Mechanical Ventilation

Reported by: SEMBRANA II, Gloria TRINIDAD, Anna Patricia

Mechanical Ventilation
Is a method used: To mechanically assist or replace spontaneous breathing. To oxygenate the blood when the patients ventilatory effort are inaequate. To control the patients respiration; example during surgery.

Mechanical Ventilator
Is a positive or negative pressure breathing device that can maintain ventilation and oxygen delivery for prolonged period. Is a machine that generates a controlled flow of air into patients airway

Indications for Mechanical Ventilation

1. Continous decrease in oxygenation or severe hypoxemic respiratory failure. :PaO2 < 55mmHg. 2. Increased arterial carbon dioxide levels or severe hypercapnic respiratory failure : PaCO2 > 55 mmHg = Respiratory acidemia

Indications for Mechanical Ventilation

3. Respiratory Distress RR >35 breaths per minute Use of accessory muscle

4. Persistent acidosis (decreased Ph level)

5. Thoracic /pulmonary and abdominal surgery - Because it allows sedation and neuromuscular blockade

Indications for Mechanical Ventilation

6. Airways protection - Patients with a condition that predisposes to aspiration via decreased cough reflex: dysphagia Altedred mental status Neurologic deficit Neuromuscular disorders

Indications for Mechanical Ventilation

7. Thoracic stabilization - massive flail chest 8. Inhalation injury 9. Incresed intracranial pressure 10. Drug overdose 11. COPD 12.Multisystem failure 13.Multiple trauma 14.Shock and trauma

Classification of Ventilators
Negative Pressure Ventilators - Exert negative pressure on the external chest/chest wall decreasing the intrathoracic pressure during inspiration. - It allows air to flow into the lung to fill its volume. - Does not require intubation of airway

Classification of Ventilators
Positive Pressure Ventilators - Positive pressure on the airway forcing alveoli to expand during inhalation. - Exhalation is passive during mechanical inspiration, air is actively delivered to the patients lungs under positive pressure

Indications for type of ventilators

Negative Pressure Ventilators Positive Pressure Ventilators

Commonly used in patients with cases of Chronic respiratory failure and neuromuscular condition such as: - Poliomyelitis - Muscular dystrophy - Amyotrophic lateral sclerosis - Myesthenia gravis

Commonly used in patients with Lung diseases (obstructive and restrictive)such as: -BAIAE - COPD -Emphysema

Types of Negative Pressure Ventilators

1. Iron Lung (Drinker respiratory tank)

The Drinker and Shaw tank-type ventilator of 1929 was one of the first negative-pressure machines widely used for mechanical ventilation.

Iron Lung (Drinker respiratory tank)

- A metal cylinder completely engulfed the patient up to the neck.

Iron Lung (Drinker respiratory tank) - When the vacuum was terminated, the negative pressure applied to the chest dropped to zero, and the elastic recoil of the chest and lungs permitted passive exhalation. - Ventilation of the patient was accomplished without the placement of a tracheostomy or an endotracheal tube.

Iron Lung (Drinker respiratory tank)

Problems encountered: 1. Led to patient discomfort.

2. Limited access to the patient by health care providers.

Types of Negative Pressure Ventilators

2. Body Wrap (pneumowrap) and chest cuirass(tortoise shell)

- requires rigid case or shell unit that allows negative pressure to be applied only to the patient's chest by using a combination of a form-fitted shell and a soft bladder.

Body Wrap (pneumowrap) and chest cuirass(tortoise shell)

- It provides a suitable and attractive option for patients with neuromuscular disorders, especially those with residual muscular function, because it does not require a tracheostomy with its inherent problems.

Body Wrap (pneumowrap) and chest cuirass(tortoise shell)

Problems encountered: 1. fitting

2. Leaks

Types of Positive Pressure Ventilators

1. Pressure cycled Ventilator - ends respiration when a preset Pressure has been reached. - Delivers a flow of air until it reaches a predetermined Pressure then cycles off. For short term use only.

Pressure cycled Ventilator

Its major limitation is that the volume of air of oxygen can vary as the patient airway resistance of compliance changes. Tidal volume may be inconsistent compromising ventilation.

Types of Positive Pressure Ventilators

2. Time cycled ventilators - Terminate or control ventilation after a preset time. - The volume of air is regulated by the length of inspiration and the flow rate of the air - Commonly used for newborn and infants.

Time cycled ventilators

Types of Positive Pressure Ventilators

3. Volume cycled Ventilators - Most commonly used type - Volume of air to be delivered with each inspiration is preset, then volume is delivered to the pt. Ventilator cycles off and exhalation occurs passively. - Constant, consistent and adequate breaths despite varying airway pressure.

Non invasive Positive Pressure ventilation

- eases the work of breathing and enhances gas exchange - To improve tissue oxygenation and to rest respiratory muscles - Eliminates the need for intubation - Decreases risk for nosocomial infection (pneumonia) - Accessible and convenient; can be used at home - For pt. With acute or chronic respiratory failure, acute pulmonary edema

Non invasive Positive Pressure ventilation

TYPES: 1. Face mask -5 to 10 L/min 2. nasal cannula- 1-6 L/min 3. Bilevel positive airway pressure (BiPAP)

Non invasive Positive Pressure ventilation

Bilevel positive airway pressure (Bi-PAP) Indication: - Hypercapnic respiratory rate - It offers independent control of inspiratory / expiratory pressures while providing pressure support ventilation. - Inspiration can be initiated by the patient or by the machine if it is programmed with a back up rate.

Bilevel positive airway pressure (Bi-PAP)

CONTRAINDICATIONS: 1. Apnea 2. Hemodynamic instability 3. Inability to tolerate the mask 4. Decreased ability to protect the airway 5. Need for suctioning 6. Decreased skin-mask air seal

Non invasive Positive Pressure ventilation

General CONTRAINDICATIONS: -dysrrythmias -respiratory arrest -cognitive impairment

MODES OF VENTILATION
AC mode (assist control ventilation) Synchronized Intermittent Mandatory Ventilation (SIMV mode) Continuous Positive Airway Pressure (CPAP mode)

AC mode
- Delivers a preset lung inflation volume at a preset minimal rate , the timing of which can be altered if the pt is able to initiate inhalation. If the patient does not initiate the minimal preset repiratory rate, the ventilator will automatically deliver them, being termed controlled ventilation.

- full support ventilation for unconsious, comatose patients.

Synchronized Intermittent Mandatory Ventilation

- A minimum number of breath are synchronously delivered to the patient but the patient may also take spontaneous breaths of varying volumes. - partial support ventilation

Continuous Positive Airway Pressure

Spontaneous breathing mode No ventilatory support Usually used for weaning

MECHANICAL VENTILATION COMPLICATIONS

1. Alveolar rupture 2. Deep vein thrombosis / pulmonary thromboembolism 3. Laryngeal dysfunction 4. Oxygen toxicity 5. Respiratory muscle atrophy 6. Tracheal necrosis

Weaning the Patient from the Ventilator

Respiratory Weaning
The process of withdrawing the patient from dependence on the ventilator Stages: 1. Removing from the ventilator 2. Removing from the tube 3. Removing from the oxygen

Respiratory Weaning
Started when the patient is recovering from the acute stage of medical and surgical problems and when the cause of respiratory failure is sufficiently reversed.

Criteria for Weaning

Vital Capacity Maximum Inspiratory Pressure
Patients ability to take deep breaths Patients respiratory muscle strength Volume of air that is inhaled or exhaled from the lungs after an effortless breath RR x TV 10-15 ml/kg Atleast -20cm H2O

7-9 ml/kg

Tidal Volume

Minute Ventilation

6L/min

Rapid/shallow breathing Patients breathing pattern RR / TV index

100breaths/min/L

Criteria for Weaning

PaO2: greater than 60mmHg FiO2: less than 40% Stable vital signs Stable arterial blood gases

Patient Preparation
Patients need to know what is expected of them during the procedure

Methods of Weaning
1. Assist-Control May be used as resting mode for patients undergoing weaning trials Provides full ventilatory support by delivering a preset tidal volume and respiratory rate

Assist-Control
Signs of distress: Rapid shallow breathing Use of accessory muscles Reduced LOC Increase in CO2 levels Decrease in O2 saturation Tachycardia

Methods of Weaning
2. Intermittent-Mandatory Ventilation Can increase the respiratory rate but each spontaneous breath receives only the tidal volume the patient generates Allows the patients to use their own muscles of ventilation to prevent muscle atrophy

Methods of Weaning
3. Synchronized Intermittent Mandatory Ventilation Delivers a preset tidal volume and number of breaths per minute Indicated for patients who satisfied the criteria for weaning but cannot sustain adequate spontaneous ventilation for long periods

Methods of Weaning
4. Pressure Support Ventilation Assists SIMV by applying a pressure plateau to the airway throughout the patienttriggered inspiration to decrease resistance by the tracheal tube and ventilator tubing

Methods of Weaning
5. Proportional Assist Ventilation Allows the ventilator to generate pressure in proportion to the patients efforts.

Methods of Weaning
6. Continuous Positive Airway Pressure Allows the patient to breathe spontaneously while applying positive pressure throughout the respiratory cycle to keep the alveoli open and promote oxygenation

Methods of Weaning
6. T-piece or Tracheostomy Mask Conducted with the patient disconnected from the ventilator, receiving humidified oxygen only and performing all work of breathing only Usually used when the patient is awake and alert, is breathing without difficulty, has good gag and cough reflexes and is hemodynamically stable

Continued intensive pulmonary care

Oxygen therapy Arterial blood gas evaluation Pulse oximetry Bronchodilator therapy Chest physiotherapy Adequate nutrition, hydration and humidification Incentive spirometry

Weaning from the Tube

Considered when the patient can breathe spontaneously, maintain an adequate airway by effectively coughing up secretions, swallow and move the jaw 1. 2. 3. 4. Changing to a smaller size tube Changing into a fenestrated tube Switching to a smaller tracheostomy button Removal of the tube

A. Changing to a smaller size tube

The smaller tube is sometimes replaced by a cuffless tracheostomy tube, which allows the tube to be plugged at lengthening intervals to monitor patient progress.

C. Switching to a smaller tracheostomy button

A tracheostomy button helps to keep the windpipe open after the larger tracheostomy tube has been removed.

D. Removal of the tube

When the tube has been removed, an occlusive dressing is placed over the stoma, which usually heals anywhere from several days to many weeks.

Weaning from the Oxygen

The patient is then weaned from the oxygen if the ventilator, cuff and tube has been successfully removed. FiO2 is gradually reduced until the PaO2 is in the range of 70-100 mmHg while the patient is breathing room air.

If PaO2 is below 70 mmHg, supplemental oxygen is recommended.

Nutrition
High fat diet may assist patients with respiratory failure who are being weaned from mechanical ventilation. Adequate protein intake is important in increasing respiratory muscle strength. High carbohydrate diet can lead to increased carbon dioxide production and retention (Should not exceed 25% of total daily calories.