Overview of Mechanical Ventilation in Critical Care

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Dr. Zia Arshad
MD, FRCP (Edin.), FCCM, FIACM, MNAMS
Professor
Department of Anaestheiology & Critical Care
King George’s Medical University
Lucknow
Mechanical Ventilation
 
Indication
Mode
Variable
Initiation of mechanical ventilation
Goal
Monitoring
Ventilator alarms and there trouble shooting
Weaning from ventilator
Complication
indication
For intubation
For ventilation
Respiratory failure
Neuromuscular disorder
Modes
CMV
AC
SIMV
PRVC
PS
ASV,APRV
variable
Respiratory rate
Tidal volume
PEEP
I:E Ratio
Pressure support
Trigger (Pressure/Flow)
Pressure limit
Controlled Mandatory ventilation
All breaths are mandatory
Preset frequency, inspiratory time/Inspiratory flow
Pressure or volume control
Trigger: Time
Limit: Volume, flow or pressure
Cycle: Time, volume 
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Volume vs. Pressure Control
Volume Preset
Set parameter is the tidal
volume; airway pressure is
variable
Constant tidal volume in the
face of changing lung
characteristics
Patient-ventilator
asynchrony due to fixed
flow rate
No leak compensation
Pressure Preset
Set parameter is airway
pressure; tidal volume
delivered is variable
Tidal volume varies with
changes in  lung
characteristics
Flow will vary according
to patient's demands
Compensates for leaks
Assist control
Like CMV
Each 
additional 
assisted breath at prefixed tidal
volume or pressureTrigger: ventilator or patient
Limit: Flow / volume or Pressure
Cycling: volume or time
Synchronised intermittent mandatory
ventilation
Synchronised mandatory breaths with spontaneous
breaths allowed in between
Ventilator creates a time window around the scheduled
delivery of mandatory breath
If a patient effort is detected, it synchronises the
machine breath with the patient’s inspiration
If no patient effort is detected, it delivers a breath at
the scheduled time
Pressure
Flow
Volume
(L/min)
(cm H
2
O)
(ml)
Time (sec
Time (sec
)
)
SIMV Mode
 
Spontaneous
 
Breath
Pressure Support
Completely
 spontaneous mode in which patient
triggers each breath
On inspiration patient exposed to a preset pressure
Inspiration is terminated when the flow rate reaches
a minimum level or % of peak flow
Trigger: Patient
Limit: Pressure
Cycling: flow
Initiating Mechanical
Ventilation
Check ventilator assembly: power connection, circuit
connection, HME filter catheter mount, gas
connections
Switch on ventilator, check on test lung
Begin Preoxygenation (aerosol precaution)
Watch for Hypotension
Infuse Fluids
Start Mechanical Ventilation
A/C:TV=350-450,   RR=20-30,  FIO2= 60-100%
Peak Flow rate 40-60 l/min
PEEP=5-10,  I:E=1:2, Sens= -0.8 - 2
GOAL
 OXYGENATION GOAL: PaO
2
55-80 mmHg or SpO
2
 
88-95%
 PLATEAU PRESSURE GOAL: ≤ 30 cm H
2
O
pH GOAL: 7.30-7.45
Acidosis Management: (pH < 7.30)
If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO
2 
< 25
(Maximum set RR = 35). 
If pH < 7.15: Increase RR to 35.
If pH remains < 7.15, TV
 
may be increased in 1 ml/kg steps until pH
> 7.15 (Pplat target of 30 may be exceeded). (Max TV =8, Min
TV=4 ml/kg)
Alkalosis Management: (pH > 7.45) Decrease vent rate if possible. 
Monitoring
Heart rate
SpO2
Respiratory rate
Pattern of respiration and signs of respiratory distress
Blood pressure
ETCO2
Expired tidal volume: equal to set tidal volume (leaks)
Peak pressure, Plateau pressure (< 30 mm Hg)
Ventilator alarms and troubleshooting
Management of other problems
Hypoxemia: check for disconnection, Increase Fio2,
Call for help, check for tube block, fluid overload,
check air entry, patient ventilator asynchrony
DOPE:
D: Disconnection/ Dislodging
O: Obstruction,
P: Pneumothorax
E: Equipment failure
There may exist multiple problems
Criteria for consideration for
Weaning/discontinuation
Underlying disease stable or improving
PaO
2
 / FiO
2
 > 200
PEEP < 5-8 cmH
2
O
FiO2 < 0.5
Reliable respiratory drive
Stable CVS
Minimal pressors or inotropes
Absence of myocardial ischemia
Capable of initiating inspiratory effort
Underlying condition has 
Resolved or improved and there is no other condition mandating MV
D
a
i
l
y
 
s
c
r
e
e
n
i
n
g
 
o
f
 
R
S
 
f
u
n
c
t
i
o
n
Not Ready
 Ready
MV and 
Daily screening
S
B
T
T-piece or PSV 
30min is enough 
Tolerated
Not tolerated
G
r
a
d
u
a
l
 
W
i
t
h
d
r
a
w
a
l
Once-daily T-piece
PSV
Weaning
Complications of MV
Airway management related complications
Hypotension
Pneumothorax/Subcutaneous emphysema
Ventilator induced lung injury
Ventilator associated pneumonia
Non invasive ventilation
Indication
Pre requisite
Contraindication
Variables
complications
CARRY HOME MESSAGE
CoViD-19 patients usually present to ICU with ARDS.
For ventilating these patients Tidal volume (TV) should
be calculated by 6 ml/kg PBW. (TVmax=8 ml/kg,
TVmin=4 ml/kg)
Ventilating a patient with ARDS: Low TV, High RR,
High PEEP and Plateau pressure < 30 cm H2O.
One should be aware of monitoring and
troubleshooting of mechanical ventilator.
Patient should be initiated on Controlled or assist
control mode of MV and once recovers can be
weaned using spontaneous breathing trial.
 
   THANK YOU
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Discussing the indication, modes, variables, and controls of mechanical ventilation as well as the differences between volume and pressure control. Exploring assist control, synchronized intermittent mandatory ventilation, and other key aspects of ventilator management by Dr. Zia Arshad.


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  1. Mechanical Ventilation Dr. Zia Arshad MD, FRCP (Edin.), FCCM, FIACM, MNAMS Professor Department of Anaestheiology & Critical Care King George s Medical University Lucknow

  2. Indication Mode Variable Initiation of mechanical ventilation Goal Monitoring Ventilator alarms and there trouble shooting Weaning from ventilator Complication

  3. indication For intubation For ventilation Respiratory failure Neuromuscular disorder

  4. Modes CMV AC SIMV PRVC PS ASV,APRV

  5. variable Respiratory rate Tidal volume PEEP I:E Ratio Pressure support Trigger (Pressure/Flow) Pressure limit

  6. Controlled Mandatory ventilation All breaths are mandatory Preset frequency, inspiratory time/Inspiratory flow Pressure or volume control Trigger: Time Limit: Volume, flow or pressure Cycle: Time, volume

  7. Volume vs. Pressure Control Volume Preset Pressure Preset Set parameter is the tidal volume; airway pressure is variable Set parameter is airway pressure; tidal volume delivered is variable Constant tidal volume in the face of changing lung characteristics Tidal volume varies with changes in lung characteristics Patient-ventilator asynchrony due to fixed flow rate Flow will vary according to patient's demands No leak compensation Compensates for leaks

  8. Assist control Like CMV Each additional assisted breath at prefixed tidal volume or pressureTrigger: ventilator or patient Limit: Flow / volume or Pressure Cycling: volume or time

  9. Synchronised intermittent mandatory ventilation Synchronised mandatory breaths with spontaneous breaths allowed in between Ventilator creates a time window around the scheduled delivery of mandatory breath If a patient effort is detected, it synchronises the machine breath with the patient s inspiration If no patient effort is detected, it delivers a breath at the scheduled time

  10. SIMV Mode Flow (L/min) Pressure (cm H2O) Volume (ml) Time (sec) Spontaneous Breath

  11. Pressure Support Completely spontaneous mode in which patient triggers each breath On inspiration patient exposed to a preset pressure Inspiration is terminated when the flow rate reaches a minimum level or % of peak flow Trigger: Patient Limit: Pressure Cycling: flow

  12. Initiating Mechanical Ventilation Check ventilator assembly: power connection, circuit connection, HME filter catheter mount, gas connections Switch on ventilator, check on test lung Begin Preoxygenation (aerosol precaution) Watch for Hypotension Infuse Fluids Start Mechanical Ventilation A/C:TV=350-450, RR=20-30, FIO2= 60-100% Peak Flow rate 40-60 l/min PEEP=5-10, I:E=1:2, Sens= -0.8 - 2

  13. GOAL OXYGENATION GOAL: PaO255-80 mmHg or SpO2 88-95% PLATEAU PRESSURE GOAL: 30 cm H2O pH GOAL: 7.30-7.45 Acidosis Management: (pH < 7.30) If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR = 35). If pH < 7.15: Increase RR to 35. If pH remains < 7.15, TVmay be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30 may be exceeded). (Max TV =8, Min TV=4 ml/kg) Alkalosis Management: (pH > 7.45) Decrease vent rate if possible.

  14. Monitoring Heart rate SpO2 Respiratory rate Pattern of respiration and signs of respiratory distress Blood pressure ETCO2 Expired tidal volume: equal to set tidal volume (leaks) Peak pressure, Plateau pressure (< 30 mm Hg)

  15. Ventilator alarms and troubleshooting Alarms Priority Causes Steps Electrical power/ gas delivery/ Battery Highest Disconnection of power supply or oxygen source Connect the power or Oxygen source Low airway pressure High Disconnection or volume leak, in appropriate alarm setting Connect ventilator, check alarm setting High airway pressure High Obstruction to flow, pneumothorax and other compliance problem (fluid overload/ abdominal hypertension) Check for Ppeak and Pplat (diff <3-5) if both high: Compliance problem (pneumothorax etc) If Ppeak and Pplat (diff>3- 5) : Resistance problem (tube/circuit block etc): suction/change tube, bronchodilator Low Expired Vt High ETT cuff leak, Circuit leak, leak from HME filter, leak from ICD Check/change ETT, Circuit, HME filter, ICD High RR High PEEP Moderate Blocked tube/bronchoconstriction Suction/bonchodilation

  16. Management of other problems Hypoxemia: check for disconnection, Increase Fio2, Call for help, check for tube block, fluid overload, check air entry, patient ventilator asynchrony DOPE: D: Disconnection/ Dislodging O: Obstruction, P: Pneumothorax E: Equipment failure There may exist multiple problems

  17. Criteria for consideration for Weaning/discontinuation Underlying disease stable or improving PaO2 / FiO2 > 200 PEEP < 5-8 cmH2O FiO2 < 0.5 Reliable respiratory drive Stable CVS Minimal pressors or inotropes Absence of myocardial ischemia Capable of initiating inspiratory effort

  18. Underlying condition has Resolved or improved and there is no other condition mandating MV Daily screening of RS function Weaning Not Ready Ready MV and Daily screening SBT T-piece or PSV 30min is enough Tolerated Not tolerated Gradual Withdrawal Once-daily T-piece PSV

  19. Complications of MV Airway management related complications Hypotension Pneumothorax/Subcutaneous emphysema Ventilator induced lung injury Ventilator associated pneumonia

  20. Non invasive ventilation Indication Pre requisite Contraindication Variables complications

  21. CARRY HOME MESSAGE CoViD-19 patients usually present to ICU with ARDS. For ventilating these patients Tidal volume (TV) should be calculated by 6 ml/kg PBW. (TVmax=8 ml/kg, TVmin=4 ml/kg) Ventilating a patient with ARDS: Low TV, High RR, High PEEP and Plateau pressure < 30 cm H2O. One should be aware of monitoring and troubleshooting of mechanical ventilator. Patient should be initiated on Controlled or assist control mode of MV and once recovers can be weaned using spontaneous breathing trial.

  22. THANK YOU

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