Working Principles

of ICU ventilators
Dr. Ananya
Contents
Classification
History
Introduction
Indications
Key terms- compliance , ventilatory work
Components
Control mechanism
Variables
Triggering
Factors to consider in mechanical ventilation
Wave-forms
Classification
According to Robert chatburn

Broadly classified into

Negative pressure ventilators
And according to the
manner in which Positive pressure ventilators
they support ventilation
Negative pressure ventilators
Exert a negative pressure on the external
chest
Decreasing the intrathoracic pressure during
inspiration allows air to flow into the lung,
filling its volume
Physiologically, this type of assissted
ventilation is similar to spontaneous
ventilation
It is used mainly in chronic respiratory
failure associated with neuromascular
conditions such as poliomyleitis, muscular
dystrophy, a myotrophic lateral sclerosis,
and mysthenia gravis.
The iron lung, often referred
to in the early days as the
"Drinker respirator", was
invented byPhillip
Drinker(1894 1972)
andLouis Agassiz Shaw
Junior,professors ofindustrial
hygiene at theHarvard
School of Public Health .
The machine was powered by
an electric motor with air
pumps from two vacuum
cleaners. The air pumps
changed the pressure inside a
rectangular, airtight metal
box, pulling air in and out of
the lungs
Biphasic cuirass
ventilation
Biphasic cuirass ventilation(BCV) is a
method ofventilation which requires the
patient to wear an upper body shell orcuirass,
so named after the body armour worn by
medieval soldiers.
The ventilation is biphasic because the
cuirass is attached to a pump which actively
controls both theinspiratory andexpiratory
phases of the respiratory cycle .
Disadvantages
Complex and Cumbersome
Difficult for transporting
Difficult to access the patient in emergency
claustrophobic
Positive pressure
ventilators
Inflate the lungs by exerting positive
pressure on the airway, similar to a bellows
mechanism, forcing the alveoli to expand
during inspiration
Expiration occurs passively.
modern ventilators are mainly PPV s and
are classified based on related features,
principles and engineering.
History
Andreas Vesalius (1555)
Vesalius is credited with the first description of positive-
pressure ventilation, but it took 400 years to apply his
concept to patient care. The occasion was the polio
epidemic of 1955, when the demand for assisted
ventilation outgrew the supply of negative-pressure
tank ventilators (known as iron lungs).
In Sweden, all medical schools shut down and medical
students worked in 8-hour shifts as human ventilators,
manually inflating the lungs of afflicted patients.
Invasive ventilation first used at Massachusetts
General Hospital in 1955.
Thus began the era of positive-pressure mechanical
ventilation (and the era of intensive care medicine).
INTRODUCTION TO MECHANICAL
VENTILATION:
CONVENTIONAL MECHANICAL VENTILATION
Mechanical ventilation is a useful modality for patients
who are unable to sustain the level of ventilation
necessary to maintain the gas exchange functions-
oxygenation and carbon dioxide elimination
The first positive-pressure ventilators were designed to
inflate the lungs until a preset pressure was reached.
In contrast, volume-cycled ventilation, which inflates
the lungs to a predetermined volume, delivers a
constant alveolar volume despite changes in the
mechanical properties of the lungs.
INDICATIONS FOR MECHANICAL
VENTILATION

Respiratory Failure
Cardiac Insufficiency
Neurologic dysfunction

Rule 1. The indication for intubation and mechanical

ventilation is thinking of it.
Rule 2. Endotracheal tubes are not a disease, and
ventilators are not an addiction
Key terms
Ventilatory work-
During inspiration , the size of the thoracic cage
increases overcoming the elastic forces of the lungs and
the thorax and resistance of the airways. As the volume of
the thoracic cage increases, intrapleural pressure becomes
more negative, resulting in lung expansion.
Gas flows from the atmosphere into the lungs as a result
of transairway pressure gradient.
During expiration, the elastic forces of the lung and
thorax cause the chest to decrease in volume and
exhalation occurs as a result of greater pressure at the
alveolus compared to atm. Press.
This ventilatory work is proportional to the pressure
required for inspiration times the tidal volume.

LOAD-
The pressure required to deliver the tidal volume is
referred to as the load that the muscles or
ventilator must work against.
load elastic ( volume & inv. Prop t0
compliance)
resistance ( Raw & inspiratory flow)
Equation of motion for respiratory system
Muscle pressure + ventilator pressure =
(volume / compliance)+
(resistance x flow)

Flow- its the unit of volume by unit of time.

Resistance- it is the force that must be
overcome to move the gas through the
conducting airways.
It is described by the poiseulles law.
Lung compliance
Lung compliance: Is the change in volume per
unit change in pressure
COMPLIANCE =
Volume / Pressure
Types
Static compliance- is measured when there is no air
flow.
Reflects the elastic properties of the lung and the chest
wall
Dynamic compliance is measured when air flow is
present
Reflects the airway resistance (non elastic resistance)
and elastic properties of lung and chest wall
Static compliance=Corrected tidal volume
Plateau pressure-PEEP
Dynamic compliance
corrected tidal volume
Peak inspiratory pressure-PEEP
What is a mechanical ventilator?
A machine or a device that fully or partially
substitute for the ventilatory work
accomplished by the patients muscles.
Components INPUT POWER
DRIVE MECHANISM
CONTROL CIRCUIT
OUTPUT WAVEFORMS
ALARMS
INPUT POWER
It can be
Pneumatically powered(uses compressed
gases)
Electrically powered(uses 120 Volts
AC/12Volts DC)
Here the electric motor drives pistons and
compressors to generate gas flows .
Microprocessor controlled- combined.
Also called as 3rd generation ventilators.
Source of Gas Supply

Air - Central compressed air, compressor,

turbine flow generator, etc
Oxygen Central oxygen source, O2
concentrator, O2 cylinder
Gas mixing unit O2 blender
DRIVE MECHANISM
Its the system used by the ventilator to
transmit or convert the input power to useful
ventilatory work.
This determines the characteristic flow and
pressure patterns produced by the ventilator.

It includes pistons
bellows
reducing valves
pneumatic circuits
Piston mechanism

Bellows mechanism

Pneumatic mechanism
Pneumatic circuits- uses pressurized gas as
power source.
these are microprocessor controlled with
solenoid valves.
use programmed algorithms in
microprocessor to open and close solenoid
valves to mimic any flow or pressure wave
pattern.
Control circuit
Its the system that governs the ventilator
drive mechanism or output control valve.
Classified as-
Open circuits- desired output is selected and
venti. achieves it without any further input
from clinician.
Closed circuits- desired output is selected
and venti. Measures a specific parameter
(flow/vol/press) continuously and input is
constantly adjusted to match desired output.
a.k.a SERVO controlled.
Control parameters

Pressure
Volume
Flow
Time
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.
If volume is set, pressure varies..if
pressure is set, volume varies..
.according to the compliance...
 Mechanical- employs levers or pulleys to
control drive mechanism.
Pneumatic
Fluidic- applies gas flows and pressure to
control direction of other gas flows and to
perform logic functions based on the COANDA
effect.
Electronic- uses resistors and diodes and
integrated circuits to provide control over the
drive mechanism.
Pressure controller
Ventilator controls the trans-respiratory
system pressure .
This trans-respiratory system gradient
determines the depth or volume of
respiration.
Based on this a ventilator can be positive or
negative pressure ventilator.
Volume controller
Volume cycled ventilation delivers a:
set volume;
with a variable Pressure - determined by
resistance, compliance and inspiratory effort
Flow controller
Allows pressure to vary with changes in patient s
compliance and resistance while controlling flow.
This flow is measured by vortex sensors or venturi
pnemotachometers.

Time controller
measures and controls inspiratory and expiratory time.
These ventilators are used in newborns and infants
Inspiratory time is a combination of the inspiratory
flow period and time taken for inspiratory pause. The
following diagram depicts how the addition of an
inspiratory pause extends total inspiratory time.
Normal inspiratory time of a spontaneously breathing healthy adult is approximately 0.
8- 1.2 seconds, with an inspiratory expiratory (I: E) ratio of 1:1.5 to 1:2 2.
Its advantageous to extend the inspiratory time in order to:
improve oxygenation - through the addition of an inspiratory pause; or to
increase tidal volume - in pressure controlled ventilation
Adverse effects of excessively long inspiratory times are haemodynamic compromise,
patient ventilator dysynchrony, and the development of autoPEEP.
Phase variables
A. Trigger .
What causes the breath to begin?
B C
B. Limit
What regulates gas flow during the breath?
A
C. Cycle .
What causes the breath to end?
Phases of ventilator supported breath
inspiration
change from inspiration to expiration
expiration
change from expiration to
inspiration
Types of ventilator breaths-
Mandatory breath
Assisted breath
Spontaneous breath
Trigger variable
Its the variable that determines start of inspiration
Triggering refers to the mechanism through which the
ventilator senses inspiratory effort and delivers gas flow or
a machine breath in concert with the patients inspiratory
effort.
Can use pressure or volume or time or flow as a trigger.
In modern ventilators the demand valve is triggered by
either a fall in pressure (pressure triggered) or a change in
flow (flow triggered).
With pressure triggered a preset pressure sensitivity has to
be achieved before the ventilator delivers fresh gas into the
inspiratory circuit. With flow triggered a preset flow
sensitivity is employed as the trigger mechanism.
Time triggering
Pressure Triggering
Breath is delivered when ventilator senses patients
spontaneous inspiratory effort.
sensitivity refers to the amount of negative pressure the patient
must generate to receive a breath/gas flow.
If the sensitivity is set at 1 cm then the patient must generate 1
cm H2O of negative pressure for the machine to sense the
patient's effort and deliver a breath.
Acceptable range - -1 to -5 cm H2O below patient s baseline
pressure
If the sensitivity is too high the patient's work of breathing will
be unnecessarily increased. It is not a reasonable course of
action to increase the sensitivity to reduce the patient's
respiratory rate as it only increases their work of breathing.
Flow Triggering
The flow triggered system has two preset variables
for triggering, the base flow and flow sensitivity.
The base flow consists of fresh gas that flows
continuously through the circuit. The patients
earliest demand for flow is satisfied by the base flow.
The flow sensitivity is computed as the difference
between the base flow and the exhaled flow
Here delivered flow= base flow- returned flow
Hence the flow sensitivity is the magnitude of the
flow diverted from the exhalation circuit into the
patients lungs. As the subject inhales and the set
flow sensitivity is reached the flow pressure control
algorithm is activated, the proportional valve opens,
and fresh gas is delivered.
 Flow trigger
Advantages -
-The time taken for the onset of inspiratory effort to the onset of
inspiratory flow is considerably less.
-decreases the work involved in initiating a breath.
Limit variable
Cycle variable
Defined as the length of one complete breathing
cycle.
Inspiration ends when a specific cycle variable is
reached.
This variable is used as a feedback signal to end
inspiratory flow delivery which then allows
exhalation to start.
Most new ventilators measure flow and use it as a
feedback signal.
So volume becomes a function of flow and time
Volume= flow x inspiratory time
Baseline variable
The variable controlled during expiration
phase.
Mostly its pressure
Basic definitions
Airway Pressures
Peak Inspiratory Pressure (PIP)
Plateau pressures
Positive End Expiratory Pressure (PEEP)
Continuous Positive Airway Pressure (CPAP)

Inspiratory Time or I:E ratio

Tidal Volume: amount of gas delivered with each
breath
Pressures
Mechanical ventilation delivers flow and volume
to the patients as a result of the development of
a positive pressure gradient between the
ventilator circuit and the patients gas exchange
units as illustrated in the diagram above. There
are four pressures to be aware of in regards to
mechanical ventilation. These are the:
Peak
Plateau
Mean; and
End expiratory pressures.
Peak Inspiratory Pressure (PIP)-
The peak pressure is the maximum pressure
obtainable during active gas delivery. This pressure
a function of the compliance of the lung and thorax
and the airway resistance including the contribution
made by the tracheal tube and the ventilator circuit.
Maintained at <45cm H2O to minimize barotrauma

Plateau Pressure-
The plateau pressure is defined as the end inspiratory
pressure during a period of no gas flow. The plateau
pressure reflects lung and chest wall compliance.
As the plateau pressure is the pressure when
there is no flow within the circuit and patient
airways it most closely represents the alveolar
pressure and thus is of considerable significance
as it desirable to limit the pressure that the
alveoli are subjected to.
Excessive pressure may result in extrapulmonary
air (eg pneumothorax) and acute lung injury.
An increase in airways resistance (including ETT
resistance) will result in an increase in PIP.
An increase in resistance will result in a
widening of the difference between PIP and
plateau pressure.
A fall in compliance will elevate both PIP and
plateau pressure.
It is generally believed that end inspiratory
occlusion pressure (ie plateau pressure) is the
best clinically applicable estimate of average
peak alveolar pressure. Although controversial
it has been generally recommended that the
plateau pressure should be limited to 35 cms
H2O.
Mean Airway Pressure-
The mean airway pressure is an average of the
system pressure over the entire ventilatory
period.

End Expiratory Pressure-

End expiratory pressure is the airway pressure
at the termination of the expiratory phase and
is normally equal to atmospheric or the
applied PEEP level.
PEEP
Positive end expiratory pressure (PEEP) refers to the
application of a fixed amount of positive pressure
applied during mechanical ventilation cycle
Continuous positive airway pressure (CPAP) refers
to the addition of a fixed amount of positive airway
pressure to spontaneous respirations, in the
presence or absence of an endotracheal tube.
PEEP and CPAP are not separate modes of
ventilation as they do not provide ventilation.
Rather they are used together with other modes of
ventilation or during spontaneous breathing to
improve oxygenation, recruit alveoli, and / or
decrease the work of breathing
Advantages
ability to increase functional residual capacity
(FRC) and keep FRC above Closing Capacity.
The increase in FRC is accomplished by
increasing alveolar volume and through the
recruitment of alveoli that would not otherwise
contribute to gas exchange. Thus increasing
oxygenation and lung compliance
The potential ability of PEEP and CPAP to open
closed lung units increases lung compliance and
tends to make regional impedances to
ventilation more homogenous.
Airway Pressures (Paw)
For gas to flow to occur there must be a
positive pressure gradient. In spontaneous
respiration gas flow occurs due to the
generation of a negative pressure in the
alveoli relative to atmospheric or circuit
pressure (as in CPAP) (refer to following
diagram).
Physiology of PEEP
Reinflates collapsed alveoli and maintains alveolar
inflation during exhalation
PEEP

Decreases alveolar distending pressure

Increases FRC by alveolar recruitment

Improves ventilation

Increases V/Q, improves oxygenation, decreases work of

breathing
Physiological Responses to CPAP / PEEP
Dangers of PEEP
High intrathoracic pressures can cause
decreased venous return and decreased
cardiac output
May produce pulmonary barotrauma
May worsen air-trapping in obstructive
pulmonary disease
Increases intracranial pressure
Alterations of renal functions and water
metabolism
AutoPEEP
During expiration alveolar pressure is greater than
circuit pressure until expiratory flow ceases. If
expiratory flow does not cease prior to the initiation
of the next breath gas trapping may occur. Gas
trapping increases the pressure in the alveoli at the
end of expiration and has been termed:
dynamic hyperinflation;
autoPEEP;
inadvertent PEEP;
intrinsic PEEP; and
occult PEEP
 effects of autoPEEP can predispose the
patient to:
an increased risk of barotrauma;
fall in cardiac output;
hypotension;
fluid retention; and
an increased work of breathing
I:E ratio
This defines the inspiration to expiration ratio.
I:E ratios are normally set as 1:2 as expiration requires a longer
time .
In severe obstructive disease such as status asthamaticus it can
be set as 1:4

Factors affecting I:E Ratio-

1. Tidal volume
2. Respiratory rate
3. Flow rate
Increasing inspiration time will increase TV, but may lead to
auto-PEEP
Tidal Volume
Tidal volume refers to the size of the breath that is delivered
to the patient.
Normal physiologic tidal volumes are approximately 5-7 ml
/ kg whereas the traditional aim for tidal volumes has been
approximately 10 - 15 ml / kg.
The rationale for increasing the size of the tidal volume in
ventilated patients has been to prevent atelectasis and
overcome the deadspace of the ventilator circuitry and
endotracheal tube.
Inspired and expired tidal volumes are plotted on the y axis
against time as depicted in the following diagram.
The inspired and expired tidal volumes should
generally correlate.
Expired tidal volumes may be less than
inspired tidal volumes if:
there is a leak in the ventilator circuit - causing
some of the gas delivered to the patient to leak into
the atmosphere
there is a leak around the endotracheal /
tracheostomy tube - due to tube position,
inadequate seal or cuff leak
there is a leak from the patient, such as a
bronchopleural fistula
Expired tidal volumes may be larger than
inspired tidal volumes due to:
the addition of water vapour in the ventilator
circuitry from a hot water bath humidifier.
Flow (V)
Flow rate refers to the speed at which a volume
of gas is delivered, or exhaled, per unit of time.
Flow is described in litres per minute .
The peak (inspiratory) flow rate is therefore the
maximum flow delivered to a patient per
ventilator breath.
Flow is plotted on the y axis of the ventilator
graphics against time on the x axis .
In the following diagram that inspiratory flow is
plotted above the zero flow line, whereas
expiratory flow is plotted as a negative deflection.
When the graph depicting flow is at zero there is
no gas flow going into or out of the patient.
Flow
primary factors to consider when applying
mechanical ventilation
the components of each individual breath, specifically
whether pressure, flow, volume and time are set by the
operator, variable or dependent on other parameters
the method of triggering the mechanical ventilator
breath/gas flow,
how the ventilator breath is terminated:
potential complications of mechanical ventilation.
methods to improve patient ventilator synchrony; and
the nursing observations required to provide a safe
and effective level of care for the patient receiving
mechanical ventilation
Time (Ti)
Time in mechanical ventilation is divided between
inspiratory and expiratory time.

Inspiratory Time
In most volume cycled ventilators used in the intensive care
environment it is not possible to set the inspiratory time.
The inspiratory time is determined by the peak inspiratory
flow rate, flow waveform and inspiratory pause. Where
inspiratory time is able to be set, flow becomes dependent
on inspiratory time and tidal volume.
The following example illustrate how these parameters effect
inspiratory time.
Ventilator settings
Tidal volume 1000mls
Peak Flow 60 lpm
Flow Waveform square / constant
Insp. Pause 0 secs
The inspiratory time for this patient would be 1 second because
gas is constantly being delivered at a flow rate of 60 lpm, which
equals 1 litre per second. If an inspiratory pause of 0.5 seconds
were applied then the inspiratory time would be increased to 1.5
seconds.
Changing the patients flow waveform from a square to a
decelerating flow waveform, without changing the flow rate, will
result in an increase in inspiratory time, because the flow of gas
is only initially set at 60 lpm and decreases throughout
inspiration
Output waveforms
Graphical representation of the control or
phase variables in relation to time.
presented as pressure
flow waveforms
volume

The ventilator determines the shape of control

variable whereas the other two depend on the
patient compliance and resistance.
Conventionally flow above X-axis is inspiration.
Advantages
Allows user to interpret, evaluate, and troubleshoot
the ventilator and the patients response to
ventilator.
Monitors the patients disease status (C and Raw).
Assesses patients response to therapy.
Monitors ventilator function
Allows fine tuning of ventilator to decrease WOB,
optimize ventilation, and maximize patient comfort.
Flow Waveforms
inspiratory flow is controlled by setting the peak
flow and flow waveform.
The peak flow rate is the maximum amount of
flow delivered to the patient during inspiration,
whereas the flow waveform determines the how
quickly gas will be delivered to the patient
throughout various stages of the inspiratory
cycle.
There are four different types of flow waveforms
available. These include the square,
decelerating (ramp),
accelerating
sine/sinusoidal waveform
Square waveform-
The square flow waveform delivers a set flow rate
throughout ventilator inspiration. If for example the peak
flow rate is set at 60 lpm then the patient will receive 60
lpm throughout ventilator inspiration.
Decelerating waveform
The decelerating flow waveform delivers the peak flow at
the start of ventilator inspiration and slowly decreases
until a percentage of the peak inspiratory flow rate is
attained.
Accelerating waveform-
The accelerating flow waveform initially
delivers a fraction of the peak inspiratory flow
and steadily increasing the rate of flow until
the peak flow has been reached.
Sine / sinusoidal waveform-
The sine waveform was designed to match
the normal flow waveform of a spontaneously
breathing patient.
Setting the Peak Flow and Flow Waveform
The flow rate should be set to match the
patients inspiratory demand. Where the
patients inspiratory flow requirements exceed
the preset flow rate there will be an imposed
work of breathing which may cause the patient
to fight the ventilator and become fatigued.
Where flow rate is unable to match the
patients inspiratory flow requirements the
pressure waveform on the ventilator graphics
screen may show a depressed or scooped
out pressure waveform.
This is often referred to as flow starvation.
The decelerating flow waveform is the most frequently
selected flow waveform as it produces the lowest peak
inspiratory pressures of all the flow waveforms.
This is because of the characteristics of alveolar
expansion. Initially a high flow rate is required to open
the alveoli. Once alveolar opening has occurred a
lower flow rate is sufficient to procure alveolar
expansion.
Flow waveforms which produce a high flow rate at the
end of inspiration (ie. square and accelerating flow
waveforms) exceed the flow requirements for alveolar
expansion, resulting in elevated peak inspiratory
pressures
Pressure waveforms
Rectangular
Exponential rise
Sine

Can be used to monitor-

Air trapping (auto-PEEP)
Airway Obstruction
Bronchodilator Response
Respiratory Mechanics (C/Raw)
Active Exhalation
Breath Type (Pressure vs. Volume)
PIP, Pplat
CPAP, PEEP
Asynchrony
Triggering Effort
References
Guide to mechanical ventilation- chang s
Breathing and mechanical support- wolfgang
oczenski
Internet references
Thank you
Advantages of Volume Cycled Ventilation
Ease of Use
Set Volumes: One of the major advantages of volume cycled
ventilation is the ability to set a tidal volume. This is of critical
importance to patients requiring tight regulation of carbon dioxide
elimination. Neurosurgical patients - post surgery / head injury and
patients suffering a neurological insult (eg post cardiac arrest) often
require CO2 regulation. This is because carbon dioxide is a potent
vasodilator.
Increased levels of carbon dioxide, in these groups of patients, may
therefore increase cerebral blood volume with a concomitant
elevation of intracranial pressure. A raised intracranial pressure may
decrease the delivery of oxygenated blood to the brain - resulting in
cerebral ischaemia. Conversely a low CO2 may cause constriction of
the cerebral vasculature also resulting in decreased oxygen delivery
and cerebral ischaemia. For these reasons volume cycled ventilation
is often the mode of choice for patients requiring CO2 regulation.
Disadvantages

The major disadvantages of volume cycled

ventilation are the variable pressure and set
flow rate. It is therefore a necessary part of
nursing practice to closely monitor the
patient's inspiratory pressure and observe the
patient for signs of flow starvation.