Out lines
• Variables of a ventilator
• Mode of ventilator
• Hypoxia management
• Trouble shootings
Variables of ventilator
• Positive-pressure breaths on the ventilator can be
categorized by three variables:
• The trigger variable (what initiates the breath),
• The limit variable (what governs the gas delivery), and
• The cycle variable (what terminates the breath).
• The variables that can regulate the triggering of
ventilation are
• Time (during controlled mechanical ventilation) or
• Flow and pressure (during assisted mechanical
ventilation).
• Ventilator gas delivery can be regulated to deliver flow,
volume, or pressure.
• When pressure triggering is used, a ventilator-delivered
breath is initiated if the demand valve senses a
negative airway pressure deflection (generated by the
patient trying to initiate a breath) greater than the
trigger sensitivity.
• When flow-by triggering is used, a continuous flow of
gas through the ventilator circuit is monitored.
• A ventilator-delivered breath is initiated when the return
flow is less than the delivered flow, a consequence of
the patient's effort to initiate a breath
Ventilator Settings
• Respiratory rate
• Positive end-expiratory pressure (PEEP)
• I: E ratio
• Fraction of inspired oxygen(Fio2)
• Trigger mode
• Tidal Volume
• Peak airway pressure
PEEP
• Applied PEEP is generally added to mitigate end-expiratory
alveolar collapse.
• A typical initial applied PEEP is 5 cmH2O.
• However, up to 20 cmH2O may be used in patients
undergoing low tidal volume ventilation like in acute
respiratory distress syndrome (ARDS)
I
I:E Ration
• During spontaneous breathing, the normal I:E ratio is
1:2, indicating that for normal patients the exhalation
time is about twice as long as inhalation time.
• If exhalation time is too short “breath stacking” occurs
resulting in an increase in end-expiratory pressure also
called auto-PEEP.
• Depending on the disease process, such as in ARDS, the
I:E ratio can be changed to improve ventilation
Fraction of inspired oxygen
• The lowest possible fraction of inspired oxygen (FiO2)
necessary to meet oxygenation goals should be used.
Usually < 60%
• This will decrease the likelihood that adverse
consequences of supplemental oxygen will develop,
such as
• absorption atelectasis,
• accentuation of hypercapnia,
• airway injury, and
• parenchymal injury
Modes of ventilator
Controlled mechanical ventilation(MCV/PCV )
Assist-Control Ventilation (A/C)
- Volume Control
- Pressure Control
Pressure Support Ventilation
Synchronized Intermittent Mandatory Ventilation
- Volume Control
- Pressure Control
Control mechanical ventilator
• The main characteristic of CMV is that the variable used by the
ventilator (and set by the health care provider) to trigger and to
cycle off the breath is time
• The limit variable that governs gas delivery during ventilator-
controlled ventilatory support is flow and volume (controlled
mechanical ventilation [CMV]) or pressure (pressure-controlled
ventilation [PCV])
Volume-cycled modes are to be preferred when
maintaining minute ventilation is crucial,
such as in head-injured patients.
Physiologic studies have suggested a more
homogeneous distribution of TV when
ventilating patients with acute respiratory
distress syndrome (ARDS) with the
pressure-cycled mode
A controlled mode able to share the theoretical advantages of
constant pressure with the guarantee of delivering a preset
VT has been recently offered in newer mechanical ventilators
“pressure-regulated volume control” or “volume plus”.
It consists of a closed-loop algorithm that,
based on the measurement of static
compliance of the respiratory system, changes
the level of applied pressure on a breath-by-
breath basis to match a “target” tidal
volume
Assist Control Ventilation
A set tidal volume (if set to volume control) or a set pressure (if set
to pressure control) is delivered at a minimum rate
Additional ventilator breaths are given if triggered by the patient
(himself ), lf no spontaneous effort occurs, the ventilator will
deliver controlled breaths at a preselected backup rate).
The variable used by the ventilator to cycle off the breath is time
The limit variable that governs gas delivery is flow and volume
(assisted/controlled mechanical ventilation [A/CMV]) or pressure
(assisted pressure controlled ventilation [A/PCV]).
Pressure Support Ventilation
PSV=> most popular partial ventilatory support
- To wean patients from controlled ventilatory
-To ventilate patients who have ARF
During PSV, the patient's spontaneous effort triggers the
ventilator and is assisted by a constant positive pressure
The patient controls the respiratory rate and
exerts a major influence on the duration of
inspiration, inspiratory flow rate and tidal
volume
The model provides pressure support to overcome
the increased work of breathing imposed by the
disease process, the endotracheal tube, the
inspiratory valves and other mechanical aspects of
ventilatory support.
Synchronized Intermittent Mandatory
Ventilation
Delivers a pre-set number of breaths at a set volume and flow
rate.
Allows the patient to generate spontaneous breaths, volumes,
and flow rates between the set breaths.
Detects a patient’s spontaneous breath attempt and doesn’t
initiate a ventilatory breath – prevents breath stacking
Breaths are given at a set minimal rate, however if the
patient chooses to breath over the set rate no
additional support is given
SIMV is usually associated with greater work of
breathing than AC ventilation and therefore is less
frequently used as the initial ventilator mode
Machine breaths:
– Delivers the set volume or pressure
Mode of ventilation provides moderate amount of
support
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Like AC, SIMV can deliver set tidal volumes (volume
control) or a set pressure and time (pressure control)
Negative inspiratory pressure generated by
spontaneous breathing leads to increased venous
return, which theoretically may help cardiac output
and function
POSITIVE END EXPIRATORY PRESSURE (PEEP):
This is NOT a specific mode, but is rather an adjunct to any of the vent modes.
PEEP is the amount of pressure remaining in the lung at the END of the expiratory
phase.
Utilized to keep otherwise collapsing lung units open while hopefully also improving
oxygenation.
Usually, 5-10 cmH2O
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Auto-PEEP or Intrinsic PEEP
– Normally, at end expiration, the lung volume is equal to the FRC
– When PEEPi occurs, the lung volume at end expiration is greater than the FRC
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Why does hyperinflation occurs?
– Air flow limitation because of dynamic collapse
– No time to expire all the lung volume (high RR or
Vt)
– Decreased Expiratory muscle activity
– Lesions that increase expiratory resistance
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Adverse effects:
Predisposes to barotrauma
Predisposes hemodynamic compromises
Diminishes the efficiency of the force generated by
respiratory muscles
Augments the Works of breathing
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Contraindications for therapeutic PEEP (>5 cm H2O)
Hypotension
Elevated ICP
Uncontrolled pneumothorax
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Continuous Positive Airway Pressure (CPAP):
This is a mode and simply means that a pre-set pressure is present in the circuit and
lungs throughout both the inspiratory and expiratory phases of the breath.
CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less
WOB.
The CPAP mode is very commonly used as a mode to evaluate the patient’s readiness
for extubation.
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ADVANTAGES OF EACH
MODE
Mode Advantages
Assist Control Ventilation (AC) Reduced work of breathing
compared to spontaneous
breathing
AC Volume Ventilation Guarantees delivery of set
tidal volume
AC Pressure Control Allows limitation of peak
Ventilation inspiratory pressures
Pressure Support Ventilation Patient comfort, improved
(PSV) patient ventilator interaction
Synchronized Intermittent Less interference with normal
Mandatory Ventilation (SIMV) cardiovascular function
DISADVANTAGES OF
EACH MODE
Mode Disadvantages
Assist Control Ventilation (AC) Potential adverse
hemodynamic effects, may
lead to inappropriate
hyperventilation
AC Volume Ventilation May lead to excessive
inspiratory pressures
AC Pressure Control Potential hyper- or
Ventilation hypoventilation with lung
resistance/compliance
changes
Pressure Support Ventilation Apnea alarm is only back-up,
(PSV) variable patient tolerance
Synchronized Intermittent Increased work of breathing
Mandatory Ventilation (SIMV) compared to AC
Case scenario
• If a child become hypoxic when on MV?
• How do you approach ?
HYPOXIA MANAGEMENT
Fio2 should be <60%
Increase PEEP
Increase I: E ration till IRV
Prone position
MECHANICAL VENTILATOR
TROUBLE SHOOTINGS
O2/Air supply down
High pressure
Low MV / High MV
High RR
Apnea ventilation
Asynchrony
Adjust alarm setting for each patient
Thank you !!!!!
