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1 Mechanical Ventilation & Strategies for Oxygenation Dawn Oddie.

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1 1 Mechanical Ventilation & Strategies for Oxygenation Dawn Oddie

2 2 What are we going to talk about?   Physiology   Ventilation classifications   Types of Ventilation   Optimising Oxygenation   Complications of Ventilation   Weaning from Ventilation

3 3 Physiology

4 4 Where it all happens! 300 million alveoli

5 5 Physiology of normal breathing How do we breathe? Low lung volume (Exhalation) / Functional residual capacity High lung volume (Inhalation) Negative pressure I:E ratio times Tidal volumes Respiratory rate Active inspiration Passive expiration

6 6 How is normal breathing controlled How do you know,   Rate - How fast / slow to breathe?   Tidal volume - How big a breathe to take in?   I:E ratio – How long to breath in / out for?   When to cough / sneeze?

7 7 Nervous Control / Chemical   Respiratory centre. Reticular formation – brain stem – –Medullary rhythmicity area – –Pneumotaxic area / Apneustic area (transition from I to E)   Inflation (Hering-Breuer) reflex - Stretch receptors   Cortical influences – cerebral cortex giving some voluntary control eg hold breath underwater   Central chemosensitive area (pH / H + ) – Medulla   Peripheral chemoreceptors (CO 2 / O 2 / H + ) – carotid bodies   Proprioceptors – joints / muscles   Other influences – Baroreceptors / Temp / Pain / stretching the anal sphincter muscle / Irritation of the air passages

8 8 Lung Volumes

9 9 Respiratory Mechanics- Compliance   Compliance is ΔV/ΔP (Change in Volume / change in pressure) – –Total lung is made up of thoracic and lung compliance   Pulmonary compliance (or lung compliance) is the ability of the lungs to stretch during a change in volume relative to an applied change in pressure.   Compliance is greatest at moderate lung volumes, and much lower at volumes which are very low or very high. LIP and UIP can be good guides   Pulmonary Surfactant increases compliance by decreasing the surface tension of water. The internal surface of the alveolus is covered with a thin coat of fluid. The water in this fluid has a high surface tension, and provides a force that could collapse the alveolus. The presence of surfactant in this fluid breaks up the surface tension of water, making it less likely that the alveolus can collapse inward. If the alveolus were to collapse, a great force would be required to open it, meaning that compliance would decrease drastically.

10 10 Respiratory Mechanics- Compliance   Low compliance indicates a stiff lung and means extra work is required to bring in a normal volume of air. This occurs as the lungs in this case become fibrotic, lose their distensibility and become stiffer.   In a highly compliant lung, as in emphysema, the elastic tissue has been damaged, usually due to their being overstretched by chronic coughing. Patients with emphysema have a very high lung compliance due to the poor elastic recoil, they have no problem inflating the lungs but have extreme difficulty exhaling air. In this condition extra work is required to get air out of the lungs.

11 11 Causes of Decreased Intrathoracic Compliance Decreased Chest Wall Compliance Decreased Lung Compliance Obesity Ascites Neuromuscular weakness Flail Chest Kyphoscoliosis Paralysis Scleroderma Pectus Excavatum Tension Pneumothorax Intubation Pulmonary oedema ARDS Connective tissue disease Sarcoidosis Dynamic Hyperinflation Lymphangitis Carcinomatosis

12 12 Some Important Physiology   V/Q Mismatch   Oxygen Cascade   Oxyhaemoglobin Dissociation Curve   Spirometry Trace

13 13 Supply and demand   V/Q mismatch – –V = Ventilation – –P = Perfusion – –Hypoxic Pulmonary Vasoconstriction   Functional alveoli   Permeable membranes   Circulating volume – with – –Adequate haemoglobin levels – –Oxygen saturation of haemoglobin (affinity) – –Oxygen dissociation – –Perfusion pressure

14 14 When room air just isn’t enough…..   Increased metabolic demand   V/Q mismatch – –Damaged alveoli / airways – –Blocked alveoli – –Inadequate circulation

15 15 Some indications to increase O 2   Acute respiratory failure eg pneumonia, asthma, pulmonary oedema, pulmonary embolus   Acute myocardial infarction   Cardiac Failure   Shock   Hypermetabolic states eg major trauma, sepsis, burns   Anaemia   Carbon monoxide poisoning   Cardio respiratory resuscitation   During / post anaesthesia   Pre-suction   Suppressant drug eg narcotics   Pyrexia (Oxygen consumption increases by 10% for each degree rise)

16 16 Effect of insufficient oxygen   Reduced oxygen supply leads to cellular shift from aerobic to anaerobic metabolism   Production of lactic acid   Increasing metabolic acidosis – –Low pH – –Low HCO 3 – –Negative base excess   Cell death / system wide failure

17 17 What is oxygen   What percentage of oxygen is in atmospheric air? In normal circumstances with a average respiratory rate sufficient to meet metabolic demands Oxygen delivery (mls O 2 /min) = Cardiac output (litres/min) x Hb concentration (g/litre) x 1.31 (mls O 2 /g Hb) x % saturation   Oxygen Consumption = mls / min

18 18 Haemoglobin

19 19 Haemoglobin   Intracellular protein contained within erythrocytes (red blood cells)   Made up of 2 pairs of polypeptide chains (2Alpha, 2 Beta), each bound to a haem group that contains iron. Each molecule of haemoglobin can combine with 4 molecules of oxygen   Primary vehicle for oxygen transportation in the blood (small amount in plasma Approx 1.5-3%)   Each haemoglobin molecule has a limited capacity for holding oxygen molecules. How much of that capacity that is filled by oxygen bound to the haemoglobin at any time is the oxygen saturation (SaO 2 )

20 20 Haemoglobin   Average 70Kg Adult = 900g of circulating haemoglobin (Hb 14-18g/dl)   1g Haemoglobin can carry 1.34ml oxygen Example, 10g/dl with an average 5l circulating volume = 500g total body haemoglobin If fully saturated 500 x 1.34 = 670ml of oxygen (Only approx 25% unloads leaving venous sats (SvO 2 ) 70-75% - useful in times of higher metabolic demand etc

21 21 The transfusion debate… Risks of vs Reduced oxygen transfusion carrying capacity

22 22 Factors affecting carriage   Timing of haemoglobin uptake and release of oxygen affected by, – –Partial pressure of oxygen (PaO 2 ) – –Temperature – –Blood pH – –Partial Pressure of Carbon dioxide (PaCO 2 )

23 23 Partial Pressure - effect of Altitude   At sea level we live under a layer of air that is several miles deep – the atmosphere. The pressure on our bodies is about the same as 10 metres of sea water pressing down on us all the time. At sea level, because air is compressible, the weight of the air around us compresses making it denser. As you go up a mountain, the air becomes less compressed and therefore thinner.

24 24 Partial Pressure - effect of Altitude The important effect of this decrease in pressure is: in a given volume of air, there are fewer molecules present. The percentage of those molecules that are oxygen is exactly the same: 21%. The problem is that there are fewer molecules of everything present, including oxygen. So why is this an issue?

25 25 Partial Pressure of gases   In a mixture of ideal gases, each gas has a partial pressure which is the pressure which the gas would have if it alone occupied the volume. The total pressure of a gas mixture is the sum of the partial pressures of each individual gas in the mixture. Dalton's law (also called Dalton's law of partial pressures) states that the total pressure exerted by a gaseous mixture is equal to the sum of the partial pressures of each individual component in a gas mixture.

26 26 Partial Pressure   Partial pressure (PP) is a way of describing how much of a gas is present. All gases exert pressure on the walls of their container as gas molecules bounce constantly of the walls   PP is also used to describe dissolved gases. In this case, the PP of a gas dissolved in blood is the PP that the gas would have, if the blood were allowed to equilibrate with a volume of gas. When blood is exposed to fresh air in the lungs, it equilibrates almost completely so that the PP of oxygen in the air spaces in the lungs is equal to the partial pressure of oxygen in the blood.   PP of arterial blood is slightly less than PP of oxygen in lungs – due to physiological shunt (some blood passing through lungs without encountering an air space)

27 27 Partial Pressure of gases   The partial pressure of a gas dissolved in a liquid is the partial pressure of that gas which would be generated in a gas phase in equilibrium with the liquid at the same temperature. The partial pressure of a gas is a measure of thermodynamic activity of the gas's molecules. Gases will always flow from a region of higher partial pressure to one of lower pressure; the larger this difference, the faster the flow.   Gases dissolve, diffuse, and react according to their partial pressures, and not necessarily according to their concentrations in a gas mixture.

28 28 Oxygen dissociation curve Dissociation curve relates oxygen saturation of Haemoglobin (Y axis) and partial pressure of arterial oxygen (X axis) in the blood

29 29 Dissociation curve explained   Extent of oxygen binding to haemoglobin depends on PaO 2 of blood, but relationship not precisely linear   Slope steeply progressive between 1.5 – 7kPa (area of most rapid uptake and delivery of oxygen to and from haemoglobin), then plateaus out between 9 – 13.5kPa   Haemoglobin almost completely saturated at 9kPa – further increases in partial pressure of oxygen will result in only slight rises in oxygen binding

30 30 Oxygen dissociation curve   The partial pressure of oxygen in the blood at which haemoglobin is 50% saturated (26.6mmHg) is known as the P 50   P 50 is conventional measure of haemoglobin affinity for oxygen   Increased P 50 indicates a right shift of the standard curve – meaning larger partial pressure necessary to maintain a 50% oxygen saturation

31 31 Oxygen dissociation curve Reduced Affinity Increased affinity

32 32 Factors influencing the position of oxygen dissociation curve To the right,   Hyperthermia   Acidosis (pH)   Increased pCO 2   Endocrine disorders Curve shifts to left,   Hypothermia   Alkalosis   Decreased pCO 2   Carbon monoxide Generally a shift to the, Right will favour unloading of oxygen to the tissues Left will favour reduced tissue oxygenation

33 33 Factors influencing the position of oxygen dissociation curve - explained To the right   As pH declines (acidosis) the affinity of haemoglobin for oxygen reduces. Result – less oxygen is bound while more oxygen is unloaded Bohr effect To the left   Temperature – as body temp falls the affinity of haemoglobin for oxygen increases. Result – more oxygen is bound while less oxygen is unloaded

34 34 mmHg vs. kPa   Both measures commonly in use   The kiloPascal: A pressure of one thousand pascals (1 kPa) is about 10.2 cm H 2 O or about 7.75 mmHg.   Atmospheric pressure is about 1034 cmH 2 O or kPa. The useful approximations are 1000 cm H 2 O or 100 kPa.   mmHg to kPa: To convert pressure in mmHg to kPa, divide the value in mmHg by 7.5. Eg. – –60mmHg = 8.0kPa – –30mmHg = 4.0kPa

35 35 The oxygen cascade   Transport has three stages (steps), – –By gas exchange in the lungs   Partial pressure gradient of oxygen (PaO 2 ) in alveoli 13.7kPa   Partial pressure gradient of oxygen (PaO 2 ) in pulmonary capillaries 5.3kPa – –Transport of gases in the blood   Partial pressure gradient of oxygen (PaO 2 ) in arterial blood 13.3kPa – –Movement from blood into the tissues   Partial pressure gradient of oxygen (PaO 2 ) in tissues 2.7kPa   Mitochondrial pressure kPa

36 36 Oxygen delivery to tissues….   The amount of oxygen bound to the haemoglobin at any time is related to the partial pressure of oxygen to which the haemoglobin is exposed.   Eg in lungs at the alveolar-capillary interface, partial pressure of oxygen is high so oxygen readily binds. As the blood circulates to other body tissue in which the partial pressure of oxygen is less the haemoglobin releases the oxygen into the tissues.   Haemoglobin cannot maintain its full bound capacity in the presence of lower oxygen partial pressures.

37 37 Supplementing Oxygen   Nasal cannula   Fixed performance mask   Variable performance mask   Non rebreathe reservoir   Tracheostomy mask   Tents / head boxes   Bag valve mask   CPAP – nasal / facial or hood   BiPAP – IPAP / EPAP   Intubation and mechanical ventilation

38 38 Indicators for initiating mechanical ventilation?

39 39 Types of positive pressure ventilation   Non invasive   Invasive

40 40 CPAP / PEEP / EPAP   Pressure applied at end of expiration to maintain alveolar recruitment   Airway pressure kept positive Beware of gas trapping (autoPEEP) in non compliant lungs

41 41 CPAP

42 42 NIV - BiPAP   IPAP / PS / ASB – –Inspiratory assistance with each spontaneous breath   EPAP – –Expiratory resistance

43 43 The science of mechanical ventilation is to optimise pulmonary gas exchange; the art is to achieve this without damaging the lungs

44 44 What is a Mechanical Ventilator?   Generates a controlled flow of gas in and out of a patient   Inhalation replenishes alveolar gas   Balance needed between O 2 replenishment and CO 2 removal

45 45 Ventilators – What do they need to do…   Mechanical ventilators are flow generators   Must be able to, – –Control – –Cycling – –Triggering – –Breaths – –Flow pattern – –Mode or breath pattern

46 46 Ventilator strategy   Aim to achieve adequate minute volume with the lowest possible airway pressure

47 47 Ventilator Classification Control – –How the ventilator knows how much flow to deliver   Can be, – –Volume controlled (volume limited, volume targeted) & pressure variable – –Pressure controlled (pressure limited, pressure targeted) & volume variable – –Dual controlled (volume targeted (guaranteed) pressure limited

48 48 Ventilator Classification Cycling   How the ventilator switches from inspiration to expiration (the flow has been delivered – how long does it stay there?) – –Time cycled e.g. pressure controlled ventilation – –Flow cycled e.g. pressure support – –Volume cycled. The ventilator cycles to expiration once a set tidal volume has been delivered.

49 49 Ventilator Classification Triggering   What causes the ventilator to cycle to inspiration. Ventilators may be…… – –Time triggered   Cycles at set frequency as determined by the rate – –Pressure triggered   Ventilator senses the patients inspiratory effort by sensing a decrease in baseline pressure – –Flow triggered   Constant flow through circuit – flow-by. Ventilator detects a deflection or change in this flow. Requires less work from the patient than pressure triggered

50 50 Ventilator Classification Breaths – –Mandatory   (controlled) – determined by the respiratory rate – –Assisted   E.g. synchronised intermittent mandatory ventilation (SIMV) – –Spontaneous   No additional assistance during inspiration e.g. CPAP

51 51 Ventilator Classification Flow pattern – –Sinusoidal (normal breathing) – –Decelerating (inspiration slows as alveolar pressure increases) – –Constant (flow continues at a constant rate until set tidal volume is delivered) – –Accelerating (not used in clinical practice)

52 52 Ventilator Classification Mode or Breath Pattern – –CMV – –Volume Assist-Control (caution with sensitivity) – –Synchronised Intermittent Mandatory Ventilation – SIMV – –Pressure support – –High frequency ventilation –BiPAP/BILEVEL – airway pressure release ventilation –Proportional assist ventilation –Automatic tube compensation Enhance patient interactivity

53 53 Methods of Ventilation   Synchronised Intermittent Mandatory Ventilation – SIMV   Pressure Control   Volume control   Pressure regulated volume control   Pressure support   Continuous positive airway pressure (CPAP)

54 54 Waveforms

55 55 So the problem is this   If the patient is hypoxic then they need O 2   If still hypoxic then they need +ve pressure   If still hypoxic then you need to increase the Ti time (at the expense of the Te time)   Adjustment of the I:E ratio (did) mean increased sedation as it was impossible to breath with the flipped ratio.   New modes have now been developed to allow spontaneous ventilation on adjusted I:E ratios e.g. BIPAP and APRV

56 56 Biphasic Positive Airway Pressure

57 57 BIPAP / APRV (Airway pressure release ventilation)

58 58 Why is mechanical ventilation bad for you?

59 59 Problems with Mechanical Ventilation Mechanical Ventilation Intubation Prolonged Ventilation Ventilator Induced Lung Injury

60 60 Problems with Intubation

61 61 Problems with Intubation   Bypass natural protective mechanisms – moisten, filter, warm   Plastic tubing – airway trauma, vocal cord damage   Pressure sores – oral or from cuff   Mouth care!   Need sedation

62 62 Sedation and Ventilation   Good Points – –Reduced pain – –Reduced stress – –Easier to nurse – –Better for relatives – –Less chance of lines falling out   Bad Points –Increased pneumonia risk –Venous thrombosis –Pressure area problems –Hypotension –Prolonged ICU stay –Better for relatives –Increased barotrauma

63 63 Problems with Prolonged Ventilation   Barotrauma   Volutrauma   Oxygen Toxicity   Pneumonia (VAP)   Sheer Stress – flow delivery

64 64 Barotrauma – pressure   Air leak from alveoli situated near respiratory bronchioles   10 – 20% of ventilated patients   Predisposing factors – –Frequent +ve pressure breaths – –Infection – –ARDS – –Hypovolaemia

65 65 Volutrauma - volume   Excessive stretch in the absence of excessive airway pressure.   If alveoli cannot over distend they are less likely to be damaged   Not just a mechanical problem but also a local and generalised inflammatory response. – –C.f. IL-6 levels in ARDS Net lung protection study.

66 66 Volutrauma

67 67 Ventilators   Aim to achieve adequate minute volume with the lowest possible airway pressure – –High PEEP levels 10 – 20 (open lung) – –Permissive hypercapnia – –Patient specific tidal volume 6 – 7ml/Kg – –Improved inverse ratio capabilities

68 68 Oxygen – the risks   Highly flammable   Compressed   Dry gas – Think humidification!   Blindness in neonates (overgrowth of blood vessels)   Drying of mucus membranes / secretions   COPD – respiratory drive   Toxic – inflammation / scarring after 40hrs with 100%   Dry eyes

69 69 Oxygen toxicity   Central nervous system – –Visual changes, ringing in ears, nausea, twitching, irritability, dizziness, convulsions   Pulmonary – –Lungs show inflammation / scarring (ARDS) and pulmonary oedema   Retinopathic – –Retinal damage

70 70 Other Complications   Decreased cardiac output   Pneumonia (VAP)   Psychological problems   Endotracheal tube complications – –Laryngeal injury – –Tracheal stenosis – –Tracheomalacia – –Endobronchial intubation – –Sinusitis

71 71 Suctioning and Mechanical Ventilation   Causes Lung de-recruitment due to – –Disconnection from the ventilator   Loss of PEEP   Worse V/Q mismatch – –Suctioning procedure itself   High negative pressure decreases lung volume   Worse if the suction is open Suction only when clinically indicated / Pre oxygenate / Minimal suction pressure / limit suction time

72 72 Prone Positioning   What a nightmare!   Can dramatically alter oxygenation   Also – –Induces a uniform V/Q distribution – –Promotes alveolar recruitment – –Promotes secretion drainage

73 73 Prone Positioning   Debate about outcome in the most hypoxic   Complications, – –Manual Handling – –Accidental Extubation – –Pressure sores – –Facial Oedema – –Line disconnection

74 74 Gattinoni et al (2001) NEJM 345 (8): 568 Oxygenation Survival Improved oxygenation, but not overall survival rate

75 75 High-Frequency Oscillatory Ventilation in Adults   Seems a nice idea   3 – 10 Hz oscillation   ‘Tidal volume’ less than normal   Less opening and closing of lungs   Well established in neonatal and paediatric population Issues,   Patients need heavy sedation / NMJ blockade   Drop in preload   Transport not possible   Clinical Ex difficult   Little research until now

76 76 HFOV for ARDS in Adults Derdak et al (2002) Am J Resp & Crit Care Med Vol 166. pp. 801 – 808   Multi-centre randomised control trial   148 patients   HFOV n = 75   Conventional Ventilation n = 73   Outcome measure was survival without mechanical ventilation at 30 days

77 77 HFOV for ARDS in Adults Derdak et al (2002) Am J Resp & Crit Care Med Vol 166. pp. 801 – 808   Non significant trend towards higher survival   37% versus 52%   P =   Big improvement in PaO 2 /FiO 2 (p = 0.008) in HFOV.

78 78 HFOV for ARDS in Adults Derdak et al (2002) Am J Resp & Crit Care Med Vol 166. pp. 801 – 808   Unanswered Questions – –Ideal timing of the intervention – –Prone position – –Nitric Oxide – –When do you discontinue – –Long term effects on lung function – –Use of volume recruitment methods

79 79 ECMO   It involves connecting the internal circulation to an external blood pump and artificial lung.   A catheter placed in the right side of the heart carries blood to a pump, then to a membrane oxygenator, where gas exchange of O 2 and CO 2 takes place.   The blood then passes through tubing back into the patient's veins or arteries.   Patients are anticoagulated

80 80 CESAR Trial (recruited 2001 – 2006) (reported 2008)   Conventional Ventilation or ECMO for Severe Adult Respiratory Failure   180 patients   Use of ECMO results in 1 extra survivor for every 6 patients treated

81 81 Your Patient is Hypoxic So What Do You Do   Remember – –“Air goes in and out and blood goes round and round” – –That just getting air into the lungs may not be enough

82 82 Your Patient is Hypoxic So What Do You Do   Decide – –How much time to you have? – –What resources are available – –Is escalation appropriate

83 83 Your Patient is Hypoxic - What Do You Do? – –Increase the supply of Oxygen – –Drive it into the lungs – –Get the lungs in the best shape possible – –Make sure blood is getting to the lungs – –Reduce the metabolic demand for oxygen

84 84 Scenarios

85 85 Case   44 year old lady 11/7 post intubation for pneumonia.   Trachy. FiO 2.3, PO 2 11   Sudden SOB   FiO 2 1.0, Sats 80% –Increase the supply of Oxygen –Drive it into the lungs –Get the lungs in the best shape possible –Make sure blood is getting to the lungs –Reduce the demand for oxygen

86 86 Case   70 year old gentleman   Sudden SOB   HR 150 bpm   RR 50   FiO –Increase the supply of Oxygen –Drive it into the lungs –Get the lungs in the best shape possible –Make sure blood is getting to the lungs –Reduce the demand for oxygen

87 87 Case   55 year old   Rescued from smoke filled room   PaO 2 7 on FiO 2 85% –Increase the supply of Oxygen –Drive it into the lungs –Get the lungs in the best shape possible –Make sure blood is getting to the lungs –Reduce the demand for oxygen

88 88 THE END


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