Highlights of Mechanical ventilation Unit 4 by xde24545

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									Modes and initiation of ventilation
By
Elizabeth Kelley Buzbee AAS, RRT-NPS
HIGHLIGHTS OF MECHANICAL
VENTILATION UNIT 4
  The modes of ventilation:
 A spontaneous breath is one that the patient
  triggers and cycles the breath, and he controls
  the VT . This breath could be assisted by the
  application of positive pressure.

 A mandatory breath is defined as one that is
  triggered and cycled by the machine. All
  mandatory breaths are assisted breaths.
The modes of ventilation: full
support modes
• CMV: continuous mandatory ventilation in which
  all breaths are mandatory.
• VC-CMV volume control also called
  Assist/Control mode
  – Set VT, f to get VE; guaranteed VT
  – Default ventilatory mode for full support with adults
• PC-CMV pressure control mode. Patient can
  trigger breaths just like with A/C
  – Set PIP, f and TI no guaranteed VT
  – Default ventilator mode for full support for infants
Indications for PC: the RCP selects
pressure ventilation when:
   The adult patient who cannot be managed with
    VC In this case, we keep the PIP less than 30
    cmH20.
   PC results in better distribution of ventilation in
    persons with unequal RAW, but consistent
    compliances.
   There is such an airway leak so that the VT are
    unstable [most common with infants and small
    children with uncuffed ET or tracheostomy tubes]
Compare PC to VC

 In PC, the airway pressures; mPAW and PIP
  will stay the same, but the VE and VT can vary
  based on patient’s time constants
 In VC the VE and VT are basically stable
  [patient can increase f so VE could vary] the
  PIP and the mPAW can be altered by patient
  time constants
Compare control mode to
Assist/control
• We control patients by giving them sedation
  and paralytic agents so that the VE we set on
  VC-CMV is exactly the same
• We can control their PaC02 thus their acid
  base balance
• In A/C, the patient can trigger breaths that
  will increase the VE, so that the VE based on
  set VT and f could be lower than the actual
  measured VE
Controlling the chronic
hypercapnic patient
 If your patient has a hypoxic drive,
  administrate enough Fi02 to get his Pa02
  between 80-100 mmHg.
 This will result in apnea and works as a form
  of sedation in the first 24 hours.
 Must wean the Fi02 to get Pa02 between 55-
  65 mmHg before weaning
Problems with A/C

 Excessively high PAW can cause problems with
  hemodynamics once patient starts to breath.

 Another problem with A/C mode is the risk of
  auto-PEEP and air trapping.
Inverse Ratio Ventilation [with
PC or with VC]
 This is a form of full support that uses
  increased Ti to raise the mPAW when
  patient’s compliance is so bad that PIP and
  Pplateau are excessive
 In IRV, the expiratory time is so short that the
  patient never completely exhales. This works
  like PEEP to recruit alveoli
Raising mPAW with IRV

 mPAW = PIP [I] + PEEP [E]
             I+E
 Because we raise the inspiratory time so
  much we can decrease the PIP
 Because we create auto-PEEP with the short
  TE, we can decrease the PEEP
Negative pressure
ventilation
 The negative pressure ventilator is a box in
  which the patient’s body [or chest wall] is
  placed. A suction device is attached to the
  box.
 The NPV merely replaces the ventilatory
  muscles.
Problems with Negative pressure
Ventilation: patient must be able to:

 protect airway
 Handle being supine all the time
 hemodynamically stable
 be comfortable in one position all the time
 handle being disconnected from vacuum for
  short time spans
More problems with NPV

 Patient can get skin lesions from movement
  of body inside the device
 Patient can get cold from ‘wind’
 Best 02 device is nasal cannula because 02
  can be sucked into the neck opening
NPV

 Classified as controllers, but newer models
  can be A/C if there is a flow sensor placed on
  the patient’s nose
 Old metal iron lungs have a constant I:E of I:I;
  newer fiberglass devices can have altered I:E
  ratios
Setting parameters on NPV:

 Change level of the vacuum to increase the VT
  [he could use a Wright’s spirometer attached
  to an IPPB mask to measure exhaled VT]
 Change the respiratory rate.
CSV


   continuous spontaneous ventilation in which
    all breaths are spontaneous.
   patient who can completely control his VE
   and only needs a little help such as with
    increased baseline pressures [CPAP]
   or some application of assisted breaths such
    as pressure support [PS]
   or who might require monitoring of VE
Pressure support ventilation

• PSV is the most common form of pressure
  cycled CSV.
• Although this does raise the airway pressure so
  that we have a higher and lower pressure, we
  call this PS rather than PIP because of the
  specific characteristics of PS
• Flow triggered and flow cycled
• Patient controls his VT, f and inspiratory time
  Indications for PS:
 When used with SIMV to reduce the WOB by
  increasing the spontaneous VT. We generally
  select the PS that will deliver a reasonable VT
  [watch the spontaneous RR]
 Can be used alone during weaning. Once a
  patient is on a PS of 5-10 cmH20, he is
  considered at a level that only compensates
  for RAW of the tubing, so is considered
  consistent with spontaneous breathing.
PSV flow patterns

 The flow pattern is descending till it reaches
  5 LPM [or 25% of the peak flow] in which the
  flow stops abruptly.
 The flow slows down as the device attempts
  to keep the PS at the preset pressure.
VT on PS

 There is no guaranteed VT, nor VE, but we can
  increase the VT by increasing the PS pressure
 We need to set VE & high f alarms closely to
  warn us of problems
 The patient sends more air to Zone III
  because he is using his diaphragm more with
  PS
To choose the correct level of PSV
there are three methods:
  •   get an appropriate VT [10-15 ml/kg] and titrate the PS level to
      achieve this VT

  •   increase the PS level till the respiratory rate is normalized [25
      bpm or less]

  •   increase the PSV until you decrease the work of breathing
      through the ET tube
  •
      – To select the appropriate level of PSV to overcome the RAW use this
         formula


      PSV= (PIP - Pplateau) x spont insp. Flow rate [l/sec]
                  Ventilator flow rate [l/sec]
PSmax

• or ‘straight pressure support’ or ‘stand alone PS’ [
  PS without SIMV.] In this case, the PS is not used
  as a weaning modality but for initial of
  mechanical ventilation.
• We generally select a PS level that will deliver 10-
  12 ml kg IBW.
• The RCP must remember that this mode is an
  assist only and the patient’s VT and VE will vary
  base on lung dynamics. There is no guaranteed
  VT.
• Patient must have an intact ventilatory drive
  for this to work
CPAP mode
spontaneous mode
• application of PEEP without any positive
  pressure breathes.
• CPAP is merely a raised baseline with a flow rate
  with adjustable Fi02
• recruits alveoli which will improve diffusion of 02
• CPAP can help return a low compliant lung back
  to normal once atelectasis has been resolved.
  The FRC should rise.
• should decrease WOB.
• proper application of CPAP should decrease
  WOB- watch respiratory rates on this
CPAP interfaces
 CPAP via the ET tube or a trach tube is called
  CPAP
 CPAP via a nose mask, face mask or full face
  mask is called nasal-CPAP [n-CPAP]
 Obviously we select the interface based on
  the patient’s ability to protect his airway
 n-CPAP indications


 The successful candidate for n-CPAP would
  be the patient who is oriented,
 has good ventilatory drive without excessive
  WOB
 and who has the ability to protect his airway.
n-CPAP contraindications

 Persons at risk for vomiting and aspiration
 persons with skin necrosis,
 claustrophobia.
CPAP indications

•   Management of the person who is in hypoxemia respiratory failure.
    This patient will have refractory hypoxemia without respiratory
    acidosis..

•   Treatment of Congestive Heart Failure [CHF] in the patient who
    has an intact ventilatory drive and can keep his PaC02 down. CPAP of
    8-12 with Fi02 100% is suggested. [Egans pp, 1095]

•   A weaning modality This invasive CPAP may be the last step before
    extubation. Generally a patient can be extubated from a CPAP of 5-7
    cmH20 [or can be extubated at a stand-alone PSV of 5-7 cmH20.
•
•   Non-invasive management of persons with obstructive sleep apnea
    [OSA
APRV
a spontaneous mode
• airway pressure release ventilation
• Patient is breathing on two different levels of
    CPAP
•
Initial settings for APRV                               for
ARDS:
• The higher CPAP is set with the Phigh, while the P low sets the
    lower pressure.
•   The RCP should also set the time interval [Thigh] for Phigh
    and the time interval [Tlow]for Plow
•   To initial APRV, the RCP looks to the patient’s Pplateau on
    PPV and uses that figure for the Phigh.
•   The Thigh is started at 4 seconds for adults and can be
    progressively increased to 10-15 seconds
•   Set the Plow at zero and use the release time [Tlow] to keep
    the pressure from dropping to zero
•   Set the Tlow at about .5 to .8 [one time constant] so that the
    breath ends with the expiratory flow at 50-75% of peak flow
What happens if the patient
goes apnic?
 During APRV ventilation if the patient was
  stop breathing, the time-cycling between
  high and low pressures would appear similar
  to PC-IRV.
 So this is a spontaneous mode that happens
  to have a back up of sorts
Contraindications to APRV

 persons with COPD or other problems
  associated with air trapping.
 persons with excessively high intracranial
  pressures [high ICP]
Bilevel ventilation

 An alternative to APRV is ‘bilevel ventilation.’
  The only difference between bilevel
  ventilation and APRV is that the patient
  spends more time at the [Plow] lower airway
  pressure than at the high airway pressure
  [Phigh].
BiPap- NIPPV

 Non-invasive positive pressure ventilation
 These BiPap breathes tend to be flow or time
  triggered, flow cycled off
 with the operator selecting PIP [called IPAP]
  and PEEP [called EPAP] and bleeding in
  supplementary 02.
 The newer Vision can get a Fi02.
 http://emedicine.medscape.com/article/1417959-treatment
contraindications/hazards of NIPPV

  – do not put this device on an apnic patient because it
      is NOT a ventilator—it is ‘a breath augmenter’.
  –   Persons who cannot protect their airways
  –   Hemodynamically unstable patients
  –   Facial burns or trauma
  –   Uncooperative patients
  –   Persons at risk for aspiration: vomiting, nose bleeds,
      unconscious, poor gag reflex
  –   Copious secretions
  –   Anatomical problems with gas exchange
Indications for NIPPV: acute
care of:
 congestive heart disease [n-CPAP or BiPap]
 COPD patient who doesn’t want to be
  intubated
 recently extubated patient who is at risk of
  failing.
 immune-suppression for whom we may not
  want to risk VAP
Indications for long-term NIPPV

 Long-term management of both obstructive
  sleep apnea and central sleep apnea
 Long-term management of patients with
  skeletal or neuromuscular disorders
 Long-term management of the COPD patient
  who has s/s of chronic hypoventilation
  [especially at night] and who is optimally
  treated with drugs and other care.
Initial settings for BiPap:

 IPAP at 8 cmH20 and EPAP at 4 cmH20.
 . Increase IPAP in increments of 2 cmH20 to
  deliver more VT.

 To hypoxemia, increase the EPAP in increments
  of 2 cm H20.

 Oddly enough, if the EPAP is raised without
  raising the IPAP, the VT might decrease because
  the VT is a function of the change in pressure or
  the ‘delta P’ [ Δ P]
The BiPap ST/D

  EPAP/CPAP: in this mode, all you get is CPAP
  IPAP: in this mode, again, all you get is CPAP.
  Spontaneous mode this is a form of PSV in which
   you select the PS with the IPAP and the PEEP with
   the EPAP. All breaths are patient triggered
  Spontaneous/timed: is their version of A/C PC
   with each breath patient or time triggered. In this
   mode you select the bpm
  Timed mode: their version of control ventilation
   in which you now select the rate and the
   inspiratory time
What is so strange about the
BiPAP ST/D circuit?
 only a single, large-bore tubing going from
  the compressor to the patient’s mask.
 constant leak at the “Whisper swivel” this
  will leak a minimal amount of gas out of the
  circuit and between the very high flow rates
  and the leak, the patient doesn’t rebreathe
  his C02. Never plug up this hole!
Adding extra 02 to the BiPap STD
without starting a fire
 add 02 at the mask,
 start machine first before adding 02 so gas
  will not leak back into machine
 never exceed 15 LPM
Compare the BiPap STD to the Vision
BiPap machine
 The BiPAP ST/D has no 02 inlet
 The Respironics Vision plugs into 50 psig 02 &
  can get 21% to 100% Fi02
 The BiPAP ST/D has no internal alarm, you
  must buy a separate alarm
 The Respironics Vision can be used for
  invasive ventilation with A/C, SIMV +PSV and
  CPAP as well as NIPPV [CPAP and S/T]

Use of critical care ventilators such as
BiPap machines in the ICU.


 As a rule, we would operate these machines
  in the PSV mode with PEEP to mimic the
  BiPap.
 It is important to understand that the alarms
  on these machines may have to be adjusted
  out of range
Dual modes
 combine mandatory ventilation with
  spontaneous ventilation
 IMV: intermittent mandatory ventilation: in
  which some breaths are mandatory and
  others are spontaneous.
 In this type of breath, the ventilator will give
  a PPV usually based on VC at timed intervals.
  The patient can breathe off a constant flow
  rate or from a demand valve at a VT and flow
  rate determined by his muscle strength,
  ventilatory drive and lung mechanics.
Advantages of IMV/ SIMV

 patient comfort
 maintains muscle coordination & muscle
  strength
 reduces V/Q mismatch;Zone III is being
  utilized,
 [4] lower PAW and is an excellent weaning
  modality
 less likely to cause air-trapping

Disadvantage of IMV/ SIMV:

 If the patient’s PPV support is removed too
  quickly the patient can suffer increased WOB

 We need to monitor the spontaneous VE , RR
  and VT, we may need to increase support by:
   increasing the SIMV rate
   adding PS
Indications for IMV/SIMV:

 IMV is a partial mode of ventilation that
  usually includes dual modes.
 weaning from CMV when the patient’s
  ventilator muscles are weakened
 an initial ventilator setting when the patient is
  at risk for air trapping and is breathing on his
  own,
 or if the patient who is able to breathe partially
  for himself is at risk for decreased CO.


The difference between SIMV and IMV:


 SIMV stands for ‘synchronized intermittent
  mandatory ventilation.’
 The mandatory breath can come in sooner if
  patient triggers within the synchronization
  window of fractions of seconds.
Special modes: PRVC

  In a pressure regulated volume control mode,
PRVC

   we are attempting to deliver the VT [because
   we are in VC mode] but we want to keep the
   airway pressures low.

  ventilator will attempt to deliver the VT at 5
       cmH20 below a preset pressure setting.
Special modes: VAPS

 volume assured, pressure support, the ventilator
  will be attempting to deliver a stable VT with PS
  breaths so that the patient has the advantage of
  stable VE as well as the advantages of
 If a PS breath fails to reach the pre-set VT, the
  breath will continue at a constant flow until the
  volume is reached. If the patient got the pre-set VT
  with the PS breath, it stays PS.
 Unlike normal PS, these breaths aren’t just flow
  triggered, but can be time triggered.
Special modes: MMV
 Mandatory minute ventilation
 gives the patient extra breaths or extra PS
  pressure to keep a predetermined minimal VE.

 This differs from apnea parameters in that
  the patient doesn’t have to actually go apneic
  for 20 seconds or more for this to activate. He
  merely needs to have hypoventilation.
One problem with MMV

 when the patient starts the rapid, shallow
  breathing associated with respiratory
  distress.
 If a patient keeps the VE up with rate only, he
  can be in a lot of distress
 It is suggested to keep the maximal high
  respiratory rate 10 BPM above the average
Special modes: ASV
 adaptive support ventilation: the RCP inputs
  the patient’s IBW and a percentage of the VE.
 The ventilator will deliver a VE based on the
  patient’s IBW.

 As the patient takes over more of the breathing
  the VE is maintained with PS breaths.
 The level of PS changes to give the VT calculated
  by the machine, The VT will be determined by
  the patient’s IBW and VD ventilation.
Special modes: PAV

 In proportional assist ventilation mode
  similar to ASV in that the ventilator will
  collect data about patient’s elasticity and
  resistance and flow or volume demands in
  order to arrive at PS levels that varies.
High frequency ventilation

 controlled ventilation- the patient is sedated
  and paralyzed
 VT of less or equal to the VD anatomical
 respiratory frequencies of 60 BPM-3600 bpm
 All HFV counts on the gas stream going down
  the ET tube (inside) AT THE SAME TIME and
  the gas flow existing (outside stream).
How does HFV work

 Penduluft action due to various time
  constants of different portions of the lungs,
  the gas moves from one lobe to another ,

 there is some bulk transfer
What are the types of HFV

 high frequency jet ventilation
 high frequency positive pressure
  ventilation
 high frequency oscillation
 combination of HFJ with CMV
Special modes: PRVC

 In pressure regulated volume control, an
  effort is made to maintain both a safe level
  of airway pressure and delivered VT.
 In PRVC, the RCP selects a PIP that will
  not be exceeded.
 To keep the VT, at this safe PIP, the
  inspiratory time and the flow rate must
  vary.
Special modes: Auto-mode:

 in some ventilators selection of the auto-
  mode will allow the ventilator to decrease
  support as a patient starts to take over the
  WOB.
 The ventilator reverts between a CMV mode
  and a spontaneous mode based on breath by
  breath assessment of the patient
Special modes: ATC

 Automatic tubing compensation, in this
  mode the ventilator will compensate for the
  RAW of the ET tube.
INITIAL VENTILATOR SETTINGS
VT, set f and VE

 Full support A/C or SIMV rate 12-16 BPM
 Partial support SIMV below 10 BPM
     8-10 ml/Kg IBW normal lungs
     6-8 ml/kg IBW asthma
     5-8 ml/ kg IBW for ARDS & COPD
   VE needs to be 80-100 ml/KgIBW
TI and Flow rates

 Inspiratory flow rates of 60-80 LPM for most
   If air hungry raise above 80
   COPD- 60-100 LPM
 Inspiratory times .80-1.2 seconds
Flow wave pattern

 Constant flows will decrease inspiratory time
  and help with I:E ratios, but can raise the PIP.
 Descending flow curve has the advantage of
  better distribution of gas into the lung, but
  will increase the TI and increase the mPAW
 Sine wave: while considered more
  physiological, a classic sine wave may not
  have enough initial flow to satisfy a patient.
  Like the descending flow pattern it will raise
  the TI and change the I:E ratio
Rise time or Ramp

 : in an effort to fine-tune flow patterns, the
  constant flow can be damped by a rise time
  adjustments. When set high, this almost
  mimics an ascending flow pattern.
Inspiratory pause

 The temporary use of the inspiratory pause
  at about .5 to 1 second is generally reserved
  for gathering Pplateau
Fi02

 100% is a good place to
 Weaning rapidly to 40-50% after ABG
 Fi02 needs to be weaned about 20% at a step.
PEEP

 may be started at zero, PEEP at 5 or less
  cmH20 is considered physiological and should
  not result in CV problems-but-- remember
  any PEEP that causes hemodynamic
  problems is excessive.
 Increase or decrease by units of 2
Humidification by HME

 is limited to persons with good fluid balances,
  normal secretions and VE less than 10 LPM
  and normal body temperatures.
 If the patient has a gross leak so that 30% of
    the delivered VT is lost, the HME will not
    work.

Humidification by heated
humidifier
 can be used with everyone but are necessary
  for patients with secretions. Keep the
  temperatures close to 330 C +/- 2
Sighs:

 multiple sighs every hour or so. These sigh
  volumes were about 1.5 x the VT.
 important if VT is less than 7 ml/kg
s/p lung resection or lung
transplants

 need lower VT and faster rates to protect the
  torn lung from rupture.
 Keep the Pplateau at or below 30 cmH20 [old
  Egan’s 1011]
lobar pneumonia:

 place patient on the good lung side so gas goes
  to the bad lung
 avoid PEEP in lobar pneumonia if possible
 Try to prolong the Ti
 Consider double lumen ET tube so we can set
  two ventilators on the patient
long-term neuromuscular
patients
 more comfortable at higher than usual VT
  [decrease the RR] of 10-12 ml/kg. These
  patients also tend to want higher flow rates.
 They can be managed with low Fi02-even .21
  as long as Sp02 is above 90-92%
 low PEEP of 3-5 to prevent atelectasis are ok
Persons with Congestive
Heart failure
 We can start with normal settings, but if the
  PIP and Pplateau are excessive, we need to
  decrease the VT
 PEEP at 10 cmH20 and wean the
 Once the patient’s compliance gets better, we
  must wean the PEEP
 If the patient has an intact ventilatory drive, &
  good VE, he could be maintained on CPAP
Initial parameters when High RAW
is an issue?
 start with SIMV because this mode is less
  likely to cause air trapping.
 minimize air trapping and auto-PEEP
COPD
 SIMV rate between 10-12 BPM : decrease this to 6-8 to
    allow time to exhale
   start at 60 and raise to100 LPM].
   A COPD patient can be started at 40-50% Fi02
    Use of PEEP with COPD is dangerous, but if the set PEEP
    and the auto-PEEP are kept about the same, the gas is
    more likely to leave the lung
   , keep Sp02 at 90-92% and keep the PaC02 and pH close
    to baseline so the patient will not suffer post-hypercapnic
    alkalosis
Asthmatic [AHI 2005 CPR CPG pp IV 141]
  Alert? may do well on BiPap machine
  SIMV rate 6-10 BPM
  VT of 6-8 ml/ kg IBW
  80-100 LPM with a descending flow pattern to
   get 1:4 or 1:5
  Start Fi02 at 100%.
  Use of PEEP with asthmatics is dangerous, but if
   the set PEEP and the auto-PEEP are kept the
   same, the gas is more likely to leave the lung.
  permissive hypercapnia,

								
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