ADULT VENTILATION

Doug McIntyre, BA, RRT

GOALS of ADULT VENTILATION

~ Provide ventilation when breathing is ineffective ~ Buy time to correct underlying cardiopulmonary complications ~ Mechanical ventilation is not a cure

Goals of Support Ventilation

~ Alveolar hypoventilation from impaired mechanics of ventilation ~ Decreased central respiratory drive ~ Decreased neuromuscular drive

Alveolar hypoventilation from impaired mechanics

~ Vital Capacity < 15 ml/kg ~ Respirations > 30 BPM ~ Negative Inspiratory Force ( NIF ) < -20 cm H2O

~ Acute congestive heart failure

Decreased central respiratory drive

~ Depressant drugs and/or postanesthesia ~ Head and/or spinal trauma ~ Brain disorders and/or tumors

~ Cheyne-Stokes Respirations

Decreased neuromuscular drive

~ ~ ~ ~ ~ Myasthenia Gravis Muscular dystrophy Spinal muscular atrophy Guillian - Barre syndrome Poliomyelitis

Rationale for Control Ventilation

~ ~ ~ ~ ~ ~ ~ Decreased central respiratory drive Decreased neuromuscular drive Flail chest Asthma Acute or chronic respiratory failure Adult Respiratory Distress Syndrome Apnea

Rationale for Control Ventilation

Flail Chest
~ ~ ~ ~ Internal stabilization of fractured ribs Reduce Pain Increase pulmonary mobility Improve pulmonary gas distribution

Rationale for Control Ventilation Asthma

~ Franklins Criteria utilizes PaCO2 and PaO2 levels to determine the level of severity of the asthma episode ~ When Franklins Criteria is IV or V consider control ventilation
Stage IV = PaCO2 35-45 torr & PaO2 < 65 torr Stage V = PaCO2 > 45 torr & PaO2 < 50 torr

Acute or chronic respiratory failure

~ Respiratory Failure defined by Barry Shapiro, MD
ABGs pH < 7.26, PaCO2 > 50 torr, PaO2 < 50 torr Acute ventilatory failure Oxygenation failure

Adult Respiratory Distress Syndrome

DISCUSSED IN DEPTH ELSEWHERE

Apnea
~ Most commonly cited reason for Control Ventilation ~ Be sure about Do Not Resuscitate (DNR) status of patient

Goals for Oxygen Management

~ Hypoxemia can usually be managed with oxygen therapy with the exception of ----~ Refractory hypoxemia which usually requires management with positive end expiratory pressure ( CPAP or PEEP )

~ Severe hypoxemia can cause respiratory insufficiency which is an indication for mechanical ventilation.

Rationale for mode selection

~ Control Mechanical Ventilation (CMV) can be either PC (Pressure Controlled) or VC (Volume Controlled). ~ Synchronized Intermittent Mandatory Ventilation ( SIMV )
PC or VC Spontaneous breaths may be PEEP or PSV (Pressure Support Ventilation)

Rationale for mode setting

~ Apnea Ventilation
Functions when the patient has an apnea period as long as the set interval (set no less than 15 seconds) Parameters are set by respiratory therapist Functions in PC and VC

Rationale Approach for Selecting Vent. Settings

~ Initial settings
Initial settings for Volume Control Initial settings for Pressure Control

~ High vs low volumes controversy

Initial settings with Volume Control ventilation

~ Tidal volume
10-12 ml/kg for normal physiology 4-6 ml/kg for ARDS

Volume Control (cont)

~ ~ ~ ~ Respiratory Rate : 10-12 BPM Sensitivity : - 0.5cm H2O or less Oxygen - start at FIO2 1.0 PIFR :
Set to desired I:E ratio 50 L/M or greater Meet patients demand

Initial settings for Pressure Control ventilation

~ Pressure control level (inspiratory pressure) should be adjusted to achieve desired tidal volume ~ Respiratory rate - 10-12 BPM ~ Inspiratory time / I:E ratio
PC Amb

Time

High vs Low Volumes controversy

~ Controversy
Low is better because less damage to the lung parenchyma (volutrauma) is noted High is better because the incidence of incomplete filling (atelectasis, etc.) is lower

High Volumes
~ High volumes ( 10 - 12 ml/kg ) are still in use with normal lung physiology ~ In ARDS high volumes are thought to
Damage lung tissue Damage the lung capillaries Damage the lung stretch receptors

Low Volumes
~ Low volumes ( 4-6 ml/kg ) are indicated with ARDS ~ Low volumes are not necessarily indicated with normal lung physiology ~ Sighs are suggested in the use of low volumes Open Lung Concept

Application of special features

~ PEEP = mainstay for ARDS
Prevents small airway closure Keeps alveoli from collapsing Increases FRC Allows use of lower FIO2

Application of special features

~ Pressure Support Ventilation ( PSV ) [formerly known as CPPB]
Supplement the spontaneously breathing patients effort
PS Baseline

Time

Next step before T-Tube in some cases

Application of special features

~ Flow-By for adults
Base setting of 15 L/M Flow sensitivity of 3-5 L/M

Flow

Time Provides a pre-charged flow source for initiation effort

Complications associated with adult ventilation

~ Volutrama is lung tissue damage associated with excessive volumes
Common with ARDS Capillary damage Tissue damage Stretch receptor damage

Complications associated with adult ventilation

~ Barotrauma is associated with excessively high pressures causing
Pneumothorax Pneumomediastium Pneumoperitoneum Extra-Pulmonary interstitial emphysema (Subcutaneous emphysema) Tension pneumothorax Venous and arterial air embolism

Barotrauma (cont)
Incidence of barotrama:
is rare with use of PIP < 60 cmH2O with PIP > 70 cmH2O, is reported at 43% incidence

Barotrauma (cont)
~ How to reduce the incidence of barotrauma
Keep plateau pressure below 30 cmH2O Keep peak inspiratory pressure below 60 cmH2O Prevent air-trapping and Auto-PEEP

Summary
The goals of Adult Ventilation are:
to provide ventilation when the patient is unable to adequately sustain ventilation and; to buy time until underlying cardiopulmonary problems are corrected.

Summary (cont)
Adult ventilation is accomplished by:
matching the appropriate mode of ventilation, settings and special features with the needs of the patient.

Summary (cont)
Although the criteria and rationale works for most patients, it does not work 100% of the time. Therefore, flexibility must be incorporated into Adult Ventilation.

Summary (cont)

A COOKBOOK DOES NOT WORK THE SAME IN EVERY KITCHEN