Mechanical Ventilation A Beginner's Guide www.philippelefevre.com
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Mechanical Ventilation
A Beginner's Guide
www.philippelefevre.com
Determinants of Gas Concentration
PaCO2PaO2
Determinants of Gas Concentration
PaCO2PaO2
1 FiO2
Determinants of Gas Concentration
PaCO2PaO2
1 FiO2
2 Alveolar Ventilation
Determinants of Gas Concentration
PaCO2PaO2
1 FiO2
2 Alveolar Ventilation
3 Shunt / VQ mismatch
Determinants of Gas Concentration
PaCO2PaO2
1 FiO2
2 Alveolar Ventilation
3 Shunt / VQ mismatch
1 Metabolic Rate
Determinants of Gas Concentration
PaCO2PaO2
1 FiO2
2 Alveolar Ventilation
3 Shunt / VQ mismatch
1 Metabolic Rate
2 Alveolar Ventilation
Respiratory Failure
Type 1 Type 2
O2 ↓ CO2 ↑O2 ↓
Type 1 Type 2
O2 ↓ CO2 ↑O2 ↓
PneumoniaBronchiolitisContusionsAtelectasisPulmonary oedemaARDSPE
CNS depressionNeuromuscular disordersPulmonary fibrosisCOPDAsthmaAirway obstruction
Type 1 Type 2
O2 ↓ CO2 ↑O2 ↓
PneumoniaBronchiolitisContusionsAtelectasisPulmonary oedemaARDSPE
CNS depressionNeuromuscular disordersPulmonary fibrosisCOPDAsthmaAirway obstruction
Modes of Ventilation
Modes of Ventilation
Mandatory
Assisted
Spontaneous
Types of Breath
Modes of Ventilation
Mandatory
Assisted
Spontaneous
Types of Breath
PressureFlow Neuromuscular
impulse
Trigger
Modes of Ventilation
Mandatory
Assisted
Spontaneous
Types of Breath
PressureFlow Neuromuscular
impulse
Trigger
Volume
Pressure(time)
Neuromuscularimpulse
Limit (cycle)
Ventilation Limit
Ventilation Limit
Volume
Ventilation Limit
Pressure
Volume
Ventilation Limit
Pressure
Volume
Neuromuscular impulse
Modes
Modes
Continuous Mandatory Ventilation (CMV)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
SIMV
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)
Pressure Support
Modes
Continuous Mandatory Ventilation (CMV)
Assist Control (AC)
Intermittent Mandatory Ventilation (IMV)
Synchronised Intermittent Mandatory Ventilation (SIMV)
Synchronised Intermittent Mandatory Ventilation with PSV (SIMV + PSV)
Pressure Support
Neurally Adjusted Ventilatory Assist
Modes of Ventilation
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Modes of Ventilation
Assist Control(Pressure Control) Greatest MAP for least PIP
SIMV + PS(volume control)
easier control of tidal volumeless prone to accidental hyperventilationbreath stacking somewhat less likely
Pressure Support Weaning
NAVA Weaning
Lung Protective Ventilation
Lung Protective Ventilation
VolutraumaOxygen Toxicity Biotrauma
Ventilator Induced Lung Injury
Tidal Volume
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N. Engl. J. Med. 2000 May 4;342(18):1301–8
10 University Hospitals of North America - The ARDS Network
RCT - Vt 12 vs 6 mL/Kg ideal body weight
861ventilated patients with ARDS / ALI
180 day mortality 31.0% vs 39.8% P=0.007
PEEP
Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N. Engl. J. Med. 2004 Jul. 22;351(4):327–36
10 University Hospitals of North America - The ARDS Network
RCT - High PEEP vs Low PEEP stratergy
861ventilated patients with ARDS / ALI
180 day mortality 31.0% vs 39.8% P=0.007
PEEP Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010 Mar. 3;303(9):865–73
10 University Hospitals of North America - The ARDS Network
RCT - High PEEP vs Low PEEP stratergy
861ventilated patients with ARDS / ALI
180 day mortality 31.0% vs 39.8% P=0.007
PEEP
PEEP (cmH2O)PEEP (cmH2O)
FiO2 Low High
0.3 5 12
0.4 8 14
0.5 10 16
0.6 12 18
0.7 14 20
0.8 14 22
0.9 18 22
1.0 20 240
5
10
15
20
25
30
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1PE
EP c
mH
20FiO2
High PEEPLow PEEP
Lung Protective Ventilation
VolutraumaOxygen Toxicity Biotrauma
Ventilator Induced Lung Injury
Atelectatrauma
Healthy Lung
Pressure
Volume
Healthy Lung
Pressure
Volume
PEEP PIP
Poorly Compliant Lung
Pressure
Volume
PEEP PIP
Poorly Compliant Lung
Pressure
Volume
PEEP PIP
Heterogeneous Lung
Pressure
Volume
PEEP PIP
Heterogeneous Lung
Pressure
Volume
PEEP PIP
High Frequency Oscillatory Ventilation
High Frequency Oscillatory Ventilation
f 3 - 10 Hz (180 - 600 breaths per minute)
Vt 5 - 30 ml
MeanAirway Pressure 35 - 45 mmHg
High Frequency Oscillatory Ventilation
f 3 - 10 Hz (180 - 600 breaths per minute)
Vt 5 - 30 ml
MeanAirway Pressure 35 - 45 mmHg
High Frequency Oscillatory Ventilation
f 3 - 10 Hz (180 - 600 breaths per minute)
Vt 5 - 30 ml
MeanAirway Pressure 35 - 45 mmHg
High Frequency Oscillatory Ventilation
f 3 - 10 Hz (180 - 600 breaths per minute)
Vt 5 - 30 ml
MeanAirway Pressure 35 - 45 mmHg
High Frequency Oscillatory Ventilation
f 3 - 10 Hz (180 - 600 breaths per minute)
Vt 5 - 30 ml
MeanAirway Pressure 35 - 45 mmHg
High Frequency Oscillatory Ventilation
f 3 - 10 Hz (180 - 600 breaths per minute)
Vt 5 - 30 ml
MeanAirway Pressure 35 - 45 mmHg
High Frequency Oscillatory Ventilation Pillow et al. Crit Care Med 2005 Vol. 33
Key Points
• Understand the nature of your patient’s respiratory failure
• Choose the mode of ventilation appropriate for your patient
• Vt 6 ml/Kg (ideal body weight)
• Titrate PEEP to FiO2 or recruit and use the open lung tool
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