Mechanical Ventilation

Internal and Critical Care Medicine Study Notes

Dr. Ali Ragab Ali

Critical Care Medicine
Damanhur Medical National Institute
Facebook (ali_ragab_ali@yahoo.com)

Dr. Ali Ragab

Mechanical ventilation
Indications of ventilatory support

Bradypnea or apnea with respiratory arrest

Tachypnea (respiratory rate > 30/minute)
Minute ventilation greater than 10 L/min
Vital capacity < 1015 mL/kg
Acute lung injury and the acute respiratory distress syndrome
PaO2 < 55 mmHg with a supplemental fraction of inspired oxygen
PaCO2 > 50 mmHg with an arterial pH less than 7.25
Exhaustion and respiratory muscle fatigue
Neuromuscular diseases
Confusion or coma
Severe shock
Severe LVF
Raised ICP

Modes of invasive mechanical ventilation

Volume cycled mechanical ventilation
Delivers a preset volume (Vt) with each breath that is specified by the operator
Peak inspiratory pressures (PIP) generated by the ventilator are variable with
each breath depending on airway resistance or compliance
A pop off pressure is assigned to prevent excessive peak pressures that abort the
breath when that pressure limit is reached
The time that is takes to deliver the (Vt) is called inspiratory time (Ti) and is
also controlled by the operator

Dr. Ali Ragab

Assist control (AC)

The AC mode consists of two modes of ventilation
Assist mode, which allows a patient with spontaneous breathing efforts to
initiate the desired machine-delivered Vt
Control mode, which provides machine breaths without regard to the patients
pattern of breathing
During the control and assisted breaths, the Vt and inspiratory flow are
exactly the same
Advantages
Guaranteed Vt will be delivered
When patients are in synchrony with the ventilator, this mode allows for
minimal patient effort and rest for fatigued respiratory muscles
Disadvantage
The potential for induced respiratory alkalosis in patients with high
respiratory drive
Patient asynchrony and respiratory muscle fatigue can occurs
I:E ratio can vary because the variable respiratory rate (RR) can alter the
expiratory phase
Synchronized intermittent mandatory ventilation (SIMV)
SIMV consists of two types of ventilation
The 1st type of ventilation is identical to AC mode, and it provides machine
delivered Vt at a preset respiratory rate
The 2nd type of ventilation allows the patient to breathe spontaneously.
The volume and rate of these spontaneous breaths depend on the patients
respiratory drive, the level of pressure support applied and the mechanical
properties of the patients respiratory system

Dr. Ali Ragab

Advantages
Advantages include insured minimum minute ventilation
SIMV is designed to allow spontaneous breathing between ventilator breaths
The IMV breaths are synchronized with the patients spontaneous breaths so
that they do not stack on top of the patients spontaneous breaths
Disadvantages
The least beneficial mode for weaning
I:E ratio cannot be fully controlled due to the variability of RR
Does not provide the same degree of respiratory muscle rest as AC mode
Pressure cycled mechanical ventilation
Delivers a flow until a preset pressure limit is reached, a preset limit is set by
the operator
Peak inspiratory pressure (PIP) is the same for each breath
Vt is variable with each breath according to airway resistance and compliance
Pressure support ventilation (PSV)
When PSV mode detects that the patient is starting to inhale, it provides a
certain level of pressure to the inspiratory circuit
The inspiratory pressure stops when the ventilator detects that the inspiratory
flow has decreased to a certain level
Advantages
Augment the patients tidal volume
Unload the patients respiratory muscle

Dr. Ali Ragab

Disadvantages
Apnea backup breaths are infrequent and less responsive than the backup from
AC
Inadequate volume could be delivered if the ETT is blocked
Decreased lung compliance can cause preset pressure limit to stop inspiration
flow before an adequate volume is delivered
Asynchrony can occur due to high inspiratory pressure setting
Pressure control ventilation
Control breaths are delivered at a preset pressure limit and a preset time
RR and time to maximal pressure limit are both operator set
Spontaneous breaths can be interspersed between the mandatory breaths
Advantages
It limits PIP and Pplat to minimize barotraumas
It can control Ti for inverse ratio ventilation to increase mean airway
pressure and augment oxygenation
Disadvantages
It cannot ensure minimal minute ventilation with airway obstruction or
poor compliance
Sedation with or without paralysis is necessary for IRV

Dr. Ali Ragab

Bilevel ventilation
Also described as biphasic positive pressure ventilation (BiPAP)
This is a ventilatory mode where two levels of airway pressure are provided,
inspiratory positive airway pressure (IPAP) and expiratory positive
airway pressure (EPAP)
Cycling between the two pressure settings maximizes pressures during
inspiration and pressures during expiration
Cycling between these two levels of airway pressure may be time cycled or
triggered by ventilatory effort
Airway pressure release ventilation (APRV)
An extreme form of bilevel ventilation, maintaining a long period of high
pressure followed by a very short period of low pressure (the release)
This result in inverse I:E ratio of 8 to 9:1
It is a time triggered, pressure limited, time cycled mode that also allow the
patient to have spontaneous breathing
Advantages
Improve oxygenation in patient with severe ARDS
Decrease the frequency of opening and closing the alveoli
Disadvantages
High number of pneumothoraces in small studies
High frequency oscillation ventilation (HFOV)
A mode of ventilation that deliver a very small Vt (1-3 ml/kg) at a very high RR
(100-600/min)

Dr. Ali Ragab

Advantages
Improve oxygenation in patient with severe ARDS
May be beneficial in patients with bronchopleural fistula
Disadvantages

High risk of barotraumas

Hypotension due to high intrathoracic pressure
Need for sedation and paralysis
Limited ability to interrupt ventilation for suctioning
Significant worsening of oxygenation on moving the patient

Continuous positive airway pressure (CPAP)

CPAP is a mode of ventilation occurs when the inspiratory and expiratory limbs
are pressurized to a preset end expiratory pressure
The patient assumes most of work of breathing by generating his own RR, VT,
and inspiratory flow time
CPAP functions as
Improves oxygenation
Upper airway soft tissue opening
Weaning modality
Initial ventilator setup
Fraction of inspired oxygen (FiO2)
Supplemental oxygen is adjusted to target an SaO2 > 90% and/or PaO2 > 60
mmHg
Oxygen should not be withhold for any concern of CO2 narcosis on MV
O2 should not be withheld for concern of toxicity
It is believed that clinically significant O2 toxicity is unlikely to occur with FiO2
<0.6 even with prolonged delivery
Dr. Ali Ragab

Tidal volume
Vt is constant in volume cycled modes and varies with each breath in pressure
limited modes
In patient without lung disease Vt of 8mL/kg of ideal body weight is used
provided PPlat remains < 30 cmH2O
Lower tidal volumes of 6mL/kg are recommended for ARDS
Inflation pressure limit
High inflation pressures cause barotraumas
Increased Pplat (end inspiratory airway plateau pressure), rather than PIP, is
most injurious, reflecting alveolar overdistension and not airway resistance
No threshold is safe but Pplat 30 cmH2O is recommended
Use of sedation with or without paralytics can decrease dynamic
hyperinflation and allow for low Pplat
Respiratory rate
For SIMV and PC modes a rate of 12-20 breaths/min are reasonable
The AC rate is set below the patients spontaneous RR to minimize the risk of
respiratory muscle atrophy
Usually set RR in accordance with Vt to provide minute ventilation of 85100mL/kg/min
Sensitivity
Sensitivity is the amount of drop in airway pressure that is required before
the ventilator senses the patients effort and assists them during AC and
PS
Sensitivity of 0.5-1 cmH2O allows very weak patients to initiate a breath

Dr. Ali Ragab

When the patient is making an effort to breathe and the machine is not
triggering in assisted modes consider
The sensitivity value is too high and needs to be reduced or
AutoPEEP is present and the applied PEEP should be increased
Minute ventilation
Minute ventilation = RR VT
Normal individuals maintain normocapnea with a minute ventilation of 5L/min
Adjustment of minute ventilation is based on PaCO2 as a marker of
ventilatory requirements
Permissive hypercapnea in ARDS and status asthmaticus to minimize the risk
of barotraumas
Permissive hypercapnea is contraindicated in patients with increased ICP
Overventilating patients with chronic CO2 retension is to be avoided because it
can lead to post hypercapnic metabolic acidosis
High ventilatory requirements are present in hypermetabolic states where
excess CO2 production needs to be eliminated
Inspiratory flow rate
The ratio of Vt (liters) to inspiratory flow rate (liters/min) determines
inspiratory time (min)
Inspiratory flow rate usually set between 40 to 80 L/min
For volume cycled mode, higher inspiratory flow rate decreases inspiratory time
to allow for greater time for passive exhalation and reduce autoPEEP in
obstructive lung disease
Higher inspiratory flow rate increases PIP but should not affect Pplat
Too rapid lung inflation can cause deformation injury

Dr. Ali Ragab

In asthma and COPD the expiratory time needs to be prolonged to allow for
adequate exhalation of traped air, achieved by

Keep I:E ratio as low as possible

Increase minute ventilation
Short inspiratory time
High inspiratory flow rate

Positive end expiratory pressure (PEEP)

PEEP is the maintenance of +ve pressure after expiration flow is completed
until the next inspiratory flow is initiated
Applied PEEP distends airways down to the alveoli and improves
ventilation/perfusion matching
Intrinsic PEEP or auto PEEP (PEEPi) is the +ve pressure that occurs from
incomplete exhalation before the initiation of the next breath
PEEPi is detected on the flow versus time curve when the expiratory flow does
not return to the baseline before the next inhalation
Applied PEEP usually ranges between 0 and 20 cmH2O and usually adjusted up
or down in 2.5 to 5 cmH2O increments
In obstructive diseases, applied PEEP can decreases the effects of auto PEEP
in spontaneously breathing patient
Complications of excessive PEEP

Overdistension
Barotraumas
Hypotension from limiting venous return
Decrease in LV diastolic compliance due to lung hyperinflation compressing the
lateral cardiac walls

The lowest possible PEEP that promote adequate oxygenation is recommended

Dr. Ali Ragab

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Adjusting the ventilator

Low PaO2 considerations

Increase FiO2
Increase PEEP
Increase I:E ratio
Consider tolerating PaO2 (permissive hypoxia)
Consider increasing pressure support/pressure control or Vt
In CMV, consider increasing sedation muscle relaxant

High PaCO2 consideration

Consider tolerating high level (permissive hypercapnea)
Keep I:E ratio as low as possible
In CMV, consider increasing sedation muscle relaxant
Failure to tolerate ventilation
Agitation or fighting the ventilator may occur at any time
If paralyzed or heavily sedated, poor tolerance may be indicated by

Hypoxemia
Hypercapnea
Ventilator alarms
Cardiovascular instability

Dr. Ali Ragab

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The 1st priority is to assess the patient

Is the patient cyanosed?

Is the chest moving?
Are breath sounds present and equal?
Are there is abnormal breath sounds?
Has the SpO2 changed?

If clinical assessment indicates a serious problem, the 1st response is to

disconnect the ventilator and manually ventilate with 100% oxygen
Poor initial tolerance
Increase FiO2 to 100% and start manual ventilation
Check ETT is correctly positioned and both lungs are being inflated
Consider tube replacement, intra tracheal obstruction, pneumothorax or
bronchospasm
Check ventilator circuit is intact and patent
Check ventilator is functioning correctly
Check ventilator settings including FiO2, PEEP, I:E ratio, VT, RR and or
pressure control
Check pressure limit settings as it may be set too low causing ventilator to
cycle to expiration prematurely
Poor tolerance after previous good tolerance
If agitation occurs in a patient who has previously tolerated mechanical
ventilation, either the patients condition deteriorated, or there is a
problem in the ventilator circuit (including artificial airway) or the ventilator
itself
Resorting to increased sedation muscle relaxant is dangerous until the cause
is understood

Dr. Ali Ragab

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Management
Remove the patient from the ventilator and start manual ventilation with 100%
oxygen
Check patency of ETT (e.g. with a suction catheter) and re-intubate if in doubt
Treat changes in the patients condition

Bronchospasm
Sputum plug
Raised intra abdominal pressure
Tension pneumothorax
Pain
Pulmonary edema

Where patients are making spontaneous respiratory effort consider

increasing pressure support or adding mandatory breaths
If patients fail to synchronize with IMV by stacking spontaneous and
mandatory breaths increasing pressure support and reducing mandatory rate
may help. Use of pressure support ventilation may also appropriate
Low Vt or low pressure alarm
Expired Vt is lower than inspired VT with
Bronchopleural fistula
Leak in the ventilator circuit
The patient should be manually ventilated while the leak is indentified and corrected
It the leak persists with manual ventilation, repositioning or replacement of ETT is
required

Dr. Ali Ragab

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High pressure alarm

Sudden increase in airway pressure indicates a change in resistance to gas flow
After patient factors have been excluded

Check patency of ETT

Re intubate if in doubt
Check patency of ventilator circuit
Look for excessive trapped water
Consider chest x-rays to identify ETT malposition (e.g. tube in main bronchus)

Mechanical ventilation discontinuation

Reversible causes of prolonged mechanical ventilation
Inadequate respiratory drive due to

Nutritional deficiencies
Sedatives
CNS abnormalities
Sleep deprivation

Respiratory muscle fatigue or weakness due to

CNS or neuromuscular diseases

Active inflammatory process (e.g. sepsis)
Nutritional and metabolic deficiency
Medications (e.g. corticosteroids)
Chronic renal failure
Intrinsic lung disease or extravascular lung water
Chest wall disorders
Cardiovascular failure
Hypoxia and hypercapnea

Psychological dependency

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Common weaning criteria

Clinical criteria

Resolution of acute phase of the disease

Adequate cough
Absence of excessive secretions
Cardiovascular and hemodynamic stability

Ventilatory criteria
Spontaneous breathing trial tolerates 20 to 30 minutes
PaCO2 < 50 mmHg with normal pH
Vital capacity > 10 mL/kg
Spontaneous Vt > 5 mL/kg
Spontaneous frequency < 35/min
Frequency/VT (rapid shallow breathing test) < 105 breaths/min/L, rapid
shallow breathing test should be measured while the patient is breathing
spontaneously and averaged over 1 minute
Minute ventilation < 10 L with satisfactory ABG

Oxygenation criteria

PaO2 > 60 mmHg (without PEEP) at FiO2 up to 0.4

PaO2 > 100 mmHg (with PEEP < 8 cmH2O) at FiO2 up to 0.4
SaO2 > 90% at FiO2 up to 0.4
PaO2/FiO2 250

Pulmonary reserve
Vital capacity > 10 mL/kg
Maximum inspiratory pressure > 30 cmH2O

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Weaning procedure
Spontaneous breathing trial (SBT)
May use T-tube, CPAP, or automatic tube compensation
Let patient breathe spontaneously for up to 30 minutes
May use low level pressure support (up to 8 cmH2O) to augment
spontaneous breathing
If patient tolerates, consider extubation when blood gas and vital signs are
satisfactory
Return patient to mechanical ventilation to rest if necessary
Only one SBT is recommended in a 24-hour period
SIMV
Not recommended as a stand-alone mode for weaning
Reduce SIMV (ventilator) frequency by 1 to 3 breaths per minute
Monitor SpO2 and obtain ABG as needed
Reduce SIMV frequency further until a frequency of 2 to 4/min is reached.
This may take only hours for patients with normal cardiopulmonary functions
but days for those with abnormal functions
If patient tolerates, consider extubation when blood gases and vital signs are
satisfactory

Pressure support ventilation (PSV)

Start PSV at a level of 5 to 15 cmH2O (up to 40 cmH2O) to augment
spontaneous Vt or spontaneous frequency 25/min is reached
Decrease PS by 3 to 6 cmH2O intervals until a level close to 5 cmH2O
If patient tolerates, consider extubation when blood gases and vital signs are
satisfactory

Dr. Ali Ragab

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When to extubate
Most patients who have well-tolerated SBT lasting 30 to 120 minutes can be
considered for extubation
General criteria for extubation

Rapid shallow breathing index < 105/min/L

Acceptable blood gases on FiO2 less than 0.4
Spontaneous minute ventilation < 10 L/min
PaO2/FiO2 250 mmHg
Maximal inspiratory pressure > 20 cmH2O
Vital capacity > 15 mL/kg
Infrequent need for suctioning (> 4 hours)
Adequate cough reflex
Absence of cardiopulmonary problems (e.g. CHF, pulmonary edema,
pneumonia, tachycardia, arrhythmia and chest retractions)

Pretreating patients at high risk for post extubation upper respiratory tract
obstruction
40 mg methylprednisolone 4 hours before extubation or
20 mg methylprednisolone every 4 to 6 hours 12 to 24 hours before
extubation
Clinical predictors for reintubation

SIMV or AC frequency > 6/min (patient is dependent on the ventilator)

Most recent pH 7.45 (oxyhemoglobin saturation curve shifts to left)
Most recent PaO2/FiO2 < 250 (poor oxygenation status)
Cough peak flow < 60 L/min (inability to protect airway and clear secretions)

Dr. Ali Ragab

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Managing discontinuation failure

Interventions to increase respiratory muscle strength

Reverse malnutrition
Correct electrolytes abnormalities
Correct hypoxemia
Correct chronic hypercapnea during MV
Reverse hypothyroidism
Maximize cardiovascular functions
Minimize sedation unless anxiety is overwhelming
Consider the use of progesterone 20 mg TID as a respiratory centre
stimulant in patients with few or no spontaneous breaths when off sedation
Treat sleep deprivation and central fatigue with short acting sedatives at night
Improve diaphragmatic functions by sitting the patient up during weaning
Mobilize patient as tolerated with early physical therapy
Consider theophylline to stimulate the respiratory centre and augment
diaphragmatic contractions

Dr. Ali Ragab

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Interventions to decrease respiratory muscle demand

Maximize treatment of systemic diseases to decrease metabolic requirements
Prescribe bronchodilators and discontinue beta blockers for increased airway
resistance
Give a course of systemic corticosteroids in exacerbation of COPD and asthma
Prescribe diuretics to reduce pulmonary edema and states of fluid overload
Routinely evaluate and treat cardiac dysfunction including myocardial ischemia
Consider replacing ETT with a larger one ( 8 mm internal diameter)
Add CPAP for marginal cardiac function to decrease LV preload
Determine whether the ventilator is increasing work of breathing, whether the
sensitivity or trigger threshold is appropriate, and whether the inspiratory flow
rate matches patient demand
Avoid hyperinflation; apply extrinsic PEEP in the presence of inspiratory
triggering threshold load from intrinsic PEEP
Evaluate overfeeding causing increased CO2 production in chronic hypercapnic
patient and the need for increased alveolar ventilation to remove this excess
product of metabolism, overfeeding may precipitate respiratory acidosis and
ongoing respiratory muscle fatigue

Dr. Ali Ragab

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