INTRODUCTION TO
MECHANICAL
VENTILATION
Citra R. Perangin-angin
History
2 Kings 4 : 34
Hippocrates (400 BC): first intubation
Paracelcus (1493-1541): bellow and oral
tube
Pre 1900 : whole-body respirators for
research
- 1930 US poliomyelitis: Emerson Iron
Lung
EARLY VENTILATOR
1937
2 Type of MV
NEGATIVE PRESSURE
VENTILATOR
POSITIVE PRESSURE
VENTILATOR
NEGATIVE PRESSURE
VENTILATOR
1. Negative pressure surrounding the body by big tank
2. Earlier ventilator in endemic polio era
3. IRON LUNG pulls the thorax cavity inspiration
4. Limited acces to the patient
POSITIVE PRESSURE
VENTILATOR (PPV)
1. Push positive pressure to the lung
2. Modern ventilator
3. Air actively push to the lung by higher pressure in ventilator
4. Must overcome the resistance and compliance of lung and
chest wall
5. Postive pressure disturbs venous return to the heart,
increases pulmonary vasculare resistance, decrease cardiac
output NON Physiologic
2 COMPONENTS
LUNG VENTILATION
AIRWAY RESISTANCE
(RAW)
COMPLIANCE
(COMPL)
AIRWAY
LUNG
RAW
CL
Indications for
Mechanical Ventilation
Ventilation abnormalities
Respiratory muscle dysfunction
Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular disease
Decreased ventilatory drive
Increased airway resistance and/or
obstruction
Indications for
Mechanical Ventilation
Oxygenation abnormalities
Refractory hypoxemia
Need for positive end-expiratory pressure
(PEEP)
Excessive work of breathing
Types of Ventilator
Breaths
Volume-cycled breath
Volume breath
Preset tidal volume
Time-cycled breath
Pressure control breath
Constant pressure for preset time
Flow-cycled breath
Pressure support breath
Constant pressure during inspiration
Basic Mode of MV
Controlled Mechanical (Mandatory)
Ventilation (CMV)
Assist-Control Ventilation (A/C)
Synchronized Intermitten Mandatory
Ventilation (SIMV)
Pressure Controled Ventilation (PCV)
Pressure Supported Ventilation (PSV)
Continous Positive Airway Pressure
(CPAP)
Partitioning of the Workload Between
the Ventilator and the Patient
How the work of breathing partitions between the patient and the
ventilator
depends on:
Mode of ventilation (e.g., in assist control most of the work is usually done by the
ventilator)
Patient effort and synchrony with the mode of ventilation
Specific settings of a given mode (e.g., level of pressure in PS and set rate in SIMV)
Modes of Mechanical Ventilation
Point of Reference:
Spontaneous Ventilation
Controlled Mechanical Ventilation
Preset rate with volume-cycled breaths
No patient interaction with ventilator, no
spontaneous breath
Advantages: rests muscles of respiration
Disadvantages: requires sedation/neuromuscular blockade, potential adverse
hemodynamic effects
Controlled Mechanical Ventilation
Fixed TV but pressure variated depends on
Resistance and Compliance of the lung
Volume control
Volume
targeted
Set TV 500 cc
Flow/volume
Volume fixed
Pressure variated
TVe 500 cc
Pres variated
Peak
Pressure
Pressure
Assist-Control Ventilation
Volume or time-cycled breaths + minimal ventilator
rate
Additional breaths delivered with inspiratory effort
Advantages: reduced work of breathing; allows
patient to modify minute ventilation
Disadvantages: potential adverse hemodynamic
effects or inappropriate hyperventilation
Assist-Control Ventilation
Additional breath triggered by the patient
are pushed until preset volume achieved
Synchronized Intermittent
Mandatory Ventilation (SIMV)
Volume or time-cycled breaths at a
preset rate
Additional spontaneous breaths at tidal
volume and rate determined by patient
Used with pressure support
Synchronized Intermittent
Mandatory Ventilation (SIMV)
Potential advantages
More comfortable for some patients
Less hemodynamic effects
Potential disadvantages
Increased work of breathing
PCV
Control mode
Predetermined pressure in predetermined
time (tyme-cycled) and fixed rate
Use to limit the inflation pressure
TV variated depends on resistance and
compliance of the lung
Often called (P) CMV
PCV
Advantages:
Prevent barotrauma
Adjusted I:E ratio
Disadvantages
Potential hyper or hypoventilation
Need sedation and NMB because of
uncomfort
Respiration muscles atrophy
Pressure-Support
Ventilation
Pressure assist during spontaneous
inspiration with flow-cycled breath
Pressure assist continues until inspiratory
effort decreases
Delivered tidal volume dependent on
inspiratory effort and
resistance/compliance of lung/thorax
PSV
Pressure support given must achieves
one or more of the following goals:
Vt 6-10 cc/kg, depending on patien needs
A slowing RR to an acceptable range
The desired minute ventilation
Approriate alarm and backup ventilation
setting are essential
Pressure-Support
Ventilation
Potential advantages
Patient comfort
Decreased work of breathing
May enhance patient-ventilator synchrony
Used with SIMV to support spontaneous
breaths
Pressure-Support
Ventilation
Potential disadvantages
Variable tidal volume if pulmonary
resistance/compliance changes rapidly
If sole mode of ventilation, apnea alarm mode
may be only backup
Gas leak from circuit may interfere with cycling
Continuous Positive Airway
Pressure (CPAP)
No machine breaths delivered
Allows spontaneous breathing at
elevated baseline pressure
Patient controls rate and tidal volume
MONITORING
Inspiratory Plateau Pressure (IPP)
Airway pressure measured at end of
inspiration with no gas flow present
Estimates alveolar pressure at endinspiration -- compliance
Indirect indicator of alveolar distension
Plateau pressure
PIP
Plateau pressure
Inspiratory Plateau
Pressure
High inspiratory plateau pressure
Barotrauma
Volutrauma
Decreased cardiac output
Methods to decrease IPP
Decrease PEEP
Decrease tidal volume
Safe Inspiratory Plataeu Pressure <
30 cmH2O
Pulmonary Mechanics
Peak pressure
Airway Resistance
Plateau pressure
I
Inspiratory Time: Expiratory Time
Relationship (I:E ratio)
Spontaneous breathing I:E = 1:2
Inspiratory time determinants with volume
breaths
Tidal volume
Gas flow rate
Respiratory rate
Inspiratory pause
Expiratory time passively determined
I:E Ratio during Mechanical
Ventilation
Expiratory time too short for exhalation
Breath stacking
Auto-PEEP
Reduce auto-PEEP by shortening
inspiratory time
Decrease respiratory rate
Decrease tidal volume
Increase gas flow rate
Auto-PEEP(intrinsic, inadvertent,
occult)
Can be measured on some ventilators
Increases peak, plateau, and mean
airway pressures
Potential harmful physiologic effects
Auto-PEEP
Can be measured on some ventilators
Increases peak, plateau, and mean
airway pressures
Potential harmful physiologic effects
Suspecting and Measuring AutoPEEP
Suspect AutoPEEP if flow at
the end of expiration does not
return to the zero baseline.
AutoPEEP is commonly measured by performing a pause at the end of
expiration. In a passive patient, flow interruption is associated with
pressure equilibration through the entire system. In such conditions,
proximal airway pressure tracks the mean alveolar pressure caused by
dynamic hyperinflation.
Interventions to reduce auto-PEEP
Decrease RR
Decrease VT
Increase gas flow rate
Permissive Hypercapnia
Acceptance of an elevated paCO2, eg.,
lower tidal volume to reduce peak airway
pressure
Contraindicated in increased ICP
Consider in severe asthma and ARDS
Critical care consultation advised
Normal Lung Mechanics and Gas
Exchange
Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs
CNS depression
NL
NL
NL
NL
NL
None
A/C, SIMV
0.21-0.40
8-12 ml/Kg
12/m
2-5
1/1.5-2
Adjusted for patients comfort
40-50
Desired
Severe Airflow Obstruction
Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs
Asthma
IMP
NL
NL
IMV-A/C
0.30-0.50
5-7 ml/Kg
15-18/m
0
1/4-5
60 L/m
60-75
Undesired
Acute on Chronic Respiratory
Failure
Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs
COPD
IMP
NL-
NL-
SIMV-A/C
0.25-0.40
6-8 ml/Kg
15-18/m
0
1/3-4
60L/m
50-60
Undesired
Acute Hypoxemic Respiratory Failure
Indications
Abnormalities:
V/Q
Shunt
Lung Mechanics:
Airway resistance
Dynamic compliance
Static compliance
Air trapping: PEEPi
Settings:
Mode
FiO2
Vt
Rate
PEEP
I/E
Peak flow
Upper limit pressure alarm
Sighs
ARDS
-
NL
NL/
None
SIMV-A/C
1
4-6 ml/Kg
24-28 /m
--
1/1.5 - 3/1
40 L/m
50-60
Undesired
