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Anatomy of the Ventilator Dean Hess PhD RRT Associate Professor of Anesthesia Harvard Medical School Assistant Director of Respiratory Care Massachusetts General Hospital Editor in Chief Respiratory Care
air O 2 filter filter PATIENT Microprocessor (mode and breath delivery) inspiratory valve(s) (flow, volume, pressure, F I O 2 ) expiratory valve (PEEP) humidifier electrical power atmosphere monitors & alarms
expired gas humidifier ventilator patient Aerosolized drug (nebulizer or MDI) filter dead space gas compression bias flow suction
Anesthesiology 2006;104:39
Crit Care Med 2007;35:260 VAP Crit Care Med 2007;35:260 Closed suction is cost-effective because the same catheter can be used multiple times; even for multiple days.
Humidification ,[object Object],[object Object],[object Object]
Crit Care Med 2007; 35:2843
[object Object],[object Object],Chest 2005; 127:335-371
Breath Delivery: Phase Variables ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pressure-triggered breath  Flow-triggered breath trigger Modern triggers are sensitive ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ventilator Breath Types ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Volume Controlled Ventilation ,[object Object],[object Object],[object Object],Volume (mL)  Pressure (cm H 2 O)  Flow (L/min) Volume (mL)  Pressure (cm H 2 O)  Flow (L/min) constant descending ramp
Pressure Controlled Ventilation ,[object Object],[object Object],[object Object],time Volume (mL)  Pressure (cm H 2 O)  Flow (L/min)
Equation of Motion Volume Ventilation E = 1/C X X P MUS  + P AW  = E V + R V . fixed volume and flow increased effort decreased airway pressure fixed pressure increased effort increased flow and tidal volume P MUS  + P AW  = E V + R V . Pressure Ventilation
Flow Dys-synchrony: VCV
Improved Synchrony
PCV 20 cm H 2 O, PEEP 10 cm H 2 O; Pplat 30 cm H 2 O transpulmonary  pressure = 45 cm H 2 O -15 cm H 2 O Active inspiratory effort ↑↑   V T
Transpulmonary Pressure ventilator support patient effort
Kallet, Respir Care 2005;50:1623
Dys-Synchrony with PCV Kallet, Respir Care 2005;50:1623
Pressure-Controlled Inverse Ratio Ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],time Volume (mL)  Pressure (cm H 2 O)  Flow (L/min)
Mireles-Cabodevila, Cleve Clin J Med 2009;76:417
Mandatory Breath Types constant descending ramp Volume (mL)  Pressure (cm H 2 O)  Flow (L/min) Volume (mL)  Pressure (cm H 2 O)  Flow (L/min) Volume (mL)  Pressure (cm H 2 O)  Flow (L/min) time time time Volume Control  Pressure Control ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pressure Support Ventilation flow cycle patient trigger pressure limit ,[object Object],[object Object],[object Object],[object Object]
Pressure Support Ventilation Adjustable rise time Adjustable flow cycle
Pressure Support and Sleep ,[object Object],[object Object],Parthasarathy, Am J Respir Crit Care Med 2002; 166:1423 Apneas per Hour
Volume-Control  vs  Pressure Control Evidence for better outcomes with either volume-control or pressure-control is lacking VCV PCV PSV Tidal volume Fixed Variable Variable Inspiratory flow Fixed Variable Variable Airway pressure Variable Fixed Fixed Inspiratory time Fixed Fixed Variable Rate Minimum set Minimum set Not set
Adaptive Pressure Control ,[object Object],[object Object],[object Object]
PCV+ (Drager); Bilevel (PB 840) Patroniti, Anesthesiology 2002; 96:788
Ventilator Modes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],No “new” mode has been shown to improve patient outcomes compared to traditional modes
SIMV flow airway pressure esophageal pressure volume spontaneous breath spontaneous breaths mandatory breath
Ventilator Modes Continuous Mandatory Ventilation (CMV) Continuous Spontaneous Ventilation (CSV) Intermittent Mandatory Ventilation (SIMV) VCV PCV Dual Control PCIRV APRV CPAP PSV PAV NAVA VCV MMV Dual Control Bilevel Dual Control Automode ASV PCV
Goals When Setting The Ventilator ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Setting the Ventilator Ventilator-Induced Lung Injury Gas Exchange Patient Comfort Hemodynamics

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Anatomy of the ventilator

  • 1. Anatomy of the Ventilator Dean Hess PhD RRT Associate Professor of Anesthesia Harvard Medical School Assistant Director of Respiratory Care Massachusetts General Hospital Editor in Chief Respiratory Care
  • 2. air O 2 filter filter PATIENT Microprocessor (mode and breath delivery) inspiratory valve(s) (flow, volume, pressure, F I O 2 ) expiratory valve (PEEP) humidifier electrical power atmosphere monitors & alarms
  • 3. expired gas humidifier ventilator patient Aerosolized drug (nebulizer or MDI) filter dead space gas compression bias flow suction
  • 5. Crit Care Med 2007;35:260 VAP Crit Care Med 2007;35:260 Closed suction is cost-effective because the same catheter can be used multiple times; even for multiple days.
  • 6.
  • 7. Crit Care Med 2007; 35:2843
  • 8.
  • 9.
  • 10.
  • 11.
  • 12.
  • 13.
  • 14. Equation of Motion Volume Ventilation E = 1/C X X P MUS + P AW = E V + R V . fixed volume and flow increased effort decreased airway pressure fixed pressure increased effort increased flow and tidal volume P MUS + P AW = E V + R V . Pressure Ventilation
  • 17. PCV 20 cm H 2 O, PEEP 10 cm H 2 O; Pplat 30 cm H 2 O transpulmonary pressure = 45 cm H 2 O -15 cm H 2 O Active inspiratory effort ↑↑ V T
  • 18. Transpulmonary Pressure ventilator support patient effort
  • 19. Kallet, Respir Care 2005;50:1623
  • 20. Dys-Synchrony with PCV Kallet, Respir Care 2005;50:1623
  • 21.
  • 22. Mireles-Cabodevila, Cleve Clin J Med 2009;76:417
  • 23.
  • 24.
  • 25. Pressure Support Ventilation Adjustable rise time Adjustable flow cycle
  • 26.
  • 27. Volume-Control vs Pressure Control Evidence for better outcomes with either volume-control or pressure-control is lacking VCV PCV PSV Tidal volume Fixed Variable Variable Inspiratory flow Fixed Variable Variable Airway pressure Variable Fixed Fixed Inspiratory time Fixed Fixed Variable Rate Minimum set Minimum set Not set
  • 28.
  • 29. PCV+ (Drager); Bilevel (PB 840) Patroniti, Anesthesiology 2002; 96:788
  • 30.
  • 31. SIMV flow airway pressure esophageal pressure volume spontaneous breath spontaneous breaths mandatory breath
  • 32. Ventilator Modes Continuous Mandatory Ventilation (CMV) Continuous Spontaneous Ventilation (CSV) Intermittent Mandatory Ventilation (SIMV) VCV PCV Dual Control PCIRV APRV CPAP PSV PAV NAVA VCV MMV Dual Control Bilevel Dual Control Automode ASV PCV
  • 33.
  • 34. Setting the Ventilator Ventilator-Induced Lung Injury Gas Exchange Patient Comfort Hemodynamics