MECHANICAL VENTILATION

INDICATIONS FOR MV

Hypoxemia
Acute respiratory acidosis
Reverse ventilatory muscle fatigue
Permit sedation and/or neuromuscular
blockade
Decrease systemic or myocardial oxygen
consumption

INDICATIONS CONTINUED
Reduce intracranial pressure through
controlled hyperventilation
Stabilize the chest wall
Protect airway
Neurologic impairment
airway obstruction

TYPES OF
CONVENTIONAL MV
Timed cycled
Home ventilators

Pressure cycled
Pressure controlled

Volume cycled
Flow cycled
Pressure support

VOLUME VENTILATION
Controlled mechanical ventilation CMV
Assist-control AC
Synchronized intermittent mandatory
ventilation SIMV
Which mode?

VENTILATOR SETTINGS
Tidal volume
10 to 15 mL/kg

Respiratory rate
10 to 20 breaths/minute
normal minute ventilation 4 to 6 L/min

Fraction of inspired oxygen

Flow rate and I:E ratio

PRESSURE SUPPORT
VENTILATION
Flow cycled
preset pressure sustained until inspiratory flow
tapers to 25% of maximal value

Comfortable
Used mainly as a weaning mode
Wean pressure until equivalent to air way
resistance
peak - plateau pressure

PRESSURE CONTROLED
VENTILATION

Pressure cycled
Volume varies with lung mechanics
Minute ventilation is not assured
Improves oxygenation
recruitment of alveoli

Lessens volutrauma?

SETTINGS FOR PRESSURE

CONTROL VENTILATION
Inspiratory pressure
I:E ratio
1:2, 1:1, 2:1, 3:1

Rate
FIO2
Peep

PRESSURE REGULATED
VOLUME CONTROLLED
Ventilate with pressure control
Preset volume
Inspiratory pressure is adjusted breath to
breath
Minute ventilation is maintained

INDICATIONS FOR PEEP

ARDS
Stabilize chest wall
Physiologic peep
Decrease Auto-peep?

CONTRAINDICATIONS FOR
PEEP
Increased intracranial pressure
Unilateral pneumonia
Bronchoplueral fistulae

PEEP

Increases FRC
Recruits alveoli
Improves oxygenation
Best Peep
based on lower inflection of pressure volume
curve

TROUBLE SHOOTING
VOLUME VENTILATION
High pressure alarm
Breath sounds
CXR

Low tidal volume

disconnected

Desaturation

TROUBLE SHOOTING
PRESSURE VENTILATION
Low tidal volumes or minute ventilation
Desaturation
Breath sounds
Patient agitation
CXR

Sedation in Mechanically
Ventilated Patients

Benzodiazepines
Opioids
Neuroleptics
Propofol
Ketamine
Dexmedetomidine

Benzodiazepines
Lorazepam
Half-life 12 to 15 hours
Major metabolite inactive

Midazolam
Half-life 1-4 hours, increased in cirrhosis, CHF,
obesity, elderly
Active metabolite

Opioid
Morphine
Fentanyl
Hydromorphone

Neuroleptics
Haloperidol
Mild agitation .5mg to 2mg
Moderate agitation 2 to 5 mg
Severe 10 to 20 mg

Side Effects
Acute dystonic reactions
Polymorphic VT
Neuroleptic malignant syndrome

Propofol
Side Effect
Hypotension
Bradycardia

Anticonvulsant
Expensive
Use short term

Ketamine

Dissociative anesthetic state

Direct cardiovascular stimulant
Brochodilator
Side Effects
Dysphoric reactions
increased ICP

Dexmedetomidine
Centrally acting alpha 2 agonist
Approved for 24 hours or less
Side Effects
Hypotension
Bradycardia
Atrial fibrillation

Maintenance of Sedation
Titrate dose to ordered scale
Motor Activity Assessment Scale MAAS
Sedation-Agitation Scale SAS
Ramsay

Rebolus prior to all increases in the

maintenance infusion
Daily interruption of sedation

NEUROMUSCULAR
BLOCKING AGENTS
Difficult to asses adequacy of sedation
Polyneuropathy of the critically ill
Use if unable to ventilate patient after
patient adequately sedated
Have no sedative or analgesic properties

Neuromuscular Blocking Agents

Depolarizing
Bind to cholinergic receptors on the motor
endplate

Nondepolarizing
Competitively inhibit Ach receptor on the
motor endplate

Depolarizing NMBA
Succinylcholine
Rapid onset less than 1 minute
Duration of action is 7-8 minutes
Pseudocholinesterase deficiency
1 in 3200

Side Effects
Hyperthermia, Hyperkalemia, arrhythmias
Increased ICP

Nondepolarizing Agents
Pancuronium
Drug of choice for normal hepatic and renal
function

Atracurium or Cisatracurium
Use in patients with hepatic and/or renal
insufficiency

Vecuronium
Drug of choice for cardiovascular instability

No bubble is so iridescent or
floats longer than that blown by
the successful teacher.
Sir William Osler

MV IN OBTRUCTIVE AIRWAY
DISEASE
Decrease barotrauma
related to mean airway pressure

Increase I:E
decrease TV and/or increase flow

Minimize auto-peep
auto-peep shown to cause most barotrauma

Permissive hypercapnea

ARDS
Set peep to pressure shown at lower
inflection point of pressure volume curve
Tidal volumes set below upper inflection
point of pressure volume curve
Use pressure control ventilation early
Minimize volutrauma

Ventilation With Lower Tidal

Volumes
Tidal volume: 6 ml/kg
Male 50 + 0.91(centimeters of height-152.4)
Female 45.5+0.91(centimeters of ht - 152.4)

Decrease or Increase TV by 1ml/kg to maintain

plateau pressure 25 to 30.
Minimum TV 4ml/kg
PaO2 55 - 88 mm Hg. Sats 88 to 95%
pH 7.3 to 7.45

CASE EXAMPLE
34 y/o female admitted with status
asthmaticus and respiratory failure
You are called to see patient for inability to
ventilate
Tidal volume 800 cc, FIO2 100%, AC 12
Peep 5 cm
PAP 70, returned TV 200 cc

Case example continued

Examine patient
CXR
Sedate
Assess auto-peep
Increase I:E
Lower PAP and MAP
Reverse bronchospasm & elect. Hypovent.

CONCLUSION
Three options for ventilation
volume, pressure, flow

Peep, know when to say no

Always assess to prevent barotrauma
ventilate below upper inflection point
assess static compliance daily
monitor for auto-peep