Ventilation of the Critically ill

Simon Giles Consultant Nurse in Critical Care Heart of England NHS Trust
Simon Giles

Simon Giles

Objectives

Review the Basic Anatomy & Physiology of Respiratory System Understand reasons Artificial Ventilation Review modes & specific strategies used in ventilating the Critically Ill Discuss specific conditions in the Critically Ill patient Be aware of possible complications
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Basic Anatomy

Upper Airway

humidifies inhaled gases site of most resistance to airflow conducting airways (anatomic dead space) respiratory bronchioles and alveoli (gas exchange)

Lower Airway

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Basic Physiology

Simon Giles http://www.biology.eku.edu/RITCHISO/301notes6.htm

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Physiology of Respiration

Ventilation

Movement of air between the alveoli and atmosphere Movement of CO2 and O2 between alveoli and capillaries Movement of O2 from the alveoli to the cells Movement of CO2 from the cells to the alveoli

Diffusion

Transport

Hypoxemia can be due to: hypoventilation V/Q mismatch shunt diffusion impairments

Abnormal Gas Exchange

Hypercarbia can be due to: hypoventilation V/Q mismatch

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RAPHAEL

GALILEO

VOELAR

ventiPAC 200D TRANSFER VENTILATOR

HAMILTON G5

Mechanical Ventilation
Ventilators deliver gas to the lungs using positive pressure at a certain rate. The amount of gas delivered can be limited by time, pressure or volume. The duration can be cycled by time, pressure or flow.
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Surgical: Post-operative support, supporting other organs failure.

Respiratory centre depression: Head injury raised intracranial pressure. Hypercapnia. Drug toxicity. Meningitis, tumours, epilepsy.
Lung Disease: ARDS (acute respiratory distress syndrome), pneumonia, acute asthma, COPD (chronic obstructive pulmonary disease). Aspiration, drowning, smoke inhalation, chemical attack e.g. anthrax, biological e.g. bird flu, legionella. Circulatory: Cardiac arrest, pulmonary oedema, shock, sepsis. Trauma: Cervical cord trauma above C4, neck fractures, facial injury, major blood loss. Neuromuscular disorders: Guillian-Barre, myasthenia gravis, poliomyelitis. Chest wall disorders: traumatic flail segment, mesothelioma. Other factors: Poor nutrition leading to muscle weakness. Abdominal distension/pain which squashes the diaphragm . Low GCS ( Glasgow Coma Scale).

The most commonly used in the ITU setting an ET (Endo-Tracheal) tube. For patient on a ventilator for longer than 7-10 days a tracheotomy is performed, as this helps with the patients weaning, its more comfortable for the patient and less dead space reducing the work of breathing for the patient, and easier for the patient to communicate (Orlando, 2007c). For short term ventilation for an operation or in an emergency, LMA (Laryngeal Mask Airway) may be used. (Leach,et al, 2004). For non invasive ventilation a tight fitting face mask is used (Leach,et al, 2004).

Video on Endotracheal Ventilation , (Bmedinago, May 2007) <http://uk.youtube.com/watch?v=cLL6XwhFEFQ>

PRESSURE BASED In a pressure-cycled ventilator, once a pre-set

pressure is reached within the ventilator, the breath is terminated and positive pressure cycle completed. (Cited from Wikimedia, 2008)

VOLUME BASED In a volume-cycled ventilator the ventilator delivers a pre-set

volume of gas with each breath to the patient as soon as the specified volume of breath is delivered, the positive pressure cycle is completed. (Cited from Wikimedia, 2008)

P-CMV (Pressure Controlled Mandatory Ventilation). Does Not allow the patient to breath and doesnt support any spontaneous efforts(Wikimedia, 2008). P-SIMV (Pressure controlled Synchronised Intermittent Mandatory Ventilation). Allows the patient to breathe synchronising with them providing some support limiting the pressure(Wikimedia, 2008). PSV/SPONT(Pressure Support Ventilation). No Set Rate used with PEEP and a set pressure , supporting the patients own respiratory pattern (Orlando, 2007c).

(S) CMV (Synchronised volume controlled Mandatory Ventilation). Does Not allow the patient to breath and doesnt support any spontaneous efforts (Hamilton, 2007). SIMV (Synchronised Intermittent Mandatory Ventilation) Allows the patient to breathe providing some support but delivers a set volume (Wikimedia, 2008)

ADAPTIVE INTELIGENT MODES

These modes provide the advantages of both pressure based modes whilst still offering a volume guarantee Allows spontaneous breathing adjusting the support required to reach the targeted volume(Hamilton, 2007).

BI-PHASIC MODES

These modes allow the patient to breath spontaneously at any time, even when the ventilator is delivering a mandatory breath. (Hamilton, 2007).

APV (cmv) (Adaptive Pressure Ventilation with pressure controlled mandatory ventilation). Targets a specified volume to be delivered. Automatic regulation in inspired pressure and flow (Hamilton, 2007). APV (simv) (Adaptive Pressure Ventilation with synchronised intermittent mandatory ventilation). Same as above. ASV (Adaptive Support Ventilation). Closed loop control ventilation system ASV responds to and adapt to the patients own spontaneous breathing pattern. Reduces the work of breathing. Patients height measured to calculate ideal body weight. Reduces weaning time (Hamilton, 2006a).

Duo PAP (Dual Positive Airway Pressure). You have to set the Rate and high airway pressure. All other advantages same as APRV (Hamilton, 2007). APRV(Airway Pressure Release Ventilation). The ventilator cycles from high CPAP to low CPAP (high lung pressure/volume to low lung pressure/volume). Allows the patient to breathe supported or un supported . Used usually for patients with severe ARDS (Neligan, 2006)

SIMV, volume-limited

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical Care Simon Giles

Pressure vs. Volume

Pressure Limited

Control FiO2 and MAP

(oxygenation)

Still can influence ventilation somewhat

(respiratory rate, PAP)

Decelerating flow pattern (lower PIP for

same TV)

Volume Limited Control minute ventilation Still can influence oxygenation somewhat (FiO2, PEEP, I-time) Square wave flow pattern

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Pressure vs. Volume

Pressure Pitfalls

tidal volume by change suddenly as patients compliance changes this can lead to hypoventilation or overexpansion of the lung if ETT is obstructed acutely, delivered tidal volume will decrease
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Volume Vitriol

no limit per se on PIP (usually vent will have upper pressure limit) square wave(constant) flow pattern results in higher PIP for same tidal volume as compared to Pressure modes

Trigger

How does the vent know when to give a breath? - Trigger patient effort elapsed time
The patients effort can be sensed as a change in pressure or a change in flow (in the circuit)
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Need a hand??
Pressure Support Triggering vent requires certain amount of

work by patient Can decrease work of breathing by providing flow during inspiration for patient triggered breaths Can be given with spontaneous breaths in IMV modes or as stand alone mode without set rate Flow-cycled
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TERMINOLOGY OF VENTILATION

FREQUENCY : BREATH RATE TV : TIDAL VOLUME IN SINGLE BREATH MV : MINUTE VOLUME (TV x BR) I:E RATIO : INSPIRATORY/EXPIRATORY RATIO PEAK PRESSURE : HIGHEST PRESSURE ON INSPIRATION PEEP : POSITVE END EXPIRATORY PRESSURE CPAP : CONTIUOUS POSITIVE AIRWAY PRESSURE FIO2 : FRACTIONAL INSPIRED OXYGEN

Initial Settings

Pressure Limited

Volume Limited

FiO2 Rate I-time or I:E ratio PEEP PIP or PAP

FiO2 Rate I-time or I:E ratio PEEP Tidal Volume

These choices are with time - cycled ventilators. Flow cycled vents are available but not commonly used in pediatrics.
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TROUBLE SHOOTING : LOW OXYGENATION

INCREASE FIO2 CHECK TV SUCTION PATIENT IF NEEDED INCREASE PEEP CHANGE I:E RATIO CHECK SEDATION

TROUBLE SHOOTING : LOW OXYGENATION

INCREASE FIO2 CHECK TV SUCTION PATIENT IF NEEDED INCREASE PEEP CHANGE I:E RATIO CHECK SEDATION

TROUBLE SHOOTING: HIGH CARBON DIOXIDE

INCREASE RESPIRATORY RATE CHANGE I:E RATIO CHECK SEDATION CHECK TIDAL VOLUMES CHECK MINUTE VOLUMES

Except...

Is it really that simple ?

Increasing PEEP can increase dead space, decrease cardiac output, increase V/Q mismatch Increasing the respiratory rate can lead to dynamic hyperinflation (aka autoPEEP), resulting in worsening oxygenation and ventilation

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Troubleshooting

Is it working ?
Look

at the patient !! Listen to the patient !!

Pulse

Ox, ABG, EtCO2 Chest X ray Look at the vent (PIP; expired TV; alarms)
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Troubleshooting

When in doubt, DISCONNECT THE PATIENT FROM THE VENT, and begin bag ventilation. Ensure you are bagging with 100% O2. This eliminates the vent circuit as the source of the problem. Bagging by hand can also help you gauge patients compliance
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Airway first: is the tube still in? (may need Breathing next: is the chest rising? Breath

Troubleshooting

DL/EtCO2 to confirm) Is it patent? Is it in the right position?

sounds present and equal? Changes in exam? Atelectasis, bronchospasm, pneumothorax, pneumonia? (Consider needle thoracentesis)

Circulation: shock? Sepsis?

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Troubleshooting

Well, it isnt working..

Right settings ? Right Mode ? Does the vent need to do more work ?
Patient unable to do so Underlying process worsening (or new problem?)

Air leaks? Does the patient need to be more sedated ? Does the patient need to be extubated ? Vent is only human..(is it working ?)
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Troubleshooting

Patient - Ventilator Interaction

Vent

must recognize patients respiratory efforts (trigger) must be able to meet patients demands (response) must not interfere with patients efforts (synchrony)
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Vent

Vent

Troubleshooting

Improving Ventilation and/or Oxygenation

can increase respiratory rate (or decrease rate if air trapping is an issue) can increase tidal volume/PAP to increase tidal volume can increase PEEP to help recruit collapsed areas can increase pressure support and/or decrease sedation to improve patients spontaneous effort
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Difficult Clinical conditions to Ventilate

ARDS

Rule of 1/3

Thoracic Surgical

BPF One lung

Complex Pneumonia

INJURED ALVEOLI OF ARDS PATIENT DURING ACUTE PHASE.

Pictures from Module 2 ARDS lecture Given by: Nurse Consultant, Simon Giles.(October, 2007).

FIBROTIC/RECOVERY PHASE.

HEALTHY ALVEOLI.
The three pictures of the alveoli show the different phases they go through in an ARDS patient. It is beyond the scope of this teaching tool to go into in-depth anatomy and physiology, but it is hoped that this gives the reader a brief glimpse, leading to further reading, improving knowledge. The author found these very useful in Understanding ARDS.

Lowered Expectations

Permissive Hypercapnia

accept higher PaCO2s in exchange for limiting peak airway pressures can titrate pH as desired with sodium bicarbonate or other buffer

Permissive Hypoxemia

accept PaO2 of 55-65; SaO2 88-90% in exchange for limiting FiO2 (<.60) and PEEP can maintain oxygen content by keeping hematocrit > 30%
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Complications

Ventilator Induced Lung Injury

Oxygen

toxicity Barotrauma / Volutrauma Peak Pressure Plateau Pressure Shear Injury (tidal volume) PEEP
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Complications

Cardiovascular Complications

Impaired venous return to RH Bowing of the Interventricular Septum Decreased left sided afterload (good) Altered right sided afterload

Sum Effect..decreased cardiac output

(usually, not always and often we dont even notice)

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Complications

Other Complications
Ventilator

Associated Pneumonia

Sinusitis
Sedation Risks

from associated devices (CVLs, A-lines) Unplanned Extubation

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Long Term Complications

Airway
Stenosis ETT Cuff / Tracheostomy Mouth / lips - erosions

Lung

Fibrosis (ARDS)

General

Critical Illness ( neuropathy )

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To Wind Up

Whistle top tour of A&P Ventilation of the Critically Ill is Often Complex Modern Machines have many different modes for difficult ventilation Positive Pressure Ventilation is harmful to lung tissue and does not cure patient