Mechanical Ventilation

Dr. Ravi Gadani

MS, FMAS
Introduction
• Mechanical ventilation is a useful modality for patients who are
unable to sustain the level of ventilation necessary to maintain the
gas exchange functions-oxygenation and carbon dioxide elimination
Introduction
• Mechanical ventilation is a method to mechanically assist or replace
spontaneous breathing
• Negative-pressure ventilation- where air is essentially sucked into the lungs
• Positive pressure ventilation- where air (or another gas mix) is pushed into
the trachea.
Negative pressure
machines
Negative pressure machines
• Iron lung ( Drinker and Shaw tank) developed in 1929 - one of the first
negative-pressure machines
• Was refined and used in polio epidemic in the 1940s.
• The machine - large elongated tank, which encases the patient up to
the neck. The neck is sealed with a rubber gasket so that the patient's
face (and airway) are exposed to the room air.
Negative pressure machines
• Air is withdrawn mechanically to produce a vacuum inside the tank,
thus creating negative pressure.
• Negative pressure - expansion of the chest- decrease in intrapulmonary
pressure, and increases flow of ambient air into the lungs.
• Vacuum is released- the pressure inside the tank equalizes to that of
the ambient pressure, and the elastic coil of the chest and lungs leads
to passive exhalation.
• Pitfall- the abdomen also expands along with the lung, cutting off
venous flow back to the heart, leading to pooling of venous blood in
the lower extremities.
Negative pressure machines
Positive pressure
machines
Positive pressure machines
• Positive-pressure ventilators work by increasing the patient's airway
pressure through an endotracheal or tracheostomy tube.
• The positive pressure allows air to flow into the airway until the
ventilator breath is terminated.
• Subsequently, the airway pressure drops to zero- elastic recoil of the
chest wall and lungs push the tidal volume -- the breath—out through
passive exhalation
Positive pressure machines
Indications
• Mechanical ventilation is indicated when the patient's spontaneous
ventilation is inadequate to maintain life.
• It is also indicated as prophylaxis for imminent collapse of other
physiologic functions, or ineffective gas exchange in the lungs.
Indications
• Acute lung injury (including ARDS, trauma)
• Apnoea with respiratory arrest, including cases from intoxication
• Chronic obstructive pulmonary disease (COPD)
• Acute respiratory acidosis, which may be due to paralysis of the
diaphragm due to
• Guillain-Barre syndrome
• Myasthenia Gravis
• Spinal cord injury
• Effect of anaesthetic and muscle relaxant drugs
Indications
• Increased work of breathing as evidenced by significant tachypnoea,
retractions, and other physical signs of respiratory distress
• Hypoxemia with arterial partial pressure of oxygen (PaO2) < 55 mm
Hg
• Hypotension including sepsis, shock, congestive heart failure
• Neurological diseases such as Muscular Dystrophy and Amyotrophic
Lateral Sclerosis
• Post operative prophylaxis in cardiac surgery and other major
surgeries
Types of ventilation
Ventilation can
be delivered

A mechanical
Hand-controlled
ventilator

Continuous-flow
Bag mask
or Anaesthesia
ventilation
(or T-piece) bag
Bag mask ventilation
Types of mechanical ventilators
Transport ICU NICU PAP
ventilators ventilators ventilators ventilators
These ventilators are
These ventilators are
specifically designed
Small larger and usually run Preterm neonate ,
for non-invasive
on AC power
ventilation.

Greater control of a
This includes
wide variety of Designed to deliver the
ventilators for use at
More rugged ventilation parameters smaller, more precise
home, in order to treat
(such as inspiratory rise volumes and pressures
sleep apnea
time).

Can be powered
pneumatically or via AC
or DC power sources.
Modes of ventilation
• Ventilators modes were classified based on how they determined
when to stop giving a breath.
 Control

Assist

Volume-cycled
Assist/ Control
mode

IMV

Modes of ventilation
SIMV

PCV

PSV

Pressure-cycled
CPAP
mode
Spontaneous
PEEP
ventilation

BiPAP
Volume cycled ventilation
• Volume ventilation - A predetermined tidal volume (Vt) is set for the
patient and is delivered with each inspiration.
• The amount of pressure necessary to deliver this volume will fluctuate
from breath to breath based on the resistance and compliance of the
patient and ventilator circuit.
• If the tidal volume is set at 500ml, the ventilator will continue to
inspire gas until it reaches its goal. Upon completion of the inspired
volume, the ventilator will open a valve allowing the patient to
passively exhale
Pressure cycled ventilation
• Pressure ventilation - A predetermined peak inspiratory pressure (PIP)
is determined based on the patient's condition and pathophysiology.
• The ventilator will flow gas into the patient until this set pressure is
reached. Upon reaching the pre set PIP, the ventilator allows for
passive exhalation.
• Caution and close observation must be given in this mode due to
potential for either hypoventilation or hyperventilation because the
tidal volume is variable.
Spontaneous ventilation
• Is not an actual mode on the ventilator since the rate and tidal
volume are determined by the patient
• It provides inspiratory flow to the patient in a timely manner
• Used with adjunctive modes like PEEP
Control Mandatory Ventilation (CMV)
• Delivers the preset tidal volume at a time triggered respiratory rate.
• Ventilator controls both the tidal volume and respiratory rate of the
patient
• Should only be used with a combination of sedatives, respiratory
depressants and neuromuscular blockers.
• If not sedated- “Fighting” the ventilator -- means the patient is
severely distressed and vigorously struggling to breathe.
 Indications- CMV
• Tetanus or seizure activities
• Complete rest for the patient for 24 hours
• Crushed chest injury patients in whom paradoxical chest wall
movement produced due to spontaneous inspiratory efforts
• Complication
• Disconnection or ventilator fails to operate is a primary hazard- in a sedated
or apneic patient is the potential for apnea and hypoxia.
Assist and Assist/ Control modes
• Assist Mode
• Patient initiates all breaths, but ventilator cycles in at initiation to give a pre
set tidal volume
• Patient controls rate but always receives a full machine breath
• Assist/ Control Mode
• Mandatory mechanical breath either triggered by patient spontaneous
inspiratory efforts(assist)
• Time triggered by a pre set respiratory rate – (control)
• Potential Hazard- Hyperventilation
Intermittent mandatory ventilation
(IMV)
• Patient receives a set number of
ventilator breaths
• Different from Control: Patient can
initiate own (spontaneous) breaths
• Different from Assist: spontaneous
breaths are not supported by machine
with fixed TV
• Ventilator always delivers breath, even
if patient exhaling
• Breath stacking is the complication.
• Rarely used now
Synchronized Intermittent
Mandatory Ventilation (SIMV)
• Ventilator delivers control breath (mandatory) to the patient at or
near the time of spontaneous breath-
• TIME TRIGGERED
• Mandatory breaths are synchronized with the patients spontaneous
breathing effort to avoid breath stacking-
• PATIENT TRIGGERED
Synchronized Intermittent
Mandatory Ventilation (SIMV)
• If the patient is breathing spontaneously between the mandatory
breaths and if patient begins to inspire just prior to ventilator time
trigger, ventilator delivers mandatory breath as an assisted patient
triggered breath.
• Mandatory breath whether time or patient triggered is controlled by
mechanical tidal volume settings.
Advantages of SIMV
• Maintains respiratory muscle strength/avoids muscle atrophy
• Reduces ventilation and perfusion mismatch
• Decreases mean airway pressure
• Facilitates weaning
Pressure Control Ventilation (PCV)
• Ventilator determines inspiratory
time – no patient participation
• Parameters
• Triggered by time
• Limited by pressure
• Affects inspiration only
• Disadvantages
• Requires frequent adjustments to
maintain adequate VE
• Patient with noncompliant lungs may
require alterations in inspiratory times
to achieve adequate TV
Pressure Support Ventilation (PSV)
• Parameters
• Triggered by patient’s own breath
• Limited by pressure
• Affects inspiration only
• Uses
• Complement volume-cycled modes (i.e., SIMV)
• Does not augment TV but overcomes resistance created by ventilator tubing
• PSV alone
• Used alone for recovering intubated patients who are not quite ready for extubation
• Augments inflation volumes during spontaneous breaths
Positive End Expiratory Pressure
(PEEP)
• Increases the end expiratory or baseline airway pressure to a value
greater than atmospheric on ventilator manometer
• Not a stand alone mode rather applied in conjunction with other
modes
• Indications
• Decreased FRC and lung compliance
• Useful in maintaining pulmonary function in non-cardiogenic pulmonary
edema, especially ARDS
Continuous Positive Airway Pressure
(CPAP)
• PEEP without pre set ventilator rate or volume
• Physiologically similar to PEEP
• May be applied with or without use of a ventilator or artificial airway
• Requires patient to be breathing spontaneously
• CPAP may be given via a facial mask , nasal mask or ET tube
Bilevel Positive Airway Pressure
-BiPAP
• An airway pressure strategy that applies independent positive airway
pressure to both inspiration and expiration
• It helps in preventing intubation of end stage COPD patients and in
supporting patients with chronic ventilator failure
• IPAP may be increased in increments of 2cmH2O to enhance pressure
boost to improve alveolar ventilation, normalise PaCO2 and reduce
the work of breathing
• EPAP should be increased by 2 cm H2O to increase functional residual
capacity and oxygenation in patients with intrapulmonary shunting
Thank you