VENTILATORS

VENTILATORS

BY
DR JAYDEB CHAKRABORTY
(PT)
• PROVIDES ARTIFICIAL SUPPORT OF
GAS EXCHANGE
• CAN BE MADE INTO USE IN CASE OF
FAILURE OF HUMAN GAS EXCHANGE
• INDICATIONS:
1. HYPOVENTILATION
2. HYPOXEMIA
3. RESPIRATORY FATIGUE
4. AIRWAY PROTECTION
 GOALS
• PROVIDE ADEQUATE ALVEOLAR VENTILATION(PaCO2)

• PROVIDE ADEQUATE OXYGENATION

• PROMOTE PATIENT-VENTILATOR SYNCRONY

• APPLY PEEP TO MAINTAIN ALVEOLAR RECRUITMENT

• USE THE LOWEST POSSIBLE FIO2

• AVOID ALVEOLAR OVERDISTENSION

 VENTILATOR SYSTEM

1. THE VENTILATOR IS POWERED BY

GAS PRESSURE AND ELECTRICITY
2. AN INSPIRATORY VALVE
3. EXPIRATORY VALVE
4. THE VENTILATOR CIRCUIT
DELIVERS FLOW B/N THE
VENTILATOR AND THE PATIENT
5. GAS CONDITIONING
A) BACTERIAL FILTERS
B)THE INSPIRED GAS IS
ACTIVELY OR PASSIVELY
HUMIDIFIED
-ACTIVE HUMIDIFIERS
-PASSIVE HUMIDIFIERS
-WATER DROPLETS
CLASSIFICATION OF
MECHANICAL
VENTILATORS
 A.NEGATIVE VS
POSITIVE-PRESSURE
VENTILATION
• THE IRON LUNG AND CHEST CUIRASS CREATE –
VE PRESSURE AROUND THE THORAX DURING THE
INSPIRATORY PHASE

• POSITIVE PRESSURE VENTILATION APPLIES +VE

PRESSURE TO THE AIRWAY DURING THE
INSPIRATORY PHASE

• EXHALATION OCCURS PASSIVELY IN BOTH.

B.INVASIVE VS NON-
INVASIVE
• INVASIVE VENTILATION IS
DELIVERED THRO A ET TUBE OR A
TRAHEOSTOMY TUBE

• NON-INVASIVE +VE PRESSURE

VENTILATION CAN BE APPLIED WITH
AN NASAL OR AN ORO-NASAL MASK
 C. FULL VS PARTIAL
VENTILATION
• FULL VENTILATORY SUPPORT PROVIDES THE
ENTIRE MINUTE VENTILATION WITH NO
INTERACTION B/N THE PATIENT AND THE
VENTILATOR.

• PARTIAL VENT SUPPORT PROVIDES A

VARIABLE PROPORTION OF THE MIN VENT,
WITH THE REMAINDER PROVIDED BY THE
PATIENT’S INSPIRATORY EFFORT
PHASE VARIABLES
 A.TRIGGER VARIABLE
• IT IS TIME WHEN THE VENTILATOR INITIATES THE
BREATH

• WHEN D PT INITIATES D BREATH, D VENT DETECTS

EITHER A PRESSURE CHANGE OR A FLOW CHANGE

• TRIGGER SENSITIVITY
PRESSURE SENSITIVITY->0.5-2 CM H20
FLOW TRIGGERING->2-3 L/MIN
B. CONTROL VARIABLE

REMAINS
CONST THRO OUT
INSPIRATION,REGARDLE
SS OF IMPEDENCE.MOST
COMMON R VOL
CONTROL AND PRESSURE
CONTROL
 1.VOL CONTROLLED
VENTILATION
• TIDAL VOL DELIVERY IS CONST REGARDLESS OF RESP SYSTEM
COMPLIANCE OR AIRWAY RESISTANCE

• PEAK INSPIRATORY PRESSURE CHANGES ACCORDING TO RESP

SYSTEM COMPLIANCE OR AIRWAY RESISTANCE

• INSPIRATORY FLOW IS FIXED REGARDLESS OF PT’S EFFORT

• INSPIRATORY FLOW PATTERNS INCLUDE CONST FLOW(SQUARE

WAVE), DECELERATING FLOW ETC

• INSPIRATORY TIME IS DETERMINED BY D INSPIRATORY

FLOW,INSPIRATORY FLOW PATTERN AND TV
 2. PRESSURE-
CONTROLLED
VENTILATION
• PRESSURE APPLIED TO D AIRWAY IS CONST REGARDLESS OF D AIRWAY
RESIS OR RESP SYS COMPLIANCE

• THE INSPIRATORY FLOW IS DECELERATING AND VARIABLE

• THE INSPIRATORY TIME IS SET ON THE VENTILATOR

• TV IS ALSO VARIABLE.
 MODES OF
VENTILATION
 A. CONTROLLED
MECHANICAL
VENTILATION
• ALL BREATHS R DELIVERED BY D
VENTILATOR & PT TRIGGERING IS NOT
POSSIBLE

• REQUIRES SEDATION AND SOMETIMES

NEUROMUSCULAR BLOCKADE
 B.ASSIST-CONTROL
VENTILATION
• THE PT CAN TRIGGER VENTILATION AT
A RATE GREATER THAN THAT SET ON
D VENTILATOR

• ALL BREATHS, WHETHER VENT-

TRIGGERED OR PT-TRIGGERED R
DELIVERED AT D SET VOL OR D SET
PRESSURE CONTROL
 C.SYNCRONISED
INTERMITTENT MANDATORY
VENTILATION(SIMV)
• THE PT RECEIVES THE MANDATORY SET
TIDAL VOL OR D SET PRESSURE CONTROL AT
D RATE SET ON THE VENTILATOR

• MANDATORY BREATHS AND SPONTANEOUS

BREATHS

• THE SPONTANEOUS BREATHS CAN BE

PRESSURE SUPPORTED BREATHS.
D.PRESSURE-SUPPORT
VENTILATION
• THE PT’S INSPIRATORY EFFORT IS ASSISTED BY D
VENTILATORAT A PRESET PRESSURE WITH PSV

• THE VENTILATOR DELIVERS BREATHS ONLY IN RESPONSE

TO PT’S EFFORTS

• TV,INSPIRATORY TIME AND RR CAN VARY WITH PSV

 E.CONTINUOUS +VE
AIRWAY PRESSURE(CPAP)
• THE VENTILATOR PROVIDES NO
INSPIRATORY ASSISTANCE

• CPAP APPLIES A +VE PRESSURE TO

THE AIRWAYS
 SPECIFIC
VENTILATOR
SETTINGS
 A.TIDAL VOL
• A TV TARGET OF 6-10 ML/KG BODY WT IS USED

• TV TARGETS HAVE DECREASED IN RECENT YRS

• ARDS-6ML/KG

• NEURO-MUSCULAR DISEASE OR P-O VENT

SUPPORT-> 8-10ML/KG

• OLD-> 6-8ML/KG
 B.RESP RATE
• 12-15/MIN TO ACHIEVE A MV OF
7-10 L/MIN

• WITH LOW TV & A LOW Ph, A

HIGHER RR MAY BE NECESSARY
 C.I:E RATIO
• EXP TIME SHOULD BE LONGER
THAN THE INS TIME( i.e., I:E OF
1:2)
 D.OXYGEN CONC.(FIO2)

• INITIATE MECHANICAL VENT

WITH AN FIO2 OF 1.0

• PULSE OXYMETRY
 E.POSITIVE END EXP
PRESSURE(PEEP)
• IS A TERM USED IN MECHANICAL VENTILATION  TO
DENOTE THE AMOUNT OF PRESSURE ABOVE ATMOSPHERIC
PRESSURE PRESENT IN THE AIRWAY AT THE END OF THE
EXPIRATORY CYCLE

• CAN IMPROVE OXYGENATION IN LUNG DISEASES

CHARACTERISED BY ALVEOLAR COLLAPSE

• MAINTAINS ALVEOLAR RECRUITMENT, INCREASES

FUNCTIONAL RESP CAPACITY AND CAN IMPROVE LUNG
COMPLIANCE

• 3-5 CM H20
• ADVERSE EFFECTS OF PEEP
1. CAN DECREASE CARDIAC
OUTPUT
2. ALVEOLAR OVER-DISTENSION
3. CAN WORSEN OXYGENATION
WITH UNILATERAL LUNG
DISEASE
COMPLICATIONS OF
MECH VENT
A.VENT INDUCED LUNG
INJURY
• OVER-DISTENSION INJURY

• DERECRUITMENT INJURY

• OXYGEN TOXICITY
 B.PATIENT-VENT
DYSSYNCHRONY
• TRIGGER DYSSYNCHRONY

• FLOW DYSSYNCHRONY

• CYCLE DYSSYNCHRONY
 C.AUTO-PEEP

• IT IS THE RESULT OF GAS TRAPPING

CAUSED BY INSUFFICIENT EXP
TIME,INCREASED EXP AIR FLOW
RESISTANCE OR BOTH.THE PRESSURE
EXERTED BY THIS TRAPPED GAS IS
CALLED AUTO-PEEP.
 D.BAROTRAUMA

• E. NOSOCOMIAL
PNEUMONIA
 DISCONTINUATION
OF MECHANICAL VENT
 CLINICAL
CONSIDERATIONS FOR
WEANING
• MECH VENT SHOULD BE WITHDRAWN ONLY WHEN D UNDERLYING
DISORDER HAS COMPLETELY RESOLVED OR HAS IMPROVED MARKEDLY

• NORMAL ARTERIAL B/GASES ON FIO2 OF 0.4

• NO SIGNIFICANT PUL INFECTION,PUL OEDEMA,ATELACTASIS OR

AIRWAY OBSTRUCTION

• ACID-BASE AND ELECTROLYTE DISTURBANCES SHOULD BE CORRECTED

PRIOR TO WEANING
 CONT
• ALERT,COOPERATIVE AND MENTALLY
PREPARED,HEMODYNAMICALLY STABLE AND OFF
INOTROPIC SUPPORT

• GEN NUTRITIONAL STATE AND NEUROMUSCULAR

STATUS MUST BE CLINICALLY ASSESSED

• WEANING SUD NOT BE ATTEMPTED IN PRESENCE OF

HIGH FEVER,SEIZURES,GASTRIC
DILATATION,PARALYTIC ILEUS,GI BLEEDS AND
HEPATIC OR CHRONIC RENAL FAILURE

• ON T-TUBE BREATHING,THERE SUD BE NO

SIGNIFICANT CHANGE IN PULSE RATE,BP,NO RESP
DISTRESS AND SUD MAINTAIN NORMAL B/GASES
 OBJECTIVE RESP
PARAMETERS FOR
WEANING
• 1) VENTILATORY PARAMETERS:
• RR < 30/MIN
• TV OF MINIMUM 5-7 ML/KG
• VC OF MINIMUM 800-1000 ML
• MAX INSPIRATORY FORCE >-20 CM H2O

• 2) ARTERIAL B/GASES:
• pH 7.35-7.45
• PaO2 70-100 mm Hg ON FIO2 OF 0.4
• PaCO2 35-45 mm Hg
 WEANING TECHNIQUE
• WEANING CAN BE PROVIDED
WITH A GRADUAL REDUCTION OF
RATE WITH SIMV, A GRADUAL
REDUCTION OF PRESSURE WITH
PSV OR WITH T-PIECE WEANING
 FAILURE TO WEAN
• INSUFFICIENTLY TREATED PUL DISEASE

• AUTO-PEEP AND HYPERINFLATION

• CONCOMITANT CARDIAC DISEASE

• NUTRITION AND ELECTROLYTE IMBALANCE

• INADEQUATE REST FOLLOWING AN EXHAUSTIVE T-

PIECE TRIAL

• SEVERE MUSCLE WEAKNESS FOLLOWING

NEUROMUSCULAR DISEASE.
LONG TIME VENTILATORY
REQUIREMENTS