Khaled R. Khasawneh, MD Assistant Professor of Medicine Division of Pulmonary and Critical Care Mechanical Ventilation
Jun 02, 2015
Khaled R. Khasawneh, MD
Assistant Professor of Medicine
Division of Pulmonary and Critical Care
Mechanical Ventilation
Physiologic Causes of Hypoxemia
• Low FiO2
• Hypoventilation
• V/Q mismatch
• Shunt
• Diffusion abnormality
Physiologic causes of Hypercapnia
• PACO2 = k x VCO2 / VA
• PACO2 = k x VCO2 / VE(1 - Vd/ Vt)
• PACO2 = k x VCO2 / (Vt x F) (1- Vd/ Vt)
• VA = (Vt - Vd) x F
• PaCO2≈ 1/ VA
Definition• The pulmonary system is no longer able to meet the
metabolic demands of the body with respect to oxygenation of the blood and/or CO2 elimination
Etiologies• Primary pulmonary pathology
• Extra-pulmonary pathology
Classification• Type 1 (Hypoxemic)
• Type 2 (Hypercapnic/Ventilatory)
• Type 3 (Peri-operative)
• Type 4 (Shock)
Type 1 (Hypoxemic)
• V/Q mismatch and shunt are the most common causes in the ICU
• Pulmonary edema
• ARDS
• Pneumonia
• Lung hemorrhage
• Atelectasis
Type 2 (Hypercapnic/Ventilatory)
• Decreased CNS drive
• Neuromuscular disease
• Increased Physiologic Dead Space (Vd)
Type 3 (Peri-operative)
• Subtype of type 1
• Decreased FRC
• Supine/ obese/ ascites
• Anesthesia
• Upper abdominal incision
• Airway secretions
Type 4 (Shock)
• Ventilator therapy to decrease work of breathing
Management of Acute Respiratory Failure
• Oxygenation
• Ventilation
• Airway control
• Ventilator management
Oxygen Delivery Devices• Nasal cannula
• Simple face mask
• Venturi mask
• Nonrebreather mask
• High flow nasal cannula
• Misty Ox
Nasal cannula
• 1 LPM = 24% FIO2
• 2 LPM = 28% FIO2
• 3 LPM = 32% FIO2
• 4 LPM = 36% FIO2
• 5 LPM = 40% FIO
Simple face mask
• 5 LPM = 40% FIO2
• 7 LPM = 44% FIO2
• 7 LPM = 48% FIO2
• 8 LPM = 52% FIO2
• 9 LPM = 56% FIO2
• 10 LPM = 60% FIO2
Venturi mask
Nonrebreather mask
High Flow Nasal Cannula
Misty Ox
Non-invasive Positive Pressure Ventilation(NIPPV)
• COPD
• Pulmonary edema
• Preventing post-extubation respiratory failure
Contraindications• Cardiac or respiratory arrest
• Inability to cooperate, protect the airway, or clear secretions
• Severely impaired consciousness
• Facial surgery, trauma, or deformity
• High aspiration risk
• Prolonged duration of mechanical ventilation anticipated
• Recent esophageal anastomosis
Devices• Standard ICU ventilator
• BIPAP
Interface• Full face mask
• Oronasal mask (Face mask)
• Nasal mask
• Nasal pillows
Mode• Assist control (AC)
• Pressure support ventilation (PSV)
• Continuous positive airway pressure (CPAP)
• Bilevel positive airway pressure (BPAP)
Predictors of Success• Clinical improvement
• Improvement of the pH
• Improvement in PaCO2
Mechanical Ventilation
Ventilator
Volume Control
AC (VC) SIMV
Pressure Control
AC (PC) SIMV PS BiPAP
Triggering
• RR 10
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 10
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
• RR 10
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 10
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
• RR 10
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 10
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
I+E = 6 secI= 0.5 secE= 5.5 secI:E = 1:11
• RR 30
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 30
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
• RR 30
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 30
• TV 500 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
I+E = 2 secI= 0.5 secE= 1.5 secI:E = 1:3
• RR 10
• TV 1000 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 10
• TV 1000 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
• RR 10
• TV 1000 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
• RR 10
• TV 1000 ml
• FIO2 50%
• PEEP 5 cmH2O
• Flow 60L/m
Volume ControlAC SIMV
I+E = 6 secI= 1 secE= 5 secI:E = 1:5
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
Pressure ControlAC SIMV
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
Pressure ControlAC SIMV
I+E = 6 secI= 0.5 secE= 5.5 secI:E = 1:11
• RR 30
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
• RR 30
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
Pressure ControlAC SIMV
• RR 30
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
• RR 30
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 0.5 sec
Pressure ControlAC SIMV
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 1 sec
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 1 sec
Pressure ControlAC SIMV
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 1 sec
• RR 10
• Pi 10 cmH2O
• FIO2 50%
• PEEP 5 cmH2O
• Ti 1 sec
Pressure ControlAC SIMV
I+E = 6 secI= 1 secE= 5 secI:E = 1:5
• Patient-triggered, pressure limited, flow-cycled breath
• Adequate spontaneous drive
• Gas flow to a preset pressure
• Support is only provided if the patient triggers the vent
• Invasive and non-invasive• No rate is set
• PS
Pressure Support
• IPAP – inspiratory positive airway pressure
• EPAP – expiratory positive airway pressure
• FIO2
BiPAP
• IPAP 10 cmH2O
• CPAP 5 cmH2O
• FIO2 50%
• PS 10 cmH2O
• PEEP 5 cmH2O
• FIO2 50%
PS VS BiPAPPS BiPAP
10
55
Peak and Plateau Pressure
CASE30 years-old male admitted with drug over dose and required ETT + MV on AC of 12/450/5 and 50% his Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O.
On day 2 patient developed an episodes of decreased SPO2 . At that time Peak airway pressure was 60 cmH2O and Plateau pressure was 15 cmH2O.
What is the etiology of the patient decreased SPO2?
A) ARDS.
B) Pulmonary edema.
C) Pneumothorax
D) Right main stem mucus plug.
CASE30 years-old male admitted with drug over dose and required ETT + MV on AC of 12/450/5 and 50% his Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O.
On day 2 patient developed an episodes of decreased SPO2 . At that time Peak airway pressure was 60 cmH2O and Plateau pressure was 15 cmH2O.
What is the etiology of the patient decreased SPO2?
A) ARDS.
B) Pulmonary edema.
C) Pneumothorax
D) Right main stem mucus plug.
CASE30 years-old male admitted with drug over dose and required ETT + MV on AC of 12/450/5 and 50% his Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O. He developed fever and chills and was difficult to wean from the ventilator secondary to aspiration pneumonia.
On day 10 patient developed an episodes of decreased SPO2 . At that time Peak airway pressure was 60 cmH2O and Plateau pressure was 40 cmH2O.
What is the etiology of the patient decreased SPO2?
A) ARDS.
B) Bronchospasm.
C) Right main stem mucus plug.
D) Biting on the ETT.
CASE30 years-old male admitted with drug over dose and required ETT + MV on AC of 12/450/5 and 50% his Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O. He developed fever and chills and was difficult to wean from the ventilator secondary to aspiration pneumonia.
On day 10 patient developed an episodes of decreased SPO2 . At that time Peak airway pressure was 60 cmH2O and Plateau pressure was 40 cmH2O.
What is the etiology of the patient decreased SPO2?
A) ARDS.
B) Bronchospasm.
C) Right main stem mucus plug.
D) Biting on the ETT.
CASE30 years-old male admitted with drug over dose and required ETT + MV on AC of 12/450/5 and 50% his Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O. He was difficult to wean from the mechanical ventilation.
On day 10 patient developed an episodes of decreased SPO2 . At that time Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O.
What is the etiology of the patient decreased SPO2?
A) ARDS.
B) Bronchospasm.
C) Right main stem mucus plug.
D) Pulmonary embolous.
CASE30 years-old male admitted with drug over dose and required ETT + MV on AC of 12/450/5 and 50% his Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O. He was difficult to wean from the mechanical ventilation.
On day 10 patient developed an episodes of decreased SPO2 . At that time Peak airway pressure was 35 cmH2O and Plateau pressure was 15 cmH2O.
What is the etiology of the patient decreased SPO2?
A) ARDS.
B) Bronchospasm.
C) Right main stem mucus plug.
D) Pulmonary embolus.
Peak and Plateau Pressure
Auto-PEEP
Santanilla JI, Daniel B, Yeow ME. Mechanical ventilation. Emerg Med Clin North Am. 2008;26(3):849-862.
Auto-PEEP• Increase intrathoracic pressure
• Alveolar overdistension
• Increase work of breathing required to trigger the ventilator
Santanilla JI, Daniel B, Yeow ME. Mechanical ventilation. Emerg Med Clin North Am. 2008;26(3):849-862.