Mechanical Ventilation

A Beginner's Guide

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Determinants of Gas Concentration

PaO2

PaCO2

Determinants of Gas Concentration

PaO2

FiO2

PaCO2

Determinants of Gas Concentration

PaO2

FiO2

Alveolar Ventilation

PaCO2

Determinants of Gas Concentration

PaO2

FiO2

Alveolar Ventilation

Shunt / VQ mismatch

PaCO2

Determinants of Gas Concentration

PaO2

FiO2

Alveolar Ventilation

Shunt / VQ mismatch

PaCO2

Metabolic Rate

Determinants of Gas Concentration

PaO2

PaCO2

FiO2

Metabolic Rate

Alveolar Ventilation

Alveolar Ventilation

Shunt / VQ mismatch

Respiratory Failure

Type 1
O2

Type 2
O2

CO2

O2
Pneumonia
Bronchiolitis
Contusions
Atelectasis
Pulmonary oedema
ARDS
PE

Type 1

O2

CO2

CNS depression
Neuromuscular disorders
Pulmonary fibrosis
COPD
Asthma
Airway obstruction

Type 2

O2
Pneumonia
Bronchiolitis
Contusions
Atelectasis
Pulmonary oedema
ARDS
PE

Type 1

O2

CO2

CNS depression
Neuromuscular disorders
Pulmonary fibrosis
COPD
Asthma
Airway obstruction

Type 2

Modes of Ventilation

Modes of Ventilation
Types of Breath
Mandatory

Spontaneous
Assisted

Modes of Ventilation
Types of Breath
Mandatory

Spontaneous
Assisted

Trigger

Flow
Pressure

Neuromuscular
impulse

Modes of Ventilation
Types of Breath
Mandatory

Trigger

Spontaneous

Flow

Assisted

Pressure

Limit (cycle)

Volume
Pressure
(time)

Neuromuscular
impulse

Neuromuscular
impulse

Ventilation Limit

Ventilation Limit
Volume

Ventilation Limit
Volume
Pressure

Ventilation Limit
Volume
Pressure
Neuromuscular impulse

Modes

Modes
Continuous Mandatory Ventilation (CMV)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
SIMV

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)

Pressure Support

Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)

Pressure Support
Neurally Adjusted Ventilatory Assist

Modes of Ventilation

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Modes of Ventilation
Assist Control
(Pressure Control)

Greatest MAP for least PIP

SIMV + PS
(volume control)

easier control of tidal volume

less prone to accidental hyperventilation
breath stacking somewhat less likely

Pressure Support

Weaning

NAVA

Weaning

Lung Protective Ventilation

Lung Protective Ventilation

Oxygen Toxicity

Biotrauma

Volutrauma

Ventilator Induced Lung Injury

Tidal Volume
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute
lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress
Syndrome Network. N. Engl. J. Med. 2000 May 4;342(18):13018

10 University Hospitals of North America - The ARDS Network

RCT - Vt 12 vs 6 mL/Kg ideal body weight
861ventilated patients with ARDS / ALI
180 day mortality 31.0% vs 39.8% P=0.007

PEEP
Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher
versus lower positive end-expiratory pressures in patients with the acute respiratory
distress syndrome. N. Engl. J. Med. 2004 Jul. 22;351(4):32736

10 University Hospitals of North America - The ARDS Network

RCT - High PEEP vs Low PEEP stratergy
861ventilated patients with ARDS / ALI
180 day mortality 31.0% vs 39.8% P=0.007

PEEP

Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive
end-expiratory pressure in patients with acute lung injury and acute respiratory distress
syndrome: systematic review and meta-analysis. JAMA. 2010 Mar. 3;303(9):86573

10 University Hospitals of North America - The ARDS Network

RCT - High PEEP vs Low PEEP stratergy
861ventilated patients with ARDS / ALI
180 day mortality 31.0% vs 39.8% P=0.007

PEEP
PEEP (cmH2O)
Low

High

0.3

12

0.4

14

0.5

10

16

0.6

12

18

0.7

14

20

0.8

14

22

0.9

18

22

1.0

20

24

30
High PEEP
Low PEEP

25

20
PEEP cmH20

FiO2

15

10

0.3

0.4

0.5

0.6

0.7

FiO2

0.8

0.9

Lung Protective Ventilation

Oxygen Toxicity

Biotrauma

Volutrauma

Atelectatrauma

Ventilator Induced Lung Injury

Healthy Lung

Volume

Pressure

Healthy Lung

Volume

PEEP

PIP

Pressure

Poorly Compliant Lung

Volume

PEEP

PIP

Pressure

Poorly Compliant Lung

Volume

PEEP

PIP

Pressure

Heterogeneous Lung

Volume

PEEP

PIP

Pressure

Heterogeneous Lung

Volume

PEEP PIP

Pressure

High Frequency Oscillatory Ventilation

High Frequency Oscillatory Ventilation

f
Vt
Mean
Airway Pressure

3 - 10 Hz
(180 - 600 breaths per minute)
5 - 30 ml
35 - 45 mmHg

High Frequency Oscillatory Ventilation

f
Vt
Mean
Airway Pressure

3 - 10 Hz
(180 - 600 breaths per minute)
5 - 30 ml
35 - 45 mmHg

High Frequency Oscillatory Ventilation

f
Vt
Mean
Airway Pressure

3 - 10 Hz
(180 - 600 breaths per minute)
5 - 30 ml
35 - 45 mmHg

High Frequency Oscillatory Ventilation

f
Vt
Mean
Airway Pressure

3 - 10 Hz
(180 - 600 breaths per minute)
5 - 30 ml
35 - 45 mmHg

High Frequency Oscillatory Ventilation

f
Vt
Mean
Airway Pressure

3 - 10 Hz
(180 - 600 breaths per minute)
5 - 30 ml
35 - 45 mmHg

High Frequency Oscillatory Ventilation

f
Vt
Mean
Airway Pressure

3 - 10 Hz
(180 - 600 breaths per minute)
5 - 30 ml
35 - 45 mmHg

High Frequency Oscillatory Ventilation

Pillow et al.
Crit Care Med 2005 Vol. 33

Key Points
Understand the nature of your patients respiratory failure
Choose the mode of ventilation appropriate for your patient
Vt 6 ml/Kg (ideal body weight)
Titrate PEEP to FiO2 or recruit and use the open lung tool