Introduction to
Invasive
Ventilation
C AT H E R I N E J O N E S
P R A C T I C E E D U C ATO R – G I C U
SEPTEMBER 2018
Plan for Session
• ‘normal’ mechanics of breathing •Invasive Ventilation
• What is Invasive Ventilation? • Modes
• Indications & Contraindications for • Parameters
Invasive Ventilation • Alarms
• Complications of Invasive Ventilation • Monitoring
• Ventilator Care Bundles..
• Weaning from Invasive Ventilation
Pulmonary
Ventilation
Key Message?
NORMAL BREATHING IS A
PRODUCT OF NEGATIVE PRESSURE
GENERATED DURING INSPIRATION
What is Invasive
Ventilation?
What is Invasive Ventilation?
• Ventilation delivered through an invasive airway such as an endotracheal tube or
tracheostomy tube
• Designed to temporarily replace or support the patients own ventilation but can
be used short or long term
• Positive Pressure used to drive gas (air/oxygen mix) through ETT/TT to inflate
the lungs
•Oxygenation is dependent on FiO2, alveolar surface area, diffusion distance
•CO2 elimination is dependent on the volume of gas moved in & the out of the
lungs
Indications:
• Established or evolving respiratory failure – Unable to maintain gas exchange
•CVS instability +/- collapse
•Neurological instability
• GCS<8 – unable to maintain airway/gas exchange
• Raised ICP – therapeutic ventilation to reduce ICP
•Metabolic acidosis – decompensating respiratory function (i.e. getting ‘tired’)
•Anaesthetic
• Airway Compromise e.g. anaphylaxis
Contraindications:
Futility…
Goals of Mechanical
Ventilation
Maintaining alveolar ventilation I.e. CO2
elimination
Delivering appropriate oxygen concentrations
Support the patients respiratory status until they
are able to self ventilate, unsupported
Complications of Invasive Ventilation
• Aspiration & VAP
•Decreased cardiac output & venous return
• What you’ll see ↓BP, ↑HR, ↓UO, worsening metabolic acidosis
• Increased intrathoracic pressure reduces venous return → increases Right ventricular afterload →
reduced output from R & L ventricles (↓ CO)
• Decreased Urine Output as a result of ↓ CO
• Ventilator Induced Lung Injury
• Volutrauma, Atelectatrauma, Biotrauma, Barotrauma, Oxygen Toxicity
• Psychological Sequalae
• PTSD, delirium
ARDSNET Trial 2000
Key Message?
TIDAL VOLUME AIM
6ML/KG OF IDEAL BODY WEIGHT
Ventilator Care Bundle (s)
• Head of Bed elevation 30-45˚
•Stress Ulcer Prophlaxis
•Daily Sedation Hold
•Oral Decontamination
•Venous Thromboprophylaxis
•?Sub-glottic aspiration http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx
Weaning
• Process through which the patient is ‘liberated’ from the ventilator
• Can be rapid or sloooow – Patient & condition dependent
• Traditional Weaning methods
• Incremental down titration of Mandatory breaths/FiO2/PS/PEEP
• Spontaneous Breathing Trial
• Weaning ‘Sprints’ to build up stamina & muscle strength
INVASIVE
VENTILATION:
MODES, SETTINGS,
MONITORING,
ALARMS
Mechanical Ventilation - MODES
Pressure Vs Volume
◦ Pressure Mode
◦ Vent delivers gas until a predetermined pressure is achieved.
◦ Often used
◦ Volume Mode
◦ Vent delivers gas until a predetermined volume is achieved.
◦ Rarely Used
Mechanical Ventilation - MODES
Spontaneous, Controlled & Intermittent.
◦ Spontaneous
◦ All breaths ‘triggered’ by patient.
◦ CPAP & Pressure Support
◦ Controlled (or Mandatory)
◦ Predetermined respiratory rate is set & delivered by vent. O
◦ Overrides any spontaneous effort from patient.
◦ Intermittent
◦ vent synchronises to any spontaneous effort by patient thereby delivering both
mandatory & spontaneous breaths.
◦ PCV+, PSIMV, PC-SIMV
Invasive Ventilation: Settings
SETTINGS – DEPENDS ON THE ‘MODE’
Pressure Support PCV+
• Pressure support • Pressure support (for patient triggered breaths)
• FiO2 • P insp (for breaths time cycled by vent, bpm)
• Rate
• CPAP
• Tinsp (inspiratory time) affects I:E ratio
• FiO2
• CPAP
Mechanical Ventilation – SETTINGS??
Invasive Ventilation: Monitoring
• F = Respiratory rate (total and patient triggered)
• Fmand (number of set breaths)
• F total (total number of breaths per minute)
• Vt – tidal volume
• MV - (minute volume)
• P peak (peak pressure reached on inspiration)
• PEEP
• I:E ratio (only if you set a respiratory rate)
• Also: SpO2, EtCO2, ABG, RR
• Chart sticker – mls / kg (normally 6ml/kg) of ideal body weight or predicted body weight.
Invasive Ventilation: Alarms
• VT (tidal volume)
• MV (minute volume)
• Pressure (peak) – unless you have a good reason make sure this does not go
above 30mmHg
• Respiratory rate (check current rate from chart)
• Apnea time (normally 15 seconds or RR=4) Don’t switch this off – only very
exceptional circumstances i.e speaking valve with trachy, you must be present
• Look at patients current values and check with someone if you are not sure.
Quick Quiz!
• Does normal breathing rely on negative pressure or positive pressure?
• Does invasive ventilation rely on negative pressure or positive pressure?
• When would you not ventilate somebody?
• What are complications of Invasive Ventilation?
• What is vT & how much should it be?
• Describe what the vent is delivering with
• CPAP/PS
• PC-SIMV
• If your patient has a problem with oxygenation what settings might be tweaked in consultation with Docs?
• If your patient has a problem with CO2 elimination what settings might be tweaked in consultation with
Docs?
Questions ?
Iron Lung Ward 1950’s
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References
Coombs et al (2013) Assessment, monitoring & interventions for the
respiratory system. In Mallett, Albarron & Richardson Eds: Critical Care
Manual of Clinical Procedures & Competencies. (Wiley & Sons, West
Sussex)
Intensive Care Foundation (2015) Handbook of Mechanical Ventilation –
A Users Guide (Intensive Care Society, London)
file:///C:/Users/User/Downloads/Ventilation%20handbook%20(1).pdf
(downloaded August 2016)
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