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Terminology
– f: rate of breathing
2
Basic pulmonary physiology
Air that moves in and out of a patient's lungs per
minute that is 7-10 L/min Minute volume (MV)
MV =Vt x f
Alveolar ventilation (VA) in contact with the
alveolar-capillary gas exchange interface
VA = (Vt - VD ) x f
Volume-pressure relation: P = V/C
3
Plateau pressure (static pressure)
• … is the pressure at the end of inspiration
with a short breath hold
• It should not be exceed 30 cmH2O
• volume = P plateau
4
Pressure-time diagram for
volume controlled constant
flow ventilation
5
Peak Airway Pressure
(dynamic pressure)
• …. is pressure during inspiration
7
Paw-peak increased but Plateau
pressure unchanged:
1. Tracheal tube obstruction
and kinking
2. Airway obstruction from
secretions
3. Acute bronchospasm
9
Paw-peak and Plateau pressure
are both increased:
1. Pneumothorax
2. Lobar atelectasis
3. Acute pulmonary edema
4. Worsening pneumonia
5. ARDS
6. COPD with tachypnea and Auto-PEEP
7. Increased abdominal pressure
8. Asynchronous breathing
10
Decreased Paw-peak:
11
Measurements
12
Measurements
13
P –T curve
14
P/T F/T V/T curves in
VCV
15
16
Increase in Ppeak–Pplat gradient
• Increased airway resistance caused
by heat and moisture exchanger (HME)
• Patient biting endotracheal tube
• Kinked or twisted endotracheal tube
• Obstruction of endotracheal tube by
secretions, mucus, blood
• Bronchospasm
• Obstruction of lower airways
Schematic of two superimposed pressure-time curves
showing a small increase in peak inspiratory pressures
(Ppeak) with a greater increase in plateau pressures
(Pplat).
This is characteristic of decreased lung compliance
Unchanged or decreased
Ppeak–Pplat gradient
• Pneumonia
• Atelectasis
• Mucus plugging of one lung
• Unilateral intubation
• Pneumothorax
• Pulmonary edema (noncardiogenic and
cardiogenic)
• Abdominal distention/pressure
Spontaneous Breathing
20
Positive End Expiratory Pressure
• … is the pressure at the end of expiration
21
1- Extrinsic PEEP
(applied PEEP by MV)
• 3 - 20 cm H2O and be started on 5 cm H2O
• It improves the oxygenation not CO2 removal
• It may be increased 3-5 cmH2O Q 10-15 min
• It has some side effects: biotraumas and
hemodynamic compromise
22
Optimal PEEP
24
PEEP
25
PEEP Disadvantages:
• 1. Decrease BP & CPP
2. Increase PCO2
26
2- Intrinsic PEEP
• …is incomplete alveolar emptying during expiration
due to air trapping
• Ventilator Factors: High inflation volumes, rapid
rate, low exhalation time
• Disease factors: Asthma, COPD (collapsed airway)
• And has some effects:
– Decreased C.O.
– Alveolar rupture
– increased work of breathing
27
Int. PEEP
• Int. PEEP may be detected in two ways:
28
Pressure cycled
• Volume
cycled
29
30
No absolute contraindications
Loss of airway anatomy
Loss airway protection
Respiratory and cardiac Failure
Apnea / Respiratory Arrest
Inadequate ventilation (acute vs. chronic)
Inadequate oxygenation
Eliminate work of breathing
Reduce oxygen consumption
Neurologic dysfunction
Central hypoventilation/ frequent apnea
Comatose patient, GCS < 8
Inability to protect airway
31
32
Control mechanisms
1. Spontaneous breathing (PSV)
33
• Setting: FiO2 and PEEP
34
Alters gas flow and volume fixed preset airway
pressure (Paw) for the duration of a preset
inspiratory time (Ti )
36
• There are no clinical outcome studies showing benefit
of one breath-targeting strategy over the other.
37
38
39
40
Control Mode Ventilation
Continuous mandatory ventilation
Continuous mechanical ventilation
Controlled mandatory ventilation
Intermittent Positive Pressure Ventilation (Dräger)
42
(CMV /AC)
but CMV :
1. Poor toleration in awake patients
2. Worsening of volume retention in COPD /
asthma
43
A/C mode
44
45
SIMV (Dräger, Hamilton)
SIMV (VC) + PS (Maquet)
VCV-SIMV (Puritan-Bennett, Respironics)
Volume SIMV (Viasys)
Intermittent demand ventilation
SIMV:
1. To prevent excess VT delivered (stacking) decreased
hyperinflation, barotrauma
2. During exhalation from a spontaneous breath
exhalation compromised
47
48
49
50
Assisted Spontaneous Breathing(Dräger)
Spontaneous mode(Hamilton, Puritan-Bennett)
Pressure support (Maquet)
CPAP (Respironic)
Pressure Support Ventilation (Viasys)
continuous positive-pressure breathing (CPPB )
EPAP
51
PSV
52
PSV / ASB / CPAP
53
CPAP / PSV / ASB
54
CPAP / PSV / ASB
With IPPV CPAP is typically used as a weaning
mode
57
Breath type & examples
58
DRÄGER Evita 2 CMV
59
DRÄGER Evita 4 CMV
60
DRÄGER Evita 2 SIMV
61
DRÄGER Evita 4 SIMV
62
DRÄGER Evita 2 CPAP
63
DRÄGER Evita 4 CPAP
64
DRÄGER Evita 2 PCV
65
DRÄGER Evita 4 PCV
66
DRÄGER Evita XL SIMV
67
68
1. Oxygen
70
3. Flow rate (Q )
• This is the rate of gas delivery (L/min).
• The range of flows that can be achieved by
current ventilation is from 10 to 160 L/min.
• Common flow settings are from 40 to 75 L/min.
• The higher the flow rate, the faster the ventilator
will reach its set volume or pressure.
• Start at Q=60 L/ min
72
73
Initial ventilator setting
74
Pressure triggering
• The sensitivity of the trigger can be adjusted by
changing the pressure drop required for
inspiratory cycling to be triggered, and this can
be set to a value between −1 cm H2O (very
sensitive) and −20 cm H2O (very insensitive)
77
Other modes
• High Frequency
Ventilation
• Proportional assist
ventilation
• Airway Pressure Release
Ventilation (Bi-level
ventilation) PCV
• T high : 4 – 6 s
T low : 0.2 – 1.5 s
• P high : up to 40 cmH2O
P low : 10 cmH2O
78
TUMS 79
TUMS 80
Noninvasive Ventilation
• For prevention of invasive MV in selected patients
• Candidates :
COPD, CHF, Asthma, hypoxia, DNR patients
and Immunocompromised patients
83
Nasal mask
TUMS 84
Advantages of NIV
The potential benefits of NIV over MV are:
TUMS 85
Disadvantages of NIV
TUMS 86
TUMS 87
ventilation
Bi-level
Bi-level ventilation.
A: Baseline pressure cycles between Plow and Phigh with spontaneous, unsupported,
patient breaths during high and low phases.
Transition from low to high phase is synchronized to the patient’s inspiration, and
transition from high to low phase is synchronized to patient’s expiration.
B: As in A, but now inspiratory efforts during the Plow phase trigger support (Psupp).
ventilation
Bi-level
Bi-level ventilation.
C: As in A, but now inspiratory effort during both Plow and Phigh phase trigger support which is targeted to the
same absolute support pressure (Psupp).
If Phigh is greater than Psupp, patient effort during Phigh becomes unsupported.
D: As in A, but now inspiratory effort during both Plow and Phigh phase trigger support which is set specifically for
each phase,relative to the baseline pressure of the phase.
Approach to NIPPV
• In hypoxemia:
EPAP + 2 cmH₂O and fix interval IPAP
• In hypercapnia:
IPAP + 2 cmH₂O and EPAP= 40% IPAP
TUMS 90
High flow nasal cannula
• … can deliver warm
and humidified air up
to 40 L/min
91
TUMS 92
1. Severe Acute Lung Injury and ARDS
• Preferred PCV
• consider permissive hypercapnia.
If able to achieve P02> 60 mm Hg on FiO2<60%, the
PCO2 may be allowed to be >40 mm Hg if pH> 7.25.
if needed, use NaHCO3
• Tv 6 – 8 ml / kg
• F 20 – 25 / min
• PEEP 8
• Monitor P plateau: if > 30 cm H2O Tv : 4 ml/kg
TUMS 93
2. Severe Asthma and COPD
• The defect is decreased gas flow.
• In conventional ventilation use higher flow rate and
lower respiratory rate to allow more time for
exhalation.
• Tv 5 -8 ml / kg
• F 8 – 10 / min
• Q 80 l/min
• PEEP 5 (50 - 80% intrinsic PEEP)
• Detection of intrinsic PEEP with wean and chest
compression
• Optimal P plateau < 30 cmH2O
TUMS 94
Monitoring of treatment in asthma
95
3. Pulmonary edema
• NIPPV is preferred
• If the patient is intubated PEEP is useful
• But in hypotensive patients min. PEEP
with continuous evaluation
TUMS 96
5. Traumatic brain injury
TUMS 97
General Guidelines for Initial Invasive Ventilator Settings in Various
Clinical Settings / Rosen`s EM
PEEP (cm
Mode FIO2 (%) VT (mL/kg) F / min I/E H2O)
99
Approach to res. distress 100
101
Indications for extubation
No weaning parameter completely accurate when used alone
TUMS 106
• ABDOMINAL PARADOX :
Inward displacement of the diaphragm during
inspiration is a sign of diaphragmatic muscle
fatigue
• HYPOXEMIA : May be due to low C.O.
• HYPERCAPNEA:
– Increase in PaCO2-PetCO2
= increase dead space ventilation
– Unchanged gradient: Respiratory muscle fatigue or
enhanced CO2 production
TUMS 107
Weaning
108
Tracheal Decannulation
• Successful weaning is not synonymous with tracheal
decannulation
• If weaned and not fully awake or unable to clear
secretions, leave ETT in place
• Tracheal decannulation increases the work of
breathing due to laryngeal edema and secretions
• Do not perform tracheal decannulation to reduce
work of breathing
TUMS 109
Inspiratory Stridor
• Post extubation inspiratory stridor is a sign of severe
obstruction and should prompt re-intubation
• Laryngeal edema (post-ext) may respond to aerosolized
epinephrine in children
• Steroids have no role
• Most need reintubation followed by tracheostomy
TUMS 110
TUMS 111
TUMS 112
Case 1
TUMS 113
With VCV setting
TUMS 114
Dräger evAita 2
Patient data
Ventilator setting
Alarm setting
TUMS 115
Vt and f
• F= 12 /min
• Vt = 600 mL (7-10 mL/kg)
TUMS 116
Pressure Support Ventilation.
TUMS 117
• Gas Delivery Waveform:
Begin with a decelerating waveform.
TUMS 120
The same patient with PCV setting
Vm = 7.2 L/min FiO2= 95%
Mode = ( in E4 , 2 ) PSV =10 cm H2O
PCV+ SIMV, .PCV. PEEP=5 cm H2O
PSV. ASB
Q = 160 L/min PC
( devise adjust the Q in =[(Paw peak) – PEEP] ×2/3
response to the = (35 – 5)× 2/3
patient`s breath.) =20 cm H2O
Wave = ramp
F = 12/ min (Paw Peak )
=PC+ PEEP
TUMS
=25 121
Order writing
1 2
SIMV PEEP :5 cm H2O
f : 12/ min PSV : 10 cm H2O
PC : 20 cm H2O Q : max (160) L/min
Ti : 1 s Wave : ramp
FiO2 : 95 %
122
Case 2
TUMS 123
• Mode : SIMV-As before, allow the patient to breathe
spontaneously when the short acting neuromuscular
blockers or heavy sedative (e.g., etomidate, fentanyl,
midazolam) used to facilitate intubation wears off.
TUMS 124
• initial f= 14 / min
• Vt = 700 ml
TUMS 125
• Fi02 : Begin with FiO2 :95% then titrate.
• PEEP : ≥5 (to maintain FRC and alveolar
recruitment with V/S consideration )
• Flow:
• A longer Ti is ideal for alveolar recruitment
and a slow flow rate will complement the
decelerating waveform and further prolong
the Ti.
• Then start with a Q of 50 L/min
TUMS 126
• Start with a higher PSV because the pulmonary compliance
is less than the normal lungs.
TUMS 127
TUMS 128