An arterial blood gas (ABG) test measures the levels of oxygen and carbon dioxide in the blood and how acidic or alkaline (pH) the blood is. This provides important information about how well the lungs are working and delivering oxygen to tissues and removing carbon dioxide. The document discusses various aspects of mechanical ventilation including indications, equipment, settings, modes, and monitoring including ABG tests to evaluate ventilation effectiveness.

2. Introduction
• Spontaneous breathing is defined as
movement of air into and out of the lungs as a
result of work done by an individual’s
respiratory muscles.
• Oxygen is a drug and should be prescribed
with a target saturation range.
• The air that we breathe contain approximately
21% oxygen.

3. Methods to administer Oxygen
• Non – Invasive :
• Invasive: Endotracheal intubation with
mechanical ventilation

4. Device of oxygen therapy in PICU

5. DEFINITION OF MECHANICAL
VENTILATOR
• A ventilator is a machine that delivers a flow
of gas for a certain amount of time by
increasing proximal airway pressure, a process
which culminates in a delivered tidal volume
through using various modes of ventilation.

6. Goals of Mechanical Ventilation
• Relieve respiratory distress
• Decrease work of breathing
• Improve pulmonary gas exchange
• Reverse respiratory muscle fatigue
• Permit lung healing
• Avoid complications

7. Indications for Mechanical Ventilation
 Airway Protection: General Anesthesia.
 Increased Work of Breathing: laryngeal edema, asthma,
COPD,cardiogenic or non-cardiogenic pulmonary edema),
pulmonary infection, pulmonary hemorrhage &fibrosis.
• Hypoxemia.
• Increased Demand: Severe acidosis, pulmonary embolism,
severe circulatory shock
 Alveolar Hypoventilation:
• Won’t breathe” Apnea , drug-induced sedation, central
nervous system disorders, or profound systemic disorders
such as circulatory shock and metabolic encephalopathy.
• “Can’t breathe” Neuromuscular Weakness: Acute: Guillain-
Barre syndrome, Chronic: myasthenia gravis, Myopathy.

8. What you need for Mechanical
ventilation
• Prepare and check all equipments for intubation:
• Cuffed and not cuffed endotracheal tube (in
neonates use uncuffed ones)
• Stylet
• Laryngoscope with blades
• Stethoscope
• Syringe
• Plaster

9. Size of tube
internal
diameter
Weigth
gram
Gestational
age (weeks)
2.5 Lower 1.000 Lower 28
3.0 1.000 - 2.000 28 - 34
3.5 2.000 - 3.000 34 - 38
3.5 – 4.0 Upper 3.000 Upper 38
SIZE & INSERTION DEPHT
OF ENDOTRACHEAL TUBE
Weigth
Depth
(cm)
Lower 1.000g 6 cm
1.000 - 2.000g 7 cm
2.000 - 3.000g 8 cm
3.000 - 4.000g 9 cm
Upper 4.000g 10cm

11. • Patient: Physical examination, Respiratory rate (set,
spontaneous), Rib cage-abdominal motion, Work of
breathing.
• Monitoring vital signs and Sp02
• ABG: Gas exchange.
• Mechanical Ventilation Machine: tidal volume,
Peak inspiratory pressure, PEEP & waveform.
Monitoring during Mechanical
Ventilation

12. Screen of Mechanical ventilation

13. What you can control in Mechanical
Ventilation
• Volume V : Tidal volume: how much air would you like to
get in and out of patient.
• Pressure P: how much pressure would you like to give.
• Rate R.R: how fast would you like the patient to breath?
Breath min
• Flow rate F.R: Flow = Volume Time. How fast would you
like the patient to push the volume in.
• Oxygen O : how much oxygen would you like to put in.
• Who is going to control the work is breath? The machine or
the patient. Trigger
• Combination of mentioned factors together will give you
selected mode of ventilation.

14. Physiology
• Airway resistance refers to the resistive forces encountered during the mechanical
respiratory cycle. The normal airway resistance is ≤ 5 cmH2O.
• Lung compliance refers to the elasticity of the lungs, or the ease with which they stretch and
expand to accommodate a change in volume or pressure.
• Lungs with a low compliance, stiff” lungs, tend to have difficulty with the inhalation process.
An example of poor compliance would be a patient with a restrictive lung disease, such as
pulmonary fibrosis.
• In contrast, highly compliant lungs, or lungs with a low elastic recoil, tend to have more
difficulty the exhalation process, as seen in obstructive lung diseases.

15. Pressure
 Peak Inspiratory Pressure (PIP or Ppeak) is the maximum pressure in the
airways at the end of the inspiratory phase.
• the PIP is a determined by both airway resistance and compliance.
• Is the main pressure to deliver the Tidal Volume.
• By convention, all pressures in mechanical ventilation are reported in “cm
H2O.” It is best to target a PIP < 35 cm H2O.
 Positive End Expiratory Pressure (PEEP) is the positive pressure that
remains at the end of exhalation.
• This additional applied positive pressure helps prevent atelectasis by
preventing the end-expiratory alveolar collapse.
• PEEP is usually set at 5 cm H2O or greater, as part of the initial ventilator
settings.

16. Inspiratory & Expiratory Time
• Inspiratory time (iTime) is the time allotted to deliver the set tidal volume (in volume
control settings) or set pressure (in pressure control settings).
• Expiratory Time (eTime) is the time allotted to fully exhale the delivered mechanical
breath.
• I:E ratio, the inspiratory to expiratory ratio, is usually expressed as 1:2, 1:3, etc. The I:E
ratio can be set directly, or indirectly on the ventilator by changing the :
• inspiratory time,
• the inspiratory flow rate, or the
• respiratory rate.
• By convention, decreasing the ratio means increasing the expiratory time. For example, 1:3
is a decrease from 1:2, just like 1/3 is less than 1/2.

17. Flow
 Peak inspiratory flow is the rate at which the breath is delivered,
expressed in L/min. A common rate is 60 L/min.
• If you increase the inspiratory flow, the breath is given faster, and that
leaves more time for exhalation. Thus, inspiratory flow indirectly changes
the I:E ratio.

18. Tidal volume (TV or VT)
 Tidal volume (TV or VT) is the volume of gas delivered to the patient with
each breath.
 The tidal volume is best expressed in both milliliters (ex: 450mL) and
milliliters/kilogram (ex: 6 mL/kg) of predicted body weight.

19. Respiratory rate & Fraction of
inspired oxygen (FiO2)
 Respiratory rate (RR or f, for “frequency”) is the mandatory number of
breaths delivered by the ventilator per minute.
 20-25 per minute for children under 2 years and 15-20 per minute for
older children(6).
 Fraction of inspired oxygen (FiO2) is a measure of the oxygen delivered
by the ventilator during inspiration, expressed at a percentage.
 Room air contains 21% oxygen. A mechanical ventilator can deliver varying
amounts of oxygen, up to 100%.

20. Anatomy of a Breath
• Breathing is a periodic event, composed of
repeated cycles of inspiration and expiration.
• Each breath, defined as one cycle of inspiration
followed by expiration, can be broken down into
four components, known as phase variables.
• Trigger: when inspiration begins
• Target: how flow is delivered during inspiration
• Cycle: when inspiration ends
• Baseline: proximal airway pressure during
expiration

21. Trigger
• The trigger variable determines when to
initiate inspiration.
• Ventilator-triggered breaths use time as the
trigger variable.
• Patient-triggered breaths are initiated by
patient respiratory efforts, utilizing pressure
or flow for the trigger variable

22. Target
• The target variable regulates how flow is
administered during inspiration.
• The variables most commonly used for the
target include flow and pressure.
• Note that volume delivered per unit time,
which is the definition of flow, is a target
variable. high flow rate or low flow rate.

23. Cycle
• The cycle variable determines when to
terminate the inspiratory phase of a breath.
• The term “to cycle” is synonymous with “to
terminate inspiration.
• ” The variables most commonly used for the
cycle include volume, time, and flow.

24. Baseline
• The baseline variable refers to the proximal airway
pressure during the expiratory phase.
• This pressure can be equal to atmospheric pressure,
known as zero end-expiratory pressure (ZEEP), in which
the ventilator allows for complete recoil of the lung
and chest wall, or
• it can be held above atmospheric pressure by the
ventilator, known as positive end-expiratory pressure
(PEEP)

25. Mode of ventilation
• Types of mode in general
• Volume control : set volume and keep an eye on pressure.
• Pressure control : set pressure and keep an eye on Volume.
• Another element is that:
• Continuous: Machine not the patient doing work of
breathing.
• Intermittent : the patient can breath between the breath
set.

26. Mode of ventilation

27. Volume-Controlled Ventilation
• Volume-controlled ventilation, the target is flow, and the
cycle is volume.
• Increasing flow reduces the time required to deliver the set
tidal volume, which reduces inspiratory time for each
breath.
• Decreasing inspiratory time for each breath will then
increase expiratory time.
• Ventilator strategies to increase expiratory time in VCV:
• Decrease respiratory rate
• Decrease tidal volume
• Increase flow rate

28. Pressure-Controlled Ventilation
• In pressure-controlled ventilation, the target is
proximal airway pressure, and the cycle is time.
• Inspiratory time can be directly reduced, leading
to an increase in expiratory time.
• Tidal volume can be reduced by decreasing
proximal airway pressure.
• With decreased tidal volume, less time is needed
to fully expire the total administered tidal
volume.

29. Ventilator variables

30. PRESSURE CONTROL
(PCV)
• A mandatory amount of preset mechanical
breaths at a preset peak inspiratory pressure
are triggered and delivered.
• If the baby does not breaths spontaneously, a
mechanical breath is automatically given at a
preset rate and pressure.
• PCV is a very common mode of ventilation
in newborn and pediatric patients.

31. Screen of Mechanical ventilation

32. Types of Waveforms
• Scalars are waveform representations of
pressure, flow or volume on the y axis vs time on
the x axis
• Loops are representations of pressure vs volume
or flow vs volume

33. An arterial blood gas (ABG) test

34. Mechanical ventilation in simple way
• Mode : neonate to infant – PCV
• Fio2: 100
• PIP: 10 till TV :5-7 cc/Kg not reaching 10 cc/kg
• PEEP : 3 preterm . term 4-5 ( if O2 low can increase PEEP till 15 but we should give
fluid and inotropic drugs if more than 10 )
• Ti: preterm: 0.28 – 0.32 – Term: 0.3 – 0.40 ( you can increases )
• R.R: 30
• Triger: 1

35. An arterial blood gas (ABG) test
• ABG: you should know its arterial or venous : (Vein: saturation So2: less than 90)
• After 10 to 20 min of intubation do ABG
o IF PO2( arterial: 80 TO 100 & vein 40 normal because you will add 40)LOW:
Increase Fio2 then Increase PEEP
o IF PO2 High more than 100: Decrease FIO2 Till 60 then decrease PEEP
 PCO2 (Arterial 35 – 45 if venous + 10 ): do washing of Tube then do ABG
o More than 45: increase R.R if not respond till maximum then increase TV (PIP) if
not increase till 8 cc/Kg if not responding (PEEP + PIP NOT MORE THAN 40) then
increase Ti if not reduce PEEP bot not becoming Hypoxia.
o Low PCO2: vise versa is correct
• PIP and PEEP NOT SAME should be at lest 6 difference
• Sedation : Medazolam then Fentanyl

36. THANKS FOR YOUR
ATTENTION