Which Dial Do I Turn!?

The Essence of Mechanical Ventilation

Peter DeBlieux, MD, FACEP LSUHSC Charity Hospital

Objectives
Describe initial ventilator settings and management of different types of patients Identify measures to optimize the mechanical ventilation while the patient is in the ED Describe the approach toward and identify patients who may benefit from noninvasive ventilation strategies

Invasive Mechanical Ventilation

Volume cycled

Pressure cycled Combined Pressure and Volume cycled

Modes of Mechanical Ventilation

CPAP Control Assist Control SIMV Pressure Support SIMV with Pressure Support

CPAP
Continuous positive airway pressure Equivalent to PEEP May be used in conjunction with pressure support Requires a spontaneously breathing patient

CPAP
Decreases the work of breathing by reducing inspiratory work Increases total lung volume Offers no back up rate Variable tidal volume dictated by effort

CPAP Mode
Lung Volume
Airway Pressure

Time

Control
Every breath is machine initiated and dictated Fixed tidal volume with each breath No utility outside of the operating room

Control Mode
Lung Volume
Airway Pressure

Time

Assist Control
Preset rate and tidal volume For each additional triggered attempt the ventilator will deliver a standard tidal volume breath Initial mode of choice for respiratory failure

Assist Control Mode

Lung Volume

Airway Pressure

Time

 Synchronized intermittent mandatory ventilation Preset rate and tidal volume synchronized to the patients efforts For each additional triggered attempt the ventilator will deliver a variable tidal volume breath dictated by patient effort and not ventilator supported

SIMV

SIMV Mode
Lung Volume
Airway Pressure

M P P

Time

Pressure Support
Preset pressure boost on inspiration Delivery of a variable tidal volume based on lung, chest wall, ventilator system compliance and patient effort Requires a spontaneously breathing patient

SIMV with Pressure Support

Offers the benefits of pressure support with the security of a back-up rate Pressure support is delivered each time the patient generates a negative inspiratory effort

SIMV + PSV
Lung Volume
Airway Pressure

Time

CPAP + PSV
Lung Volume

Airway Pressure

Time

What knobs do I need to know, and where do I set them?

Am J Respir Care Med 2000;161:1450-1458

Respiratory Rate
Typically set 10-20 bpm Must be set in consideration of tidal volume as the product results in minute ventilation Caution in reactive airways disease

Respiratory Rate
RR = 20 (resp cycle 3 seconds)
I
E

RR = 12 (resp cycle 5 seconds

I
E

Tidal Volume
8-10 cc/kg ideal body weight Factors together with respiratory rate to produce minute ventilation Consider reductions in patients with reactive airways disease or multilobar infiltrates to 6-8 cc/kg

PEEP
Positive end expiratory pressure Increases residual volumes and total lung volumes 5 cm H2O is considered physiologic by some and unnecessary by others High levels may limit venous return and potentially injure the lung

Alveolar Distention
PEEP
Good U g l y

6 cc/kg

10-15 cc/kg

Bad

Increasing Tidal Volume and Plateau Pressure Overdistending healthy alveoli

FIO2
Positive pressure ventilation alters the normal pulmonary physiology Start with 100% FIO2 and titrate to pulse oximetry Lung injury due to high levels of oxygen occurs at prolonged time greater than 24 hours at FIO2 greater than 70%

Peak Flow
The speed that a tidal volume is delivered Typically preset at 60 L/min Increased from 80-120 L/min in those patients with reactive airways disease May increase PIP but not plateau pressures

Sensitivity
The ventilators ability to sense the patients inspiratory efforts Measured in negative pressure cm H2 O Typically set at -2 cm H2O The more negative the pressure setting, the greater the work of breathing

Settings Summary
Mode Assist Control Respiratory rate 12-20 Tidal volume 8-10 cc/kg IBW PEEP 5 cm H2O FIO2 100% Peak flow 60 L/min

Lung Pressures
Peak Inspiratory Pressure (PIP)the highest inflection point reached during delivery of a breath Dictated by system and patient compliance No correlation with risk of lung injury

Lung Pressures
Plateau Pressure - if an inspiratory pause is placed at the end of inspiration, the needle comes to rest at a point- the plateau pressure Reflects the pressure witnessed by the alveolus and correlates with the risk of lung injury > 30 cm H2O

Plateau Pressure
Lung Volume Peak Airway Pressure Plateau Pressure

Airway Pressure
Time

Adjustments
To affect oxygenation, adjust:
FiO2 PEEP

To affect ventilation, adjust:

Respiratory rate Tidal volume

Ventilator Induced Lung Injury

High Pressures High Volumes High FIO2 Rapid Alveolar Opening Alveolar Injury
Am J Respir Crit Care Med 1998;158:1831-1838

VILI
Bronchial rupture Pneumothorax Pneumomediastinum Pulmonary interstitial emphysema Air emboli
N Engl J Med 2000 May 4;342(18):1301-8 / Resp Care Clin Nor Am 6:2,2000:213-252

Noninvasive Mechanical Ventilation CPAP BIPAP- bilevel positive airway pressure

Chest 1998;113:1339

Requirements for NIPPV

Cooperative patient

Spontaneously breathing patient

FiO2 Requirements < 50% Availability of equipment and therapist

Contraindications to NIPPV
Rapid deterioration Decreased mental status Aspiration risks Facial instability Excess secretions Chest 1998;113:1339

Case One
A 38 yo male presents with a history of MVC, sustaining a closed head injury. His presenting GCS was a 12 and during your secondary survey you note a decrease in responsiveness and a reduction in his GCS to 8, a dilated right pupil and paralysis of his left side. Quickly he is intubated ..

What are the recommendations for initial mechanical ventilator settings in a severely brain injured patient?

Severe Brain Injury

Mode __________ Respiratory rate ______ Tidal volume ____cc/kg IBW PEEP __cm H2O FIO2 ____% Peak flow ___L/min

Severely Brain Injured

Maintain PCO2 between 32-28 cm H2O Temporary measure only to limit blood flow to the brain in hopes of reducing ICP; renal compensation within 12 hours.

Case Two
A 52 year-old male presents somnolent with a depressed mental status following the ingestion of a fifth of whiskey and a full prescription of Valium. He presented with a respiratory rate of 4 and no gag reflex.

What are the recommendations for initial mechanical ventilator settings in an intoxicated patient with depressed respiratory drive?

Depressed Drive
Mode __________ Respiratory rate ______ Tidal volume ____cc/kg IBW PEEP __cm H2O FIO2 ____% Peak flow ___L/min

Depressed Drive
Aspiration risks remain in intubated patients
Depressed mental status Lavage and charcoal Supine positioning

Case Three
A 23 yo female with a history of asthma presents with acute onset of shortness of breath. Her RR is 34 and she has an initial PEFR of 100. Despite continuous aerosol therapy, steroids, oxygen, and magnesium. Her clinical exam and PEFR is unchanged. She is now anxious and confused.

What are the recommendations for mechanical ventilator settings in acute asthma?

Reactive Airways
Mode __________ Respiratory rate ______ Tidal volume ____cc/kg IBW PEEP __cm H2O FIO2 ____% Peak flow ___L/min

Case Four
A 55 yo female presents with multilobar pneumonia extensively involving both lung fields. She is not maintaining oxygen saturations on 100% NRB and she begins to tire.

What are the choices for patients with multilobar infiltrates, edema and extensive disease patterns?

Multilobar Disease
Mode __________ Respiratory rate ______ Tidal volume ____cc/kg IBW PEEP __cm H2O FIO2 ____% Peak flow ___L/min

Case Five
A 30 yo male has just been placed on mechanical ventilation following a severe MVC. He sustained multiple rib fractures that created a flail segment and awaits CT scan of his head and abdomen. The mechanical ventilator begins to alarm and the nurse informs you his BP is 60/palp!!

How do you trouble shoot mechanical ventilators??

Trouble Shooting
Disconnect the patient from the ventilator and bag the patient with 100% oxygen Confirm ETT placement-A Auscultate the lungs-B Consider other causes of circulatory compromise-C Keep needle and tube thoracostomy kit handy

Common Problems
ETT- extubation, plug, mainstem, kink Tension pneumothorax Dynamic hyperinflation Agitation Equipment failure - ventilator, suction, oxygen delivery, nebulizer