MECHANICAL

VENTILATION

BY
DR.G.SREENIVAASAN
GRADE I SPECIALIST,
ANAESTHESIOLOGY DEPT.,
IGGH & PGI.
SPONTANEOUS
RESPIRATION

NEGATIVE PRESSURE
BREATHING
MECHANICAL VENTILATION

POSITIVE PRESSURE
BREATHING
 DRY AIR

 O2 -20.98%
 CO2 -O.04%
 N2 -78.06%
 ARGON & HELIUM -0.92%
 Conducting Zone

 Conducting zone
• Provides rigid
conduits for air to
reach the sites of
gas exchange
• Includes all other
respiratory
structures (e.g.,
nose, nasal cavity,
pharynx, trachea,
primary,
secondary and
tertiary Bronchi )
• No Gas exchange
 RESPIRATION
 Involuntary
-Medulla=>Pacemaker
-Pons
-Limbic system
-Hypothalamus
 Voluntary
-Cerebral cortex
 IV ventricle
-Inspiratory neurons
-Expiratory neurons
 NEURAL INPUT

 Carotid(Pao2)
 Central(PaCO2,[H+])
 Proprioceptive receptors
 Cerebral cortex
 RESPIRATORY SYSTEM

 Neural and muscular components

 Inherent properties of the lungs
 Diffusion across alveolar capillary
membrane
 RESPIRATORY SYSTEM
 Elastance
-Force tending to return the lung to
its original size after stretching it
CM H2O / LIT
 Compliance
-Measure of change in volume per
unit of pressure change in lung
litres/cm of H2O
 Total compliance 100 ml /cm of H20
 RESPIRATORY SYSTEM
 Resistance

-Measure of the impedance to air flow

-Measured as the amount of pressure
required to cause a unit change of gas
flow rate
cm H2O/lit/sec

 Work of breathing
-Energy required for ventilation
 RESPIRATORY SYSTEM

-Inspiratory Alveolar pressure (-3 cmH20)

-Expiratory Alveolar Pressure (+2cmH2O)
-Alveolar Pressure change (5cmH2O)
-Normal compliance of the lung
(100ml/cmH2O)
-Volume of air transferred(5*100=500ml)
-500ml*12(frequency)=6 lit(MV)
PIP=FLOW*RES+VOLUME/COMPLIANCE
 INDICATIONS
 RESPIRATORY FAILURE

 PaO2 <50 MM OF Hg on FiO2 of 50 % (Failure

to oxygenate)

 PaCO2 >50 MM OF Hg with pH of 7.25 or less

(failure to ventilate)
 RESPIRATORY FAILURE
 Neuromuscular Competence
-GB syndrome, Poliomyelitis, MG

 Decrease in compliance
-Pulmonary Edema, Pneumonia,
ARDS

 Increase in resistance
-Bronchial asthma,COPD
 GOALS

 Alveolar ventilation
 Arterial oxygenation
 Adverse effects
 Ensure patient’s comfort
 Reduce work of breathing
 BASIC PARAMETERS
 Airway access
 Sedation and muscle relaxation
 Ventilator settings
Mode
Respiratory rate
Tidal volume
FiO2
Inspiratory flow rate
PEEP
Setting the alarm limits
Ancillary therapy
 Follow up
ABG
 Basic Ventilator Parameters
 FiO2  Tidal volume (VT)
• The amount of gas that is
• Fractional delivered during inspiration
concentration of expressed in mls or Liters.
inspired oxygen Inspired or exhaled.
delivered expressed
as a % (21-100)

Flow
 Breath Rate (f) • The velocity of gas flow or
• The number of times volume of gas per minute
over a one minute
period inspiration is
initiated (bpm)
 MODE
 Method or the way in which a
BREATH is delivered by altering or
changing the available variables is
called mode of ventilation.
 PHASES OF VENTILATION
 INSPIRATORY PHASE
 INSPIRATION TO EXPIRATION
 EXPIRATORY PHASE
 EXPIRATION TO INSPIRATION
 TYPES OF BREATH
Mandatory breath Breath started and ended
by machine

Spontaneous breath Breath started and ended

by patient

Assisted breath Breath started by patient

and ended by machine
 Volume Control Breath Types

60

Paw SEC
cmH20
1 2 3 4 5 6
-20
120 INSP

Flow SEC

L/min 1 2 3 4 5 6

120 EXH

If compliance decreases the pressure increases to

maintain the same Vt
 PEEP
 Definition
• Positive end expiratory pressure
• Application of a constant, positive pressure such that
at end exhalation, airway pressure does not return
to a 0 baseline

 Used with other mechanical ventilation modes such as

A/C, SIMV, or PCV

 Referred to as CPAP when applied to spontaneous

breaths
 PEEP
 Increases functional residual capacity (FRC)
and improves oxygenation
• Recruits collapsed alveoli
• Splints and distends patent alveoli
• Redistributes lung fluid from alveoli to
perivascular space

5 cm
H2O
PEEP
 CPAP
 Definition
• Continuous positive airway pressure
• Application of constant positive pressure
throughout the spontaneous ventilatory cycle

 No mechanical inspiratory assistance is provided

• Requires active spontaneous respiratory drive

 Same physiologic effects as PEEP

 CPAP
 May decrease WOB

 Tidal volume and rate determined by patient

 Often final form of support before extubation

10 cm
H2O

PEEP
Time
 Basic Modes of Ventilation
 Control
Assist/Control
 (S)IMV
 PCV
 PSV
 Control

 Delivery of a P

mandatory
breath at a set
time interval -
time is the
trigger to start F

the breath
 Assist Control
P
 Patient is
able to
trigger the
start of
inspiration
F
 SYNCHRONIZE INTERMITTENT
MANDATORY VENTILATION -
SIMV
 A minimum P
mandatory breath
rate is set with
spontaneous
breathing
supported
F
between the
mandatory cycles
 Volume vs…
Pressure Control Ventilation
Volume Ventilation Pressure Ventilation

 Volume delivery  Volume delivery varies

constant  Inspiratory pressure
 Inspiratory pressure constant
varies  Inspiratory flow varies
 Inspiratory flow
constant
 Pressure Control Ventilation -
PCV
P
 The ventilator
delivers a set
pressure limit
over a set
inspiratory time F
 PRESSURE CONTROLLED
VENTILATION
 Clinician sets inspiratory pressure above PEEP, the rate
and IT
 I:E ratio also set to determine inspiratory time
 Delivers flow rate and volume to maintain set inspiratory
pressure for the set inspiratory time
 Alveolar pressure never exceeds
 ARDS
 PRESSURE CONTROL
VENTILATION
 Advantages
• Limits risk of barotrauma
• May recruit collapsed alveoli
• Improved gas distribution

 Disadvantages
• Tidal volumes vary when patient
compliance changes (i.e. ARDS, pulmonary
edema)
• With increases in I-time, patient may
require sedation and/or paralysis
 PRESSURE SUPPORT
VENTILATION - PSV
 The ventilator P
delivers a set
pressure limit
with end
inspiration
driven by the F
patient
 PRESSURE SUPPORT
VENTILATION
 Spontaneous breathing augmented
 Fixed amount of pressure
 Patient controls flow and time of each breath
 5-15 cm H2O to permit TV ~ 5 ml/kg
 Pressure is reduced in decrements of 3.5 cm
H20
 Extubation done when PS is 5 cm H2O
 BI LEVEL

 Is a spontaneous P
breathing mode in
which two levels
of pressure and
hi/low are set
F
 What is Bilevel ventilation?
 Enabled utilizing an active exhalation valve

 Substantial improvements for spontaneous

breathing
• Better synchronization, more options for
supporting spontaneous breathing, and
potential for improved monitoring

Spontaneous Breaths
Synchronized Transitions

Spontaneous Breaths
P

T
 INITIAL VENTILATOR
SETTINGS
 A/C OR CMV
- Hypoxaemic respiratory failure
- Hypoventilatory respiratory failure
- Post op respiratory failure
- Shock
• PCV
- ARDS
• SIMV with PS
- Weaning
 MECHANICAL VENTILATION
TIDAL VOLUME

 5-7 ml/kg

 Low lung volume +PEEP

 Plateau Pressure < 35 cm H2O

 RATE,VOLUME AND PRESSURE

TV : 7M/KG

RR : 10-20/m

IP : 35 cm H2o

IE : 1:2 to 1:3
 STRATEGIES
VENTILATOR TRADITIONAL LUNG-
PARAMETERS PROTECTIVE
Tidal Volume 10-15 ml/kg 6-8 ml/kg

End-Inspiratory Peak Pressure<50 cm Plateau Pressure<35

Pressure H2O cm H2O

Positive End- Only when needed to 5-15 cm H2O

Expiratory Pressure keep th FiO2 below
0.6
Arterial Blood Normal or Usual Hypercapnia allowed
Gases(Targets) PaCO2 pH=7.2 – 7.44
pH=7.36-7.44
 TROUBLESHOOTING
 70YR old man Mr.NIRMAL a known diabetic,
HT,IHD,LVF admitted with respiratory distress
and put on mechanical ventilator over the next
12 hrs with lasix,dobutamine and mechanical
ventilator support patient stabilized

 Patient suddenly became restless and agitated

on mechanical ventilator. He was sweating,
Tachycardia and extremities were cold
WHAT WILL YOU DO ?
Distress on ventilator

Disconnect
Bag the patient with 100% O2

Relief No Relief
A,B,C
 NO RELIEF WITH BAGGING
 AIRWAY
No relief

Is there Airway Obstruction??

YES NO

Tube Kinking Respiratory

Tube Biting Cardiac
Suction Catheter be Other
passed
Change the tube
 Breathing
respiratory problem

Breath sounds Bil. Present Unilateral Breath sounds

• Crepts • Tube in right

• Rhonchi
• Rhonchi bronchus(withdraw
• Secretion tube)
• Secretions
• Crepts • Collapse(Suction B’Scopy)
• Pnemothorax(CXR, ICD

Suction
 SUCTION
SUCTION

Improvement No improvement

Evaluate CVS Nebulize

CVP,BP,I/O

Lasix
Improvement

• Worsening of
underlying
condition
• Pnemonia
 CIRCULATION
 BP
 CVP
 PAWP
 ECG
 CXR
 ABG
 BED SIDE ECHO
 CIRCULATION
 Is there Shock ?
 Ongoing Myocardial Ischaemia?
 Pulmonary Edema?
 Arrythmia?
 Pulmonary embolism?
 OTHER PROBLEMS
 Abdomen
- Abdominal distention
- Pain in Post op patients
• CNS
- Abnormal respiratory drive
-Increased ICP
-CT brain
-Check ABG
 VENTILATOR ALARMS
 Low Ventilation Alarm
-Leak
-decreased RR
-decreased compliance
-Increased resistance
-Altered Setting
• High Ventilation Alarm
-Increased Triggering
-Increased RR
-Change settings
 High Pressure Alarm(Intermittent)
- cough, Secretion
- asynchrony

 High Pressure Alarm(Persistent)

-Airway obstruction
-Secretion
-Bronchospasm
-Tube main stem bronchus
- Pnemothorax
-Collapse
-Pulmonary edema
 Low Pressure Alarm
- Leaks
-Ventilator failure
-Altered settings

 Low Oxygen alarm

-Central oxygen
-Blender problem
-Oxygen sensor problem
 VOLUME CONTROLLED
VENTILATION
 High Pressure alarm
 MV/TV alarm remain unchanged

PRESSURE CONTROLLED
VENTILATION
 MV Alarm
 PATIENT VENTILATOR
ASYNCHRONY

 Is there an airway problem?

 Is there a respiratory problem?
 Is there a cardiac problem?
 Is there a CNS problem?
 Mode and settings are appropriate?
 WEANING
 Process of discontinuation of ventilation
 Adequacy of airway protection
 Sustain spontaneous respiration

SUCCESS OF WEANING
• Adequacy of gas exchange
• Performance of respiratory pump
 PARAMETERS TO ACCESS
 Pao2/Fio2 >= 200
 Pao2/PAo2 <= 350mm Hg
 Pao2>=60mm Hg with Fio2 <= 0.35
 Vital capacity >= 10 -15 ml /kg
 Maximum –ve Inspiratory Pressure< -30cms
H20
 Minute Ventilation<10 lit /min
 HOW TO WEAN?
 Team approach
 Ensure adequate sleep
 Check electrolytes/pH
 Check ET/TT tube size and patency
 Good pulmonary toilet
 Satisfactory bronchodilator therapy
 Prop up position
 METHODS TO DISCONTINUE

 Abrupt of discontinuation of MV
- Post op patients can be put on Tpiece
and extubation
 Spontaneous breathing trial
- Tpiece or through ventilator circuit
- 30-120 min
 SIMV

 Decreased RR – 1 to 3 breaths /min

 Check ABG after 30 min
 If pH > 7.30 till SIMV rate is 0 => Extubate
 PRESSURE SUPPORT
VENTILATION
 Spontaneous breathing augmented
 Fixed amount of pressure
 Patient controls flow and time of each breath
 5-15 cm H2O to permit TV ~ 5 ml/kg
 Pressure is reduced in decrements of 3.5 cm
H20
 Extubation done when PS is 5 cm H2O
 DIFFICULT WEAN
 Metabolic alkalosis
 Sedative drugs
 Malnutrition
 Acute respiratory acidosis
 Hypokalemia
 CRF
 Hypothyroidism
 Respiratory muscle fatigueness
 Increased CO2 production
 Metabolic acidosis
 Increased WOB
POTENTIAL COMPLICATIONS
OF MV
 Ventilator malfunction
• Manually ventilate patient
 Barotrauma
• Alveolar rupture due to overdistention
• Monitor PIP, breath sounds
 Oxygen toxicity
• goal: FIO2 < .50 and PaO2 > 70
 Cardiovascular compromise/arrhythmias
• Monitor vital signs
 POTENTIAL COMPLICATIONS OF
MV

 Infection
• ET tube bypasses natural airway defense mechanisms
 Nosocomial pneumonia, aspiration pneumonia

• Good handwashing, provide mouth and tube care

 Psychological
• Patients may be extremely anxious and/or agitated
• Give consistent, calming explanations, offer reassurance
• Sedation, anti-anxiety agents frequently indicated
 NEONATAL VENTILATION
CATEGORY AIRWAY COMPLIANCE
RESISTANCE (lit/cmH2O)
(cm
H2O/lit/sec)
New born 30-50 0.003-0.005

Infants 20-30 0.01-0.02

Small children 20 0.02-0.04

Adults 2-4 0.07-0.1

 CLINICAL CRITERIA
 Retractions(Intercostal,Supraclavicula
r,suprasternal)
 RR>60/min
 Cyanosis
 Intractable apnoea

LAB CRITERIA
 PaCO2 >60 mm Hg
 PaO2 <50 mm Hg or SaO2<80%
with FiO2 1.0
 pH<7.25
 VENTILATOR STRATEGY
BODY WEIGHT 5KG

FLOW RATE 5-7 lit/min

FiO2 Keep PaO2 at 50-70 mm
Hg
IMV rate 20-30/min
IT 0.6-0.8 sec
INSPIRATION Sufficient enough for
PRESSURE adequate chest
excursion(20-25 cm H2O)
PEEP 4-5 cm H2O
I:E RATIO 1:1 - 1:2
 ASTHMA AND OBSTRUCTIVE
DISEASE
INDICATION

 Respiratory arrest and circulatory collapse

 Respiratory muscle fatigue
 PaCO2 >42 mm Hg
 Thoracic abdominal paradox
 Quiet chest
 pH<7.25
 RR>40/min
 Altered mental status
 PaO2 < 60 mm Hg
 VENTILATOR SETTING
AIM Low Dynamic hyperinflation
Low respiratory muscle activity
MODE A/C mode or CMV

FiO2 1.0

RR 8-10/min

IFR 80-100 lit/min

PEEP 0

SENSITIVITY -1 TO -2 cm H2O

TV 6 TO 8 ml/kg
NEUROMUSCULAR DISEASES
 CMV

 ACMV

HEAD INJURY
INDICATION:
 ICP> 15 cm Hg
 PaO2 <75 mm Hg
 PaCO2 >45 mm Hg
 Repeated seizures
 Coma
 HEAD INJURY (contd..)
VENTILATOR STRATEGY

MODE : CMV OR A/C mode

FiO2 : 1.0
IFR : 60-70 lit/min
TV : 10-12 ml/kg
RR : 12-14 /min
I:E : 1:2
PEEP : 5-7 cm H2O
 CARDIOGENIC PULMONARY
EDEMA

LESS SURELY ILL Non invasive CPAP

PATIENTS BIPAP

PSV with CPAP

SURELY ILL CMV OR A/C mode

PATIENTS with PEEP
 ARDS
TV 5-7 ml/kg
IFR 60-70 lit/min
FLOW PATTERN Decelerating
RR To keep PaCO2 and
pH normal
PEEP 8-12 cm H2O
FiO2 Decreased from 1.0
PLATEAU PRESSURE Decreased 35 cm
H2O
MODE A/C or SIMV mode or
PCV
 ORAL vs NASAL INTUBATION

VARIABLES ORAL NASAL

Ease of procedure Apnoeic Patient Awake breathing
patient

Nasal Bleeding No yes

Sinusitis No Yes
Patient comfort Less More
Bite block Required Not required
Oral hygiene Difficult Easy
Accidental extubation More likely Less likely

Tube size Larger,shorter Smaller,longer

Suctioning Easier More difficult

Laryngeal damage More Less
 PROLONGED INTUBATION
1. Tracheal mucosal damage
- Increased cuff pressure,airway pressure and duration
of intubation
2. Infection
- Bacteria absent below the glottis
- Bacterial contamination 8 times more with tracheostomy
- Wash hands and wear sterile gloves
- Sterile precaution for endotracheal suction
- Closed system suction (Stericath)
- Antibiotic therapy
- Physiotherapy
- Nutritional support
3. Inability to talk
4. Malposition and unplanned extubation
 PREPARATION FOR INTUBATION

 S : SUCTION
 A : AIRWAY
 L : LARYNGOSCOPE
 T : TUBE
 TRACHEOSTOMY

 Improved suctioning
 Decreased WOB
 Decreased Dead space
 Improved patient comfort
 Cuffed tubes PVC
 ANALGESIA AND SEDATION
OPIOD ANALGESICS
 Morphine

 Pethidine

 Fentanyl

BENZODIAZEPINES
 Midazolam

 Lorazem

 Diazepam

INRAVENOUS ANAESTHETIC AGENTS

 Propofol
 ANALGESIA AND SEDATION
NEUROMUSCULAR BLOCKADE

 REFRACTORY HYPOXAEMIA
 INVERSE RATIO VENTILATION
 DECREASED 02 CONSUMPTION
 INTRACRANIAL HYPERTENSION
 TETANUS
 INJ.ATRACURIUM-
 5-10MICROGRAM/MIN(0.2MG/KG)
 INJ.VECURONIUM-
0.8MICROGRAM/KG/MIN(0.1MG/MIN)
 VARIABLE- PERFORMANCE DEVICES

O2 DELIVERY INTENDED O2 TRACHEAL O2

SYSTEM CONC.(%) CONC.(%)
NASAL CANNULA
3 L/min 22.4
10 L/min 46.2
15 L/min 60.9
FACE MASK
10L/MIN
60 53.4
15L/MIN
100 68.1
VENTURI MASK
4 L/min 28 24.2
8 L/min 40 36.4
 NURSING CARE IN ICU
 Suction canister with regulator and connecting
tubing
 Sterile 14 Fr. suction catheter or closed in-line
suction catheter
 Sterile gloves
 Normal saline
 Yankuer suction-tip catheter and nasogastric tube
 Intubation equipment: Manual resuscitator bag
(MRB), Laryngoscope and blade, Wire guide,
Water soluble lubricant,
 Endotracheal attachment device (E-tad) or tape
 Get order for initial ventilator settings
 Sedation prn
 NURSING CARE IN ICU (contd..)

 Avoid cross-contamination by frequent hand

washing
 Decrease risk of aspiration (cuff occlusion of
trachea, positioning, use of small-bore NG tubes)
 Suction only when clinically indicated, using sterile
technique
 Ensure adequate nutrition
 Avoid neutralization of gastric contents with
antacids and H2 blockers.
 NURSING CARE IN ICU (contd..)
 Observe changes in respiratory rate and depth; observe for SOB
and use of accessory muscles.

 An increase in the work of breathing will add to fatigue; may

indicate patient fighting ventilator.

 Prevent accidental extubation by taping tube securely, checking

q.2h.; restraining/sedating as needed.

 Inspect thorax for symmetry of movement.

 Determines adequacy of breathing pattern; asymmetry may

indicate haemothorax or pneumothorax.

 Measure tidal volume and vital capacity.

 NURSING CARE IN ICU (contd..)
 Asses for pain

 Pain may prevent patient from coughing and deep breathing.

 Elevate head of bed 60-90 degrees.

 This position moves the abdominal contents away from the diaphragm,
which facilitates its contraction.

 Monitor ABG’s.

 Determines acid-base balance and need for oxygen.

 Assess LOC, listlessness, and irritability.

 These signs may indicate hypoxia.

 NURSING CARE IN ICU (contd..)

 Observe skin color and capillary refill.

Monitor CBC
 Administer oxygen as ordered.
 Decreases work of breathing and supplies
supplemental oxygen.
 NURSING CARE IN ICU (contd..)
 Observe for tube obstruction; suction prn; ensure adequate
humidification.

 Reposition patient q. 1-2 h.

 Repositioning helps all lobes of the lung to be adequately perfused and

ventilated.

 Provide nutrition as ordered, e.g. TPN, lipids or enteral feedings.

 Calories, minerals, vitamins, and protein are needed for energy and
tissue repair.

 Potential for pulmonary infection r/t compromised tissue integrity.

 Secure airway and support ventilator tubing.

 Prevent mucosal damage.

 NURSING CARE IN ICU (contd..)
 Provide good oral care q. 4 h.; suction when need
indicated using sterile technique; handwashing with
antimicrobial for 30 seconds before and after patient
contact.

 Measures aimed at prevention of nosocomial

infections.

 Assess for GI problems. Preventative measures

include relieving anxiety, antacids or H2 receptor
antagonist therapy, adequate sleep cycles, adequate
communication system.

 Most serious is stress ulcer. May develop constipation.

 NURSING CARE IN ICU (contd..)

 Observe skin integrity for pressure ulcers;

preventative measures include turning patient at
least q. 2 h.;

Reduce anxiety, gain cooperation and

participation in plan of care.

.
 ANATOMY OF ABG

PH 7.40 mm Hg

PaO2 98 mm Hg

PaCO2 40 mm Hg

HCO3 24 mm Hg
 ABG

FiO2 PaO2

0.3 150

0.4 200

0.5 250

0.8 400

1.0 500
 APPROACH IN ABG

Normal arterial pH=7.4(0.02)

 Acidaemic : pH < 7.38

 Alkalemic : pH > 7.42
 APPROACH TO ABG (contd..)

Is the primary disturbance metabolic ?

 If HCO3 <20 – metabolic acidosis

 If HCO3 >26 – metabolic alkalosis
 APPROACH TO ABG (contd..)

Is the primary disturbance respiratory?

 If PaCO2 >40 – respiratory acidosis

 If PaCO2 <30 – respiratory alkalosis
 ABG
pH 7.30
PaO2 80 mm Hg
PaCO2 28 mm of Hg
HCO3 12 mm of Hg
Sat 92 %

????

METABOLIC
ACIDOSIS
 ABG
pH 7.46
PaO2 96 mm Hg
PaCO2 48 mm of Hg
HCO3 34 mm of Hg
Sat 98 %

????

METABOLIC
ALKALOSIS
 ABG
pH 7.34
PaO2 80 mm Hg
PaCO2 62 mm of Hg
HCO3 29 mm of Hg
Sat 92%

????

RESPIRATORY
ACIDOSIS
 ABG
pH 7.44
PaO2 96 mm Hg
PaCO2 24 mm of Hg
HCO3 16 mm of Hg
Sat 99 %

????

RESPIRATORY
ALKALOSIS
THANK YOU !!!!