Initiation & Principles of Mechanical Ventilation

DR.G.Madhavi MD Asst.prof.of anesthesiology

Primary goals of mechanical ventilation

Adequate oxygenation Adequate ventilation

Reduce work of breathing

Avoid VALI

Pao2 Paco2 pH

Indications
Ventilatory failure

Oxygenation failure

Indications of Mechanical Ventilation

Acute Respiratory Failure Impending Respiratory Failure Prophylactic Ventilatory Support Hyperventilation Therapy

Indications of Mechanical Ventilation

Acute Respiratory Failure

Inability of a patient to maintain adequate PaO2, PaCO2, and potentially pH Type I Type II Type III Type IV

Indications of Mechanical Ventilation

Type I-oxygenation failure Pneumonia ARDS COPD Asthma Pulmonary edema Idiopathic pul fibrosis Pulmonary HTN Type II-ventilation failure o Drug intoxication o Narcotic over dose o Amyotic lateral sclerosis o Guillian barre syn o Myasthenia gravis o Poliomyelitis o Intracranial bleed o Polymyositis

Indications of Mechanical Ventilation

Type III combination of oxygenation and ventilation failure ARDS COPD Asthma Type IV perfusion failure

Decreased perfusion to respiratory muscles secondary to shock

Indications of Mechanical Ventilation

Prophylactic ventilator Support:
Clinical conditions in which there is a high risk of future respiratory failure

Myocardial infarction, Major surgery, Prolonged shock, Smoke injury

Indications of Mechanical Ventilation

Hyperventilation Therapy

Ventilator support is instituted to control and manipulate PaCO2 to lower than normal levels

Acute head injury

Impending Ventilatory Failure

Respiratory failure is imminent in spite of therapies Patient is barely maintaining normal blood gases at the expense of significant WOB NOTE: Early intervention corrects hypoxemia and acidosis imposed on the major organs and reduces stress placed on the cardiopulmonary system

Assessment Of Impending Failure

VT < 5 ml/kg Respiratory rate > 35 breaths/minute, <6 BPM Minute ventilation- <4L or >10 L/min VC < 15ml/kg (<1 L) MIP < -20 cm H2O Impaired mental status GCS< 8 Cardio vascular instability

Laboratory criteria
CRITERIA VENTILATION

NORMAL VALUES

CRITICAL VALUES

pH PaCO2 (mm Hg) Dead space to tidal volume ratio (VD/VT)

OXYGENATION

7.35 to 7.45 35 to 45 0.3 to 0.4

<7.20 >55 and rising >0.6

PaO2

80 to 100mmHg

Alveolar to arterial O2 3 to 30mmHg difference P(A-a)O2 Ratio of arterial to alveolar PO2 0.75 (PaO2/PAO2) PaO2/FIO2 475 PaO2 = FiO2 600

< 60mm on O2 >0.5 < 40mmHg @ anyFiO2 > 300 on O2@>0.6 <0.15 <200

MODES

Modes of Ventilation
It depends on which a breath is delivered by altering or

changing the available variables (volume or pressure).

Components:

1.Type of breath 2.Control variable 3.Phase variable 4.Conditional variable

Types of breath

Mandatory breath Assisted breath

Spontaneous breath Supported breath

Mandatory :A positive pressure breath that is controlled, triggered and cycled by the ventilator in accordance with programmed settings.

Assisted : A breath that is triggered by the patient, but controlled and cycled by the ventilator. Other than being triggered by the patient, an assisted breath is identical to a mandatory breath.

Supported :A positive pressure breath that is triggered and cycled by the patient but controlled by the ventilator. Supported breaths are delivered with positive pressure, but may vary in length, tidal volume or pressure depending on the patients respiratory muscle compliance. Spontaneous :A breath that is initiated controlled and ended by the patient without any input from the ventilator. Spontaneous breaths are negative pressure breaths.

2. Control variables

Pressure Volume Flow

Pressure = volume or Resistance x flow compliance Volume = flow x time

Ventilator respiratory cycle

The change from expiration to inspiration or what triggers (initiates) a breath. Inspiration or breath delivery; largely determined by the control variable.

The change from inspiration to expiration or what cycles (ends) a breath.

Expiration or a passive process dependent on time. Each of these phases has a set of variables associated with it.

3.Phase variables

Trigger
Machine

Cycling
Limiting
Volume Pressure Flow

Patient

Time Flow Volume Pressure

Triggering

Machine triggering Time triggered

Patient triggering Flow triggered Pressured triggered

Flow triggering reduces the work of breathing when compared with pressure triggering because there is always some background gas flow from the patient and no delay in inspiratory valve opening

Initiation of Mechanical Ventilation

Full Ventilatory Support (FVS)

Assumes essentially all the work of breathing Majority initially require FVS Assist Control (A/C) SIMV if rate is 12 BPM or higher Ex: ARF,apnea,depressed CNS, drug overdose,flial chest, stroke etc

Partial Ventilatory Support (PVS)

Provides less than total amount of WOB Allows pt to respond to paCO2, by Ve VQ match,HD,need for sedation,atrophy Common during weaning SIMV at lower rates <8 -10, PSV, BIPAP

Volume controlled mode

Volume limited, volume targeted

Pressure variable
ADVANTAGE Maintains constant tidal volume

Precise control of partial pressure of carbondioxide

DISADVANTAGE Potential for high airway pressure and acute lung injury Inability to compensate for leaks

Modes Graphical representation

CMV
Absent Respiratoryefforts Preset breaths/min-setTv Air hunger- WOB Bucking theventilatorPVD Disad : Rm weakness Hemodynamic prob Heavy sedation

Monitoring PIP Etv

Volume Assist-control (V-AC)

Volume Assist-control (V-AC)

Triggering device set Intact resp drive Pt controls B yet gives FVS Disadvantages: Respiratory alkalosis Ventilatory drive Auto- PEEP Monitoring PIP Etv Pt sense of comfort Ts & Flow rate (WOB) Acid base status HV-change mode SIMV consider sedation

Volume SIMV (V-SIMV)

Volume SIMV (V-SIMV)

Volume IMV, SIMV (V-SIMV)

IMV Pt gets set RR and Tv Demand valve placed in circuit with reservoir bag Disadvantage : stacking SIMV Sensor introduced- SB within a window assisted MB delivered if pt will not initiate in the window All SB not assisted Disadvantages

Normal resp drive not all WOB Less alkalosis, muscle atrophy, hemodynamic effects, gas distribution Monitor :- Total RR<30 - Spont Tv - PIP - Etv-leaks - PVD Reassure, sedate low dose, add PS

Pressure control ventilation

Pressure A/C: Respiratory rate is preset and every breath is augmented by preset amount of inspiratoty pressure. VT is not set- varies with breath

Pressure SIMV :A combination of pressure AC and spontaneous breathing

Pressure support : patients spontaneous respiratory activity is augmented by delivery of preset amount of inspiratoy +ve pressure

Pressure support ventilation-PSV in VCV & PCV

As inspiration ends on the basis of flow criterion (not pressure, time or volume), patient determines RR, Vt, inspiratory time a purely spontaneous mode Complements volume and pressure cycled modes. To overcome system resistance in the spontaneous or SIMV- PSVmode Set pressure at (PIP Pplateau) achieved in a volume breath or at 5 to 10 cm H20 to achieve a target VT
PSV alone : Used alone for recovering intubated pts who are for

weaning. Augments inflation volumes during spontaneous breaths

Volume control ventilation(vela)

Volume A/C Respiratory rate Tidal volume Peak inspiratory flow Inspiratory pause PEEP FiO2 Trigger sensitivity (flow trigger) Volume SIMV PSV additional parameter

Pressure control ventilation

Pressure A/C Respiratory rate Inspiratory pressure Inspiratory time PEEP Flow Trigger Fio2 Tidal volume is not set in pressure control Pressure SIMV PSV is additional

Volume control ventilation

Patient parameters on the side panel Spontaneous resp rate Mandatory resp rate Total respiratory rate Minute ventilation (VE) Spontaneous VE Inspired Tv (Vti) Exhaled Tv (Vte) Inspiratory time (Ti) Expiratory time (TE) I:E ratio P peak P mean PEEP O2 inlet pressure FiO2

Mechanical Ventilation

Double edged weapon

Initial Ventilator Settings Volume Controlled Ventilation

Minute ventilation
VE for a male = 4 x BSA VE for a female = 3.5 x BSA

BSA =0.007184 X Ht 0.725 X Wt 0.425

Increase this by 5% per F above 99 F or 9% per C above 37 C 20% for metabolic acidosis 5% per 2000 feet above sea level 50 % to 100% increased in direct proportion with REE Decrease this by 9% per C between 35 C and 37 C

VE : Wt in kgs = Ht in cms 100 (M), Ht in cms 95 (F) 100ml/kg

Initial Ventilator Settings Tidal volume (VT)

Minimum of 4-5 ml/kg IBW Maximum up to 10 ml/kg IBW in lbs

For Women IBW (lbs) = 105 + 5(H - 60) For Men IBW (lbs) = 106 + 6(H 60)
where H is height in inches. (to convert to kg, divide by 2.2). Predicted Body Weight in kilograms

50+0.91 (Ht in cms 152.4) for males 45.5+0.91 (Ht in cms 152.4) for females

Tidal volume- contd

Initial setting is 8-10ml/kg IBW Ideally, a tidal volume should be chosen that maintains a PPlat <30 cm H2O Maintain adequate Tv irrespective of mode Tidal volume actually delivered to the patient is usually lower than the ventilator delivered tidal volume Tve (50ml)

Causes

- Leakage from ventilator circuit

- Leakage from ET Tube cuff - Circuit compressible volume loss (pediatrics, low Tv)

Tidal volume- contd

Circuit Compressible Volume Loss

The amount of volume lost can be added to the VT setting to ensure that the patient is receiving the desired tidal volume

Example: A patients estimated VT is 400 ml. Her peak pressure reading during inspiration is 30 cm H2O and circuit compression factor is 2.9 mL/cm H2O.How should you set the desired VT? Volume lost = 2.9 mL/cm H2O x 30 cm h2O = 87 ml.Actual volume received by the patient = 400 87 mL = 313ml To compensate,increase set VT to 487 mL to deliver the 400ml

Respiratory Frequency (f)

Radford nomogram determines the respiratory rate if Weight of the patient and Tidal volume required is known or Minute ventilation calculated on the basis of Brocas index / BSA is divided by Tidal volume in litres f = VE / VT

Inspiratory pause: Improves gas distribution and reduces Vd/Vt ratio. Clinically used to estimate plateau pressure.

Peak inspiratory flow rate

Peak flow rates set low (20-50L/min) : PIP, better distribution of gases and Ti. Peak flow should be increased if Ti has to be reduced as in OAD (>60 L/min) The flow control is usually calibrated in L/min, so the value for flow needs to be converted to L/sec. (Ex;30 lit/min = 0.5 lit/sec) Changing flow patterns may affect PIFR, TI and/or TE depending on the ventilation type

Inspiratory flow rate

Flow rate = MV x Sum of I : E Ratio (3-5times VE)

PIFR is c.determinent of Ti & hence IER. So PIFR is adjusted for each pt on the basis of desired IER

VT x f x ( I + E Ratio)
High flow rate

Low flow rate Longer inspiratory time Lower PIP Better distribution of gases

Short inspiratory time High PIP Higher expiratory time

Take a Walk in My Shoes

To see how the patient feels when inspiratory flow is insufficient, try this. Exercise vigorously enough that you feel a bit short of breath. Now place a drinking straw between your lips and form a tight seal. Pinch your nose, and breathe only through the straw. How does it feel?

PCV settings
Set inspiratory pressure to achieve VT as calculated for VCV. Set frequency to achieve same VE f = VE /VT
Inspiratory time (Ti): Set inspiratory percentage to achieve an I/E ratio of 1 : 2.

Types of Waveforms
Pressure Modes Volume Modes

Volume

Flow

Pressure

Time

Flow Patterns
Constant Flow-rectangular/square Sine flow Ascending ramp Descending ramp Decaying exponential

Flow pattern selection

Use a constant flow pattern initially because it enables the clinician to obtain baseline measurements of lung compliance and Raw - common default pattern VCV Decelerating flow is at peak at the onset of inspiration and gradually decelerates-alveolar recruitment in non homogenous lungs- paO2, PIP.
Flow pattern selection is not specific if Paw, gas exchange and hemodynamics are similar. Requires careful monitoring.

Selection of Fio2
Is fractional inspired conc. of oxygen (FiO2 0.6 = 60% O2)
The goal in selecting FiO2 is paO2 60 - 100 mm Hg. If the PaO2 is not in the desired range, the following equation

can be used to estimate FiO2

Initiate with higher FiO2 (0.7-1.0) and titrate after initial ABG

Desired FiO2 = [PaO2 (desired) x FiO2 (known)] 1. PaO2(known)

If more than 0.6 is required, consider additional strategies

Oxygenation strategies
prio rity 1 Increase FiO2 Methods

2
3

Improve ventilation & reduce mechanical dead space

Improve circulation-fluid replacement (Hypovolemia) vasopressors (shock) cardiac drugs (CHF)

4 5 6

Maintain normal hemoglobin level Initiate CPAP only with adequate spontaneous ventilation Consider APRV

7
8 9

Initiate PEEP - titrate optimum PEEP

Consider inverse ratio ventilation- increases dwell time Consider ECMO, HFV, hyperbaric oxygenation or IVOX device

Trigger sensitivity setting

Sensitivity is normally set so that patients can easily flow or

pressure-trigger a breath.

Flow triggering is set in a range of 1 to 3 L/min below the base

flow.
Pressure sensitivity is commonly set between -0.5 and -2 cm

H2O.
Flow triggering is now the preferred method of triggering,

because it has a slightly faster response time

PEEP

PEEP 5-20cm H20 PEEP and FiO2 are adjusted in tandem

Increases FRC Recruits collapsed alveoli and improves V/Q matching Enables maintenance of adequate PaO2 at a safe FiO2 level Disadvantages :Increases intrathoracic pressure, barotrauma

Lung protection
Peak air way pressure < 40 cm of H2O
Mean Airway pressure < 25 cm of H2O Plateau pressure < 30 cm of H2O

BAROTRAUMA

Derived parameter I:E ratio

Duration of inspiration in comparison with expiration (I:E ratio) Normal Ti should make 33% of respiratory cycle range 0.3-4sec 66% time is spent on expiration Normally set at 1: 2 (Range: 1:1.5 1:4) I:E ratio is a function of flow rate , inspiratory time and frequency

In some ventilators Ti / %Ti are set where RR & Tv control flow In other ventilators (vela) peak inspiratory flow rate , RR needs to deliver tidal volume in comfortable time determine I:E

I : E Ratio
Determined mainly by inspiratory flow rate High flow rate Short inspiratory time I:E ratio changes Higher expiratory time

I:E Ratio ~ VT, Ti flow rate, RR

Ventilation strategies
prio rity Methods

Increase mechanical rate - control rate in A/C mode

- SIMV rate

Increase spontaneous tidal volume- nutritional support - bronchodilators -largest ETT, initiate PSV Increase mechanical tidal volume Tv

Reduce mechanical dead space - low compliance circuit

- shorten ETT, tracheostomy

Consider HFJV, HFOV

Guide lines for initiation of mechanical ventilation

Initial FiO2 should be 1.0 there after titrated to maintain oxygenation so that SpO2 is 92-94% Initial tidal volume = 8-10ml/kg in pts with normal compliance Maintain peak inspiratory pressure < 50mmHg

Maintain inspiratory plateau pressure 30mmHg

Choose appropriate respiratory rate and minute ventilation to target pH, but not paCO2

TI should contribute to 33% of TCT

Set the trigger sensitivity to allow minimal effort to inspiration. Beware of autocycling.

Set a PEEP of 5 to 10 cm H2O to support the cardiac function.

Ventilator alarm settings

High Minute Ventilation Set at 2 L/min or 10%-15% above baseline minute ventilation Patient is becoming tachypneic (respiratory distress) Ventilator is self-triggering High Respiratory Rate Alarm Set 10 15 BPM over observed respiratory rate Patient is becoming tachypneic (respiratory distress) Ventilator self-triggering

Ventilator alarm settings

Low Exhaled Tidal Volume Alarm Set 100 ml or 10%-15% lower than expired mechanical tidal volume Causes

System leak Circuit disconnection ET Tube cuff leak

Low Exhaled Minute Ventilation Alarm Set at 2 L/min or 10%-15% below minimum SIMV or A/C backup minute ventilation Causes

System leak Circuit disconnection ET Tube cuff leak

Ventilator alarm settings

High Inspiratory Pressure Alarm Set 10 15 cm H2O above PIP Common causes: Water in circuit Kinking or biting of ET Tube Secretions in the airway Bronchospasm Tension pneumothorax Decrease in lung compliance Increase in airway resistance Coughing

Ventilator alarm settings

Low Inspiratory Pressure Alarm Set 10 15 cm H2O below observed PIP Causes System leak Circuit disconnection ET Tube cuff leak High/Low PEEP/CPAP Alarm (baseline alarm) High: Set 3-5 cm H2O above PEEP Circuit or exhalation manifold obstruction Auto PEEP Low: Set 3-5 cm H2O below PEEP Circuit disconnect

Ventilator alarm settings

Apnea Alarm Set with a 15 20 second time delay In some ventilators, this triggers an apnea ventilation mode High/Low FiO2 Alarm High: 5% - 10% over the analyzed FiO2 Low: 5% - 10% below the analyzed FiO2

High/Low Temperature Alarm Heated humidification High: No higher than 37 C Low: No lower than 30 C

Mechanical ventilation in ALI/ARDS

GOALS: PaO2: 55-80mm Hg(7.3-10.7kPa) Pplat : </=30 cm H2O VT:6mL/kg PBW pH:>7.15 is acceptable START WITH ASSIST/CONTROL WITH VT OF 8mL/kg

Decrease by 1mL/kg at a time over the next 4 hours until VT of 6mL/kg is reached. If Pplat >30cm H2O, decrease VT by 1 mL/kg at a time until VT is 4mL/kg or arterial pH reaches 7.15.

Contd..

If using VT of 4mL/kg and Pplat is <25cm H2O, VT can be increased until Pplat is 25cm H2O or VT is 6ml/kg again. If Pplat of </=30cm of H2O is achieved with a VT>6ml/kg and a lower VT is clinically problematic (i.e. need for sedation), a higher VT is maintained.

INITIATION OF PEEP IN ARDS Initiate PEEP at 5cm H2O and titrate up in increments of 2cm of H2O. Full recruitment effect may not be apparent for several hours.

Monitor BP,HR & PaO2 or SpO2 during PEEP titration and at intervals while the patient is receiving PEEP therapy Optimal PEEP settings are typically 8-15cm of H2O

AECOPD
Acute exacerbation of COPD with dyspnea, tachypnea, and acute respiratory acidosis plus at least one of the following: Acute cardiovascular instability Altered mental status/persistent uncooperativeness Inability to protect the lower airway Copious or unusually viscous secretions Abnormalities of the face or upper airway that would prevent effective NIPPV

Basic guide lines for copd

As far as possible use noninvasive ventilation to help avoid problems associated with artificial airway use (Bilevel PAP)

It has been noted that VC- or PC-CMV may unload the work of the respiratory muscles more than SIMV

AC mode in an alert patient with COPD may increase the risk of hyperinflation and elevated lung pressures - monitored carefully

COPD - Guidelines
Ventilatory support should be restricted to 24-48hours unless otherwise indicated

VT of 6to 8mL/kg with a rate of 8 to 12 breaths/min, and TI 0.6 to 1.2

sec is acceptable

New RR = Rate x PaCO2(current) PaCO2(desired)

Provide the longest expiratory time (TE) possible.(I:E ratio 1:3 1:4) This might include decreasing TI, increasing TE, reducing f and/or VT, and permissive hypercapnia (e.g., PaCO2 = 50 to 60 mm Hg; pH 7.30 to 7.40) PEEP 5 cm H2O or about 50-80% of auto- PEEP can be used initially.

Guidelines for asthma

With PC-CMV it is easier to keep the pressures controlled PIP may be high due to the high Raw Plateau pressures must still be kept low (<30 cm H2O) despite the high PIP An FIO2 , 0.5 as needed to keep the PaO2 60 -100 mm Hg. Permissive hypercapnia (PaCO2 45-80 mm Hg) as long as pH range is 7.10 to 7.20. Sedation and paralysis may permit resting of fatigued respiratory muscles, particularly during the first 24 hours.

Guidelines for asthma contd

Avoid or reduce air trapping (auto-PEEP) by providing long expiratory times f = <8 breaths/min VT = 4 to 8 mL/kg; TI= 1 sec Inspiratory gas flow = 80 to 100 L/min descending flow waveform. The occurrence of barotrauma in the form of pneumothorax monitor for this potential problem

Guidelines for ACPE and CHF

NPPV improves oxygenation, PaCO2, WOB, and reduce myocardial work, allow time for drugs to become effective. In severe CHF, PEEP and/or PPV may have beneficial effects on myocardial function and improve oxygenation.

Careful evaluation, particularly if PEEP > 10 to 15 cm H20

The use of VC- or PC-CMV is recommended to avoid spontaneous breathing, which may divert increased blood flow and oxygen consumption to the respiratory muscles.

Initial Ventilator Settings Based on Pulmonary Disorder

Lung Disease Mode VT Rate Flow Flow (mL/ Breaths L/m Wave in form kg /min IBW)
10 to 12 8 to 12 60

TI Sec

PEEP FIO2 cm H20

5 0.5

Normal Lungs

VC- or PCCMV

Descendi 1 ng or constant

COPD

VC- or PCCMV

8 to 10

8 to 12

>60( Descendi 0.6- 5 or 80ng or 1.2 50% 100) constant of Auto PEEP
60 Descendi 1 ng or constant 5

<0.5

Neuromusc VCular CMV Disorder

12 to 15

8 to 12

0.21

Lung Disease

Mode

VT Rate Flow Flow (mL/ Breaths L/m Wave in form kg /min IBW) 4 to 8 < 8 80100

TI Sec

PEEP FIO2 cm H20 Only to offset autoPEEP 5 to >15 0.5

Asthma

VC- or PCCMV

Descendi 1 ng

ARDS

VC- or PCCMV VC- or PCCMV

4 to 8 15 to 25 60 Descendi 1 ng or constant 8 to 10 10 60

CHF

Descendi 1 to 5 to 10 1 ng or 1.5 constant

Dual control modes

Dual control within a breath Dual control breath to breath

VAPS

PRESSURE LIMITED FLOW CYCLED

PRESSURE LIMITED TIME CYCLED

VS

PRVC

INSPIRATORY TIME, TIDAL VOLUME, AND FLOW

TI can be determined when VT and flow are known and the flow pattern is a constant or square waveform.

TI = VT / Flow

If VT is 0.5 L and flow is 1 L/sec, then TI equals 0.5 L/1L/ sec, or 0.5 sec. Conversely, VT can be determined when TI and flow are known and flow is constant:

VT = flow X TI

If TI is 2 sec and flow is 0.5 L/sec, VT = (2 sec) X (0.5 L/sec) = 1 L

CALCULATING TOTAL CYCLE TIME AND FREQUENCY

Some ventilators use TI and TE or TCT to determine ventilator frequency. To determine these values, calculate the length of the respiratory cycle and see how many cycles occur in 1 minute.

TCT = TI + T E
For example, if the TI is 2 sec and the TE is 4 sec, then: TI+ TE = 2 sec + 4 sec = 6 sec 60 sec/ TCT = f 60 sec/ 6 sec = 10 breaths in a minute

Initiation of Mechanical Ventilation

Initial Ventilator Settings

Flow Pattern

(Oakes Ventilation Management; ch.5)

Pressure control ventilation

Neuromuscular Disorders
These usually have a normal ventilatory drive and nearnormal lung function. Most of these disorders cause respiratory muscle weakness, so these patients have trouble coughing and clearing secretions and tend to develop atelectasis and pneumonia. They have a risk of aspiration due to weak glottic response. Ventilation for progressive respiratory muscle weakness that eventually leads to respiratory failure (e.g., Guillain-Barre and myasthenia gravis).

Guiidelines- NM Disorders
Patients with spinal cord injuries- quadriplegia require full ventilatory support. Other patients only require partial support until their own breathing capacity returns (myasthenia gravis).

Negative or positive pressure ventilation Noninvasive or invasive ventilation Assist/Control mode (CMV) Volume ventilation High VT (10 mL/kg) f = 8 to 12 breaths/min Inspiratory flow rates 60 L/min to meet patient need Flow waveform: constant or descending ramp PEEP = 5 cm H2O may be needed to relieve dyspnea FIO2 = 0.21- 0.4

Flow suddenly increases during inspiration (dashed line and shaded area). There is slight dip in the pressure curve that occurs simultaneously with an increase in flow. The dashed lines represent actual flow, pressure, and volume delivery. The solid line represents the process without active patient inspiration.