Presented by: Jacob Riegelsberger

BS, LP, CCEMT-P, FP-C

 The use of external equipment and supplies to assess,
assist and/or artificially control a patient’s ventilatory
cycle (Inhalation and Exhalation).

 Can be invasive (IVPP) or non-invasive (NIPPV) and

employ the following accouterments:
 Ventilator Machine (e.g. LTV 1200)
 Ventilator circuit/tubing
 ETT/Trach.
 Pressure cuff monitors
 HME
 Waveform capnography
 Frees up healthcare providers for other tasks
 Grants complete or partial control of Airway &
Breathing with ability to assess and regulate the overall
process.
 Oxygenation
 Off-gassing (EtCO2)
 Measure Pressures and Volumes
 Strict Metabolic requirements
 Hypoxic & Hypercapneic Respiratory failure
 Post PAI w/ extended transport times (> 10 min)
 Real time assessment, measurement and calculation of
ventilation status (PIP, PEEP, Pplat, Ve, Vte, etc…) w/
consideration to trending and interventions!!!
 Age and severity of patient – older or sicker leads to greater challenge
when weaning from ventilator
 Muscle atrophy and loss of drive to breathe.
 Severe pathologies require more time on the vent, can lead to other
pathologies (e.g. VAP)

 Decreases Cardiac Output (CO) by INCREASING intrathoracic

pressure.

 Hypovolemia (i.e. dehydration through respiratory cycle)

 HME (Heat & Moisture Exchanger)
 Adequate Fluid admin / Fluid Resuscitation

 ***PPV is NOT intrinsic***

 Does not reflect the natural breathing process (e.g. neg pressure
ventilation).
 Harmful to Anatomy (barotrauma and volutrauma, shearing force)
 Alters physiology (Oxgen Free Radicals/breakdown of tissues)
 The principles of Mechanical Ventilation are the same
regardless of the device used, but consider the
limitations of each device respectively:

 Rescue Ventilators – small/lightweight, very limited

capabilities, used in remote or pre-hospital settings.
Usually only offer Vt, f and I time settings. No alarms
available. Dynamic airway pressures and other
information (Vte, PIP, Pplat, Flow (LPM)), etc... not
obtainable.

 Hospital Ventilators – reliable and capable, controlled

by RRT with MD order, not always compatible w/ pre-
hospital equipment or vent. circuits. Values can be
additive or absolute.

 Pre-hospital Ventilators – Specific for transport arena.

Must be rated for aviation use by manufacturer. Must
be mounted/secured per FAA regulations.
 PIP – Peak Inspiratory Pressure - a
measure of airway resistance
during inspiration.
 Normal is <30 cmH20

 Pplat – Plateau Pressure – a

measure of static pressure in the
lungs at the level of the alveoli at
end-inspiration.
 Better predictor of alveolar/Paw and
is BEST for monitoring lung
compliance and prevention of
Barotrauma.
 Normal is <30 cmH20
 PIPs and Pplats:
 An elevated PIP with normal Pplat = an airway issue
(mucous plug/secretions, obstructed ETT,
bronchospasm, aspiration etc…)

 An elevated Pplat with normal PIP = a lung parenchyma

issue (Pulmonary Embolism)

 If BOTH are elevated consider: Pleural effusion, abd.

Distention/diaphragmatic rupture, pneumothorax,
pulmonary edema, severe infection
Causes of Increased Airway Resistance (i.e. High PIP)

Type Condition
COPD Emphysema
Bronchitis
Bronchiectasis/Atelectasis
Mechanical Obstruction Mucous plug
ETT clamping/pt. biting ETT
Gen. Obstruction (fluid or
foreign body
Infection Pneumonia
Sepsis w/ ARDS
Reactive/Restrictive Asthma
Cystic Fibrosis
Bronchospasm (Allergic Rxn)
 PEEP – Positive End Expiratory Pressure –
 The minimal pressure maintained during exhalation. Best for oxygenation
and gas exchange & “Recruitment”
 Prevents patient from completely exhaling which keeps alveoli open, while
increasing surface area for continued gas exchange and maintaining Mean
Airway Pressure (MAP).
 Important for understanding Henry’s Law and Graham’s Laws and the
solubility of gases!!!

Intrinsic PEEP = 3-5 cmH20 [FOR PTs OF ANY AGE]

Extrinsic PEEP = > 5 cmH20

PEEP > 8 cmH20 REQUIRES ETT clamping or loss of recruitment WILL

occur IMMEDIATELY!
  “Auto PEEP-ing” – generated by patient with pursed lips,
cough or other expiratory reflex. Aimed at increasing
intrinsic PEEP in presence of pathological state. (e.g.
COPD = pursed lips, exacerbated cough reflex, to splint
open dynamic airways (e.g. bronchi/bronchioles) and
alveoli for better gas exchange

**BALLOON EXERCISE**

 Excellent for:
 Asthma, COPD, Emphysema, Bronchitis, CHF, Pulmonary
Edema or ANY patient who requires increased gas exchange.
 Great for:
 Asthma
 COPD
 Emphysema
 Bronchitis
 CHF
 Pulmonary Edema
 or ANY patient who requires increased gas exchange.

 Caution with:
 Pneumothorax
 Late stage/severe Asthma or COPD
 Diaphragmatic rupture
 Traumatic asphyxiation or crush injuries.
 PS – Pressure Support – augments the flow of gas to help
patient overcome the negative pressure of the vent. circuit
when taking a spontaneously generated breath
 Can be used in NIPPV (BiPAP) or IPPV (SIMV mode only)
 Normal is 5-15 CmH20 (Typical is 10 cmH20)

 Ve – Minute Volume – total volume of gas moved in and

out of the pulmonary system each minute. [ f x Vt = Ve ]
 Normal 4-8 LPM

 Vt – Tidal Volume – the total volume of gas inhaled with

each breath (patient generated or ventilator)
 Normal 6-10 ml/kg
 *Based on IBW*
 Bias Flow – the basal flow rate ALWAYS flowing through
the vent. circuit to assist with patient triggering.
 Normal 0-40 lpm (LTV manuf. setting of 10 lpm)
 Ensures MAP and that CO2 doesn't accumulate in the
inspiratory limb upon patient exhalation.
 A lower bias flow is the reason PS must be used. That way
patients can more easily inhale and overcome the negative
pressure of the vent. circuit.

 I:E Ratio – Inspiratory and Expiratory phase.

 Ex. 1:6 = 1 part inhalation to 6 parts exhalation.
 “Inverted I:E ratios” increase MAP and oxygenation
 Is considered a last ditch maneuver - can have deleterious
effects!!!
 Sensitivity – a provider controlled setting that
determines the difficulty level for a patient to generate
a spontaneous breath.
 Ranges from 1 to 9 (1 = Easier, 9 = Near Impossible)
 Typical = 3
 Important for rough transports or patients in AC mode.

 Oxygen Concentration (expressed as . or %)

 Room air FiO2 .21 = 21%
 Low Pressure Source (E Cylinder) = 100%
 High Pressure Source 21% to 100% and everything in
between (e.g. .50 or .40 or .60 = 50%, 40%, 60% resp.)
 I-Time – Inspiratory Time –
 The duration of time it takes for a target to deliver a
breath. Longer I-Times contribute to recruitment and
mean Mean Airway Pressure(Paw)
Patient Duration in Seconds
Adult 0.8 – 1.5
Pedi 0.6 – 0.8
Infant 0.4 – 0.5
Neonate 0.3 – 0.4

 Example – VLV – takes 0.8 seconds to deliver 500 Vt (adult)

 Example – PVL – takes 0.4 seconds to deliver 20 cmH20 PIP
(infant)
 Lung Compliance Vs. Lung/Chest Wall Elastic Resistance

 Compliance – a measure of the lung/chest wall’s ability to

expand = “distensibility”
 (High vs. Low) Based on airway resistance, lung parenchyma,
alveolar surface tension, presence (or absence of) of pulmonary
surfactant
 {High} = Easier to ventilate | {Low} = more difficult to ventilate

 Elastic Resistance “Elasticity or Elastance” – lung and chest

wall recoil – a measure of the ease with which lung and chest
wall return to their normal resting position/size.
 Based on chest wall, alveolar surface tension, and integrity of lung
connective tissue/fibers/proteins.
 {High} = more difficult to ventilate | {Low} = Easier to ventilate
Compliance and Elasticity are reciprocal forces (i.e. there is a
certain pressure change required for a unit volume change.
 Compliance DECREASES as Elasticity INCREASES
 Obesity
 Emphysema (lack of pulmonary Surfactant)
 Chest Wall Restriction (e.g. Circumferential burns, traumatic asphyxiation/crush injuries)

 Compliance INCREASES as Elasticity DECREASES

 Bronchitis, Asthma
 Allergic Rxn
 Infection (e.g. Pneumonia)
 Cystic Fibrosis

 SPECIAL CONSIDERATIONS – Pulmonary Edema/Pneumothorax/ARDS/Toxic Exposure,

Electrical Injuries/burns, severe COPD, or only one lung…. 

 Example: Asthma patient = distended lungs and chest wall = High compliance as lungs
expand easily, but low elasticity due to inability to return to resting position from air
trapping. ** Late cases we see both low compliance and low elasticity w/ TLC reached =
inability to expand lungs further, or recoil lung/chest**

 Example: Circumferential thermal burns to torso = low compliance as lungs don’t easily
due to high elastic forces from: internal swelling, fluid shifts, increased alveolar surface
tension and burned integument (skin) restricting chest excursion.
 Oxygenation -FiO2 and PEEP
 Exercise Henry's Law (solubility of gases).
 Surface Area
 Pressure on top of the gas
 Gas concentration

 Utilizing PEEP increases surface area of the alveoli and encourages

gas exchange at the alveolar/capillary interface

 By providing an FiO2 > .21 (> 21%) we increase the concentration of

the gas being infused.

 Graham's Law - the law of diffusion states:

 1.) the larger the gradient the faster molecules diffuse and
 2.) the shorter the distance the faster the molecules diffuse.
 Larger molecules diffuse more slowly, and ALL molecules will diffuse
slower if being placed into a viscous solution (e.g. water VS. oil, honey
or maple syrup, or BLOOD 
 Trigger - A Trigger is what initiates a breath based on a set
schedule per minute (i.e. Modes: CMV, AC, IMV, SIMV,
PSV, Oscillation, etc.)
 “Dictates the pattern of mechanical and patient generated
breaths”

 Target - A Target is what each ventilation is aiming to

achieve (i.e. deliver a breath to a preset volume or preset
pressure or total flow ‘lpm’).
 “How the breath is given”

 Cycle - A cycle is what stops the ventilation cycle (i.e. when

the preset volume or pressure is achieved)
 “How the breath stops”
A Target is what each ventilation cycle is aiming to achieve
(i.e. deliver a breath to a preset volume or preset pressure)

 Comes in two flavors:

 Volume –
 “Volume Limited Ventilation / Volume Targeted Ventilation /
Volume Cycled Ventilation”…....all mean the same thing!
 Ventilator breath delivers gas until a present tidal volume has been
achieved.
 Example: Vt of 500 ml

 Pressure –
 “Pressure Limited Ventilation / Pressure Targeted Ventilation /
Pressure Cycled Ventilation”…....all mean the same thing!
 Ventilator breath delivers gas until a preset pressure has been
achieved. Volume varies due to airway resistance and lung
compliance.
 Example: PIP of 20 cmH2o
 Volume Targeted Ventilation –
 Mechanical breath administered is in the form of a preset
tidal volume (Vt)
 Pressure becomes the DEPENDENT variable as the total
pressure experienced (PIP and Pplat) depends on the total
volume administered, airway/lung compliance and chest wall
elasticity. Check vent for relative pressures.

 Considerations:
 ALI and Volutrauma, Hx of Pulmonary bleps or spontaneous
pneumothorax, ARDS, History of Lobectomy, known or suspected
tension pneumothorax

MUST watch pressure(s) in volume target setting!!!!

 Pressure Targeted Ventilation –
 Mechanical breath administered in the form of a preset pressure (PIP)

 Has added benefit of “decreasing –or- decrescendo” flow type.

 Volume becomes DEPENDENT variable as any volume could be infused

as long as the preset pressures are being reached.

 Best for Lung Protective Strategy: Cystic Fibrosis, Asthma, COPD

pathologies, Pneumonia. ARDS, Upper airway, neck, or
anterior/posterior or circumferential thoracic burns leading to tissue
swelling or restricted chest excursion.

 Must be cautious with pressure as it can lead to under ventilating the

patient if preset/desired airway pressures are achieved too early and
thus not allowing for enough volume to be administered (e.g. asthma)
Leads to a Low Minute Ventilation

MUST watch volumes in Pressure Target setting!!!

 A Trigger is what initiates a breath based on a set schedule
per minute.

 Breaths initiated by:

 Ventilator Time (e.g. setting f and Vt)
 Example: Rate (f) of 10 BPM = 1 breath ~ q 6 seconds
 Example: Rate (f) of 12 BPM = 1 breath ~ q 5 seconds
 Spontaneous Patient-Generated Breaths
 In the spontaneously breathing patient, a patient-generated breath
may/may not trigger the ventilator
 SIMV – Pressure Support (PS) is used
 AC – full volume breath is administered
 Comes in different Modes:
 CMV, AC, IMV, SIMV, PSV, CPAP, BiPAP, Oscillation
 Controlled Mandatory Ventilation (CMV)
 Trigger - Time
 Target - VTV or PTV
 Provides a present tidal volume (Vt) or Pressure (PIP) at a
preset rate (f)
 Patient is UNABLE to exhibit effort or spontaneously breathe
around ventilator breaths. Leads to “air hunger” in the
under-sedated patient.
 Requires generous use of analgesia, sedation & NMBA!
 Common w/ older model vents. and Rescue Ventilators
 Ideal for: pts who require strict physiologic monitoring (ICP,
TBI, SAH) and lower metabolic demand.
 A/C – Assist Control

 Trigger – Time or Patient

 Target – VTV or PTV
 Provides a present tidal volume (Vt) or Pressure (PIP) at
a preset rate (f) and allows the pt. to take a breath BUT
the breath will be ASSISTED and ultimately provided by
the ventilator (e.g. the pt starts to breath they get a full-
on ventilator breath at preset volume or pressure
setting)
 Requires analgesia, sedatives and possibly NMBA
 Can lead to respiratory alkalosis, gas retention and
breath stacking if pt. not allowed to exhale.
 Setting Sensitivity - inadvertent knocking of the vent.
circuit creates negative pressure in the circuit,
mimicking a pt. generated breath. (i.e. breath stacking!)
 Ideal for: Patients who require complete or partial
ventilation control w/ adequate analgesia/sedation.
Stationary patients in a facility (i.e. non transport
environment). Patient's with neuromuscular
compromise.
 IMV – Intermittent Mechanical Ventilation
 Trigger – Time or Patient
 Target – VTV or PTV
 Provides a present tidal volume (Vt) or Pressure (PIP) at a
preset rate (f) and allows the pt. to take a spontaneously
generated breath in between ventilator breaths.
**Is an Asyncrhonous Mode **

 Pt. generated breaths are un-assisted, and therefore may vary

in Vt (e.g. 50 ml or 400 ml)
 Leads to variable Vt delivery and WOB.

 MUST have PS set!!! We want to help them breathe when

taking breaths on their own! Can lead to “air hunger” and
"bucking of the tube” if PS not set or analgesia/sedatives not
used.
 IMV may lead to air trapping, breath stacking and gas
retention.
 Ideal for:
 Transport environment
 Patients with pain and light sedation only, no NMBAs on
board.
 Assessing interventions/treatments for current pathology
 Not ideal for:
 Patient's with such severe pathologies that normal pressure
and volume settings would be deleterious and worsen
outcome, thereby warranting a different mode (e.g.
oscillation).
 SIMV – Synchronized Intermittent Mechanical Ventilation
 **BEST for the critically ill and injured**
 Trigger – Time or Patient
 Target – VTV or PTV
 Provides a present tidal volume (Vt) or Pressure (PIP) at a
preset rate (f) and allows the pt. to take a spontaneously
generated breath in between ventilator breaths.
 Pt. generated breaths are un-assisted, and therefore may vary
in Vt (e.g. 50 ml or 400 ml)
 MUST have PS set!!! We want to help them breathe. Can
lead to “air hunger” and "bucking of the tube” if not.
 Can lead to air trapping, breath stacking and gas retention.
 Same benefits and cautions as IMV mode.
 How SIMV differs from IMV – Before each ventilator breath
is to be given there is a “window” (seen in Yellow below)
which assesses and senses for spontaneous patient effort. If
the ventilator senses the patient trying to draw a breath
during that period of time the ventilator will provide a full-on
ventilator breath (VLC or PLV)

 This adaptive feature allows for a more natural and intrinsic

respiratory pattern and more closely mirrors a natural
ventilation cycle and reduces incidence breath stacking!!!
CMV A/C

IMV SIMV
 PSV – Pressure Support Ventilation –
 A mode that utilizes the pt’s intrinsic rate and ventilatory
effort.

 Pt still intubated but breathing at sufficient rate and volume

which does NOT warrant a more aggressive mode (A/C,
SIMV, etc…)

 Used to wean patient’s off ventilator.

 Requires judicious use of analgesia for comfort, sedatives used

mildly or withheld.

 **Can be unreliable in patients experiencing apnea or

incrased WOB**

 Begs the question of why not extubate and use NIPPV?!

 If PS set TOO LOW
 the pt may not get a large enough Vt. Can also lead to a
shorter inspiratory drive time causing the patient to
double trigger spont. Breaths and auto-PEEP.

 If PS set TOO HIGH

 the pt. may feel overinflated and actively exhale to
terminate the breath which increases WOB.

MUST watch Ve (Minute Ventilation) in PSV

 Mode Trigger Target Cycle
CMV Time Volume Volume
Pressure Pressure
A/C Time or Patient Volume Volume
Pressure Pressure
IMV Time or Patient Volume Volume
Pressure Pressure
Flow
SIMV Time or Patient Volume Volume
Pressure Pressure
Flow
PSV Patient n/a Flow
 NIPPV – Non-Invasive Positive Pressure Ventilation
[CPAP & BiPAP]

 CPAP – Continuous Positive Airway Pressure

 Sometimes termed “PEEP”
 CPAP is an expiratory maneuver where PEEP is the RESULT of that
maneuver. Encourages gas exchange and oxygenation.
 Requirements for use:
 Spontaneously breathing pt. w/ ability to clear airway secretions
 Awake and able to follow commands....NOT obtunded/depressed.
 Ability to be coached!
 Mask seal is PARAMOUNT!!!!!!!!!!!!!!!!
 BiPAP – Bi-Level Positive Airway Pressure
 “PEEP w/ Pressure Support”

 Is BOTH an inspiratory maneuver (PS) and expiratory maneuver

(CPAP).

 Allows for expiratory support in the form of PEEP (splinting airways

and alveoli open) while also providing an inspiratory augmentation
(a little extra kick when the patient takes a breath).

 Perfect for the spontaneously breathing patient who requires both

aggressive oxygenation and ventilation with consideration to
underlying pathology (e.g. Emphysema).

 Requirements for use:

 Spontaneously breathing pt. w/ ability to clear airway secretions
 Awake and able to follow commands....NOT obtunded/depressed.
 Ability to be coached!
 Mask seal is PARAMOUNT!!!!!!!!!!!!!!!!!
 A cycle is what stops the ventilation cycle:

 Four Flavors:
 Volume Cycle – ventilation stops when a preset tidal volume is
achieved within lungs.

 Pressure Cycle – ventilation stops when a preset pressure is

achieved within lungs

 Time Cycle – ventilation stops when a preset inspiratory time

has elapsed.

 Flow Cycle – ventilation stops when a preset flow rate has

been achieved.

 Cycle = internal system of checks/balances to ensure we

achieve our ‘target’ goal. If we set PIP of 20, we should be
getting a PIP of 20!!! Go hand-and-hand w/ alarms!!!
 Any time a problem is encountered with the Ventilator
your FIRST action is to:
Remove the patient from the ventilator and ventilate manually
with BVT w/ PEEP valve in place!!!!

 Troubleshooting Mnemonics (SCOPE & DOPE)

 SCOPE - Assesses High Pressure Alarms
 S- Suction
 C- Connections
 O- Obstruction
 P- Pneumothorax
 E- ETT migration to L/R main stem
 Mnemonics continued…
 DOPE
 D- Dislodgement
 O- Obstruction
 P- Pneumothorax
 E- Equipment

 Other Considerations:
 Low O2 Saturation
 Check settings (f and Vt / PIP, Plat, PEEP)
 Inspiratory time
 ETT location/migration
 Sxn
 Pneumothorax
 Pulmonary Embolism & Pulmonary Edema
 54 y/o (80 kg) male transported to hospital ED by EMS for
acute exacerbation of COPD. Family states symptoms
worsening over last 2 hours.
 Hx of COPD/Emphysema, daily smoker (2 packs/day)+
intoxicating elixirs.

 EMS Assessment & Tx

 Assessment:
 Patient found sitting in living room chair appears to be in distress
and grabbing chest. BP unobtainable, RA SpO2 87% Intercostal
and supraclavicular retractions. Transport time of 8 min to ED.
 Treatment:
 12-lead with “Inferior STEMI”
 NRB 15 1pm @ [100%] = SpO2 90%
 ASA 324 mg / Nitro SL 0.4 x 1
 Lungs – CEBTA
 18 g IV RAC w/ SL
 Solumedrol 125mg IV + Albuterol
 Hospital Assessment & Treatment:
 Assessment:
 Patient presenting with tachycardia, respiratory fatigue and
slowing resp. rate, decreased chest excursion and low SpO2.

 Respiratory failure???? Absolutely!!!

 Tx:
 PAI with fentanyl, versed and Succinylcholine
 Mechanical Ventilation
 Serial 12-leads revealed pt NOT having a STEMI and VS
Obtained
 ABGs
 Chest X-Ray
 NS bolus at 20ml/kg for hypotension post PAI (SBP 90)
 ABGs:
 pH = 7.3
 HCO3- = 22
 PCO2 = 50
 PaO2 = 65

Metabolic Panel and CBC unavailable.

HEMS Transport team activated.
 Hospital Ventilator Settings:
 A/C w/ no spontaneous effort
 Rate 12
 VLV - Vt of 500ml
 I-Time = 1 sec.
 PEEP 5 CmH20
 SpO2 at 94%

 TT arrives and finds:

 Patient ventilating well, pain/sedation not indicated, good
chest excursion, confirms ETT placement and patency
verified. Lungs are diminished in apex and bases. Report
obtained from ED RN. Bilateral AC Ivs with NS at TKO.
 At time of Transport TT elects to change vent settings
 Mode/Trigger =SIMV
 Rate = 12
 Target = PLV 15/5 (PIP = 20 cmH2o)
 I time = 1 sec.
 PEEP 5 cmH2o
 SpO2 increases to 97% and maintains

 Switched sedative to Ketamine for continued low SBP and

diminishing lung sounds. Albuterol MDI. NS bolus 20
ml/kg prn for SBP then TKO.
 Patient improvement noted. TOC at receiving ED. Follow
up revealed high BUN/Cr and relative hypernatremia.
Patient discharged 5 days later.

 What went wrong with this patient???

 HEMS TT responds to scene call for 2 vehicle MVC
rollover, multiple patients with injuries.
 Patient is 24 y/o male, restrained driver of SUV
involved in 2 car MVC. Fellow occupants were
unrestrained and ejected at time of rollover + DOS.
 EMS finds patient inside vehicle w/ GCS of 3, patent
airway, breathing at 10/min and shallow w/ unilateral
chest wall excursion and bleeding scalp lac. Patient
extricated, backboarded, moved to ambulance and PAI
w/ secondary injuries addressed. Patient is
progressively becoming hypotensive with lung sounds
absent L side.
 TT arrives to find patient intubated w/ BVT and PEEP valve
in place. Unilateral chest wall movement observed to R
side only, flail chest confirmed to L side. Lung sounds
present R, Absent L.
 Flail chest splinted. Left side needle decompression w/ +
air return. VS normalize TT packages patient and moves to
Aircraft.
 Transport time to level 1 Trauma Center 35 min.
 En route patient SpO2 drops and high pressure alarms
sound.
 What is your immediate action?? What are your follow up
actions? What is the problem??