Learning Objectives Covered 1. Explain Respiratory Failure and the two types of respiratory failure: hypoxemic and hypercapnic respiratory failure 2. List and describe the indications and objectives for ventilator support 3. Explain the advantages and disadvantages of volume and pressure ventilation> Background Mechanical Ventilation is indicated to assist the patient who cannot maintain adequate oxygenation, alveolar ventilation or lacks the ability to protect his or her own airway.The inability of a patient to maintain either the normal delivery of oxygen to the tissues or the normal removal of carbon dioxide from the tissues is referred to as acute respiratory failure. Though the three common indications for mechanical ventilation includes inability to maintain adequate oxygenation, inability to maintain adequate alveolar ventilation and/or inability to protect one’s own airway. There are more specific indications for mechanical ventilation and can be found in the table below. Indications   Definition Example Apnea Absence of breathing Cardiac Arrest Acute Respiratory Failure (ARF) Inability of a patient to maintain adequate: PaO2, PaCO2, and, potentially, pH. Hypoxemic RF Hypercapnic RF Impending Respiratory Failure Respiratory failure is immi-nent in spite of therapies. Commonly defined as:
 Pt is barely maintaining (or
 gradually deteriorating) normal  blood gases but
 with significant WOB. Neuromuscular Disease (N-M) Status Asthmaticus Chronic Respiratory Failure Repeated failures after attempts to liberate from the ventilator (extubations, Trach Collar trials, etc.) SEVERE: Obesity Hypoventilation Syndrome COPD Pulmonary Fibrosis Prophylactic Ventilatory Support Clinical indication = high risk of respiratory failure. Ventilatory support is instituted to ↓ WOB,minimize O2consumption and hypoxemia, reduce cardiopulmonary stress, and/or control airway with sedation. Brain injury Heart muscle Injury Major surgery Shock (prolonged) Smoke injury Trauma (some) Hyperventilation Therapy Ventilatory support is instituted to control and manipulate PaCO2 tor lower than normal level  Acute head injury (↑ ICP) (not immediately after injury) *respiratoryupdate.com Respiratory failure can be acute or chronic and is classified as either hypoxemic or hypercapnic. During hypoxemic respiratory failure, the patient’s ventilatory demands exceed the lung's ability to provide blood oxygenation resulting in muscle fatigue. Hypoxemic respiratory failure is defined as a PaO2 below the predicted normal range for the patient’s age under ambient conditions. A normal PaO2 for a patient that is 60 years or younger on room air is 80-100mmHg. When a patient is hypoxemic their body naturally responds to the low PaO2by increasing respiratory rate and/or tidal volume (an increase in minute ventilation). An increase in minute ventilation leads to hyperventilation. During hyperventilation, a greater than normal amount of CO2 is exhaled resulting in a low PaCO2 (h ...

1. Learning Objectives Covered
1. Explain Respiratory Failure and the two types of respiratory
failure: hypoxemic and hypercapnic respiratory failure
2. List and describe the indications and objectives for ventilator
support
3. Explain the advantages and disadvantages of volume and
pressure ventilation>
Background
Mechanical Ventilation is indicated to assist the patient who
cannot maintain adequate oxygenation, alveolar ventilation or
lacks the ability to protect his or her own airway.The inability
of a patient to maintain either the normal delivery of oxygen to
the tissues or the normal removal of carbon dioxide from the
tissues is referred to as acute respiratory failure. Though the
three common indications for mechanical ventilation includes
inability to maintain adequate oxygenation, inability to maintain
adequate alveolar ventilation and/or inability to protect one’s
own airway. There are more specific indications for mechanical
ventilation and can be found in the table below.
Indications
Definition
Example
Apnea
Absence of breathing
Cardiac Arrest
Acute
Respiratory Failure (ARF)
Inability of a patient to maintain adequate: PaO2, PaCO2,
and, potentially, pH.
Hypoxemic RF
Hypercapnic RF
Impending
Respiratory Failure

2. Respiratory failure is immi-nent in spite of therapies.
Commonly defined as: Pt is barely maintaining
(or gradually deteriorating) normal blood gases but with
significant WOB.
Neuromuscular
Disease (N-M)
Status Asthmaticus
Chronic
Respiratory Failure
Repeated failures after attempts to liberate from the ventilator
(extubations, Trach Collar trials, etc.)
SEVERE:
Obesity Hypoventilation Syndrome
COPD
Pulmonary Fibrosis
Prophylactic
Ventilatory Support
Clinical indication = high risk of respiratory failure.
Ventilatory support is instituted to ↓
WOB,minimize O2consumption and hypoxemia,
reduce cardiopulmonary stress, and/or control airway
with sedation.
Brain injury
Heart muscle
Injury
Major surgery
Shock (prolonged)
Smoke injury
Trauma (some)

3. Hyperventilation Therapy
Ventilatory support is instituted to control and
manipulate PaCO2 tor lower than normal level
Acute head injury
(↑ ICP)
(not immediately
after injury)
*respiratoryupdate.com
Respiratory failure can be acute or chronic and is classified as
either hypoxemic or hypercapnic. During hypoxemic respiratory
failure, the patient’s ventilatory demands exceed the lung's
ability to provide blood oxygenation resulting in muscle fatigue.
Hypoxemic respiratory failure is defined as a PaO2 below the
predicted normal range for the patient’s age under ambient
conditions. A normal PaO2 for a patient that is 60 years or
younger on room air is 80-100mmHg. When a patient is
hypoxemic their body naturally responds to the low PaO2by
increasing respiratory rate and/or tidal volume (an increase in
minute ventilation). An increase in minute ventilation leads to
hyperventilation. During hyperventilation, a greater than normal
amount of CO2 is exhaled resulting in a low
PaCO2 (hypocapnia).
Hypercapnic respiratory failure is defined as a PaCO2 level
above 50mmHg and a rising and a falling pH of 7.25 or less.
Hypercapnic respiratory failure may be accompanied by a
normal or low PaO2. A patient who is experiencing hypercapnic
respiratory failure is in imminent danger of cardiopulmonary
arrest and mechanical ventilation is essential.
Once the need for mechanical ventilation has been established
and the airway is secured the practitioner must select the type of
ventilator, breath type and ventilator mode that is most
appropriate for the patient.
The selection of a ventilatory support strategy is based on the
type of respiratory failure the patient demonstrates. For

4. example, a patient in hypoxemic respiratory failure can be
treated with various oxygen therapy devices to manage the
patient’s oxygenation status. The practitioner must be careful to
identify when a patient is experiencing refractory hypoxemia.
Refractory hypoxemia is a lack of oxygen in the blood that does
not respond to oxygen alone. These patients experience
intrapulmonary shunting, such as with pneumonia, pulmonary
edema, and atelectasis, which requires PEEP along with oxygen.
Patients who experience refractory hypoxemia can be treated
with devices such as high flow oxygen delivery devices and
CPAP.
In a patient presenting with hypercapnic respiratory failure, the
patient must be treated with ventilatory support to mange the
patients PaCO2 levels and acid-base status. For example, a
patient in hypercapnic respiratory failure must be intubated and
placed on mechanical ventilation. However, if hypercapnic
respiratory failure is noticed soon enough then practitioners can
treat these patients with noninvasive ventilatory support
(NIPPV) or Bipap. NIPPV has been proven to be effective when
implemented early and set correctly.
Either noninvasive ventilation or invasive ventilation can be
used as a ventilatory support strategy. Noninvasive ventilation
(NIV or NIPPV) is defined as any mode of ventilation that does
not require an invasive artificial airway (endotracheal tube or
tracheostomy tube). NIV/NIPPV includes CPAP or CPAP in
combination with any mode of pressure limited or volume
limited ventilation (BiPaP).
Invasive mechanical ventilation is defined as positive pressure
ventilation delivered via an endotracheal tube or tracheostomy
tube.
Once it as been determined that the patient should be placed on
noninvasive mechanical ventilation one of two methods can be
chosen:
1. CPAP (continuous positive airway pressure)
2. Noninvasive positive airway pressure (NIPPV) or BiPaP
Once it has been determined that the patient needs invasive

5. mechanical ventilation the practitioner must determine the mode
of ventilation and breath delivery type.
Modes of Ventilation
· Type of breath (mandatory, spontaneous, assisted)
· Targeted control breath (volume or pressure)
· Timing of breath delivery (continuous mandatory ventilation
(CMV), SIMV, or spontaneous
There are three types of positive pressure ventilators.
Volume cycled
a. Pressure is applied to the airway until a preset volume is
delivered.
b. Minute volume will remain constant.
c. Airway pressure will increase or decrease depending on the
patient's compliance and/or airway resistance.
d. Volume cycled ventilators can be used with most patients.
Pressure cycled
a. Apply positive pressure to the airways until a preset pressure
limit is reached.
b. Tidal volume (Vt) is adjusted by increasing or decreasing the
pressure limit.
c. Although peak pressure (PIP) will remain constant, the
volume will change as lung compliance/resistance change.
Time cycled
a. These ventilators provide positive pressure until a preset time
is reached.
b. The peak inspiratory pressure (PIP) is usually limited by an
adjustable pop-off valve.
c. Tidal Volume (Vt) is adjusted by increasing or decreasing the
peak inspiratory pressure, inspiratory time, or flow.
There are three breath delivery techniques aka modes of
ventilation.
1. Continuous Mandatory Ventilation (CMV)
a. All breaths are mandatory and can be volume or pressure
targeted.
b. Breaths can be patient triggered or time triggered.
c. When the breaths are patient triggered, CMV mode is called

6. A/C (assist/control)
d. When the breaths are time triggered the CMV mode is called
control mode.
e. CMV is commonly volume targeted (volume control
continuous mandatory ventilation (VC-CMV)
f. CMV can also be pressure targeted (pressure control
continuous mandatory ventilation (PC-CMV)
2. Synchronized Intermittent Mandatory Ventilation (SIMV)
a. Periodic volume-or pressure-targeted breaths occur at set
intervals.
b. Between mandatory breaths, the patient breaths
spontaneously at any desired pressure without receiving a
mandatory breath.
c. Synchronized Intermittent Mandatory Ventilation (SIMV)
works the same way as IMV except that the mandatory breaths
are time triggered rather than patient triggered.
3. Spontaneous
a. Spontaneous breathing - the patient can breathe through the
ventilator circuit (T-piece method). The ventilator monitors the
patient's breathing and can activate an alarm if necessary.
b. CPAP
c. PSV – (pressure support ventilation). The ventilator provides
a constant pressure during inspiration once it senses the patient
has made an inspiratory effort.
There are less frequently used modes such as MMV, APRV and
PAV as well as HFV, which will be later discussed.
Initial Settings for Mechanical Ventilation
1. Ventilation mode
a. Control, assist/control, IMV/SIMV
b. Any mode is acceptable for initial set up
2. Tidal volume, respiratory rate, FiO2 and PEEP
a. Tidal volume - 6-8 ml/kg of ideal body weight
b. Respiratory rate - 12 -18 breaths per minute
c. FiO2 - if patient is on room air or you have no prior
information, start the patient at 40-60%. If the patient is
currently on oxygen, set the ventilator FiO2 to the patient's

7. current setting.
d. PEEP - if the patient is currently on PEEP/CPAP keep it at
the same level. If the patient is not currently on PEEP/CPAP
start at 0-10 cm H2O.
Ventilation Mode
Modes of ventilation
1. Assist Mode
a. Patient initiates all breaths
b. No minimum respiratory rate
2. Control Mode
2. Ventilator will initiate breaths at a preset rate
2. Does not allow patient to initiate breaths
2. Indicated for head trauma/surgery patients
1. Assist/Control
c. Allows patient to set the respiratory rate
c. The ventilator will maintain a minimum rate
c. May be used with most patients
c. Ventilator controls tidal volume for every breath
1. SIMV Mode
d. Allows patient to breath spontaneously
d. Ventilator provides a minimum minute ventilation
1. Pressure Control Ventilation (PCV)
e. Pressure controlled breaths
e. Used when PIP is very high
e. Exhaled Vt will vary
e. Adjust IT or PIP as needed.
1. Pressure Support Ventilation (PSV)
f. Pressure support adds a preset amount of pressure during a
spontaneous breath
f. Helps the patient overcome the resistance of breathing
through an ETT and ventilator circuit
Prompt
For this assignment, you will provide detailed responses to the
following questions.
A 32-year-old man presents to the emergency department with a
2-day history of fever and cough. His chest film shows a right

8. middle lobe infiltrate. His room air ABG showed:
pH: 7.32
PCO2: 32 torr
PO2: 78 torr
HCO3- 18
He was started on antibiotics and admitted to the floor. Four
hours later, the nurse calls because she is concerned he is doing
worse. On your arrival to the room, his blood pressure is 85/60,
his pulse is 120 beats/min and his oxygen saturation, which had
been 97% on 2L oxygen via nasal cannula, is now 78% on a
non-rebreather mask. The patient is obviously laboring to
breathe with use of his accessory muscles and is less responsive
than he was on admission. On the lung exam, he has crackles
throughout the bilateral lung fields. The chest film now shows
increasing bilateral, diffuse lung opacities. An ABG is done
while on the non-rebreather and shows:
pH: 7.17
PCO2: 65
PO2: 58
HCO3- 16
1. Based on the clinical presentation of this patient, discuss how
you would address the treatment. Include in your answer the
following information: possible diagnosis, and what would be
appropriate therapy (invasive vs noninvasive ventilation), and
why?
2. Based on your choice of ventilation for this patient, discuss
appropriate initial settings to properly ventilate this patient.
Include and explain the following information in your answer:
If you choose noninvasive ventilation be sure to include IPAP
and EPAP settings (defend your position). If you choose
invasive ventilation be sure to include Mode of ventilation,
Tidal Volume (VT), respiratory rate (frequency), oxygen
percentage (FI02), Positive End Expiratory Pressure (PEEP) or
any other therapy that may be indicated.
Submit your answers in at least 500 words on a Word document.
You must cite at least three references in APA format and

9. defend and support your position.