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Pressure
Constant Volume
Control Control
Outline
• What is the question?
• Ventilation Physiology
• Asthma Pathology
• Data on Decelerating Flow
• If you have to ventilate…the preferred
approach
Ventilation Myths
• Increasingly Complex (Marketing directors)
• Host of New “Toys”
• New Modes: Do Not Describe Functionality
• Different Ventilator Manufacturers
– Similar modes = different functions
– Cute names that mean nothing
– Don’t say what they do
– Measures are inaccurate
Key Functionality of Ventilators
• Flow Pattern
– Gas Flow Delivered & Distribution During Inspiration
– Decelerating or Constant
• Limit
– Safety: Prevents the Ventilator from Exceeding Preset limit
– Volume or Pressure
• Cycle
– When Inspiration Ends
• Trigger
– How the Breath is Initiated
• Breath Type
– Single or Mixed
Effects of Flow Pattern on Airway
Pressures
Decelerating Square
Flow
(l/sec)
PIP
(cm H2O)
Pressure
Constant Volume
Control Control
Outline
• What is the question?
• Ventilation Physiology
• Asthma Pathopsiology
• Data on Decelerating Flow
• If you have to ventilate…the preferred
approach
Pathophysiology of Asthma
• Marked increased airways resistance
• Prolonged Time Constant
• TC = Resistance x Compliance
Retained Gas
Results in PEEPi
Beginning Termination
of of Premature
Exhalation Exhalation Termination of
Exhalation
Intrinsic PEEP/Dynamic Hyperinflation
• Expiratory gas flow continues at the
end of the time allotted for exhalation.
• PEEPi may lead to excessive MAP.
– Pulmonary effects:
• Barotrauma
– Cardiac effects:
• Impedance of venous return
• Decreased cardiac output
Systemic Venous Return
(RV Preload)
PSV RAP = mean systemic venous pressure
PPV increases
right atrial pressure
Right Atrial
Pressure spontaneous
breathing
0
0 Max
Systemic Venous Return
Effect of Lung Volume on PVR
Overexpansion
DHI
PVR Atelectasis
Total PVR
Small Vessels
Large Vessels
FRC
Lung Volume
Overdistention and C.O.
1000
950
PEEP 5 PEEP 10
900
Cardiac 850
Output 800
750
(mL/min) 700
650
600
550
500
10 15 20
Cheifetz: CCM 1998 Tidal Volume (mL/kg)
Outline
• What is the question?
• Ventilation Physiology
• Asthma Pathology
• Data on Decelerating Flow
• If you have to ventilate…the
preferred approach
Decelerating Flow in Asthma
• Pressure controlled ventilation in severe asthma.
Lopez Pediatr Pulmonol 1996;21:401
• Pressure-support ventilation in children with severe
asthma. Wetzel Crit Care Med 1996;24:1603-1605.
• Refractory asthma, part 2: airway interventions and
management. Jagoda A. Ann Emerg Med. 1997;29:275-
281
• Mechanical ventilation for children with status
asthmaticus. Sabato K, Hanson JH. Respir Care Clin
North Am. 2000;6:171-188.
• Decelerating Flow in 51 Pediatric Asthma Patients
Decelerating Flow in Asthma
• Hypothesis:
• VCV with constant flow distributes more
volume to the less obstructed airways with
shorter TC and less volume to longer TC.
• Uneven Ventilation, Hyperexpansion of “normal
lung” under-ventilation of obstructed units
• Elevated PIP and higher airways resistance
• Decreased Compliance
• High resistance, short IT = Premature
termination of breath and set VT not achieved
Decelerating Flow in Asthma
• Decelerating flow
• Flow varies;
• High at first (overcomes high resistance) to
achieve set pressure early in inspiration
• Lower later in inspiration to maintain this
pressure through the inspiratory time.
Decelerating Flow in Asthma
• Decelerating flow
• Provides a relatively constant inflation pressure:
• Large airways fill with peak flow, smaller airways
with slower flow
• Lung units with short TC attain final volume early
• Lung units with long TC continue to receive
volume later in inspiration
• Pressure equilibrium more even ventilation
• Lower Pplat or better ventilation for same PIP
• Increased Compliance
Decelerating Flow in 51
Pediatric Asthma Patients
Sarnaik, PCCM 2004
pH
VCV PCV
Mode of Ventilation
Decelerating Flow in 51
Pediatric Asthma Patients
PaCO2
VCV PCV
Mode of Ventilation
Decelerating Flow in 51
Pediatric Asthma Patients
• In Pts with PCO2>45, median time to
reversal was 5 hrs
• SaO2 >95% in all patients
• 2 pts with Pneumos pre PCV
• 1 pts developed pneumothorax, 1 pt subq
emphesema; all well tolerated and resolved
• 100% survival
• 100% neuro intact
• Median ventilation 4-107 hrs.
Adults Agree!
Decelerating flow not just for kids!
• Measurement of air trapping, PEEPI and DHI in
mechanically ventilated patients. Blanch Respir Care.
2005;50:110-124.
• Clinical Review: Severe Asthma Papiris Critical Care
2002;6:30-44.
• Lung Protective Strategies for Acute Severe Asthma.
Brown. J of Resp Care Pract. 2002;2
• Refractory asthma, part 2: airway interventions and
management. Jagoda Ann Emerg Med. 1997;29:275-281.
• Mechanical ventilation for children with status
Outline
• What is the question?
• Ventilation Physiology
• Asthma Pathology
• Data on Decelerating Flow
• If you have to ventilate…the
preferred approach
Ventilation Approach
• Get the gas out…Limit lung injury!
• A volume/minute ventilation
“measurement / guarantee” during
decelerating flow is preferred