VENTILATORS!

A Practical Guide
Ben White
 GOALS

1) To discuss the basics of machine assisted ventilation

2) To provided a resource for future residents in managing ventilators
3) To demystify certain vents and vent modes
HISTORY OF VENTILATION

- Long

- Interesting

- Not very useful

 VARIABLES

• FiO2

• PEEP

• Rate

• Vt – Tidal Volume

• PIP – Peak Insp Pressure

• I-Time

• PS – Pressure Support

• Ramp
 VARIABLES

OXYGENATION VENTILATION
• FiO2 • Rate
• PEEP • PIP
• I-time • Volume

• PS (Kinda)
 1 y/o w/ RSV

Admitted to floor yesterday DOI

#2 on NC

Significantly increased WOB

CASE overnight

Transferred to PICU, no
improvement on BiPAP so intubated

What are your vent settings?

 RATE

• Range generally 10-30

• Above 30 start worrying about
breath stacking
• Below 10 worry about periods of
apnea
• Patient will often breath above your
set rate
• Think about your pressure support
• Select appropriate rate when pt
paralyzed

RATE CO2
 PIP
( P E A K I N S P I R ATO RY P R E S S U R E )

• Independent variable in PC mode / Dependent in VC mode

• Healthy lungs usually will have PIPs in low to mid 10s
• (Value includes PEEP)
• Vents have “pop-off” that prevents too high of pressures and
barotrauma
• <30 is fine PIP CO2
• 30-35 is concerning
• >35 is usually avoided
 VOLUME

• Independent variable in VC mode / Dependent in PC mode

• Normal tidal volume ~5-10 mL/kg (depends where you look)
• Target 6-8 mL/kg in PICU
• Target 4-6 mL/kg in NICU
• Higher Vt risks volutrauma
Vt CO2
• Typically set and then not adjusted much
 PRESSURE SUPPORT

• Gives extra support for spontaneous patient breaths

• Represents a pressure given in addition to pt’s effort
• (Value does not include PEEP)
• Should be set at a baseline level to overcome ETT resistance
• 10 for ETT 3.0-3.5
• 8 for ETT 4.0-4.5
• 6 for ETT >5.0
• Adjust up if pt taking small spontaneous volumes compared to vent given breaths
• Adjust down in preparation for extubation (but not below level for tube
compensation)
 FIO2

• - Under 60% probably Ok

• - Over 60%
• - Getting sicker
• - Is PEEP high enough?
• - pHTN?
• - Oxygen toxicity
• - ROP in neonates <31 wks
• - Pulm and CNS cellular effects
• Primarily effects oxygenation by
determining lung expansion
• Physiologic PEEP ~ 5 cm H2O
• Range from 5-10 typically
• As high as 14 on rare occasions
• Once >10 often start thinking about
oscillators PEEP
(POSITIVE END EXPIRATORY
• Increase for:
PRESSURE)
• FiO2’s >60%
• CXR findings of poor
expansion/atelectasis
• Decrease for:
• FiO2’s <50%
• CXR findings of overexpansion
• Typically a set value
• In some modes is patient
controlled
• Increased i-time can improve
oxygenation
• I-time setting: I-TIME
• No set guidelines
• Range: 0.3-1.2 sec
• Titrate to pt comfort and
oxygentation
 Trigger

 How is the Limit

breath initiated?
Cycle
 Time
 What variable
VENTILATOR  Flow/Pressure is targeted?
 What ends the
MODES change
 Pressure breath?
 Volume  Time
 Flow decay
 Volume
reached
 Classic Classic Drager

 IMV  A/C (Assist Control)  SIMV

(Intermittent mandatory
ventilation)  Flow triggered  PCV
(with backup)
 Time triggered  CMV
 Pressure or Volume
 Pressure or Volume targeted  CPAP
targeted  MMV
 Time cycled
 Time cycled  APRV
 PSV
VENTILATOR  SIMV (Pressure support  PSV-VG
(Synchronized IMV) ventilation)
MODES
 Time and flow  Flow triggered
triggered (with backup)
 Pressure or Volume  Pressure targeted
targeted
 Flow cycled
 Time cycled
 • 1 y/o w/ RSV bronchiolitis intubated on DOI #4
• Pressure limiting at 30
CASE • Getting ~ 6 mL/kg Tv
• Gas: 7.25/55/57/21/-3
 SIMV
(DRAGER FOR SIMV-PRVC)

• Autoflow
• Turns normal pressure control into volume
targeted mode
• Maintains decelerating flow waveform
• Main benefit = Lower airway pressures
Volume Control Pressure Control
 Variables Advantages Disadvantages
• Tv set • Consistent volumes, • Ventilation difficulty with
• PIP varies limiting atelectasis or air leaks
• PS for spontaneous volutrauma
breaths • Autoweaning as
compliance improves

SIMV
(DRAGER FOR SIMV-PRVC)
 Variables Advantages Disadvantages

• PIP set • Control over pressure • Vt can have large

• Tv varies • Reduce PIPs with swings with
• PS for large air leaks compliance changes
spontaneous
breaths

PCV
(DRAGER FOR SIMV-PC)
 Variables Advantages Disadvantages
• Tv or PIP set • Rest/Comfort mode • De-conditioning of
• The other varies for pt respiratory muscles?
• Every breath fully • Will need to switch
supported to a weaning mode

CMV
(DRAGER FOR A/C)
 Variables Advantages Disadvantages

• PS • Comfortable, pt • No guaranteed MV
• Set backup RR driven ventilation • Risk of insufficient
• Usually used with low • Pt controls i-time ventilation
PEEP and MV

CPAP
(DRAGER FOR PSV)
 Variables Advantages Disadvantages
• Minute ventilation • Comfortable • Less control over
• (RR + TV) • Pt has unrestricted ventilation
• PS spontaneous breathing
• Vent delivers breaths if
MV falls below goal

MMV
(MANDATORY MINUTE VENTILATION)
 Variables Advantages Disadvantages
• Set P-high and P-low • Comfortable • Vt not controlled
• Set time in each • Pt has unrestricted • Increased WOB?
• Inverse I:E Ratio spont. breathing
• Permits consistent
higher MAP

APRV
(AIRWAY PRESSURE RELEASE VENTILATION)
 APRV
(AIRWAY PRESSURE RELEASE VENTILATION)
 Variables Advantages Disadvantages
• Tv set • Better synchrony • Ventilation
• PS set with pt controlling difficulty with
• PIP varies I-time air leaks
• I-time variable

PSV-VG
(PSV WITH VOLUME GUARANTEE)
 • 1 y/o w/ RSV bronchiolitis intubated on DOI #4
• Worsening hypoxia and hypercapnia
CASE
• Gas: 7.1/74/52/19/-4
• CXR – Significantly increased RLL opacities
 OSCILLATOR

Variables Advantages Disadvantages

• Hz • Constant distending • May need heavy
• Amp pressure sedation/paralysis for
• MAP • Ability to use high optimal function
MAPs • High pressures affecting
• Active exhalation cardiac output
• Limiting of VILI?
AMP
MAP 23 35

33

Hz CO2 AMP CO2 MAP Oxygenation

Hz 7.5
 OSCILLATOR

• Indications
• Hypoxic respiratory failure
• Premature infants
• Rescue ventilation
• Pearls
• Look for bounce
• Hz will depend on age
• Amp should be < 3x MAP
• Some leak is needed
 VDR
(VOLUMETRIC DIFFUSIVE
(Ventilator of Death and Regret)
RESPIRATOR)

Variables Advantages Disadvantages

• Percussive Rate (Hz)
• Conventional Rate (I:E)
• P-high
• P-low
• Secretion Removal • May need heavy
• Ability to use high sedation/paralysis for
MAPs optimal function
• More distending • Pressures reliable?
pressure than conv. • Provider comfort

PR CO2 CR/P-high CO2 P-Low Oxygenation

• Indications
• Secretion management
• Rescue ventilation
 VDR
(VOLUMETRIC DIFFUSIVE RESPIRATOR)
 JET VENTILATOR

Variables Advantages Disadvantages

• Percussive Rate (Hz) • Ability to use high • May need heavy
• Conventional Rate MAPs sedation/paralysis for
• PIP • More distending optimal function
• PEEP pressure than conv. • Provider comfort
• I-time set at 0.02s • Advantages of Osc with
more effective
ventilation?
• Reliable pressure
readout

PR CO2
 Indications

• Interstitial emphysema
• Rescue ventilator

Notes

JET VENTILATOR • Oscillatory ventilation using a flow

interrupter
• Used in conjunction with convention vent
• Provides PEEP and conventional rate
• Servo pressure? Huh?
• Measure of lung compliance similar to
Vt in a PCV type mode
FUNCTIONS OF MAP
AND FREQUENCY
WITH BABYLOG 8000