Objectives

To Understand
Indications for Positive Pressure Ventilation
Invasive Positive Pressure Ventilation
Non-invasive positive pressure ventilation

How positive pressure ventilation helps

Reduce the work of breathing
Restore adequate gas exchange

The basics of
Positive pressure ventilation
Basic vent modes

Noninvasive positive pressure ventilation

Criteria for liberation from mechanical ventilation

Indications for Initiating IPPV

Ventilation Abnormality Hypercapnic Respiratory Failure

Respiratory muscle dysfunction

Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular disease

Decreased ventilator drive

Drugs
Neurologic disorder

Increased airway resistance/airflow obstruction

COPD/asthma

Indications for initiating IPPV

Intubation to facilitate procedure
Decreased mental status (unable to protect
airway)
Excessive secretions / Pulmonary toilet
Increased ICP Therapeutic Hyperventilation
Decrease systemic or myocardial oxygen
consumption

Common Modes of Ventilation

Volume targeted ventilation (flow controlled, volume cycled)
AC Assist Control or CMV Continuous Mandatory Ventilation
SIMV with PS-Synchronized Intermittent Mandatory Ventilation with
Pressure Support

Pressure targeted ventilation (pressure controlled, time

cycled)
PCV-Pressure controlled ventilation
SIMV with PS
PSV-Pressure Support Ventilation

Pressure and Volume Targeted

Ventilation
In pressure-targeted ventilation: airway pressure
and inspiratory time are set, while tidal volume
and flow are variable
In volume-targeted ventilation: tidal volume and
flow are preset and pressure and inspiratory time
are variable

Assist-Control
Set variables:
Tidal Volume, Respiratory Rate, flow
PEEP and FiO2

Mandatory breaths
Ventilator delivers set rate at the set tidal volume

Spontaneous breaths
Additional breaths can be triggered by the patient but
these breaths will still be at the set tidal volume

Assist-Control
Advantages
Increased ventilator support / decreased work of
breathing

Disadvantages
Hyperventilation
Hemodynamic effects
Vent-patient mismatch

Pressure Support
Pressure = set variable
Mandatory breaths: none
Spontaneous breaths
Ventilator provides a preset pressure assist, which
terminates when flow drops to a specified fraction
(typically 25%) of its maximum
Patient effort determines size of breath and flow rate

SIMV-Synchronized Intermittent
Mandatory Ventilation
Key set variables
Tidal volume, flow rate, respiratory rate
PEEP, FiO2, pressure support

Mandatory breaths
Ventilator delivers a fixed number of cycles with a preset
volume at preset flow rate

Spontaneous breaths
Tidal volume is determined by patient effort and is
assisted by the set amount of pressure support

SIMV-Synchronized Intermittent
Mandatory Ventilation
Advantages
Increased ventilatory support / decreased work of
breathing
Less risk of hyperventilation

Disadvantages
More work of breathing than assist-control

PEEP-Positive End Expiratory

Pressure
Helps prevent alveolar collapse during expiration
Can help improve oxygenation by
recruiting/opening collapsed alveoli
Decreases Preload-may help in acute pulmonary
edema, but can reduce cardiac output at high
levels
Can cause over distension of areas of normal
lung

Initiation of Mechanical Ventilation

Assist-Control Mode
Initial FiO2 = 1.0; decrease to maintain
SpO2>92% to 94%
Rate and minute ventilation appropriate for
clinical needs
PEEP to support oxygenation
Initial tidal volume = ?

Tidal Volume
Normal tidal volume is 7-8cc/kg ideal body wt
In the past tidal volumes of 10-15cc/kg were
standard
Barotrauma and volutrauma can be caused by
over distention of alveoli and can worsen acute
lung injury
ARDS Network study of lower tidal volumes
showed significant reduction in mortality and time
on ventilator with 6cc/kg vs. 12cc/kg

Important Pitfalls and Problems

Associated with PPV
Potential detrimental effects associated with PPV
Heart
Decreased pre-load

Lungs
Barotrauma/Volutrauma
Ventilator Associated Pneumonia
Pneumothorax

Gas exchange
May increase dead space (compression of capillaries)

Monitoring and Assessment

Measures After Initiation of IPPV
Chest radiograph
Vital signs
SpO2
Patient-ventilator
synchronization
Arterial blood gas

Inspiratory pressures

Inspiratory: expiratory ratio

Auto-PEEP

Ventilator alarms

High Airway Pressure

Airway Problem
Increased Airway
Resistance

Bronchospasm
Mucous Plugging
Biting ET tube
Obstructed ET Tube
Pinched Circuit Tubing

Lung/Chest Wall Problem-Decreased Lung Compliance

Pulmonary Edema
ARDS
Pulmonary Fibrosis
Stiff Chest Wall
Pleural Effusion
Pneumothorax

Inspiratory Pressures
Peak inspiratory pressure (Ppeak)
Inspiratory plateau pressure (Pplat)

Airway Resistance and Respiratory

System Compliance
Airway resistance = (Peak airway pressure
Plateau pressure) divided by the flow
Compliance = change in volume divided by the
change in pressure (Reflected in Plateau
pressure)
High Peak & High Plateau-Lung Problem
High Peak & Normal Plateau-Airway Problem

Auto-PEEP
Air Trapping/Breath Stacking-Failure to Fully
Exhale Previous Tidal Volume
Diagnosis-Waveform analysis

Auto-PEEP
Consequences
Increased Inspiratory pressures/ increased intrathoracic
pressures
Decreased venous return to the heart
Hypotension
Worsened oxygenation

Interventions to decrease auto-PEEP

Disconnect Patient from Ventilator
Decrease respiratory rate
Decrease tidal volume

Noninvasive Ventilation
Ventilatory assistance provided via mask without
intubation
Can be volume or pressure mode
Patients must meet criteria to be candidates

Candidates for NPPV

Respiratory condition expected to improve in 4872 hours
Alert, cooperative
Hemodynamically stable
Able to control airway secretions
Able to coordinate with ventilator
No contraindications

Key Differences Between NIPPV and

IPPV
Advantages of NIPPV

Disadvantages of NIPPV

Allows the patients to maintain normal functioning

Speech
Eating

Helps avoid the risks and complications related to

Intubation
Sedation
Less ventilator associated
pneumonia

Less airway pressure is tolerated

Does not protect against aspiration

No access to airway for suctioning

Not tolerated by some patients

Pressure sores

Clinical Use of NIPPV in Intensive

Care
Decompensated COPD (Hypercapnic Respiratory
Failure)
Cardiogenic Pulmonary Edema
Hypoxic Respiratory Failure
Other possible indications
Weaning (post-extubation)
Obesity hypoventilation syndrome
Post-surgery
Asthma

Contraindications to NIPPV
Cardiac or respiratory arrest
Nonrespiratory organ failure
Severe encephalopathy (e.g. GCS<10)
Severe upper gastrointestinal bleeding
Hemodynamic instability or unstable cardiac arrhythmia
Facial surgery, trauma, or deformity
Upper airway obstruction
Inability to cooperate/protect the airway
Inability to clear respiratory secretions
High risk for aspiration

Initiating NIPPV
Initial settings
Start with low pressures
IPAP 8-12 cmH2O
EPAP 3-5 cmH2O

Adjust inspired O2 to keep O2 sat > 90%

Increase IPAP gradually up to 20 cm H2O (as tolerated) to:

Alleviate dyspnea
Decrease respiratory rate
Increase tidal volume
Establish patient-ventilator synchrony

Discontinuation of Mechanical
Ventilation
To discontinue mechanical ventilation requires
Patient preparation
Assessment of readiness
For independent breathing
For extubation

A brief trial of minimally assisted breathing

An assessment of probably upper airway patency after
extubation

Either abrupt or gradual withdrawal of positive pressure,

depending on the patients readiness

Other Factors
Secretions
How frequent is suctioning occurring?
Consistency

Base line
Chronic COPD
CO2 retention

Rapid Shallow breathing Index

Resp rate/ tidal volume
If RSBI > 105: 95% extubations fail
If RSBI < 105: 80% extubations successful

Extubation Parameters
Respiratory Rate <40/min
Tidal Volume 5 ml/kg
Minute Ventilation < 10L/min
Vital Capacity 10 ml/kg
PaO2/FiO2 ratio >200
NIF -25cmH2O

Three Methods for Gradually

Withdrawing Ventilator Support
Although the majority of patients do not require
gradual withdrawal of ventilation, those that do
tend to do better with graded pressure
supported weaning than with abrupt transitions
from Assist/Control to CPAP or with SIMV used
with only minimal pressure support

Extubation Criteria
Ability to protect upper airway
Effective cough
Alertness

Improving clinical condition

Adequate lumen of trachea and larynx
Leak test during airway pressurization with the cuff
deflated

Extubated
Add supplemental oxygen
Watch for signs of decompensation
Avoid over sedation
Encourage coughing
Incentive spirometer
Out of bed