MECHANICAL

VENTILATION
PART-I
 OBJECTIVE

• Describe indication of mechanical ventilation.

• Describe the principles of mechanical ventilation.
• Describe modes of mechanical ventilation.
 + + + Spontaneous breathing

Positive pressure Negative pressure

ventilation ventilation
 MECHANICAL
VENTILATION

Mechanical ventilation is a supportive therapy used to assist

patients who are unable to maintain adequate oxygenation or
carbon dioxide elimination. These patients usually exhibit signs
of acute respiratory failure and are not candidates for less
invasive methods of respiratory support. There are
invasive and non-invasive techniques of mechanical
ventilation.
 INDICATIONS

Invasive mechanical ventilation is hazardous,

uncomfortable, and expensive and should only be
utilized when indicated. Major indications for
mechanical ventilation are:
• The partial pressure of oxygen in arterial blood
(PaO2) cannot be maintained above 50mm Hg
despite high levels of delivered oxygen.
Clinical example: Acute Respiratory Distress
Syndrome (ARDS).
 INDICATIONS

• The partial pressure of carbon dioxide in arterial blood

rises above 50 torr.
Clinical example: Acute Respiratory Failure (ARF)

Demands
 INDICATIONS

• Ventilation becomes inefficient and/or exhausted.

Clinical example: bronchospasm, flail chest and
impending respiratory failure.
• Airway protection
Clinical example: tracheal injury, edema, severe head
injury and facial fractures
 INDICATIONS

Some examples of exceptions to these indications are:

• A patient with chronic obstructive pulmonary disease

(COPD) may be clinically stable with
abnormal arterial blood gas (ABG) values and will not
require mechanical ventilation unless
CO2 levels rise above their normal values.
• Patients with neuromuscular disease may be placed on
mechanical ventilation in order to
prevent respiratory distress or arrest due to their decreased
strength to ventilate
 GOAL

The goal of mechanical ventilation is to

improve ventilation, oxygenation, lung
mechanics and
patient comfort while preventing
complications. Mechanical ventilators
provide supportive therapy.
The ventilator is not a cure for any disorder,
rather it allows support of breathing while
disease processes are treated.
 PHYSICAL CHARACTERISTICS
OF POSITIVE PRESSURE
VENTILATORS

Positive pressure ventilators used in the critical care

setting have several characteristics in common:

• A mechanical or pneumatic system to push gas

under positive pressure.
• Electrical and gas connections.
• Exhalation valve that allows the patient to exhale
through the closed system.
• User interface that allows the clinician to modify
various parameters to individualize therapy
• Software programming that monitors machine
performance, detects alarm conditions, and
produces graphic or digital data displays.
• Airway pressure sensor and display (gauge and/or
digital readout). The airway pressure gauge
monitors airway pressure during inhalation,
exhalation and at rest. If the airway pressure
exceeds or falls below preset limits an alarm will
sound
 BASIC MECHANISM OF PPV

Pressure
PressureDifference
Difference

Gas
GasFlow
Flow
PxV
Time
Time

Volume
VolumeChange
Change
 VENTILATOR MODES AND
VARIABLES

A ventilator mode is a description of how breaths are

supplied to the patient. The mode describes
how breaths are controlled (pressure or volume), and how
the four phases of the respiratory cycle
are managed. The four phases are described as:
• The change from expiration to inspiration or what triggers
(initiates) a breath
• Inspiration or breath delivery; largely determined by the
control variable
• The change from inspiration to expiration or what cycles
(ends) a breath
• Expiration or a passive process dependent on time
 CONTROL VARIABLES

There are two fundamental methods to control the

delivery of a breath. The clinician can choose to
keep either volume or pressure constant from breath to
breath. The control variables most
commonly used to describe modes of ventilation are
volume-controlled (VC) ventilation and
pressure-controlled (PC) ventilation. Within these two
categories are multiple ways to tailor specific
modes
 PHASE VARIABLES

Beyond control variables, phase variables provide a more

detailed picture of ventilator function.
The phase variables control the transitions between
inspiration and expiration and include trigger
and cycle variables
 TRIGGER VARIABLES

Trigger variables determine how a breath is started. A breath

can be initiated (triggered) either by
the patient, the ventilator or the clinician. Patient-triggered
breaths generally occur in response to
changes in pressure or flow.
• Spontaneous breath is completely regulated by the patient
with no contribution by the ventilator.
• Assisted breath is initiated by the patient, but all other
aspects of the breath are controlled by the
ventilator.
• Supported breath is initiated and ended by the patient, but
the breath is delivered under positive
pressure by the ventilator.
 CYCLE VARIABLES

Cycle variables determine how a breath is ended. A positive

pressure breath will always end
because a variable has reached a set value. The change from
inspiration to expiration can be
determined by:
• Volume cycle (desired volume met),
• Flow cycle (desired flow met),
• Pressure cycle (desired pressure met), or
• Time cycle (elapsed time was met)
 VENTILATOR SETTINGS

there are essentially seven variables of volume ventilators that are

manipulated to optimize the patient’s ETCO2, SaO2 or arterial
blood gases. These variables are tidal
volume (TV), rate, fraction of inspired oxygen (FiO2), airway
pressure, PEEP, pressure support, and
mode.
 TERMINOLOGY RELATED
TO VENTILATOR SETTINGS

• Mandatory: A positive pressure breath that is controlled,

triggered and cycled by the ventilator in accordance with
programmed settings.
• Assisted: A breath that is triggered by the patient, but
controlled and cycled by the ventilator. Other than being
triggered by the patient, an assisted breath is identical to a
mandatory breath.
• Supported: A positive pressure breath that is triggered and
cycled by the patient but controlled by the ventilator.
Supported breaths are delivered with positive pressure, but
may vary in length, tidal volume or pressure depending on
the patient’s respiratory muscle compliance.
 TERMINOLOGY RELATED
TO VENTILATOR SETTINGS

• Spontaneous: A breath that is initiated controlled and

ended by the patient without any input from the
ventilator. Spontaneous breaths are negative pressure
breaths.
 MODE OF VENTILATOR

There are three basic modes of ventilation: continuous

mandatory ventilation (CMV), assist-control
(A/C) and intermittent mandatory ventilation (IMV).
Any of these modes can be volume-controlled
(VC) or pressure-controlled (PC).

• Continuous mandatory ventilation (CMV):

as the name implies, is completely controlled by the
ventilator; no spontaneous breaths are allowed. It is
pressure or volume-controlled, machine
triggered and machine cycled.
 MODE OF VENTILATOR

• Assist-control ventilation (A/C):

allows the patient to trigger a breath, but the machine otherwise
controls all breaths. It is pressure or volume-controlled, machine
and patient triggered, and machine cycled.

• Intermittent mandatory ventilation (IMV):

provides a minimum number of programmed breaths;
the patient may initiate spontaneous breaths at any time. In this
mode a machine breath will be pressure or volume controlled,
machine triggered and machine cycled. A spontaneous breath
will be pressure controlled, patient triggered and patient cycled.
 MODE OF VENTILATOR

The modes are most appropriately identified by first

indicating the control variable (volumecontrolled
or pressure-controlled) followed by the mode. For example,
the correct abbreviation for volume-controlled continuous
mandatory ventilation is VC-CMV. The choice of mode
depends upon patient characteristics and the type of
equipment available
 TIDAL VOLUME

Tidal volume (TV) is the volume of gas delivered to the patient

with each breath. Tidal volume may also be expressed as VT.
TV is only set for volume-controlled modes of ventilation and
is usually 8-12cc/kg of body weight.

Excessive tidal volumes have been linked to ventilator-induced

acute lung injury called volutrauma.
Volutrauma is now believed to be one of the greatest threats to
the lung posed by mechanical Ventilation.
 TIDAL VOLUME

Acute lung disease typically produces some areas of the lung

that are severely diseased and others that are nearly normal.
Gas flow will always follow the path of least resistance.
When large tidal volumes are delivered under positive
pressure the delivered gas flows more rapidly and
forcefully into the more normal areas
This rapid forceful introduction of gas causes over-distension
of the alveoli in these areas, leading to parenchymal injury, loss of
surfactant and possible alveolar rupture. It is now thought that
excessive volume rather than excessive pressure is the most
common cause of ventilator-induced pneumothorax.
 RATE

The set ventilatory rate is the minimum number of

breaths delivered to the patient per minute. The
actual rate may be higher than the set rate if the
patient is initiating spontaneous breaths. Rate is also
a determinant of ventilation, and is adjusted in
response to the patient’s CO2 levels. Minute
ventilation is the rate multiplied by the tidal volume
 OXYGEN PERCENTAGE

The fraction of inspired oxygen (FiO2) is the amount

of oxygen delivered to the patient. FiO2 can be
expressed as a decimal fraction or a percentage.
Oxygen concentrations of greater than 0.50 (50%)
increase the risk of oxygen toxicity if delivered for
more than 24 hours. Supplemental oxygen is
administered in response to low PaO2, SpO2, or
indicators of tissue hypoxia
 PEAK AIRWAY PRESSURE

Airway pressure reflects global alveolar pressure . The

highest pressure recorded in the ventilatory cycle is called the
peak airway pressure or peak inspiratory pressure (PIP). The
maximum allowable PIP is set on the ventilator.
Excessive pressure can lead to barotrauma or pneumothorax.
If the PIP exceeds the set value, an alarm will sound and gas
delivery will halt until the next breath is triggered. In
pressure-controlled modes the PIP will be constant for each
breath. In volume-controlled modes, the PIP will vary from
breath to breath
 PEAK AIRWAY PRESSURE

The normal peak inspiratory pressure on a

mechanically ventilated patient with normal lungs is
approximately 20cm H2O. The maximum allowable
peak pressure varies from patient to patient.
 POSITIVE END EXPIRATORY
PRESSURE (PEEP)

The normal airway pressure at the end of expiration and

before inspiration is zero. Application of pressure by the
ventilator at this stage of the ventilatory cycle is called
PEEP. PEEP aids in propping open alveoli that would
otherwise collapse during the expiratory phase. It is a very
effective treatment modality for V/Q mismatching caused
by atelectatic processes, and is a key component of
ventilator therapy for patients with ARDS.
 POSITIVE END EXPIRATORY
PRESSURE (PEEP)

PEEP enhances oxygenation by increasing

the number of available gas exchange units and is adjusted in
response to measures of oxygenation.
PEEP is measured at the bedside by noting the airway
pressure reading at the end of expiration. If
the reading is greater than zero, PEEP is present. A PEEP
setting of 5cm H2O is considered equivalent to the effect of
the closed glottis, and is called physiologic PEEP.
Therapeutic PEEP levels range from 10 – 35 cm H2O or
more.
 PRESSURE SUPPORT

Pressure support can be used in combination with other ventilatory

modes that permit spontaneous
breathing. Pressure support works by responding to a patient’s
inspiratory effort with a positive
pressure breath delivered at a set pressure. The patient can draw
more volume by contributing
muscular effort to the breath, or the ventilator can deliver the entire
breath if muscular effort is not
sustained. A pressure support breath is pressure controlled, patient
triggered, pressure limited, and
patient cycled. The volume of a pressure support breath will vary
in proportion to the patient’s
inspiratory effort
 PRESSURE SUPPORT

Pressure support can be used to compensate for the increased

airway resistance of an endotracheal
tube, or to facilitate weaning from mechanical ventilation.
Pressure support enhances spontaneous
tidal volumes and therefore is adjusted in response to CO2
levels. Pressure support typically ranges
from 5 – 30 cm H2O
 TYPES OF VENTILATOR
BREATHS

Pressure
PressureDifference
Volume-cycled breath Difference

“Volume breath”
Gas
GasFlow
Present tidal volume Flow

Time-cycled breath Time

Time
“Pressure control breath”
Volume
VolumeChange
Change
Constant pressure for preset time
Flow-cycled breath
“Pressure support breath”
Constant pressure during inspiration
MODES OF VENTILATION
ON SCALAR GRAPHICS

FLOW

PRESSURE

VOLUME
 FLOW SETTINGS

The ventilator and/or the respiratory muscles create

the pressure that results in a flow of gas. In
mechanical ventilation, flow is usually set indirectly.
Most ventilators calculate the flow rate based
on the selected control variable (volume or pressure)
and the rate. The highest point of the flow
waveform represents peak flow
 MODES OF MECHANICAL
VENTILATION

Point of Reference:
Paw Spontaneous Ventilation
+

-
 SPONTANEOUS BREATH

Flow
(L/m)

Pressure
(cm H2O)

Volume
(mL)
Time (sec)
 CONTINUOUS POSITIVE
AIRWAY PRESSURE(CPAP)

• No machine breaths delivered

• Allows spontaneous breathing at elevated baseline pressure
• Patient controls rate and tidal volume

Paw
+

-
Volume-limited mode

? cm H2O

Fixed Tidal
Volume
 CONTROLLED
MECHANICAL
VENTILATION

• Present rate with volume or time-cycled breaths

• No patient interaction with ventilator
• Advantages: rests muscles of respiration
• Disadvantages: requires sedation/neuromuscular blockade,
potential adverse hemodynamic effects
 CONTROLLED
MECHANICAL
VENTILATION (CMV)

Airway pressure

+
0
-
Time
 ASSIST-CONTROL
VENTILATION

• Volume or time-cycled breaths + minimal ventilator rate

• Additional breaths delivered with inspiratory effort
• Advantages:
• reduced work of breathing
• allows patient to modify minute ventilation
• Disadvantages: potential adverse hemodynamic effects
 ASSIST-CONTROL
VENTILATION

Airway
pressure

+
0
-
Time
 CONTROLLED MODE
(VOLUME-TARGETED
VENTILATION)
Time-triggered, Flow-limited, Volume-cycled Ventilation
Preset Peak Flow

Flow
(L/m)

Dependent on
Pressure CL & Raw
(cm H2O)
Preset VT
Volume Volume Cycling
(mL)

Time (sec)
 CONTROLLED MODE
(VOLUME-TARGETED
VENTILATION)

Dependent on
CL & Raw
Peak (pop off) pressure

Pressure
(cm H2O)
Preset VT
Volume Volume Cycling

(mL)

Time (sec)
 SYNCHRONIZED
INTERMITTENT MANDATORY
VENTILATION (SIMV)

• Volume or time-cycled breaths at preset rate

• Additional spontaneous breaths of tidal volume
and rate determined by patient
• Used with pressure support
 PRESSURE CONTROLLED MODE
(PRESSURE -TARGETED
VENTILATION)
Patient-triggered, Pressure-limited, Time-cycled Ventilation

Time-Cycled

Flow
(L/min)

Set PC
Pressure level
(cm H2O)

Volume
(ml)

Time (sec)
 PRESSURE-SUPPORT
VENTILATION

• Pressure assist during spontaneous inspiration with flow-

cycled breath
• Pressure assist continues until inspiratory effort decreases
• Delivered tidal volume dependent on inspiratory effort
and resistance/compliance of lung/thorax
 PRESSURE-SUPPORT
VENTILATION (PSV)

Airway
pressure

+
0
-
Time
 PSV

Patient Triggered, Flow Cycled, Pressure limited Mode

Flow Flow
Flow Cycling
Cycling
(L/m)

Set PS
level
Pressure
(cm H2O)

Volume
(mL)
Time (sec)
 PRESSURE-SUPPORT
VENTILATION

• Potential advantages
• Patient comfort
• Decreased work of breathing
• May enhance patient-ventilator synchrony
• Used with SIMV to support spontaneous breaths
 PRESSURE-SUPPORT
VENTILATION

• Potential disadvantages
• Variable tidal volume if pulmonary resistance/compliance
changes rapidly
• If sole mode of ventilation, apnea alarm mode may be
only backup
• Gas leak from circuit may interfere with cycling
Volume

SB PSV 10
 SPONTANEOUS MODES

Continuous Positive Airway Pressure

Paw CPAP

Pressure Support Ventilation

Paw PS
 INSPIRATORY PLATEAU
PRESSURE

• High inspiratory plateau pressure

• Barotrauma
• Volutrauma
• Decreased cardiac output
• Methods to decrease IPP
• Decrease PEEP
• Decrease tidal volume
 INSPIRATORY TIME: EXPIRATORY
TIME RELATIONSHIP (I:E RATIO)

• Spontaneous breathing I:E - 1:2

• Inspiratory time determinants with volume breaths
• Tidal volume
• Gas flow rate
• Respiratory rate
• Inspiratory pause
• Expiratory time passively determined
 I:E RATIO

Lung
volume
Flow = 40 L/s Flow = 80 L/s

I EI EIE I E I E I E

Time
 I:E RATIO DURING
MECHANICAL VENTILATION

• Expiratory time too short for exhalation

• Breath stacking
• Auto-PEEP
• Reduce auto-PEEP by shortening inspiratory time
• Decrease respiratory rate
• Decrease tidal volume
• Increase gas flow rate
 AUTO-PEEP

• Can be measured on some ventilators

• Increases peak, plateau, and mean airway pressures
• Potential harmful physiologic effects
 VENTILATION-INDUCED
LUNG INJURY*

Atelectrauma: Volutrauma:
Repetitive alveolar Over-distension of normally
collapse and reopening of aerated alveoli due to
the under-recruited excessive volume delivery
alveoli

*Dreyfuss: J Appl Physiol 1992

THANK YOU

Dr. Hind warrag