BASIC PRINCIPLES OF

MECHANICAL VENTILATION

LECTURES FOR MBChB LEVEL 5.

 OUTLINE
 INTRODUCTION
 CLASSIFICATION OF MECHANICAL VENTILATORS
 INDICATIONS FOR MECHANICAL VENTILATION
 GOALS OF MECHANICAL VENTILATION
 MODES OF VENTILATION
 COMPLICATIONS OF MECHANICAL VENTILATION
 WEANING FROM MECHANICAL VENTILATION
 INTRODUCTION

• 1928, the first mechanical ventilator.

• It was a negative-pressure ventilator, known as the Drinker-
Shaw tank ventilator or the “iron lung”.
• Made up of a metal cylinder engulfing patient up to the neck.
• A vacuum pump created negative pressure in the chamber,
resulting in chest expansion.
 INTRODUCTION….

• Change in chest geometry reduced the intrapulmonary

pressure allowing room air to flow into the patient's
lungs.
• When the vacuum was terminated, the negative
pressure dropped to zero (atmospheric pressure), and
the elastic recoil of the chest and lungs permitted
passive exhalation.
• There was no need for endotracheal or tracheostomy
DRINKER-SHAW TANK VENTILATOR
 INTRODUCTION….

• Drinker-Shaw tank ventilator was cumbersome and

uncomfortable with no access to patient
• 1931, Emerson introduced the Emerson tank ventilator
used extensively during the polio epidemics 1940s &
1950s
• Today, Negative-pressure ventilators have been
replaced by Positive-pressure ventilators.
 INTRODUCTION….
• Positive-pressure ventilation means that pressure is
applied at the patient's airway through an endotracheal
or tracheostomy tube (insp. is +ve as opposed to –ve in
spontaneous resp)
• The positive pressure causes the gas to flow into the
lungs until the ventilator breath is terminated.
• Elastic recoil of the chest results in passive exhalation by
pushing the tidal volume out.
 INTRODUCTION….

• Mechanical ventilation is indicated when spontaneous

ventilation is inadequate to sustain life.
• It’s also indicated as a measure to control ventilation in
critically ill patients and
• As prophylaxis for impending collapse of other
physiologic functions
 INTRODUCTION…..

• During the polio epidemic in Scandinavia and the United

States in the early 1950s it was noted that manual
mechanical ventilation reduced mortality from 80-25%.
• This was, however, found to be labour intensive leading to
the gradual adaptation of positive-pressure machines used
in the operating rooms for use in the ICUs.
 CLASSIFICATION OF POSITIVE-
PRESSURE
VENTILATORS
• Ventilators are classified by their method of cycling
from the inspiratory phase to the expiratory phase
• The signal to terminate the inspiratory activity of the
machine is either a preset volume (for a volume-cycled
ventilator), a preset pressure limit (for a pressure-
cycled ventilator), or a preset time factor (for a time-
cycled ventilator).
CLASSIFICATION OF POSITIVE-
PRESSURE
VENTILATORS…..

• Volume-cycled ventilation is the most common form of

ventilator cycling used due to its production of a
consistent tidal volume.
INDICATIONS FOR MECHANICAL
VENTILATION
1. Respiratory failure (hypoxia, acidosis, hypercarbia etc)
2. Cardiopulmonary arrest
3. Trauma esp. of head, neck and chest
4. Cardiovascular impairment (strokes, tumors, infection,
emboli, trauma)
5. Neurological impairment (drugs, poisons, myasthenia
gravis, Gullain Barre syndrome, bulbar poliomyelitis,
quadriplegia, etc.)
6. Pulmonary impairment (infections, tumors, pneumothorax,
COPD, trauma, pneumonia, poisons, ARDS, ALI)
GOALS OF MECHANICAL
VENTILATION:
• 1. Treat hypoxemia
• 2. Treat acute respiratory acidosis
• 3. Relief of respiratory distress
• 4. Prevention or reversal of atelectasis
• 5. Resting of ventilatory muscles
MODES OF VENTILATION
• Basically two modes:
1) Spontaneous (no machine involvement except in
negative-pressure ventilation)
2) Mechanical (machine involved)
• Mechanical ventilation is essentially a process that replaces
all or part of the action of the inspiratory muscles as well as
the neural control of breathing. It can be classified as:
• (a) Invasive and
• (b) Non-invasive ventilation (i.e. without endotracheal or
tracheostomy tube)
 NON-INVASIVE VENTILATION (NIV
OR NPPV)
 RESPIRATORY CYCLES

Two basic types of respiratory cycles can be defined.

• 1. The ventilator “controls” the inspiratory phase by
replacing the respiratory muscle effort and the neural
control by the patient. This is the “controlled” cycle
(initiated by the ventilator).
• 2. The ventilator only “assists” the inspiratory
muscles that are active. This is the “assisted” cycle
(initiated by the patient).
 RESPIRATORY CYCLES….
The cycle of the mechanical ventilator can also be
classified according to variables that are controlled
during inspiration:
• time,
• flow,
• volume or
• pressure.
In clinical practice, hybrid modes (assist-control) are
utilized.
 CONTROLLED VENTILATION:
1. VCV – Volume Cycled/Controlled Ventilation:
• the cycle depends on a predetermined tidal volume
(normally 6-8mls/Kg but varies with the pathophysiology)
2. PCV – Pressure Cycled/Controlled Ventilation:
• the cycle depends on a predetermined (based on clinical
condition) peak inspiratory pressure (PIP)
• Every breath is fully supported by the ventilator. In classic
control modes, patients were unable to breathe except at
the controlled set rate. They were deeply sedated and/or
paralyzed.
 CONTROLLED
VENTILATION…..

• Every breath is fully supported by the ventilator. In

classic control modes, patients were unable to breathe
except at the controlled set rate. They were deeply
sedated and/or paralyzed.
• In newer control modes, machines may act in assist-
control, with a minimum set rate and all triggered
breaths above that rate also fully supported.
 ASSISTED VENTILATION:

• Assist control (A/C) - patient able to trigger a positive pressure

inflation with each breath
• Synchronized intermittent mandatory ventilation (SIMV) - patient
able to trigger only a pre-set number of positive pressure inflations
• Pressure support (PS) - Flow-limited mode of ventilation (not
volume-limited or pressure-limited). Delivers inspiratory pressure
until the predetermined is achieved (~25% of peak). Clinician sets
inspiratory pressure, applied PEEP (Positive End Expiratory
Pressure), and FiO2 (Fraction of Inspired Oxygen). Patient triggers
each breath
 ASSISTED VENTILATION….
• CPAP (Continuous Positive Airway Pressure) -
Continuous level of positive airway pressure. Patient
initiates all breaths. Functionally similar to PEEP. Good
for OSA (Obstructive Sleep Apnea), cardiogenic
pulmonary edema
• BPAP (Bi-level Positive Airway Pressure) - Mode used
during NPPV. Delivers set IPAP and EPAP. Tidal Volume
is determined by difference between IPAP-EPAP
 ASSISTED VENTILATION…..
• Pressure-regulated volume control (PRVC) - A form of PACV
(Pressure Assist-Control Ventilation) that uses tidal volume as
a feedback control for continuously adjusting the pressure
target. Clinician sets tidal volume target and the ventilator
then automatically sets the inspiratory pressure.
• Airway Pressure Release Ventilation (APRV) - Time-triggered,
pressure-limited, and time-cycled mode. High continuous
positive airway pressure (P high) is delivered for a long
duration (T high) and then falls to a lower pressure (P low) for
a shorter duration (T low). Allows spontaneous breathing
(with or without PS) during both the inflation and deflation
phases.
 ASSISTED VENTILATION…..
• Biphasic Ventilation - Similar to APRV, except that T low
is longer during biphasic ventilation, allowing more
spontaneous breaths to occur at P low
• Adaptive Support Ventilation (ASV) - Ventilator delivers
a desired minute ventilation set by clinician. Breaths
are pressure-control + pressure support for triggered
breaths to achieve desired respiratory rate.
• automatically adjusts respiratory rate and inspiratory
pressure to achieve
 ASSISTED VENTILATION…..

• High-frequency ventilation (HFV) - Keeps the lung

inflated for extended period of time to maximize
alveolar recruitment. HFV uses very high breathing
frequencies (120-900 breaths/min) coupled with very
small tidal volumes (<1 mL/kg) to provide gas exchange
in the lungs. Supplied by either jets or oscillators.
 COMPLICATIONS OF MECHANICAL
VENTILATION
• 1. Barotrauma/Volutrauma/pneumothorax
• 2. Nosocomial/Ventilator Associated Pneumonia
• 3. Cardiovascular complications e.g. hypotension/low
cardiac output
• 4. Airway complications
• 5. GI hemorrhage (stress ulcers)
• 6. Failure of tracheostomy stoma to close
• 7. Equipment failure
WEANING FROM MECHANICAL
VENTILATION
Weaning is the process of liberating the patient from
mechanical support and from endotracheal tube.
Stages of weaning:
• 1) Treatment of acute respiratory failure
• 2) Suspicion that weaning may be possible
• 3) Assessment of readiness to wean
• 4) Spontaneous breathing trial (SBT);
• 5) Extubation; and possibly
WEANING FROM MECHANICAL
VENTILATION…

Weaning failure is defined as one of the following:

• 1) Failed SBT;
• 2) Re-intubation and/or resumption of ventilatory
support following successful extubation; or
• 3) Death within 48 hours following extubation.
THE END

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