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Basic Mechanical Ventilation
DR. SATYABRATA ROY CHOWDHOURY
RMO CUM CLINICAL TUTOR
PEDIATRIC MEDICINE
MEDICAL COLLEGE KOLKATA
Indication of Mechanical Ventilation
1. Pneumonia
2. ARDS
3. Pulmonary
Edema
4. Inhalation Injury
5. Pulmonary
Thromboebolism
1. Upper
airway
obstruction
2. Asthma
3. Bronchiolitis
1. Encephalopathy
2. Neuromuscular
disorder
3. Myopathy
4. Bony deformity
1. Cardiac
failure and
cardiogenic
shock
2. Septic
Shock
Mechanical Ventilator
Volume Change
Time
Gas Flow
Pressure Difference
Basics of respiratory mechanics important to
mechanical ventilation
Compliance
Volume
Pressure
3
1
Decreased FRC – Atelectasis
ARDS
5cm
15c
m
20c
m
Over expansion – Asthma
2
Conditions Associated with Decreased
Total Respiratory Compliance
Decreased Lung compliance
Fall in FRC
• ARDS
• Diffuse Pneumonitis
• Pulmonary Edema
• Atelectasis
Decreased Chest wall
comp.
• Abdominal distension
• Chest wall edema
• Chest trauma/ surgery
Over-expansion of lung volume
• Asthma
• Bronchiolitis
• Excessive CPAP/PEEP
“The Feature of the Tube”
Airway Resistance
Pressure Difference = Flow Rate x Resistance of the Tube
Resistance is the amount of pressure required to deliver a given flow of
gas and is expressed in terms of a change in pressure divided by flow.
R = Δ P
Flow
P1 P2
Basic Mechanical Ventilation.pptx
Goals of mechanical ventilation
❖ To provide adequate ventilation and oxygenation with
minimal intervention
❖ Minimize the risk of lung injury
❖ Reduce patient work of breathing (WOB)
❖ Optimize patient comfort
What we expect from a Ventilator ?
• Ventiltor must recognise patient’s respiratory
efforts.(trigger)
• Ventilator must be able to meet patient’s
demand(response)
• Ventilator must not interfere with patient’s
effort.(synchrony)
To understand a ventilator breath cycle, we must know how the
ventilatory breath starts, sustains, and stops inspiration and
maintain expiration
MX-0776 Rev03 Page 11
Inspiration
Expiration
1)Starting of Inspiration or Trigger
start of
Inspiration
End of
Inspiration and
start of
Expiration
3) The end of inspiration or Cycle
2) Inspiration itself or Limit
2) Expiration or Baseline
Phase variables
•Trigger
Start of
Inspiration
•Limit, control
Sustain
Inspiration
•Cycle
Inspiration to
expiration
transition
Trigger
• Time – Control Breath
• Flow
Assist Breath
• Pressure
More sensitive
Flow Trigger – More Sensitive
Set at 5 = 1L/min flow
Basic Mechanical Ventilation.pptx
ARDS/Injured lun
– Pressue control
/PRVC
Obstructive lung
disease – Volume
Neuroprotection -
Volume
Pressure Control
Pressure limited
Volume fluctuates depending
on the compliance
Flow decelerating type
Pressure is constant
throughout the inspiration
Volume Control
flow is constant
Volume limited
Pressure varies through out the
inspiration and depends on pick
compliance
PC vs VC Ventilator Setting
• Transition point from the inspiratory phase to the expiratory phase
Cycling = Expiratory Trigger
MX-0776 Rev03 Page 19
Modes
Trigger
variable
Limit
variable
Cycle
Volume
targeted
Pressure,
flow or time
Volume
Set inspiratory
time
Pressure
targeted
Pressure,
flow or time
Pressure
Set inspiratory
time
Pressure
support
Pressure or
flow
pressure Flow cycle
• A mode of mechanical ventilation may be defined, in general,
as a predetermined pattern of patient-ventilator interaction
What Is a Mode of Mechanical Ventilation?
CMV
IMV
Assist
Cont.
SIMV
Mode
Set-Point,
Dual
mode,
Servo
Optimal
Volume,
pressure
Ventilator
Breath Control
Variable
Breath
Sequence
Targeting
Scheme (method
of feed back)
VENTILATOR MODES
CMV/IPPV ACV SIMV CPAP
Volume Pressure Volume Pressure
Control Mandatory Ventilation
⮚ Breaths are delivered either as
preset volume or pressure
⮚ Cycling occurs when the preset
volume, pressure (or time) is
achieved
⮚ Patient spontaneous breaths not
allowed.
⮚ Used in theatre and in very
unwell ICU patients -heavily
sedated or completely paralysed.
Intermittent Mandatory Ventilation (IMV)
• Ventilator Delivers preset time
triggered mandatory breaths
• Patient is allowed to take
spontaneous breath without any
support.
• Advantage
• Less sedation
• Less haemodynamic instability
• More patient Comort
• Disadvantage -
• Breath Stacking - Barotrauma
Assist Control
• Ventilator delivers a fully
supported breath whether time or
patient triggered.
• Patient is able to trigger the start
of inspiration
• Trigger – Time/Flow/Pressure
• Limit – Pressure/Flow
• Cycle – Time
Basic Mechanical Ventilation.pptx
SIMV
• The ventilator attempts to synchronize the
delivery of mandatory breaths with the
spontaneous efforts of the patient.
• Breaths are time triggered but synchronized
with patients effort
• However, when the breath is patient
triggered, the ventilator delivers a pressure-
supported breath (at a level set by the
clinician).
Pressure
Flow
Volume
(L/min)
(cm H2O)
(ml)
Set PC level
Time
(sec)
SIMV Mode
(Pressure-Targeted Ventilation)
Spontaneous
Breath
Pressure
Flow
Volume
(L/min)
(cm H2O)
(ml)
SIMV + PS
(Pressure-Targeted Ventilation)
PS Breath
Set PS level
Set PC level
Time
(sec)
Time-Cycled Flow-Cycled
Basic Mechanical Ventilation.pptx
PSV/CPAP
• Patient triggered (flow/pressure)
• Flow cycled
• Respiratory Rate is controlled by
patient
• PS to set to achieve TV 5-6 ml/kg
• Weaning Mode
• TV is variable
• Set back up ventilation
PSV
Time (sec)
Flow
L/m
Pressure
cm H2O
Volum
e
mL
Flow Cycling
Set PS
level
Patient Triggered, Flow Cycled, Pressure limited Mode
Dual Control MODE
• PRVC: Pressure Regulated Volume Control
• Basically pressure control mode
• Flow decelerating type
• Fixed tidal volume is ensured
• Ventilator uses a feedback method on a
breath-to-breath basis, to continuously adjust
the pressure delivered to achieve the tidal
volume target
Basic Mechanical Ventilation.pptx
Basic Mechanical Ventilation.pptx
Volume Guarantee: New Approaches in Volume Controlled Ventilation for Neonates. Ahluwalia J,
Morley C, Wahle G. Dräger Medizintechnik GmbH. ISBN 3-926762-42-X
Ventilator Parameters
Tidal Volume
Tidal volumes should be 3–6 mL/kg predicted body weight for
patients ARDS
Physiologic range (5–8 mL/kg ideal body weight) for patients with
normal lung
Tidal volumes should be 8–10 mL/kg predicted body weight for
patients neurological disorder
Pressure
• PIP
• Platue Pressure
HOW MUCH ?
Assess bedside while bagging
Mild - 10 -12 cmH2o
Moderate - 15-18 cmH2o
Severe – 18-20 cmH2o
Inspiratory plateau pressure limit of 28 cm H2 O
Slightly higher plateau pressures (29–32 cm H2 O) for patients with
increased chest wall elastance .
Total pressure = frictional forces (Resistance)
+ Elastic recoil of lungs and chest wall
P plat and PIP
P plat is measured by inspiratory hold for 4-5 sec.
Basic Mechanical Ventilation.pptx
PEEP
Optimizing PEEP
HELPS:
• Recruits, reduces oxygen requirements
• Helps to take the lung to the better part of
compliance
• Prevents atelecto-trauma
ADVERSE:
• Excess PEEP causes decreased venous return
• Hypotension
• Baro trauma
How much PEEP to start with ?
• Moderate to Severe ARDS – 8-10 cmH2O
• Asthma/Bonchiolitis – 3-5 cmH2O
• Raised ICP – 4-5 cmH2O
• Cardiogenic Pulmonary Edema – 6-8 cmH2O
• 60 sec
Total breath Time = ‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬
Breath Rate
Example Rate = 30 , Total time 60/30 = 2 sec.
If I:E ratio - 1:2 ------then
Ti = 0.66 so , TE = 1.33 sec
• Primarily effects MAP and oxygenation
• Inverse ratio (1:1) – used in ARDS.
• Prolonged expiratory rates (1:3 or 1:4) – Spasm of small airway
Short Ti-inadequate Oxygenation
Short Te- inadequate CO2 out leads auto PEEP
I:E Ratio (Inspiratory-Expiratory ratio)
Actual I Time setting
• Inspiratory time needs to reflect the age of the child.
• Typically for newborns - 0.5 seconds
• 1 year age - 0.8 seconds
• >2 years it is - 1 second, which if needed, can go up to
1.2 seconds
Basic setting of Ventilator in PICU
• Choice of ventilator mode: control ? Support/assist?
• AC Mode – Severe ARDS, Comatose child, Neuroprotection,
Cardiogenic schock ,
• SIMV + PS – Pneumonia, Bronchiolitis , Asthma
• Start all parameters at normal physiological demand and change
accordingly
1. FiO2: 50-60 %, or 100 % .target SO2 >94-95, PaO2 60-80, Hypo &
hyper oxaemia act as double edged sword
2. PIP: 15 - 18, assessed by BAE, chest rise, VT, RD & SO2
3. PEEP: low-3-4, medium 5-8, high 8-15
4. RR: normal physiological rate, <1yr 30-35, 1-5 yr, 25-30/min
What is the most effective way of
improving oxygenation in ARDS ?
A.Optimize PEEP
B. Increase FiO2
C. Increase PIP
D.Increase Inspiratory time (Ti)
In Assist control VC mode which one is
false ?
• Patient can trigger breath
• TV will be same for all breath
• PIP and Pplat are different
• In ARDS PIP requirement increases but Pplat
remains same
• Target Pplat in ARDS – 28 - 30
In SIMV + PS Mode all are true except
• Patient triggered breaths are supported
• For patient triggered breath cycling is Time
• TV/PIP is same for all beath
• It can be weaning mode
Thank You !

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Basic Mechanical Ventilation.pptx

  • 1. Basic Mechanical Ventilation DR. SATYABRATA ROY CHOWDHOURY RMO CUM CLINICAL TUTOR PEDIATRIC MEDICINE MEDICAL COLLEGE KOLKATA
  • 2. Indication of Mechanical Ventilation 1. Pneumonia 2. ARDS 3. Pulmonary Edema 4. Inhalation Injury 5. Pulmonary Thromboebolism 1. Upper airway obstruction 2. Asthma 3. Bronchiolitis 1. Encephalopathy 2. Neuromuscular disorder 3. Myopathy 4. Bony deformity 1. Cardiac failure and cardiogenic shock 2. Septic Shock
  • 4. Basics of respiratory mechanics important to mechanical ventilation
  • 5. Compliance Volume Pressure 3 1 Decreased FRC – Atelectasis ARDS 5cm 15c m 20c m Over expansion – Asthma 2
  • 6. Conditions Associated with Decreased Total Respiratory Compliance Decreased Lung compliance Fall in FRC • ARDS • Diffuse Pneumonitis • Pulmonary Edema • Atelectasis Decreased Chest wall comp. • Abdominal distension • Chest wall edema • Chest trauma/ surgery Over-expansion of lung volume • Asthma • Bronchiolitis • Excessive CPAP/PEEP
  • 7. “The Feature of the Tube” Airway Resistance Pressure Difference = Flow Rate x Resistance of the Tube Resistance is the amount of pressure required to deliver a given flow of gas and is expressed in terms of a change in pressure divided by flow. R = Δ P Flow P1 P2
  • 9. Goals of mechanical ventilation ❖ To provide adequate ventilation and oxygenation with minimal intervention ❖ Minimize the risk of lung injury ❖ Reduce patient work of breathing (WOB) ❖ Optimize patient comfort
  • 10. What we expect from a Ventilator ? • Ventiltor must recognise patient’s respiratory efforts.(trigger) • Ventilator must be able to meet patient’s demand(response) • Ventilator must not interfere with patient’s effort.(synchrony)
  • 11. To understand a ventilator breath cycle, we must know how the ventilatory breath starts, sustains, and stops inspiration and maintain expiration MX-0776 Rev03 Page 11 Inspiration Expiration 1)Starting of Inspiration or Trigger start of Inspiration End of Inspiration and start of Expiration 3) The end of inspiration or Cycle 2) Inspiration itself or Limit 2) Expiration or Baseline
  • 12. Phase variables •Trigger Start of Inspiration •Limit, control Sustain Inspiration •Cycle Inspiration to expiration transition
  • 13. Trigger • Time – Control Breath • Flow Assist Breath • Pressure More sensitive Flow Trigger – More Sensitive Set at 5 = 1L/min flow
  • 15. ARDS/Injured lun – Pressue control /PRVC Obstructive lung disease – Volume Neuroprotection - Volume
  • 16. Pressure Control Pressure limited Volume fluctuates depending on the compliance Flow decelerating type Pressure is constant throughout the inspiration
  • 17. Volume Control flow is constant Volume limited Pressure varies through out the inspiration and depends on pick compliance
  • 18. PC vs VC Ventilator Setting
  • 19. • Transition point from the inspiratory phase to the expiratory phase Cycling = Expiratory Trigger MX-0776 Rev03 Page 19 Modes Trigger variable Limit variable Cycle Volume targeted Pressure, flow or time Volume Set inspiratory time Pressure targeted Pressure, flow or time Pressure Set inspiratory time Pressure support Pressure or flow pressure Flow cycle
  • 20. • A mode of mechanical ventilation may be defined, in general, as a predetermined pattern of patient-ventilator interaction What Is a Mode of Mechanical Ventilation? CMV IMV Assist Cont. SIMV Mode Set-Point, Dual mode, Servo Optimal Volume, pressure Ventilator Breath Control Variable Breath Sequence Targeting Scheme (method of feed back)
  • 21. VENTILATOR MODES CMV/IPPV ACV SIMV CPAP Volume Pressure Volume Pressure
  • 22. Control Mandatory Ventilation ⮚ Breaths are delivered either as preset volume or pressure ⮚ Cycling occurs when the preset volume, pressure (or time) is achieved ⮚ Patient spontaneous breaths not allowed. ⮚ Used in theatre and in very unwell ICU patients -heavily sedated or completely paralysed.
  • 23. Intermittent Mandatory Ventilation (IMV) • Ventilator Delivers preset time triggered mandatory breaths • Patient is allowed to take spontaneous breath without any support. • Advantage • Less sedation • Less haemodynamic instability • More patient Comort • Disadvantage - • Breath Stacking - Barotrauma
  • 24. Assist Control • Ventilator delivers a fully supported breath whether time or patient triggered. • Patient is able to trigger the start of inspiration • Trigger – Time/Flow/Pressure • Limit – Pressure/Flow • Cycle – Time
  • 26. SIMV • The ventilator attempts to synchronize the delivery of mandatory breaths with the spontaneous efforts of the patient. • Breaths are time triggered but synchronized with patients effort • However, when the breath is patient triggered, the ventilator delivers a pressure- supported breath (at a level set by the clinician).
  • 27. Pressure Flow Volume (L/min) (cm H2O) (ml) Set PC level Time (sec) SIMV Mode (Pressure-Targeted Ventilation) Spontaneous Breath
  • 28. Pressure Flow Volume (L/min) (cm H2O) (ml) SIMV + PS (Pressure-Targeted Ventilation) PS Breath Set PS level Set PC level Time (sec) Time-Cycled Flow-Cycled
  • 30. PSV/CPAP • Patient triggered (flow/pressure) • Flow cycled • Respiratory Rate is controlled by patient • PS to set to achieve TV 5-6 ml/kg • Weaning Mode • TV is variable • Set back up ventilation
  • 31. PSV Time (sec) Flow L/m Pressure cm H2O Volum e mL Flow Cycling Set PS level Patient Triggered, Flow Cycled, Pressure limited Mode
  • 32. Dual Control MODE • PRVC: Pressure Regulated Volume Control • Basically pressure control mode • Flow decelerating type • Fixed tidal volume is ensured • Ventilator uses a feedback method on a breath-to-breath basis, to continuously adjust the pressure delivered to achieve the tidal volume target
  • 35. Volume Guarantee: New Approaches in Volume Controlled Ventilation for Neonates. Ahluwalia J, Morley C, Wahle G. Dräger Medizintechnik GmbH. ISBN 3-926762-42-X Ventilator Parameters
  • 36. Tidal Volume Tidal volumes should be 3–6 mL/kg predicted body weight for patients ARDS Physiologic range (5–8 mL/kg ideal body weight) for patients with normal lung Tidal volumes should be 8–10 mL/kg predicted body weight for patients neurological disorder
  • 37. Pressure • PIP • Platue Pressure HOW MUCH ? Assess bedside while bagging Mild - 10 -12 cmH2o Moderate - 15-18 cmH2o Severe – 18-20 cmH2o Inspiratory plateau pressure limit of 28 cm H2 O Slightly higher plateau pressures (29–32 cm H2 O) for patients with increased chest wall elastance .
  • 38. Total pressure = frictional forces (Resistance) + Elastic recoil of lungs and chest wall
  • 39. P plat and PIP P plat is measured by inspiratory hold for 4-5 sec.
  • 41. PEEP
  • 42. Optimizing PEEP HELPS: • Recruits, reduces oxygen requirements • Helps to take the lung to the better part of compliance • Prevents atelecto-trauma ADVERSE: • Excess PEEP causes decreased venous return • Hypotension • Baro trauma
  • 43. How much PEEP to start with ? • Moderate to Severe ARDS – 8-10 cmH2O • Asthma/Bonchiolitis – 3-5 cmH2O • Raised ICP – 4-5 cmH2O • Cardiogenic Pulmonary Edema – 6-8 cmH2O
  • 44. • 60 sec Total breath Time = ‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬ Breath Rate Example Rate = 30 , Total time 60/30 = 2 sec. If I:E ratio - 1:2 ------then Ti = 0.66 so , TE = 1.33 sec • Primarily effects MAP and oxygenation • Inverse ratio (1:1) – used in ARDS. • Prolonged expiratory rates (1:3 or 1:4) – Spasm of small airway Short Ti-inadequate Oxygenation Short Te- inadequate CO2 out leads auto PEEP I:E Ratio (Inspiratory-Expiratory ratio)
  • 45. Actual I Time setting • Inspiratory time needs to reflect the age of the child. • Typically for newborns - 0.5 seconds • 1 year age - 0.8 seconds • >2 years it is - 1 second, which if needed, can go up to 1.2 seconds
  • 46. Basic setting of Ventilator in PICU • Choice of ventilator mode: control ? Support/assist? • AC Mode – Severe ARDS, Comatose child, Neuroprotection, Cardiogenic schock , • SIMV + PS – Pneumonia, Bronchiolitis , Asthma • Start all parameters at normal physiological demand and change accordingly 1. FiO2: 50-60 %, or 100 % .target SO2 >94-95, PaO2 60-80, Hypo & hyper oxaemia act as double edged sword 2. PIP: 15 - 18, assessed by BAE, chest rise, VT, RD & SO2 3. PEEP: low-3-4, medium 5-8, high 8-15 4. RR: normal physiological rate, <1yr 30-35, 1-5 yr, 25-30/min
  • 47. What is the most effective way of improving oxygenation in ARDS ? A.Optimize PEEP B. Increase FiO2 C. Increase PIP D.Increase Inspiratory time (Ti)
  • 48. In Assist control VC mode which one is false ? • Patient can trigger breath • TV will be same for all breath • PIP and Pplat are different • In ARDS PIP requirement increases but Pplat remains same • Target Pplat in ARDS – 28 - 30
  • 49. In SIMV + PS Mode all are true except • Patient triggered breaths are supported • For patient triggered breath cycling is Time • TV/PIP is same for all beath • It can be weaning mode