Basics of ventilatory support

Dr. Fiona
 “Mechanical ventilation”

Use of sophisticated life support technology aimed

at maintaining tissue oxygenation and removal of

carbon dioxide
 Indications for mechanical ventilation

• Most common: respiratory failure

 Postoperative respiratory failure
 Sepsis

 Pneumonia

 Trauma

 ARDS

 Aspiration

• Others: COPD exacerbation, coma,

neuromuscular disease etc.
Signs of respiratory failure
Goals of mechanical ventilatory support

• Adequate alveolar ventilation

• Oxygen delivery

• Restore acid base balance

• Reduce work of breathing

• Minimize side effects

 Ventilator initiation
Choose a ventilator

Negative pressure ventilation? Positive pressure ventilation?

Noninvasive? Invasive?

Choose a mode

Initial settings?
 Ventilator initiation
 Establishing an interface

 Volume controlled versus pressure

controlled?
  Partial ventilatory support versus full?

PARTIAL FULL
SUPPORT SUPPORT

CPAP PSV SIMV CMV

 Modes of ventilation
Assist Control Ventilation
• Every breath supported by machine
• Patient or time triggered
• Volume or pressure limited
• Provides full support
• Advantages: minimum, safe level of ventilation
assured
• Disadvantages: poorly tolerated by awake;
hyperventilation, high airway pressure are risks
 Modes of ventilation…
Continuous Mandatory Ventilation
• Every breath delivered by machine
• Time triggered
• Volume or pressure limited
• Provides full support
• Advantage: eliminates work of breathing
• Disadvantages: poorly tolerated by awake; danger
of disconnection, ventilator muscle atrophy
 Modes of ventilation…
Intermittent or Synchronized Intermittent Mandatory
Ventilation (IMV or SIMV)
• Patients breathe spontaneously between mandatory
machine breaths
• Machine breath time cycled (IMV) or patient triggered
(SIMV)
• Volume or pressure limited
• Provides full or partial support
• Can be combined with pressure support ventilation
(PSV)
 IMV and SIMV
• Advantages: lower mean airway pressures, can
vary amount of support, maintain ventilator
muscle strength, better synchrony, physiologic
spontaneous breathing incorporated

• Disadvantages: hypoventilation, ventilatory

muscle fatigue, breath stacking, weaning may be
prolonged
 Modes of ventilation…

Pressure Support Ventilation (PSV)

• Patient’s spontaneous inspiration assisted
with selected level of positive pressure
• Patient triggered
• Pressure limited, flow cycled
• Advantages: reduces work of breathing, may
improve synchrony
 Modes of ventilation…
Pressure-Control Ventilation
• Time or patient triggered
• Pressure limited, time cycled
• Advantages: useful when limiting Pplat is a concern,
prolonged I:E ratio can be administered, improved
gas distribution
• Disadvantage: high mean airway pressure can
decrease venous return
 Commonly used modes

• Assist-control

• SIMV with PSV

 Key ventilatory settings
Trigger Method

Pressure trigger Flow trigger

Sensitivity: Sensitivity:
Specific to ventilator
-0.5 to -1.5 cm H2O Varies: 0.1 to 20 L min-1
 Key ventilatory settings

Tidal Volume (VT)

Volume control ventilation 8 – 10 ml kg-1

Pressure control ventilation Pressure limit

of 12 to 30 cm H2O to achieve VT : 8 – 10 ml kg-1

Rate
12 to 16 breaths min-1
 Tidal volume and rate settings
Patient type VT Frequency
(ml kg-1) (breaths min-1)
Normal lungs 8-10 12-16
Neuromuscular disease, 10-12 8-12
postoperative period
Acute restrictive disease, ALI, 6-8 15-35
ARDS (Open lung strategy)
Obstructive lung disease 8-10 10-12
(COPD)
Acute severe asthma 4-6 10-12
exacerbation
 Key ventilatory settings

FIO2

• 1.0 if little known about patient/ grave condition

• Reduce to 0.4 to 0.5 or less as soon as possible

to avoid oxygen toxicity and absorption
atelectasis
 Key ventilatory settings

• Inspiratory flow: 40 to 80 L min-1, adjusted to

meet patient’s spontaneous inspiratory flow
• Inspiratory time: 0.8 to 1.2 s

• I:E ratio: 1: 2 or lower

• Inspiratory flow waveform: e.g.: constant,

decreasing, sine
• Inspiratory pause: up to 10% of inspiratory time
 Key ventilatory settings
Positive end-expiratory pressure (PEEP) or
continuous positive airway pressure (CPAP)
• Maintain lung volume, improve oxygenation

• Indication to start: PaO2  50 - 60 mm Hg and

FIO2 0.4 - 0.5

• Start with 5 cm H2O and make small increments

of 2 - 3 cm H2O
 Limits and alarms
• Low pressure, low PEEP alarms
• High pressure limit and alarm
• Volume alarms (low VT, high/low minute
ventilation)
• High rate alarm
• Apnea alarm
• High/low O2 alarm
• I:E ratio and alarm
• High/low temperature alarm
• Humidification: inspired gas temperature 33°
± 2° C
• Periodic sighs
• Open lung strategy: Pressure limited
ventilation with low VT of 4 - 8 ml kg-1, PEEP 2
cm H2O above lower inflection point
• Lung recruitment strategy: sustained CPAP of
40 cm H2O for 30 – 40 s
 Care of a patient on a ventilator
Physical assessment
• General appearance
• Level of consciousness
• Signs of anxiety
• Colour
• Examination of respiratory system:
inspection, palpation, percussion,
auscultation
 Care of a patient on a ventilator

• Care of the artificial airway:

 placement, size, cuff pressure, depth
 extra intubation equipment available by bedside
 suction catheters, gloves, sterile water and
suction equipment
• Bedside availability of manual resuscitator
with oxygen supply
 Care of a patient on a ventilator

• Ventilator setting assessment and

adjustment
Peak, plateau and airway pressures
Rate and tidal volumes
Trigger effort, I:E ratio, humidification and
temperature
Patient ventilator interaction
 Care of a patient on a ventilator
• Monitoring:
continuous pulse oximetry
as needed ABGs
chest radiographs
• Cardiovascular assessment: heart rate,
blood pressure, ECG
• Other systems: CNS, hepatic, renal
• Nutrition
 Techniques to improve oxygenation and
ventilation
 PEEP
 Lung recruitment maneouvers
 Bronchial hygiene: postural drainage, bronchodilators,
chest physiotherapy, humidification
 Pressure controlled ventilation with prolonged
inspiratory time
 Prone positioning
 Open lung techniques
 Monitoring oxygenation
• Arterial Pulse Oximetry
• Oxygen consumption:
 Fick’s method
 Analysis of inspired and expired gases
• Alveolar-Arterial Oxygen Tension difference:
[P(A-a)O2] Normal: 5 - 15 mmHg
• PaO2/FIO2 ratio
• Quantification of shunt
 Monitoring ventilation
• Measurement of patient’s VT, rate, minute
volume
• Dead space/tidal volume : VD/VT ratio.
Normal: 0.2 to 0.4
• Monitoring of inspired and exhaled gases, and
tidal volumes
• Capnography: PEtCO2 1 - 5 mmHg less than
PaCO2
 Other parameters to be noted

• Respiratory system compliance: C= V/P

Normal 60 to 100 ml cm H2O-1
• Airway resistance: Raw = (Ppeak- Pplat)/ Flow
• Peak and plateau pressures, mean
airway pressure
• Auto PEEP
 Weaning

“Gradual reduction of mechanical

ventilatory support that allows the patient
to resume spontaneous breathing in an
incremental manner”
 Assess patient type
1. Those for whom removal from ventilator
is quick and routine
2. Those who need a systematic approach
to discontinuing ventilatory support
3. Ventilator- dependable or “unweanable”
Duration on ventilator: if  72 hours, can be
removed quickly
Criteria to consider before weaning

Subjective clinical assessments

 Resolution of acute phase of disease
 Adequate cough
 Physician believes discontinuation
possible
 Patient motivated and psychologically
prepared
 Objective measurements
• Patient can breathe spontaneously
• Adequate oxygenation
•PaO2  60 mm Hg with FIO2  0.4 – 0.5
•PEEP  5 – 8 cm H2O
•PaO2/ FIO2 150 - 300

• Stable CVS

•HR < 140 min-1

•stable BP
•no or minimal pressors
 Objective measurements…
• Afebrile
• No significant respiratory acidosis
• Adequate Hb ( 8-10 g dl-1)
• Adequate mentation
• Stable metabolic state:
 adequate nutrition
 electrolytes and minerals
 Preparing the patient for weaning

• Decrease disease imposed ventilatory load: treat

respiratory infection, bronchospasm, airway
edema
• Patient should be allowed to sleep at night on a
level of ventilatory support that ensures
ventilatory muscle strength
• Communication and encouragement
 Methods of weaning

1 Spontaneous breathing
trials
(SBTs)

2 Synchronized intermittent
mandatory ventilation
(SIMV)

3 Pressure support
Ventilation
(PSV)
 Spontaneous Breathing T-tube Trials
• Trials several times a day interspersed with periods
of mechanical ventilation
• Start with 5 min off ventilator (or if patient can
tolerate 30 to 120 min)
• Work up to 20 to 30 min reassess condition
Unsuccessful give 24 hr period rest
• Tolerates 30 to 120 min trial: disconnect ventilator
• During day, rest of 2 - 4 hours between trials
• Trials stopped at night
 SIMV
• Gradual reduction of machine rate based
on ABG analysis and patient assessment
• Patient challenged to provide portion of
ventilation
• SIMV can be combined with PSV to
overcome work of breathing
 PSV
• Supports patient’s spontaneous inspiration
with selected level of positive airway pressure
• Initially set to achieve VT of 8 to 10 ml kg-1
• Then gradually reduced to 5 to 10 cm H2O to
overcome work of breathing
• T-tube trial may then be attempted for 30 to
120 min
 Monitoring the patient during weaning

• Ventilatory status: rate, pattern, dyspnea,

fatigue, sweating, use of accessory muscles,

abdominal paradox. Measurement of PaCO2

• Rapid shallow breathing index: f/VT < 105

• Oxygenation: Pulse oximetry, PaO2 and SaO2

• CVS status: HR, BP, cardiac rhythm

Thank you!