Mechanical Ventilation

Irene Bandoh
Introduction

Mechanical ventilation is one of the most common interventions made in intensive

care. It is often life saving, but there are life threatening side effects associated with
its use.

Mechanical Ventilation refers to the use of Life-Support Technology to perform the

work of breathing for patients who are unable to do so on their own

A mechanical ventilator is a device used to replace or assist breathing in order to

move air into the lungs and permit spontaneous deflation of the lungs

• The decision to ventilate a patient should be considered early, should be planned

and shouldn’t be delayed until it becomes an emergency
 Origins of mechanical ventilation
The era of intensive care medicine began with positive-pressure ventilation
• Negative-pressure
ventilators (“iron lungs”)
• Non-invasive ventilation first
used in Boston Children’s
Hospital in 1928
• Used extensively during polio
outbreaks in 1940s – 1950s
• Positive-pressure The iron lung created negative pressure in
abdomen as well as the chest, decreasing
cardiac output.
ventilators
• Invasive ventilation first used at
Massachusetts General Hospital
in 1955
• Now the modern standard of
mechanical ventilation

Iron lung polio ward at Rancho Los Amigos

Hospital in 1953.
Indications
• Established or imminent respiratory failure from any cause
• Helps to reduce the work of breathing and myocardial oxygen
consumption in patients who have compromised myocardial function
and muscle fatigue e.g. shock
• Controlled hyperventilation in patients with closed head injury to help
reduce intracranial pressure
• Inability to protect airway as a result of trauma, neurological
dysfunction, Anaesthesia or drug overdose
• Cardiopulmonary arrest
GOALS OF VENTILATION
• Treat hypoxemia/hypercapnia
• Relieve respiratory distress/reverse fatigue
• Decrease Myocardial O2 demand
• Prevention or reversal of atelectasis
• Breath for the sedated/paralysed patient
Types of ventilators

Types of
Ventilators

Mechanical Manual ventilators

ventilators Bag-Mask-Valve devices
Anaesthesia bags

Positive pressure ventilators

Negative pressure
Anaesthetic
ventilators
ICU
Iron lung
Transport
Ventilatory modes

• A ventilator mode describes how each breath is delivered to a

patient by the ventilator
• A ventilator mode may provide
• A partial ventilatory support e.g. SIMV, CPAP, BiPAP
• Total ventilatory support e.g. IPPV (or CMV)
• Each breath delivered may either be;
• pressure-controlled (pressure-targeted ventilation)
• volume controlled (volume-targeted ventilation)
• dual-controlled mode
Common settings on the ventilator

• FiO2
• Frequency of breath
• I:E ratio
• Extrinsic PEEP
• Pressure support
• Tidal volume
• Inspiratory pressure
• Alarm set ups
• Patient type; adult/pediatric/neonate
Definitions
• FiO2: Fraction of inspired oxygen. It’s the percentage oxygen
delivered to the patient. The FiO2 range is from 0.21 (room air) to 1
(100% O2).
• PEEP: Positive end expiratory pressure is the amount of pressure in
the lungs at the end of exhalation. The initial PEEP for patients
admitted to ICU is usually between 5 and 10 cm H2O.
• I:E ratio: refers to the ratio of inspiratory time: expiratory time. In
normal spontaneous breathing, the expiratory time is about twice as
long as the inspiratory time. This gives an I:E ratio of 1:2
• Tidal volume: is the amount of air delivered with each breath.
• Frequency: set respiratory rate based on patient’s age and needs
• Tinsp
Ventilation modes

• To deliver inspiratory volume, the operator most

commonly sets either a volume or a pressure

• The primary variable the ventilator adjusts to achieve

inspiration is called the control variable
CONTROL VARIABLES

• The primary variable the ventilator adjusts to achieve inspiration

• Mechanical ventilators can control 3 variables, but only one at a time

• Pressure- Pressure Controlled
• Volume- Volume Controlled
• Flow- Flow Controlled
Pressure control and volume control are the commonest modes
Volume Control
• Refers to modes of ventilation where the volume of the tidal breath is set.
E.g. we set the ventilator to deliver a breath of 500 ml.

• Setting the rate is normally mandatory for this method of controlling

ventilation. E.g. we set the tidal volume (Vt) at 500 ml to be delivered at a
rate of 14 bpm (breath per minute). The ventilator in this example is set to
deliver a minute volume of 500 x 14 = 7 litres.

• The airway pressure in this mode of ventilation will depend on the lung and
chest wall compliance.
Pressure Control
• Refers to modes of ventilation where the pressure of the tidal breath is set.
E.g. we set the ventilator to deliver a breath pressure of 30 cm H20.
• Setting the rate is normally mandatory for this method of controlling
ventilation. E.g. we set the breath pressure at 30 cm H20 to be delivered at a
rate of 14 bpm (breath per minute).
• The tidal volume in this mode of ventilation will depend on the lung and
chest wall compliance.
• Indeed the tidal volume might change from breath to breath depending on
many factors.
Pressure or Volume Controlled
• The choice between these two modes of ventilation is often a matter of
clinician preference, as there is no evidence that either mode is superior to
the other in relation to any clinically important outcome.
• If pressure controlled mode is chosen, the inspiratory pressure is set. You
have to then note what Vt is being delivered to the patient to make sure that
it is the Vt that you want to deliver.
• If Volume controlled mode is used, the Vt is set. Here the effect on airway
pressures has to be noted to make sure that the airway pressures are within
safe limits.
Non- invasive ventilation

Advantages:
• 1.allows speech
• 2.ideal for patients with nocturnal hypoventilation
• 3.complications of intubation –avoided
• 4. does not require heavy sedation
• 5. Provides flexibility in initiating and removing mechanical
ventilation
Disadvantages of NIV
• 1. Mask leakage
• 2. lack of airway protection
• 3. patient should be alert with normal respiratory drive
• 4. Claustrophobia
• 5. slower correction of blood gas abnormalities
• 6. facial pain and skin pressure ulcerations
• 7. gastric distention
• 8. apparatus uncomfortable for patients
Non invasive ventilation

• Absolute contraindications;
• Respiratory arrest, cardiovascular instability, patient with
tracheoesophageal fistula, inability to protect the airway or high
risk of aspiration scenarios, uncooperative patient, facial
trauma, severe head injury

• Relative contraindications;
• Copious secretions, facial abnormalities, extreme obesity
1.CPAP:
• Patient continuously receives a set air pressure, during both inspiration and
expiration.
• Best suited for:
 patients with obstructive sleep apnea
cardiac patients requiring ventilatory assistance but not requiring immediate
intubation
2.BiPAP
• This provides a set inspiratory pressure and a different set expiratory pressure
• Patient has full control over the respiratory rate, inspiratory time and depth of
inspiration
Modes
• IMV Modes: intermittent mandatory ventilation modes –ventilator
breaths only. Patient not allowed to breath

• Assist Control Ventilation- Ventilator breath is given at intervals based

on respiratory rate/frequency. If patient makes an effort, ventilator takes
over and makes it a machine breath. So patient is allowed to initiate the
breath.

• Pressure Support Ventilation-The patient controls the respiratory rate

and does most of the breathing. The model provides pressure support to
overcome the increased work of breathing imposed by the disease
process, the endotracheal tube, the inspiratory valves and other
mechanical aspects of ventilatory support.
• SIMV-Most commonly used mode, Spontaneous breaths and
mandatory breaths can both be taken. If patient initiates a breath, the
ventilator allows the patient to breath fully and breaths are
synchronizes that with the machine breaths.

• BIPAP-

• CPAP-
Complications of Mechanical Ventilation

Pulmonary
• Barotrauma/volutrauma
• Tension Pneumothorax
• Respiratory muscle atrophy
• Pneumomediastinum/Pneumopericardium
• Pneumoperitoneum
• Ventilator induced lung injury(VILI)
• Ventilator associated pneumonia

Psychological Effects
• Inability to communicate
Cardiovascular Effects
• Decreased Venous Return
• Decreased Cardiac Output
• Increased Pulmonary Vascular Resistance

Removal of natural defence mechanisms with intubation:

• Contamination of ventilator circuits
• Contamination through suctioning
Others
• Patient-ventilator asynchrony (“fighting the ventilator”)
• Difficulty weaning after prolonged mechanical ventilation
• Accidental ventilator disconnection/leak/failure
 Indications for weaning
No weaning parameter completely accurate when used alone
• Clinical parameters Numerical Normal Weaning
Parameters Range Threshold
• Resolution/Stabilization of
P/F > 400 > 200
disease process
Tidal volume 5 - 7 ml/kg 5 ml/kg
• Hemodynamically stable
Respiratory rate 14 - 18 < 40
• Intact cough/gag reflex breaths/min breaths/min

• Spontaneous respirations Vital capacity 65 - 75 ml/kg 10 ml/kg

Minute volume 5 - 7 L/min < 10 L/min
• No need for frequent suctioning
• Acceptable vent settings
• FiO2< 50%, PEEP < 8, PaO2 >
75, pH > 7.25
• General approaches
• SIMV Weaning
• Pressure Support Ventilation
(PSV) Weaning
• Spontaneous breathing trials
• T-Piece weaning