Basic Concept and Core Knowledge in
Mechanical Ventilation
Roy Christian
Overview
• Introduction to Ventilation Principles
• Respiratory Anatomy and Physiology
• Indications for Ventilation
• Modes of Ventilation
• Patient Management
• Complications
• Questions
Introduction
• Ventilation is the movement of air into and
out of the alveoli.
Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn), Lippincott, Philadelphia, USA
Introduction
Mechanics of Ventilation:
• Elasticity
• Compliance
• Resistance
• Pressure
• Gravity
Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
• Respiratory Structures
• Respiratory Zones
• Partitioning of Respiratory Pressures
• Boyles Law
• Respiratory Volumes and Capacity
• Ventilation and Perfusion
Anatomy and Physiology
Respiratory Structures
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
Respiratory Zones
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
Partitioning of Respiratory Pressures
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
Boyles Law
Increase V =
Decreased P
Decreased V =
Increased P
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
Boyles Law
• Air flows from a region of higher pressure to
a region of lower pressure.
• To initiate a breath, airflow into the lungs
must be precipitated by a drop in alveolar
pressures.
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
Respiratory Volumes and Capacity
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Anatomy and Physiology
air
Ventilation venous blood
wa
arterial blood
y
and
Perfusion
perfusion without normal ventilation ventilation without
ventilation= shunt and perfusion perfusion = deadspace
Porth CM, 1998, Pathophysiology (5th Edn), Lippincott, Philadelphia, USA
Indications for Ventilation
• Airway Compromise (potential)
• Respiratory Failure
– pH: <7.25
– PaCO2: >50 mmHg
– PaO2: <50 mmHg
• Increased Work of Breathing
• Head Injury Management
Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn), Lippincott, Philadelphia, USA
Objective of Ventilation
• Support though illness
• Reversal of hypoxemia
• Reversal of acute respiratory acidosis
• Relief of respiratory distress
• Resting of the ventilatory muscles
• Decrease in oxygen consumption
• Reduction in intracranial pressures
• Stabilisation of the chest wall
Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn), Lippincott, Philadelphia, USA
Modes of Ventilation
• freq • Pmax
• Vt • Paw
• MV
• fspn
• I:E ratio • MVspn
• Trigger
• PEEP
Diepenbrock NH, 1999, Quick Reference to Critical Care, Lippincott, Philadelphia, USA: P166.
Modes of Ventilation
• Controlled
– Pressure Control (PC)
– Volume Control (VC)
• Supported
– Continuous Positive Airway Pressure (CPAP)
– Pressure Support (PS)
• Combined
– SIMV (PC) + PS
– SIMV (VC) + PS
Diepenbrock NH, 1999, Quick Reference to Critical Care, Lippincott, Philadelphia, USA: P166.
Modes of Ventilation:
Control
Controlled Mechanical Ventilation:
• The Minute Volume is determined by the
ventilator
• The patient has no option to overridethe
ventilator
Modes of Ventilation:
Control
Pressure Control:
• A preset peak inspiratorypressure is
delivered to the patient at a preset
respiratory rate
• Volume is not preset and is determined by
the mechanics of ventilation.
(elasticity, compliance, resistance, pressure,
gravity)
Modes of Ventilation:
Control
Volume Control:
• A preset tidal volume is delivered at a
present respiratory rate
• 7 – 10 mls/kg
50kg = 350 – 500mls
70kg = 490 – 700mls
90kg = 630 – 900mls
Modes of Ventilation:
Support
Continuous Positive Airway Pressure:
• A spontaneous breathing mode, wherethe
patient generates their own breath
• The ventilator maintains a constant positive
pressure on expiration (PEEP)
• Aims to increase Functional Residual
Capacity
Modes of Ventilation:
Support
Pressure Support:
• A spontaneous breathing mode
• Need for additional support to achieve
optimal tidal volumes
• Ventilator delivers a constant preset
pressure on inspiration
CPAP + PS = BiPAP
Modes of Ventilation:
Combined
Synchronised Intermitted Mandatory
Ventilation:
• Similar to IMV
• If the patient initiates a breath and the
ventilator synchronises so the ventilator
doesn’t deliver a breath at the same time
Modes of Ventilation:
Combined
SIMV (PC) + PS:
• Pressure controlled ventilation with
pressure support on spontaneousbreaths
SIMV (VC) + PS:
• Volume controlled ventilation with pressure
support on spontaneous breaths
SIMV (VC) +
PS
Freq: 10
Vt: 500
(MV = 5.0)
PEEP: 5
PS: 10
Patient Management
• Monitoring
• Suctioning
• Other
– Sedation
– Positioning
– Oral and Eye Care
Patient Management:
Monitoring
• ECG
• SpO2
• ETCO2
• Alarm limits
• Air Entry / Work of Breathing
• Ventilator observations and alarm limits
• Full assessment
Patient Management:
Suctioning
• Suction……
– Increasing airway pressures
– Decreasing SpO2
– Increased work of breathing
• Pre-oxygenate (100% oxygen)
• Less than 15 Seconds
Patient Management:
Other
• Sedation
– Propofol, Morphine and Midazolam
• Positioning
– 2/24
• Oral and eye care
– 2/24
Complications
• Airway
– Aspiration, decreased clearance of secretions,
predisposition to infection
• Endotracheal Tube
– Tube kinking, sputum plug, right main
bronchus intubation, tube migration, cuff
failure, laryngeal oedema
• Mechanical
– Ventilator malfunction, hypoventilation,
hyperventilation, barotrauma, pneumothorax
Indications for Mechanical Ventilation in Patients
with Cardiovascular Failure
• Increased work of the myocardium
– Decrease myocardial work with MV
• Increased work of breathing
– Reduce the work of breathing with MV
• Hypoxemia
– Reverse hypoxemia withMV
Terima Kasih