KGMU

CoViD-19 EPIDEMIC: BASICS OF

MECHANICAL VENTILATION

Dr Suhail Sarwar Siddiqui

MD, DM, EDIC
Assistant Professor
Department of Critical Care Medicine
King George’s Medical University (KGMU) Lucknow
Contents
• Sensitization
• Background of MV
• Indications
• Classification
• Basic design and concepts: ventilator design and modes
• Initial ventilator setting
• Troubleshooting
• Monitoring during MV
• Complications
• Weaning from MV
Sensitization
• CoVid -19: Pandemic/national disaster
• All routine services closure
• Gearing up to fight the pandemic
• All the forces unite
• Know your armamentarium
• Protect yourself
Background of MV
Background of MV

Bjorn Ibsen (1915-2007) Municipal Hospital, Copehagen

Indications of Mechanical
Ventilation
• Poor Oxygenation

• Raised CO2 level

• Increased Work of breathing

 Classifications of MV
Non Invasive Ventilation
Basic design and concepts: modes
• Controlled/ /Mandatory breaths:
• Volume Control Ventilation (VCV)
• Pressure Control Ventilation (PCV)

• Supported breaths:
• Pressure support ventilation (PSV)

• Mixed breaths:
• Synchronized Intermittent Mandatory Ventilation (SIMV)
• Assisted modes
Basic design and concepts

• All ventilators do only one thing: Push in air in inspiration

• Compressor +Two valves
• Inspiration
I. valve =Open
E. valve = Closed
• Insp Pause = both valves closed
• Expiration
 I. valve = Closed
E. valve = Open
• Exp Pause (PEEP) = both valves closed
 Phase variables of a Breath
Limit
Inspiration

Flow (L/min)
Cycle

Trigger Time (sec)

Cycle
Time Time/Volume
Pressure Pressure
Trigger
Flow Expiration Flow

Courtesy: Prof J V Divatia

 Triggering

Patient Machine
Pressure
(cmH20)

Time (sec)

Courtesy: Prof J V Divatia

Inspiration - Limit
• If one or more inspiratory variables rises no higher than some preset
value
• However inspiration is not terminated because the limit is reached
• It remains at that level till changeover to expiration occurs
Inspiratory Plateau Pressure
Volume Controlled Ventilation

PIP P Plateau by End

inspiratory hold
maneuver
Paw (cm H2O)

Exhalation Valve Opens

Pplateau
Inspiratory Pause
(Palveolar)
Expiration

Time (sec)
Inspiratory
Begin Inspiration Hold
Begin Expiration Courtesy: Prof J V Divatia
 Inspiration
Peak inspiratory flow rate Inspiratory valve closes
PIFR Inspiration
Beginning of expiration
exhalation valve opens
Inspiratory
Flow (L/min)

Time Expiratory Time

TI TE

Insp Time (sec)

Pause
Beginning of inspiration
exhalation valve closes
Expiration

Courtesy: Prof J V Divatia

 Volume vs. Pressure Control
Volume Preset Pressure Preset
• Set parameter is the tidal • Set parameter is airway
volume; airway pressure is pressure; tidal volume
variable delivered is variable
• Constant tidal volume in the face • Tidal volume varies with
of changing lung characteristics
changes in lung characteristics
• Patient-ventilator asynchrony
due to fixed flow rate • Flow will vary according to
patient's demands
• No leak compensation
• Compensates for leaks
 CMV
• All breaths are mandatory
• Preset frequency, inspiratory time/Inspiratory
flow
• Pressure or volume control
• Trigger: Time
• Limit: Volume, flow or pressure
• Cycle: Time, volume
 Controlled Mode
(Pressure-Targeted Ventilation)
Time Triggered, Pressure Limited, Time Cycled Ventilation

Time - Cyc le d
Flo w
(L/min)

Se t PC le vel

Pre s s
(cm H2O)
ure

Vo lume
(ml)
E ssentials of Ventilator G raphics Time (se c) ©2000 RespiM edu

Controlled Mode
(Volume-Targeted Ventilation)
Time triggered, Flow limited, Volume cycled Ventilation
Pre se t Pe a k Flo w

Flow
(L/m)

De pe nde nt o n
Pressure C L & Ra w
(cm H2O)
Pre se t VT
Volume Vo lum e Cyc ling
(mL)
Essentials of Ventilator Graphics
Time (s e cc)) ©2000 RespiMedu
 Like CMV
• Each additional assisted breath at prefixed tidal Assist
volume or pressureTrigger: ventilator or patient
Limit: Flow / volume or Pressure Control
Cycling: volume or time

Assisted Mode
(Volume-Targeted Ventilation)
Patient triggered, Flow limited, Volume cycled Ventilation

Flow
(L/m)

Pressure
(cm H2O)

Pre se t VT
Volume Vo lum e Cyc ling
(mL)
Time (sec)
Essentials of Ventilator Graphics ©2000 RespiMedu
SIMV
• IMV
• Machine triggered breaths with spontaneous breaths
allowed in between
• SIMV
• Synchronised mandatory breaths with spontaneous
breaths allowed in between
• Ventilator creates a time window around the scheduled
delivery of mandatory breath
• If a patient effort is detected, it synchronises the
machine breath with the patient’s inspiration
• If no patient effort is detected, it delivers a breath at
the scheduled time
 SIMV Mode

Flow
(L/min)

Pressure
(cm H2O)

Volume
(ml)

Time (sec) Courtesy: Prof J V Divatia

Spontaneous Breath
Pressure Support
• Completely spontaneous mode in which patient
triggers each breath
• On inspiration patient exposed to a preset
pressure
• Inspiration is terminated when the flow rate
reaches a minimum level or % of peak flow
Trigger: Patient
Limit: Pressure
Cycling: flow
 PSV
Flow
(L/m)

Set PS
level Rise
Rise
Pressure Time
(cm H2O)

Volume
(mL)
Time (sec)
Courtesy: Prof J V Divatia
 Initiating Mechanical Ventilation
• Check ventilator assembly: power connection, circuit connection, HME
filter catheter mount, gas connections
• Switch on ventilator, check on test lung
• Begin Preoxygenation (aerosol precaution)
• Watch for Hypotension
• Infuse Fluids
• Start Mechanical Ventilation
• A/C:TV=350-450, RR=20-30, FIO2= 60-100%
• Peak Flow rate 40-60 l/min
• PEEP=5-10, I:E=1:2, Sens= -0.8 - 2
Predicted Body Weight, TV and Minute
Ventilation
• The predicted body weight calculated as
• Males: 50+0.91(height cm -152.4);
• Female: 45.5+0.91( height cm -152.4).
TV= 6 ml/kg PBW
MVm= 4XBSA
• Calculate predicted body weight (PBW) MVf= 3.5XBSA
• Males = 50 + 2.3 [height (inches) - 60] MV= 100 ml/kg of
• Females = 45.5 + 2.3 [height (inches) -60] PBW
GOALS

• OXYGENATION GOAL: PaO255-80 mmHg or SpO2 88-95%

• PLATEAU PRESSURE GOAL: ≤ 30 cm H2O

• pH GOAL: 7.30-7.45
• Acidosis Management: (pH < 7.30)
• If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR = 35).
• If pH < 7.15: Increase RR to 35.
• If pH remains < 7.15, TV may be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30
may be exceeded). (Max TV =8, Min TV=4 ml/kg)
• Alkalosis Management: (pH > 7.45) Decrease vent rate if possible.
Other settings
• I:E=1:2, Vt: 500 ml, RR= 20/min
• Inspiratory flow rate=?
• Total cycle time (TCT)= 60 sec/RR=60 sec/20= 3
• Required I:E= 1:2= hence 1+2=3, divide 3 seconds into 3 parts.
• So Ti=1 sec, Te=2 sec.
• So to deliver 500 ml in 1 seconds inspiratory flow should be 0.5 L/sec.
Which is equal to 30 litre/min.
Initiating Mechanical Ventilation

• Confirm bilateral chest expansions

• Start Sedation +/- Relaxants
• Insert Central Line, Foleys Catheter & NG Tube
• Check X Ray & ABG in 10-20 Min.
• Start Anti Gastritis and DVT Prophylaxis & Eye Care
Monitoring on MV
• Heart rate
• SpO2
• Respiratory rate
• Pattern of respiration and signs of respiratory distress
• Blood pressure
• ETCO2
• Expired tidal volume: equal to set tidal volume (leaks)
• Peak pressure, Plateau pressure (< 30 mm Hg)

TREND IS YOUR FRIEND

 Types of Waveforms
• Scalars and Loops:

• Scalars: Plot pressure, volume, or flow against time. Time is the x-axis

• Loops: Plot pressure or flow against volume. (P/V or F/V). There is no

time component.
Types of Scalars
Types of Loops

P-V Loop F-V Loop

 Ventilator alarms and troubleshooting
Alarms Priority Causes Steps
Electrical power/ gas Highest Disconnection of power supply or Connect the power or Oxygen
delivery/ Battery oxygen source source
Low airway pressure High Disconnection or volume leak, in Connect ventilator, check alarm
appropriate alarm setting setting

High airway pressure High Obstruction to flow, pneumothorax Check for Ppeak and Pplat (diff
and other compliance problem <3-5) if both high: Compliance
(fluid overload/ abdominal problem (pneumothorax etc)
hypertension) If Ppeak and Pplat (diff>3-5) :
Resistance problem (tube/circuit
block etc): suction/change tube,
bronchodilator

Low Expired Vt High ETT cuff leak, Circuit leak, leak from Check/change ETT, Circuit, HME
HME filter, leak from ICD filter, ICD

High RR Moderate Blocked tube/bronchoconstriction Suction/bonchodilation

High PEEP
Management of other problems
• Hypoxemia: check for disconnection, Increase Fio2, Call for help,
check for tube block, fluid overload, check air entry, patient ventilator
asynchrony
DOPE:
D: Disconnection/ Dislodging
O: Obstruction,
P: Pneumothorax
E: Equipment failure

There may exist multiple problems

 Criteria for consideration for
Weaning/discontinuation
• Underlying disease stable or improving
• PaO2 / FiO2 > 200
• PEEP < 5-8 cmH2O
• FiO2 < 0.5
• Reliable respiratory drive
• Stable CVS
• Minimal pressors or inotropes
• Absence of myocardial ischemia
• Capable of initiating inspiratory effort
Underlying condition has
Resolved or improved and there is no other condition mandating MV

Daily screening of RS function

Not Ready Ready Weaning

MV and SBT
Daily screening
T-piece or PSV
30min is enough

Tolerated Not tolerated

Gradual Withdrawal
Esteban. AJRCCM 1997;156:459
Once-daily T-piece Esteban. AJRCCM 1999;159:512
PSV
Ely. NEJM 1996;335:1864
Difficult weaning
• A: Airway and lung dysfunction (resistance/compliance problem)
• B: Brain dysfunction (delirium, depression)
• C: Cardiac dysfunction (Cardiomyopathy)
• D: Diaphragm/ respiratory muscle
• E: Endocrine and metabolic (hypokalemia, hypomagenesimia,
hypophosphatemia, malnutrition, hypothyroidism, met. Acidosis,
fever)

Heunks et al Critical Care; 2010

Complications of MV
• Airway management related complications
• Hypotension
• Pneumothorax/Subcutaneous emphysema
• Ventilator induced lung injury
• Ventilator associated pneumonia
CARRY HOME MESSAGE
• CoViD-19 patients usually present to ICU with ARDS.
• For ventilating these patients Tidal volume (TV) should be calculated
by 6 ml/kg PBW. (TVmax=8 ml/kg, TVmin=4 ml/kg)
• Ventilating a patient with ARDS: Low TV, High RR, High PEEP and
Plateau pressure < 30 cm H2O.
• One should be aware of monitoring and troubleshooting of
mechanical ventilator.
• Patient should be initiated on Controlled or assist control mode of MV
and once recovers can be weaned using spontaneous breathing trial.
• In patients with difficult weaning ascertain and correct the cause.
THANK YOU