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Positive Pressure Ventilation

1) Assist control ventilation (AC) delivers a set number of mandatory breaths while allowing spontaneous breathing on top of it. Volume control AC aims for a set tidal volume while pressure control AC uses a set driving pressure. 2) Positive pressure ventilation can be delivered via volume control or pressure control modes. Volume control modes deliver a set tidal volume while pressure control uses a set driving pressure and allows tidal volumes to vary. 3) Synchronized intermittent mandatory ventilation (SIMV) is similar to AC but allows spontaneous breaths to be synchronized with the ventilator using pressure support to augment patient effort.

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Rayhan Shariff
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496 views20 pages

Positive Pressure Ventilation

1) Assist control ventilation (AC) delivers a set number of mandatory breaths while allowing spontaneous breathing on top of it. Volume control AC aims for a set tidal volume while pressure control AC uses a set driving pressure. 2) Positive pressure ventilation can be delivered via volume control or pressure control modes. Volume control modes deliver a set tidal volume while pressure control uses a set driving pressure and allows tidal volumes to vary. 3) Synchronized intermittent mandatory ventilation (SIMV) is similar to AC but allows spontaneous breaths to be synchronized with the ventilator using pressure support to augment patient effort.

Uploaded by

Rayhan Shariff
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© © All Rights Reserved
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INVASIVE POSITIVE PRESSURE VENTILATION

Yellow Team Group Presentation


02/26/2018
Compliance
• C= V/P
• Compliance comes from chest wall and lungs
in a parallel circuit manner =>
• 1/200+ 1/200 = 1/100
• These compliance are not individual entities
so change in compliance of chest wall will
affect total compliance of the respiratory
system and vice versa.
Assist Control Ventilation
• “Control” – set number of breaths are
delivered
• “Assist” – if patient wants to take a
spontaneous breath, machine will aid in the
process once minimum negative pressure is
triggered.
• Can be volume controlled or pressure control
• VC-AC or VC-PC
VC-AC
• The tidal volume and the RR is set.
• Machine will give whatever pressure is
required to generate set tidal volume.
• Tidal volume should be based on PBW
(depends on height and gender).
• ARDSNET study showed VILI is due to
volutrauma and less barotrauma.
• Recommend 4-6ml/kg of tidal volume.
VC-AC (continued)
• Plateau pressure – relates to static compliance
and reflects pressure in the small airways and
alveoli when there is no airflow
• End Inspiratory Hold Maneuver for 0.5-1sec
• Ideally Plateau Pressure should be 30-35 cm
H2O.
• Compliance and plateau pressure are inversely
related.
• In VC, machine turns off flow once the target
tidal volume has been reached.
VC-AC (continued)
PC-AC
• The driving pressure, the rate and the i-Time
is set.
• The driving pressure is the change in pressure
that occurs during the course of a breath.
• The normal I:E is 1:2 - 1:4 -- > breathing in
takes 1 sec and exhaling takes 2 secs/4secs.
• I:E >=1:1 reverse ventilation – refractory
ARDS and must heavily sedate patient.
PC-AC (Continued)
• Driving pressure = base pressure at the end
of expiration (PEEP) to a Peak Pressure and
holds it for I-time and drops back to PEEP.
• So the tidal volume generated by the driving
pressure depends on the compliance.
• The driving pressure should be set at
whatever pressure generates a tidal volume
of 6ml/kg.
PC-AC (Continued)
PC-AC (Continued)
• Drawback is that compliance can change in
critically ill patients, therefore generated tidal
volumes may be erratic.
• Be mindful of barotrauma due to high Peak
pressures (PEEP + Driving Pressure) and
should not exceed 30-35cm H2O.
VC vs PC
SIMV
• Synchronized Intermittent Mandatory
Ventilation
• Similar to AC that ventilator is set to deliver a
pre-set number of breaths.
• Different from AC, if the machine detects the
patient is trying to breath on their own, it will
delay the machine breath and let patient
breath on their own – “synchrony”.
SIMV (continued)
• Problem is that tidal volume is dependent on
patient’s effort and strength and can be
variable.
• SIMV is therefore usually equipped with PS
(pressure support – different from pressure
control in AC).
• PS is the pressure the ventilator applies
whenever it detects the patient taking a
breath on their own.
SIMV (continued)
• On SIMV, the rate (12-18) and tidal volume
(6ml/kg) are set similar to AC.
• Initial PS @ 10cm H2O and can be changed
based on pulled tidal volumes.
• As PS is decreased, patient can also be
assessed for readiness of extubation.
A graphical presentation of AC vs SIMV
Triggering
• Can be via change in pressure vs change in
flow.
• Pressure trigger requires PEEP to drop by a
present amount.
• Pressure triggers are difficult in a patient with
COPD/Asthma or any condition with
autopeep or dynamic hyper-inflation.
Triggering (continued)
• To make triggering easier, vents allow
triggering to be initiated by inspiratory flow.
• Flow triggering may be too sensitive
(independent of PEEP) and can auto-cycle
with oscillation from water or secretions.
Conclusion
• Ventilator is not a permanent solution.
• Consider dynamic Hyperinflation/auto-PEEP
if RR is increased and PaCO2 remains high.
• Patient will come off the vent when ready –
daily SBT with with T-piece or low level
pressure support.
References
• The Ventilator Book; William Owens, MD.
• The Little ICU Book; Paul Marino, MD.
THE END

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