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Mechanical Ventilation

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Ariel Hidalgo

on 2 March 2016

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Transcript of Mechanical Ventilation

Use of Mechanical Ventilation
Oxygenation vs Ventilation


Shear Stress/Atelectrauma

Hemodynamic implications

Oxygenation is the movement of oxygen molecules into the lungs and ultimately into our blood stream to reach our bodies organ systems, works by the simple diffusion.

Ventilation deals with control and ultimately the removal of carbon dioxide from the body.

Control CO2 elimination.

Improve impaired oxygenation.

Assist (‘rest’) the respiratory muscles.
Positive Pressure Ventilation
1.Acute Respiratory Failure
Hypoxemic respiratory failure (SaO2 <90% despite FiO2>0.6)
Hypercarbic respiratory failure (PCO2 >50mmHg and pH <7.3)

2.Inability to protect airway, declining mental status (GCS <8 high risk for aspiration)

3.Respiratory arrest or apnea (eg, due to CNS disease, drug overdose)

4.Upper airway trauma

5.Relieve the work of breathing in shock

6.Operative procedures

Indications for Mechanical Ventilation
List indications for mechanical ventilation.

Discuss the physiologic processes (Oxygenation and Ventilation) important to consider when managing the ventilated patient.

Describe and differentiate modes of ventilation.

Anticipate, identify, and manage complications that may arise during mechanical ventilation.

58 year old man presented to ED with suspected CVA. Vitals: 165/95, 94 bpm, 16, normal temperature. The Patient's pupils respond slowly and unequally to light, breath sounds are diminished in the lung bases. A "snoring" sound is heard during inspiration. the patient is not responsive to painful stimuli.

What is the next best step?
Respiratory Physiology
Factors that control oxygenation
Mechanical Ventilation
Ogugua Ndili Obi, MD, MPH
Pulmonary Critical Care Fellow
Brody School of Medicine at ECU

An active process initiated when diaphragm contracts and intercostal muscle contract (rib cage expands).

Passive process which occurs secondary to diaphragmatic relaxation and elastic recoil of lungs and thorax.


Complete reversal of normal physiologic breathing.

Air flow into lungs is now the result of a machine (ventilator) pushing or forcing air into lungs.

Factors that Control Ventilation
Overdistention of alveoli which may lead to air leaks, pneumothorax, pneumomediastimum and proinflammatory cascade which may worsen ARDS.

Shear Stress/Atelectrauma
Damage which may occur when repetitively opening and closing lung units.

Can lead to damage of normal lung units and progression of ARDS.

Hemodynamic Consequences of Positive Pressure Ventilation
Modes of Mechanical Ventilation
The type and pattern of breath delivery constitute the "mode" of ventilation.

The mode is determine by looking for the following factors:

Type of Breath (mandatory, spontaneous or assisted).

Variable being controlled ( pressure vs volume)

Volume targeted vs Pressure Targeted Ventilation
In pressure targeted ventilation an airway pressure limit is set while flow and tidal volume become the dependent variables.

In volume targeted ventilation a target volume and flow are preset and
pressure and inspiratory time become dependent variables.

Continuous Mandatory Ventilation (CMV)
Breathing is completely controlled by ventilator.
Preset RR and Vt, does not allow for spontaneous breaths.

Patient RR=10bpm (breath every 6 sec) Vt=500cc

Every 6 sec he will get 500cc regardless of whether he wants to breath 8bpm or 20bpm and regardless of whether he wants to take in 300cc or 7oocc

Volume Assist Control Ventilation
Set rate and set Vt however patient can take spontaneous breaths.

Once ventilator is triggered it will deliver a set Vt.

Patient RR=4bpm (Every 15 sec) Vt=500cc
Patient will get breath at 15,30,45,and 60 seconds

If patient wants to take a breath at 10 sec. he can but he will get 500cc regardless of whether he wants 300cc or 7oocc

Pressure Assist Control Ventilation
Preset RR and PIP but allows patient can take spontaneous breath however once ventilator is triggered a preset pressure is given.

Patient with ARDS RR=4bpm (breath every15 sec) with a PIP=25 cm H2O.
Patient wants to take breath at 10 sec. he can but will get a PIP=25 and get a Vt dependent of lung compliance and airway resistance.

Pressure Support
Is an assisted form of ventilation, i.e the patient must have a reliable spontaneous respiratory drive.

The operator sets the pressure to support each breath , PEEP, Fio2 and triggering parameter.

The patient controls the RR.
Pressure Regulated Volume Control

A control mode which delivers a set tidal volume with each breath at the lowest possible peak pressure.

Pressures are adjusted by the ventilator once a preset Vt is reached.

A 45-year-old woman is evaluated in the emergency department for the acute onset of dyspnea, wheezing, and progressive respiratory distress. She has a history of severe persistent asthma with two previous admissions to the intensive care unit, one of which required intubation. She has not responded to aggressive bronchodilation therapy and intravenous corticosteroids.

On physical examination, she is in marked distress and is anxious. Temperature is 37.0 °C , BP 145/100, HR 120/min and RR 25/min. Pulmonary examination reveals very faint wheezing.

Arterial blood gas studies breathing ambient air show a PCO2 of 80 mm Hg (10.6 kPa), a PO2 of 50 mm Hg (6.7 kPa), and a pH of 7.08.

She undergoes rapid sequence induction and intubation and is started on mechanical ventilation.
Which of the following strategies in establishing ventilator settings is most appropriate for this patient?
A. Decreased inspiratory flow
B. Increased minute Ventilation
C. Prolonged expiratory time
D. Prolonged inspiratory time
A 25-year-old woman is admitted to the ICU for respiratory distress. She has ALL and received cytotoxic chemotherapy 2 weeks before ICU admission. She has had fever and leukopenia for 7 days.

Onphysical examination, she is in marked respiratory distress. Temp 39.0 °C, BP 110/70 mm Hg, HR 130/min, RR 42/min, SpO2 80%. Weight is 50.0 kg (110.2 lb). Ideal body weight is calculated as 50.0 kg (110.2 lb).

She is intubated and started on mechanical ventilation in the assist/control mode at a rate of 25/min, tidal volume of 300 mL, PEEP of 5 cm H2O, and FIO2 of 100% . ABG shows a pH of 7.42, PCO2 of 30 mm Hg, and PO2 of 45 mm Hg. Peak airway pressure is 26 cm H2O, and the plateau pressure is 24 cm H2O.
What ventilator changes should be made to improve this patient's oxygenation?

A. Increase PEEP.
B. Increase RR.
C. Increase Vt.
D. Start inhaled nitric oxide.

A 50-year-old man is evaluated in the intensive care unit for ARDS secondary to CAP. He is intubated and placed on mechanical ventilation.

On physical examination, temp is 38.3 °C, BP is 120/60 mm Hg and HR 110/min. The patient's ideal body weight is 60.0 kg. He is sedated and is not using accessory muscles to breathe.

Vent settings are volume control with a rate of 18/min, Vt of 360 mL, PEEP of 24 cm H2O, an FIO2 of 80%, a peak pressure of 34 cm H2O, and a plateau pressure of 32 cm H2O. Oxygen saturation by pulse oximetry is 96%.
What ventilator settings need to be change in order to avoid complications?

A. Decrease RR
B. Decrease Vt
C. Decrease FiO2
D. Decrease PEEP


Ventilator Waveforms
Plateau Pressure
Is the pressure applied to the small airways and alveoli.

The goal plateau pressure is <30 cm H2O.

Without lung disease, peak inspiratory pressure is only slightly above the plateau pressure.

How do you calculate plateau pressure on a ventilator??
End inspiratory hold
A. Auto PEEP
B. Trigger Dyssynchrony
C. Flow Starvation
D. Auto Triggering
A. Auto PEEP
B. Trigger Dyssynchrony
C. Flow Starvation
D. Auto Triggering
A. Auto PEEP
B. Trigger Dyssynchrony
C. Flow Starvation
D. Auto Triggering
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