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To Understand
Indications for Positive Pressure Ventilation
Invasive Positive Pressure Ventilation
Non-invasive positive pressure ventilation
The basics of
Positive pressure ventilation
Basic vent modes
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
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
Lungs
Barotrauma/Volutrauma
Ventilator Associated Pneumonia
Pneumothorax
Gas exchange
May increase dead space (compression of capillaries)
Inspiratory pressures
Auto-PEEP
Ventilator alarms
Bronchospasm
Mucous Plugging
Biting ET tube
Obstructed ET Tube
Pinched Circuit Tubing
Pulmonary Edema
ARDS
Pulmonary Fibrosis
Stiff Chest Wall
Pleural Effusion
Pneumothorax
Inspiratory Pressures
Peak inspiratory pressure (Ppeak)
Inspiratory plateau pressure (Pplat)
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
Noninvasive Ventilation
Ventilatory assistance provided via mask without
intubation
Can be volume or pressure mode
Patients must meet criteria to be candidates
Disadvantages of NIPPV
Speech
Eating
Intubation
Sedation
Less ventilator associated
pneumonia
Pressure sores
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
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
Other Factors
Secretions
How frequent is suctioning occurring?
Consistency
Base line
Chronic COPD
CO2 retention
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
Extubation Criteria
Ability to protect upper airway
Effective cough
Alertness
Extubated
Add supplemental oxygen
Watch for signs of decompensation
Avoid over sedation
Encourage coughing
Incentive spirometer
Out of bed