Mechanical Ventilation

Epidemiology
28 day international study
361 ICUs in 20 countries All consecutive adult patients who received MV for > 12 hours
33% Patient admitted to those ICUs received mechanical ventilation
Mean age 59 M > F (61 v. 39%)
Esteban et al. JAMA 2002

 Indication for mechanical ventilation

Acute respiratory failure 68%
Post-op (21%) Pneumonia 14% CHF 10% Sepsis 9% Trauma 8% ARDS 4.5% Aspiration 2.5% Cardiac arrest 1.9%

Acute on chronuic respiratory failure

COPD 10% Asthma 1.5% Chronic respiratory disease (non_COPD) 1.8%

Coma 16.7% Neuromuscular disease 1.8%

Ventilator Modes Used Each Day During the Course of Mechanical Ventilation

Esteban, A. et al. JAMA 2002;287:345-355.

Copyright restrictions may apply.

 Duration of mechanical ventilation

Overall 5.9days COPD pts 5.1 days ARDS pts 8.8 days

ICU LOS: 11.2 days Hospital LOS: 22.5 days

 Mortality:
ICU mortality 30.7% Hospital mortlaity 39.2%

Kaplan-Meier Curves of the Probability of Survival Over Time of Mechanical Ventilation

Esteban, A. et al. JAMA 2002;287:345-355.

Copyright restrictions may apply.

Mechanical ventilation
Physiology:
Positive pressure ventilation versus naturanl negative pressure ventilation

Effects:
Heterogeneous ventilation
Preferential ventilation of the non-dependent regions

Increased physiologic dead space Improvement of physiologic shunt causes by atelectasis and/or alveolar filling Rapid disuse atrophy of the diaphragm Impairment of mucociliary clearance

 Cardiovascular effects:
Decreased venous return
Exacerbated by:
Auto-PEEP Applied PEEP Intravascular volume depletion Cardiac tamponnade

Increased right ventricular afterload:

Compression of the pulmonary vascular bed Increased PVR

May decrease left ventricular afterload

Lung exansion decreased extramural pressure

Mechanical ventilation
Benefits
Improves gas exchange by improved V/Q matching predominantly be decreasing shunt Decreased work of breathing

Mechanical ventilation: Complications

Barotrauma
Incidence ~3% To Avoid: Keep plateau pressure < 35 cm

VILI
Over stretch Atelectotrauma

Auto-PEEP Asyncrhony

Mechanical ventilation: Modes

Choices:
Mandatory v. non-mandatory
Mandatory
Volume v. pressure limited ventilation Mandatory rate Modes: SIMV Assist Control PCV Hybrid Modes: PRVC, SIMV/PRVC

Non-mandatory or assisted breaths

PSV

Variables: some default values

Trigger sensitivity: -1 to -3 cm Tidal volume: 6-8mg/kg/IBW Rate: 10 to 14 PEEP: 5 cm H2O Flow rate: 60 L/min I to E ratio

Volume limited v. pressure limited

Volume limited
Physician sets:
Tidal volume Rate

Pressure limited
Physician sets:
Peak airway pressure Inspiratory time

Guaranteed constant tidal volume Guaranteed minute ventilation High peak pressures

Tidal volume and minute ventilation depends entirely on patient factors: compliance and airway resistance Associated with lower peak airway pressure Associated with more homogenous gas distribution

No difference in mortality, oxygenation, or work of breathing

P = Vt/CR + Vt/Ti * R + PEEPtotal

Where CR = compliance of the respiratory system, Ti = inspiratory time and V T/Ti = Flow, RR = resistance of the respiratory system and PEEP total = the alveolar pressure at the end of expiration = external PEEP + auto (or intrinsic) PEEP, if any. Auto PEEP = PEEP total P extrinsic (PEEP dialed in the ventilator) adds to the inspiratory pressure one needs to generate a tidal breath.

 Peak pressure Plateau pressure

Surrogate for peak alveolar distending pressure

Peak Plateau
Resistive pressure

Mean airway pressure

Pressure applied acorss the lung and chest wall averaged throughout the ventilary cycle

 Patient factors:
Airway resistance Compliance of the respiratory system
Chest wall recoil Lung recoil

Assist-Control
Set variables
Tidal volume Flow rate or Ti PEEP FiO2 Mandatory rate

Spontaneous breaths
Additional cycles can be triggered; they are identical to the mandatory breath

SIMV
Set variables
Targeted volume Flow rate Manatory frequency PEEP FiO2 PS augmentation for spontaneous breaths

Spontaneous breaths
Unrestricted and aided by the selected level of pressure support

PCV
Set variables:
Peak pressure Inspiratory time Frequency of mandatory breaths

Spontaneous breaths
PCV (AC): same as mandatory breaths PCV/SIMV: unsupported or pressure supported

Tidal volume during PCV

Changes in mechanics
Increased airway resistance Decreased respiratory system compliance

Increased auto-PEEP Decreased inspiratory time

Waveforms

Waveforms

Waveforms

Waveforms
Ventilator change Flow (lpm)

Pressure (cm H2O)

Volume (mL)

Waveforms

Airway pressure
40 30 20 10

Pause

Time

Waveforms

Pause

 What changes on the ventilator should you make for hypoxemia? What changes for hypercapnia and respiratory acidosis? Hypotension on the ventilator?