Mechanical Ventilatory Support

Dr. Yidersal S. (internist)

A.K.E.G.H
May/2022
Outline
• Introduction to MV
• Indications for mechanical ventilation
• Types of mechanical ventilation
• Mods of mechanical ventilation
• Complications of mechanical ventilation
• Weaning and extubation
INTRODUCTION 

• Mechanical ventilation (MV) is a special device used to assist or

replace spontaneous breathing.
• Also called positive pressure ventilation in the modern word.
History of MV 1928 polio
Objectives of mechanical ventilation
 INDICATIONS
1. The primary indication for initiation of MV is respiratory failure:
a. Hypoxemic
b. Hypercarbic
2. Air way protection
.To prevent Aspiration in deeply sedated & unconscious patient
.Maintain patency in obstruction(Asthma, Anaphylaxis, Tumor)
3. Hyperventilation Therapy- raised ICP
5. Increased ventilator demand: eg;- septic shock, severe metabolic acidosis
TYPES OF MECHANICAL VENTILATION

• There are two basic methods of MV:

Noninvasive ventilation (NIV) and
Invasive (or conventional mechanical) ventilation (MV).
Invasive Non-Invasive
Noninvasive Ventilation

Noninvasive Ventilation:
• NIV usually is provided with a tight-fitting face mask, helmet or a
hood.
• It is often used when the need for ‘ventilatory’ support is likely to be
short-lived.
• NIV has proved highly effective in exacerbations of COPD.
• It is most frequently implemented as bilevel-PAP ventilation or PSV.
Indications
• Younger age
• Lower acuity of illness (APACHE score)
• Able to cooperate, better neurologic score
• Less air leaking, intact dentition
• Moderate hypercarbia (PaCO2 >45 mmHg, <92 mmHg)
• Moderate acidemia (pH <7.35, >7.10)
• Improvements in gas exchange and heart/ respiratory rates within
first two hours.
Noninvasive Ventilation
 Conventional MV

• Conventional MV is implemented once a cuffed tube is inserted into the

trachea.
• Allows conditioned gas (warmed, oxygenated, and humidified) to be
delivered to the airways and lungs.
MODES OF VENTILATION

• Mechanical ventilation can deliver different types of breaths.

• They are defined by the combination of three features:
Trigger – what initiates breath?
 Timer or patient effort
Target – what regulates gas flow during breath?
 Predetermined flow rate or pressure limit.
Termination – what terminates breath?(Cycle)
 The signal for a ventilator to end inspiration may be volume, time, or
flow-related.
Types of breaths
Volume control
Volume assist
Pressure control
 Pressure assist
Modes of Ventilation

1.Controlled(CMV)
2.Assist Control (AC)
3.Synchronized Intermittent Mandatory Ventilation (SIMV)
4.Pressure Support Ventilation(PSV)
5.CPAP
Controlled mechanical ventilation
• During CMV, the minute ventilation is determined entirely by the set
respiratory rate and tidal volume.
• The patient does not initiate additional minute ventilation above that
set on the ventilator.
• CMV does not require any patient work.
Controlled mechanical ventilation
Advantage Disadvantage
• Prevents excessive airway • Very uncomfortable and
pressures. requires deep sedation +/-
paralysis.
• Avoid regional alveolar
• Unable to guarantee
over distention.
minimum VE.
• May lead to earlier
liberation from MV.
Assist-Control Ventilation

• Most widely used mode of ventilation.

• Patient or timer initiated.
• Ventilatory rate is determined either by the patient or by the operator-
specified backup rate.
• Each patient-initiated breath receives the set tidal volume from the
ventilator
• It ensures a backup minute ventilation.
• E.g =20 breath, 500tv mev=10L(minimum)
• patient add 5breath additional 2.5 L =mev=12.5L
Assist-Control Ventilation
Disadvantage
Advantage
• Respiratory alkalosis
• Guarantees a minimum minute
ventilation. • Auto-PEEP
• Low work of breathing • Hypotension
• Patient comfort. • Respiratory muscle paralysis
Intermittent Mandatory Ventilation

• SIMV differs from ACMV in that only a preset number of breaths are
ventilator-assisted.
• Mandatory breaths are delivered in synchrony with the patient’s
inspiratory efforts.
• SIMV allows patients with an intact respiratory drive to exercise
inspiratory muscles between assisted breaths.
• Thus it is useful for both supporting and weaning intubated patients.
Intermittent Mandatory Ventilation

Advantage
Disadvantage
• Patient control
• Comfort from spontaneous • Potential dyssynchrony
breaths
• Can provide wide range of • May result in hypoventilation
respiratory support
• Increased work of breathing
Pressure-Support Ventilation

• Patient -triggered, flow-cycled, and pressure-limited.

• It provides graded assistance to augment every spontaneous
respiratory effort.
• Patients receive ventilator assistance only when the ventilator detects
an inspiratory effort.
Pressure-Support Ventilation

Advantage
For weaning patients from MV Disadvantage
Comfortable mode for awake Patient must trigger each breath
and conscious patient Minimum MV cannot be guaranteed
Can be combined with SIMV Associated with poor quality sleep
mode Central apnea might develop if
applied to patients with poor
respiratory drive
Ventilator Asynchrony
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

• CPAP is not a true support mode of ventilation because all ventilation

occurs through the patient’s spontaneous efforts.
• Delivery of a continuous level of positive airway pressure
• The ventilator does not cycle during CPAP
• It is functionally similar to PEEP
• No additional pressure above the level of CPAP is provided.
• Used to assess extubation potential
Bilevel positive airway pressure (BPAP)

• It is a mode used during NPPV

• Combination of CPAP & PSV

• It delivers a preset inspiratory positive airway pressure (IPAP) and

expiratory positive airway pressure (EPAP)

• The tidal volume correlates with the difference between the IPAP and
the EPAP.
Common Ventilator Settings

• Respiratory Rate

• Tidal Volume (VT)

• Peak Flow/ Flow Rate/Flow pattern

• I:E Ratio (Inspiration to Expiration Ratio)

• PEEP

• Fraction of inspired oxygen (FIO2)

Variables that govern how a ventilator functions and interacts with the patient

Control variable
‘The Mode of Ventilation’
Pressure, flow, or volume
controlled

Limit Variable
Volume, pressure or flow
can be set to be constant
or reach a maximum

Triggering variable
pressure, flow or volume
sensing that initiates
the vent cycle

Cycle variable
Pressure, volume, flow,
or time that ends the
inspiratory phase
Initial ventilator settings in different disease states
Respiratory Rate

• The number of breaths the ventilator will deliver/minute (12-16 BPM)

• For ACV, the RR is typically set four breaths per minute below the
patient's native rate.
• For SIMV, the rate is set to ensure that at least 80 percent of the
patient's total VE is delivered by the ventilator.
• For patients with ARDS, the required RR is higher (up to 35 BPM), in
order to facilitate low tidal volume ventilation.
Tidal Volume (VT)

• Is the amount of air delivered with each breath.

• 8-12 ml/kg IBW
Positive end-expiratory pressure(PEEP)

• Prevent premature airway closure and alveolar collapse at end

expiration.
• Improves oxygenation by increasing functional residual capacity
(FRC)
• Reduce the fraction of inspired oxygen (FiO2) being provided to the
patient.
• Often it is set at 5 cmH2O, a level thought to be equivalent to
physiologic PEEP.
Peak Flow/ Flow Rate

• The speed of delivering air per unit of time

• Peak flow rates of 60 L per minute is standard
• Higher flow rates (80-100 L/min) shortens inspiratory time and
increases expiratory time ( ie, decreases I:E ratio)
• Deliver TV quickly
• Reduce likelihood of auto-PEEP
• High flow rate generally preferred in obstructive lung disease and
acute respiratory acidosis.
Inspiratory to expiratory (I:E) ratio
• The normal I:E ratio is 1:2 or 1:3
• Can be reduced to 1:4 or 1:5 in the presence of obstructive airway
disease, which requires greater time for expiration.
• Inverse I:E ratio may be necessary in states of low compliance, such as
ARDS.
• Inverse ratio ventilation may improve oxygenation in ARDS without
elevating peak alveolar and inspiratory plateau pressures.
The ‘square wave’ flow pattern

The inspiratory flow rate

remains constant over Inspiratory
the entire inspiration. arm

flow
The expiratory flow is
determined by the
elastic recoil of the
time
respiratory system and
resistance of intubated
airways

Expiratory
Inspiratory time = Tidal volume arm
Flow rate
The ‘decelerating ramp’ flow pattern

The inspiratory flow rate

decelerates as a function
Inspiratory
of time to reach zero flow
arm
at end inspiration

flow
For a given tidal volume,
the inspiratory time is
longer in this type of flow
pattern as compared to time
the square wave pattern

Expiratory
Inspiratory time = Tidal volume arm
Flow rate
Trouble Shooting /ventilator alarm
• The new doctor often panics when ‘things go wrong’ in a
mechanically ventilated patient.
• Generally, a calm logical and systematic approach solves most
problems.
• Basic rules:
1 .Airway
2 .Breathing
3 .Circulation And, as for every emergency,
4 .Get help early if unsure. Don’t be proud.
Trouble Shooting /ventilator alarm
• Causes:
• Anxiety
• Pain
• Inadequate ventilator settings
• ETT malfunction
• Pulmonary parenchymal process
• Tension pneumothorax
• Severe auto-PEEP
Problem with airflow
Decreased lung compliance
Auto PEEP

• Incomplete expiration prior to the initiation of the next breath causes

progressive air trapping.
• Accumulation of air increases alveolar pressure at the end of expiration,
which is referred to as auto-PEEP.
• Causes — There are three common situations during which
auto-PEEP develops:
High minute ventilation,
Expiratory flow limitation eg-COPD
Prolonged inspiratory time
Detecting Auto-PEEP

Recognize
Auto-PEEP
when

Expiratory flow continues

and fails to return to
the baseline prior to the new
inspiratory cycle
Patient ventilator-asynchrony
Patient-Ventilator Asynchrony occurs when the timing of the ventilator cycle is
not simultaneous with the timing of the patient’s respiratory cycle.
Ineffective triggering of a ventilator - commonest cause
Breath stacking- patient triggers a new breath before the completion of the prior
ventilator-delivered breath
It is common during low tidal volume ventilation
Double triggering ventilator
ventilator delivers two breaths in rapid sequence
Ineffective triggering

Notice the two changes in pressure (negative deflections) and

flow (positive deflections). They represent inspiratory efforts
which fail to trigger the ventilator. A too high trigger level or
the presence of intrinsic PEEP can cause ineffective
triggering.
Airway or tube secretions

Flow volume loop

Normal flow-volume showing a ‘saw tooth’
loop pattern typical of
retained secretions
Patient ventilator-asynchrony
Management
•Double trigger----reduce sensitivity
•ETT blockage----suction
•Ineffective triggering----increasing sensitivity
•Auto PEEP-----↓VE, ↓ I-time, ↑E-time,
•Hypoxia post-intubation----↑PEEP, FIO2,check ETT patency
GENERAL SUPPORT DURING VENTILATION

• Sedation and analgesia to maintain an acceptable level of comfort.

• Prevention of venous thrombosis and decubitus ulcers.
• Prophylaxis against diffuse gastrointestinal mucosal injury.
• Nutritional support.
GENERAL SUPPORT DURING VENTILATION

• Airway toilet
• Eye care
• Mouth care
 COMPLICATIONS OF MECHANICAL VENTILATION

• Endotracheal intubation and MV have direct and indirect effects on

the lung and upper airways, the cardiovascular and the
gastrointestinal system.
COMPLICATIONS OF MECHANICAL VENTILATION
COMPLICATIONS OF MECHANICAL VENTILATION
Barotrauma
• Barotrauma is physical damage to body tissues caused by a difference
in pressure between a gas space inside the body and its surrounding
external environment.
Barotrauma
Alveolar rupture — Processes that underlie alveolar rupture are ventilator-
related and/or disease-related.
• Ventilator-related:
• General agreement is that in most cases, PIP
Positive pressure ventilation
greater than 50 cm H O, Pplat greater than 35 cm
2

Elevated pressures H O,MAP greater than 30 cm H O, and PEEP

2 2

• Disease-related  greater than 10 cm H O may induce the

2

• Asthma,COPD, chronic interstitial development

lung disease, of
andbarotrauma. !!!!!!!!!!!!!!!
ARDS have all been identified
as independent risk factors for barotrauma
Direct injury
Ventilator-induced lung injury
• VILI/VALI–is an acute lung injury affecting the airways and
parenchyma that is caused by or exacerbated by mechanical
ventilation.
• Alveolar overdistension, atelectrauma, and biotrauma are the
principal mechanisms.
Ventilator-induced lung injury
• Alveolar injury results in high alveolar permeability, interstitial and
alveolar edema, alveolar hemorrhage, hyaline membranes, loss of
functional surfactant, and alveolar collapse (ie, findings similar to
those observed in ARDS).
Lung protective Ventilation Protocol
WEANING FROM MECHANICAL VENTILATION

• Discontinuing mechanical ventilation is a two step process that

consists of:
1. Readiness Testing and
2. Weaning
CLINICAL CRITERIA
CHOOSING A WEANING METHOD

1. Spontaneous breathing trials (SBTs)

2. Progressive decreases in the level support during (PSV), and (SIMV)

3. Early extubation with immediate use of NPPV

Duration of a weaning trial
• The optimal duration of an SBT is unknown but typically ranges from
30 minutes to two hours.
• For patients who fail their initial SBT and ventilated for more
prolonged periods , longer trials of up to two hours may be
warranted.
WEANING FROM MECHANICAL VENTILATION
Signs of Weaning Failure

Diaphoresis
Dyspnea & Labored respiratory pattern
Increased anxiety ,Restlessness, Decrease in level of consciousness
Dysrhythmia ,Increase or decrease in PR of > 20 beats /min or PR >
140b/m ,Sustained PR>20% higher or lower than baseline.
Increase or decrease in BP of > 20 mm Hg SBP>180 or <90 mm Hg
Increase in RR of > 10 above baseline , Sustained RR greater than 35
breaths/minute
TV ≤5 mL/kg, Sustained VE <200 mL/kg/minute
Extubation

• Extubation refers to removal of the endotracheal tube

(ETT).
• It is the final step in liberating a patient from
mechanical ventilation.
PRIOR TO EXTUBATION

• Extubation should not be ordered until it has been determined that

the patient is able to protect the airway and the airway is patent.
Airway protection
• Cough strength
• Level of consciousness
• Amount of secretions
PRIOR TO EXTUBATION

Airway patency
• Testing for a cuff leak prior to extubation is the most common method
used to determine whether airway patency may be decreased.
• Neither sensitive nor specific.
PRIOR TO EXTUBATION

• Risk factors — Risk factors for postextubation laryngeal edema

include:
Prolonged intubation (variably defined as ≥36 hours to ≥6 days)
Age greater than 80 years
A large endotracheal tube (>8 mm in men, >7 mm in women)
A ratio of ETT to laryngeal diameter greater than 45 percent
A small ratio of patient height to ETT diameter
An elevated Acute Physiology and Chronic Health Evaluation
(APACHE) II score
A GCS score <8, traumatic intubation.
PRIOR TO EXTUBATION

Female gender
A history of asthma
Excessive tube mobility due to insufficient fixation
Insufficient or lack of sedation
Aspiration
The presence of an orogastric or nasogastric tube  
EXTUBATION PROCEDURE

•  The patient is placed into an upright position and both the oral cavity and the
endotracheal tube (ETT) are suctioned.
• Instructions are given for the patient to take a deep breath and then exhale.
• During exhalation, the cuff is deflated and the ETT is removed in a single, smooth
motion. Orogastric tubes are typically removed simultaneously.
• Following extubation, the oral cavity is again suctioned and supplemental oxygen
is administered by facemask.
• The oxyhemoglobin saturation, heart rate, respiratory rate, and blood pressure
are monitored throughout the extubation process.
• Patients with increased secretions may require more frequent or nasotracheal
suctioning.
POSTEXTUBATION MANAGEMENT

• All patients should be closely monitored following extubation.

• In many patients, early aggressive management with oxygenation and
airway clearance can prevent reintubation.
• This may include suctioning, bronchodilator therapy, diuresis, or
noninvasive ventilation (NIV).
 Prolonged MV and Tracheostomy
• From 5 to 13% of patients undergoing MV will go on to require
prolonged MV (>21 days).
• A tracheostomy is thought to be more comfortable, to require less
sedation, and to provide a more secure airway and may also reduce
weaning time.
Take home messages
MV is a special device used to assist or replace spontaneous
breathing.
Common modes of MV:CMV,AC,SIMV,PSV and CPAP
The primary objectives of MV are to decrease the work of breathing,
thus avoiding respiratory muscle fatigue, and to reverse life-
threatening hypoxemia and progressive respiratory acidosis.
Use calm, logical and systematic approach to solve ventilator
troubles.
Always anticipate complications of mechanical ventilation.
Try to liberate the patient from MV as early as possible!!!!
 References
1. Harrison’s principle of internal medicine, 20th edition.
2. Uptodate 2018
3. Medscape
4. Basic respiratory mechanics relevant for mechanical ventilation-Peter C. Rimensberger.
5. Handbook of Mechanical Ventilation-intensive care foundation.
6. ATS Ventilator Waveforms: Basic Interpretation and Analysis-Steven Holets, RRT CCRA
7. CHEST/ATS recommendations 2017
8. Asynchrony During Mechanical Ventilation Karen J. Bosma, MD, FRCPC
9. ARDSnet: NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary
10. Manual of “our ICU MV machine“
Thank you!