Mechanical Ventilation

MECHANICAL VENTILATION DEFINITIONS

• Ventilation: Movement of Air Into and
DEFINITIONS
Out of the Lung (Breathing)
MODES
COMPLICATIONS
SCENARIOS • Respiration: Extraction of Oxygen
from Inspired Air and Release of
Duke University School of Medicine Carbon Dioxide (Gas Exchange)
Surgical Intensive Care Unit Elective Rotations

PURPOSE OF VENTILATION MECHANICAL VENTILATION

• Provide Adequate Oxygen (O2) to
Meet Metabolic Requirements
• Remove Waste Product of
Metabolism: Carbon Dioxide(CO2)
• Provides Adequate Fresh Gas to Ventilate
• Provides Supplemental Oxygen
• Recruits Collapsed Alveoli to Support Respiration
• Increases Functional Residual Capacity (FRC)
• Assists or Assumes Breathing
• During Recovery From Anesthesia
• During Chemical Paralysis
• In Patients With Diminished Pulmonary Reserve
• During Recovery From Traumatic Injury
• Chest Injury With Pulmonary Contusion

MODES OF VENTILATION CYCLES

• Classified by the Amount of Work Assumed • Volume Cycled: Inspiration ends when preset
by the Ventilator tidal volume has been delivered
• Control or Assist Control • Pressure Cycled: Inspiration ends when preset
• Classified by the Target Used to End inspiratory pressure has been reached
Inspiratory Phase of Each Delivered Breath • Time Cycled: Inspiration ends when preset
• Volume inspiratory time has elapsed
• Pressure • Flow Cycled: Inspiration ends when a preset
• Time inspiratory (terminal) flow is reached

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VOLUME TARGETED
PRESSURE TARGETED VENTILATION
VENTILATION
• Set Tidal Volume (TV) • Constant Inspiratory Pressure
• Inspiratory Cycle Ends When TV Delivered • Tidal Volume Becomes Variable
• Ventilator Generates Sufficient Pressure to • Affected by Airway Resistance, Lung Compliance,
Deliver Set Volume Patient Effort
• Independent of Airway Resistance
• Causes of Decreased Tidal Volume
• Independent of Lung Compliance
• Increased Resistance
• High-Pressure Limit Alarm
• Decreased Compliance
• Limited Current Use
• Decreased Patient Effort
• Alveolar Stretch Injury
• Low minute ventilation alarm

PRESSURE SUPPORT VENTILATION COMPARISON

Volume Target Pressure Target Pressure Target
(Volume A/C) (Pressure A/C) (PS)
• Pressure Target Mode Trigger Patient or Time Patient or Time Patient
• No Set Respiratory Rate Tidal Volume Guaranteed Variable Variable
• Inspiration Inspiratory Flow Fixed High then taper High then taper
• Patient Triggered Cycle Volume Time Flow taper
• Ends When Flow Falls to Preset Level Advantage Guaranteed Vt Rapid gas mixing Rapid gas mixing
Assist synchrony Assist synchrony
• Excellent Weaning Mode Disadvantage Possible No guaranteed Vt No guaranteed Vt
dyssynchrony
• Gradual Reduction in Ventilatory Support
• Sensitive, Highly Adjustable
• More Comfortable
• Less Sedation

TIDAL VOLUME (Vt)
• Volume of Gas Inspired and Expired in
One Breath
• Normal: 5-8 cc/kg of Ideal Body Weight
• 70 kg patient: 350-560 cc Tidal Volume
• Ventilated Patient: Need 5-7 cc/kg
RESPIRATORY RATE
• Number of Breaths Per Minute (BPM)
• Trigger: Factor that begins inspiratory phase
• Controlled Breaths
• Triggered by Ventilator
• Determined by Set Rate
• Ten BPM Setting: Breath is Triggered
Every 6 Seconds
• Assisted Breaths: Triggered by Patient Effort
• Ventilator Sensitivity Adjusted
• Avoid Insignificant Patient Effort Triggering a
Delivered Breath

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CHANGE PCO2 INCREASE PO2

• Alter Minute Ventilation • Increase Fio2
• Respiratory rate
• Increase Mean Airway Pressure (Paw)
• Tidal volume
• Permissive Hypercapnia • Paw: Average Pressure Created Within
• Used In Non-Compliant Lungs (ARDS) the Lung Over One Minute
• Non-Heterogeneous Process • Paw Increased By
• Avoidance of Barotrauma and Volutrauma to Unaffected
Regions • Increases in PEEP
• Maintain pH > 7.25 • Increases Inspiratory time
• Proper Physiologic Milieu
• HCO3 if necessary

END-EXPIRATORY PRESSURE PEAK INSPIRATORY PRESSURE (PIP)

• Baseline Pressure: Pressure in • PIP: Pressure at end of active inspiration

patient/ventilator circuit at end-expiration
• PEEP: Positive end expiratory pressure
• Ubiquitous
• ZEEP: Zero end expiratory pressure
• NEEP: Negative end expiratory pressure
necessary to overcome airway resistance
(flow resistance) and lung compliance
(tissue resistance)
• Airway resistance can increase work of
breathing
• PIP reflects both airway tone and lung
stiffness - increased by bronchospasm
and/or atelectasis

PLATEAU PRESSURE USES OF MECHANICAL VENTILATION

• Pressure required to overcome tissue resistance

and inflate alveoli • Hypoxia
• Measured via 2 second pause at end inspiration • Airway Protection
• Gas flow ceases • Respiratory Assistance
• Static pressure measurement • “Control the Organism”
• General measurement of lung stiffness • Offer Support in Extremis
• Minimize Energy Expenditure

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SYSTEMATIC RESPONSE TO HYPOXIA

HYPOXIA: DIFFERENTIAL DIAGNOSIS • Turn FiO2 to 100%
• Take Patient OFF Ventilator
• Hypoventilation • Bag the Patient on FiO2 100%
• V/Q Mismatch:
• Bronchospasm • Rapid Assessment ABC From “Patient to
• Increased Secretions Wall”
• Alveolar Edema (Hyaline Membranes on Histology
• Endotracheal Tube: Position, Patency
• Right to Left Cardiac Shunt
• Blood flows past non-ventilated alveoli • Auscultate: Rule Out Tension Pneumothorax
• Not amenable to increasing inspired oxygen fraction • Ventilator: Circuit, Functional State, Oxygen
• Atelectasis
• Lung Consolidation
• Pulmonary Edema

SYSTEMATIC RESPONSE TO HYPOXIA

• Arterial Blood Gas INVERSE RATIO VENTILATION (IRV)
• Portable CXR
• With No Other Proximate Cause, Adjust • Normal I:E ratio 1:2
• 10 Breaths Per Minute
Ventilator Settings
• Two seconds for inspiration
• Maintain 100% FiO2 • Four seconds for expiration
• Increase Mean Airway Pressure • Expiration is passive
• Increase Inspiratory Time • Time for chest wall relaxation
• Chemically paralyze patient • Heavy sedation required to tolerate IRV
• Paralysis to ablate patient interaction with ventilator
• Avoid dysynchrony
• Avoid gas retention (“Auto” PEEP)

IATROGENIC LUNG INJURY

HIGH LEVELS OF PEEP AND IRV
• Increased intrathoracic pressure
• Decreased venous return and impaired
cardiac output
• Difficult assessment of volume status
• PA Catheter to guide fluid management
• Both Barotrauma and Volutrauma
• “Stretch-induced” acute lung injury resembles
ARDS
• Pneumothorax
• Mediastinal and subcutaneous emphysema
• Pneumocyte and Endothelial cell damage
• Pulmonary edema
• Minimization of injury with PEEP
• Alveolar recruitment
• Decreased shear force to alveoli

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NON-CONVENTIONAL MECHANICAL
VENTILATION
HIGH FREQUENCY VENTILATION (HFV)
• Inhaled Nitric oxide
• Local vasodilatation
• Doses in parts per million
• Active in non-collapsed alveolar capillaries • Three Major Types
• Gas gets to vessels • High frequency positive pressure ventilation
• Prone positioning (HFPPV)
• ARDS is heterogeneous • High frequency jet ventilation (HFJV)
• Responders and non-responders by CT • High frequency oscillation (HFO)
• Efficacy within first hour
• Turn every 12 hours
• Requires high degree of coordination in ICU
• High frequency ventilation (HFV)

COMPARISON OF HFV COMPLICATIONS OF HFV

F Inspiration Expiration
(breaths/min) • HFPPV and HFJV
CV 2- 40 Active Passive • Air trapping, overdistension and circulatory
depression secondary to passive expiration
HFPPV ~60-100 Active Passive
• Uncommon with HFO
HFJV ~100-200 Active Passive • Active expiration
HFO UP TO Active Active
~2400

HIGH FREQUENCY OSCILLATION BASIC HFO PARAMETERS

• Small tidal volume at very high rates • Set frequency (5hz)
Frequency: 1-15 Hz • I:E ratio (1:3)
• Limits lung stretch • FiO2 100%
• Usually maintains normal pCO2 • Mean Airway Pressure: VACV mean +
• Improved lung integrity 5cm H20
• Improved pulmonary function • Flow rate: VACV Minute Ventilation x 3
• Less inflammation • ABG in 20 minutes

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Patient #1-History
• 73 year old 80 kg male with 6cm infrarenal
SICU POSTOPERATIVE AAA
• PMH: HTN, COPD, DM, Afib,
SCENARIOS • Creatinine: 2.3 baseline
• NKDA
• Medications: toprol, lanoxin, flovent,
serevent, combivent and prozac
• CXR: NAD
• Hct 44

Patient #1 OR Course Patient #1-SICU Arrival Data

• Uncomplicated AAA repair with bifurcated graft
• 3 hours combined GA/thoracic epidural
• 750 ucg fentanyl, 1mg midazolam/12.5mg
bupivacaine
• Paralyzed/reversed
• EBL 750cc UO 450cc
• Colloid 1500cc crystalloid 4000cc
• Stable hemodynamics
• Last ABG intraop base excess -4 (7.35/38)
• Extubated
• BP 149/59, P 100, temp 35.8, RR 10
• ABG 7.19/63/176/23/-5/97% Hct 26 K 4.9
• Short time later pt with PVC’s, EKG with
ischemia
• Stimulated, epidural infusion held
• Resuscitation with blood, colloid
• 4 hours later 7.24/60/80/25/-2 95.3%

Patient #2-History Patient #2-OR Course

• 74 year old, 71kg female with PMH: HTN, • Pancreaticoduodenectomy (Whipple)
pancreatic adenocarcinoma • 6 hour case, GA
• PMH: DM, preop chemo with 5FU • 750 ucg fentanyl, 2mg midazolam
• Paralyzed/reversed
• Meds: insulin, prilosec, roxicet, compazine
• EBL 900cc, UO 2100 cc
• CXR: NAD, EKG: NSR rate 70s • Intraoperative Fluids:
• Colloid 1000cc
• Crystalloid 5000cc
• 2 hours prior to end of case: ABG BE -2 HCT 32 (7.44/36)

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Patient #2-SICU Arrival Data POTENTIAL COMPLICATIONS OF

EARLY EXTUBATION
• Extubated
• BP 83/39, RR 12, P 66, Temp 37 • Respiratory failure
• ABG 7.14/77/152/25/-5/95.7% • Hypoxia
• Hct 28 k3.9 • Hypercapnia
• Pt without respiratory drive • Hypotension
• Hypotensive • Arrhythmias
• Reintubated on arrival • Ischemia

CONTINUED INTUBATION GUIDELINES

TO EXTUBATE OR NOT TO EXTUBATE
• Known SICU Destination
• No advantage to early (OR) Extubation
• Unless standard extubation criteria are met in OR
• No Metabolic Acidosis (Base Excess –3 or Less)
• Fully Reversed Neuromuscular Blockade
• ABC: Verification via Blood Gas
• Airway and Breathing: Mental Status
• SICU Allows for Controlled Emergence From Anesthesia
• Verification of Neuromuscular Blockade Reversal
• Stable Environment
• Any Transport is a Risk
FOR SICU ADMISSION
• Hemodynamically unstable (SBP<100 or >180, HR<60 or >120)
• New onset arrhythmias
• Vasopressors within last 60 minutes of case
• Intraoperative cardiac arrest
• Intraoperative blood loss > 4-6 units
• Continued transfusion requirements or Hct < 26
• Total fluid resuscitation > 8 liters or 10 liters including blood products
• New onset or progressive metabolic acidosis
• Hypothermia <35 degrees Celsius
• Uncertainty with regard to adequacy of fluid resuscitation
• FiO2 greater than 50% (paO2<70)
• SICU arrival after 8pm
• Any question/concern of patient’s status

SUMMARY
• Conventional ventilation may contribute to ARDS
• Avoid volutrauma and barotrauma
• Hypoxia:
• Increase FiO2 to 100%
• Bag the Patient
• Then find out why
• Consider HFV for treatment of refractory hypoxemia
• SICU destination:
• Leave intubated unless stable milieu

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