Ventilation: Basic Principles

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Presentation to participants of the 'Resuscitation Workshop' in the Emergency Department - Canberra Hospital, 2006

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  • Elasticity: is the return of the original shape of matter after the alteration by an outside force Compliance: is how easily a tissue is stretched, and therefore inflation of the lungs Resistance: is determined by the radius of the airway, therefore an decrease is diameter of the airway will result in an increase in resistance and therefore the amount of effort required to ventilate the patient will be increased. Pressure: the total volume of gases exert pressure against the walls of the alveoli (such as O2, NO, CO2 and other gases) Gravity: gravity effects ventilation depending on the position of patient, position of insult or injury
  • The conducting airways consist of the nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles. Conducting Zones: the first 16 generations of branching make up the conducting airways, and the last 7 constitute the respiratory zone (or respiratory and transitional zone). BR, bronchus; BL, bronchiole; TBL, terminal bronchiole; RBL, respiratory bronchiole; AD, alveolar duct; AS, alveolar sacs.
  • Therefore, when there is no movement of air into or out of the lungs, alveolar and atmospheric pressures have reached an equilibrium.
  • Lung Volumes: Tidal Volume: volume of air inhaled and exhaled with each breath Inspiratory Reserve Volume: Maximum volume of air that can be inhaled after a normal breath Expiratory Reserve Volume: Maximum volume of air that can be exhaled after a normal breath Residual Volume: Volume of air remaining in the lungs after maximum exhalation Lung Capacities: Vital Capacity: Maximum volume of air exhaled from the point of maximum inspiration Inspiratory Capacity: Maximum volume of air inhaled after normal expiration Functional Residual Capacity: Volume of air remaining in the lungs after normal expiration Total Lung Capacity: Volume of air in the lungs after a maximum inspiration and equal to the sum of all four volumes.
  • Uncomfortable for the patient who is awake. Therefore not appropriate for the patient who is being weaned from the ventilator
  • Ventilator maintains a constant PEEP Supported ventilation is used only on spontaneously breathing patients with their own respiratory drive and therefore the ability to generate their own breath such as: pneumonia, cardiogenic pulmonary oedema, post-operative hypoxia, lung collapse, asthma ,etc…
  • Ventilation: Basic Principles

    1. 1. Ventilation: Basic Principles Jamie Ranse Registered Nurse Emergency Department The Canberra Hospital
    2. 2. <ul><li>Introduction to Ventilation Principles </li></ul><ul><li>Respiratory Anatomy and Physiology </li></ul><ul><li>Indications for Ventilation </li></ul><ul><li>Modes of Ventilation </li></ul><ul><li>Patient Management </li></ul><ul><li>Complications </li></ul><ul><li>Questions </li></ul>Overview
    3. 3. <ul><li>Ventilation is the movement of air into and out of the alveoli. </li></ul>Introduction Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn) , Lippincott, Philadelphia, USA
    4. 4. <ul><li>Mechanics of Ventilation: </li></ul><ul><li>Elasticity </li></ul><ul><li>Compliance </li></ul><ul><li>Resistance </li></ul><ul><li>Pressure </li></ul><ul><li>Gravity </li></ul>Introduction Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn) , Lippincott, Philadelphia, USA
    5. 5. <ul><li>Respiratory Structures </li></ul><ul><li>Respiratory Zones </li></ul><ul><li>Partitioning of Respiratory Pressures </li></ul><ul><li>Boyles Law </li></ul><ul><li>Respiratory Volumes and Capacity </li></ul><ul><li>Ventilation and Perfusion </li></ul>Anatomy and Physiology
    6. 6. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Respiratory Structures
    7. 7. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Respiratory Zones
    8. 8. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Partitioning of Respiratory Pressures
    9. 9. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Boyles Law Increase V = Decreased P Decreased V = Increased P
    10. 10. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA <ul><li>Boyles Law </li></ul><ul><li>Air flows from a region of higher pressure to a region of lower pressure. </li></ul><ul><li>To initiate a breath, airflow into the lungs must be precipitated by a drop in alveolar pressures. </li></ul>
    11. 11. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Respiratory Volumes and Capacity
    12. 12. Anatomy and Physiology perfusion without ventilation = shunt normal ventilation and perfusion ventilation without perfusion = dead space airway venous blood arterial blood Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Ventilation and Perfusion
    13. 13. <ul><li>Airway Compromise (potential) </li></ul><ul><li>Respiratory Failure </li></ul><ul><ul><li>pH: <7.25 </li></ul></ul><ul><ul><li>PaCO 2 : >50 mmHg </li></ul></ul><ul><ul><li>PaO 2 : <50 mmHg </li></ul></ul><ul><li>Increased Work of Breathing </li></ul><ul><li>Head Injury Management </li></ul>Indications for Ventilation Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7 th Edn) , Lippincott, Philadelphia, USA
    14. 14. <ul><li>Support though illness </li></ul><ul><li>Reversal of hypoxemia </li></ul><ul><li>Reversal of acute respiratory acidosis </li></ul><ul><li>Relief of respiratory distress </li></ul><ul><li>Resting of the ventilatory muscles </li></ul><ul><li>Decrease in oxygen consumption </li></ul><ul><li>Reduction in intracranial pressures </li></ul><ul><li>Stabilisation of the chest wall </li></ul>Objective of Ventilation Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7 th Edn) , Lippincott, Philadelphia, USA
    15. 15. <ul><li>freq </li></ul><ul><li>Vt </li></ul><ul><li>MV </li></ul><ul><li>I:E ratio </li></ul><ul><li>Trigger </li></ul><ul><li>Ramp </li></ul>Modes of Ventilation Diepenbrock NH, 1999, Quick Reference to Critical Care, Lippincott, Philadelphia, USA: P166. <ul><li>Pmax </li></ul><ul><li>Paw </li></ul><ul><li>fspn </li></ul><ul><li>MVspn </li></ul><ul><li> </li></ul><ul><li>PEEP </li></ul>
    16. 16. <ul><li>Controlled </li></ul><ul><ul><li>Pressure Control (PC) </li></ul></ul><ul><ul><li>Volume Control (VC) </li></ul></ul><ul><li>Supported </li></ul><ul><ul><li>Continuous Positive Airway Pressure (CPAP) </li></ul></ul><ul><ul><li>Pressure Support (PS) </li></ul></ul><ul><li>Combined </li></ul><ul><ul><li>SIMV (PC) + PS </li></ul></ul><ul><ul><li>SIMV (VC) + PS </li></ul></ul>Modes of Ventilation Diepenbrock NH, 1999, Quick Reference to Critical Care, Lippincott, Philadelphia, USA: P166.
    17. 17. Modes of Ventilation: Control <ul><li>C ontrolled M echanical V entilation: </li></ul><ul><li>The Minute Volume is determined by the ventilator </li></ul><ul><li>The patient has no option to override the ventilator </li></ul>
    18. 19. Modes of Ventilation: Control <ul><li>P ressure C ontrol: </li></ul><ul><li>A preset peak inspiratory pressure is delivered to the patient at a preset respiratory rate </li></ul><ul><li>Volume is not preset and is determined by the mechanics of ventilation. </li></ul><ul><li>(elasticity, compliance, resistance, pressure, gravity) </li></ul>
    19. 20. Modes of Ventilation: Control <ul><li>V olume C ontrol: </li></ul><ul><li>A preset tidal volume is delivered at a present respiratory rate </li></ul><ul><li>7 – 10 mls/kg </li></ul><ul><ul><ul><li>50kg = 350 – 500mls </li></ul></ul></ul><ul><ul><ul><li>70kg = 490 – 700mls </li></ul></ul></ul><ul><ul><ul><li>90kg = 630 – 900mls </li></ul></ul></ul>
    20. 21. Modes of Ventilation: Support <ul><li>C ontinuous P ositive A irway P ressure: </li></ul><ul><li>A spontaneous breathing mode, where the patient generates their own breath </li></ul><ul><li>The ventilator maintains a constant positive pressure on expiration (PEEP) </li></ul><ul><li>Aims to increase Functional Residual Capacity </li></ul>
    21. 22. Modes of Ventilation: Support <ul><li>P ressure S upport: </li></ul><ul><li>A spontaneous breathing mode </li></ul><ul><li>Need for additional support to achieve optimal tidal volumes </li></ul><ul><li>Ventilator delivers a constant preset pressure on inspiration </li></ul><ul><li>CPAP + PS = BiPAP </li></ul>
    22. 23. Modes of Ventilation: Combined <ul><li>S ynchronised I ntermitted M andatory V entilation: </li></ul><ul><li>Similar to IMV </li></ul><ul><li>If the patient initiates a breath and the ventilator synchronises so the ventilator doesn’t deliver a breath at the same time </li></ul>
    23. 24. Modes of Ventilation: Combined <ul><li>SIMV (PC) + PS : </li></ul><ul><li>Pressure controlled ventilation with pressure support on spontaneous breaths </li></ul><ul><li>SIMV (VC) + PS : </li></ul><ul><li>Volume controlled ventilation with pressure support on spontaneous breaths </li></ul>
    24. 25. SIMV (VC) + PS Freq: 10 Vt: 500 (MV = 5.0) PEEP: 5 PS: 10
    25. 26. <ul><li>Monitoring </li></ul><ul><li>Suctioning </li></ul><ul><li>Other </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Oral and Eye Care </li></ul></ul>Patient Management
    26. 27. <ul><li>ECG </li></ul><ul><li>SpO 2 </li></ul><ul><li>ETCO 2 </li></ul><ul><li>Alarm limits </li></ul><ul><li>Air Entry / Work of Breathing </li></ul><ul><li>Ventilator observations and alarm limits </li></ul><ul><li>Full assessment </li></ul>Patient Management: Monitoring
    27. 28. <ul><li>PRN </li></ul><ul><ul><li>Increasing airway pressures </li></ul></ul><ul><ul><li>Decreasing SpO 2 </li></ul></ul><ul><ul><li>Increased work of breathing </li></ul></ul><ul><li>Pre-oxygenate (100% oxygen) </li></ul><ul><li>Less than 15 Seconds </li></ul>Patient Management: Suctioning
    28. 29. Patient Management: Other <ul><li>Sedation </li></ul><ul><ul><li>Propofol, Morphine and Midazolam </li></ul></ul><ul><li>Positioning </li></ul><ul><ul><li>2/24 </li></ul></ul><ul><li>Oral and eye care </li></ul><ul><ul><li>2/24 </li></ul></ul>
    29. 30. <ul><li>Airway </li></ul><ul><ul><li>Aspiration, decreased clearance of secretions, predisposition to infection </li></ul></ul><ul><li>Endotracheal Tube </li></ul><ul><ul><li>Tube kinking, sputum plug, right main bronchus intubation, tube migration, cuff failure, laryngeal oedema </li></ul></ul><ul><li>Mechanical </li></ul><ul><ul><li>Ventilator malfunction, hypoventilation, hyperventilation, barotrauma, pneumothorax </li></ul></ul>Complications
    30. 31. Questions
    31. 32. Ventilation: Basic Principles Jamie Ranse Registered Nurse Emergency Department The Canberra Hospital

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