MECHANICAL VENTILATION

Things “I” wish I knew when I

was an Intern

Amit Gupta, MD
Internal Medicine
North Mississippi Medical Center
 Mechanical Ventilation
1. Indications for Intubation and Ventilation
2. Principles of Mechanical Ventilation
3. Patterns of Assisted Ventilation
4. Ventilator Dependence: Complications
5. Liberation from Mechanical Ventilation:
Weaning
6. Troubleshooting
7. Arterial Blood Gases
 Indications for Mechanical
Ventilation
 “….An opening must be attempted in the
trunk of the trachea, into which a tube or cane
should be put; You will then blow into this so
that lung may rise again….And the heart
becomes strong….”
-Andreas Vesalius (1555)
Indications for Mechanical
Ventilation
1. “Thinking” of Intubation:
elective v/s emergent
2. “Act of weakness?”
3. Endotracheal tubes are not a disease and
ventilators are not an addiction
4. And the usual elective and emergent
indications that you all know!
 Objectives of Mechanical
Ventilation
Improve pulmonary gas exchange
Reverse hypoxemia and Relieve acute respiratory acidosis
Relieve respiratory Distress
Decrease oxygen cost of breathing and reverse respiratory
muscle fatigue
Alter pressure-volume relations
Prevent and reverse atelectasis
Improve Compliance
Prevent further injury
Permit lung and airway healing
Avoid complications
 Strategies for Mechanical
Ventilation
Ventilatory Traditional Lung-Protective
Parameter
Inflation Volume 10-15 ml/kg 5-10 ml/kg

End-insp. Peak Pr<50cm Plateau Pr<35

pressure water
PEEP PRN to keep 5-15 cm of water
FiO2<0.6
ABG Normal, pH 7.36- Hypercapnia
7.44 allowed, pH 7.2-
7.4
 Monitoring Lung Mechanics
Proximal Airway Pressures (end-inspiratory)
1. Peak Pressure
Function of: Inflation volume, recoil force of
lungs and chest wall, airway resistance
2. Plateau Pressure
Occlude expiratory tubing at end-inspiration
Function of elastance alone
 Use of Airway Pressures
Peak Pressure increased Plateau Pressure
unchanged:

Tracheal tube obstruction

Airway obstruction from secretions
Acute bronchospasm

Rx: Suctioning and Bronchodilators

 Use of Airway Pressures
Peak Pressure and Plateau Pressure are
both increased:
Pneumothorax
Lobar atelectasis
Acute pulmonary edema
Worsening pneumonia
COPD with tachypnea
Increased abdominal pressure
Asynchronous breathing
 Use of Airway Pressures
Decreased Peak Pressure :

System air leak: Tubing disconnection, cuff leak

Rx: Manual inflation, listen for leak

Hyperventilation: Enough negative intrathoracic

pressure to pull air into lungs may drop Pk.
 Compliance
Static Compliance (Cstat):
Distensibility of Lungs and Chest wall
Cstat = Vt/Pl
Normal C stat: 50-80 ml/cm of water
Provides objective measure of severity of illness in a
pulmonary disorder
Dynamic Compliance:
Cdyn: Vt/Pk
*Subtract PEEP from Pl or Pk for compliance
measurement
Use Exhaled tidal volume for calculations
 Patterns of Assisted Ventilation
 Assist Control
 Intermittent Mandatory Ventilation
 Pressure Controlled Ventilation
 Pressure Support Ventilation
 Positive end-expiratory ventilation
 Continuous Positive Airway Pressure
 Assist Control Ventilation
Volume-cycled lung inflation
Patient can initiate each mechanical breath or Ventilator
provides machine breaths at a preselected rate
Maintain I:E ratio to 1:2 to 1:4. An increase in Peak flow
decreases the time for lung inflation and increases the I:E
Ratio
I:E ratio of <1:2 can cause hyperinflation by air trapping
Diaphragmatic contraction continues during Assist Control
Ventilation and increases the work of breathing.
 Assist Control Ventilation
Adverse effects:
In a tachypneic patient>>Lead to overventilation and
severe respiratory alkalosis>> Hyperinflation and
Auto-PEEP>> Lead to Electromechanical
dissociation
 Intermittent Mandatory Ventilation

 Delivers volume cycled breaths at a preselected

rate with spontaneous breathing between machine
breaths
 Less Alkalosis and Hyperinflation
 Synchronized Intermittent Mandatory Ventilation
 Intermittent Mandatory Ventilation

Disadvantages:
Increased work of Breathing:
Spontaneous breathing through a high resistance circuit
Solution: Add Pressure support
Cardiac Output Changes:
Cardiac O decreased by decreasing ventricular filling
Cardiac O increased by reducing ventricular afterload
More significant decrease in patients with Left Ventricular
dysfunction
 IMV vs. ACV
Switch to IMV for:
Rapid breathers with alkalosis and over-
Inflation
Switch to ACV for:
Patients with respiratory muscle weakness
and
LV dysfunction
 Pressure Controlled Ventilation

 Pressure cycled breathing, fully ventilator controlled

 Inspiratory flow rate decreases exponentially during lung
inflation
 (+)Reduces peak airway pressure and improves gas
exchange
 (-)Inflation volume varies with changes in mechanical
properties of the lungs.
 Suited for patients with neuromuscular diseases and
normal lung mechanics
 Inverse ratio Ventilation
 PCV combined with prolonged inflation time
 Inspiratory flow rate is decreased
 I:E ratio reversed to 2:1
 Helps prevent alveolar collapse
 (-) Hyperinflation, Auto-PEEP and decreased
cardiac output
 Use: ARDS with refractory hypoxemia or
hypercapnia ?mortality benefit
 Pressure Support Ventilation
 Pressure augmented breathing
 Allows patient to determine the inflation volume
and respiratory cycle duration
 Uses: augment inflation during spontaneous
breathing or overcome resistance of breathing
through ventilator circuits (during weaning)
 Popular an a non-invasive mode of ventilation via
nasal or face masks
 Positive end-expiratory pressure
 Alveolarpressure at end-expiration is above
atmospheric pressure : PEEP

 Extrinsic PEEP

 Auto PEEP
 Positive end-expiratory pressure
 EXTRINSIC PEEP
 Applied by placing pressure limiting valve in the
expiratory limb of ventilator circuit
 Prevents end-expiratory alveolar collapse and
recruits collapsed alveoli
 This decreases intrapulmonary shunting, improves
gas exchange and improves lung compliance,
allowing the FiO2 to be reduced to less toxic
levels
 Positive end-expiratory pressure
Cardiac Performance:
Greater reduction in cardiac filling and cardiac output (Q),
irrespective of level of PEEP!
It is a function of PEEP induced increase in mean
intrathoracic pressure
Oxygen transport Do2:
Do2 = Q X 1.3 X Hb X SaO2
Systemic O2 delivery may vary with the effect of PEEP on
the Cardiac Output.
 Positive end-expiratory pressure
 Best PEEP: Monitor Cardiac Output
 Another measure: Venous Oxygen Saturation
 If VOS decreases after PEEP applied= Drop CO
 Swan-Ganz catheter may be indicated in most
patients on PEEP
 Positive end-expiratory pressure
 CLINICAL USES:
 Reduce toxic levels of FiO2 (ARDS not
pneumonia)
 Low-volume ventilation
 Obstructive lung disease (Extrinsic=Occult PEEP)
 Positive end-expiratory pressure
 CLINICAL MISUSES:
 Reducing Lung Edema
 Routine PEEP
 Mediastinal Bleeding after CABG
Continuous positive Airway Pressure

 Spontaneous breathing
 Patient does not need to generate negative
pressure to receive inhaled gas
 CPAP replaced spontaneous PEEP
 Use: Non-intubated patients (OSA, COPD)
 Occult PEEP
 Intrinsic or Auto-PEEP or Hyperinflation
 Incomplete alveolar emptying during expiration
 Ventilator Factors: High inflation volumes, rapid rate,
low exhalation time
 Disease factors: Asthma, COPD
 Consequences: Decreased CO/EMD, Alveolar
rupture, Underestimation of thoracic compliance,
increased work of breathing.
 If extrinsic PEEP does not increase Pk, then occult
PEEP is present
 Complications of Mechanical Ventilation

 Toxic effects of Oxygen

 Decreased cardiac output
 Pneumonia and sepsis
 Psychological problems
 Ventilator dependence
 Complications of Mechanical Ventilation

 Purulent sinusitis
 Laryngeal Damage
 Aspiration :Value of routine tracheal suctioning
 Tracheal Necrosis (pressure below 20mm water)
 Alveolar rupture: Pneumothorax,
pneumomediastinum, subQ emphysema,
pneumoperitoneum
 Basilar and sub-pulmonic air collections in the
supine position, as seen on X-ray
 Liberation from Mechanical Ventilation:
Weaning

 Weaning: Gradual withdrawal of mechanical ventilation

 Misconceptions:
Duration- longer duration, harder to wean
Method of weaning determines ability to wean
Diaphragm weakness is a common cause of failed weaning
Aggressive nutrition support improves ability to wean
Removal of ET tube reduces work of breathing
Bedside Weaning Parameters
Parameter Normal Adult Threshold for
range weaning
PaO2/FiO2 >400 200
Tidal Volume 5-7ml/kg 5ml/kg
Resp. Rate 14-18/min <40/min
Minute Ventl. 5-7L/min <10L/min
Vital capacity 65-75ml/kg 10ml/kg
Bedside Weaning Parameters
Maximal >-90 cm Water (F) -25cm of water
Inspiratory >-120 cm water
Pressure (M)
Rate/Tidal Volume <50/min/L <100/min/L
 Maximal Inspiratory Pressure
 Pmax: Excellent negative predictive value if less
than –20 (in one study 100% failure to wean at
this value)
An acceptable Pmax however has a poor positive
predictive value (40% failure to wean in this study
with a Pmax more than –20)
 Frequency/Volume ratio
 Index of rapid and shallow breathing RR/Vt
 Single study results:

RR/Vt>105 95% wean attempts unsuccessful

RR/Vt<105 80% successful
• One of the most predictive bedside parameters.
 T-Piece Weaning
 On-off toggle switch that circulates between on and off the
ventilator
 Inhaled gas is delivered at a high flow rate
 Varied protocols: like 30min-2hr on and off, or keep as
long as possible and if tolerated for >2-4hr…. Deemed
successsful (RR, TV, HR, diaphoresis, sat)
 Failed T piece: Resume Vent support till comfortable, 24h

vent Airflow with CPAP

patient
 T-Piece with Ventilator
 Drawback: increased resistance due to vent tubing
and actuator valve in circuit
 Provide minimum pressure support (PSV) :Pmin
 Pmin= PIFR X R
 PIFR is during spontaneous breathing
 R is airflow resistance during mech ventilation
 R= Pk-Pl/Vinsp
 (Vinsp:inspiratory flow rate delivered by the vent)
 IMV Weaning
 Gradual decrease in no of machine breaths in
between the spontaneous breaths
 False security: It does not adjust to patient’s
ventilatory demands to maintain constant MV
 End point in IMV weaning is the T-piece trial
 Most important to recognize when a patient is
capable of spontaneous unassisted breathing
 T-piece more rapid than IMV
 Complicating Factors
 DYSPNEA
 Anxiety and dyspnea are detrimental (low dose
haloperidol or morphine)
 CARDIAC OUTPUT
 Increased LV afterload can reduce CO, impair
diaphragm function, promote pulmonary edema
 (Use Swan to monitor CO, may use dobutamine)
 ELECTROLYTE DEPLETION
 OVERFEEDING
 The Problem Wean
 RAPID BREATHING: Check TV
 Low TV>> Resume vent support
 TV not low…….. Check arterial pCO2
 Arterial pCO2 decreased>sedate (anxiety)
 Arterial pCO2 not decreased> Resume vent
 The Problem Wean
 ABDOMINAL PARADOX
 Inward displacement of the diaphragm during inspiration is
a sign of diaphragmatic muscle fatigue
 HYPOXEMIA
 May be due to low CO and MVO2
 HYPERCAPNIA
 Increase in PaCO2-PetCO2: increase dead space
ventilation
 Unchanged gradient: Respiratory muscle fatigue or
enhanced CO2 production
 Tracheal Decannulation
 Successful weaning is not synonymous with
tracheal decannulation
 If weaned and not fully awake or unable to clear
secretions, leave ETT in place
 Contrary to popular belief, tracheal decannulation
increases the work of breathing due to laryngeal
edema and secretions
 Do not perform tracheal decannulation to reduce
work of breathing
 Inspiratory Stridor
 Post extubation inspiratory stridor is a sign
of severe obstruction and should prompt
reintubation
 Laryngeal edema (post-ext) may respond to
aerosolized epinephrine in children
 Steroids have no role
 Most need reintubation followed by
tracheostomy
 ARDS and Low Volume Ventilation
 ARDS Network trial : NEJM May 4, 2000 p1301-08
 Traditional: TV 10-15ml/kg, keep plateau<50cm water
 Low TV ventilation: TV 6ml/kg, keep plateau<30cm water
 Need high RR in Low TV group to prevent acidosis
 Permissive hypercapnia tolerated well, if needed, use IV bicarb
to maintain pH
 May add PEEP in addition to the low TV group to prevent
atelectrauma (open-close alveoli>> alveolar fracture)
 Results: Lower mortality in the Low TV group (31% v/s 39.8%
p<0.007); Higher days without vent use and lower average
plateau pressures in low TV group.