Mechanical ventilation

Ventilator settings
Breath Type: mode
2. Mandatory
Breaths that the ventilator delivers to the
patient at a set frequency, volume, flow
Ventilator controls start and/or stop (the
machine triggers and/or cycles the breath)
VCV, PCV
1. Spontaneous
Patient controls start (patient-triggered)
and stop (patient-cycled) [Ti, RR] and VT
PSV, CPAP
Mandatory ventilation

Ventilator settings





PCV or VCV?

PCV vs VCV
PCV VCV
Control
setting
PIP, Ti, rise time VT, PIF, flow
pattern
VT, flow
Variable Constant
PIP Constant Variable
Cycle Time Volume
Distribution of
ventilation
More uniform in
variable RC lung
Less uniform in
variable RC lung
PIF = peak insp. flow, PIP = peak insp. pressure, RC =
time constant, Ti = insp. time, VT = tidal volume
VCV or PCV?

PCV: benefit

PCV or VCV for ARDS?
Esteban A. Chest 2000; 117: 1690-6.
PCV
VCV
In-hospital mortality
RCT, compared PCV vs square-wave
flow VCV, limit Paw < 35 cmH
2
O
No difference
in gas
exchange and
lung
compliance
Low tidal volume ventilation
(LTVV): ARMA study
ARDS Network. NEJM 2000; 342: 1301-8.
6 vs 12 ml/kg VT
In-hospital death
39.8%

31%
(p=0.007)
VCV
If compliance decreases or airway resistance
increases, the pressure increases to maintain Vt
VCV: pressure variable
1 2 3 4
5 6
SEC
1 2 3 4
5 6
P aw
cmH
2
0
60
-20
120
120
SEC
Insp
Exp
Flow
L/min
Useful in patients with relatively normal lung + need
constant minute ventilation (PaCO
2
) eg. IICP, met
acidosis
VCV
Parameters
set

Peak inspiratory flow (PIF)
Flow should be set to meet a patients
inspiratory demand
At least 4 x VE of the patient
40 80 L/min
Which pattern? Square or decelerating


Flow shapes: VCV
Flow pattern
Square (rectangular): short Ti,
Te, high Paw
Obtain measurements of lung
compliance and airway resistance
Decelerating: better distribution of
ventilation, Ti, PIP, and mean
Paw ( oxygenation)

better for both OAD and low
compliance (beware of Te)

Airway Pressure
C = VT / P [ P = P
Plat
PEEP ]
R = P / V [ P = P
peak
P
plat
]
Paw = PEEP + VT/C + RV
.
.
Waveform showing high airways resistance


This is an abnormal pressure-time waveform

time
p
r
e
s
s
u
r
e

P
peak
P
res
P
plat
P
res
Scenario # 1
The increase in the peak airway pressure is driven
entirely by an increase in the airways resistance
pressure. Note the normal plateau pressure.

e.g. ET tube
blockage,
bronchospasm,
secretion
P
aw(peak)
= Flow x Resistance + Volume x 1/ Compliance + PEEP

time
f
l
o
w

Square wave
flow pattern
Normal
Waveform showing increased airways resistance
P
peak
P
plat
P
res
Square
wave flow
pattern

Waveform showing decreased lung compliance


This is an abnormal pressure-time waveform

time
p
r
e
s
s
u
r
e

P
res
P
plat
P
res
Scenario # 2
The increase in the peak airway pressure is driven
by the decrease in the lung compliance.
Increased airways resistance is often
also a part of this scenario.

e.g. pulm edema
Pneumonia, PTX
Normal
time
f
l
o
w

Square wave
flow pattern
P
aw(peak)
P
aw(peak)
= Flow x Resistance + Volume x 1/ Compliance + PEEP

Waveform showing decreased lung compliance
P
peak
P
plat
P
res
Square
wave flow
pattern

Waveform showing normal lung compliance and airway
resistance


A patient with sudden onset of dyspnea
and desaturation. No change in compliance
& resistance was observed. Dx = ?
time
p
r
e
s
s
u
r
e

P
res
P
plat
P
res
Scenario # 3
P
aw(peak)
= Flow x Resistance + Volume x 1/ Compliance

time
f
l
o
w

Square wave
flow pattern
P
aw(peak)
Pulmonary
embolism
PCV
Parameters
set
Initial MV settings for PCV
Pressure setting: initiate pressure at 10
15 cm H
2
O adjust to achieve
desired VT
If start with VCV:
Set at P
plat
during VCV: adjust to achieve
desired VT or
Use PIP during VCV minus 5 cm H
2
O (PIP
5) as a starting point adjust to achieve
desired VT
Pitfall of
PCV
PCV settings in
a patient (PBW
= 45 kg) with
severe CAP
(bilateral
alveolar
infiltration)
Are they
appropriate?
PCV
Parameters
set
Volume
inadequate
in PCV


Short Normal Long
How to set Ti in PCV?
1 2 3 4
5 6
SEC
1 2 3 4
5 6
V
T
600 cc
120
120
SEC
.
V
LPM
0
450 cc
Setting appropriate Ti in PCV
May start at 0.8-1.2 sec.
500 cc
450 cc
Lost V
T
1 2 3 4
5 6
SEC
1 2 3 4
5 6
V
T
600 cc
120
120
SEC
.
V
LPM
0
Setting appropriate Ti in PCV
PSV
Initial settings:
PS level
FiO
2

CPAP
Trigger (type,
sensitivity)
Inspiratory rise
time
Expiratory flow
sensitivity
(Esens)

Cautions:
Cant be used in heavily sedated,
paralyzed, or comatose patients
Respiratory muscle fatigue if pressure
is set too low
PSV
Spontaneous breathing trial (SBT): 5-7
cmH
2
O
Adjusted to keep RR < 25-30 /min
Pressure-oriented ventilation:
PCV, PSV (variable flow)
Tidal volume is depending on:
Set target pressure
Ti
Respiratory system compliance
Airway resistance
Rise time



Patient effort

Initial flow in PCV, PSV
Flow pattern: decelerating exponential
Flow change on demand
Inspiratory rise time
More inspiratory flow demand: rapid rise
time
PCV: Flow pattern variable
PSV
PCV & PSV:
rise time
Rise time =
50%
Adjusted by
monitor
ventilator
waveforms
Conclusion
VCV PCV PSV
Control VT, flow Pressure Pressure
Variable Pressure VT, flow VT, flow
Cycled Volume Time Flow
How much VT?
Range of 6 12 ml/kg IBW
10 12 ml/kg IBW (normal lung
function)
8 ml/kg IBW (obstructive lung disease)
6 ml/kg IBW (ARDS) can be as low
as 4 ml/kg
VT chosen should maintain a P
Plat
<30 cm H
2
O
Minute ventilation
= RR x VT (L/min)
Normal = 5-10 L/min
Respiratory rate: normal 12-18 /min
Adjust RR and VT to keep PaCO
2
and pH in
acceptable range
PaCO
2
= k V
CO2
/ RR (VT VD)
(PaCO
2
x RR x VT)
1
= (PaCO
2
x RR x VT)
2


.
Examples
GBS on VCV: VT 450 ml, RR 16/min,
PaCO
2
= 50
What is the target PaCO
2
for this
patient?
Ans 40
What is the target VE for this patient?
Ans 9 lit/min (RR x VT = 9,000)


I : E ratio
Mean anything?
Adjust PIF, VT, Ti, RR to keep enough Te
PEEP
Initial set at 3 5 cmH
2
O
Restores FRC and physiological PEEP
that existed prior to intubation
Adjust to correct hypoxemia in diffuse
intrapulmonary Rt-to-Lt shunt
Mild ARDS: 5-8 cmH
2
O
Moderate-severe ARDS: 10-13 cmH
2
O
Help to trigger MV in AE-COPD
FiO
2
Oxygenation failure: 1.0
Hypercapnic failure: 0.4
MV in asthma
VE < 10 L/min,
VT 6-10 ml/kg,
RR 10-14
TE > 4 sec., PIF
60-80 L/min (VCV)
Oddo M. Intensive Care Med 2006; 32: 501-10.
Monitoring of hyperinflation by using
Pplateau (<30 cmH
2
O) instead of
measuring end-expiratory pause (PEEPi)
Applied PEEP +
MV in COPD
V
E
, VT may be 5-7 ml/kg (PCV < 30
cmH
2
O), RR
Permissive hypercapnia (may allow pH
down to pH 7.0-7.2, PaCO
2
up to 90)
High PIF (> 60 L/min), long Te
Add PEEP (80-85% of PEEPi) if PEEPi
loads patients effort to trigger the MV
Mehrishi S. Hosp Physic 2004: 30-6.
Budweiser S. Int J COPD 2008; 3: 605-18.
MacIntyre N. Proc Am Thorac Soc 2008; 5: 530-5.
Applied PEEP for COPD
Improve
triggering
PEEPi = 10, applied PEEP =5, trigger = -2

Expiratory flow in COPD
ARDS: Berlin definition
Timing < 1 wk of a known clinical insult or new or
worsening respiratory symptoms
CXR or CT Bilateral opacities (not effusions, lobar/lung
collapse, or nodules)
Origin of edema Not fully explained by cardiac failure or fluid
overload (need objective assessment if no risk
factor present)

Oxygenation
Mild PaO
2
/FiO
2
201-300 with PEEP/ CPAP > 5 cmH
2
O
Mod PaO
2
/FiO
2
101-200 with PEEP > 5 cmH
2
O
Severe PaO
2
/FiO
2
< 100 with PEEP > 5 cmH
2
O
The ARDS Definition Task Force. JAMA 2012;307:2526-33.
How to set low VT in ARDS?: modified
from ARMA trial
Initial VT of 6 ml/kg PBW (any ventilator mode),
limit Pplat < 30 cmH
2
O
PBW () = 2.3 x (Ht in inches - 60) + 50
PBW () = 2.3 x (Ht in inches - 60) + 45.5
Allow permissive hypercapnia
RR up to 35 /min (target pH 7.3-7.45)
VT can be adjusted to < 6 ml/kg (as low as 4 ml/kg)
if Pplat > 30 cmH
2
O
VT can be adjusted upto 8 ml/kg if severe dyspnea
(keep Pplat < 30 cmH
2
O)

ARDS Network. NEJM 2000; 342: 1301-8.
MV protocol for ARDS

Severity
Mild
LTVV with
low PEEP
(<10 cmH
2
O)
Moderate
to severe
LTVV with high PEEP
(10 -15 cmH
2
O)
SpO
2
or PaCO
2
or Crs
Adjust by assessment of
recruitment potential
MV in normal lung
Neuromuscular disease, CVA, IICP,
metabolic acidosis
VT 10-12 ml/kg
PEEP 3-5 cmH2O
RR 14-16 /min
Adjust to keep normal gas exchange
Dont forget to double dose of medications !!!
Aerosol Rx during MV
Oxygen therapy
O
2
therapy devices and estimated FiO
2
Devices O2 flow
(L/min)
Estimated FiO
2
Cannula
2-6
0.21 + (0.04 x flow)


Simple mask
6 0.35
7 0.40
8 0.45
9 0.50
10 0.55
O
2
therapy devices and estimated FiO
2
Devices O
2
flow (L/min) Estimated FiO
2

Partial
rebreathing
mask
6 0.35
7 0.40
8 0.45
9 0.50
10 0.60
Non-rebreathing
mask
> 10 0.95 + 5%
O
2
delivery systems
Acute setting with FiO
2
< 0.4 : Cannula
Acute setting with FiO
2
0.4-0.6 : Mask
+ reservoir bag (rebreathing mask)

Acute setting with FiO
2
> 0.6 : Non-
rebreathing mask, NPPV, MV with
PEEP

Acute setting with chronic hypercapnia
eg COPD : Cannula, Venturi mask
Thank you for your
attention