Understanding Mechanical Ventilation in Critical Care Environments

 
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Mechanical Ventilation is ventilation
of the lungs by artificial means
usually by a ventilator.
 
A ventilator delivers gas to the lungs
with either negative or positive
pressure.
 
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Basic terminologies – Respiratory cycle (Ti/Te/PIP/PEEP/Vt)
 
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Negative-pressure ventilators
 
Positive-pressure ventilators.
 
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Positive-pressure ventilators deliver
gas to the patient under positive-
pressure, during the inspiratory
phase.
 
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1- 
1- 
Volume Ventilators.
Volume Ventilators.
 
2-
2-
 Pressure Ventilators
 Pressure Ventilators
 
3-
3-
 High-Frequency Ventilators
 High-Frequency Ventilators
The volume ventilator is 
The volume ventilator is 
commonly used
commonly used
 in
 in
critical care settings.
critical care settings.
 
The basic principle of this ventilator is that
The basic principle of this ventilator is that
a designated volume of air is delivered
a designated volume of air is delivered
with each breath.
with each breath.
 
The amount of 
The amount of 
pressure
pressure
 required to deliver
 required to deliver
the set volume 
the set volume 
depends on :-
depends on :-
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1-
1-
 Volume Ventilators
 Volume Ventilators
Therefore, 
Therefore, 
peak inspiratory pressure
peak inspiratory pressure
(PIP )
(PIP )
 must be monitored
 must be monitored
 in volume
 in volume
modes because it varies from breath
modes because it varies from breath
to breath.
to breath.
 
With this mode of ventilation, a
With this mode of ventilation, a
respiratory rate, inspiratory time,
respiratory rate, inspiratory time,
and tidal volume are selected for the
and tidal volume are selected for the
mechanical breaths.
mechanical breaths.
The use of pressure ventilators 
The use of pressure ventilators 
is
is
increasing 
increasing 
in critical care units.
in critical care units.
 
A typical pressure mode 
A typical pressure mode 
delivers a
delivers a
selected gas pressure to the patient early
selected gas pressure to the patient early
in inspiration, and sustains the pressure
in inspiration, and sustains the pressure
throughout the inspiratory phase.
throughout the inspiratory phase.
 
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2-
2-
 Pressure Ventilators
 Pressure Ventilators
Although 
Although 
pressure is consistent
pressure is consistent
 with these
 with these
modes, volume is not.
modes, volume is not.
 
Volume will change with changes in
Volume will change with changes in
resistance or compliance,
resistance or compliance,
 
Therefore, 
Therefore, 
exhaled tidal volume is the
exhaled tidal volume is the
variable to monitor closely.
variable to monitor closely.
 
With pressure modes, 
With pressure modes, 
the pressure level to
the pressure level to
be delivered is selected, and with some
be delivered is selected, and with some
mode options
mode options
 (i.e., pressure controlled
 (i.e., pressure controlled
[PC], described later), 
[PC], described later), 
rate and inspiratory
rate and inspiratory
time are preset as well.
time are preset as well.
 
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High-frequency ventilators 
High-frequency ventilators 
use small
use small
tidal volumes (1 to 3 mL/kg) at
tidal volumes (1 to 3 mL/kg) at
frequencies greater than 100
frequencies greater than 100
breaths/minute.
breaths/minute.
 
The high-frequency ventilator
The high-frequency ventilator
accomplishes oxygenation by the
accomplishes oxygenation by the
diffusion of oxygen and carbon
diffusion of oxygen and carbon
dioxide from high to low gradients of
dioxide from high to low gradients of
concentration.
concentration.
 
This diffusion movement is increased
This diffusion movement is increased
if the kinetic energy of the gas
if the kinetic energy of the gas
molecules is increased.
molecules is increased.
 
A high-frequency ventilator would be
A high-frequency ventilator would be
used 
used 
to achieve lower peak ventilator
to achieve lower peak ventilator
pressures, thereby lowering the risk
pressures, thereby lowering the risk
of barotrauma
of barotrauma
.
.
 
Inspiratory
hold
Expiratory
hold
100% FiO2
Accept Mode
Alarms reset
Preset
variables
and
alarms
outcom
es
Mode
 
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The way the machine ventilates the
patient
 
How much the patient will
participate in his own ventilatory
pattern.
 
Each mode is different in determining
how much work of breathing the
patient has to do.
 
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A- 
A- 
Volume Modes
Volume Modes
 
B- 
B- 
Pressure Modes
Pressure Modes
 
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1- 
1- 
Assist-control 
Assist-control 
(A/C)
(A/C)
 
2- 
2- 
Synchronized intermittent
Synchronized intermittent
     mandatory ventilation 
     mandatory ventilation 
(SIMV)
(SIMV)
 
1- Assist Control Mode A/C
1- Assist Control Mode A/C
The ventilator provides the patient with a
The ventilator provides the patient with a
pre-set tidal volume at a pre-set rate .
pre-set tidal volume at a pre-set rate .
 
The patient may 
The patient may 
initiate a breath on his
initiate a breath on his
own
own
, but the 
, but the 
ventilator assists by delivering
ventilator assists by delivering
a specified tidal volume to the patient.
a specified tidal volume to the patient.
Patient can initiate breaths that are
Patient can initiate breaths that are
delivered at the preset tidal volume.
delivered at the preset tidal volume.
 
 
 
 
Client can breathe at a higher rate than the
Client can breathe at a higher rate than the
preset number of  breaths/minute
preset number of  breaths/minute
 
Modes of ventilation- AC
The 
The 
total respiratory rate
total respiratory rate
 is determined by
 is determined by
the number of spontaneous inspiration
the number of spontaneous inspiration
initiated by the patient
initiated by the patient
 plus 
 plus 
the number of
the number of
breaths set on the ventilator.
breaths set on the ventilator.
 
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If the patient wishes to breathe faster, he
If the patient wishes to breathe faster, he
or she can 
or she can 
trigger the ventilator and
trigger the ventilator and
receive a full-volume breath.
receive a full-volume breath.
Often used as initial mode of
Often used as initial mode of
ventilation
ventilation
 
When the patient is too weak to
When the patient is too weak to
perform the work of breathing (e.g.,
perform the work of breathing (e.g.,
when emerging from anesthesia).
when emerging from anesthesia).
 
Disadvantages:
Disadvantages:
 
Hyperventilation,
Hyperventilation,
 
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The ventilator provides the patient with a pre-set
The ventilator provides the patient with a pre-set
number of breaths/minute at a specified tidal
number of breaths/minute at a specified tidal
volume and FiO
volume and FiO
2
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.
 
In between the ventilator-delivered breaths
In between the ventilator-delivered breaths
, the
, the
patient is able to 
patient is able to 
breathe spontaneously at his
breathe spontaneously at his
own tidal volume and rate
own tidal volume and rate
 with no assistance
 with no assistance
from the ventilator.
from the ventilator.
 
However, unlike the A/C mode, 
However, unlike the A/C mode, 
any breaths taken
any breaths taken
above the set rate are spontaneous breaths taken
above the set rate are spontaneous breaths taken
through the ventilator circuit.
through the ventilator circuit.
 
Synchronized Intermittent Mandatory Ventilation (SIMV)
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Adding pressure support
Adding pressure support
 during
 during
spontaneous breaths can 
spontaneous breaths can 
minimize the risk
minimize the risk
of increased work of breathing.
of increased work of breathing.
 
Ventilators breaths are 
Ventilators breaths are 
synchronized
synchronized
 with
 with
the patient spontaneous breathe.
the patient spontaneous breathe.
   ( no fighting)
   ( no fighting)
 
 
SIMV + PS Ventilation
 
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1-
1-
 Pressure-controlled ventilation 
 Pressure-controlled ventilation 
(PCV)
(PCV)
2-
2-
 Pressure-support ventilation 
 Pressure-support ventilation 
(PSV)
(PSV)
 
3-
3-
 Continuous positive airway pressure
 Continuous positive airway pressure
                                                             
                                                             
(CPAP)
(CPAP)
 
4- 
4- 
Positive end expiratory pressure 
Positive end expiratory pressure 
(PEEP)
(PEEP)
 
5-
5-
 Noninvasive bilevel positive airway
 Noninvasive bilevel positive airway
pressure ventilation 
pressure ventilation 
(BiPAP)
(BiPAP)
 
Inverse ratio ventilation (IRV) mode
Inverse ratio ventilation (IRV) mode
reverses this ratio so that 
reverses this ratio so that 
inspiratory time
inspiratory time
is equal to, or longer than, expiratory time
is equal to, or longer than, expiratory time
(1:1 to 4:1).
(1:1 to 4:1).
 
Inverse I:E ratios are used in conjunction
Inverse I:E ratios are used in conjunction
with pressure control 
with pressure control 
to improve
to improve
oxygenation
oxygenation
 by expanding stiff alveoli by
 by expanding stiff alveoli by
using longer distending times, thereby
using longer distending times, thereby
providing more opportunity for gas
providing more opportunity for gas
exchange and preventing alveolar
exchange and preventing alveolar
collapse.
collapse.
 
Constant positive airway pressure
Constant positive airway pressure
 during
 during
spontaneous breathing
spontaneous breathing
 
CPAP allows the nurse to observe the
CPAP allows the nurse to observe the
ability of the patient to breathe
ability of the patient to breathe
spontaneously while still on the ventilator.
spontaneously while still on the ventilator.
 
CPAP can be used 
CPAP can be used 
for intubated and
for intubated and
nonintubated patients.
nonintubated patients.
 
It may be used as 
It may be used as 
a weaning mode
a weaning mode
 and for
 and for
self breathing patients
self breathing patients
 (nasal or mask
 (nasal or mask
CPAP)
CPAP)
 
 
 
 
4
4
-
-
 
 
C
C
o
o
n
n
t
t
i
i
n
n
u
u
o
o
u
u
s
s
 
 
P
P
o
o
s
s
i
i
t
t
i
i
v
v
e
e
 
 
A
A
i
i
r
r
w
w
a
a
y
y
 
 
 
 
 
 
 
 
 
 
P
P
r
r
e
e
s
s
s
s
u
u
r
r
e
e
 
 
(
(
C
C
P
P
A
A
P
P
)
)
 
5
5
-
-
 
 
P
P
o
o
s
s
i
i
t
t
i
i
v
v
e
e
 
 
e
e
n
n
d
d
 
 
e
e
x
x
p
p
i
i
r
r
a
a
t
t
o
o
r
r
y
y
 
 
 
 
 
 
 
 
 
 
p
p
r
r
e
e
s
s
s
s
u
u
r
r
e
e
 
 
(
(
P
P
E
E
E
E
P
P
)
)
Positive pressure applied at the end
of expiration during mandatory \
ventilator breath
 
positive end-expiratory pressure with
positive-pressure (machine) breaths.
 
U
U
s
s
e
e
s
s
 
 
o
o
f
f
 
 
C
C
P
P
A
A
P
P
 
 
&
&
 
 
P
P
E
E
E
E
P
P
Prevent atelactasis or collapse of alveoli
 
Treat atelactasis or collapse of alveoli
Improve gas exchange & oxygenation
Treat hypoxemia refractory to oxygen
therapy.(prevent oxygen toxicity
 
Treat pulmonary edema ( pressure help
expulsion of fluids from alveoli
 
C
C
o
o
m
m
m
m
o
o
n
n
 
 
V
V
e
e
n
n
t
t
i
i
l
l
a
a
t
t
o
o
r
r
 
 
S
S
e
e
t
t
t
t
i
i
n
n
g
g
s
s
p
p
a
a
r
r
a
a
m
m
e
e
t
t
e
e
r
r
s
s
/
/
 
 
c
c
o
o
n
n
t
t
r
r
o
o
l
l
s
s
Fraction of inspired oxygen (FIO
Fraction of inspired oxygen (FIO
2
)
)
Tidal Volume (VT)
Tidal Volume (VT)
Peak Flow/ Flow Rate
Peak Flow/ Flow Rate
Respiratory Rate/ Breath Rate /
Respiratory Rate/ Breath Rate /
Frequency ( F)
Frequency ( F)
Minute Volume  (VE)
Minute Volume  (VE)
I:E  Ratio  (Inspiration to Expiration
I:E  Ratio  (Inspiration to Expiration
Ratio)
Ratio)
Sigh
Sigh
 
 
 
F
F
r
r
a
a
c
c
t
t
i
i
o
o
n
n
 
 
o
o
f
f
 
 
i
i
n
n
s
s
p
p
i
i
r
r
e
e
d
d
 
 
o
o
x
x
y
y
g
g
e
e
n
n
(
(
F
F
I
I
O
O
2
)
)
The percent of oxygen concentration that
the patient is receiving from the
ventilator.  
(Between 21% & 100%)
   (room air has 21% oxygen  content).
 
 
Initially a patient is placed on a high level
of FIO
2 
(60% or higher).
Subsequent changes in FIO
2
 are based on
ABGs and the SaO
2
.
In adult patients
 the initial FiO
2
 may be set at
100% until arterial blood gases can document
adequate oxygenation.
 
An FiO
2 
of 100% for an extended period of time
can be dangerous 
( oxygen toxicity)
 but it can
protect against hypoxemia
 
For infants
, and especially 
in premature infants
,
high levels of FiO
2
 (>60%) should be  avoided.
 
Usually the FIO
2
 is adjusted to maintain an SaO
2
of greater than 90% (roughly equivalent to a
PaO
2
 >60 mm Hg).
 
Oxygen toxicity
 is a concern when 
an FIO
2
 of
greater than 60% is required
 for more than 25
hours
 
 
 
T
T
i
i
d
d
a
a
l
l
 
 
V
V
o
o
l
l
u
u
m
m
e
e
 
 
(
(
V
V
T
T
)
)
The volume of air delivered to a patient
The volume of air delivered to a patient
during a ventilator breath.
during a ventilator breath.
 
The amount of air inspired and expired
The amount of air inspired and expired
with each breath.
with each breath.
 
Usual volume selected is between 
Usual volume selected is between 
5 to 15
5 to 15
ml/ kg body weight)
ml/ kg body weight)
 
 
 
 
P
P
e
e
a
a
k
k
 
 
F
F
l
l
o
o
w
w
/
/
 
 
F
F
l
l
o
o
w
w
 
 
R
R
a
a
t
t
e
e
The speed of delivering air per unit of
time, and is expressed in liters per
minute.
 
The higher the flow rate, the faster
peak airway pressure is reached and
the shorter the inspiration;
The lower the flow rate, the longer
the inspiration.
 
 
 
 
R
R
e
e
s
s
p
p
i
i
r
r
a
a
t
t
o
o
r
r
y
y
 
 
R
R
a
a
t
t
e
e
/
/
 
 
B
B
r
r
e
e
a
a
t
t
h
h
 
 
 
 
 
 
R
R
a
a
t
t
e
e
 
 
/
/
 
 
F
F
r
r
e
e
q
q
u
u
e
e
n
n
c
c
y
y
 
 
(
(
 
 
F
F
)
)
The number of breaths the ventilator will
The number of breaths the ventilator will
deliver/minute 
deliver/minute 
(10-16 b/m).
(10-16 b/m).
 
Total respiratory rate equals 
Total respiratory rate equals 
patient rate
patient rate
plus ventilator rate.
plus ventilator rate.
 
T
T
h
h
e
e
 
 
n
n
u
u
r
r
s
s
e
e
 
 
d
d
o
o
u
u
b
b
l
l
e
e
-
-
c
c
h
h
e
e
c
c
k
k
s
s
 
 
t
t
h
h
e
e
 
 
f
f
u
u
n
n
c
c
t
t
i
i
o
o
n
n
i
i
n
n
g
g
o
o
f
f
 
 
t
t
h
h
e
e
 
 
v
v
e
e
n
n
t
t
i
i
l
l
a
a
t
t
o
o
r
r
 
 
b
b
y
y
 
 
o
o
b
b
s
s
e
e
r
r
v
v
i
i
n
n
g
g
 
 
t
t
h
h
e
e
p
p
a
a
t
t
i
i
e
e
n
n
t
t
s
s
 
 
r
r
e
e
s
s
p
p
i
i
r
r
a
a
t
t
o
o
r
r
y
y
 
 
r
r
a
a
t
t
e
e
.
.
For adult patients and older children:-
For adult patients and older children:-
With COPD
With COPD
 
A reduced tidal volume
A reduced tidal volume
A reduced respiratory rate
A reduced respiratory rate
 
For infants and younger children:-
For infants and younger children:-
 
A small tidal volume
A small tidal volume
Higher respiratory rate
Higher respiratory rate
 
 
 
 
 
M
M
i
i
n
n
u
u
t
t
e
e
 
 
V
V
o
o
l
l
u
u
m
m
e
e
 
 
 
 
(
(
V
V
E
E
)
)
The volume of expired air in one
minute .
 
Respiratory rate times tidal volume
equals minute ventilation
                                          VE  =  (VT x F)
In special cases, hypoventilation or
hyperventilation is desired
 
 
 
I
I
:
:
E
E
 
 
 
 
R
R
a
a
t
t
i
i
o
o
 
 
 
 
(
(
I
I
n
n
s
s
p
p
i
i
r
r
a
a
t
t
i
i
o
o
n
n
 
 
t
t
o
o
 
 
 
 
 
 
E
E
x
x
p
p
i
i
r
r
a
a
t
t
i
i
o
o
n
n
 
 
R
R
a
a
t
t
i
i
o
o
)
)
:
:
-
-
The ratio of inspiratory time to
expiratory time during a breath
                                         (Usually = 1:2)
 
 
 
S
S
e
e
n
n
s
s
i
i
t
t
i
i
v
v
i
i
t
t
y
y
(
(
t
t
r
r
i
i
g
g
g
g
e
e
r
r
 
 
S
S
e
e
n
n
s
s
i
i
t
t
i
i
v
v
i
i
t
t
y
y
)
)
The sensitivity function controls the
The sensitivity function controls the
amount of patient effort needed to initiate
amount of patient effort needed to initiate
an inspiration
an inspiration
 
Increasing the sensitivity
Increasing the sensitivity
 (requiring less
 (requiring less
negative force) 
negative force) 
decreases the amount of
decreases the amount of
work
work
 the patient must do to initiate a
 the patient must do to initiate a
ventilator breath.
ventilator breath.
 
Decreasing the sensitivity increases the
Decreasing the sensitivity increases the
amount of negative pressure
amount of negative pressure
 that the
 that the
patient needs to initiate inspiration and
patient needs to initiate inspiration and
increases the work of breathing.
increases the work of breathing.
 
E
E
n
n
s
s
u
u
r
r
i
i
n
n
g
g
 
 
h
h
u
u
m
m
i
i
d
d
i
i
f
f
i
i
c
c
a
a
t
t
i
i
o
o
n
n
 
 
a
a
n
n
d
d
t
t
h
h
e
e
r
r
m
m
o
o
r
r
e
e
g
g
u
u
l
l
a
a
t
t
i
i
o
o
n
n
All air delivered by the ventilator passes through
All air delivered by the ventilator passes through
the water in the humidifier, where it is warmed
the water in the humidifier, where it is warmed
and saturated.
and saturated.
 
H
H
u
u
m
m
i
i
d
d
i
i
f
f
i
i
e
e
r
r
 
 
t
t
e
e
m
m
p
p
e
e
r
r
a
a
t
t
u
u
r
r
e
e
s
s
 
 
s
s
h
h
o
o
u
u
l
l
d
d
 
 
b
b
e
e
 
 
k
k
e
e
p
p
t
t
 
 
c
c
l
l
o
o
s
s
e
e
 
 
t
t
o
o
b
b
o
o
d
d
y
y
 
 
t
t
e
e
m
m
p
p
e
e
r
r
a
a
t
t
u
u
r
r
e
e
 
 
3
3
5
5
 
 
º
º
C
C
-
-
 
 
3
3
7
7
º
º
C
C
.
.
 
In some rare instances (severe hypothermia), the
In some rare instances (severe hypothermia), the
air temperatures can be increased.
air temperatures can be increased.
 
The humidifier should be 
The humidifier should be 
checked for adequate
checked for adequate
water levels
water levels
 
Complications
Complications
of Mechanical Ventilation:-
of Mechanical Ventilation:-
I- 
I- 
Airway Complications,
Airway Complications,
II-
II-
 Mechanical complications,
 Mechanical complications,
 
III-
III-
 Physiological Complications,
 Physiological Complications,
 
IV-
IV-
 Artificial Airway Complications.
 Artificial Airway Complications.
 
N
u
r
s
i
n
g
 
c
a
r
e
 
o
f
 
p
a
t
i
e
n
t
s
 
o
n
m
e
c
h
a
n
i
c
a
l
 
v
e
n
t
i
l
a
t
i
o
n
Assessment:
Assessment:
 
1-
1-
 Assess the patient
 Assess the patient
 
2-
2-
 Assess the artificial airway (tracheostomy
 Assess the artificial airway (tracheostomy
    or endotracheal tube)
    or endotracheal tube)
 
3-
3-
 Assess the ventilator
 Assess the ventilator
 
N
N
u
u
r
r
s
s
i
i
n
n
g
g
 
 
I
I
n
n
t
t
e
e
r
r
v
v
e
e
n
n
t
t
i
i
o
o
n
n
s
s
1-
1-
Maintain airway patency &
Maintain airway patency &
oxygenation
oxygenation
2-
2-
 Promote comfort
 Promote comfort
3-
3-
 Maintain fluid & electrolytes balance
 Maintain fluid & electrolytes balance
4- 
4- 
Maintain nutritional state
Maintain nutritional state
5- 
5- 
Maintain urinary & bowel
Maintain urinary & bowel
elimination
elimination
6-
6-
 Maintain eye , mouth and
 Maintain eye , mouth and
cleanliness and integrity:-
cleanliness and integrity:-
7-
7-
 Maintain mobility/ musculoskeletal
 Maintain mobility/ musculoskeletal
function:-
function:-
 
N
N
u
u
r
r
s
s
i
i
n
n
g
g
 
 
I
I
n
n
t
t
e
e
r
r
v
v
e
e
n
n
t
t
i
i
o
o
n
n
s
s
8-
8-
 Maintain safety:-
 Maintain safety:-
9- 
9- 
Provide psychological support
Provide psychological support
10-
10-
 Facilitate communication
 Facilitate communication
11- 
11- 
Provide psychological support &
Provide psychological support &
information to family
information to family
12- 
12- 
Responding to ventilator alarms
Responding to ventilator alarms
/Troublshooting
/Troublshooting
       ventilator alarms
       ventilator alarms
13- 
13- 
Prevent nosocomial infection
Prevent nosocomial infection
14- 
14- 
Documentation
Documentation
 
 
 
 
 
 
 
 
 
 
 
N
N
o
o
n
n
i
i
n
n
v
v
a
a
s
s
i
i
v
v
e
e
 
 
B
B
i
i
l
l
a
a
t
t
e
e
r
r
a
a
l
l
 
 
P
P
o
o
s
s
i
i
t
t
i
i
v
v
e
e
 
 
 
 
 
 
 
 
 
 
A
A
i
i
r
r
w
w
a
a
y
y
 
 
P
P
r
r
e
e
s
s
s
s
u
u
r
r
e
e
 
 
V
V
e
e
n
n
t
t
i
i
l
l
a
a
t
t
i
i
o
o
n
n
 
 
(
(
B
B
i
i
P
P
A
A
P
P
)
)
BiPAP is a noninvasive form of mechanical
BiPAP is a noninvasive form of mechanical
ventilation 
ventilation 
provided by means of a nasal
provided by means of a nasal
mask or nasal prongs, or a full-face mask.
mask or nasal prongs, or a full-face mask.
 
The system allows the clinician to select
The system allows the clinician to select
two levels of positive-pressure support
two levels of positive-pressure support
:
:
 
An inspiratory pressure support level
An inspiratory pressure support level
(referred to as IPAP)
(referred to as IPAP)
 
An expiratory pressure called EPAP
An expiratory pressure called EPAP
(PEEP/CPAP level).
(PEEP/CPAP level).
 
 
C
r
i
t
e
r
i
a
 
f
o
r
 
U
s
i
n
g
 
o
f
 
C
P
A
P
 
o
r
B
i
P
A
P
:
 
P
a
t
i
e
n
t
s
 
w
h
o
 
a
r
e
 
c
a
n
d
i
d
a
t
e
s
 
f
o
r
 
C
P
A
P
 
o
r
B
i
P
A
P
 
s
h
o
u
l
d
 
m
e
e
t
 
t
h
e
 
f
o
l
l
o
w
i
n
g
 
g
e
n
e
r
a
l
c
r
i
t
e
r
i
a
:
A
w
a
k
e
A
b
l
e
 
t
o
 
f
o
l
l
o
w
 
b
a
s
i
c
 
c
o
m
m
a
n
d
s
P
r
o
t
e
c
t
 
t
h
e
i
r
 
a
i
r
w
a
y
N
o
t
 
a
c
t
i
v
e
l
y
 
v
o
m
i
t
i
n
g
N
o
t
 
h
a
v
i
n
g
 
s
e
i
z
u
r
e
s
 
I
n
i
t
i
a
l
 
B
i
P
A
P
 
S
e
t
t
i
n
g
s
:
 
C
o
m
m
o
n
 
i
n
i
t
i
a
l
 
i
n
s
p
i
r
a
t
o
r
y
 
p
o
s
i
t
i
v
e
 
a
i
r
w
a
y
 
p
r
e
s
s
u
r
e
 
(
I
P
A
P
)
 
i
s
1
0
 
c
m
 
H
2
0
 
(
l
a
r
g
e
r
 
p
a
t
i
e
n
t
s
 
m
a
y
 
n
e
e
d
 
1
5
 
c
m
 
H
2
0
)
E
x
p
i
r
a
t
o
r
y
 
p
o
s
i
t
i
v
e
 
a
i
r
w
a
y
 
p
r
e
s
s
u
r
e
 
(
E
P
A
P
)
 
i
s
 
5
 
c
m
 
H
2
0
A
d
j
u
s
t
 
f
r
o
m
 
t
h
e
r
e
 
u
s
u
a
l
l
y
 
b
y
 
2
-
5
 
c
m
 
H
2
0
R
a
t
e
 
o
f
 
1
0
-
1
2
 
b
r
e
a
t
h
s
 
p
e
r
 
m
i
n
u
t
e
 
(
c
a
n
 
i
n
c
r
e
a
s
e
 
r
a
t
e
 
i
f
 
n
e
e
d
i
n
g
t
o
 
g
e
t
 
r
i
d
 
o
f
 
m
o
r
e
 
C
O
2
)
F
i
O
2
 
i
n
i
t
i
a
l
l
y
 
i
s
 
s
e
t
 
a
t
 
1
0
0
%
 
a
n
d
 
t
h
e
n
 
t
i
t
r
a
t
e
d
 
d
o
w
n
 
o
n
c
e
s
t
a
b
i
l
i
z
e
d
 
H
i
g
h
 
a
i
r
w
a
y
 
p
r
e
s
s
u
r
e
 
-
 
i
n
 
a
d
d
i
t
i
o
n
 
t
o
 
p
r
o
v
i
d
i
n
g
 
a
l
a
r
m
 
b
r
e
a
t
h
 
s
h
o
u
l
d
 
b
e
p
r
e
s
s
u
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Mechanical ventilation, overseen by Dr. Manish Sharma, Pediatric Intensivist at JK Lon Hospital, Jaipur, is essential for treating respiratory failure. It involves using ventilators to deliver gas to the lungs and meet specific goals like correcting hypoxemia and hypercapnia. This process requires understanding basic terminologies, criteria for ventilatory support, types of ventilators, and indications for ventilation.


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  1. MECHNICAL VENTILATION DR MANISH SHARMA Additional Superintendent JK Lon Hospital (PAEDIATRIC INTENSIVIST) In Charge Accident/Emergency, JK Lon Hospital, Jaipur SMS MEDICAL COLLEGE , JAIPUR

  2. Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator. A ventilator delivers gas to the lungs with either negative or positive pressure.

  3. Indications and Goals for Ventilation Type I or hypoxemic respiratory failure Type II or hypercapnic respiratory failure Goals : Correct hypoxemia PO260mmHg, O2Saturation 90% Correct hypercapnia PCO2~ 40mmHg Reduce work of breathing and hence cardiac workload Provide rest to respiratory muscles and reduce oxygen cost of breathing

  4. Basic terminologies Respiratory cycle (Ti/Te/PIP/PEEP/Vt)

  5. Criteria for institution of ventilatory support: Parameters Ventilation indicated Normal range A- Pulmonary function studies: Respiratory rate (breaths/min). Tidal volume (ml/kg body wt) Vital capacity (ml/kg body wt) Maximum Inspiratory Force (cm HO2) >10- 15 15-20,20-25 < 5 6-8 < 15 65-75 <-20 75-100

  6. Criteria for institution of ventilatory support: Parameters Ventilation indicated Normal range B- Arterial blood Gases PH PaO2 (mmHg) PaCO2 (mmHg) PaO2/FiO2 < 7.25 <60 >50 <100 7.35-7.45 75-100 35-45 >500

  7. Types of Mechanical ventilators: Negative-pressure ventilators Positive-pressure ventilators.

  8. Positive-pressure ventilators Positive-pressure ventilators deliver gas to the patient under positive- pressure, during the inspiratory phase.

  9. Types of Positive-Pressure Ventilators 1- Volume Ventilators. 2- Pressure Ventilators 3- High-Frequency Ventilators

  10. 1- Volume Ventilators The volume ventilator is commonly used in critical care settings. The basic principle of this ventilator is that a designated volume of air is delivered with each breath. The amount of pressure required to deliver the set volume depends on :- - Patient s lung compliance - Patient ventilator resistance factors.

  11. Therefore, peak inspiratory pressure (PIP ) must be monitored in volume modes because it varies from breath to breath. With this mode of ventilation, a respiratory rate, inspiratory time, and tidal volume are selected for the mechanical breaths.

  12. 2- Pressure Ventilators The use of pressure ventilators is increasing in critical care units. A typical pressure mode delivers a selected gas pressure to the patient early in inspiration, and sustains the pressure throughout the inspiratory phase. By meeting the patient s inspiratory flow demand throughout inspiration, patient effort is reduced and comfort increased.

  13. Although pressure is consistent with these modes, volume is not. Volume will change with changes in resistance or compliance, Therefore, exhaled tidal volume is the variable to monitor closely. With pressure modes, the pressure level to be delivered is selected, and with some mode options (i.e., pressure controlled [PC], described later), rate and inspiratory time are preset as well.

  14. 3- High-Frequency Ventilators High-frequency ventilators use small tidal volumes (1 to 3 mL/kg) at frequencies greater than 100 breaths/minute. The high-frequency ventilator accomplishes oxygenation by the diffusion of oxygen and carbon dioxide from high to low gradients of concentration.

  15. This diffusion movement is increased if the kinetic energy of the gas molecules is increased. A high-frequency ventilator would be used to achieve lower peak ventilator pressures, thereby lowering the risk of barotrauma.

  16. outcom es Alarms reset Mode Inspiratory hold Expiratory hold 100% FiO2 Accept Mode Preset variables and alarms

  17. Ventilator mode The way the machine ventilates the patient How much the patient will participate in his own ventilatory pattern. Each mode is different in determining how much work of breathing the patient has to do.

  18. Modes of Mechanical Ventilation A- Volume Modes B- Pressure Modes

  19. A- Volume Modes 1- Assist-control (A/C) 2- Synchronized intermittent mandatory ventilation (SIMV)

  20. 1- Assist Control Mode A/C The ventilator provides the patient with a pre-set tidal volume at a pre-set rate . The patient may initiate a breath on his own, but the ventilator assists by delivering a specified tidal volume to the patient. Patient can initiate breaths that are delivered at the preset tidal volume.

  21. Modes of ventilation- AC

  22. The total respiratory rate is determined by the number of spontaneous inspiration initiated by the patient plus the number of breaths set on the ventilator. In A/C mode, a mandatory (or control ) rate is selected. If the patient wishes to breathe faster, he or she can trigger the ventilator and receive a full-volume breath.

  23. Often used as initial mode of ventilation When the patient is too weak to perform the work of breathing (e.g., when emerging from anesthesia). Disadvantages: Hyperventilation,

  24. 2- Synchronized Intermittent Mandatory Ventilation (SIMV) The ventilator provides the patient with a pre-set number of breaths/minute at a specified tidal volume and FiO2. In between the ventilator-delivered breaths, the patient is able to breathe spontaneously at his own tidal volume and rate with no assistance from the ventilator. However, unlike the A/C mode, any breaths taken above the set rate are spontaneous breaths taken through the ventilator circuit.

  25. Synchronized Intermittent Mandatory Ventilation (SIMV)

  26. The tidal volume of these breaths can vary drastically from the tidal volume set on the ventilator, because the tidal volume is determined by the patient s spontaneous effort. Adding pressure support during spontaneous breaths can minimize the risk of increased work of breathing. Ventilators breaths are synchronized with the patient spontaneous breathe. ( no fighting)

  27. SIMV + PS Ventilation

  28. B- Pressure Modes 1- Pressure-controlled ventilation (PCV) 2- Pressure-support ventilation (PSV) 3- Continuous positive airway pressure (CPAP) 4- Positive end expiratory pressure (PEEP) 5- Noninvasive bilevel positive airway pressure ventilation (BiPAP)

  29. Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to, or longer than, expiratory time (1:1 to 4:1). Inverse I:E ratios are used in conjunction with pressure control to improve oxygenation by expanding stiff alveoli by using longer distending times, thereby providing more opportunity for gas exchange and preventing alveolar collapse.

  30. 4- Continuous Positive Airway Pressure (CPAP) Constant positive airway pressure during spontaneous breathing CPAP allows the nurse to observe the ability of the patient to breathe spontaneously while still on the ventilator. CPAP can be used for intubated and nonintubated patients. It may be used as a weaning mode and for self breathing patients (nasal or mask CPAP)

  31. 5- Positive end expiratory pressure (PEEP) Positive pressure applied at the end of expiration during mandatory \ ventilator breath positive end-expiratory pressure with positive-pressure (machine) breaths.

  32. Uses of CPAP & PEEP Prevent atelactasis or collapse of alveoli Treat atelactasis or collapse of alveoli Improve gas exchange & oxygenation Treat hypoxemia refractory to oxygen therapy.(prevent oxygen toxicity Treat pulmonary edema ( pressure help expulsion of fluids from alveoli

  33. Common Ventilator Settings parameters/ controls Fraction of inspired oxygen (FIO2) Tidal Volume (VT) Peak Flow/ Flow Rate Respiratory Rate/ Breath Rate / Frequency ( F) Minute Volume (VE) I:E Ratio (Inspiration to Expiration Ratio) Sigh

  34. Fraction of inspired oxygen (FIO2) The percent of oxygen concentration that the patient is receiving from the ventilator. (Between 21% & 100%) (room air has 21% oxygen content). Initially a patient is placed on a high level of FIO2 (60% or higher). Subsequent changes in FIO2 are based on ABGs and the SaO2.

  35. In adult patients the initial FiO2 may be set at 100% until arterial blood gases can document adequate oxygenation. An FiO2 of 100% for an extended period of time can be dangerous ( oxygen toxicity) but it can protect against hypoxemia For infants, and especially in premature infants, high levels of FiO2 (>60%) should be avoided. Usually the FIO2 is adjusted to maintain an SaO2 of greater than 90% (roughly equivalent to a PaO2 >60 mm Hg). Oxygen toxicity is a concern when an FIO2 of greater than 60% is required for more than 25 hours

  36. Tidal Volume (VT) The volume of air delivered to a patient during a ventilator breath. The amount of air inspired and expired with each breath. Usual volume selected is between 5 to 15 ml/ kg body weight)

  37. Peak Flow/ Flow Rate The speed of delivering air per unit of time, and is expressed in liters per minute. The higher the flow rate, the faster peak airway pressure is reached and the shorter the inspiration; The lower the flow rate, the longer the inspiration.

  38. Respiratory Rate/ Breath Rate / Frequency ( F) The number of breaths the ventilator will deliver/minute (10-16 b/m). Total respiratory rate equals patient rate plus ventilator rate. The nurse double-checks the functioning of the ventilator by observing the patient s respiratory rate.

  39. For adult patients and older children:- With COPD A reduced tidal volume A reduced respiratory rate For infants and younger children:- A small tidal volume Higher respiratory rate

  40. Minute Volume (VE) The volume of expired air in one minute . Respiratory rate times tidal volume equals minute ventilation VE = (VT x F) In special cases, hypoventilation or hyperventilation is desired

  41. I:E Ratio (Inspiration to Expiration Ratio):- The ratio of inspiratory time to expiratory time during a breath (Usually = 1:2)

  42. Sensitivity(trigger Sensitivity) The sensitivity function controls the amount of patient effort needed to initiate an inspiration Increasing the sensitivity (requiring less negative force) decreases the amount of work the patient must do to initiate a ventilator breath. Decreasing the sensitivity increases the amount of negative pressure that the patient needs to initiate inspiration and increases the work of breathing.

  43. Ensuring humidification and thermoregulation All air delivered by the ventilator passes through the water in the humidifier, where it is warmed and saturated. Humidifier temperatures should be kept close to body temperature 35 C- 37 C. In some rare instances (severe hypothermia), the air temperatures can be increased. The humidifier should be checked for adequate water levels

  44. Complications of Mechanical Ventilation:- I- Airway Complications, II- Mechanical complications, III- Physiological Complications, IV- Artificial Airway Complications.

  45. Nursing care of patients on mechanical ventilation Assessment: 1- Assess the patient 2- Assess the artificial airway (tracheostomy or endotracheal tube) 3- Assess the ventilator

  46. Nursing Interventions 1-Maintain airway patency & oxygenation 2- Promote comfort 3- Maintain fluid & electrolytes balance 4- Maintain nutritional state 5- Maintain urinary & bowel elimination 6- Maintain eye , mouth and cleanliness and integrity:- 7- Maintain mobility/ musculoskeletal function:-

  47. Nursing Interventions 8- Maintain safety:- 9- Provide psychological support 10- Facilitate communication 11- Provide psychological support & information to family 12- Responding to ventilator alarms /Troublshooting ventilator alarms 13- Prevent nosocomial infection 14- Documentation

  48. Noninvasive Bilateral Positive Airway Pressure Ventilation (BiPAP) BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or nasal prongs, or a full-face mask. The system allows the clinician to select two levels of positive-pressure support: An inspiratory pressure support level (referred to as IPAP) An expiratory pressure called EPAP (PEEP/CPAP level).

  49. Criteria for Using of CPAP or BiPAP: Patients who are candidates for CPAP or BiPAP should meet the following general criteria: Awake Able to follow basic commands Protect their airway Not actively vomiting Not having seizures

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