This document discusses mechanical ventilation and provides information on various ventilator settings and modes. It describes settings for tidal volume, respiratory rate, PEEP, FiO2, I:E ratio and more. It also covers different types of patients that may require ventilation including COPD, asthma and ARDS patients. Troubleshooting tips are provided for issues like rising pressures and patient agitation. The goals of ventilation depend on the condition but may include reducing work of breathing, controlling hypoventilation and limiting airway pressures.

1. MECHANICAL
VENTILATION
Soumya Ranjan Parida
Basic B.Sc. Nursing 4th
year
Sum Nursing College

2. Presentation
Different settings to consider
Monitoring of the patient
Different type of patient
COPD, Asthma
ARDS
Trouble shooting

3. Ventilator settings

4. Ventilator settings
1. Ventilator mode
2. Respiratory rate
3. Tidal volume or pressure settings
4. Inspiratory flow
5. I:E ratio
6. PEEP
7. FiO2
8. Inspiratory trigger

5. CMV

6. A/CV

7. SIMV

8. PSV(pressure support
ventilation)
Spontaneous inspiratory efforts trigger
the ventilator to provide a variable flow
of gas in order to attain a preset airway
pressure.
Can be used in adjunct with SIMV.

9. Respiratory Rate
1. What is the pt actual rate demand?

10. Tidal Volume or
Pressure setting
Maximum volume/pressure to achieve
good ventilation and oxygenation
without producing alveolar
overdistention
Max cc/kg? = 10 cc/kg
Some clinical exceptions

11. Inspiratory flow
Varies with the Vt, I:E and RR
Normally about 60 l/min
Can be majored to 100- 120 l/min

12. I:E Ratio
1:2
Prolonged at 1:3, 1:4, …
Inverse ratio

13. FIO2
The usual goal is to use the minimum
Fio2 required to have a PaO2 >
60mmhg or a sat >90%
Start at 100%
Oxygen toxicity normally with Fio2
>40%

14. Inspiratory Trigger
Normally set automatically
2 modes:
Airway pressure
Flow triggering

15. Positive End-expiratory
Pressure (PEEP)
What is PEEP?
What is the goal of PEEP?
 Improve oxygenation
 Diminish the work of breathing
 Different potential effects

16. PEEP
What are the secondary effects of PEEP?
 Barotrauma
 Diminish cardiac output
 Regional hypoperfusion
 NaCl retention
 Augmentation of I.C.P.?
 Paradoxal hypoxemia

17. PEEP
Contraindication:
No absolute CI
Barotrauma
Airway trauma
Hemodynamic instability
I.C.P.?
Bronchospasm?

18. PEEP
What PEEP do you want?
Usually, 5-10 cmH2O

19. Monitoring of the
patient

20. Look at your patient
Question your pt
Examine your pt
Monitor your pt
Look at the synchronicity of your pt breathing

21. Pressures

22. Compliance pressure
(Pplat)
Represent the static end inspiratory
recoil pressure of the respiratory
system, lung and chest wall respectively
Measures the static compliance or
elastance

23. Pplat
Measured by occluding the ventilator 3-5 sec
at the end of inspiration
Should not exceed 30 cmH2O

24. Peak Pressure (Ppeak)
Ppeak = Pplat + Pres
Where Pres reflects the resistive
element of the respiratory system (ET
tube and airway)

25. Ppeak
Pressure measured at the end of inspiration
Should not exceed 50cmH2O?

26. Auto-PEEP or Intrinsic
PEEP
What is Auto-PEEP?
Normally, at end expiration, the lung
volume is equal to the FRC
When PEEPi occurs, the lung volume at
end expiration is greater then the FRC

27. Auto-PEEP or Intrinsic
PEEP
Why does hyperinflation occur?
Airflow limitation because of dynamic
collapse
No time to expire all the lung volume (high
RR or Vt)
Expiratory muscle activity
Lesions that increase expiratory resistance

28. Auto-PEEP or Intrinsic
PEEP
Auto-PEEP is measured in a relaxed pt with
an end-expiratory hold maneuver on a
mechanical ventilator immediately before the
onset of the next breath

29. Auto-PEEP or Intrinsic
PEEP
Adverse effects:
 Predisposes to barotrauma
 Predisposes hemodynamic compromises
 Diminishes the efficiency of the force
generated by respiratory muscles
 Augments the work of breathing
 Augments the effort to trigger the ventilator

30. Different types of
patient

31. COPD and Asthma
Goals:
Diminish dynamic hyperinflation
Diminish work of breathing
Controlled hypoventilation
(permissive hypercapnia)

32. Diminish DHI
Why?

33. Diminish DHI
How?
Diminish minute ventilation
 Low Vt (6-8 cc/kg)
 Low RR (8-10 b/min)
 Maximize expiratory time

34. Diminish work of
breathing
How:
Add PEEP (about 85% of PEEPi)
Applicable in COPD and Asthma.

35. Controlled hypercapnia
Why?
Limit high airway pressures and thus
diminish the risk of complications

36. Controlled hypercapnia
How?
Control the ventilation to keep adequate
pressures up to a PH > 7.20 and/or a
PaCO2 of 80 mmHg

37. Controlled hypercapnia
CI:
Head pathologies
Severe HTN
Severe metabolic acidosis
Hypovolemia
Severe refractory hypoxia
Severe pulmonary HTN
Coronary disease

38. A.R.D.S.
Ventilation with lower tidal volume as
compared with traditional volumes for
acute lung injury and the ARDS
The Acute Respiratory Distress
Syndrome Network
N Engl J Med 2000;342:1301-08

39. Methods
March 96 – March 99
10 university centers
Inclusion:
Diminish PaO2
Bilateral infiltrate
Wedge < 18
Exclusion
Randomized

40. Methods
A/C 28d or weaning
2 groups:
 1. Traditional Vt (12cc/kg)
 2. Low Vt (6cc/kg)
End point:
 1. Death
 2. Days of spontaneous breathing
 3. Days without organ failure or barotrauma

41. Results
The trails were stopped after 861 pt because
of lower mortality in low Vt group

42. Trouble Shooting

43. Trouble Shooting
Doctor, doctor, his pressures are going
up!!!
What is your next step?

44. Trouble Shooting
1. Call the I.T., he will take care of it!
2. Where is the staff?
3. I dont know this pt, and run!
4. Ask which pressure is going up

45. Trouble Shooting
Ppeak is up
Look at your Pplat

46. Trouble Shooting
If your Pplat is high, you are faced with
a COMPLIANCE problem
If your Pplat is N, you are faced with a
RESISTIVE problem
DD?

47. Trouble Shooting

48. Trouble Shooting
Doctor, doctor, my patient is very
agitated!
What is your next step?

49. Trouble Shooting
1. Give an ativan to the nurse!
2. Give haldol 10mg to the patient!
3. Take 5mg of morphine for yourself!
4. Look at your pt!

50. Trouble Shooting
At the time of intubation, fighting is
largely due to anxiety
But what do you do if pt is stable and
then becomes agitated?

51. Trouble Shooting
1. Remove pt from ventilator
2. Initiate manual ventilation
3. Perform P/E and assess monitoring indices
4. Check patency of airway
5. If death is imminent, consider and treat
most likely causes
6. Once pt is stabilized, undertake more
detailed assessement and management

52. Trouble Shooting

53. Conclusion
Type ofpatient Tidal Volume RR PEEP FIO2 Ins. Flow I:E Note Note
Normal 10 cc/kg 10 to 12 0 to 5 100%. 60 l/min 1:2.
ARDS 6 cc/kg 10 to 12 5 to 15 100%. 60 l/min 1:2.
COPD 6 cc/kg 10 to 12 5 to 10 100%. 100 to 120 1:3 to 1:4 PH>7.2
PCO2 <80 mmhg
Triggerto consider
Trauma 10 cc/kg 10 to 12 0. 100%. 60 l/min 1:2.
Pediatric 8-10 cc/kg Varies age 3 to 5 100%. 60 l/min 1:2. Triggerto consider