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2020

VENTILATOR

INTRODUCTION

If you’ve never done mechanical ventilation before we’re going to introduce you to the basics so you can
go in and actually feel competent about managing a patient on a ventilator. We’re going to start with
the basics starting right now.

DEFINITION - The first thing you’ve got to know is you’ve got to know the definition of some of these
things. You’ve got the patient. That’s pretty easy. Then you’ve got this thing coming out of their mouth.
That’s the endotracheal tube. We’re going to show this a little bit more later. Then, you have it hooked
up to a big machine with a bunch of knobs on it, and dials and output. This is what we know as the ET
tube. That’s the endotracheal tube. Then finally you’ve got the actual ventilator. That’s important to
know because sometimes people are intubated. That means we put a tube down into their mouth
because they need airway protection. Sometimes we do it, in other words, because they can’t protect
their airway. They can’t protect stuff, liquids and solids, from going down their airway where that stuff
shouldn’t go. Needlessly because of this, it’s not too comfortable. We’ve got to sedate them and when
we sedate them, we’ve got to put them on a ventilator. That might be one reason we would have to do
this. The other reason is because they can protect their airway okay but they just can’t breathe on their
own. They’re struggling to breathe so we help them out with the mechanical portion of breathing and
that’s where the ventilator comes in.

The way we deliver that is through the endotracheal tube. It’s kind of important to know what an
endotracheal tube looks like. The basic is pretty much the same all the way around. It’s this long tube
that kind of looks like this. That’s the part that connects to the ventilator. This is the part that goes
inside the patient. Actually, you’ll see that there is a balloon on the end of that endotracheal tube and
the thing that allows you to blow it up is a little thing that goes up, called the pilot balloon. It goes up.
Actually, the pilot part comes out and it looks like a little pilot balloon that youcan kind of feel what the
pressure is. Then there’s a little part where you can inject air into it. When this goes down and you
intubate somebody it goes into their mouth past their vocal cord, specifically, and down into the
trachea. The vocal cords usually end up about right here so this is going down into somebody’s trachea.
Then usually it branches off. You’ve got the left and the right main stem bronchus. Here you have the
endotracheal tube going down. Now, this balloon gets inflated here so that stuff that might make it
down here doesn’t go past and go into the lungs. It’s called airway protection. We blow up the balloon
here after we intubate them to make sure that happens. In some versions of this still have a little device
right here that also comes out. The purpose of that is to suck secretions that might come up and go out
and that’s called subglottic suctioning. That’s kind of an option. This is the basic anatomy of an
endotracheal tube. Of course we just talked about the ventilator. That’s got a bunch of buttons and
whistles and things were going to talk about a little bit. Going back to our patient again. We’ve got our
endotracheal tube.

We’ve got our ventilator. What’s the purpose of this ventilator? The purpose of the ventilator is to
maintain homeostasis between the due gas concentrations that we’re talking about here, which is
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carbon dioxide and oxygen. Oxygen is being put into the patient and carbon dioxide is coming out. For
the most part we want to keep those close to normal. There’s some exceptions to that. Here’s the point
though. There’s many different ways to put air into somebody. We can say we’re going to put air into
somebody based on volume. We’re going to put a certain X amount of volume into somebody and then
let it come back out. That’s one way of doing it. Another way of ventilating somebody is saying we’re
going to inflate them to a certain pressure. We’re going to have this ventilator put a certain amount of
pressure into the patient and then when the pressure is released it’s going to come back out. We can do
that. Now, we can do it at a certain rate. We can do this fast and we can do it slow so in other words,
how many breaths per minute. We can also adjust the flow rate. In other words, we can put a certain
volume in but we can get that volume slowly or we can give that volume very quickly. The other thing
that we can do is we can decide how much pressure to leave in there at the end of when we put the air
in and then we can decide how much pressure to leave in there after we’re done putting the air in.
Finally, we can decide how much oxygen we want to put in there. How much? We can put a lot or we
can put a little. Now, just to further complicate this just so you can kind of see where we’re going with
this, we can have the ventilator be in charge of when the patient gets a breath or we can have the
patient be in charge of when they want to get a breath.

Think about all of these different variabilities. Now, you can quickly see how there are so many different
ways that you can ventilate somebody and each one of these ways is a different mode of ventilation.
You may have heard of these before, like AC or SIMV or pressure support, or CPAP. These are all
different modes and we’re going to go through some of these modes and show you how it makes sense
about how this is working. Here’s our system. Over here, we’ve got the ventilator. Here, we’ve got the
tubing that goes to the endotracheal tube down into the lungs and we’ve got our balloon here, filled
with air to make sure nothing else gets down there. We are ventilating our right lung and our left lung.
Let’s talk about the first mode of ventilation. This will become important later.

MODE

ASSIST CONTROL - The first mode that I want to talk about is AC. The other way we call it is assist
control. The other name for it also is continuous mandatory ventilation or CMV. This is the most
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common mode of ventilation that you’ll see, especially on a medicine floor or medicine unit. The key
here is that the patient triggers the vent. How does that happen? Well, the patient takes a breath in and
therefore there is a negative pressure here, which causes a negative pressure to be sensed here, at the
ventilator. The other way you can sense it is by flow, if there is a flow that actually goes through here by
the negative pressure. As soon as the ventilator picks up on that negative pressure, it’s going to deliver a
specific volume. There is an actual dial on here where you can actually turn the knob to a specific
volume or you can enter it in. That volume can be anywhere from 500 CC’s all the way up to 600 CC’s,
usually. The ideal way of ventilating somebody would be around eight milliliters per kilogram, ideal body
weight. Anyway, whatever that volume is, it’s going to deliver that specific volume in AC mode
ventilation. Now, the patient can trigger it. You could also set up a backup mode or a rate. What does
that mean? If I set the rate to, for instance, twelve because there are twelve, five second intervals in one
minute. That means every five seconds the ventilator will give a breath to the patient of a specific
volume, every five seconds only if the patient does not take a breath. If the patient is breathing above
twelve then the ventilator will only give breaths when the patient triggers it by trying to take a breath in.
In other words, if you set the mode to AC, set in a volume and set a rate of twelve, the patient can never
breathe less than twelve times per minute.

Now there’s something you should understand about this, which is very important. You may recall from
chemistry and equation that says PV equals nRT. In this system temperature is constant. R, of course, is
always a constant and is a constant. The thing that you must realize is that pressure and volume are
inverse in proportional to themselves. In other words, as the volume of the gas goes up the pressure
goes down, if you have the same amount of gas. However, the other way of looking at this is compliance
which I’ll abbreviate as a C. Compliance is equal to the change in volume over the change in pressure,
which means to say that if the pressure changes a little bit and the volume changes a lot, then you have
a very compliant lung. If you don’t have a very compliant lung, it’s going to take a lot of pressure to
make just a small amount of change. Here’s the point. The point is that these set of lungs have a specific
compliance and if you are delivering a specific volume into these lungs, you are going to get a specific
pressure after you deliver that volume. That pressure can change depending on the compliance. The
point of this is that you need to have a readout that tells you what the pressure is in that lung so you can
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know what the compliance is. In other words, in this mode of ventilation, you set the title volume and
the ventilator will tell you what the pressure is so you’re setting the title volume. You’re setting how
much volume of gas is going to go into the lung and based on the compliance of the lung, it will tell you
what the pressure is. If the compliance of the lung goes down, then typically you’ll have higher
pressures. If the compliance of the lung is very high, in other words a very compliant lung, then your
pressures are going to tend to be on the lower side.

PRESSURE CONTROL - Now, let’s make this converse to pressure control. In pressure control what we’re
doing is we’re setting a pressure. In other words, we’re going to decide how much pressure we’re going
to ventilate this patient with. As you can imagine, if we’re setting a pressure, there is a specific
compliance to this lung, depending on what state it is in, and if we set a certain pressure if the
compliance of this lung is very low, then you can imagine we’re going to have lower volumes. However,
if the compliance of this lung is very high, then we’re going to have higher volumes because remember
compliance is equal to the change in volume over the change in pressure. In pressure control, you can
also have the patient or time triggering a set change in pressure. Depending on the compliance, the
volume can change. The key here is that you have to have alarms set up and you need to know and
understand what those alarms mean. What could happen here, let’s for instance say in a pressure
control situation where you’re giving a specific pressure, if the compliance of these lungs somehow drop
precipitously all of a sudden because of some pathology, which we’ll get into, you will notice the
volumes will drop. You would want to know that. You could set an alarm on the lower side of the
volume so that if the volumes did go down, an alarm would go off saying that you’re not ventilating.
Conversely, if you were back in our previous mode which was assist control and you’re setting a certain
volume, if the compliance of the lung dropped in that situation then, as you would realize, the pressure
would start to go up because you’re trying to put a set amount of volume into a low compliant lung.
When that happens, the pressure goes up. The pressure would then trigger an alarm. The point here is
in pressure control, you’re setting a pressure and your output to read is your volume. In AC, it’s the flip
of this.
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CPAP or PEEP - CPAP is typically the term that is used if this is non-invasive ventilation. In other words,
instead of putting a tube down into someone's throat, we instead did a mask to fit over their face. Like a
BiPAP mask or a CPAP mask, in fact, it's what it's called. That would be more CPAP. If you have a
ventilator on invasively then it's known as PEEP.

What is this, what is this mode of ventilation? This mode of ventilation is simply, you're not dialing in a
vent setting. You're not dialing in a specific volume, in fact, what you are dialing in however, is a
pressure. But this pressure is continuous. In other words, it doesn't matter whether the patient is
breathing in or whether the patient is breathing out. They're always getting the same amount of
pressure. You can set CPAP anywhere from 5 centimeters of water pressure all the way up to 20. PEEP is
usually measured in millimeters of mercury and that can be anywhere from 5 to 20 as well. These
pressures that we see here are pressures that are there on inspiration and specifically on exhilaration
and that's where this PEEP comes from. PEEP stands for positive end-expiratory pressure. That positive
end-expiratory pressure is there even at the end of exhilaration so that when you breath out, instead of
having 0 pressure in your lungs, there's actually still pressure in there. Let's say it's set to 5, there's still
pressure of 5 in your airways.

Now, what's the purpose of this? Basically you're breathing in and out with the same pressure, this
could have a lot of good impact in the non-invasive mode if you've got obstructive sleep apnea because
that pressure in your air way is going to keep your tongue forward, so it'll keep your air way open so you
don't have obstructive sleep apnea. In the invasive mode of ventilation here, remember these air ways
come down to small little tiny airways where they have little grape light clusters. That PEEP or that
positive end-expiratory pressure is really good at keeping those alveoli open and what we call recruited.
If you like to keep those alveoli open, you can increase the PEEP on the ventilator, and usually is it's own
switch here, or basically, it's own dial where you can increase the positive and expiratory pressure.

PS MODE -The next mode of ventilation is called pressure support or just PS. This is like PEEP and CPAP,
except it only occurs on inhalation. This is like AC except that instead of delivering a specific volume, this
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patient is going to get a certain amount of pressure. It delivers a specific pressure support for each
breath. The patient initiates all the breaths. Patients initiates each breath. This is a little different from
pressure control, where in pressure control you can actually set the rate. Higher pressure supports give
bigger breaths. The bigger the pressure, the bigger the breath is going to be. This is a very popular
weaning mode of ventilation as well as CPAP from what we talked about. We've already talked about 4
different modes. We've talked about the AC where the patients triggers the ventilator and the patient
gets a specific volume of breath, we've talked about pressure control where the patient or the ventilator
can both cause the ventilator to give a specific pressure and then come back down to specific pressure
and we've talked about CPAP where the patient is on a continuous pressure regardless of whether or
not they're taking a breath in or out. Then we just talked about pressure support ventilation where on
each breath that the patient triggers the ventilator on, they get a specific amount of pressure. That
could be anywhere from 5 to 15. We're going to go into these modes a little bit more carefully and kind
of dissect them out a little bit more for your benefits.

ORDERS FOR VENT

There's 4 things that you should know about writing the orders for vent.
1. The first thing you need to know is you need to write a MODE. In this case we're going to do AC.
Remember that's assist control continuous mandatory ventilation. This means that whenever
the patient triggers the ventilator, he's going to get a certain amount of volume. But you're
going to set up a backup rate.
2. The other thing that you put with this is a BACKUP RATE. If we put 16, that means, the patient is
going to receive at least 16 breaths per minute if he doesn't breath, the ventilator's going to give
that to him anyway. The next thing you're going to put int, since this is AC, you need to put in a
tidal volume. Let's just say it's going to be 550 milliliters.
3. The next thing you put in is THE FIO2. What is that? The FIO2 is the fractional inspiration of
oxygen. Let's just say we're going to set it to 50%, that means 50% of the volume the patient's
breathing is going to be oxygen.
4. Finally, the last thing that we set is the PEEP, let's say it's 5. These are the 4 things that generally
are set in AC mode ventilation which is the most common mode of ventilation that you'll see in
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a medical intensive care unit. What we're saying here is we're using assist control, that means
that the patient get's a certain volume. We're writing in what that volume is, we are putting in
how much FIO2 the patient's going to be receiving, how much oxygen and then how much
pressure is going to be left in the circuit at the end of exhilaration. Remember this pressure is
there to recruit alveoli.

What you'll notice here is that the first 2 parameters are going to affect carbon dioxide. How fast
you're breathing and how much breath you're taking with your breath is going to affect your minute
ventilation. The last 2 is going to affect your oxygenation. Obviously, the amount of oxygen you put
in is going to affect how much oxygen you read on your saturation. As it turns out, the higher the
PEEP, the more alveoli you can recruit and therefore the better the oxygenation is going to be. We
can manipulate these values to get the effect that we want with the blood gas. By the way, if there's
any questions about blood gas, please refer to our acid base lectures on interpretation of acid base
and blood gases.

Let's take a look and see what a pressure volume flow graph would look for AC mode of ventilation.
What we have here recall is AC 16, tidal volume 550, FIO2 of 50% and a PEEP of 5. The first thing you
want to notice, let's look at the pressure diagram. Remember there's a PEEP of 5 and so there will
always be a certain amount of pressure in the circuit until the patient takes a breath. When the
patient takes a breath in, that pressure is going to go down to a negative pressure. At that point, it's
breath. The volume that gets delivered is going to go up to a certain preset volume tidal volume. As
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that volume start to enter into the lung, the pressure in the lung is going to go up until it reaches the
same point at a maximum. Flow into that lung is going to start right at that time and it's going to
immediately go up and it's going to be a constant flow that you can preset until it reaches that point.
This here, you can actually set, by the way, it's not here it the 4 different settings but you can
actually set how fast that flow is going to go in. That's important when talking about ventilating
patients in COPD. When you have that preset title volume that you've set into your ventilator, this is
when your ventilator is going to stop giving flow and what you'll see is, flow will not only stop, but
flow will start to come out of the patient and start to go back to normal. When that happens, the
pressure in the lung will start to fall back down, but it will not go to 0 because remember we have a
PEEP of 5, that means there's always a pressure of 5 left in there. Of course, when that occurs,
volume will come back out of the lung again and come back to 0. What we have now is the status
quo where we have a pressure of 5 left in the lung, flow is back to 0 and volume is back to 0, and the
same thing will happen again. If the patient decides to have another breath, the pressure will go
back to 0 and go beyond it which will trigger the ventilator to do the same thing again. You'll see
that the flow rate will go up and then back down again. Here, right when the ventilator is triggered,
you will see volume go back into the lungs and then come out again. Here, of course, as soon as the
trigger is set, you will see flow go up at a certain constant rate until the target volume is reached
then flow will come back out again, then it will go to 0.

If the patient decides not to get a breath, we're talking about about a patient, let's say who is overly
sedated, but you've set a backup rate. Because you set a backup rate, the ventilator is not going to
allow the patient to go long without a breath. That will look a little bit different. Because the patient
will not have triggered a breath, you will just see, instead of a negative deflection, you will just see it
go up. At that time when it decides to go up, everything else on the ventilator will look the same.
Flow up, flow across, flow down. Notice that in a patient triggered breath, you will see a negative
deflection in the pressure circuit, but in a ventilator given breath, it will be missing. This is a good
time to, again, talk about compliance of the system. Notice that when we're talking about the AC
mode of ventilation, there is a preset tidal volume that we are entering into in this ventilator. If for
some reason the compliance of the system goes down, the ventilator is still going to give the same
volume, but what you would see, you would see a higher pressure. That higher pressure is a result
of decreased compliance in the lung. Of course, the thing to know there is you can actually set a
pressure alarm here so that if the compliance of the lung does go down, and what I mean when the
compliance of the lung goes down is let's say if he comes with pulmonary edema or there's
pneumothorax or there's something that prevents the lung from expanding as easily as it would've
normally been. If this pressure exceeds the set pressure alarm, there will be a bell that goes off and
the respiratory therapist or the nurse will be drawn to the bedside because there's a problem.
Remember in AC mode, you dial in the volume, the pressure is variable depending on the
compliance. But, as most things in medicine, it's not always as simple as you may think. There's
actually 2 types of pressures that you've got to be concerned about. 1 is a peak pressure and the
other is a plateau pressure.
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PEAK PRESSURE AND PLATEAU PRESSURE

We just talked about peak pressures and plateau pressures and we wanted to get into that a little bit
more and talk about what the difference is between those two. Going back to our drawing, I can explain
those two types of pressures here using our picture. When air is going actually into the lung, the biggest
resistance to that air going in or the biggest pressure that's being delivered is a result of the airways
When air is actually moving, when it's dynamic, when it's actually going in, the thing that's generating
the pressure that you'll see up here if you had a pressure gauge is actually the airways. Now, once the
air is in the lungs and it's actually in the air sacks and there's no more air movement and that's the key,
once the air has stopped, once the lungs have inflated, once there is no more movement in the airways,
the thing that determines the pressure in the air circuit is no longer the resistance of the airways, it is
now the actual compliance of the lung because the pressure that is being transmitted back into the main
airway is what is the compliance throughout the entire lung.
That's important to know. There's two things that you'll see on pressure, there's a peak pressure:
1. The peak pressure is when there is air flow. The air flow, the peak pressure has to do with the
airways.
2. Then there's something called the plateau pressure. That is when the air stops. The plateau
pressure, when the air stops, has to do with lung compliance.
That is extremely important because here's the point, if there is a problem with the airways, you're
going to see the peak pressure's going up and we'll explain what that is. If you see a problem with lung
compliance itself, you're going to see a problem with the plateau pressures.

Let's show you what the definition is for those. Let's look at pressure and let's look at flow. First of all on
pressure, if I am ventilating a patient and I inflate their lungs, the pressure's going to go up and when I
release it the pressure's going to go down. How does that look in terms of flow? Well, when you're
talking about flow, obviously when pressure is going up flow is going up. Then there's a certain amount
of flow and then when the pressure starts to come down, flow goes in the opposite direction until it
finally comes back to baseline. That's what it looks like. Now, let's say I do a specific maneuver. Let's say
I go ahead and I have the lungs inflated but then I hold the lungs at inflation. There's going to reach an
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equilibrium when the air has gone in, that there will be a holding or a plateau of pressure and then a
release. What that means is air is going in, so there's flow. When I go ahead and I hold that breath ...
This is a breath hold. When I hold that breath, air flow is going to go to zero until I release that breath
and then it's going to go down and come back up. This right here is inhalation and this right here is
exhalation. This is not a normal breath. This is where I actually do a breath hold. The purpose of this is to
show you the difference here. This area right here is the peak pressure. Whereas this area here is the
plateau pressure. Peak pressure is at the beginning. This has to do with ... Let's do it in the right color.
This peak pressure right here has to do with airways. This plateau pressure here has to do with lung
compliance. Based on those readings, let's give an example where we would have a high peak
pressure. This peak pressure ... Specifically what we're looking at is the difference right there. Let's go
ahead and reconstruct what that would look like. This is an example of a high peak pressure. If the
difference between the peak pressure and the plateau pressure is greater than five millimeters of
mercury, that is an elevated peak pressure. Let's take a look at the other extreme. Here, clearly the
problem is not with the peak pressure. Here the problem is with a high plateau pressure. Again, we
have a plateau pressure elevation and we have a peak pressure elevation. This is something that you can
actually do at the bedside with a ventilator, if the pressure alarm is going off, you're going to want to ask
your respiratory therapist or if you are a respiratory therapist, you're going to want to know is it a
problem with plateau pressure or peak pressure.

PEAK PRESSURE - Let's talk about why that's important. A high peak pressure remember it has to do
with airways. What are some things that could happen on a ventilator that would give you a high peak
pressure? One of them is bronchospasm. If a patient all of the sudden becomes bronchospastic, their
peak airway pressure is going to go up. What happens if there are secretions? Specifically dried
secretions that are plugging up the endotracheal tube. That could do it as well. A mucus plug, kind of the
same lines or the tip of the endotracheal tube is occluded. These are all things that could cause peak
airway pressure alarms in a patient with AC mode ventilation.
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PLATEAU PRESSURE - What about plateau pressure? Remember this has to do with the lung compliance.
What are some things that would drop lung compliance?
1. Pneumothorax could drop lung compliance.
2. Pulmonary edema, that could do it pretty quickly.
3. ARDS, pneumonia. ARDS and pneumonia are things that happen more chronically.
You could have flash pulmonary edema. Obviously pneumothorax would happen rather quickly as well.

“Knowing the difference between plateau pressure and peak pressure could actually be very
diagnostically helpful in a patient who is acutely decompensating so you should know it.“

AC MODE
With that knowledge, let's go back to our four inputs in terms of AC mode ventilation. We said earlier
that there were a few things that we could set things up with. For instance, we could set the rate, the
backup rate that is, the tidal volume, the FIO2, and the peep.
1. We said that these things here, the rate and the tidal volume would effect carbon dioxide and
these things here would effect oxygen and that's correct. Let's further qualify these things. The
rate, obviously if you increase the rate you're going to get increased ventilation. Remember
when you're increasing ventilation, every time a patient breathes there's a little bit of dead
space so you're increasing the amount of dead space. Probably a more efficient way of
increasing ventilation would just be to increase the title volume because remember, with every
breath there's about a hundred and fifty cc's of dead space. When you increase the title volume,
you're actually getting 100% ventilation for every amount of increase in title volume that you're
getting. When you increase the respiratory rate, you're increasing the number of times you
breathe. With that is included a dead space of about 150 cc's. This is air that goes into the
trachea and the bronchi where there is not gas exchange. The bottom line here is that you could
increase ventilation by either increasing the rates or increasing the title volume. A 5% increase
in title volume is probably more efficient than a 5% increase in the rate.
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COPD-The one thing that I would say is that if you're talking about a patient however in COPD,
remember they have a hard time getting air out. It's possible that the air might not be able to get out
before the next breath. This is particularly important and if you have too high of a respiratory rate or too
much of a title volume. If you give a breath before the first breath is able to be exhaled, you could get
something called breath stacking in COPD and actually paradoxically increasing either the rate or the
title volume and a patient with COPD could actually decrease your minute ventilation and actually
increase the CO2. Just be careful of that. The other thing that I would say about title volume is that be
careful of it being too high because when the title volume goes in and out, remember your alveoli are
going in and out. As a result of that you could be getting collapsing and opening of your alveoli back and
forth. That type of movement can cause inflammation. That's something that you don't want to have in
things like ARDS.

ARDS-In ARDS we typically like to have low tidal volumes. We can talk about that more later.

2. Now, what about oxygen? FIO2 is pretty self-explanatory. Obviously the higher the FIO2, the
higher the PAO2 is going to be. We'd like to have it, if you can, less than 50% because FIO2 is
greater than 50% can cause bronchitis in the ICU.
3. The peep remember is the pressure left in the circuit, in the lungs, in the alveoli at the end of
exhalation. The more pressure there is, the more likely those alveoli are going to be open and
therefore oxygen exchange is going to go up. Peep opens up more alveoli. Here's the other
problem with peep. Remember that if you increase the pressure in the lungs at the end of
exhalation you're also increasing the intrathoracic pressure. That could have good effects and
that could have bad effects but remember what major organ sits inside the thorax? Your heart.
If you're putting pressure on your lungs to keep the alveoli open, you're also putting pressure on
your heart. Now if you put pressure on your heart, that's going to increase the pressure in the
right atrium. Remember in the venous system blood flows back to the heart in a process known
as venous return and it's a down slope hill. In other words, blood is going to go from an area of
high pressure to an area of low pressure. The more there is a difference between these two
pressures, the faster blood is going to come back to the heart. If we are increasing the peep
intrathoracically, that's going to increase the pressure in the right atrium and this low pressure
system is going to be not as low. If it's not going to be as low, that means the gradient between
these is not going to be as much. Therefore we're going to have less venous return. Less venous
return translates into less cardiac output. Less cardiac output means lower blood pressure.
Here's the trade off, increasing the peep may improve your oxygenation but it can lower blood
pressure. That could be a problem. Sometimes having less venous return is not a problem. In
fact, it may be beneficial. If for instance someone is in congestive heart failure, the pressure
behind this heart can... Or the amount of blood behind this heart can be alleviated by increasing
the pressure in the right atrium. In patients who have congestive heart failure and they get
intubated, increasing the PEEP can actually improve lung aeration. You could also get the same
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effect by the way with just using Bi-PAP or CPAP on patients with congestive heart failure. That's
why it works so well and increasing the end expiratory pressure is very beneficial.

Pressure

SAMPLE PROBLEM - We're going to go ahead and do a sample problem here to see if you can
understand what you might need to do on a ventilator given a specific situation. Let's say that you were
covering a patient who was in AC mode. You would see this. You'd see AC 12, that means twelve breaths
per minute, tidal volume 400, FIO2 of 40 percent and a peep of 5. Let's say that the blood gas results
were 7.26, 60, 55, 26. For those of you who don't know, this is the Ph.

That's a little low. This is the PCO2. That's a little high. This is the PO2. That's low. This is the bicarb. For
those of you who don't know how to interpret these, please look at our medical acid based lectures. The
Ph is low. The PCO2 is high. Because these are going in opposite directions, this has to be a respiratory
disorder. Because the Ph is low, it's a respiratory acidosis. We're under-ventilating here most likely. Also,
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the PO2 is low, as well, so we're under-oxygenating. What things could we do to these vent settings to
improve this patient's blood gas? Let's assume that this patient is sedated. When I say that, that should
clue you into the fact that if the patient's AC is set at 12, that means they're actually probably breathing
at 12. That's important because if they're not sedated and they're set at an AC of 12, they could be
breathing at 16 or 20 because they're controlling the rate. If you sedated them with Morphine or Ativan
or Versed or some other sedative, then their respiratory center may not be functioning and they may be
what we call riding the vent. When they're riding the vent, they're sedated and their AC is at 12. Now,
if I were to drop this rate, they would probably follow it down or of course if I were to increase the rate,
they would follow it up. Now, the opposite is true if they're not being sedated. Let's say that they're not
being sedated, that their AC backup rate is set at 12, but they're breathing at, let's just say, 18. If they're
breathing at 18 and I increase the AC rate from 12 to 14, am I really doing any change? No, I'm
increasing the backup rate, but because they're breathing well above the backup rate, that is not going
to have any effect of the blood gas.

What I'm telling you here in this case, (solution)


1. is that they are sedated and they are what we call riding the ventilator, so they're at an AC of 12
and they're actually breathing at respiratory rate, or what we call a spontaneous respiratory
rate, of 12. What could we do to improve ventilation and oxygenation? Based on our previous
discussion, you know that we could increase the AC to 14 or 16. Okay. You could also use odd
numbers, but we just like to use even numbers because it's just easier for some reason.
2. Tidal volume doesn't need to be 400. 400 could be a little bit low. We could go up to 500. Those
are 2 changes that we could make, which would improve the Ph and reduce the PCO2.
3. Now, let's look at our FIO2. It's a 40 percent, and our PO2 is pretty low at 55. The PEEP is 5.
There's a lot of things we can do. We can change either the FIO2 or we can change the PEEP. If
this patient's blood pressure is marginal, I'm probably not going to want to increase the PEEP. As
we told you before, the reason why we don't want to increase the PEEP is because increased
PEEP increases intrathoracic pressure. Intrathoracic pressure increases the pressure in the right
atrium. Increasing the pressure in the right atrium decreases venous return, and as you know,
decreased venous return reduces cardiac output which reduces blood pressure. I.E. increase
peep decreases blood pressure, usually. If the blood pressure is marginal, I'd probably want to
go with increasing the FIO2 on the ventilator to improve our oxygenation. Now, on the other
hand if this patient is a congestive heart failure patient on the ventilator, then we have plenty of
venous return coming back to the heart and probably some pulmonary edema in the alveoli.
Increasing the peep to 10 in that case may actually be beneficial because that increased and
expiratory pressure is going to push that pulmonary edema out of the alveolus. It's going to
increase the right atrial pressure, push back that fluid that's congesting it, and allow the heart to
work at a better efficiency. You can see here that depending on the clinical situation you may
want to choose one versus the other. We're going to sort of get into some special circumstances
here coming up.
RESULT - I wanted to show you that as a possibility so we were to get a blood gas later 7.40, 40, 80,
26.
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Okay, so now you know how to adjust vent settings. Let's us look at a couple of special cases here.

ARDS - Let's look at a thing called ARDS. Now, what is ARDS? ARDS is adult respiratory distress
syndrome, or acute respiratory distress syndrome. Used to be known as adult, but it's acute respiratory
distress syndrome. This is an inflammatory condition which affects the lungs diffusely and you can see it
after any type of infection. I'm talking urinary tract infection, pneumonia, aspiration, terrible ARDS. Here
is basically what happens. The lungs become very stiff, so the compliance of the lungs drops. Because of
that you'll see elevated plateau pressures. Sometimes you'll get pneumothoraces in the lungs. Here's
the key, though. You get a restrictive lung physiology, the lungs become very, very stiff. Also, in the
alveoli, there is a lot of hyaline membrane that gets deposited. As a result, if you were to look
microscopically at the alveoli level, they would be filled with fluid and they would be collapsed. Now the
problem is, is that they had found in research studies that when they ventilated these people with high
tidal volumes, it was opening up and closing these alveoli. Opening up, closing. Opening up, closing.
Every single time the patient took a breath in and out, they would open up and close, and that let to one
thing and one thing only. That was inflammation. That they believed led to death. They had idea. They
said let's go ahead and do something different.

Let's do something called the open lung model. The open lung model was this. Let's go ahead and stint
open as many alveoli as we possibly can using high levels of peep. Okay, we're talking peep around 12,
14 ... It just depended on how much the oxygen was diminished by. The lower the oxygen levels were,
the higher levels of peep that they used. They felt that is the oxygen was low that these alveoli needed
to be recruited. More they needed to be recruited, the more peep they added. As they added this peep,
they were able to open up these alveoli. Now, with these alveoli open, they didn't want them to
derecruit. In other words, these didn't want them to close. What they did was they had just tiny tidal
volumes. The key here is high PEEP, low tidal volume. What I mean by low tidal volume, I'm talking 6 to
8 milliliters per kilogram ideal body weight. By the way, ideal body weight is measured by your height.
You measure somebody's height and that converts into what their ideal body weight is in kilograms.
Once you know what that is, multiply it by 6 to 8, and that's the range of tidal volume that you should be
using. We're talking usually in the 4 to 500 hundred range. Okay? When they did this type of strategy
with ARDS, they found that survival improved. Mortality went down. They were able to affect change.
That is the standard of care now with ARDS. If you have ARDS in a patient, you want to make sure that
you're using low tidal volumes and increasing your PEEP for recruitment.
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COPD-Okay, let's talk about the other special case, COPD. Completely, completely different problem.
The compliance of the lung in COPD is actually high, but the problem here is that these airways are
obstructed, and so it's very hard to get the air out. As a result of that, air gets trapped, and because air
gets trapped, the key there is that you have very long expiratory phases. Now, the key with this is, these
patients that come in typically have high CO2 levels. The temptation there is when you see a high CO2
level, it's to do what? It's to increase the respiratory rate and to increase the tidal volume. When you do
that, you're increasing the amount of air in the lungs, and it takes longer for that air to get out. You
need more time for that air to come out, otherwise you're going to stack another breath on top of the
old one. If you're increasing the respiratory rate, you're not allowing more time. In fact, you're allowing
less time for that air to come out. Think about it this way. If the respiratory rate that you set on a patient
is 12, how much time do you have for a complete breath cycle? You have 5 seconds because 12 goes
into 60 seconds 5 times for 5 seconds. Let's say you set the rate to 15. How many seconds do you have
then? 4 seconds. You can see that by increasing the rate here from 12 to 15, you chopped off an entire
second per breath to get that air out. They key here is, normally when somebody takes a breath in, it's
usually one third, two thirds, in terms of inhalation and exhalation.

Okay? What we can do in COPD is we can actually affect the time it takes to take a breath in. This is
called the inspiratory flow rate. Typically it's around 60 liters per minute. Now, in patients with COPD,
what do we want to do with THE INSPIRATORY FLOW RATE? We would love for that air to get in very
quickly so that we could have more time for exhalation. In other words, we want to decrease the
inspiratory time by increasing the inspiratory flow rate. In other words, get the air in quickly so you can
have the rest of your 5 seconds to have the air come out. My recommendation for inspiratory flow rates
and indeed the society's recommendation, is they should usually be around 80 to 100. If you can get the
air in quickly, you have more time for that air to come out. Avoid the temptation to increase the
respiratory rate because you make actually make the carbon dioxide worse by increasing the respiratory
rate or the tidal volume. The strategy that I would employ in somebody with COPD is make sure that the
inspiratory flow rate is high. Make sure they're getting very good bronchodilators, and look at the flow
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volume loops on the ventilator. Make sure that flow is returning back to 0 before the next breath goes in
because if flow is not returning back to 0 before the next breath is being initiated or air is going in, then
you must be getting breath stacking. If you get breath stacking, you can hyperinflate, and if you
hyperinflate, you will increase the intrathoracic pressure to be very high which is going to increase
cardiac output and the patient will code because their blood pressure will go down very low. By the way,
the treatment for that is to simply disconnect the patient from the ventilator so they have time to
exhale and get all that air out. That is COPD. That is a special case. We could talk a long time about that,
but I think we have discussed the basics here over the last few lectures. We've talked about what the
ventilator is. We've talked about what the endotracheal tube is, what it looks like, what its purpose is,
what the different modes are, what kind of alarms there are, the peak pressure, the plateau pressure,
and how to affect change on a ventilator using the venting, and now finally a couple of special cases. I
would practice these things. Read up more about it, and we can talk a little bit more about specific cases
and the ventilator in future lectures. I think this is a good basic introduction to what the terms mean and
what to do on the ventilator.

WEANING AFF VENTILATOR


We're going to talk about liberation from the ventilator. Now, this is kind of an interesting term and the
old term for this was weaning from the ventilator. Weaning from the ventilator. Well, we used to use
this in terms of getting people off ventilators, now, we just kind of use that term when we're talking
about breast feeding so the more appropriate term is liberation from the ventilator. We try to use this
as much as possible, so we've talked about, in our former lectures, about putting people on the
ventilator using the endotracheal tube, the vent settings, how we come across with the vent settings.

What they're trying to be doing and now we're going to talk about how do we get them off and what do
we look for when people are on the ventilator? Well, the first thing I want you to be aware of is when
anyone is on a ventilator, you really want to make sure that:
1. every single day you are lifting sedation
2. when you've lifted that sedation, you're doing a weaning trial. Now, I just used that term
weaning. You're doing a liberation trial.
The purpose of that is to see whether or not your patient can liberate themselves from the ventilator.
Can they come off the ventilator and if you don't do this every single day, the research has shown that
people stay on ventilators longer than they should be and this is not a good thing because you can
actually get pneumonias and complications from being on the ventilator for too long.

Of course, there are exceptions to this rule here:


1. if the patient is on an FIO2 of more than 45%, that's probably a good reason not to even bother
doing a set of parameters to see whether or not they can come off the ventilator.
2. The other thing of course, is if they're very unstable or if they're on high amounts of
vasopressors.
Those would be exceptions to that rule but generally speaking, when someone is on a ventilator, in fact,
there are protocols in intensive care units to make sure that you are lifting sedation on a daily basis. It's
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called a sedation holiday and they're also doing what they call liberation or weaning trials. This was
made very clear in a recent article that was published that was called the "Wake Up and Breathe Trial".
This showed that practicing this type of a protocol was very important.

SBT (WEANING AFF SUCCESS INDICATOR)- Let's say your patient has had their sedation lifted and you
start a weaning, or a liberation trial, what are you going to actually do and see whether or not the
patient is going to succeed and come off the ventilator? Basically, what you are going to do is you are
going to do something that is called an SBT. That is known as a SPONTANEOUS BREATHING TRIAL.
1. If the patient is on AC ventilation, pressure support, or SIMV or some other supportive ventilatory
mode, you're going to switch them to some sort of combination of, in most cases, pressure
support, which means they're getting a certain amount of pressure with every breath that they take
in. They might also be on a specific peep and that's usually around five or so.
2. The other mode that you could do is something called Tube Compensation. Simply, this
compensates for the resistance of the tube.

MONITORING - The bottom line is that there are several ways that you can do a spontaneous breathing
trial. What you want to do is get the support as low as physiological and see how the patient does over
the next one, two, three hours.

DRAW A BLOOD GAS- An ABG.

GENERALLY SPEAKING:
1. if the patient looks like they're comfortable.
2. Looks like they're able to take in some deep breaths.
3. They're not breathing too quickly, we'll get into some of those parameters later.
4. They've got a blood gas that look pretty good, what I mean by pretty good is it's usually greater
... The PH is greater than 7.35 and it's less than a PCO2 of 45 and the PO2 is in a reasonable
range, so somewhere 60 to 70 or above and the patient looks comfortable, then that's a good
spontaneous breathing trial.

RBT - SOME OF THE OTHER FACTORS that we see, let's run down those. There's something called the
rapid shallow breathing index. This is also known as the Tobin Index. Named after the gentleman who
came up with this and it's basically the respiratory rate divided by the total volume. The respiratory rate
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is in terms of breaths per minute, so you can put down here, the respiratory rate which would be, let's
say 20 and the total volume, which is in liters. You'd want to put that maybe if it's 500ml, then you
would put a .5, so 20 divided by .5 is going to be about 40. Now, the key with the rapid shallow
breathing index, as you can see from this equation, very simple equation. The higher the respiratory rate
goes, the higher the RSBI and the lower the total volume goes, the higher the RSVI. That's not a good
situation. If you see somebody coming off the ventilator and they're breathing rapidly and shallow, if it is
above about 105, that's not usually a good sign. You want patients to be breathing slowly and with deep
breaths. If the RSBI is less than 105, that's a good sign. That's a positive sign. Other things to look for is if
the NIF is around negative 30. That's usually a good sign that they're able to take a good deep breath in.
Some other things that you might see is a minute ventilation of less than 15 liters per minute. This just
shows that the metabolic requirements of the patient are not so demanding that they're going to have
to breath very fast when they get off the ventilator. That's probably the reason why they got on the
ventilator in the first place. If the minute ventilation is less than 15 liters per minute, that's usually a
good sign. All of what we've just talked about here, since the beginning of this video, is in terms of what
are the mechanics of ventilation and is the patient ready to come off the ventilator, so these are all
numbers that you should look at. I would say that the most important that we've talked about so far is
simply, what does the blood gas look like at the end of a spontaneous breathing trial, after about two or
three hours?

In fact, there are four things which I want to talk about. There are four specific things on your checklist
that you must say yes, the patient is ready to fly, when they're coming off the ventilator. Think about
this as a plane taking off and you're going through a checklist of things to make sure that everything is
working before you lift that plane off.
1. The first thing, is everything that we've talked about up to this point is the mechanics of
ventilation good? The way you can check this one off is if they have completed a spontaneous
breathing trial and they've got a good blood gas. That would be a check.
2. The next thing is mental status. In other words, is the patient mentally alert enough to protect
their airway? Remember now, sometimes this is the particular reason why they got intubated in
the first place, so if somebody comes in with a drug overdose, obviously their lungs should be
working fine. It's just the brain that's running the lungs, isn't working fine and they may swallow
stuff and it may go down into their lungs and that is the reason why people get intubated.
Obviously, if it's a factor for them being intubated, it could also be a factor for them being
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extubated. You want to make sure that they can actually protect their airway before you take
that endotracheal tube out. If they've got a good gag reflex and they're awake, they don't have
to be deriving the quadratic formula, but if you feel that they can protect their airway than
that's a good check there.
3. The next thing is secretions. They may have a good mechanics of ventilation. They may have a
good mental status but if there are copious think secretions coming up from the endotracheal
tube that you don't feel this patient is going to be able to clear, then you may need to leave the
tube in. If on the other hand, you think that they can, secretions are not a problem, then that's a
check.
4. The final thing that we check for is something known as an air leak. This has something to do
with the endotracheal tube itself. Let me demonstrate what I mean by that. If we've got a
trachea, you know that when we put the endotracheal tube in, there is a balloon that we inflate.
That's this green thing right here. Now, when that balloon is inflated, it prevents secretions from
going down into the trachea. That's how we protect the airway. Now, because of that balloon,
there can be swelling that occurs and so you may actually have such swelling in this area that
when you deflate that cuff, in other words, when that balloon is deflated and you put positive
pressure into this lung, the air may not be able to get out. Normally when you deflate that
balloon, air should be able to come out. You should be able to hear that passing by the trachea.
You should be able to hear what we call an air leak. An air leak is good. It's positive. It's a good
sign, but if you've got tracheal swelling and you deflate the cuff and there is no air leak, you do
not hear any sound coming up in the patient's mouth, that is probably because there is swelling
and if you were to remove that endotracheal tube, it is possible that your airway could be closed
off. That is not a good thing. When you're ready to extubate, the last thing we do if all of these
things look good is we check an air leak. If we hear an air leak, then all systems are go.
These are the four things that I look at before taking the endotracheal tube out of a patient. This doesn't
mean that nothing bad is going to happen to the patient. That's why you watch very carefully when you
extubate and you see what's going to happen, but these are the four things that they've got to pass
before I will take that endotracheal tube out.
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