Basics for beginners

Mechanical Ventilation
Definition:
It is a method to mechanically assist or replace spontaneous breathing when patients can
not do so on their own.

General Considerations
Mechanical ventilation has resulted in profoundly improved survival from acute and
chronic respiratory failure.
Mechanical ventilation in the intensive care unit (ICU) is delivered under positive
pressure in contrast to normal human breathing in which inspiration induces negative
pressure in the thorax. This makes the complications of barotrauma and hypotension
predictable. To achieve ventilation, rate, tidal volume (VT), fraction of inspired oxygen
(FIO 2 ), and positive end-expiratory pressure (PEEP) are selected. It is useful to track the
product of VT and rate, the minute ventilation ( E), to assess for complications and
readiness to wean. A normal E is less then 10 L/min.

Pressures in ventilators: There are two types of pressures used in ventilators.

a. Negative pressure ventilators: The best example is iron lung that creates a
negative pressure environment around the patients chest, thus sucking air into the
lungs. This is a large elongated tank, which encases the patient up to the neck.
The neck is sealed with a rubber gasket so that the petients face and airway are
exposed to the room air. This was largely used to treat patients with respiratory
paralysis due to poliomyelitis

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 b. Poistive pressure ventilators: This is the main form of ventilators currently used.
These ventilators work by increasing the pressure in the patients airway, and thus
forcing additional air into the lungs.

The fundamental difference between positive pressure and negative pressure is, in
positive pressure ventilation, air is introduced into the lungs forcefully creating
positive pressure, but in negative pressure ventilation, negative pressure is created
outside of the lungs that sucks the chest to inflate, and creates negative pressure
within lungs, as a result air flows into the lungs.

Ventilation: Invasive Vs non-invasive:

The difference is just use of a tube (i.e. endotracheal tube, tracheostomy tube). If you use
endotracheal tube, it is invasive ventilation. If you do not use, it is non-invasive
ventilation.

Non-invasive ventilation can be delivered with the use either of:

a. Negative pressure ventilators (e.g. Iron lung)
b. Positive pressure assistance to the airway by mask (using NIPPV). Non Invasive
Positive Pressure Ventilation (NIPPV) can be delivered by several appliances,
including face masks, nasal masks, nasal pillows etc

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 Bi-PAP setting:

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Nasal/face mask:

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Nasotracheal intubation:

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Positive pressure machines:

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Negative-pressure ventilation

Negative-pressure ventilators support ventilation by lowering the pressure

surrounding the chest wall during inspiration and reversing the pressure to
atmospheric level during expiration. These devices augment the tidal volume by
generating negative extrathoracic pressure.
Several of these devices, such as body ventilators and iron lungs, are available
and either cover the whole body below the neck or apply negative pressure to the
thorax and abdomen.

Noninvasive positive-pressure ventilation (NPPV)

NPPV is delivered by a nasal or face mask, therefore eliminating the need for
intubation or tracheostomy. NPPV can be given by a volume ventilator, a
pressure-controlled ventilator, a bilevel positive airway pressure (BIPAP or
bilevel ventilator) device, or a continuous positive airway pressure (CPAP)
device. Volume ventilators are often not tolerated because they generate high
inspiratory pressures that result in discomfort and mouth leaks.
NPPV delivers a set pressure for each breath (with a bilevel or standard ventilator
in the pressure-support mode). Although positive-pressure support is usually well
tolerated by patients, mouth leaks or other difficulties are sometimes encountered.
BIPAP ventilators provide continuous high-flow positive airway pressure that
cycles between a high positive pressure and a lower positive pressure.
NPPV may be used as an intermittent mode of assistance depending on patients'
clinical situations. Instantaneous and continuous support is given to the patients in
acute respiratory distress. As the underlying condition improves, ventilator-free
periods are increased as tolerated, and support is discontinued when the patient is
deemed stable. In most studies, the duration of NPPV use in patients with acute
on chronic respiratory failure averages 6-18 hours.
The total duration of ventilator use varies with the underlying disease;
approximately 6 hours is used for acute pulmonary edema and more than 2 days is
used for COPD exacerbation.

Mechanisms of action

NPPV decreases the work of breathing and thereby improves alveolar ventilation
while simultaneously resting the respiratory musculature. The improvement in gas
exchange with BIPAP occurs because of an increase in alveolar ventilation.
Externally applied expiratory pressure (eg, positive end-expiratory pressure
[PEEP]) decreases the work of breathing by partially overcoming the auto-PEEP,
which is frequently present in these patients. The patients generate a less negative
inspiratory force to initiate a breathing cycle.

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Inhalation and exhalation:

In spontaneous mode, upon detection of inspiration, higher pressure is delivered

until the flow rate falls below the threshold level. The expiratory pressure with
bilevel pressure support is equivalent to the PEEP, and the inspiratory pressure is
equivalent to the sum of the PEEP and the level of pressure support.
In timed mode, biphasic positive airway pressure ventilation alternates between
the inspiratory and expiratory pressures at fixed time intervals, which allows
unrestricted breathing at both pressures. This differs from the spontaneous mode
of BIPAP, which cycles on the basis of the flow rates of the patient's own
breathing.
Supplemental oxygen can be connected to the device, but a higher flow of oxygen
therapy is usually required.
NPPV is more effective in a relaxed patient and is not optimal in an anxious
uncooperative patient or a patient fighting the ventilator. Patients must be
adequately prepared with properly fitting masks, and the increase of the
inspiratory and the expiratory pressures should occur gradually.
Effectiveness should be determined clinically by improved respiratory distress,
decreased patient discomfort, and improved results from arterial blood gas
determinations.

BIPAP ventilator versus conventional ventilator

The conventional ventilator offers a number of advantages, such as the delivery of precise
oxygen concentrations and separate inspiratory and expiratory tubing that minimizes
carbon dioxide rebreathing. Patient disconnection can be readily detected because
monitoring and alarm features are more sophisticated in conventional ventilators than in
bilevel systems.

Nasal mask versus face mask

No randomized trials have compared nasal masks to full face masks in NPPV. Most
patients in acute respiratory failure are mouth breathers; therefore, a facial mask may be
preferable in some patients. These patients should be carefully observed because of the
risk of aspiration.

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Neurally Adjusted Ventilatory Assist (NAVA)

NAVA is a new positive pressure mode of mechanical ventilation, where the

ventilator is controlled directly by the patient's own neural control of breathing.
The neural control signal of respiration originates in the respiratory center, and
are transmitted through the phrenic nerve to excite the diaphragm. These signals
are monitored by means of electrodes mounted on a nasogastric feeding tube and
positioned in the esophagus at the level of the diaphragm. As respiration increases
and the respiratory center requires the diaphragm for more effort, the degree of
ventilatory support needed is immediately provided.
This means that the patient's respiratory center is in direct control of the
mechanical support required on a breath-by-breath basis, and any variation in the
neural respiratory demand is responded to by the appropriate corresponding
change in ventilatory assistance.

Choosing amongst ventilator modes

Assist-control mode minimizes patient effort by providing full mechanical

support with every breath. This is often the initial mode chosen for adults because
it provides the greatest degree of support.
In patients with less severe respiratory failure, other modes such as SIMV may be
appropriate.
Assist-control mode should not be used in those patients with a potential for
respiratory alkalosis, in which the patient has an increased respiratory drive. Such
hyperventilation and hypocapnia (decreased systemic carbon dioxide due to
hyperventilation) usually occurs in patients with end-stage liver disease,
hyperventilatory sepsis, and head trauma. Respiratory alkalosis will be evident
from the initial arterial blood gas obtained, and the mode of ventilation can then
be changed if so desired.
Positive End Expiratory Pressure may or may not be employed to prevent
atelectasis in adult patients. It is almost always used for pediatric and neonatal
patients due to their increased tendency for atelectasis.
High frequency oscillation is used most frequently in neonates, but is also used as
an alternative mode in adults with severe ARDS.
Pressure Regulated Volume Control is another option.

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Guidelines for the use of NPPV in patients with acute respiratory failure

Blood gas findings

o Partial pressure of carbon dioxide in arterial gas (PaCO 2 ) greater than 45
mm Hg
o pH less than 7.35 but more than 7.10
o PaO 2 and fraction of inspired oxygen (FIO 2 ) less than 200
Clinical inclusion criteria
o Signs or symptoms of acute respiratory distress
o Moderate-to-severe dyspnea, increased over usual
o Respiratory rate greater than 24 breaths per minute
o Accessory muscle use
o Abdominal paradox
o Gas exchange
o PaCO 2 greater than 45 mm Hg and pH less than 7.35
o PaCO 2 -to-FIO 2 ratio less than 200 mm Hg
Diagnosis
o COPD exacerbation
o Acute pulmonary edema
o Pneumonia
Contraindications
o Respiratory arrest
o Inability to use mask because of trauma or surgery
o Excessive secretions
o Hemodynamic instability or life-threatening arrhythmia
o High risk of aspiration
o Impaired mental status
o Uncooperative or agitated patient
o Life-threatening refractory hypoxemia (alveolar-arterial difference in
partial pressure of oxygen [PaO 2 ] <60 mm Hg with FIO 2 of 1)
Factors predictive of success
o Younger age
o Lower acuity of illness (ie, acute physiology and chronic health evaluation
[APACHE] score)
o Patient able to cooperate
o Ability to coordinate breathing with ventilator
o Moderate hypercapnia (PaCO 2 >45 mm Hg but <92 mm Hg)
o Moderate acidemia (pH >7.10 but <7.35)
o Improvement in gas exchange and heart and respiratory rates within first 2
hours

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Protocol for Initiation of NPPV in patients with acute respiratory failure

Position the head of the bed at a 45 angle.

Choose the correct size of mask and initiate ventilator at CPAP (expiratory
positive airway pressure or EPAP) of 0 cm water with a pressure support of 10 cm
water.
Hold the mask gently on the patient's face until the patient is comfortable and in
full synchrony with the ventilator.
Apply wound care dressing on the patient's nasal bridge and other pressure points.
Secure the mask with head straps, but avoid a tight fit.
Slowly increase CPAP to more than 5 cm water.
Increase pressure support (ie, inspired positive airway pressure or IPAP, 10-20 cm
water) to achieve maximal exhaled tidal volume (10-15 mL/kg).
Evaluate that ventilatory support is adequate, which is indicated by an
improvement in dyspnea, a decreased respiratory rate, achievement of desired
tidal volume, and good comfort for the patient.
Oxygen supplementation is achieved through NPPV machine-to-machine oxygen
saturation of greater than 90%.
A backup rate may be provided in the event the patient becomes apneic.
In patients with hypoxemia, increase CPAP in increments of 2-3 cm water until
FiO 2 is less than 0.6.
Set the ventilator alarms and backup apnea parameters.
Ask the patient to call for needs, and provide reassurance and encouragement.
Monitor with oximetry, and adjust ventilator settings after obtaining arterial blood
gas results.

Benefits of NPPV

In acute respiratory failure, NPPV offers a number of potential advantages over

invasive PPV. These advantages include the avoidance of intubation-related trauma, a
decreased incidence of nosocomial pneumonia, enhanced patient comfort, a shorter
duration of ventilator use, a reduction in hospital stay, and ultimately, reduced cost.

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Guidelines for use of NPPV in chronic respiratory failure resulting from restrictive
processes

Blood gas and clinical criteria
o PaCO 2 greater than 45 mm Hg
o Nocturnal hypoventilation and symptoms (eg, hypersomnolence, morning
headache)
Appropriate diagnosis
o Neuromuscular diseases
o Thoracic deformity
o Obesity hypoventilation syndrome
o Obstructive sleep apnea unresponsive to CPAP
Exclusions
o Inability to clear secretions
o Moderate-to-severe bulbar involvement
o Uncooperative patients
o Patients who need continuous ventilatory support

Indication of mechanical ventilation:

Mechanical ventilation is indicated when the patient's spontaneous ventilation is

inadequate to maintain life.
It is also indicated as prophylaxis for imminent collapse of other physiologic
functions, or ineffective gas exchange in the lungs.
Because mechanical ventilation only serves to provide assistance for breathing
and does not cure a disease, the patient's underlying condition should be
correctable and should resolve over time.
In addition, other factors must be taken into consideration because mechanical
ventilation is not without its complications

Common medical indications for use include:

Acute lung injury (including ARDS, trauma)

Apnea with respiratory arrest, including cases from intoxication
Chronic obstructive pulmonary disease (COPD)
Acute respiratory acidosis with partial pressure of carbon dioxide (pCO 2 ) > 50
mmHg and pH < 7.25, which may be due to paralysis of the diaphragm due to
Guillain-Barr syndrome, Myasthenia Gravis, spinal cord injury, or the effect of
anaesthetic and muscle relaxant drugs
Increased work of breathing as evidenced by significant tachypnea, retractions,
and other physical signs of respiratory distress
Hypoxemia with arterial partial pressure of oxygen (PaO 2 ) with supplemental
fraction of inspired oxygen (FiO 2 ) < 55 mm Hg
Hypotension including sepsis, shock, congestive heart failure

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 Note: Mechanical ventilation does not mandate endotracheal intubation, nor
does intubation require mechanical ventilation. For example, endotracheal
intubation may be life saving in a case of impending upper airway obstruction or
high risk for aspiration, without need for a ventilator.

Types of ventilators:

Ventilation can be delivered via:

A. Hand-controlled ventilation such as:

Bag valve mask
Continuous-flow or Anaesthesia (or T-piece) bag
B. A mechanical ventilator.

Types of mechanical ventilators include:

Transport ventilators. These ventilators are small, more rugged, and can
be powered pneumatically or via AC or DC power sources.
ICU ventilators. These ventilators are larger and usually run on AC
power (though virtually all contain a battery to facilitate intra-facility
transport and as a back-up in the event of a power failure). This style of
ventilator often provides greater control of a wide variety of ventilation
parameters (such as inspiratory rise time). Many ICU ventilators also
incorporate graphics to provide visual feedback of each breath.
PAP ventilators. These ventilators are specifically designed for non-
invasive ventilation. This includes ventilators for use at home, in order to
treat sleep apnea.

Modes of mechanical ventilation:

A "mode" of mechanical ventilation refers to the program by which the ventilator

interacts with the patient, the relationship between the possible types of breaths allowed
by the ventilator, and the variables that define inspiration.
Inspiration is defined by three variables:
trigger
limit
cycle

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Trigger is the change detected by the ventilator that causes inspiration to begin;
Limit is the value that cannot be exceeded during inspiration (volume, pressure, or flow)
Cycle is the value that when reached, terminates inspiration.

Using these definitions, three breath types are possible:

Full ventilator control (mandatory), the ventilator controls the breathing
Partial ventilator control (assisted), ventilator assist with patients breathing
Full patient control (spontaneous), patient controls the breathing completely.

The most commonly used modes in adults are volume limited.

In controlled mechanical ventilation (CMV), there is no patient triggering; rather, all
breaths are ventilator triggered, limited, and cycled. CMV is used in patients who make
no respiratory effort, such as those with neuromuscular paralysis.
In assist/control ventilation (ACV), by contrast, the clinician sets a minimum rate and
tidal volume. The patient can trigger the ventilator at a more rapid rate, and will receive
the set volume each time.
In intermittent mandatory ventilation (IMV), ventilator-limited (ie, volume or pressure)
breaths are similarly delivered at a set (minimum) rate, but the patient can breathe
spontaneously by triggering a demand valve between machine-limited breaths.

In current ventilators IMV is modified to synchronized IMV (SIMV), in which the

ventilator synchronizes machine breaths with patient effort.

In the patient who does not trigger the ventilator, CMV, ACV, and SIMV are
qualitatively identical. In assist control, there is a greater potential for respiratory
alkalosis and intrinsic PEEP (PEEP i ), or "autoPEEP,"

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 What is auto-PEEP (PEEPi):
This is persistent positive alveolar pressure at end of expiration, often with
associated hyperinflation, due to delivery of full machine breaths for all patient
efforts. The hyperinflation results from insufficient time for the lungs to empty. This
causes gas trapping, and builds up of positive pressure in the lungs.
Is the patient gas trapping? Expiratory flow does not return to baseline before
inspiration commences (i.e. gas is trapped in the airways at end-expiration).

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In principle, machine breaths in the assist/control or IMV modes can be defined by a set
volume or pressure.

If volume control is selected, the tidal volume is fixed, and airway pressure varies with
the resistance and compliance of the patient's lungs and chest wall.
If pressure control is selected, a fixed inspiratory pressure level is maintained for a set
inspiratory time or inspiration:expiration (I:E) ratio, and tidal volume and flow vary with
patient effort and mechanics.

Two additional common modes of ventilation are continuous positive airway pressure
(CPAP) and pressure support ventilation (PSV).

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 CPAP is spontaneous breathing with no mandatory or assisted breaths; a constant
level of pressure is applied to the airway throughout the respiratory cycle. The mode
CPAP is similar to PEEP, which is not a mode but is the addition of baseline positive
pressure during mechanical ventilation.

In PSV, breaths are patient triggered, pressure limited, and flow cycled. That is, with
no machine backup rate, the ventilator assists the patient's inspiratory effort with a
preset pressure. Patients determine their own respiratory rate, inspiratory time, and
tidal volume.

PSV can be combined with other modes, such as SIMV, to assist patient efforts
between the set machine breaths.

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 Although the ventilator performs the full work of breathing in CMV and the patient
performs the full work of breathing in CPAP, two important points should be
emphasized.
First, the ideal work of breathing for the mechanically ventilated patient
remains unclear (ie, the ideal amount that prevents muscle atrophy, yet permits
rest).
Second, patient work of breathing is not necessarily less in ACV or SIMV than
in PSV, particularly if patientventilator synchrony is optimized in PSV

Several newer "alternative" ventilatory modes have been developed in recent years in an
attempt to combine attractive features of pressure and volume ventilation into a single
mode that will deliver the minimum necessary ventilator pressure for a tidal volume goal.
Modes including mandatory minute ventilation (MMV) "automatically" titrate the amount
of ventilator assistance to changing patient mechanics and breathing drive. These modes
have not yet been shown to improve clinical end points in prospective trials, but are
increasingly encountered in general practice.

Ventilator Settings:

The major variables to set for the volume-controlled modes, ACV and SIMV are
respiratory rate,
tidal volume,
flow rate and pattern,
FIO 2 , (fraction of inspired oxygen) and
PEEP level.

Respiratory rate:
Although a rate of 1020 breaths/min is generally appropriate for most patients
with respiratory failure, patients with airflow limitation who are at risk for
developing PEEP i may benefit from lower rates and patients with a need for high
minute ventilation due to metabolic acidosis need higher rates.
In SIMV, it is best to initially deliver at least 80% of minute ventilation with
machine breaths.
In ACV, setting the rate about 4 breaths/min below the patient rate ensures that the
patient and not the machine is dictating minute ventilation, and yet provides
adequate backup if the patient becomes apneic.

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Tidal Volume:
Although tidal volumes as high as 10 mL/kg (and perhaps higher) may be
appropriate for patients without lung disease, lower volumes are otherwise
indicated.
In acute respiratory distress syndrome (ARDS), the use of a tidal volume of 6
mL/kg (ideal body weight) was associated with improved mortality compared with
12 mL/kg, and should be considered the standard of care.
A tidal volume of 68 mL/kg is often used in obstructive lung disease (asthma,
COPD) to avoid high airway pressures and development of PEEP i .
In fact, studies of asthma and ARDS suggest that a lung protective ventilatory
strategy, termed "permissive hypercapnia," may lead to improved outcomes.
This strategy reduces tidal volumes and/or rate and allows a respiratory acidosis to
a pH as low as 7.157.20.
Generally, when increased ventilation is needed, it is more effective to adjust
minute ventilation by changes in rate rather than tidal volume, because
increases in tidal volume occasionally have the paradoxical effect of slowing
respiratory rate.
Frequent arterial blood sampling to check CO 2 tension in the stable patient can be
avoided by noting the minute ventilation needed to achieve a given level of
PaCO 2 .

Flow rate and pattern:

The peak flow rate determines the maximal inspiratory flow delivered by the
ventilator during inspiration. Although 60 L/min is a common initial peak flow
setting, higher flows, with subsequent higher peak inspiratory pressure are
commonly needed for high ventilatory demand or underlying airway
obstruction.
Flow is delivered during the inspiratory period via one of three waveforms:
constant (square wave),
decelerating (ramp wave), or
sinusoidal.

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 What is the difference between constant, decelerating and sinusoidal flow
waveforms?

Flow of gas is calculated in liters per minute. Flow commences at the beginning of a
breath and stops at the end of the breath. Gas flows into the lungs in inspiration and
out of the lungs in expiration. The pattern of expiratory flow is more or less the same
for different modes of ventilation, as long as the expiratory phase is long enough to
prevent gas trapping.

The normal flow pattern of gas moving in and out of the lungs is sinusoidal.

In volume control ventilation a variety of different wave patterns can be used.

In clinical practice, constant and decelerating flow patterns are used; the latter is
preferred. In constant, decelerating and sinusoidal flow patterns, the inspiratory flow
rate is equal to the peak flow rate, but the mean flow rate is higher in constant flow
patterns rather than the other two. This suggests that this pattern will cause more
shearing injury to the lung parenchyma. Therefore a decelerating flow pattern is
probably the most effective flow pattern it ensures peak flow early in inspiration,
while simultaneously minimizing flow during the phase of the inspiratory cycle in
which the patient is least likely to need it.

Although important differences in clinical outcome have not been demonstrated

for particular flow patterns, decelerating flow is most commonly used because it
may achieve better gas exchange (ie, lower alveolararterial oxygen gradient and
lower dead space) as well as lower peak inspiratory pressure, despite higher mean
airway pressure.
To improve oxygenation in ARDS, mean airway pressure is increased. To do this
in volume-controlled modes, the peak inspiratory flow rate is decreased. In
pressure control ventilation, inspiratory time is increased (pressure control) to

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 reach an I:E ratio greater than 1, a practice termed inverse ratio ventilation (IRV).
IRV is uncomfortable for the patient, often requiring deep sedation or even
paralysis, and carries the risk of gas trapping, it should be used selectively and by
experienced clinicians.

Fraction of inspired osygen (FIO2):

The FIO 2 is typically started at 1.0 (100% oxygen).
Although the literature does not stipulate a cutoff for a safe level of inspired
oxygen in humans, concerns over oxygen radical-mediated lung injury have led to
the common practice of decreasing the FIO 2 below 0.50.6 as soon as feasible.
Pulse oximetry may be used to titrate FIO 2 , with one study suggesting that a
threshold of 92% in light-skinned patients and 95% in darker-skinned patients
ensures adequate oxygenation.
Measurement of partial pressure of arterial oxygen by arterial blood gas (PaO 2
>5560 mm Hg is typically acceptable) is recommended at the start of ventilation
to verify accuracy of pulse oximetry for each patient.

Positive End Expiratory Pressure (PEEP):

PEEP is selected to improve oxygenation.
It can also be used to improve work of breathing and inspiratory triggering in
patients with PEEP i .
Potential adverse effects of PEEP include elevation of intracranial pressure and
hemodynamic compromise/hypotension.
PEEP improves oxygenation mostly by "recruiting" lung units.
Paradoxically, PEEP may sometimes worsen oxygenation by
decreasing cardiac output and thereby the oxygen saturation of mixed
venous blood returning to the lungs,
directing pulmonary blood flow to more consolidated airspaces by
compressing alveolar capillaries in nondiseased, more compliant airspaces,
or
promoting right-to-left interatrial shunting. Because high levels of PEEP
reduce cardiac output and impair oxygen delivery to tissues, measurement
of the effect of PEEP on oxygen delivery, termed a "best PEEP trial," may
be helpful.
In patients with airflow limitation (eg, COPD), PEEP i increases the work of
breathing by increasing the inspiratory effort needed to initiate ventilator flow. In
such patients with dynamic airflow limitation and expiratory airway collapse,

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 addition of ventilator PEEP up to 85% of the PEEP i level may improve
inspiratory triggering and work of breathing. However, given the potential for
worsening of hyperinflation, particularly for patients with asthma, PEEP for this
purpose should be used cautiously. A stable inspiratory plateau pressure (Pplat)
after addition of ventilator PEEP suggests absence of worsened hyperinflation

PEEP is an adjuvant to the mode of ventilation used to help maintain functional residual
capacity (FRC). At the end of expiration, the PEEP exerts pressure to oppose passive
emptying of the lung and to keep the airway pressure above the atmospheric pressure.
The presence of PEEP opens up collapsed or unstable alveoli and increases the FRC and
surface area for gas exchange, thus reducing the size of the shunt. For example, if a large
shunt is found to exist based on the estimation from 100% FiO 2 , then PEEP can be
considered and the FiO 2 can be lowered (< 60%) in order to maintain an adequate
PaO 2 , thus reducing the risk of oxygen toxicity.

In addition to treating a shunt, PEEP may also be useful to decrease the work of
breathing. In pulmonary physiology, compliance is a measure of the "stiffness" of the
lung and chest wall. The mathematical formula for compliance (C) = change in volume /
change in pressure. The higher the compliance, the more easily the lungs will inflate in
response to positive pressure. An underinflated lung will have low compliance and PEEP
will improve this initially by increasing the FRC, since the partially inflated lung takes
less energy to inflate further. Excessive PEEP can however produce overinflation, which
will again decrease compliance. Therefore it is important to maintain an adequate, but
not excessive FRC.

Indications.

PEEP can cause significant haemodynamic consequences through decreasing venous

return to the right heart and decreasing right ventricular function. As such, it should
be judiciously used and is indicated for adults in two circumstances.

If a PaO 2 of 60 mmHg cannot be achieved with a FiO 2 of 60%

If the initial shunt estimation is greater than 25%

If used, PEEP is usually set with the minimal positive pressure to maintain an adequate
PaO 2 with a safe FiO 2 . As PEEP increases intrathoracic pressure, there can be a
resulting decrease in venous return and decrease in cardiac output. A PEEP of less than
10 cmH 2 O is usually safe in adults if intravascular volume depletion is absent. Lower
levels are used for pediatric patients. Older literature recommended routine placement of
a Swan-Ganz catheter if the amount of PEEP used is greater than 10 cmH 2 for
hemodynamic monitoring. More recent literature has failed to find outcome benefits with
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routine PA catheterisation when compared to simple central venous pressure monitoring]
If cardiac output measurement is required, minimally invasive techniques, such as
oesophageal doppler monitoring or arterial waveform contour monitoring may be
sufficient alternatives. PEEP should be withdrawn from a patient until adequate PaO 2
can be maintained with a FiO 2 < 40%. When withdrawing, it is decreased through 1-2
cmH 2 O decrements while monitoring haemoglobin-oxygen saturations. Any unacceptable
haemoglobin-oxygen saturation should prompt reinstitution of the last PEEP level that
maintained good saturation.

Positioning

Prone (face down) positioning has been used in patients with ARDS and severe
hypoxemia. It improves FRC, drainage of secretions, and ventilation-perfusion matching
(efficiency of gas exchange). It may improve oxygenation in > 50% of patients, but no
survival benefit has been documented.

Sedation

Most intubated patients receive sedation through a continuous infusion or scheduled

dosing to help with anxiety or psychological stress. Daily interruption of sedation is
commonly helpful to the patient for reorientation and appropriate weaning.

Prophylaxis

To protect against ventilator-associated pneumonia, patients' bed is often elevated

to about 30.
Deep vein thrombosis prophylaxis with heparin or sequential compression device
is important in older children and adults.
A histamine receptor (H2) blocker or proton-pump inhibitor may be used to
prevent gastrointestinal bleeding, which has been associated with mechanical
ventilation

Modification of settings

In adults when 100% FiO 2 is used initially, it is easy to calculate the next FiO 2 to
be used and easy to estimate the shunt fraction. The estimated shunt fraction
refers to the amount of oxygen not being absorbed into the circulation. In normal
physiology, gas exchange (oxygen/carbon dioxide) occurs at the level of the
alveoli in the lungs. The existence of a shunt refers to any process that hinders this
gas exchange, leading to wasted oxygen inspired and the flow of un-oxygenated
blood back to the left heart (which ultimately supplies the rest of the body with
unoxygenated blood).

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 When using 100% FiO 2 , the degree of shunting is estimated by subtracting the
measured PaO 2 (from an arterial blood gas) from 700 mmHg. For each difference
of 100 mmHg, the shunt is 5%. A shunt of more than 25% should prompt a search
for the cause of this hypoxemia, such as mainstem intubation or pneumothorax,
and should be treated accordingly. If such complications are not present, other
causes must be sought after, and PEEP should be used to treat this intrapulmonary
shunt. Other such causes of a shunt include:

Alveolar collapse from major atelectasis

Alveolar collection of material other than gas, such as pus from pneumonia, water
and protein from acute respiratory distress syndrome, water from congestive heart
failure, or blood from haemorrhage

Monitoring the Ventilated Patient

Managing a patient on the mechanical ventilator necessitates monitoring respiratory
physiological variables. These variables track progression and resolution of disease,
complications of mechanical ventilation, patient comfort, work of breathing, and
likelihood of successful patient liberation from the ventilator.

RESPIRATORY MECHANICS
Variables indicated on all mechanical ventilators include exhaled tidal volume and airway pressure. For the
patient on volume-cycled ventilation for whom breath-to-breath volume is constant, airway pressure at any
moment depends on:

the impedance of the respiratory system to air delivery (ie, respiratory system compliance and
airflow resistance),

patient effort, and

patient synchrony with the ventilator.

Respiratory system refers to the lung (parenchyma and airways) and its surrounding chest wall (pleura and
thoracoabdominal cage). Although lung and chest wall mechanics may be distinguished with the use of
invasive tools such as the esophageal balloon, this is rarely needed. Specifically, it is important to
remember that pressures caused by changes in compliance of the chest wall, such as pneumothorax or even
abdominal distention, are transmitted to the lung.

Pressure at the airway opening (Pao) will increase with any increase in PEEP, PEEP i , flow, resistance
(eg, bronchospasm), or tidal volume, and with any decrease in compliance (eg, pneumothorax).

Pao increases progressively during inspiration with volume delivery by the ventilator until it reaches its
peak, the peak inspiratory pressure (PIP), at the moment the full tidal volume is delivered.

triplehelix 29 Mechanical Ventilation

Pao likewise normally decreases to atmospheric (or to PEEP, if PEEP is programmed into the ventilator) at
the end of exhalation, as the respiratory system empties. The downstream pressure in the alveolar
compartment (which includes PEEP and PEEP i ), reflecting respiratory system compliance, can be
measured at the airway opening in isolation from the additional pressure generated in the airways by
stopping flow (ie, making flow zero), and thereby making pressure generated by flow through the airways
zero.

In practice, the maximum pressure of the alveolar compartment reached at completion of the tidal volume,
or plateau pressure (Pplat), can be monitored by programming a 1.0-s end-inspiratory pause of zero flow.
The PIP Pplat difference equals the flow-resistive pressure (ie, the pressure generated by flow along the
airways).

These measurements apply best to volume-controlled ventilation, in which flow and tidal volume are
programmed. By contrast, in pressure-controlled ventilation in which a constant pressure is applied to the
airway opening for a prescribed inspiratory time, PIP is often equal to Pplat, as can be demonstrated by
observing an end-inspiratory period of zero flow on the ventilator flow-time graph.

The monitoring variables of static compliance (Cstat), resistance to airflow (R), and intrinsic PEEP (PEEP i )
can be easily derived at the bedside. These variables are used to adjust the ventilator, follow disease
progression, and monitor response to therapy.

triplehelix 30 Mechanical Ventilation

 Normally, at end exhalation (before the next delivered breath), the tidal volume in the alveolar
compartment fully empties, and both expiratory airflow and alveolar pressure fall to zero. However, if
elevated airflow resistance slows alveolar emptying beyond the available expiratory period,
particularly in settings of decreased expiratory time (eg, elevated respiratory rate) and/or decreased
alveolar driving pressure (eg, emphysema), positive alveolar pressure, or PEEP i , may persist at end
exhalation. PEEP i is often initially detected by observing the flow graphic on the ventilator for
persistent flow at end-expiration. PEEP i is measured by programming a 1.0-s end-expiratory pause of
zero flow into the ventilator. PEEP i may cause hypoventilation, hypotension, or a false elevation in
pulmonary capillary wedge pressure. Strategies to minimize PEEP i include decreasing the respiratory
rate, use of bronchodilators, or addition of PEEP.

THE MECHANICALLY VENTILATED PATIENT IN ACUTE RESPIRATORY

DISTRESS
A useful approach to the ventilated patient who develops acute hypoxemia is depicted
below. By observing PIP and measuring Pplat, the problem can often be localized either
to the alveolar or the airways compartment, and an immediate differential diagnosis can
be generated. Specifically, elevation of PIP with an unchanged Pplat (ie, PIPPplat
increased) may indicate mucus plugging or bronchospasm. Elevation of both PIP and
Pplat in parallel (ie, PIPPplat unchanged) may indicate pneumothorax, pulmonary
edema, or pneumonia. Alternatively, if neither is elevated, the possibility of a vascular
event altering gas exchange should be considered (ie, pulmonary embolism).

triplehelix 31 Mechanical Ventilation

 What is the Peak inspiratory pressure (PIP) and Plateau Pressure (Pplat)?

The plateau pressure is the pressure applied (in positive pressure ventilation) to the
small airways and alveoli. It is believed that control of the plateau pressure is
important, as excessive stretch of alveoli has been implicated as the cause of ventilator
induced lung injury.

The peak pressure is the pressure measured by the ventilator in the major airways,
and it strongly reflects airways resistance. For example, in acute severe asthma, there
is a large gradient between the peak pressure (high) and the plateau pressure (normal).

In pressure controlled ventilation, the pressure limit is (usually) the plateau pressure
due to the dispersion of gas in inspiration. In volume control, the pressure measured
(the PAW) by the ventilator is the peak airway pressure, which is really the pressure at
the level of the major airways. To know the real airway pressure, the plateau pressure
which is applied at alveolar level, the volume breath must be made to simulate a
pressure breath.

An inspiratory hold (0.5 to 1 second) is applied, and the airway pressure, from the
initial peak, drops down to a plateau. The hold represents a position of no flow.

triplehelix 32 Mechanical Ventilation

triplehelix 33 Mechanical Ventilation
What is permissive hypercapnia?

With acute respiratory distress syndrome (ARDS), a tidal volume of 6-8 mL/kg is used
with a rate of 10-12/minute. This reduced tidal volume allows for minimal volutrauma
but may result in an elevated pCO 2 (due to the relative decreased oxygen delivered) is
called permissive hypercapnia, but this elevation does not need to be corrected.

Sighs:

An adult patient breathing spontaneously will usually sigh about 6-8 times/hr to
prevent microatelectasis, and this has led some to propose that ventilators should
deliver 1.5-2 times the amount of the preset tidal volume 6-8 times/hr to account
for the sighs. However, such high quantity of volume delivery requires very high
peak pressure that predisposes to barotrauma.
Currently, accounting for sighs is not recommended if the patient is receiving 10-
12 mL/kg or is on PEEP. If the tidal volume used is lower, the sigh adjustment
can be used, as long as the peak and plateau pressures are acceptable.
Sighs are not generally used with ventilation of infants and young children.

Connection to ventilators

There are various procedures and mechanical devices that provide protection against
airway collapse, air leakage, and aspiration:

Face mask - In resuscitation and for minor procedures under anaesthesia, a face
mask is often sufficient to achieve a seal against air leakage. Airway patency of
the unconscious patient is maintained either by manipulation of the jaw or by the
use of nasopharyngeal or oropharyngeal airway. These are designed to provide a
passage of air to the pharynx through the nose or mouth, respectively. Poorly
fitted masks often cause nasal bridge ulcers, a problem for some patients. Face
masks are also used for non-invasive ventilation in conscious patients. A full face
mask does not, however, provide protection against aspiration.

Laryngeal mask airway - The laryngeal mask airway (LMA) causes less pain
and coughing than a tracheal tube. However, unlike tracheal tubes it does not seal

triplehelix 34 Mechanical Ventilation

 against aspiration, making careful individualised evaluation and patient selection
mandatory.

Tracheal intubation is often performed for mechanical ventilation of hours to

weeks duration. A tube is inserted through the nose (nasotracheal intubation) or
mouth (orotracheal intubation) and advanced into the trachea. In most cases tubes
with inflatable cuffs are used for protection against leakage and aspiration.
Intubation with a cuffed tube is thought to provide the best protection against
aspiration. Tracheal tubes inevitably cause pain and coughing. Therefore, unless a
patient is unconscious or anaesthetized for other reasons, sedative drugs are
usually given to provide tolerance of the tube. Other disadvantages of tracheal
intubation include damage to the mucosal lining of the nasopharynx or
oropharynx and subglottic stenosis.

Oesophageal obturator airway - commonly used by emergency medical

technicians, if they are not authorized to intubate. It is a tube which is inserted
into the oesophagus, past the epiglottis. Once it is inserted, a bladder at the tip of
the airway is inflated, to block ("obturate") the oesophagus, and air or oxygen is
delivered through a series of holes in the side of the tube.

Cricothyrotomy - Patients who require emergency airway management, in whom

tracheal intubation has been unsuccessful, may require an airway inserted through
a surgical opening in the cricothyroid membrane. This is similar to a
tracheostomy but a cricothyrotomy is reserved for emergency access.

Tracheostomy - When patients require mechanical ventilation for several weeks,

a tracheostomy may provide the most suitable access to the trachea. A
tracheostomy is a surgically created passage into the trachea. Tracheostomy tubes
are well tolerated and often do not necessitate any use of sedative drugs.
Tracheostomy tubes may be inserted early during treatment in patients with pre-
existing severe respiratory disease, or in any patient who is expected to be
difficult to wean from mechanical ventilation, i.e., patients who have little
muscular reserve.

triplehelix 35 Mechanical Ventilation

 Mouthpiece - Less common interface. It does not provide protection against
aspiration. There are lip seal mouthpieces with flanges to help hold them in place
if patient is unable.

The other method of classifying mechanical ventilation is based on how to determine when to start
giving a breath. Similar to the termination classification noted above, microprocessor control has
resulted in a myriad of hybrid modes that combine features of the traditional classifications. Note that
most of the timing initiation classifications below can be combined with any of the termination
classifications listed above.

Assist Control (AC). In this mode the ventilator provides a mechanical breath with either a pre-
set tidal volume or peak pressure every time the patient initiates a breath. Traditional assist-
control used only a pre-set tidal volume--when a preset peak pressure is used this is also
sometimes termed Intermittent Positive Pressure Ventilation or IPPV. However, the initiation
timing is the same--both provide a ventilator breath with every patient effort. In most ventilators a
back-up minimum breath rate can be set in the event that the patient becomes apnoeic. Although a
maximum rate is not usually set, an alarm can be set if the ventilator cycles too frequently. This
can alert that the patient is tachypneic or that the ventilator may be auto-cycling (a problem that
results when the ventilator interprets fluctuations in the circuit due to the last breath termination
as a new breath initiation attempt).
Synchronized Intermittent Mandatory Ventilation (SIMV). In this mode the ventilator provides a
pre-set mechanical breath (pressure or volume limited) every specified number of seconds
(determined by dividing the respiratory rate into 60 - thus a respiratory rate of 12 results in a 5
second cycle time). Within that cycle time the ventilator waits for the patient to initiate a breath
using either a pressure or flow sensor. When the ventilator senses the first patient breathing
attempt within the cycle, it delivers the preset ventilator breath. If the patient fails to initiate a
breath, the ventilator delivers a mechanical breath at the end of the breath cycle. Additional
spontaneous breaths after the first one within the breath cycle do not trigger another SIMV
breath. However, SIMV may be combined with pressure support (see below). SIMV is frequently
employed as a method of decreasing ventilatory support (weaning) by turning down the rate,
which requires the patient to take additional breaths beyond the SIMV triggered breath.
Controlled Mechanical Ventilation (CMV). In this mode the ventilator provides a mechanical
breath on a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable
for children and adults who are conscious and is usually only used in an unconscious patient. It
may also be used in infants who often quickly adapt their breathing pattern to the ventilator
timing.
Pressure Support Ventilation (PSV). When a patient attempts to breath spontaneously through an
endotracheal tube, the narrowed diameter of the airway results in higher resistance to airflow,
and thus a higher work of breathing. PSV was developed as a method to decrease the work of
breathing in-between ventilator mandated breaths by providing an elevated pressure triggered by
spontaneous breathing that "supports" ventilation during inspiration. Thus, for example, SIMV
might be combined with PSV so that additional breaths beyond the SIMV programmed breaths are
supported. However, while the SIMV mandated breaths have a preset volume or peak pressure,
the PSV breaths are designed to cut short when the inspiratory flow reaches a percentage of the
peak inspiratory flow (e.g. 10-25%). Also, the peak pressure set for the PSV breaths is usually a
lower pressure than that set for the full ventilator mandated breath. PSV can be also be used as an
independent mode. However, since there is generally no back-up rate in PSV, appropriate apnoea
alarms must be set on the ventilator.
Continuous Positive Airway Pressure (CPAP). A continuous level of elevated pressure is
provided through the patient circuit to maintain adequate oxygenation, decrease the work of
breathing, and decrease the work of the heart (such as in left-sided heart failure - CHF). Note that
no cycling of ventilator pressures occurs and the patient must initiate all breaths. In addition, no

triplehelix 36 Mechanical Ventilation

 additional pressure above the CPAP pressure is provided during those breaths. CPAP may be
used invasively through an endotracheal tube or tracheostomy or non-invasively with a face mask
or nasal prongs.
Positive End Expiratory Pressure (PEEP) is functionally the same as CPAP, but refers to the use
of an elevated pressure during the expiratory phase of the ventilatory cycle. After delivery of the
set amount of breath by the ventilator, the patient then exhales passively. The volume of gas
remaining in the lung after a normal expiration is termed the functional residual capacity (FRC).
The FRC is primarily determined by the elastic qualities of the lung and the chest wall. In many
lung diseases, the FRC is reduced due to collapse of the unstable alveoli, leading to a decreased
surface area for gas exchange and intrapulmonary shunting, with wasted oxygen inspired. Adding
PEEP can reduce the work of breathing (at low levels) and help preserve FRC.

Complications of Mechanical Ventilation

Multiple direct complications of mechanical ventilation have been described.
Other indirectly associated complications of mechanical ventilation include critical
illness polyneuropathy, acalculous cholecystitis, and venous thromboembolism. Three of
these, barotrauma, ventilator-induced lung injury, and altered hemodynamics, will be
discussed below, as both direct and indirect complications have important practical
implications.
Pulmonary

Barotrauma (eg, pneumothorax, pneumomediastinum, systemic gas embolism, etc)

Ventilator-induced lung injury (ie, volutrauma, atelec-trauma, biotrauma)

Oxygen toxicity

Ventilator-associated pneumoni

Tracheal stenosis

Cardiac

Reduced cardiac output/hypotension

Right ventricular ischemia

Propagation of right-to-left interatrial shunt

Gastrointestinal

Ileus

Gastrointestinal hemorrhage

Renal

triplehelix 37 Mechanical Ventilation

 Fluid retention

Hyponatremia

Cerebrovascular

Increased intracranial pressure

BAROTRAUMA

Barotrauma is the term for the specific complications of extra-alveolar air such as
pneumothorax or pneumomediastinum thought to occur from alveolar rupture into
the adjacent bronchovascular interstitium.
It is less common than in earlier days of positive pressure ventilation, likely
because of attention to patient ventilator synchrony and high peak airway
pressures.
In rare instances the air extravasates into blood vessels with resultant air emboli
in the brain, heart, or skin causing changes in mental status, cardiac arrhythmias,
and livedo reticularis.

VENTILATOR-INDUCED LUNG INJURY (VILI)

Intriguingly, although VILI is synergistic with preexistent lung injury, positive-pressure

ventilation of even the normal lung can produce pathological hyaline membrane changes
indistinguishable from ARDS. Studies in the early 1970s introduced the concept of
"barotrauma," or pressure-induced lung injury,demonstrating that high inflation pressures injured
the lung. Subsequent studies showed that the injurious variable was the transpulmonary pressure
distending the lung rather than peak alveolar pressure (ie, alveolar pressure minus pleural
pressure), or, more simply, end-inspiratory volume. This, in turn, led to the current VILI concept
of volume-induced lung injury, or "volutrauma," with its implication that patients with decreased
chest wall compliance from abdominal distention or other restrictive causes may be relatively
"protected" from high airway pressures on the ventilator.

A multicenter NIH-sponsored ARDS trial, which demonstrated improved mortality using a low (6
mL/kg ideal body weight) compared to a high tidal volume strategy (12 mL/kg ideal body
weight), supports this volutrauma idea.

The lung in patients with ARDS is heterogeneously affected, with the dependent, consolidated
lung not participating in gas exchange. Only the relatively nondiseased, compliant portion of the
lung is vulnerable to overdistention by the delivered tidal volume. This has led practitioners to
theorize that pressure ventilation, with a uniform pressure ceiling in all lung units, is less injurious
to the relatively normal lung than volume ventilation, which directs volume along the path of least
resistance primarily to the nondiseased lung.

triplehelix 38 Mechanical Ventilation

 Despite these claims, however, no well-designed, randomized, controlled trial has shown a
difference in outcome between pressure- and volume-targeted ventilation in patients with ARDS.

Finally, perhaps the most interesting recent concept of VILI is that of "biotrauma," the idea that
VILI may lead to multiple organ dysfunction syndrome by "leakage" of both stretch-induced
injurious lung cytokines and bacteria into the systemic circulation. Lower tidal volumes have been
shown to generate fewer cytokines, and are associated with less extrapulmonary organ
dysfunction.

This phenomenon may explain why most patients with ARDS die of extrapulmonary
complications rather than from respiratory failure itself.

ALTERED HEMODYNAMICS

Positive-pressure ventilation and PEEP both cause hypotension by reducing

cardiac output, with a blood pressure drop that is most dramatic immediately
following endotracheal intubation.
PEEP decreases venous return, and thus cardiac output, primarily by compressing
the inferior vena cava. By increasing pulmonary vascular resistance and right
ventricular afterload, high levels of PEEP may also:
decrease right ventricular systolic function, particularly for patients with
underlying right ventricular dysfunction or right coronary artery disease,
aggravate right ventricular ischemia, and
propagate right-to-left interatrial shunting through a patent foramen ovale.
PEEP reduces left ventricular afterload, and thereby may occasionally
lead to improved left ventricular function and cardiac output in patients
with dilated cardiomyopathy.
Because of this therapeutic effect of the ventilator, both occult left ventricular
ischemia and left ventricular systolic dysfunction may occasionally complicate
ventilator weaning.

When to Withdraw Mechanical Ventilation?

Withdrawal from mechanical ventilationalso known as weaningshould not be

delayed unnecessarily, nor should it be done prematurely. Patients should have
their ventilation considered for withdrawal if they are able to support their own
ventilation and oxygenation, and this should be assessed continuously.
There are several objective parameters to look for when considering withdrawal,
but there is no specific criteria that generalizes to all patients.
The best measure of when a patient may be extubated is the Rapid Shallow
Breathing Index (RSBI) (Tobin Index).

triplehelix 39 Mechanical Ventilation

 This is calculated by dividing the respiratory rate by the tidal volume in
liters(RR/TV). A rapid shallow breathing index of less than 100 is considered
ideal for extubation. Certainly, other measures such as patient's mental status
should be considered.

.
WEANING STRATEGY

First, most patients ( 75%) do not need to be "weaned" from the ventilator; a
graduated reduction of support is unnecessary, particularly for postoperative
patients.
The majority can simply be extubated after their first successful attempt at
spontaneous breathing. For patients who fail their initial attempts at spontaneous
breathing, synchronized intermittent mandatory ventilation (SIMV) weaning
appears to be inferior and may even prolong the duration of mechanical
ventilation.
Next, most of the long list of classic "weaning parameters" (eg, maximum
inspiratory pressure, respiratory rate, vital capacity) are poorly predictive of
successful liberation. The clinical gestalt of even experienced practitioners is
often poorly predictive of successful liberation.
Lastly, the duration of ventilation can be reduced by using validated clinical
parameters, such as the rapid-shallow breathing index (RSBI), in a protocol-
directed approach.
Most experts agree that the process of liberation should involve an initial
achievement of clinical criteria of readiness (eg, SaO 2 90% with FIO 2 0.5 and
PEEP 5 cm H 2 O, no or low-dose vasopressors, mental status at least easily
arousable, some indication of improvement in the initial cause of respiratory
failure, minute ventilation ideally <1215 L/min), followed by some form of
initial spontaneous breathing trial (SBT).
The initial trial may be by a T-piece (breathing without any assistance through the
endotracheal tube with a flowing gas source), PSV, or CPAP (ie, PEEP without
inspiratory pressure assistance).
Initial SBT failure should be followed by reassessment and a more gradual
weaning mode

triplehelix 40 Mechanical Ventilation

Criteria for Assessing Tolerance of a Spontaneous Breathing Trial.

Acceptable oxygenation: SaO 2 90% or PaO 2 60 mm Hg on FIO 2 0.5

Acceptable ventilation: increase in PaCO 2 10 mm Hg or pH decrease 0.10

Acceptable respiratory rate: respiratory rate 35 breaths/min or < 50% increase

in rate

Acceptable hemodynamics: heart rate 140 beats/min or an increase 20% of

baseline; systolic blood pressure 80 mm Hg and 160 mm Hg, or change of <
20% from baseline

RSBI (rate/tidal volume) < 100 breaths/min/L

No signs of elevated work of breathing, such as thoracoabdominal paradox or

excessive use of accessory muscles

No signs of distress, such as diaphoresis or agitation

Perhaps the best-validated and easiest index to assess readiness to wean is the RSBI,
which is the respiratory rate divided by tidal volume in liters. When the RSBI is less
than 100, as measured for 1 min on T-piece, the patient is likely to achieve successful
extubation.

For those patients who fail the initial SBT, three different methods for subsequent
weaning are generally used: SIMV, PSV, and T-piece. The latter two have gained
predominant support in the literature as effective weaning modes, and the former
should be abandoned as a primary weaning strategy.
SIMV involves a stepwise reduction of the mandatory respiratory rate (eg, a
decrease by two breaths/min twice daily) until the patient can tolerate a minimal
rate ( 4 breaths/min), with the remainder of breaths unassisted.
PSV typically involves the stepwise reduction in PS level (eg, by 2 cm H 2 O twice
daily) until a minimal PS level is reached (eg, 5 cm H 2 O). This low pressure is
thought to approximate the work of breathing off the ventilator by "overcoming"
the additional work of breathing imposed by the endotracheal tube. PSV was the
most effective mode when compared to SIMV and T-piece in a large randomized
trial, and is used in many centers.
T-piece involves unassisted spontaneous breathing by disconnection of the
endotracheal tube from the ventilator circuit and reconnection to a flowing,
oxygen-enriched source of gas. It was the most effective weaning mode in a
second large randomized controlled trial. Although progressive increases in T-
triplehelix 41 Mechanical Ventilation
 piece trial duration and daily number (eg, increasing from a few minutes twice a
day to two or more hours several times daily) are commonly used, and, in fact,
may be necessary in chronically ventilator-dependent patients, once-daily T-piece
trials have been shown to be as effective as multiple daily trials for patients
without complications.
In sum, for the patient who fails an initial attempt at spontaneous breathing,
several strategies, all using SBTs, are available for progressive withdrawal from
the ventilator: daily SBTs (T-piece, CPAP, or PS); T-piece, CPAP, or PS trials of
increasing duration; or gradual decreases in PS level. In certain cases an argument
can be made for the superiority of one of these methods. For example, patients
with COPD may occasionally have difficulty tolerating PSV. Second, because
patients with congestive heart failure (CHF) may derive enough assistance in
cardiac performance from positive pressure ventilation, it is arguably most
predictive to perform their SBTs on T-piece.

THE DIFFICULT-TO-WEAN PATIENT

Failure to wean commonly reflects an imbalance of excessive respiratory

workload and insufficient respiratory muscle strength or endurance, with a typical
pattern of tachypnea and shallow tidal volumes.
Depending on the clinical scenario, occult coronary ischemia, occult left
ventricular dysfunction/pulmonary edema, PEEP i , concretions narrowing the
endotracheal tube, and critical illness myopathy/polyneuropathy should be
considered.
Most patients, particularly those with diaphragmatic dysfunction, congestive heart
failure, emphysema, morbid obesity, or abdominal distention, should be
positioned upright during weaning.
Electrolytes affecting muscle function, including potassium, magnesium, and
phosphate, should be repleted, and correction of metabolic acidosis should be
considered, particularly if excessive minute ventilation persists.
Lastly, in patients with COPD exacerbation who fail SBTs, extubation straight to
noninvasive positive pressure ventilation [ie, bilevel positive airway pressure
(BiPAP)] can be tried. In such patients, studies show improved weaning rates,
less nosocomial pneumonia, and decreased mortality.

triplehelix 42 Mechanical Ventilation

Causes of Failure to Wean from Mechanical Ventilation.

Respiratory muscle weakness

Electrolyte depletion (eg, hypokalemia, hypomagnesemia), malnutrition

Critical illness polyneuropathy

Inadequate rest

Prolonged paralysis or myopathy (eg, neuromuscular agents, corticosteroids,

aminoglycosides)

Decreased ventilatory drive

Hypothyroidism

Excessive administration of sedatives or opiates

Increased ventilatory load

Increased resistance: bronchospasm, secretions, plugged endotracheal tube

Decreased lung compliance: pulmonary edema, ARDS

Decreased chest wall compliance: pleural effusions, abdominal distention, and obesity

Increased minute ventilation: elevated dead space ventilation, fever, and overfeeding

Intrinsic PEEP

Cardiac problems

Left ventricular dysfunction

Coronary ischemia

triplehelix 43 Mechanical Ventilation

Daily evaluation: (Do NOT wean if any one is present)
Dopamine infusion >5mcg/kg/min
Systolic BP <90 mmHg
HR <50 or > 130 bpm
Temperature >100.4F
FiO2 >50% or PEEP >8 cm H20

Weaning assessment (Do NOT wean if any one is present):

RR >35 breaths/min
Spontaneous tidal volume <0.3 L
Rapid Shallow Breathing Index >100
O2 saturation <90%
HR <50 or >130 bpm, or increase from baseline >20 bpm
Prominent accessory muscle use

triplehelix 44 Mechanical Ventilation

 A System for Analyzing Ventilator Waveforms

Step 1: -determine the CPAP level

This is the baseline position from which there is a downward deflection on, at least,
beginning of inspiration, and to which the airway pressure returns at the end of
expiration.

Step 2: Is the patient triggering?

There will be a negative deflection into the CPAP line just before inspiration.

triplehelix 45 Mechanical Ventilation

Step 3: What is the shape of the pressure wave?

If the curve has a flat top, then the breath is pressure limited, if it has a triangular or
sharks fin top, then it is not pressure limited and is a volume breath

Step 4: What is the flow pattern?

If it is constant flow (square shaped) this must be volume controlled, if decelerating, it

can be any mode.

Step 5: Is the patient gas trapping?

Expiratory flow does not return to baseline before inspiration commences (i.e. gas is
trapped in the airways at end-expiration). This indicates auto-PEEP.

triplehelix 46 Mechanical Ventilation

Step 6 : The patient is triggering is this a pressure supported or SIMV or VAC
breath?

This is easy, the pressure supported breath looks completely differently than the volume
control or synchronized breath: the PS breath has a decelerating flow pattern, and has a
flat topped airway pressure wave. The synchronized breath has a triangular shaped
pressure wave.

triplehelix 47 Mechanical Ventilation

Step 7: The patient is triggering is this pressure support or pressure control?

The fundamental difference between pressure support and pressure control is the length
of the breath in PC, the ventilator determined this (the inspired time) and all breaths
have an equal i time. In PS, the patient determined the duration of inspiration, and this
varies from breath to breath.

triplehelix 48 Mechanical Ventilation

Step 8: Is the patient synchronizing with the ventilator?

Each time the ventilator is triggered a breath should be delivered. If the number of
triggering episodes is greater than the number of breaths, the patient is asynchronous with
the ventilator. Further, if the peak flow rate of the ventilator is inadequate, then the
inspiratory flow will be "scooped" inwards, and the patient appears to be fighting the
ventilator.

triplehelix 49 Mechanical Ventilation

Patient-Ventilator Dysynchrony

Dysynchrony is a term which describes a patient fighting the ventilator. If we

assume that this is not because the patient is undersedated and is rebelling against
the endotracheal tube, in the majority of cases failure to synchronize is due to
inadequate flow delivery from the ventilator.
If the flow of gas is inadequate, the patient attempts to suck gas out of the
ventilator which is extremely unpleasant. This only occurs in volume control
modes.
In pressure control, flow is unlimited the reason is that flow is related to the
pressure gradient between the upper and lower airway a deeper attempted
inspiration makes the pressure in the alveoli more negative in relation to the upper
airway (this is true also in normal individuals, how else would you take a deep
breath!), and the pressure gradient is larger and the flow greater.
In volume limited ventilation, this flexibility (which is physiological) does not
exist. Of course, as with most problems in critical care, a number of technological
solutions have been developed. the first was pressure augmentation.

triplehelix 50 Mechanical Ventilation