Page 102-105

Positive Pressure Ventilation

All external applications of mechanical ventilation largely require a method of administering
positive pressure for delivery of a predetermined volume of gas. Positive pressure ventilation
is related to the creation of a super atmospheric pressure (greater than 760mm Hg), which
generated at the upper airway. The resultant pressure gradien between the upper airway and
the alveoli then allows for the pushing gas volume. This delivery system may be administered
via a mask system ( noninvasive) or invasively via an ET tube or tracheostomy. The concept,
put quite simply, is to decrease the need for the development of a significant negative
pressure or force, supplanting that requirement with the super atmospheric pressure.

Noninnvasive Positive Pressure Ventilation (NIPPV OR NPPV)

Positive pressure support may be administered via a mask, nasal mask, helmet, or mouth seal.
This may also be presented as CPAP or BIPAP. The early application of NPPV or
noninvasive mechanical ventilation (NIMV) may enhance respiratory rescue and may be
appication include airway obsrtuction disorders, chest wall disease, neuromuscular weakness,
and sleep related breathing disorders.
1. CPAP A mode of assistance with positive pressure via application of a constan
pressure to the airways. This method does not supply any volume breath, rather
maintains airway and alveolar opening in order to facilitate inspiration and decrease
collaps during exhalation. Very similliar in concept and design to methods applied for
sleep apnea.
2. BIPAP a mode of ventilatory assitance that uses alternating inspiratory possitive
pressure (IPAP) and expiratory possitive pressure (EPAP) to enhance variable
spontaneuos tidal volumes. The resistance and complience of the airways will
determine the IPAP driving pressure necessary to produce a desired tidal volume.
The level of EPAP needed is based on the oxygenation status of the patient. The
Physician determine goal (ussually 8 to 12 ml/kg) and an oxygenation goal the
clinician will use to determine the titration range for IPAP, EPAP, and Fi02. BIPAP
(may be reffered to as Bi Level) mode can be found on many conventional ventilators
and on freestanding units used for NPPV.

Invasive Mechanical Ventilation

After intubation, the nurse or respiratory therapist should do the following :
1. Confirm the placement of the ET tube using a CO2 detector and then auscultate for
bilateral breath sounds.
2. Mark and chart the centimeter mark on the tube using the teeth as a reference point.
3. Secure the tube to the face and head.
4. Cut/ shorten the tube to reduce dead space, taking care not to cut the pilot ballon, so
only 4 cm protrudes from the teeth.

5. Over the next 4 hours, monitor for the development of a life threathening tension
pneumothoraks, by assesing for hipoxia, bradycardia, tachycardia, and moderate to
life threathening hypotension.

Basic Ventilation Modes

Assist Control Ventilation (A/C or ACV)
This mode can be used with either volume or pressure as a limit. In assist control (often
labeled volume control, or pressure control of ACV), patients may receive either
controlled or ventilators deliver breath. The inspiratory flow rate is measured in liters per
minute, and it determines how quickly the breath is delivered. The time required to
complete inspiration is determined by the tidal volume delivered and the flow rate Ti =
Vt/ flow rate. The breath is limited by reaching either the preset volume (volume control)(VC) or pressure (when volume is delivered reaching a predeterminated pressure
(pressure control((PC).
The patient can generate a request for an additional breath between mandatory ventilator
breath and the ventilator will turn on delivering breaths at the preset volume or pressure
control levels.
All breath in ACMV are ventilator assited : Set rate plus patient generated request (
effort).
Ventilator rate + Patient request rate = Total Respiratory Rate
Every breath, whether ventilator determined or patient requested, is a ventilators breath
and predetermined for either pressure or volume control.

Synchronized Intermittent Mandatory Ventilation (SIMV)

The different between ACMV and SIMV is that in SIMV the patient may take
spontaneous NON- VENTILATED breaths between the required ventilator breath. In
addition, the ventilator is synchonized to deliver the mandatory breath (controlled volume
or pressure) when the patient intiates inspiration. SIMV is generally administered in
conjunction with pressure support, which is applied on spontaneous flow by breath.
Only set rate breath in SIMV are ventilators assited. Set rate plus patient generated
request (effort).
Ventilator rate + Patient Request Rate = Total Respiratory Rate
VOLUME VERSUS PRESSURE CONTOLLED MECHANICAL VENTIALTION
VOLUME CONTROL
PRESSURE CONTROL
Volume delivery constant
Volume delivery varies
Inspiratory pressure varies
Inspiratory pressure constant
Inspiratory flow constant
Inspiratory flow varies
Inspiratory time determined by set flow Inspiratory time set by clinician
and Vt

Pressure Support Ventilation (PSV)

PSV augments or support a patient spontaneous inspiration with a preselected pressure
level. Pressure is applied (via flow of gas) at the initiation of inspiration and ends when a
minimun inspiratory flow rate is reached.PSV creates less patient discomfort and
diphragmatic stress than assist control or SIMV alone. These two methods are flow
triggered/ limited and (pressure) and volume controlled.
Mode and method of ventilation should be determined by patient need and provider
expertise rather than by individual bias.

Breath Limit
1. Time limited or cycled: Relates to time that inspiratory flow is administered and is
determined by a preset time or percent of cycle that relates to inspiration.Inspiratory
time is increased to deliver a volume controlled or pressure controlled breath over a
longer time of the breath cycle.
2. Pressure Controlled (PC) : The peak inspiratory pressure (PIP) is preset based on
the estimated tidal volume reqiurements.A smaller tidal volume may be given if the
preset pressure is reached too soon, such as in a state of flow compliance or high
airway resistance.
3. Volume Control (VC) : Volume is preset and the pressure is variable in order to
deliver the preset volume.

Basic Ventilation Adjuncts

Positive End Expiratory Pressure (PEEP) and Alveolar Mechanics
The application of trapping of fresh gas (flow) is known as PEEP. PEEP increased
functional residual capacity (FRC) and compliance while decreasing dead space
ventilation. Generally, PEEP pressure range from 2,5-20 cm H2O. Higher pressure
(greather than 35 cm H2O) may be used if the patient can tolerated the increased and if
the condition is warranted.