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HIGHLIGHTS OF MECHANICAL

VENTILATION UNIT 4
Modes and initiation of ventilation
By
Elizabeth Kelley Buzbee AAS, RRT-NPS
The modes of ventilation:

A spontaneous breath is one that the patient
triggers and cycles the breath, and he controls
the V
T
. This breath could be assisted by the
application of positive pressure.

A mandatory breath is defined as one that is
triggered and cycled by the machine. All
mandatory breaths are assisted breaths.

The modes of ventilation: full
support modes
CMV: continuous mandatory ventilation in which
all breaths are mandatory.
VC-CMV volume control also called
Assist/Control mode
Set VT, f to get VE; guaranteed VT
Default ventilatory mode for full support with adults
PC-CMV pressure control mode. Patient can
trigger breaths just like with A/C
Set PIP, f and TI no guaranteed VT
Default ventilator mode for full support for infants
Indications for PC: the RCP selects
pressure ventilation when:
The adult patient who cannot be managed with
VC In this case, we keep the PIP less than 30
cmH
2
0.
PC results in better distribution of ventilation in
persons with unequal R
AW
, but consistent
compliances.
There is such an airway leak so that the V
T
are
unstable [most common with infants and small
children with uncuffed ET or tracheostomy tubes]

Compare PC to VC
In PC, the airway pressures; mPAW and PIP
will stay the same, but the VE and VT can vary
based on patients time constants
In VC the VE and VT are basically stable
[patient can increase f so VE could vary] the
PIP and the mPAW can be altered by patient
time constants
Compare control mode to
Assist/control
We control patients by giving them sedation
and paralytic agents so that the VE we set on
VC-CMV is exactly the same
We can control their PaC02 thus their acid
base balance
In A/C, the patient can trigger breaths that
will increase the VE, so that the VE based on
set VT and f could be lower than the actual
measured VE
Controlling the chronic
hypercapnic patient
If your patient has a hypoxic drive,
administrate enough Fi0
2
to get his Pa0
2

between 80-100 mmHg.
This will result in apnea and works as a form
of sedation in the first 24 hours.
Must wean the Fi02 to get Pa02 between 55-
65 mmHg before weaning
Problems with A/C
Excessively high P
AW
can cause problems with
hemodynamics once patient starts to breath.

Another problem with A/C mode is the risk of
auto-PEEP and air trapping.

Inverse Ratio Ventilation [with
PC or with VC]
This is a form of full support that uses
increased Ti to raise the mPAW when
patients compliance is so bad that PIP and
Pplateau are excessive
In IRV, the expiratory time is so short that the
patient never completely exhales. This works
like PEEP to recruit alveoli
Raising mPAW with IRV
mPAW = PIP [I] + PEEP [E]
I + E
Because we raise the inspiratory time so
much we can decrease the PIP
Because we create auto-PEEP with the short
TE, we can decrease the PEEP
Negative pressure
ventilation
The negative pressure ventilator is a box in
which the patients body [or chest wall] is
placed. A suction device is attached to the
box.
The NPV merely replaces the ventilatory
muscles.

Problems with Negative pressure
Ventilation: patient must be able to:
protect airway
Handle being supine all the time
hemodynamically stable
be comfortable in one position all the time
handle being disconnected from vacuum for
short time spans
More problems with NPV
Patient can get skin lesions from movement
of body inside the device
Patient can get cold from wind
Best 02 device is nasal cannula because 02
can be sucked into the neck opening


NPV
Classified as controllers, but newer models
can be A/C if there is a flow sensor placed on
the patients nose
Old metal iron lungs have a constant I:E of I:I;
newer fiberglass devices can have altered I:E
ratios

Setting parameters on NPV:

Change level of the vacuum to increase the V
T

[he could use a Wrights spirometer attached
to an IPPB mask to measure exhaled V
T
]
Change the respiratory rate.

CSV
continuous spontaneous ventilation in which
all breaths are spontaneous.
patient who can completely control his V
E

and only needs a little help such as with
increased baseline pressures [CPAP]
or some application of assisted breaths such
as pressure support [PS]
or who might require monitoring of V
E


Pressure support ventilation
PSV is the most common form of pressure
cycled CSV.
Although this does raise the airway pressure so
that we have a higher and lower pressure, we
call this PS rather than PIP because of the
specific characteristics of PS
Flow triggered and flow cycled
Patient controls his VT, f and inspiratory time

Indications for PS:


When used with SIMV to reduce the WOB by
increasing the spontaneous V
T.
We generally
select the PS that will deliver a reasonable V
T

[watch the spontaneous RR]
Can be used alone during weaning. Once a
patient is on a PS of 5-10 cmH
2
0, he is
considered at a level that only compensates
for RAW of the tubing, so is considered
consistent with spontaneous breathing.

PSV flow patterns
The flow pattern is descending till it reaches
5 LPM [or 25% of the peak flow] in which the
flow stops abruptly.
The flow slows down as the device attempts
to keep the PS at the preset pressure.

VT on PS
There is no guaranteed VT, nor VE, but we can
increase the VT by increasing the PS pressure
We need to set VE & high f alarms closely to
warn us of problems
The patient sends more air to Zone III
because he is using his diaphragm more with
PS


To choose the correct level of PSV
there are three methods:

get an appropriate V
T
[10-15 ml/kg] and titrate the PS level to
achieve this V
T


increase the PS level till the respiratory rate is normalized [25
bpm or less]

increase the PSV until you decrease the work of breathing
through the ET tube

To select the appropriate level of PSV to overcome the R
AW
use this
formula

PSV= (PIP - P
plateau
) x spont insp. Flow rate [l/sec]
Ventilator flow rate [l/sec]

PS
max

or straight pressure support or stand alone PS [
PS without SIMV.] In this case, the PS is not used
as a weaning modality but for initial of
mechanical ventilation.
We generally select a PS level that will deliver 10-
12 ml kg IBW.
The RCP must remember that this mode is an
assist only and the patients V
T
and V
E
will vary
base on lung dynamics. There is no guaranteed
V
T
.
Patient must have an intact ventilatory drive
for this to work

CPAP mode
spontaneous mode
application of PEEP without any positive
pressure breathes.
CPAP is merely a raised baseline with a flow rate
with adjustable Fi0
2
recruits alveoli which will improve diffusion of 0
2

CPAP can help return a low compliant lung back
to normal once atelectasis has been resolved.
The FRC should rise.
should decrease WOB.
proper application of CPAP should decrease
WOB- watch respiratory rates on this

CPAP interfaces
CPAP via the ET tube or a trach tube is called
CPAP
CPAP via a nose mask, face mask or full face
mask is called nasal-CPAP [n-CPAP]
Obviously we select the interface based on
the patients ability to protect his airway
n-CPAP indications

The successful candidate for n-CPAP would
be the patient who is oriented,
has good ventilatory drive without excessive
WOB
and who has the ability to protect his airway.

n-CPAP contraindications
Persons at risk for vomiting and aspiration
persons with skin necrosis,
claustrophobia.
CPAP indications

Management of the person who is in hypoxemia respiratory failure.
This patient will have refractory hypoxemia without respiratory
acidosis..

Treatment of Congestive Heart Failure [CHF] in the patient who
has an intact ventilatory drive and can keep his PaC0
2
down. CPAP of
8-12 with Fi02 100% is suggested. [Egans pp, 1095]

A weaning modality This invasive CPAP may be the last step before
extubation. Generally a patient can be extubated from a CPAP of 5-7
cmH
2
0 [or can be extubated at a stand-alone PSV of 5-7 cmH
2
0.

Non-invasive management of persons with obstructive sleep apnea
[OSA

APRV
a spontaneous mode
airway pressure release ventilation
Patient is breathing on two different levels of
CPAP


Initial settings for APRV for
ARDS:

The higher CPAP is set with the P
high
, while the P
low
sets the
lower pressure.
The RCP should also set the time interval [T
high
] for P
high

and the time interval [T
low
]for P
low

To initial APRV, the RCP looks to the patients P
plateau
on
PPV and uses that figure for the P
high
.
The T
high
is started at 4 seconds for adults and can be
progressively increased to 10-15 seconds
Set the P
low
at zero and use the release time [T
low
] to keep
the pressure from dropping to zero
Set the T
low
at about

.5 to .8 [one time constant] so that the
breath ends with the expiratory flow at 50-75% of peak flow

What happens if the patient
goes apnic?
During APRV ventilation if the patient was
stop breathing, the time-cycling between
high and low pressures would appear similar
to PC-IRV.
So this is a spontaneous mode that happens
to have a back up of sorts

Contraindications to APRV
persons with COPD or other problems
associated with air trapping.
persons with excessively high intracranial
pressures [high ICP]

Bilevel ventilation
An alternative to APRV is bilevel ventilation.
The only difference between bilevel
ventilation and APRV is that the patient
spends more time at the [P
low
] lower airway
pressure than at the high airway pressure
[P
high
].

BiPap- NIPPV
Non-invasive positive pressure ventilation
These BiPap breathes tend to be flow or time
triggered, flow cycled off
with the operator selecting PIP [called IPAP]
and PEEP [called EPAP] and bleeding in
supplementary 0
2
.
The newer Vision can get a Fi0
2
.
http://emedicine.medscape.com/article/1417959-treatment



contraindications/hazards of NIPPV

do not put this device on an apnic patient because it
is NOT a ventilatorit is a breath augmenter.
Persons who cannot protect their airways
Hemodynamically unstable patients
Facial burns or trauma
Uncooperative patients
Persons at risk for aspiration: vomiting, nose bleeds,
unconscious, poor gag reflex
Copious secretions
Anatomical problems with gas exchange

Indications for NIPPV: acute
care of:

congestive heart disease [n-CPAP or BiPap]
COPD patient who doesnt want to be
intubated
recently extubated patient who is at risk of
failing.
immune-suppression for whom we may not
want to risk VAP

Indications for long-term NIPPV
Long-term management of both obstructive
sleep apnea and central sleep apnea
Long-term management of patients with
skeletal or neuromuscular disorders
Long-term management of the COPD patient
who has s/s of chronic hypoventilation
[especially at night] and who is optimally
treated with drugs and other care.

Initial settings for BiPap:

IPAP at 8 cmH
2
0 and EPAP at 4 cmH
2
0.

.
Increase IPAP in increments of 2 cmH
2
0 to
deliver more V
T
.

To hypoxemia, increase the EPAP in increments
of 2 cm H
2
0.

Oddly enough, if the EPAP is raised without
raising the IPAP, the V
T
might decrease because
the V
T
is a function of the change in pressure or
the delta P [ P]


The BiPap ST/D


EPAP/CPAP: in this mode, all you get is CPAP
IPAP: in this mode, again, all you get is CPAP.
Spontaneous mode this is a form of PSV in which
you select the PS with the IPAP and the PEEP with
the EPAP. All breaths are patient triggered
Spontaneous/timed: is their version of A/C PC
with each breath patient or time triggered. In this
mode you select the bpm
Timed mode: their version of control ventilation
in which you now select the rate and the
inspiratory time

What is so strange about the
BiPAP ST/D circuit?

only a single, large-bore tubing going from
the compressor to the patients mask.
constant leak at the Whisper swivel this
will leak a minimal amount of gas out of the
circuit and between the very high flow rates
and the leak, the patient doesnt rebreathe
his C0
2
. Never plug up this hole!

Adding extra 0
2
to the BiPap STD
without starting a fire

add 0
2
at the mask,
start machine first before adding 0
2
so gas
will not leak back into machine
never exceed 15 LPM

Compare the BiPap STD to the Vision
BiPap machine

The BiPAP ST/D has no 0
2
inlet
The Respironics Vision plugs into 50 psig 0
2
&
can get 21% to 100% Fi0
2

The BiPAP ST/D has no internal alarm, you
must buy a separate alarm
The Respironics Vision can be used for
invasive ventilation with A/C, SIMV +PSV and
CPAP as well as NIPPV [CPAP and S/T]


Use of critical care ventilators such as
BiPap machines in the ICU.


As a rule, we would operate these machines
in the PSV mode with PEEP to mimic the
BiPap.
It is important to understand that the alarms
on these machines may have to be adjusted
out of range

Dual modes

combine mandatory ventilation with
spontaneous ventilation
IMV: intermittent mandatory ventilation: in
which some breaths are mandatory and
others are spontaneous.
In this type of breath, the ventilator will give
a PPV usually based on VC at timed intervals.
The patient can breathe off a constant flow
rate or from a demand valve at a V
T
and flow
rate determined by his muscle strength,
ventilatory drive and lung mechanics.

Advantages of IMV/ SIMV

patient comfort
maintains muscle coordination & muscle
strength
reduces V/Q mismatch;Zone III is being
utilized,
[4] lower P
AW
and is an excellent weaning
modality
less likely to cause air-trapping


Disadvantage of IMV/ SIMV:

If the patients PPV support is removed too
quickly the patient can suffer increased WOB

We need to monitor the spontaneous V
E
, RR
and V
T
, we may need to increase support by:
increasing the SIMV rate
adding PS


Indications for IMV/SIMV:

IMV is a partial mode of ventilation that
usually includes dual modes.
weaning from CMV when the patients
ventilator muscles are weakened
an initial ventilator setting when the patient is
at risk for air trapping and is breathing on his
own,
or if the patient who is able to breathe partially
for himself is at risk for decreased CO.



The difference between SIMV and IMV:
SIMV stands for synchronized intermittent
mandatory ventilation.
The mandatory breath can come in sooner if
patient triggers within the synchronization
window of fractions of seconds.

In a pressure regulated volume control mode,
we are attempting to deliver the V
T
[because
we are in VC mode] but we want to keep the
airway pressures low.

ventilator will attempt to deliver the V
T
at 5
cmH
2
0 below a preset pressure setting.

Special modes: PRVC


PRVC

Special modes: VAPS
volume assured, pressure support, the ventilator
will be attempting to deliver a stable V
T
with PS
breaths so that the patient has the advantage of
stable V
E
as well as the advantages of
If a PS breath fails to reach the pre-set V
T
, the
breath will continue at a constant flow until the
volume is reached. If the patient got the pre-set VT
with the PS breath, it stays PS.
Unlike normal PS, these breaths arent just flow
triggered, but can be time triggered.

Special modes: MMV
Mandatory minute ventilation
gives the patient extra breaths or extra PS
pressure to keep a predetermined minimal V
E
.

This differs from apnea parameters in that
the patient doesnt have to actually go apneic
for 20 seconds or more for this to activate. He
merely needs to have hypoventilation.


One problem with MMV
when the patient starts the rapid, shallow
breathing associated with respiratory
distress.
If a patient keeps the V
E
up with rate only, he
can be in a lot of distress
It is suggested to keep the maximal high
respiratory rate 10 BPM above the average
Special modes: ASV
adaptive support ventilation: the RCP inputs
the patients IBW and a percentage of the V
E
.
The ventilator will deliver a V
E
based on the
patients IBW.

As the patient takes over more of the breathing
the VE is maintained with PS breaths.
The level of PS changes to give the VT calculated
by the machine, The VT will be determined by
the patients IBW and VD ventilation.

Special modes: PAV
In proportional assist ventilation mode
similar to ASV in that the ventilator will
collect data about patients elasticity and
resistance and flow or volume demands in
order to arrive at PS levels that varies.

High frequency ventilation
controlled ventilation- the patient is sedated
and paralyzed
VT of less or equal to the VD
anatomical
respiratory frequencies of 60 BPM-3600 bpm
All HFV counts on the gas stream going down
the ET tube (inside) AT THE SAME TIME and
the gas flow existing (outside stream).
How does HFV work
Penduluft action due to various time
constants of different portions of the lungs,
the gas moves from one lobe to another ,

there is some bulk transfer

What are the types of HFV
high frequency jet ventilation
high frequency positive pressure
ventilation
high frequency oscillation
combination of HFJ with CMV

Special modes: PRVC
In pressure regulated volume control, an
effort is made to maintain both a safe level
of airway pressure and delivered V
T
.
In PRVC, the RCP selects a PIP that will
not be exceeded.
To keep the V
T
, at this safe PIP, the
inspiratory time and the flow rate must
vary.


Special modes: Auto-mode:
in some ventilators selection of the auto-
mode will allow the ventilator to decrease
support as a patient starts to take over the
WOB.
The ventilator reverts between a CMV mode
and a spontaneous mode based on breath by
breath assessment of the patient

Special modes: ATC
Automatic tubing compensation, in this
mode the ventilator will compensate for the
R
AW
of the ET tube.
INITIAL VENTILATOR SETTINGS
VT, set f and VE
Full support A/C or SIMV rate 12-16 BPM
Partial support SIMV below 10 BPM
8-10 ml/Kg IBW normal lungs
6-8 ml/kg IBW asthma
5-8 ml/ kg IBW for ARDS & COPD
VE needs to be 80-100 ml/KgIBW
TI and Flow rates
Inspiratory flow rates of 60-80 LPM for most
If air hungry raise above 80
COPD- 60-100 LPM
Inspiratory times .80-1.2 seconds

Flow wave pattern
Constant flows will decrease inspiratory time
and help with I:E ratios, but can raise the PIP.
Descending flow curve has the advantage of
better distribution of gas into the lung, but
will increase the T
I
and increase the mP
AW

Sine wave: while considered more
physiological, a classic sine wave may not
have enough initial flow to satisfy a patient.
Like the descending flow pattern it will raise
the T
I
and change the I:E ratio


Rise time or Ramp
: in an effort to fine-tune flow patterns, the
constant flow can be damped by a rise time
adjustments. When set high, this almost
mimics an ascending flow pattern.

Inspiratory pause

The temporary use of the inspiratory pause
at about .5 to 1 second is generally reserved
for gathering P
plateau

Fi02

100% is a good place to
Weaning rapidly to 40-50% after ABG
Fi02 needs to be weaned about 20% at a step.

PEEP
may be started at zero, PEEP at 5 or less
cmH20 is considered physiological and should
not result in CV problems-but-- remember
any PEEP that causes hemodynamic
problems is excessive.
Increase or decrease by units of 2

Humidification by HME
is limited to persons with good fluid balances,
normal secretions and V
E
less than 10 LPM
and normal body temperatures.
If the patient has a gross leak so that 30% of
the delivered V
T
is lost, the HME will not
work.


Humidification by heated
humidifier
can be used with everyone but are necessary
for patients with secretions. Keep the
temperatures close to 33
0
C +/- 2

Sighs:
multiple sighs every hour or so. These sigh
volumes were about 1.5 x the V
T.
important if VT is less than 7 ml/kg
s/p lung resection or lung
transplants
need lower V
T
and faster rates to protect the
torn lung from rupture.
Keep the P
plateau
at or below 30 cmH
2
0 [old
Egans 1011]

lobar pneumonia:

place patient on the good lung side so gas goes
to the bad lung
avoid PEEP in lobar pneumonia if possible
Try to prolong the Ti
Consider double lumen ET tube so we can set
two ventilators on the patient

long-term neuromuscular
patients

more comfortable at higher than usual V
T

[decrease the RR] of 10-12 ml/kg. These
patients also tend to want higher flow rates.
They can be managed with low Fi02-even .21
as long as Sp02 is above 90-92%
low PEEP of 3-5 to prevent atelectasis are ok

Persons with Congestive
Heart failure
We can start with normal settings, but if the
PIP and P
plateau
are excessive, we need to
decrease the V
T

PEEP at 10 cmH20 and wean the
Once the patients compliance gets better, we
must wean the PEEP
If the patient has an intact ventilatory drive, &
good VE, he could be maintained on CPAP

Initial parameters when High R
AW

is an issue?

start with SIMV because this mode is less
likely to cause air trapping.
minimize air trapping and auto-PEEP

COPD
SIMV rate between 10-12 BPM : decrease this to 6-8 to
allow time to exhale
start at 60 and raise to100 LPM].
A COPD patient can be started at 40-50% Fi02
Use of PEEP with COPD is dangerous, but if the set PEEP
and the auto-PEEP are kept about the same, the gas is
more likely to leave the lung
, keep Sp02 at 90-92% and keep the PaC0
2
and pH close
to baseline so the patient will not suffer post-hypercapnic
alkalosis

Asthmatic [AHI 2005 CPR CPG pp IV 141]

Alert? may do well on BiPap machine
SIMV rate 6-10 BPM
V
T
of 6-8 ml/ kg IBW
80-100 LPM with a descending flow pattern to
get 1:4 or 1:5
Start Fi02 at 100%.
Use of PEEP with asthmatics is dangerous, but if
the set PEEP and the auto-PEEP are kept the
same, the gas is more likely to leave the lung.
permissive hypercapnia,

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