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VENTILATION
BY
DR.G.SREENIVAASAN
GRADE I SPECIALIST,
ANAESTHESIOLOGY DEPT.,
IGGH & PGI.
SPONTANEOUS
RESPIRATION
NEGATIVE PRESSURE
BREATHING
MECHANICAL VENTILATION
POSITIVE PRESSURE
BREATHING
DRY AIR
O2 -20.98%
CO2 -O.04%
N2 -78.06%
ARGON & HELIUM -0.92%
Conducting Zone
Conducting zone
• Provides rigid
conduits for air to
reach the sites of
gas exchange
• Includes all other
respiratory
structures (e.g.,
nose, nasal cavity,
pharynx, trachea,
primary,
secondary and
tertiary Bronchi )
• No Gas exchange
RESPIRATION
Involuntary
-Medulla=>Pacemaker
-Pons
-Limbic system
-Hypothalamus
Voluntary
-Cerebral cortex
IV ventricle
-Inspiratory neurons
-Expiratory neurons
NEURAL INPUT
Carotid(Pao2)
Central(PaCO2,[H+])
Proprioceptive receptors
Cerebral cortex
RESPIRATORY SYSTEM
Work of breathing
-Energy required for ventilation
RESPIRATORY SYSTEM
Decrease in compliance
-Pulmonary Edema, Pneumonia,
ARDS
Increase in resistance
-Bronchial asthma,COPD
GOALS
Alveolar ventilation
Arterial oxygenation
Adverse effects
Ensure patient’s comfort
Reduce work of breathing
BASIC PARAMETERS
Airway access
Sedation and muscle relaxation
Ventilator settings
Mode
Respiratory rate
Tidal volume
FiO2
Inspiratory flow rate
PEEP
Setting the alarm limits
Ancillary therapy
Follow up
ABG
Basic Ventilator Parameters
FiO2 Tidal volume (VT)
• The amount of gas that is
• Fractional delivered during inspiration
concentration of expressed in mls or Liters.
inspired oxygen Inspired or exhaled.
delivered expressed
as a % (21-100)
Flow
Breath Rate (f) • The velocity of gas flow or
• The number of times volume of gas per minute
over a one minute
period inspiration is
initiated (bpm)
MODE
Method or the way in which a
BREATH is delivered by altering or
changing the available variables is
called mode of ventilation.
PHASES OF VENTILATION
INSPIRATORY PHASE
INSPIRATION TO EXPIRATION
EXPIRATORY PHASE
EXPIRATION TO INSPIRATION
TYPES OF BREATH
Mandatory breath Breath started and ended
by machine
60
Paw SEC
cmH20
1 2 3 4 5 6
-20
120 INSP
Flow SEC
L/min 1 2 3 4 5 6
120 EXH
5 cm
H2O
PEEP
CPAP
Definition
• Continuous positive airway pressure
• Application of constant positive pressure
throughout the spontaneous ventilatory cycle
10 cm
H2O
PEEP
Time
Basic Modes of Ventilation
Control
Assist/Control
(S)IMV
PCV
PSV
Control
Delivery of a P
mandatory
breath at a set
time interval -
time is the
trigger to start F
the breath
Assist Control
P
Patient is
able to
trigger the
start of
inspiration
F
SYNCHRONIZE INTERMITTENT
MANDATORY VENTILATION -
SIMV
A minimum P
mandatory breath
rate is set with
spontaneous
breathing
supported
F
between the
mandatory cycles
Volume vs…
Pressure Control Ventilation
Volume Ventilation Pressure Ventilation
Disadvantages
• Tidal volumes vary when patient
compliance changes (i.e. ARDS, pulmonary
edema)
• With increases in I-time, patient may
require sedation and/or paralysis
PRESSURE SUPPORT
VENTILATION - PSV
The ventilator P
delivers a set
pressure limit
with end
inspiration
driven by the F
patient
PRESSURE SUPPORT
VENTILATION
Spontaneous breathing augmented
Fixed amount of pressure
Patient controls flow and time of each breath
5-15 cm H2O to permit TV ~ 5 ml/kg
Pressure is reduced in decrements of 3.5 cm
H20
Extubation done when PS is 5 cm H2O
BI LEVEL
Is a spontaneous P
breathing mode in
which two levels
of pressure and
hi/low are set
F
What is Bilevel ventilation?
Enabled utilizing an active exhalation valve
Spontaneous Breaths
Synchronized Transitions
Spontaneous Breaths
P
T
INITIAL VENTILATOR
SETTINGS
A/C OR CMV
- Hypoxaemic respiratory failure
- Hypoventilatory respiratory failure
- Post op respiratory failure
- Shock
• PCV
- ARDS
• SIMV with PS
- Weaning
MECHANICAL VENTILATION
TIDAL VOLUME
5-7 ml/kg
TV : 7M/KG
RR : 10-20/m
IP : 35 cm H2o
IE : 1:2 to 1:3
STRATEGIES
VENTILATOR TRADITIONAL LUNG-
PARAMETERS PROTECTIVE
Tidal Volume 10-15 ml/kg 6-8 ml/kg
Disconnect
Bag the patient with 100% O2
Relief No Relief
A,B,C
NO RELIEF WITH BAGGING
AIRWAY
No relief
YES NO
Suction
SUCTION
SUCTION
Improvement No improvement
Lasix
Improvement
• Worsening of
underlying
condition
• Pnemonia
CIRCULATION
BP
CVP
PAWP
ECG
CXR
ABG
BED SIDE ECHO
CIRCULATION
Is there Shock ?
Ongoing Myocardial Ischaemia?
Pulmonary Edema?
Arrythmia?
Pulmonary embolism?
OTHER PROBLEMS
Abdomen
- Abdominal distention
- Pain in Post op patients
• CNS
- Abnormal respiratory drive
-Increased ICP
-CT brain
-Check ABG
VENTILATOR ALARMS
Low Ventilation Alarm
-Leak
-decreased RR
-decreased compliance
-Increased resistance
-Altered Setting
• High Ventilation Alarm
-Increased Triggering
-Increased RR
-Change settings
High Pressure Alarm(Intermittent)
- cough, Secretion
- asynchrony
PRESSURE CONTROLLED
VENTILATION
MV Alarm
PATIENT VENTILATOR
ASYNCHRONY
SUCCESS OF WEANING
• Adequacy of gas exchange
• Performance of respiratory pump
PARAMETERS TO ACCESS
Pao2/Fio2 >= 200
Pao2/PAo2 <= 350mm Hg
Pao2>=60mm Hg with Fio2 <= 0.35
Vital capacity >= 10 -15 ml /kg
Maximum –ve Inspiratory Pressure< -30cms
H20
Minute Ventilation<10 lit /min
HOW TO WEAN?
Team approach
Ensure adequate sleep
Check electrolytes/pH
Check ET/TT tube size and patency
Good pulmonary toilet
Satisfactory bronchodilator therapy
Prop up position
METHODS TO DISCONTINUE
Abrupt of discontinuation of MV
- Post op patients can be put on Tpiece
and extubation
Spontaneous breathing trial
- Tpiece or through ventilator circuit
- 30-120 min
SIMV
Infection
• ET tube bypasses natural airway defense mechanisms
Nosocomial pneumonia, aspiration pneumonia
Psychological
• Patients may be extremely anxious and/or agitated
• Give consistent, calming explanations, offer reassurance
• Sedation, anti-anxiety agents frequently indicated
NEONATAL VENTILATION
CATEGORY AIRWAY COMPLIANCE
RESISTANCE (lit/cmH2O)
(cm
H2O/lit/sec)
New born 30-50 0.003-0.005
LAB CRITERIA
PaCO2 >60 mm Hg
PaO2 <50 mm Hg or SaO2<80%
with FiO2 1.0
pH<7.25
VENTILATOR STRATEGY
BODY WEIGHT 5KG
FiO2 1.0
RR 8-10/min
PEEP 0
SENSITIVITY -1 TO -2 cm H2O
TV 6 TO 8 ml/kg
NEUROMUSCULAR DISEASES
CMV
ACMV
HEAD INJURY
INDICATION:
ICP> 15 cm Hg
PaO2 <75 mm Hg
PaCO2 >45 mm Hg
Repeated seizures
Coma
HEAD INJURY (contd..)
VENTILATOR STRATEGY
S : SUCTION
A : AIRWAY
L : LARYNGOSCOPE
T : TUBE
TRACHEOSTOMY
Improved suctioning
Decreased WOB
Decreased Dead space
Improved patient comfort
Cuffed tubes PVC
ANALGESIA AND SEDATION
OPIOD ANALGESICS
Morphine
Pethidine
Fentanyl
BENZODIAZEPINES
Midazolam
Lorazem
Diazepam
REFRACTORY HYPOXAEMIA
INVERSE RATIO VENTILATION
DECREASED 02 CONSUMPTION
INTRACRANIAL HYPERTENSION
TETANUS
INJ.ATRACURIUM-
5-10MICROGRAM/MIN(0.2MG/KG)
INJ.VECURONIUM-
0.8MICROGRAM/KG/MIN(0.1MG/MIN)
VARIABLE- PERFORMANCE DEVICES
This position moves the abdominal contents away from the diaphragm,
which facilitates its contraction.
Monitor ABG’s.
Calories, minerals, vitamins, and protein are needed for energy and
tissue repair.
.
ANATOMY OF ABG
PH 7.40 mm Hg
PaO2 98 mm Hg
PaCO2 40 mm Hg
HCO3 24 mm Hg
ABG
FiO2 PaO2
0.3 150
0.4 200
0.5 250
0.8 400
1.0 500
APPROACH IN ABG
????
METABOLIC
ACIDOSIS
ABG
pH 7.46
PaO2 96 mm Hg
PaCO2 48 mm of Hg
HCO3 34 mm of Hg
Sat 98 %
????
METABOLIC
ALKALOSIS
ABG
pH 7.34
PaO2 80 mm Hg
PaCO2 62 mm of Hg
HCO3 29 mm of Hg
Sat 92%
????
RESPIRATORY
ACIDOSIS
ABG
pH 7.44
PaO2 96 mm Hg
PaCO2 24 mm of Hg
HCO3 16 mm of Hg
Sat 99 %
????
RESPIRATORY
ALKALOSIS
THANK YOU !!!!