Mechanical Ventilator
Shahzaib
MECHANICAL VENTILATION
Goals
Maintain patient comfort
Allow a normal, spontaneous breathing pattern whenever possible
Maintain a PaCO2 between 35-45 mmHg
Maintain a PaO2 sufficient to meet cellular oxygen demands but avoid oxygen
toxicity
Avoid respiratory muscle fatigue and atrophy
Indications for Mechanical ventilation
Airway Instability
Respiratory failure
RESPIRATORY FAILURE
The etiology of patient respiratory failure can be divided into two categories
1.Failure to oxygenate
2.Failure to ventilate
RESPIRATORY FAILURE
Failure to oxygenate
-Characterized by decreased Pa02
Failure to ventilate
-Characterized by increased PaCO2
MECHANICAL VENTILATION
Breath Types
There are two basic breath types
1-Spontaneous or demand
Initiated by the patient
2- Ventilator or mandatory
Initiated by the ventilator (time triggered)
Variables
Breaths are defined by these variables
Control: Constant throughout inspiration, regardless of changes in respiratory
impedance
Trigger: Initiates the inspiratory phase
Limit: Maximal set inspiratory pressure or flow
Cycling: The factor that terminates the inspiratory cycle
Control Variable
Flow (volume) controlled
-pressure may vary
Pressure controlled
-flow and volume may vary
Time controlled
- pressure, flow, volume may vary
Trigger Variable
Time -control ventilation
Pressure -patient assisted
Flow -patient assisted
Volume -patient assisted
Limit Variable
Inspiratory - delivery limits Maximum value that can be reached but will not end
the breath
Volume
Flow
Pressure
Cycling Variable
The phase variable used to terminate inspiration
Volume
Pressure
Flow
Time
Goals of Ventilator Modes
1 Maintain adequate oxygenation
2. Maintain adequate ventilation
3. Reduce work of breathing
4. Improve patient comfort
Goals of Ventilator Modes Cont...
Support of Adequate Oxygenation
1.Oxygen responsive hypoxemias
Pneumonia
Sepsis
Inhalation injury
2.Oxygen refractory hypoxemias
Atelectasis
Aspiration
ALI/ARDS
Goals of Ventilator Modes Cont...
3. Support of Adequate Ventilation
Airway compromise
Muscle fatigue / weakness
Paralysis/spinal cord injury
Neuromuscular disease
Chest wall injury
Why new modes?
Regardless of the mode used, the goals are:
To avoid lung injury
Keep the patient comfortable
Wean the patient from mechanical ventilation as soon as possible.
MODES OF MECHANICAL
VENTILATION
Volume Control Ventilation
The ventilator delivers a pre-determined VT at a preset frequency
Advantages
Guaranteed minute ventilation
Disadvantages
No patient interaction. The patient can not initiate a breath
Assist/Control Ventilation
The ventilator delivers a pre-determined VT with each inspiratory effort generated
by the patient. A back-up frequency is set to insure a minimum VE Assisted
breath, the patient must lower the airway pressure by a preset amount, called the
trigger sensitivity
Advantages
Patient can increase VE by increasing respiratory rate
Disadvantages
Dys-synchrony
Respiratory alkalosis
Dynamic hyperinflation
Intermittent Mandatory Ventilation(IMV)
Intermittent mandatory ventilation (IMV) is a type of ventilatory support in which
mandatory positive pressure breaths are delivered at preset time intervals.
Between these breaths, the patient may breathe spontaneously.
IMV is associated with patient-ventilator dys synchrony because the mandatory
breaths are not delivered in concert with the patient's inspiratory effort.
A mechanical breath could therefore be delivered during a spontaneous
inspiration, leading to lung overdistention,
Synchronized Intermittent Mandatory
Ventilation (SIMV).
The ventilator delivers a predetermined VT at a preset frequency and allows the
patient to take spontaneous breaths between ventilator breaths Spontaneous
breaths may be augmented with pressure support.
Advantages
Improved venous return
Disadvantages
Increased oxygen consumption
Increased work of breathing
Pressure Control Ventilation (PCV)
The practitioner sets the maximal pressure obtained by the ventilator (preset
Pressure), frequency and time the pressure is sustained (inspiratory time).
Inspiratory time is set as a percent of the total cycle or absolute time in seconds.
Pressure Control Ventilation (PCV)
Advantages
Tidal volume variable with constant peak airway pressure
Full ventilatory support
Decreased mean airway pressure
Control frequency
• Disadvantages
Requires sedation or paralysis
Ventilation does not change in response to clinical changing needs
Pressure Support Ventilation (PSV)
The ventilator delivers a predetermined level of positive pressure each time the
patient initiates a breath. A plateau pressure is maintained until inspiratory flow
rate decreases to a specified level
Pressure Support Ventilation (PSV)
Advantages
The flow rate, inspiratory time, and frequency are variable and determined by the
patient
Decreased inspiratory work
Enhanced muscle reconditioning
Disadvantages
Requires spontaneous respiratory effort
Delivered volumes affected by changes in compliance
Positive End Expiratory Pressure (PEEP)
PEEP is the application of positive pressure to change baseline variable during CMV, SIMV, IMV
and PCV. PEEP is primarily used to improve oxygenation in patients with severe hypoxemia.
Advantages
Improves oxygenation by increasing FRC
Decreases physiological shunting
Improved oxygenation will allow the FIO2 to be lowered
Increased lung compliance
Decreased work of breathing
Disadvantages
Increased incidence of pulmonary barotrauma
Potential decrease in venous return
Increased intracranial pressure
Inverse Ratio Ventilation (IRV)
During normal spontaneous breathing, the ratio of inspiratory to expiratory time is
1:2 to 1:3.
During inverse ratio ventilation, the inspiratory time is prolonged, lasting up to
50% to 75% of the respiratory cycle, which yields an inspiratory to expiratory
time ratio of 1:1 to 3:1
IRV ventilation may be accomplished in a pressure controlled, time cycled mode
(PCV-IRV) or a volume cycled mode (VCV-IRV)
Inverse Ratio Ventilation (IRV)
Advantages
Maintains elevated mean airway pressure, while maintaining safe peak alveolar
pressures
Recruitment of lung units with decreased compliance
Disadvantages
Auto-PEEP
Exacerbation of hemo-dynamic instability
Barotrauma
Requires deep sedation and paralysis
Adaptive support ventilation (ASV)
Adaptive support ventilation (ASV) evolved as a form of mandatory minute
ventilation implemented with adaptive pressure control.
ASV automatically selects the appropriate tidal volume and frequency for
mandatory breaths and the appropriate tidal volume for spontaneous breaths on
the basis of the respiratory system mechanics and target minute alveolar
ventilation.
Ventilator settings in adaptive support
ventilation
Ventilator settings in ASV are:
Patient height
Sex
Percent of normal predicted minute ventilation
Fio2
PEEP
Clinical applications of adaptive support ventilation
ASV is intended as a sole mode of ventilation, from initial
support to weaning.
Theoretical benefits of adaptive support ventilation
In theory, ASV offers automatic selection of ventilator settings, automatic
adaptation to changing patient lung mechanics, less need for human manipulation of
the machine, improved synchrony, and automatic weaning.
