1. Mechanical Ventilation: The Basics and Beyond
Presented By:
Diana Gedamke, BSN, RN, CCRN
Marion College - Fond du Lac

2. Mechanical Ventilation
“…an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again…and the heart becomes strong…”
Andreas Vesalius (1555)

3. Mechanical Ventilation
First described in 1555
First used in patient care during the polio epidemic of 1955
Medical students became human ventilators
First positive pressure ventilator was used at Massachusetts General Hospital

4. Indications for MV Acute Respiratory Failure (66%) Coma (15%)
Acute Exacerbation of COPD (13%)
Neuromuscular Disorders (5%)
Esteban et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000;161:

5. Indications for MV Acute Respiratory Failure ARDS Heart Failure
Pneumonia
Sepsis
Complications of Surgery
Trauma

6. Objectives of MV Decrease WOB
Reverse life-threatening hypoxemia or acute progressive respiratory acidosis
Protect against ventilator-induced lung injury
Wean and extubate as soon as possible

7. Caring for the Mechanically Ventilated Patient
Endotracheal tube
Position
Stability
Cuff inflation
Patency
Oral cavity
Trauma to lip and palate
Secretions

8. Caring for the Mechanically Ventilated Patient
Patient Position
Patient-Ventilator Synchrony
Physical Assessment
VS, General assessment, breath sounds
Ventilator Mode
Alarms
Reason for intubation
MV in disease states
Does patient still need to be intubated and mechanically ventilated?

9. Endotracheal Tube Nasal or oral Size (6 – 8.5 cm) Position
21 cm from the teeth in women & 23 cm in men
Confirm position by CXR (even when breath sounds are bilateral)
3 - 5 cm above carina
Affects of head position

10. Endotracheal Tube
Position
End Tidal CO2 to confirm ETT placement

11. Normal Airway

12. Endotracheal Tube Positioning

13. Complications of Intubation and Mechanical Ventilation
Sinusitis - occurs in > 25% of patients ventilated > 5days; nasal > oral; subtle findings (unexplained fever & leukocytosis), polymicrobial
Laryngeal damage - ulceration, granulomas, vocal cord paresis, laryngeal edema
Aspiration/Ventilator-associated pneumonia - occurs despite cuffed tube
Tracheal necrosis - tracheal stenosis, tracheomalacia
Death – ventilator malfunction/inadvertent
disconnection/endotracheal tube dysfunction/VAP

14. Preventing Infection Sterile suctioning Elevate HOB to 45 degrees
assess as routine part of assessment; only suction when patient needs it
Elevate HOB to 45 degrees

15. Positive Pressure Ventilation
Volume-cycled ventilation
Pressure-preset ventilation

16. PB 7200

17. Volume-cycled Ventilation
Delivers a preset volume of gas with each machine breath—airway pressures increase in response to the delivered breath
Airway pressures are higher in patients with low compliance or high resistance—high pressures indicate risk of ventilator-induced lung injury

18. Spontaneous Breathing vs. Positive Pressure Ventilation

19. Volume-cycled Ventilation
Assist Control (AC)
Synchronized Intermittent Mandatory Ventilation (SIMV)

20. Assist-control (AC) Most widely used mode of MV
Delivers a minimum number of fixed- volume breaths
Patients can initiate extra assisted breaths (will get full set volume with each effort)

21. Pressure-time Tracings Assist Control Mode

22. Synchronized Intermittent Mandatory Ventilation (SIMV)
Delivers preset number of fixed-volume breaths
Patient can breathe spontaneously between breaths (rate and depth determined by patient)
Patients often have trouble adapting to intermittent nature of ventilatory assistance

23. Pressure-time Tracings SIMV Mode

24. Pressure-preset Ventilation
Delivers a predefined target pressure to the airway during inspiration
Resulting tidal volume (VT) and inspiratory flow profile vary with the impedance of the respiratory system and the strength of the patient’s inspiratory efforts
Includes pressure-control (PC) and Pressure support (PS)

25. Pressure-control (PC) Ventilation
Delivers a preset gas pressure to the airway for a set time and at a guaranteed minimum rate
Patient can breathe in excess of set rate
Tidal volume achieved depends on pressure level, lung mechanics, and patient effort
Inspiratory flow rate variable

26. Pressure Support (PS) Delivers preset airway pressure for each breath
Variable parameters: Inspiratory and expiratory times (respiratory rate), flow rate, and tidal volume (VT)

27. SIMV + PS
Spontaneous breaths allowed in SIMV are assisted by PS

28. New Modes of MV New modes often introduced
Involves nothing more than a modification of the manner in which positive pressure is delivered to the airway and of the interplay b/n mechanical assistance and patient’s resp effort
Goals: enhance respiratory muscle rest, prevent deconditioning, improve gas exchange, prevent lung damage, improve synchrony, foster lung healing

29. Ventilator Settings Respiratory rate Tidal volume FiO2
Inspiratory:Expiratory (I:E) ratio
Pressure limit
Flow rate
Sensitivity/trigger
Flow waveform

30. Inspiratory Flow (V) Waveform
Square waveform Decelerating Waveform
(constant flow) (decelerating flow)

31. Inspiratory Flow (V) Waveform
Square waveform: volume of gas is evenly distributed across inspiratory time. Has highest peak pressure and lowest mean airway pressure. Ideal for those at risk for autopeeping due to short inspiration time

32. Inspiratory Flow (V) Waveform
Decelerating waveform: Volume of gas flow is high at the beginning of inspiration then tapers off toward the end of the breath. Has lowest peak pressure and highest mean airway pressure. Increased inspiratory time; useful in ARDS.

33. Patient-Ventilator Synchrony
Check for:
Symmetric chest inflation
Regular breathing pattern
Respiratory rate < 30 bpm
Synchrony between patient effort and machine breath
Paradoxical breathing

34. Patient-Ventilator Synchrony
Inspiratory effort expended by patients with acute respiratory failure is x normal
Don’t eliminate respiratory effort: causes deconditioning and atrophy

35. Patient-Ventilator Asynchrony
Possible causes:
Anxiety or pain
Ventilator settings may not be appropriate: check ABG and alert individual responsible for ventilator orders
Auto-PEEP
Pneumothorax

36. Ventilator Alarms and Common Causes
High Pressure
Low Pressure
Low Exhaled Volume
Kink in tubing
Patient biting ETT
Ventilator disconnected from ETT
Pressures exceeding high pressure limit
Secretions
Cuff leak
Coughing
Extubation
Ventilator disconnected
Bronchospasm
Foreign body

37. Definitions
PEEP – positive-end-expiratory pressure applied during mechanical ventilation
CPAP - continuous positive airway pressure applied during spontaneous breathing

38. PEEP
Improves oxygenation - increases functional residual capacity (FRC) above closing volume to prevent alveolar collapse
permits reduction in FIO2
Reduces work of breathing
Increases intrathoracic pressure - decreases venous return to right heart - decreases CO
Titrate to least amt. necessary to achieve O2 sat > 90% or PO2 > 60 mm Hg with FiO2 < 0.6

39. Auto-PEEP
Auto-PEEP/intrinsic PEEP (PEEPi)/inadvertent PEEP/occult PEEP - positive end expiratory alveolar pressure occurring in the absence of set PEEP. Occurs when expiratory time is inadequate.

40. Assessing Flow Waveform for Presence of Auto-PEEP

41. Resistance and Compliance

42. Definitions Peak Airway Pressure (Ppk)
An increase in Ppk indicates either an increase in airway resistance or a decrease in compliance (or both).
Plateau Pressure (Ppl) - end-inspiratory alveolar pressure

43. Airway Pressure Analysis

44. Ventilator-Induced Lung Injury
High volumes and pressures can injure the lung, causing increased permeability pulmonary edema in the uninjured lung and enhanced edema in the injured lung
Alveolar overdistention + repeated collapse and re-opening of alveoli

45. Mechanical Ventilation in Obstructive Lung Disease
resistance to expired flow
results in air trapping/hyperinflation
hyperinflation may result in cardiopulmonary compromise
Goal: meet minimal requirements for gas exchange while minimizing hyperinflation
Allow increased time for expiratory flow

46. Increasing Time for Exhalation
Decrease inspiratory time
Increase flow rate
Square waveform
Decrease minute ventilation (VE)
RR x TV

47. Monitoring Patients with Obstructive Lung Disease Requiring Mechanical Ventilation
Monitor plateau pressure: in general, Pplat < 30 cm H20 to decrease risk of hyperinflation and alveolar overdistension
Permissive hypercapnia

48. Respiratory Failure Due to Asthma
Watch for overventilation post intubation
High Ppk common
May require sedation to establish synchronous breathing with ventilator
Avoid paralytics
Ventilate as stated above (Increase exhalation time by decreasing RR and TV, increasing inspiratory flow rate, and using square waveform)
May want to use SIMV

49. Respiratory Failure Due to COPD
Ppk typically not as elevated as in asthma; when it is, think other pathologic processes
Many patients with COPD have chronic hypercapnia; ventilatory support titrated to normalize pH and not PCO2
Small levels of set PEEP may decrease WOB
May try NIPPV

50. Noninvasive Positive Pressure Ventilation (NIPPV)
Cooperative patient
Functionally intact upper airway
Minimal amount of secretions
Done by full face or nasal mask
Watch for gastric distension; may increase risk of aspiration
May use standard ventilators
Monitor patients closely for decompensation and need for intubation

51. ARDS: A Three Lung Unit Model
Normal
Non-recruitable
Recruitable

52. Respiratory Failure Due to ARDS
Refractory hypoxemia
Avoid ventilator induced lung injury
pressure-limited approach
keep Pplat < 30 cm H20
small tidal volumes (6 ml/kg)
permissive hypercapnia
Avoid O2 toxicity; apply moderate levels of PEEP

53. ARDS May need to increase inspiratory time
Inverse ratio ventilation (IRV)
I:E > 1:1
May require sedation/paralysis
Use as second-line strategy if PEEP fails to improve oxygenation

54. Mechanical Ventilation in Patients with Neuromuscular Weakness
Present with acute or subacute respiratory failure, usually with hypercapnia
progressive neurologic dysfunction (amyotrophic lateral sclerosis, muscular dystrophies, Guillain-Barre, CNS dysfunction due to head injury or drug ingestion)
usually ventilated without difficulty unless RF is complicated by secondary conditions (atelectasis or pneumonia)
lung compliance and gas exchange remain relatively normal

55. Does My Patient Still Need to Be Intubated and Mechanically Ventilated?
Evaluate daily when patient is hemodynamically stable and improving
Use “weaning checklist”

56. Discontinuation of MV
Most ( %) are able to have MV discontinued after reversal of physiologic process requiring support
No single approach to weaning has been shown to be better than any other
A particular approach, when improperly applied, can prolong process
General rules: work, rest, feed, allow to sleep

57. Weaning “Checklist” 1. Patient status 2. Mental status
Reversal of physiologic derangements requiring ventilatory support
Globally improving patient
2. Mental status
Alert, cooperative, able to follow commands
3. Secretions/airway protection
Absence of copious, thick, secretions
Patient ability to handle secretions/protect airway/intact gag reflex

58. Weaning “Checklist” 4. Oxygenation Ventilation
In general, need Pa02 > 60 torr (SaO2 >90%) on FiO2 < = 0.4 and PEEP < = 5.0 cm H2O
Ventilation
Baseline PCO2 achieved with Ve < 12 L/min
Rapid shallow breathing index, f/VT < 100 during spontaneous breathing (VT is in liters, e.g. 25/.4 = 62.5 with Ve = 10 L/min is predictive of success)

59. Weaning “Checklist”
If criteria 1 – 5 are met, decrease ventilatory support by, decreasing pressure support, or a trial of CPAP or t-piece. If tolerating after 2 hours, extubate.
If any of the above criteria are not met, continue ventilatory support and correct physiologic derangements (see below).
With regard to #5 (ventilation), if f/VT > 100, there is inadequate strength (assessed by NIF) or excessive ventilatory load (assessed by compliance) or both. (The patient must be strong enough for any given load to maintain spontaneous respirations.)

60. Weaning “Checklist” NIF must be more negative than –25 cm H2O
If not, increase strength (check TFTs, nutrition, Ca, Mg, PO4, K, avoid fatigue, avoid lung hyperinflation,? paralytics, ? aminoglycosides, ? critical illness polyneuropathy)
Increased ventilatory load – what is causing decreased compliance? (ARDS, pulmonary edema, pneumonia, atelectasis)

61. Weaning Methods
1. Trials of spontaneous breathing alternating with full ventilatory support
2. SIMV (longer than spontaneous breathing and PS)
3. PS

62. Weaning
Monitor clinical parameters: HR, RR, subjective distress, pulse oximetry, cardiac rhythm
If patient deteriorates either clinically or physiologically, terminate weaning trial
In general, initiate only one weaning trial in a 24-hour period

63. Extubation Reliable indices are not available LOC Gag Cough Secretions
Head lift
Do early in day
Suction and re-intubation equipment
Laryngeal edema, laryngeal spasm

64. Re-intubation 10 - 20% of patients require re-intubation
Mortality in these patients is > 6x as high as mortality among patients who can tolerate extubation

65. Case Study
You are the ICU nurse picking up Mr. James, who was admitted and intubated yesterday for pneumonia. You enter the room and notice that he is tachypneic and restless. His ventilator settings are: AC, rate 14, VT 700, FiO2 60%. He is currently breathing at a rate of 24. His O2 sat is 100%.

66. Case Study
What lab test would you check to assess his ventilatory status?
ABG
What are possible causes of his increased respiratory rate?
Secretions, anxiety, pain, vent settings may not be appropriate

67. Case Study ABG results: pH 7.48, PCO2 28, pO2 120
Based on the ABG, his vent settings are changed to SIMV, rate 10, PS +10, VT 700, FiO2 40%. How will these settings help Mr. James?

68. Case Study
You are the ICU nurse caring for a patient that was intubated for an exacerbation of COPD. When you enter the room, you notice that the patient is breathing out of synchrony with the ventilator and appears agitated and restless. The high pressure alarm is sounding. What could be the possible causes?

69. Case Study
Secretions, wrong vent settings (possible hyperinflation), anxiety

70. Case Study
You start your shift at 7:00 am and are picking up a patient that has been intubated for over a week for ARDS. You are told that he is doing well and may be able to be weaned today. When you complete your assessment, what will you specifically look at to report on rounds?

71. Case Study Patient status Mental status Secretions/airway protection
Oxygenation
Ventilation

72. Case Study Patient status 2. Mental status
Reversal of physiologic derangements requiring ventilatory support
Globally improving patient
2. Mental status
Alert, cooperative, able to follow commands
3. Secretions/airway protection
Absence of copious, thick, secretions
Patient ability to handle secretions/protect airway/intact gag reflex

73. Case Study Oxygenation Ventilation
In general, need Pa02 > 60 torr (SaO2 >90%) on FiO2 < = 0.4 and PEEP < = 5.0 cm H2O
Ventilation
Baseline PCO2 achieved with Ve < 12 L/min
Rapid shallow breathing index, f/VT < 100 during spontaneous breathing (VT is in liters, e.g. 25/.4 = 62.5 with Ve = 10 L/min is predictive of success)

74. Case Study
Increase strength: check TFTs, nutrition, Ca, Mg, PO4, K, avoid fatigue, avoid lung hyperinflation,? paralytics, ? aminoglycosides, ? critical illness polyneuropathy
Decrease load: ARDS, pulmonary edema, pneumonia, atelectasis

75. Case Study
Your patient with ARDS remains hypoxemic despite a high FIO2. What are other strategies to improve oxygenation?
Increase PEEP, check HBG, prone positioning, change vent settings to increase inspiratory time

76. Case Study Question
In caring for a ventilated patient, what strategies should you use to decrease the risk of VAP?
Closed suctioning only when needed
Frequent oral care
Upright patient

77. Case Study Question
Your intubated patient is requiring moderate amounts of PEEP to improve oxygenation. Discuss strategies to decrease the risk of complications from increased PEEP.
Increase volume, vasopressors, positive inotropic therapy, may need to decrease PEEP

78. Case Study
You are caring for a patient that was intubated for hypoxemic respiratory failure due to ARDS. Initial vent settings are AC, RR 18, TV 10 cc/kg, PEEP 7.5 cm H2O. On these settings, her Ppk is 45 cm H2O and Pplat is 38 cm H2O. There is no auto-PEEP. ABG is PO2 70 mm Hg, PCO2 46 mm Hg, and pH Which of the following ventilator changes would you make first?

79. Case Study decrease FiO2 decrease TV increase PEEP
decrease inspiratory flow rate
change to pressure control

80. References
Tobin MJ. Advances in mechanical ventilation. N Engl J Med, Vol. 344, No. 26, June 28, 2001.
Hall et al. Principles of Critical Care (2nd ed) (MV chapter)
Campbell RS et al. Pressure-controlled versus volume-controlled ventilation: does it matter? Resp Care 2002 (47;4)