The Newest To-Do with Mechanical Ventilation

B. McLean

Lungs as a two compartment model

First compartment: AIRWAYS.
Do not participate in gas exchange referred as anatomic dead space

Second compartment: ALVEOLAR UNITS

responsible for gas exchange

Lung Mechanics

resistance = Dpressure / Dflow

flow

transairway pressure transrespiratory pressure volume transthoracic pressure

Elastance (compliance) = Dpressure / Dvolume

Lung Compliance and Elasticity

Compliance is ability of lungs to stretch
Low compliance in fibrotic lungs (and other restrictive lung diseases) and when not enough surfactant

Elasticity (= Elastance) is ability to return to original shape

Low Elasticity in case of emphysema due to destruction of elastic fibers.

Normal lung is both compliant AND elastic

Airway Resistance
The walls of the conducting respiratory passageways have resistance to the normal flow of air into the lungs The smaller the diameter, the greater the resistance Any condition that obstructs the air passageway increases resistance, and more pressure is generated to force air through (increasing the PiP) difference of pressure between mouth and alveoli. determined by 4 factors:
Flow rate Length of the airway. Physical properties of the gas Radius of the airway.

Compliance
How volume changes as a result of pressure change (C = V/P) Describes distensibility of the system PPlat
Represents the static end inspiratory recoil pressure of the respiratory system, lung and chest wall respectively Measures the static compliance or elastance

Assessment and Documentation of MV

Monitoring Airway Pressures
Peak Inspiratory Pressure (PIP or PPeak)
The highest pressure observed during inspiration Used to calculate dynamic compliance (CD) A constant VT with an PIP may indicate a in lung

compliance (CL) or an in Raw A declining PIP may indicate a leak or may a sign of improvement in CL or Raw

Peak and Plateau Pressures: Pattern Recognition

PiP with a Normal Pplateau

= Increased Raw
ETT trouble, Bronchospasm Give Bronchodilators

PiP with a Pplateau

= Decreased Compliance
ARDS, IPF, Pneumothorax, Effusions, Check synchronous expansion, BS, P/F

Oxygenation Basics

Gas concentration in alveoli

Maximum ventilation Normal Alveolar PO2 Normal Alveolar PCO2

PO2

Normal Hyper oxygenation

PCO2

Alveolar ventilation

Alveolar ventilation

Determined by:
absorption or excretion of gas level of alveolar ventilation Opening pressures (low inflection) Collapsing pressures

Interventions Fi02
Ventilation

MaP PEEP

Ventilation Basics

Simple terms
Ventilatory Modes
CMV, IMV, SIMV, A/C, PCV

Adjuncts to Mechanical Ventilation

PEEP, CPAP, PSV

Modes
Whenever a breath is supported by the ventilator, regardless of the mode, the limit of the support is determined by a preset pressure OR volume.
Volume Limited: preset tidal volume Pressure Limited: preset PIP or PAP

Assist Control Modes

Modes
Control Mode:
Every breath is fully supported by the ventilator In classic control modes, patients were unable to breathe except at the controlled set rate In newer control modes, machines act in assist-control, with a minimum set rate and all triggered breaths above that rate fully supported.

The Control VariableInspiratory Breath Delivery

Flow (volume) controlled
pressure may vary

Pressure controlled
flow and volume may vary

Time controlled (HFOV)

pressure, flow, volume may vary

Mechanical Ventilation
If volume is set, pressure varies..if pressure is set, volume varies.. .according to the compliance...
COMPLIANCE = D Volume / D Pressure

Assist Control
Pt. always receives a mechanical breath, cycled by time or patient effort Indicated when full ventilatory support is needed, used when pt. has a stable respiratory drive (10-12 spontaneous rate) Patient does ONLY the work necessary to trigger the vent
Typically, minimal (ie, 2 cm H2O)

EVERY breath receives desired VT or PC

Control Modes
Assist/Control (usually abbreviated A/C) AC, Volume
Tidal Volume is set and remains constant Respiratory Rate is set Patient may initiate a ventilator breath beyond set rate Airway Pressure varies according to lung compliance Ventilator will deliver set volume whether patient triggers a breath or mandatory breath is being delivered

Assist-control: Volume
Set variables
Volume, TI or flow rate, frequency, flow profile (constant or decel) PEEP and FIO2

Mandatory breaths
Ventilator delivers preset volume and preset flow rate at a set back-up rate

Spontaneous breaths
Additional cycles can be triggered by the patient but otherwise are identical to the mandatory breath.

Assist-control, volume

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical Care

Assist Control/Volume Control

Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger

Assist Control/Volume Control: Pressure /time relationsip

Both breaths receive the set tidal volume Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger

Assist Control/Volume Control

Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger

Assist Control/Volume Control: Pressure measures

Both breaths receive the set tidal volume

Mandatory Ventilator Breath On time

Ventilator Assist Spontaneous trigger

Peak pressure depends on the flow rate, tidal volume and lung mechanics

PEEP is the start and finish pressure

When to use PC, AC

Lung Compliance and Elasticity

Compliance is ability of lungs to stretch
Low compliance in fibrotic lungs (and other restrictive lung diseases) and when not enough surfactant

Elasticity ( Elastance) is ability to return to original shape Normal lung is both compliant AND elastic

Measuring pressures
PIP (Peak Inspiratory Pressure) Highest proximal airway pressure reached during inspiration MAP (Mean Airway Pressure) Average proximal airway pressure during the entire respiratory cycle, major determinate for oxygenation Plateau Pressure Airway pressure measured during an inspiratory hold. Used to determine a patients static lung compliance

Inspiratory Hold: PIP and Plateau pressures (VC)

Peak Pressure
Plateau
Proximal airway pressure

Inspiratory Hold

Over-distention

Resistance vs........... Compliance Load

Peak Pressure (Resistance)
Proximal airway pressure

Plateau (Distendability)

Inspiratory Hold

Pressure Control
Pressure Control Ventilation (usually abbreviated PCV or sometimes PCIRV)
Upper Airway Pressure Level is set and remains constant Respiratory Rate is set Tidal volumes will vary according to lung compliance Ventilator will deliver gas flow to set pressure level whether patient triggers a breath or mandatory breath is being delivered A lung protective mode

Pressure-Controlled Ventilation

Lucangelo, Respir Care 2005; 50:55

Pressure Control Breath Types

60

Paw
cmH20 -20 120

SEC

6
INSP

Flow
L/min

SEC

6
EXH

120

Volume/Flow Control
Inspiration
20

Pressure Control
Inspiration
20

Expiration

Expiration

Paw

Pressure
0
20 1

Paw
2

0
0 20 1

Volume
0 3 0 1 2 0 3 0 1 2

Flow

Time (s)

Time (s)

-3

-3

Pressure Regulated VC
Pressure Regulated Volume Control (usually abbreviated PRVC)
Tidal Volume is set, however may or may not remain constant Respiratory Rate is set Ventilator will deliver volume according to patients lung compliance A lung protective mode

Volume vs Pressure Control Ventilation

Volume Ventilation Volume delivery constant Inspiratory pressure varies Inspiratory flow constant Inspiratory time determined by set flow and VT Pressure Ventilation Volume delivery varies Inspiratory pressure constant Inspiratory flow varies Inspiratory time set by clinician

Pressure vs. Volume

Pressure Limited
Control FiO2 and MAP (oxygenation) Still can influence ventilation somewhat (respiratory rate, PAP) Decelerating flow pattern (lower PIP for same TV)

Volume Limited
Control minute ventilation Still can influence oxygenation somewhat (FiO2, PEEP, I-time) Square wave flow pattern

Pressure vs. Volume

Pressure Pitfalls
tidal volume by change suddenly as patients compliance changes this can lead to hypoventilation or overexpansion of the lung if ETT is obstructed acutely, delivered tidal volume will decrease

Volume Vitriol
no limit per se on PIP (usually vent will have upper pressure limit) square wave(constant) flow pattern results in higher PIP for same tidal volume as compared to Pressure modes

Dealers Choice
Pressure Control
FiO2 Rate I-time PEEP PIP

Volume Control
FiO2 Rate Tidal Volume PEEP I time MV

MAP

Why PEEP?
PEEP will decrease the cardiac output more critically and will also cause an increase in mPaw Why is this?
PEEP is always used with positive pressure ventilation CPAP is used with spontaneously breathing patients

Assessment and Documentation of MV

Monitoring Airway Pressures
Plateau Pressure (PPlateau)
Obtained by using the ventilators inspiratory pause of 0.5 1.5 seconds Static pressure is read when no gas flow is occurring Reflects the elastic recoil of the alveolar walls and thoracic cage against the volume of air in the lungs Cannot be measured accurately if the patient makes active respiratory efforts

Pplat and FRC

Measured by occluding the ventilator 3-5 sec at the end of inspiration Should not exceed 30 cmH2O

Peak and Plateau Pressures

Avoid:
Ppeak > 45 cm H2O Pplateau > 32 cm H2O

Peak and Plateau Pressures: Pattern Recognition

PiP with a Normal Pplateau

= Increased Raw
ETT trouble, Bronchospasm Give Bronchodilators

PiP with a Pplateau

= Decreased Compliance
ARDS, IPF, Pneumothorax, Effusions, Check synchronous expansion, BS, P/F

PEEP
Definition
Positive end expiratory pressure Application of a constant, positive pressure such that at end exhalation, airway pressure does not return to a 0 baseline

Used with other mechanical ventilation modes such as A/C, SIMV, or PCV Referred to as CPAP when applied to spontaneous breaths

PEEP
Increases functional residual capacity (FRC) and improves oxygenation
Recruits collapsed alveoli Splints and distends patent alveoli Redistributes lung fluid from alveoli to perivascular space

5 cm H2O PEEP

Problems with Auto-PEEP

Increased Pplat and over-distention
Increase work-of-breathing Hemodynamic effects Pneumothorax

Difficulty triggering ventilator

PEEP
Increases the PIP and mPaw In a study where PEEP was increased to 15cmH20 over 90 sec. the CVP and PAP had a considerable increase while the aortic pressure and CO decreased drastically. PEEP is used with PPV If a decrease in CO is seen due to PPV and PEEP intravascular volume expansion and positive inotropic agents can be used

Supportive Modes of Ventilation

Synchronized Intermittent Mandatory Ventilation (SIMV)
Tidal Volume/ Pressure control is set and delivered on each mandatory breath Respiratory Rate is set When a patient triggers the ventilator spontaneously , the patient receives a Pressure Supported breath

SIMV
Key set variables
Targeted volume (or pressure target), flow rate (or inspiratory time, Ti), mandated frequency PEEP, FIO2, pressure support

Mandatory breaths
Ventilator delivers a fixed number of cycles with a preset volume at preset flow rate. Alternatively, a preset pressure is applied for a specified Ti

Spontaneous breaths
Unrestricted number, aided by the selected level of pressure support

Synchronized Intermittent Mandatory Ventilation (SIMV)

Mandatory Ventilator Breath On time Fixed volume Spontaneous breath No ventilator assist Variable volume

Synchronized Intermittent Mandatory Ventilation (SIMV

Peak pressure depends on the flow rate, tidal volume and lung mechanics

Peak pressure not applicable

SIMV + Pressure Support

Mandatory Ventilator Breath On time Set volume Spontaneous trigger Pressure Support Variable volume

PEEPagain!

Basic Ventilator Modes

MODE VC
PC
Orders (FIO2, PEEP) Initiate Terminate (cycled) Flow Pressure VT

VT, RR (I:E)
Pinsp, RR (I time)

(P)atient (C)ontrolled
P, C

VT
I time

constant (usually)
decelerate

rising
constant

fixed
varies with compliance

Types of Ventilation
Volume Control
Pressure Control

A/C SIMV

A/C

PEEP

SIMV Support

When Patient requires aggressive Fi02 and/or PEEP, remember..

The Dangers of Overdistention

Repetitive shear stress
inflammatory response air trapping

Phasic volume swings: volutrauma Injury to normal alveoli

The Dangers of Atelectasis

compliance intrapulmonary shunt FiO2 WOB inflammatory response Give PEEP

ARDS

Ware & Matthay NEJM, 2000

Histopathology of VILI

Belperio et al, J Clin Invest Dec 2002; 110(11):1703-1716

What is our Goal??

Break the pulmonary injury sequence!!!
Lung Protection
Provide small alveolar volume swings Provide minimal alveolar pressure swings Provide lower peak airway pressures

Lung Recruitment
Open the lung with sustained inflation Prevent alveolar collapse

Advanced Management
Lung Protective Ventilation Strategies Avoid regional over distension Avoid barotrauma Transpulmonary pressure < 35 cm H2O Avoid repeated opening/closing of airway PEEP Avoid oxygen toxicity FIO2 as low as possible Lung Recruitment Strategies: Recruitment manuevers HFOV Inverse Ratio Ventilation APRV:

Role of Mechanical Ventilation in Lung Injury

Past Practices
Low or normal arterial CO2 Normal acid-base or alkalosis

Current Trends
Increasing tolerance for high or very high arterial CO2 Respiratory acidosis

Larger tidal volumes No PEEP

Small tidal volumes Optimal PEEP

Lung Protection

PEEP
Good.
Recruits Alveoli Improves FRC Redistributes Pulmonary Edema Fluid PaO2

Bad.
Venous Return / C.O. Risk of Barotrauma

Downloaded from www.ardsnet.org

Ventilation with lower tidal volumes as compared with traditional tidal volumes
The Acute Respiratory Distress Syndrome Network 2000.

861 patients randomly assigned to 6ml/kg or 12 ml/kg group 9 % decrease in mortality in low tidal volume group Targeted at 6 ml/kg PBW Range of 4-8 ml/kg depending on plateau pressures & pH Plateau pressures measured after 0.5 sec end-inspiration pause 30 cmH20

RESULTS Lower tidal volumes (6ml/kg) decreased mortality in patients with acute lung injury and acute respiratory distress syndrome
Increased the number of days without ventilator use

Increased organ failurefree days Decrease levels of IL-6 in low tidal volume group

Guidelines from ARDS Network

NIH NHLBI ARDS Clinical Network, Mechanical Ventilator Summary, revised Jan. 2005

Tidal Volume Strategies in ARDS

Traditional Approach High priority to traditional goals of acid-base balance and patient comfort Lower priority to lung protection
Low Stretch Approach High priority to lung protection Lower priority to traditional goals of acidbase balance and comfort

Why arent all patients on PLV

Compliance with LPV Before publication After publication Day 0 3% 1% Day 3 6% 3% Day 7 9% 7%

Changing Medical Practice is the Most Difficult Task

6 ml/kg tidal volume ventilation for ARDS Reasons for Non-Compliance
Reluctance to give up control to a protocol Patient comfort Acidosis Oxygenation

Therefore:
Most patients with ARDS are not managed with LPV

The open lung concept

ARDS multiple atelectasis, % of recruitable lung varied widely, from negligible to >50% The treatment for alveolar collapse is lung recuitment, the open lung concept (OLC) In healthy lungs, % of recruitable lung close to zero because normal function surfactant maintains alveolar units in a noncollapse status The goal of OLC collapse atelectasis and optimal gas exchange

The open lung concept

initial inspiratory pressure recruit collapsed alveoli, then minimal pressure prevent lung from collapsing Intrapulmonary suction renewed collapse of alveoli PaO2, must balance secretion management with alveolar recruitment Early OLC ( < 72hrs ) higher response rate, related to the change from exudate to a fibroproliferative process

PEEP
protection
Decreases atelectasis PaO2

recruitment
Recruits Alveoli Improves FRC PaO2

How Much PEEP?

Always pursue the sweet spot!

Overdistention
20

Sweet Spot

10

Atelectasis

Airway Pressure (cmH20)

0 13 33 38

Conflicting Actions of Higher Airway Pressure

Lung Unit Recruitment and Maintenance of Aerated Volume
Gas exchange
Improved Oxygenation Distribution of Ventilation

Lung protection
Parenchymal Damage Airway trauma

Increased Lung Distention

Impaired Hemodynamics Increased Dead Space Potential to Increase Tissue Stress

Only If Plateau Pressure Rises

What is a Recruitment Maneuver?

A Recruitment Maneuver is a procedure where a sustained positive pressure is applied, to an injured lung, over an increment of time, to recruit, open and keep open closed alveoli.

Why is Recruitment done?

Recruitment maneuvers are performed to help improve oxygenation, help improve distribution of ventilation, and improve shunts. To try and determine the Optimal PEEP to keep the lung from dynamic collapse and alveolar de-recruitment. *It is also done to re-recruit the lungs once there has been a break in the ventilation circuit.*

Opening and Closing Pressures in ARDS

High pressures may be needed to open some lung units, but once open, many units stay open at lower pressure.

50 40 Opening pressure Closing pressure

From Crotti et al AJRCCM 2001.

30 %
20

10 0
0 5

10 15 20 25 30 35 40 45 50 Paw [cmH2O]

Recruitment Maneuver
Purpose: Prolonged high alveolar pressure to recruit collapsed lung units Procedure: PEEP 30 40 cm H2O for 2040 sec. (subsequent high PEEP to maintain recruitment Repeat maneuver after a ventilator disconnect Specific approach and safety to be determined

How do you know it worked?

Improvements in oxygenation.
A 20% change or greater in PaO2/FIO2

Improvements in intrapulmonary shunting. Improvements in lung mechanics. Greater Tidal Volume for same pressure in (PC). Same Tidal Volume at less pressure in (VC).

How do you know it worked?

Lower Plateau Pressure for the same Vt after a RM has been applied. *Best after disconnection from ventilator or post suctioning. *Rapidly counters the prolonged drop in PaO2 post suction.

Conventional and Recruitment

Recruitment Maneuver Case Study

32 yr. Old woman transferred with sevr ARDS secondary to streptococcal sepsis: BP 50/30; pH 7.00; PaCO2 78; PaO2 21; PC34 (VT 300); PEEP 15; FIO2 1.0; rate 20 Recruitment maneuver: PEEP 40, PC 20, rate 10, I:E 1:1 for 2 minutes. Dramatic improvement in PaO2 and tidal volume PEEP 25 cm H2O needed to sustain recruitment Extubated 6 days after. Discharged 2 wks after.

Finding the sweet spot

BiLevel is not APRV but Both are protective

What is BiLevel Ventilation?

spontaneous breathing mode in which two levels of pressure hi/low are set Substantial improvements for spontaneous breathing
better synchronization, more options for supporting spontaneous breathing, and potential for improved monitoring

BiLevel Ventilation

Spontaneous Breaths 60

Synchronized Transitions

Spontaneous Breaths

Paw
cmH20 -20

What is BiLevel Ventilation?

At either pressure level the patient can breathe spontaneously
spontaneous breaths may be supported by PS if PS is set higher than PEEPH, PS supports spontaneous breath at upper pressure

BiLevel Ventilation

PressHigh + PS 60 Press H

Pressure Support

Paw
cmH20 -20

Press L

Then What Is APRV?

breathing mode in which two levels of pressure hi/low are set: sudden short releases in pressure to rapidly reduce continuous opening and allow for ventilation (Ex. C02) Can work in spontaneous or apneic patients Difference between the two: APRV very short expiratory time for PRESSURE RELEASE APRV looks like inverse I:E ratio BUT spontaneous breathing is allowed ONLY at upper pressure level
TH 5-8 secs TL 0.3 secs

Airway Pressure Release Ventilation Waveform

Pressure

50

Pressure hi

Release time (Tlo)

25 Time high (Thi) 0

Pressure lo

Time

APRV (Airway Pressure Release Ventilation)

Indications
Partial to full ventilatory support Patients with ALI/ARDS Patients with refractory hypoxemia due to collapsed alveoli Patients with massive atelectasis May use with mild or no lung disease

APRV (Airway Pressure Release Ventilation)

Advantages
Allows inverse ratio pressures (IRV) with or without spontaneous breathing (less need for sedation or paralysis) Improves patient-ventilator synchrony if spontaneous breathing is present Improves mean airway pressure Improves oxygenation by stabilizing collapsed alveoli Allows patients to breath spontaneously while continuing lung recruitment Lowers PIP May decrease physiologic deadspace

APRV (Airway Pressure Release Ventilation)

Disadvantages and Risks
Variable VT Could be harmful to patients with high expiratory resistance (i.e., COPD or asthma) Auto-PEEP is usually present (and desired) Caution should be used with hemodynamically unstable patients Asynchrony can occur if spontaneous breaths are out of sync with release time Requires the presence of an active exhalation valve

Maintaining Opening APRV - Principle of Operation

BiLevel (BIPAP,PCV+)
Preset RR, IT, PEEP & Pip Switches between press. based on pt insp and exp.

APRV
Preset T high, T low, P high & P low Switches between P high & P low based on set time intervals.

Oxygenation Index
OI = FiO2 x Paw PaO2
Predictor of mortality High value = bad outcome

Principles of Ventilation

Theoretical advantages of HFOV

Smaller VT
Limit alveolar overdistension

Higher mean airway pressure (mPaw/Pmaw)

More alveolar recruitment

Constant mPaw during inspiration and expiration

Preventing end-expiratory alveolar collapse

Rapid rates (up to 900 baby breaths/min) lung protective due to decreased volutrauma more efficient conventional ventilation methods

Pressure and Volume Swings

During HFOV, the entire cycle operates in the safe window and avoids the injury zones
INJURY

HFOV

INJURY

When Should HFOV be Initiated?

If FIO2 > .60 and PEEP > 10 cmH2O and unable to maintain SpO2 > 88% Unable to maintain Pplat < 30 cmH2O mPaw on CV is > 24 cmH2O Oxygen Index > 24

Patient requiring paralysis for oxygenation

ARDSnet or APRV not providing improvement

Earlier intervention produces better outcomes!!!!

Derdak S et al. Am J Respir Crit Care Med. 2002;166:801-808.

Mechanics of HFOV
FORGET any thing you apply in any other ventilation support mode (except Fi02) How does it work?
Gas Exchange

MAP Power/Amplitude Frequency Inspiratory Time %

107

Oxygenation and Ventilation

P (Amplitude)

Hz

(Frequency)

mPaw

(Mean Airway)

108

Mean Airway Pressure (mPaw)

Amplitude (DP)

Power Knob

I-Time %

Frequency (Hz)

mPaw Bias Flow Adjust

HFOV 3100B Mean Airway Pressure

Mean Airway Pressure (mPaw) is created by the continuous flow of gas

25-40 LPM

HFOV 3100B Power/Amplitude

Amplitude is a measurement created by the force that the piston moves with based on the POWER setting, resulting in a volume displacement and a visual CHEST WIGGLE It is represented by a peakto-trough pressure swing across the mean airway pressure

Primary control for ventilation (PaCO2 removal)

HFOV Amplitude Attenuation

proximal

trachea alveoli

HFOV 3100B Frequency/Hertz

Secondary control for ventilation Frequency controls the time allowed for the piston to move forward and backward Frequency has the largest impact on tidal volume than any other setting The lower the frequency, the greater the volume displaced

Principles of Ventilation
Frequency
To evaluate the effects of changes in frequency with regards to CO2 elimination, let us look at 2 different frequencies
4 Hz 8 Hz

Principles of Ventilation

Therefore, lower 4 Hz frequencies result in larger volume displacement which improves CO2 elimination
8 Hz

HFOV 3100B Inspiratory Time %

% IT controls the time for the movement of the piston during inhalation and therefore can assist with ventilation Increasing % IT may also have an impact on lung recruitment by increasing delivered mPaw

Allows more time for piston travel resulting in larger tidal volume

Theory of Operation
Controls for Oxygenation and Ventilation are mutually exclusive Oxygenation is primarily controlled by the Mean Airway Pressure (mPaw) and the FiO2 Ventilation is primarily determined by
amplitude which effects stroke tidal volume (DeltaP) frequency of the ventilator.

HFOV Simplified
CPAP with a wiggle
CPAP used to maintain Open Lung
control the CPAP level with mean airway pressure (mPaw)

Wiggle used to ventilate

We control the wiggle with amplitude (DP)

Safe Zone

Oscillations

Principles of Ventilation

Choosing Rotation Must not have contraindications CLRT or Kinetic Therapy Soft surface P/F > 300 Fi02 < 0.4 PEEP < 5 At risk for pneumonia, decubitius ulcer, atelectasis, immobility issues

Roto Rest Platform Prone

Roto Prone Prone

P/F < 300 Fi02 > 0.4 PEEP > 5

P/F < 200 Fi02 > 0.5 PEEP > 10 Alternative ventilation pPlat > 35

CMV PC APRV

Used with permission from B. McLean

Vent settings to improve ventilation

RR and TV are adjusted to maintain VE and PaCO2 Respiratory rate Max RR at 35 breaths/min Efficiency of ventilation decreases with increasing RR Decreased time for alveolar emptying TV Goal of 10 ml/kg Risk of volutrauma Other means to decrease PaCO2 Reduce muscular activity/seizures Minimizing exogenous carb load Controlling hypermetabolic states Permissive hypercapnea Preferable to dangerously high RR and TV, as long as pH > 7.15

Vent settings to improve oxygenation

MawP and FiO2 are adjusted in tandem Increased MawP Increases FRC Prevents progressive atelectasis and intrapulmonary shunting Prevents repetitive opening/closing (injury) Recruits collapsed alveoli and improves V/Q matching Resolves intrapulmonary shunting Improves compliance Enables maintenance of adequate PaO2 at a safe FiO2 level Disadvantages Increases intrathoracic pressure (may require pulmonary a. catheter) May lead to ARDS Rupture: PTX, pulmonary edema
Oxygen delivery (DO2), not PaO2, should be used to assess optimal PEEP.

Current Strategies for ARDS

Toolbox for this disease process
ARDSnet Study (6 ml/kg)
High PEEP lower Vt strategies

APRV, Bi-Level, Bi-Vent HFOV Therapeutic Modalities

Lung Recruitment Maneuvers Kinetic Therapy

Summary
Discuss, defend, discuss Protect Recruit turn turn turn oygenate? ventilate? flow that blood