Introduction

Indications
Basic anatomy and physiology
Modes oI ventilation
Selection oI mode and settings
Common problems
Complications
Weaning and extubation
Indications
Respiratory Failure
pnea / Respiratory rrest
inadequate ventilation (acute vs. chronic)
inadequate oxygenation
chronic respiratory insuIIiciency with FTT
Indications
Cardiac Insufficiency
eliminate work oI breathing
reduce oxygen consumption
Neurologic dysfunction
central hypoventilation/ Irequent apnea
patient comatose, GCS 8
inability to protect airway
asic Anatomy
Upper irway
humidiIies inhaled gases
site oI most resistance to airIlow
Lower irway
conducting airways (anatomic dead space)
respiratory bronchioles and alveoli (gas
exchange)
asic Physiology
Negative pressure circuit
Gradient between mouth and pleural
space is the driving pressure
need to overcome resistance
maintain alveolus open
overcome elastic recoil Iorces
Balance between elastic recoil oI chest
wall and the lung
asic Physiology
http://www.biology.eku.edu/RITCHISO/301notes6.htm
ormal pressure-volume
relationship in the lung
http://physioweb.med.uvm.edu/pulmonaryphysiology
'entilation
Carbon Dioxide
!aCO
2
k * metabolic production
alveolar minute ventilation
lveolar MV resp. rate * eIIective tidal vol.
EIIective TV TV - dead space
Dead Space anatomic physiologic
ygenation
Oxygen:
Minute ventilation is the amount oI Iresh gas
delivered to the alveolus
!artial pressure oI oxygen in alveolus (!

O
2
) is the
driving pressure Ior gas exchange across the
alveolar-capillary barrier
!

O
2
(tmospheric pressure - water
vapor}*FiO
2
) - !
a
CO
2
/ RQ
Match perIusion to alveoli that are well ventilated
Hemoglobin is Iully saturated 1/3 oI the way thru
the capillary
ygenation
http://www.biology.eku.edu/RITCHISO/301notes6.htm

vs. ygen
Abnormal Cas Echange
Hypoxemia can be due
to:
hypoventilation
V/Q mismatch
shunt
diIIusion
impairments
Hypercarbia can be
due to:
hypoventilation
V/Q mismatch
Due to differences between oxygen and CO
2
in their
solubility and respective disassociation curves, shunt and
diffusion impairments do not result in hypercarbia
Cas Echange
Hypoventilation and V/Q mismatch are the
most common causes oI abnormal gas
exchange in the !ICU
Can correct hypoventilation by increasing
minute ventilation
Can correct V/Q mismatch by increasing
amount oI lung that is ventilated or by
improving perIusion to those areas that are
ventilated
echanical 'entilation
What we can manipulate..
Minute Ventilation (increase respiratory rate, tidal
volume)
!ressure Gradient -a equation (increase
atmospheric pressure, FiO
2,
increase ventilation,
change RQ)
SurIace rea volume oI lungs available Ior
ventilation (increase volume by increasing airway
pressure, i.e., mean airway pressure)
Solubility ?perIlurocarbons?
echanical 'entilation
Ventilators deliver gas to the lungs
using positive pressure at a certain
rate. The amount oI gas delivered
can be limited by time, pressure or
volume. The duration can be
cycled by time, pressure or Ilow.
omenclature
irway !ressures
!eak Inspiratory !ressure (!I!)
!ositive End Expiratory !ressure (!EE!)
!ressure above !EE! (!! or A!)
Mean airway pressure (M!)
Continuous !ositive irway !ressure (C!!)
Inspiratory Time or I:E ratio
Tidal Volume: amount oI gas delivered with
each breath
odes
Control Modes:
every breath is Iully supported by the ventilator
in classic control modes, patients were unable to
breathe except at the controlled set rate
in newer control modes, machines may act in
assist-control, with a minimum set rate and all
triggered breaths above that rate also Iully
supported.
odes
IMV Modes: intermittent mandatory
ventilation modes - breaths 'above set rate
not supported
SIMV: vent synchronizes IMV 'breath with
patient`s eIIort
!ressure Support: vent supplies pressure
support but no set rate; pressure support can
be Iixed or variable (volume support, volume
assured support, etc)
odes
Whenever a breath is supported by the
ventilator, regardless oI the mode, the limit
oI the support is determined by a preset
pressure OR volume.
Volume Limited: preset tidal volume
!ressure Limited: preset !I! or !!
echanical 'entilation
II volume is set, pressure varies...iI
pressure is set, volume varies...
..according to the compliance....
COMPLIANCE
'olume / Pressure
ompliance
Burton SL & Hubmayr RD: Determinants oI !atient-Ventilator Interactions:
Bedside WaveIorm nalysis, in Tobin MJ (ed): !rinciples & !ractice of Intensive
Care Monitoring
Assist-control, volume
Ingento E! & Drazen J: Mechanical Ventilators, in Hall JB,
Scmidt G, & Wood LDH(eds.): !rinciples of Critical Care
I', volume-limited
Ingento E! & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt
G, & Wood LDH(eds.): !rinciples of Critical Care
$I', volume-limited
Ingento E! & Drazen J: Mechanical Ventilators, in Hall JB,
Scmidt G, & Wood LDH(eds.): !rinciples of Critical Care
ontrol vs. $I'
Control Modes
Every breath is
supported regardless of
~trigger
Can`t wean by
decreasing rate
Patient may
hyperventilate if agitated
Patient / vent
asynchrony possible and
may need sedation +/-
paralysis
SIMV Modes
'ent tries to synchronize
with pt`s effort
Patient takes ~own
breaths in between (+/- PS)
Potential increased work of
breathing
Can have patient / vent
asynchrony
Pressure vs. 'olume
!ressure Limited
Control FiO
2
and
M! (oxygenation)
Still can inIluence
ventilation
somewhat
(respiratory rate,
!!)
Decelerating Ilow
pattern (lower !I!
Ior same TV)
Volume Limited
Control minute
ventilation
Still can inIluence
oxygenation
somewhat (FiO
2,
!EE!, I-time)
Square wave Ilow
pattern
Pressure vs. 'olume
!ressure !itIalls
tidal volume by change
suddenly as patient`s
compliance changes
this can lead to
hypoventilation or
overexpansion oI the
lung
iI ETT is obstructed
acutely, delivered tidal
volume will decrease
Volume Vitriol
no limit per se on !I!
(usually vent will have
upper pressure limit)
square wave(constant)
Ilow pattern results in
higher !I! Ior same
tidal volume as
compared to !ressure
modes
%rigger
How does the vent know when to give a
breath? - 'Trigger
patient eIIort
elapsed time
The patient`s eIIort can be 'sensed as a
change in pressure or a change in Ilow
(in the circuit)
eed a hand??
!ressure Support
'Triggering vent requires certain amount oI
work by patient
Can decrease work oI breathing by providing
Ilow during inspiration Ior patient triggered
breaths
Can be given with spontaneous breaths in IMV
modes or as stand alone mode without set rate
Flow-cycled
Advanced odes
!ressure-regulated volume control
(!RVC)
Volume support
Inverse ratio (IRV) or airway-pressure
release ventilation (!RV)
Bilevel
High-Irequency
Advanced odes
!RVC
control mode, which delivers a set
tidal volume with each breath at the
lowest possible peak pressure. Delivers
the breath with a decelerating Ilow
pattern that is thought to be less injurious
to the lung.. 'the guided hand.
Advanced odes
Volume Support
equivalent to smart pressure support
set a 'goal tidal volume
the machine watches the delivered
volumes and adjusts the pressure support
to meet desired 'goal within limits set
by you.
Advanced odes
irway !ressure Release Ventilation
Can be thought oI as giving a patient two
diIIerent levels oI C!!
Set 'high and 'low pressures with release
time
Length oI time at 'high pressure generally
greater than length oI time at 'low pressure
By 'releasing to lower pressure, allow lung
volume to decrease to FRC
Advanced odes
Inverse Ratio Ventilation
!ressure Control Mode
I:E ~ 1
Can increase M! without increasing !I!:
improve oxygenation but limit barotrauma
SigniIicant risk Ior air trapping
!atient will need to be deeply sedated and
perhaps paralyzed as well
Advanced odes
High Frequency Oscillatory Ventilation
extremely high rates (Hz 60/min)
tidal volumes anatomic dead space
set & titrate Mean irway !ressure
amplitude equivalent to tidal volume
mechanism oI gas exchange unclear
traditionally 'rescue therapy
active expiration
Advanced odes
High Frequency Oscillatory Ventilation
patient must be paralyzed
cannot suction Irequently as disconnecting the
patient Irom the oscillator can result in volume
loss in the lung
likewise, patient cannot be turned Irequently so
decubiti can be an issue
turn and suction patient 1-2x/day iI they can
tolerate it
Advanced odes
Non Invasive !ositive !ressure Ventilation
Deliver !S and C!! via tight Iitting mask
(Bi!!: bi-level positive airway pressure)
Can set 'back up rate
May still need sedation
Initial $ettings
!ressure Limited
FiO
2
Rate
I-time or I:E ratio
!EE!
!I! or !!
Volume Limited
FiO
2
Rate
I-time or I:E ratio
!EE!
Tidal Volume
These choices are with time - cycled ventilators.
Flow cycled vents are available but not commonly
used in pediatrics.
Initial $ettings
Settings
Rate: start with a rate that is somewhat
normal; i.e., 15 Ior adolescent/child, 20-30
Ior inIant/small child
FiO
2
: 100 and wean down
!EE!: 3-5
Control every breath (/C) or some (SIMV)
Mode ?
ealer's hoice
!ressure Limited
FiO
2
Rate
I-time
!EE!
!I!
Volume Limited
FiO
2
Rate
%idal Jolume
!EE!
I time
%idal 'olume (
& M') 'aries
PIP ( & MAP)
'aries
M'
MAP
Adjustments
To aIIect
oxygenation,
adjust:
FiO
2
!EE!
I time
!I!
To aIIect
ventilation,
adjust:
Respiratory
Rate
Tidal Volume
MAP
M'
Adjustments
!EE!
Can be used to help prevent alveolar
collapse at end inspiration; it can also
be used to recruit collapsed lung spaces
or to stent open Iloppy airways
Ecept...
Is it really that simple ?
Increasing !EE! can increase dead space,
decrease cardiac output, increase V/Q
mismatch
Increasing the respiratory rate can lead to
dynamic hyperinIlation (aka auto-!EE!),
resulting in worsening oxygenation and
ventilation
%roubleshooting
Is it working ?
Look at the patient !!
Listen to the patient !!
!ulse Ox, BG, EtCO
2
Chest X ray
Look at the vent (!I!; expired TV;
alarms)
%roubleshooting
When in doubt, DISCONNECT THE
!TIENT FROM THE VENT, and begin
bag ventilation.
Ensure you are bagging with 100 O2.
This eliminates the vent circuit as the source
oI the problem.
Bagging by hand can also help you gauge
patient`s compliance
%roubleshooting
irway Iirst: is the tube still in? (may need
DL/EtCO
2
to conIirm) Is it patent? Is it in the
right position?
Breathing next: is the chest rising? Breath
sounds present and equal? Changes in exam?
telectasis, bronchospasm, pneumothorax,
pneumonia? (Consider needle thoracentesis)
Circulation: shock? Sepsis?
%roubleshooting
Well, it isn`t working...
Right settings ? Right Mode ?
Does the vent need to do more work ?
!atient unable to do so
Underlying process worsening (or new
problem?)
ir leaks?
Does the patient need to be more sedated ?
Does the patient need to be extubated ?
Vent is only human...(is it working ?)
%roubleshooting
!atient - Ventilator Interaction
Vent must recognize patient`s
respiratory eIIorts (trigger)
Vent must be able to meet patient`s
demands (response)
Vent must not interIere with patient`s
eIIorts (synchrony)
%roubleshooting
Improving Ventilation and/or Oxygenation
can increase respiratory rate (or decrease rate iI
air trapping is an issue)
can increase tidal volume/!! to increase tidal
volume
can increase !EE! to help recruit collapsed
areas
can increase pressure support and/or decrease
sedation to improve patient`s spontaneous
eIIort
owered Epectations
!ermissive Hypercapnia
accept higher !aCO2s in exchange Ior limiting
peak airway pressures
can titrate pH as desired with sodium
bicarbonate or other buIIer
!ermissive Hypoxemia
accept !aO2 oI 55-65; SaO2 88-90 in
exchange Ior limiting FiO2 (.60) and !EE!
can maintain oxygen content by keeping
hematocrit ~ 30
Adjunctive %herapies
!roning
re-expand collapsed dorsal areas oI the lung
chest wall has more Iavorable compliance curve
in prone position
heart moves away Irom the lungs
net result is usually improved oxygenation
care oI patient (suctioning, lines, decubiti)
trickier but not impossible
not everyone maintains their response or even
responds in the Iirst place
Adjunctive %herapies
Inhaled Nitric Oxide
vasodilator with very short halI liIe that can be
delivered via ETT
vasodilate blood vessels that supply ventilated
alveoli and thus improve V/Q
no systemic eIIects due to rapid inactivation by
binding to hemoglobin
improves oxygenation but does not improve
outcome
omplications
Ventilator Induced Lung Injury
Oxygen toxicity
Barotrauma / Volutrauma
!eak !ressure
!lateau !ressure
Shear Injury (tidal volume)
!EE!
omplications
Cardiovascular Complications
Impaired venous return to RH
Bowing oI the Interventricular Septum
Decreased leIt sided aIterload (good)
ltered right sided aIterload
Sum EIIect...decreased cardiac output
(usually, not always and oIten we don`t
even notice)
omplications
Other Complications
Ventilator ssociated !neumonia
Sinusitis
Sedation
Risks Irom associated devices (CVLs,
-lines)
Unplanned Extubation
Etubation
Weaning
Is the cause oI respiratory Iailure gone or
getting better ?
Is the patient well oxygenated and
ventilated ?
Can the heart tolerate the increased work
oI breathing ?
Etubation
Weaning (cont.)
decrease the !EE! (4-5)
decrease the rate
decrease the !I! (as needed)
What you want to do is decrease what
the vent does and see iI the patient can
make up the diIIerence..
Etubation
Extubation
Control oI airway reIlexes
!atent upper airway (air leak around tube?)
Minimal oxygen requirement
Minimal rate
Minimize pressure support (0-10)
'wake patient