Introduction to

Mechanical
Ventilation

Charles S. Williams RRT, AE-C

Learning Objectives:

Indications for intubation and

mechanical ventilation.

Review the different modes of

ventilation and complications.

Case study.

Ventilator weaning and indicators.

Short-term vs. Long-term weaning.

Key Terms:

Tidal Volume, (Vt)

The volume of air inhaled and exhaled
each breath.

Respiratory rate, (RR,f)

Number of breaths per minute, also
known as frequency.

Minute Ventilation, (VE)

The total amount of air moving in and
out of the lungs in 1 minute, (Vt x RR).

Key Terms:

PEEP (Positive End Expiratory Pressure)

Positive pressure applied at the alveoli at the
end of exhalation.

FIO2 (Fractional Inspired Oxygen)

Amount of oxygen. Expressed as a percentage,
21%-100%

I:E ratio, (Inspiration/Expiratoy ratio)

Normal I:E ratio = 1:2, 1:3

When do we intubate?

To facilitate mechanical
ventilation.

To maintain an open pathway

between the upper and lower
airway.

To protect the lower airway

from aspiration.

Assist with pulmonary

toileting.

Indications for Mechanical

Ventilation:

Apnea or Impending Respiratory Failure:

(ARDS, CHF, Status Asthmaticus, Neuromuscular disease)

Acute Respiratory Failure:

Hypoxemic (Type I failure; oxygenation)
Hypercapnic (Type II failure; CO2 elimination)

Prophylactic Support:
(Post-op, Post MI, Brain injury, etc.)

Hyperventilation Therapy:
(Acute head injury)

Modes of Ventilation

Modes of Ventilation:

CPAP/PEEP

BiPAP (Non-invasive
ventilation)
Pressure Support /
Volume Support

SIMV

Volume Control
Pressure Control

PRVC

Servo-I ventilator from Maquet, Inc.

Modes of Ventilation:
Example:

Pressure

Describes the type of breath

being delivered:
Pressure or volume

/ Support
Control = Set mandatory rate on
ventilator
Support = Spontaneous breaths

Modes of Ventilation:
Spontaneous Breathing
Inspiration

Exhalation

No ventilator support
Produces a sinusoidal pressure waveform on
graphics display.

Modes of Ventilation:

CPAP/PEEP
CPAP
Continuous Positive Airway Pressure

15

spontaneous
breaths

PEEP
Positive End Expiratory Pressure
15

Ventilator
breath

Positive pressure applied to

spontaneous breathing patients.
Can be used to treat Obstructive
Sleep Apnea

Positive pressure applied at the

end of exhalation on ventilator
breaths.

CPAP/PEEP can improve oxygenation by holding the alveoli open.

May decrease venous blood return if too much positive pressure is
applied. This can effect blood pressure and cardiac output

Modes of Ventilation:
Creates a pocket of air
that splints open the
upper airway to help treat
obstructive sleep apnea

Holds
bronchioles and
smaller airways
open

Keeps alveoli dry

in patients with
CHF, fluid overload

Helps oxygen to
move across the
alveolar-capillary
membrane

Modes of Ventilation:

Inspiratory Positive
Airway Pressure (IPAP)

+
Expiratory Positive
Airway Pressure (EPAP)
Bipap Vision from Respironics, Inc.

Modes of Ventilation:
15

IPAP

IPAP

EPAP

EPAP

A form of non-invasive ventilation (NIV)

Adds a second pressure setting (insp.)

Inspiratory Positive
Airway Pressure (IPAP)

+
Expiratory Positive
Airway Pressure (EPAP)

EPAP = CPAP
BiPAP has same benefits as CPAP plus:
a) Reduces WOB

b) Improves ventilation (CO2

elimination).

Modes of Ventilation:
PS - Adds pressure to spontaneous breaths to enhance
inspiratory tidal volume.
VS - Automatically adjusts the amount of pressure
needed to obtain a desired tidal volume.
15

Pressure Support

Weaning modes
PS may be used alone or in
combination with other modes.

Modes of Ventilation:

15
Pressure
Support

Ventilator
breath

Spontaneous breaths

Weaning mode
Allows for combined ventilator
assisted and spontaneous breaths.
Pressure support is usually added
for spontaneous breaths.

Modes of Ventilation:
Breaths are delivered at a preset volume.
Pressure is variable, Flow remains constant during
inspiration.

Ventilator
breath

Spontaneous
breath

Advantage:
Guarantees delivery of desired tidal volume
Disadvantages:
Increased risk of barotrauma due to potentially high peak pressures.
Fixed flowrate may not meet patients inspiratory demand.

Modes of Ventilation:
Breaths are delivered at a preset pressure.
Pressure remains constant during inspiration, Flow is variable.
Usually used for stiff, non-compliant lungs (ARDS).

15

Pressure setting
Ventilator
breath

Spontaneous
breath

Advantages:
Less risk of lung injury due to high peak pressures
Variable flow rate can better meet patients demand
Disadvantage:
Delivery of tidal volume will vary depending on lung compliance, etc.

Modes of Ventilation:

Considered a dual ventilator mode.

Combines the advantages of both

Volume Control (guaranteed tidal volume)
and Pressure Control Ventilation. (lower
peak pressures, variable flow).

Attempts to deliver the desired tidal

volume, using the lowest possible
pressure.

Use clinically as you would standard

Volume Control.

Modes of Ventilation:
Control Modes
Not used for weaning.
Usually requires sedation.
Does allow for spontaneous breathing.
Patient triggered breaths and ventilator
breaths will be identical.

What Mode is Best for my Patient?

Patients that are apneic or require lots of
sedation, generally should be on a Control
mode like Volume Control, PRVC, etc.

What Mode is Best for my Patient?

Pressure Control
mode is usually
indicated when peak
inspiratory pressures
are high.
Patients with ARDS,
Adult Respiratory
Distress Syndrome,
and patients with
stiff, non-compliant
lungs).

What Mode is Best for my Patient?

Spontaneous breathing patients
generally do well in SIMV mode. The
patient may feel more in control of
their breathing.

Adding Pressure Support to SIMV can

reduce muscle fatigue and may allow for
more synchronous breathing efforts with
the ventilator.

What Makes a Complete Order for ventilation?

Case Study:

36 yr. old female,

admitted to SJRMC,
with respiratory
distress due to
bacterial pneumonia.

Case Study:

Laboratory Results:

WBC: 24,000

ABG: pH 7.12, PaCO2 74, PaO2 45,

HCO3 24 on 100% O2

(hypoxic and hypercapnic respiratory failure)

Chest x-ray:

Extensive Bilateral Pneumonia.

Patient is intubated and place

on the ventilator.
Vent settings:
Mode: SIMV/PS
Tidal volume: 600 ml
Resp Rate: 20
FiO2: 100%
Pressure Support: 10, PEEP: 5

Case Study: cont

ABGs after 30 minutes on ventilator:

pH 7.22, PaCO2 64, PaO2 74, HCO3 24.

Peak airway pressures are measuring *50 cm H2O.

IV steroids and antibiotics are started.
She is very agitated. IV sedation is increased.
(Peak airway pressures continue to be 50cm H2O
or higher).
Decision is made to switch to Pressure control
ventilation mode due to high peak pressures.
*In general, keeping peak pressures < 30cm H2O is desirable.

Case Study: cont

Vent settings:
Mode: Pressure Control
Inspiratory Pressure: 26
Resp Rate: 24
FiO2: 100%
PEEP: 5

Insp. Pressure is adjusted to maintain exhaled tidal volume

of 550-600 ml

After switching to PCV, Her peak airway pressure is now

measuring 31cm H2O (26+5), instead of 50cm H2O.
(Much lower risk of developing a pneumothorax due to barotrauma.)

ABGs eventually improve to normal range:

pH 7.42, PaCo2 44, PaO2 110, HCO3 24.

Case Study: conclusion

As the patient began to oxygenate better,

sedation was weaned and she returned to
SIMV/PS mode.

Within 5 days of intubation she was

extubated. And was soon discharged
home.

Complications to Mechanical Ventilation:

Ventilator Induced Lung Injury, (VILI)

Barotrauma
Caused by excessive pressure

Volutrauma
Caused by excessive volume

Oxygen Toxicity

Oxygen
Barotrauma,
Complications
to
Mechanical
Ventilation:
Toxicity
Volutrauma

Complications from ventilator-induced lung injury

Complications to Mechanical Ventilation:

Ventilator Associated Pneumonia, (VAP)

A sub-type of Hospital Acquired

Pneumonia, (HAP).
Usually occurs within 48 hours of being
ventilated.

Complications to Mechanical Ventilation:

Decreased Cardiac Output and Blood Pressure

Increased intrathoraic pressures can

increase the pressure surrounding the
heart and major blood vessels.
This can impede blood flow to the heart
causing a decreased CO/BP.

Ventilator Weaning

Ventilator Weaning

Control modes
Pressure Control
Volume Control
PRVC

Combined

Support modes

SIMV

Pressure Support
Volume Support
CPAP

Indications for Weaning

Resolution of acute phase of

disease
FIO2 of 40% or less, Peep 5-10
Stable vital signs
Stable ABGs (minimal acidosis)
No continuous IV sedation
Adequate cough
RSBI less than 100

Indications for Weaning

Reliable predictor of weaning
outcomes.

RSBI
Rapid Shallow
Breathing Index

Pt is allowed to breath
without vent support for 1
minute, RR is then divided by
exhaled tidal volume.
Normal value is < 100.
Performed every a.m. in
conjunction with RN sedation
vacation.

Approaches to weaning:

Decreasing SIMV rate

Decreasing levels of Pressure Support
Spontaneous Breathing Trials

Approaches to weaning:
Decreasing SIMV rate
The SIMV rate is decreased by 2 breaths/min every 4-6
hours as tolerated.

When the SIMV rate is down to 4, and is tolerated for 2-4

hours , the patient is then considered for extubation or
changing to pressure support mode.
Example order: Wean IMV rate by 2, every 4-6 hours as
tolerated. Maintain RR < 30 w/ no respiratory distress.

Approaches to weaning:
Decreasing Levels of Pressure Support
Pressure Support level is slowly decreased over time.
When the patient has tolerated a pressure support level of
5 -7, for 2-4 hours, the patient is considered weaned.
Example order: Wean pressure support by 2 every 6-8 as
tolerated. Maintain RSBI < 100. Lowest pressure 5cm
H2O*.
*PS 5 is maintained to overcome airway resistance from breathing tube

Approaches to weaning:
Spontaneous Breathing Trials
The patient is removed from the vent and placed
on T-Bar or left attached to the ventilator and
placed on Flow-By mode.
The patients vital signs are monitored during
the trial, usually for 30-120 mins.

Example order: May attempt SBT x 30 min as

tolerated BID.

Short-term weaning
vs.
Long-term weaning

Short-term weaning:

Example: post-op open

heart patient.
The FiO2 is weaned to a
stop point of 40%. The
RR is weaned by 2
breaths with a stop
point of 2-4 breaths
/minute.
The patient is then
placed on CPAP and
weaning parameters are
obtained along with
ABGs.

Respiratory Therapist obtaining weaning parameters

Short-term weaning:

The patient is then extubated with physician

approval.

Most open heart patients meet a goal

extubation time of 6 hours or less.

Long-term weaning:
Some patients may take longer to wean
due to MSOF, poor nutritional status,
etc.
Even though it can be a slow and long
process, the most complex patient can
be weaned.
PS weaning proves to be an effective
tool to help wean long-term patients.

Thank You!