1)ventilator set in AC-VCV mode + deflated cuff (at VT of 10-12 ml/kg ??)
 The leak was taken to be the difference between the preset
inspiratory VT and the average of the lowest three of the subsequent
six expiratory VTs.
A leak >110 mL or 15-20 % was considered to be a positive test.
Milo Engoren Chest, Oct 1999; 116: 1029 - 1031.

2) Using thresholds of 130 ml and 12 % to determine the presence of

significant leak, the sensitivity and the specificity of the test were,
respectively, 85% and 95%.

Jaber et al. Intensive Care Med. 2003 Jan;29(1):69-74.

 Patients Who Pass SBT
2) Consider extubation to Preventative NIV in high risk patients
Question 3
In high-risk patients receiving MV <24 hrs who have passed a SBT, does extubation to
preventive NIV compared to no NIV have a favorable effect on duration of ventilationn,
ventilator free days, extubation success (libration< 48 hrs), duration of ICU stay , short-term
mortality (60 days), or long-term mortality)
BT
Recommendation: we Recommend extubation to preventative NIV in high
risk patients (immediately after extubation).
(Strong recommendation,moderate quality evidence).

Risk factors included

- Older age,
- Comorbidities such as COPD or congestive HF
- Hypercapnia during the SBT

Chest. 2017; 151 (1):166-180. doi:10.1016/j.chest. 2016. 10. 036

Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
Extubation Process
 Consider fasting

 Upright position

 Secretion suctioning

 Stand-by Intubation Kit

 Oxygen therapy

 Chest physiotherapy
 Stages of Weaning

Principles & Practice of Mechanical Ventilation: Martin Tobin ,3rd edition, 2013
 Criteria For Extubation Failure:
- RR > 25 breaths/min for 2 h

- Pulse > 140 beats/min or sustained increase or decrease of > 20%

- Clinical signs of respiratory muscle fatigue or increased work of breathing

- SpO2 < 90%; PaO2 < 80 mmHg on FIO2 > 0.50

- Hypercapnia (PaCO2 > 45 mmHg or > 20% from pre-extubation), pH < 7.33

Weaning from mechanical ventilation, Task Force: ERS, ATS, ESICM, SCCM. Eur Respir J 2007
 Patients Who Fail
SBT

>> Difficult & Prolonged Weaning

1- Was my patient truly Ready for weaning?

2 -What are Causes of the SBT Failure?

and What are readily Reversible factors that can be corrected?

3- How should we continue Mechanical Ventilatory support?

Weaning of MV
 Definitions

 Stages of Weaning
 Readiness Criteria
 Spontaneous Breathing Trial (SBT)
 Extubation

 Classification Of Weaning
 Classification of Weaning
“According to the difficulty and length of the weaning process”

Mechanical ventilation

Simple Weaning Initial weaning failure (Failed SBT or Reintubation)

Difficult Weaning ≤ 7 d, ≤ 3 x SBT

Several failed weaning trails

Weaned Prolonged Weaning > 7 d, > 3 x SBT

Death

Long Term Ventilation

SBT: Spontaneous breathing trial Boles JM, et al. Eur Respir J 2007; 29:1033-
 Classification of Weaning
“According to the difficulty and length of the weaning process”

Group/Category Definition

successful extubation on the First attempt without

Simple Weaning
difficulty

Patients who fail initial weaning

Difficult Weaning and require Up To Three SBT or as long as 7 days from the
first SBT to achieve successful weaning

Patients who fail At Least Three weaning attempts or

Prolonged Weaning require >7 days of weaning
after the first SBT

Weaning from mechanical ventilation, Task Force: ERS, ATS, ESICM, SCCM. Eur Respir J 2007
 Summary
Weaning Success
Extubation and the absence of ventilatory support 48 h following the extubation.

Weaning Failure
defined as one of the following:

1)failed SBT;

2)reintubation and/or resumption of ventilatory support following successful extubation within 48 h

3)death within 48 h following extubation.

 Summary
Stages of Weaning
 Troubleshooting

& Alarm interpretation

Troubleshooting
- Hypotension

- Respiratory Distress &/or Hypoxemia

- Alarm Activation
Trouble-Shooting of MV

1) Hypotension after MV
Hypotension After MV ????

 Consider:

 Drug induced

 Air trapping - AutoPEEP

 Tension Pneumothorax

 How to differentiate
 Trouble Shooting of MV

2) Sudden Respiratory Distress, Dyspnea

+/- Hypoxemia
+/- High pressure/Low volume alarm
 Respiratory Distress in MV Patients ??

Patient-Related Causes Ventilator-Related Causes

• Artificial airway problems

Patient-ventilator asynchrony
Artificial Airway Problems
That Can Lead to Sudden Respiratory Distress

• Obstruction: Secretions And Mucous plugging of airways

• Kinking/Patient Biting of the ET

• Tube Migration (flexion and extension of the head and neck can
move the endotracheal tube [ET] in the airway an average of 2 cm
down and up, respectively)
- Migration of the ET above the vocal cords

- Migration of the ET into the right main stem bronchus

- Impingement of the ET on the carina

• Rupture or leakage of the ET cuff

• Development of a Tracheoesophageal Fistula

Respiratory Distress in MV Patients ??
Patient-Related Causes Ventilator-Related Causes
• Artificial airway problems
• Circuit leak
• Bronchospasm • Circuit disconnection
• Secretions • Ventilator malfunction

• Pulmonary edema
Patient-ventilator asynchrony
• Pulmonary embolus
- Inappropriate ventilator mode
• Dynamic hyperinflation
• Pneumothorax - Inappropriate trigger sensitivity
- Inappropriate inspiratory flow setting
• Abnormal respiratory drive
- Inappropriate cycle variable
• Drug-induced problems
• Anxiety/ Pain - Inappropriate PEEP setting
• Alteration in body posture
• Abdominal distention
Management of Sudden Respiratory Distress

2 Pathways
 Management of Sudden Respiratory Distress
“1st Pathway”
1.Ensure adequate ventilation and oxygenation
- Assess the monitors, SpO2, HR, etc
- Visually assess the patient ….. Chest rise & work of breathing
- Auscultation of the chest …. Present or not …. Equal or not
2.Disconnect the patient from the ventilator.

3.Begin Manual Ventilation using a self-inflating resuscitation bag containing

80% to 100% oxygen; maintain normal ventilating pressures, and use a PEEP
attachment if the patient has been on high PEEP (≥10 cm H2O).

4.Manually Evaluate compliance and resistance through bag ventilation

Management of Sudden Respiratory Distress

“1st Pathway”
5.Perform a Rapid Physical Examination and assess monitored
Indexes And Alarms.
Peak pressure & Plateau pressure

6.Check the Airway Patency by passing a Suction Catheter.

7.If Cardiac Arrest appears imminent, treat the most likely problems:
Pneumothorax And Airway Obstruction.
Management of Sudden Respiratory Distress

Sudden Respiratory
Distress
Management of Sudden Respiratory Distress
Management of Sudden Respiratory Distress

2nd Pathway

Once the patient’s condition has stabilized, perform a more Detailed

Assessment and provide any additional treatment required.
 Management of Sudden Respiratory Distress

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Management of Sudden Respiratory Distress

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Management of Sudden Respiratory Distress

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Management of Sudden Respiratory Distress

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Alarm
Activation
 A common Scenario
A nurse at the ICU station hears the ECG monitor alarm, which shows a
pattern of asystole. She goes to the patient’s bedside, begins
cardiopulmonary resuscitation, and a normal sinus rhythm is quickly restored.
What happened ??

The patient had been disconnected from the ventilator or tube was blocked
&
the alarm’s volume adjustment is on the lowest setting
 Ventilator Alarms
 Never ignore an alarm.

 Never mute the alarm on regular basis.

 Find out for yourself what alarm is on.

 Check the patient then Silence the alarm.

 Levels of Alarms
Level 1: Immediately Life-Threatening

Example events:
• Electrical power failure
• No gas delivery to patient
• Exhalation valve failure
• Device Failure

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Levels of Alarms
Level 2: Potentially Life-Threatening

Example events:
• Circuit leak …… Low pressure Alarm
• Circuit partially obstructed ….. High Pressure Alarm
• I:E ratio inappropriate
• Inappropriate oxygen level (gas/blender failure)
• Inappropriate PEEP level (too low/too high)

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 Levels of Alarms
Level 3: Not Life-Threatening but a Potential Source of Patient Harm

Example events:
• High respiratory rates
• Low VT
• High FIO2
• Heater/humidifier malfunction

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 1) High-Pressure Alarms
Conditions Related to the Airway •Conditions Related to the Lungs
•Coughing • Increased airway resistance
• (e.g., secretions, mucosal edema, bronchospasm)
•Secretions or mucus in the airway
• Decreased compliance
•Patient biting on the ET • (e.g., pneumothorax, pleural effusion)

•Kinking of the ET inside the mouth or in the back of • Patient-ventilator asynchrony

the throat
•Impingement of the ET on the trachea or carina •Changes in the Ventilator Circuit
•Changes in the position of the ET (i.e., migration of • Accumulation of water
the tube into the right mainstem bronchus)
• Kinking in the inspiratory circuit
• Malfunction in the inspiratory or expiratory
• valves

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 * What to do for High-Pressure Alarm

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 * What to do for High-Pressure Alarm

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 * What to do for High-Pressure Alarm

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 * What to do for High-Pressure
Alarm

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 2) Low-Pressure Alarms

• Patient disconnection • Circuit leaks

• Disconnection of the inspiratory or • Exhalation valve leaks

expiratory tubing of the ventilator • Cracked or leaking valves
circuit • Unseated valves
• Humidifiers • Improperly connected valves
• Filters
• Airway leaks
• Water traps • Inadequate endotracheal tube (ET) cuff inflation
• Inline nebulizers • Rupture of ET cuff
• Proximal pressure monitors • Migration of ET into upper airway above the vocal
• cords
Exhaled gas monitoring devices
• Inline closed-suction catheters
• Chest tube leaks
• Temperature monitors

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 * What to do for Low-Pressure Alarm

1. Check for disconnection.

2. Check for leaks

3. Confirm connection of proximal pressure line

4. Low-pressure alarm may be accompanied by a low minute ventilation

(VE) or low tidal volume (VT) alarm.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 3) What to do for Low VT & low VE Alarm ??

• Mostly in pressure modes

• Causes are similar to those for high or low-pressure alarms.

• Determine whether spontaneous ventilation has decreased for some

reason.

• Verify that all alarms have been set appropriately.

• Check flow sensor for disconnection or malfunction.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 4 ) What to do for Apnea Alarm
1. Determine whether the patient is apneic.

2. Check for leaks.

3. Check the sensitivity setting to be sure that the ventilator can detect
patient effort.

4. Check the alarm-time interval and the volume setting, when

appropriate.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
 5) What to do for High VT, high VE, and/or high f Alarm ??

• Check machine Sensitivity level for autotriggering.

• Check for possible Cause of increased patient VE.

• Ensure alarms have been set appropriately.

• If an External Nebulizer is in use, reset the alarm until the treatment is

finished, then return the alarm to the appropriate setting.

• Check the Flow Sensors for calibration, contamination, or malfunction.

J.M. Cairo. (2016). Pilbeam’s mechanical ventilation: physiological and clinical applications
6) What to do for Low or high FIO2 Alarm ??

7) What to do for Low-Source Gas Pressure

or Power Input Alarm ?

8) What to do for Ventilator Inoperative

Alarm or Technical Error Message Alarm ?
 Summary
Hypotension on MV : Drug induced, AutoPEEP & Tension Pneumothorax
Respiratory Distress in MV Patients/ High airway pressure alarm:
- 1st pathway : exclude airway obstruction & tension pneumothorax

- 2nd pathway : detailed examination to reach cause

Never ignore an alarm

Low-Pressure Alarm : leak or disconnection
Pressure alarms ……. in volume modes
Volume & minute ventilation alarms ……. in pressure modes
Nursing management
Care Essentials for Patients on Mechanical Ventilation

•Maintain a patent airway. Per policy, note endotracheal (ET) tube position (centimeters)
and confirm that it is secure. If the patient has a tracheostomy, check that the ties or
Velcro straps are secure and that the stoma appears healthy.

•Assess oxygen saturation, bilateral breath sounds for adequate air movement, and
respiratory rate per policy.

•Check vital signs per policy, particularly blood pressure after a ventilator setting is
changed. Mechanical ventilation increases intrathoracic pressure, which could affect blood
pressure and cardiac output.
• Assess patient’s pain, anxiety and sedation needs and medicate as ordered.

• Complete bedside check: ensure suction equipment, bag-valve mask and artificial airway
are functional and present at bedside. Verify ventilator settings with the prescribed
orders.

• Suction patient only as needed, per facility policy; hyper-oxygenate the patient before
and after suctioning and do not instill normal saline in the ET or tracheostomy tube;
explain procedure to patient; suction for the shortest time possible and use the lowest
pressure required to remove secretions. Monitor for upper airway trauma as evidenced
by new blood in secretions.
• Monitor pulse oximetry and arterial blood gas (ABG) after adjustments are made to

ventilator settings and during weaning to ensure adequate oxygenation and acid-base

balance.

• To minimize the risk for ventilator-associated pneumonia (VAP), implement best practices

such as strict handwashing; aseptic technique with suctioning; elevating head of bed 30-45

degrees (unless contraindicated); providing sedation vacations and assessing patient’s

readiness to extubate; providing peptic ulcer disease prophylaxis; providing deep vein

thrombosis prophylaxis; and performing oral care with chlorhexidine, per your facility

policy.
• For awake patients, provide writing tools or a communication board to facilitate
communication. Ask yes or no questions so that the patient can respond by nodding their
head.

• The use of an evidence-based bundled approach to managing pain and agitation, and
promoting early mobility has been shown to decrease ventilator days and the incidence
of delirium.
Monitor Ventilator Settings and Patient Responses

• One of the basic responsibilities of the nursing staff taking care of the ventilated patients
is to regularly monitor the settings of the machine and the responses of the patients. This
involves nurses deeply observe different parameters like blood pressure, heart rate and
most importantly oxygen saturation and end-tidal carbon dioxide level. Nurses are
trained to vigilantly monitor and adjust various settings of the ventilators to guarantee
optimal oxygenation as well as smooth ventilation.
Assessment of Airways and Breathing

• Nurses are assumed to examine sounds coming out of the lungs of the patient, expansion
of airways, and breathing patterns as a whole. They must be eligible to identify any signal
of respiratory discomfort, airway obstruction or any other medical complication like
pneumothorax. Timely recognition of these issues and prompt reaction in case of
emergency is a part of training of nurses to avoid major consequences.
Suctioning and Airway Management

• Airway management is crucial to provide proper ventilation and avoid aspiration. Nurses
are responsible to clear the secretions from the airway of the ventilated patients and
prevent accumulation of unnecessary mucus that can hinder breathing. Nurses are
responsible to minimize the strain to the airway tissues using specialized suctioning
techniques.
Managing Ventilator Associated Complications

• Pneumonia and lung injury are common complications associated with mechanical
ventilation, especially when ventilation gets prolonged. Nurses can play an important role
in avoiding such complications. They are responsible to practice infection control
techniques including oral care to avoid oral cavity infections, ensure patient’s proper
positioning to avoid pneumonia or pressure ulcers and encourage chest physiotherapy or
early mobilization to maintain lung functionality.
Nurse’s Communication and Collaboration

• Mechanical ventilation involves a multidisciplinary approach where nurses are at the

forefront to collaborate with physicians, healthcare professionals and most importantly
with respiratory therapists. To accurately judge the progress of the patient and adjust the
settings of the ventilator accordingly, nurses need to address the status of the patient
promptly and precisely with the doctors and therapists.
Weaning and Extubation

• The decision of weaning patient off ventilation facility is totally dependent on the
observation and recommendation of the nurses. The nurses are bound to assess and
timely address the factors that can help physicians to decide whether a patient is ready
for extubation. Skilled nursing assistance during extubation also reduces expected
complications and facilitates the shifting to spontaneous breathing.
Nurses Should Provide Basic Education to Patient and
Family

• The duty of a nurse does not end after the patient is weaned off the ventilator or is
shifted his home. Nurses take the responsibility to educate patients as well as family
members about mechanical ventilation instead. They inform caregivers the purpose of
the ventilating machine, its benefits or associated potential risks and expectations during
treatment. Proper communication with the patient or its family members ensures proper
care of the patient even when nursing staff is not approachable.
Mahmoud shaqria