MECHANICAL

VENTILATION

BY JULIET .W. CHEGE

BACKGROUND
• 2nd Century: Roman physician Galen first used
mechanical breathing by blowing air into the larynx
of a dead animal using a reed.
• Author George Poe used a mechanical respirator to
revive an asphyxiated dog.
• 1929: First negative-pressure machines; The
Drinker and Shaw tank-type ventilator.Known as the iron lung, a
metal cylinder that completely engulfed the patient up to the
neck.
CONT…..
• A vacuum pump created negative pressure in the
chamber, that expands the patient's chest.
• The change in chest geometry reduce the
intrapulmonary pressure and allow ambient air to
flow into the patient's lungs.
• When the vacuum is terminated, the negative pressure
applied to the chest dropped to zero, and the elastic recoil of
the chest and lungs permitted passive exhalation
Chest
cuirass(negativ
e pressure
ventilation)
• PARTS OF VENTILATOR
a) Heat & Moisture Exchanger
(HME) Filter
b)BREATHING CIRCUIT
Humidifier
Flow sensor
Y-PIECE
CATHETER MOUNT
 Common Ventilator Settings
parameters/ controls
• Fraction of inspired oxygen (FIO2)
• Tidal Volume (VT)
• Peak Flow/ Flow Rate
• Respiratory Rate/ Breath Rate / Frequency ( F)
• I:E Ratio (Inspiration to Expiration Ratio)
• PEEP
 Fraction of inspired oxygen (FIO2)
• The percent of oxygen concentration that the patient is
receiving from the ventilator. (Between 21% & 100%)
• Initially a patient is placed on a high level of FIO2 (60% or
higher).
• Subsequent changes in FIO2 are based on ABGs and the
SaO2.
• The lowest possible fraction of inspired oxygen (FiO2)
necessary to meet oxygenation goals should be used.
Tidal Volume (VT)
• The volume of air delivered to a patient during a ventilator
breath.
• The amount of air inspired and expired with each breath.
• Usual volume selected is between (5 to 15 ml/ kg body
weight)
• The large tidal volumes may lead to (volumtrauma) aggravate
the damage inflicted on the lungs.
 Respiratory Rate/ Breath
Rate / Frequency ( F)
• The number of breaths the ventilator will deliver/minute (10-16 b/m).

Positive End-Expiratory Pressure (PEEP)

• PEEP is the pressure in the lungs (alveolar pressure)
above atmospheric pressure (the pressure outside of the
body) that exists at the end of expiration
Peak Flow/ Flow Rate
• The velocity of gas flow or volume of gas delivered by the
ventilator per minute (L/min)
• The higher the flow rate, the faster peak airway pressure is
reached and the shorter the inspiration;
• The lower the flow rate, the longer the inspiration.
I:E Ratio (Inspiration to
Expiration Ratio)
• During spontaneous breathing, the normal I:E ratio is 1:2,
indicating that for normal patients the exhalation time is
about twice as long as inhalation time.
• If exhalation time is too short “breath stacking” occurs
resulting in an increase in end-expiratory pressure also called
auto-PEEP.
• Minute Volume (V E ) : The amount of lung volume exhaled in 1
minute. Normal lung volume is 8 to10 L/min
• Peak Inspiratory Pressure (PIP) : Peak pressure measured as each
ventilator breath is given. To guard against barotrauma, high and low-
pressure alarms are set in relation to the PIP.
• Normal PIP is less than 35 cm H 2O .
• If resistance increases in the lungs or lung compliance decreases as a
result of a pathologic condition (i.e.,ARDS), the PIP will increase.If
there is a disconnection or leak in the ventilatorcircuit, the PIP will
sound an alarm indicating a low value.
• Trigger :
• The patient’s breath can be sensed as a change of flow in the circuit
and it can allow the spontaneous breath to occur.
• It is what causes the breath to begin (signal to open the inspiratory
valve)
Trigger
• Machine (controlled): the ventilator will trigger regular breaths at a frequency
which will depend on the set respiratory rate, ie, they will be ventilator time
triggered.

• Patient (assisted): If the patient makes an effort to breathe and the ventilator
can sense it (by either sensing a negative inspiratory pressure or an inspiratory
flow) and deliver a breath, it will be called a patient triggered breath.
• Sensitivity : This setting adjusts how much effort the patient must generate
(negative inspiratory force) before the ventilator delivers a breath. Activated
only in the assist/control or SIMV (synchronized intermittent mandatory
ventilation) modes.
INDICATION FOR MECHANICAL
VENTILATION
• Neurological impairment (drugs, poisions , snake bite, trauma) with “Glasgow
Coma Scale “ (GCS) ≤ 8.
• Respiratory Failure
Arterial PaO2 <60 mm Hg (on supplemental Oxygen).
Arterial PaCO2 >50 mm Hg (in the absence of chronic airway disease)
• . Evidence of elevated work of breathing:
Respiratory rate > 35 breaths/minute
• Presence of retraction or nasal flaring.
• Paradoxical or divergent chest motion.
Cardiopulmonary arrest.
Neuromuscular disorders.
Lung Diseases.
CONT….
TYPES OF MODES
• Negative pressure ventilation
• Positive pressure ventilation

• Negative pressure Ventilators: (

(Rarely used in modern day medicine)
• Are applied externally to the patient.
• Decrease the atmospheric pressure surrounding the thorax to initiate
inspiration
• Currently used for patients with neuromuscular disease. iron lung and
chest cuirass.
Cont….

Disadvantages:
Limited access for patient care
Inability to monitor pulmonary mechanics
 Patient discomfort
POSITIVE PRESSURE VENTILATION
A positive pressure ventilation inflate the lungs by exerting
positive pressure in the airway forcing the alveoli to expand
during inspiration. Expiration occurs passively.
Inspiration can be triggered either by the patient or
machine.
Classification of Positive Pressure
Ventilation
Volume controlled
• Deliver a preset tidal volume
• Allows pressure to vary with changes in resistance and compliance
• Volume delivery remains constant

. Pressure controlled
• Deliver a preset inspiratory pressure during each inspiration
• Volume delivery may vary
Continuous mandatory mode
• Control (CMV)
• Assist control (AC)
Intermittent Mandatory mode
• IMV (Intermittent Mandatory Ventilation)
• SIMV ( synchronized Intermittent Mandatory Ventilation)
Spontaneous mode
• Continuous Positive Airway Pressure (CPAP)
• BiLevel Positive Airway Pressure (BiPAP)
Controlled Mandatory Ventilation (CMV)
• The ventilator initiates and controls both the volume
delivered and the frequency of breaths. Patient cannot
trigger ventilation. Patient should be sedate and possibly
paralyzed.
contd
Advantages
• Guaranteed volume(or pressure ) with each breath
• Low patient workload
 Disadvantages
• Spontaneous breath not allowed
• Needs deep sedation & Paralysis
• Apnea & Hypoxia if accidentally disconnected
• Ventilator dependence
Assist Control Mode (AC)
• Assist-control ventilation allows the patient to initiate a ventilator
breath (assisted or patient-triggered ventilation), but if this is not
possible, ventilator breaths are delivered at a preselected rate
(controlled or time-triggered ventilation).
• The ventilator breaths during ACV can be volume-controlled or
pressure-controlled.
• Used for the patients who can initiate a breath but who have
weakened respiratory muscles such as Gullain Barre Syndrome, post
cardiac or respiratory arrest, pulmonary oedema, ARDS etc.
AC MODE
Advantages
• Increase Patients comfort
• Patients work of breathing is low
• Patient can control the frequency

Disadvantages
• Risk of Hyperventilation
Intermittent Mandatory Ventilation
• Intermittent mandatory ventilation provides a combination
of mechanical breaths and spontaneous breaths .
• Mechanical breaths are delivered at preset intervals and a
preselected tidal volume, regardless of patient’s efforts.
• Patient is allowed to breath independently except during
certain prescribed intervals.
Advantages
• Allows spontaneous breath of any tidal volume

Disadvantages
• Increase work of breathing
• Asynchrony
Synchronized Intermittent Mandatory
Ventilation (SIMV)
• SIMV also delivers a preset tidal volume and number of breaths per
minute .
• Mandatory breaths are synchronised with the patient's own
inspiratory effort which is more comfortable for the patient
• Between ventilator delivered breaths the patient can breath
spontaneously.
• It is one of the weaning modes
Advantages
• The mandatory breath is delivered in synchrony with patient effort. This makes
greater comfort during breathing.
• The patients respiratory muscles remain active, and so disuse atrophy is less
common.

Disadvantages
• Hypoventilation is possible if the patient is not capable of spontaneous
breathing.
• Excessive work of breathing is possible during spontaneous breaths unless an
adequate level of pressure support is applied.
Spontaneous mode
1. Continuous positive airway pressure(CPAP)

2. Noninvasive bilevel positive airway pressure ventilation (BiPAP)

Continuous Positive Airway Pressure (CPAP)
• Constant positive airway pressure during spontaneous breathing
• This is a mode and simply means that a preset pressure is present in
the circuit and lungs throughout both the inspiratory and expiratory
phases of the breaths.
• CPAP serves to keep alveoli from collapsing, resulting in better
oxygenation and less work of breathing.
• It is very commonly used as a mode to evaluate the patients
readiness for weaning or extubation.
Cont….
• The purpose of CPAP is to improve and support the patient’s
oxygenation. CPAP does not improve the patient’s ventilatory status,
so the patient must be breathing spontaneously if CPAP is in use.
Indication:
• Hypoxemic respiratory failure
• Obstructive sleep apnea
• Congestive heart failure
• Weaning from ventilation
Bilevel Positive Airway Pressure Ventilation
(BiPAP)
• TBilevel positive airway support (BPAP), as the name implies,
delivers two set levels of positive airway pressure
• one during inspiration (IPAP)
• and one during expiration (EPAP)
Pressure –control mode
The volume of gas is delivered until the preset pressure has been
reached.
• Breaths are triggered by the patient,The patient may receive a
variable tidal volume(VT), depending on lung compliance, as well as
airway and circuit compliance.
• Two of the most common pressure-targeted modes are:
• Pressure-support (PS) and
• Pressure-control (PC) ventilation
Pressure support ventilation
• Augments the patient’s spontaneous breaths with a preset amount of
inspiratory pressure.
• The patient’s respiratory drive must be intact in order for the patient to
initiate spontaneous breaths.
 Main parameters to set:
Pressure-support level,sensitivity, FiO 2 , and PEEP.
• It is also used in conjunction with other modes to supplement spontaneous
breaths, as with synchronized intermittent mandatory ventilation (SIMV).
Advantage:
• Patient has control over the ventilatory process.
Pressure-control mode
• Respiratory rate is set and every breath is augmented by a
preset amount of inspiratory pressure.
• Once triggered, the gas is delivered until the preset pressure
is reached.
• If the patient takes spontaneous breaths, those breaths are
also augmented by the preset inspiratory pressure.(assist on)
Cont…
• Parameters to set:
• Inspiratory-pressure limit,
• Respiratory rate,
• Inspiratory time,
• Sensitivity,
• Fio 2 , and
• PEEP.
• This mode is useful in controlling high-plateau pressures, which
prevents the patient from developing barotrauma.
COMPLICATION OF MECHANICAL
VENTILATION
• Ventilator induced lung injury
• Oxygen toxicity
• Cardiovascular compromise
• Other body systems compromise
• Patient-ventilator dyssnchrony
• Ventilator associated pneumonia
• Hypoventilation and hyperventilation
VENTILATOR INDUCED LUNG INJURY
(VILI)
• Mechanical ventilation can cause two types of injury to the lungs
• Air leaks
• Biotrauma
Air leaks:
Are due to:
• Excessive pressure in the alveoli (barotrauma)
• Excessive volume in the alveoli (volutrauma) or
• Shearing due to repeated opening and closing of the alveoli
(atelectrauma)
CONT..
• When a mechanical ventilation breath is forced into the patient, the
positive pressure tends to follow the path of least resistance to the
normal or relatively normal alveoli, potentially causing overdistention.
• Overdistention sets off an inflammatory cascade that augments or
perpetuates the initial lung injury,causing additional damage to
previously unaffected alveoli.
• Barotrauma, volutrauma and atelectrauma can cause release of
cellular mediators and initiation of inflammatory-immune response.
This is known as biotrauma
• Biotrauma can lead to acute respiratory diseasesyndrome (ARDS)
PREVENTION OF VILI
• The plateau pressure (pressure needed to inflate the alveoli) should
be kept at less than 32cmH2O,
• Positive end expiratory pressure (PEEP) should be used to avoid end-
expiratory collapse and reopening and
• A lower tidal volume between 6-8ml/kg
OXYGEN TOXICITY
Increased FIO2 and its duration of use.
• Its due to the production of oxygen free radicals,such as superoxide
anion e.t.c.
• Can cause a variety of complications ranging from mild
tracheobronchitis and absorptive atelectasis to diffuse alveolar
damage that is indistinguishable from ARDS.
• Use the lowest FIO2 that accomplishes satisfactory oxygenation.
VENTILATOR ASSOCIATED
PNEUMONIA (VAP)
• Sub-group of hospital acquired pneumonia(HAP).
• Development of pneumonia within 48 to 72 hours after endotracheal
intubation.
• Placement of artificial airway bypasses and impairsmany of the lung’s
normal defense mechanisms.
• A number of prevention strategies can be bundledto reduce the risk of
VAP( ventilator Bundles)
o Suctioning
o Oral care
o nebulization
HYPERVENTILATION
• Hyperventilation and hypoventilation:
• Hyperventilation: Lowers Paco2 and increases arterial pH. It causes
alveolar overdistention and an alkalotic pH.
• Respiratory alkalosis causes hypokalemia,decreased ionized calcium,
and increased affinity of hemoglobin for oxygen (left shift of the
oxyhemoglobin dissociation curve)
CARDIAC EFFECT
• Cardiac effects:
• Positive pressure ventilation can decrease cardiac output. Increased intrathoracic
pressure decreases venous return and right heart filling, reducing cardiac output.
• With spontaneous breathing, venous return to the right atrium is greatest during
inhalation, when the intrathoracic pressure is lowest.
• During positive pressure ventilation, venous return is greatest during exhalation.
Positive pressure ventilation may increase pulmonary vascular resistance.
• The increase in alveolar pressure, particularly with PEEP, has a constricting effect
on the pulmonary vasculature.
• Increase in pulmonary vascular resistance decreases left ventricular filling and
cardiac output
GASTRIC EFFECT
• Gastric distention: When air leaks around ETT or tracheostomy tube
cuff
• Vomiting as a result of pharyngeal stimulation from artificial airway
• Hypomotility and constipation due to immobility,paralytic agents,
analgesics and sedatives
• Stress ulcer formation and gastrointestinal bleeding
• Stress ulcer prophylaxis should be provided
NEUROMUSCULAR EFFECTS
• Increased risk of critical illness and weakness(polyneuropathy and
polymyopathy).
• Paralysis may cause ventilator-induced diaphragm
• dysfunction.
• Excessive respiratory muscle activity can result in muscle fatigue.
• Appropriate balance between respiratory muscle activity and support
from the ventilator is important.
• Mobilization is necessary (physiotherapy)
Sleep effects:
• Mechanically ventilated patients may not have normal sleep patterns.
• Sleep deprivation can produce delirium, patient ventilator
asynchrony, and sedation-induced ventilator dependency.

• Patient-ventilator asynchrony:
• • Asynchrony: Lack of coordination between a
• patient's respiratory center output and the
• response of the ventilator
• • Lack of synchrony between the breathing efforts of
• the patient and the ventilator.
• • Patients not breathing in synchrony with the
• ventilator appear to be fighting or ‘’bucking’’ the
• ventilator
PATIENT VENTILATOR ASYNCHRONY
• Asynchrony: Lack of coordination between a patient's respiratory
center output and the response of the ventilator
• Lack of synchrony between the breathing efforts of the patient and
the ventilator.
• Patients not breathing in synchrony with tMay be due to poor trigger
sensitivity, auto-PEEP,incorrect inspiratory flow or time
setting,inappropriate tidal volume, or inappropriate mode.
Mechanical malfunctions:

• A variety of mechanical complications can occur during mechanical

ventilation.
• These include:
 Accidental disconnection,
 Leaks in the ventilator circuit,
 Loss of electrical power, and
Loss of gas pressure.
The mechanical ventilator system should be
• monitored frequently to prevent mechanical malfunctions
Benefits of mechanical ventilation
• It helps decrease the patient’s work of breathing which helps the
respiratory muscles rest and recover.
• It helps the patient get adequate amounts of oxygen.
• It provides stability and allows medications to work while the patient
heals.
• It helps the patient achieve adequate ventilation by
• removing carbon dioxide for effective gas exchange