Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices...

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Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern Hospital 6 October 2009

Transcript of Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices...

Page 1: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Mechanical VentilationPrinciples and Practices

Dr LAU Chun Wing Arthur

Department of Intensive CarePamela Youde Nethersole Eastern Hospital6 October 2009

Page 2: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

In this lecture, you will learn

Major concepts in respiratory physiology General concepts of noninvasive and

invasive ventilation Different modes of mechanical

ventilation: VC, PC, CPAP + PS, SIMV Settings for different clinical scenarios:

COPD, asthma, APO, neuromuscular disease

Page 3: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Four important equations in respiratory medicine

PaCO2 is measured in mm Hg, VCO2 in ml/min (STPD), and VA in L/mPaCO2 is measured in mm Hg, VCO2 in ml/min (STPD), and VA in L/min (BTPS); hence the in (BTPS); hence the units must be converted to mm Hg. This conversion is achieved byunits must be converted to mm Hg. This conversion is achieved by the constant, 0.863.the constant, 0.863.

Page 4: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Four important concepts in assisted ventilation

Know the set of pathophysiology in your patient

Resistance = ∆Pressure/∆Flow High: COPD, asthma

Compliance = ∆Volume/∆Pressure Low (lung): ARDS, APO, pneumonia Low (chest wall): neuromuscular diseases High: emphysema

Know how to and how much to correct the pathophysiology (e.g. open lung approach, protective lung strategy, permissive hypercapnia)

Page 5: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Invasive ventilation

Page 6: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern
Page 7: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

ICU ventilators

Viasys AveaSiemens Servo i

Puritan Bennett 840

Draeger Evita 4

Have to be equipped with a “noninvasive mode”: leak-tolerant, use only the essential alarms

Page 8: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Hybrid ventilators

Viasys VelaBird VSO2

Page 9: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Home ventilators

Respironics BiPAP VisionVersamed iVent Breas PV 102

Breas LTV 1000 Sirio NIV-S

Page 10: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Heated Humidifier

Page 11: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Heat and Moister exchanger (HME)

Page 12: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern
Page 13: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern
Page 14: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Key terms in Mechanical Ventilation

Tidal volume Rate: breaths per minuteMinute ventilation PEEP FiO2 I:E ratio, Inspiratory flow rate Pressure control pressure CPAP, Pressure support

Page 15: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Control mode 1Assist Control Ventilation

TV is set Rate is set Airway pressure varies with lung

compliance Ventilator delivers a fixed volume

(patient triggers or mandatory)

Page 16: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Control mode 2Pressure control ventilation

PCV is set Rate is set Insp time is set Volume varies according to lung

compliance Ventilator delivers a fixed pressure

(patient triggers or mandatory)

Page 17: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

VC PC

Page 18: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Support mode

Patient must be able to breathe spontaneously

1. Pressure support + CPAP: each spontaneous breath is supported on top of the CPAP (PEEP) level till the target pressure level is achieved

2. Volume support + CPAP: each spontaneous breath is supported on top of the CPAP (PEEP) level till the target volume is achieved

Backup: ventilator switches to control mode if there is apnoea for a set period

Page 19: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Control + Support modeSynchronized Intermittent Mandatory Ventilation (SIMV)

PC + PS: each spontaneous breath is supported till the target pressure level is achieved

VC + PS: each spontaneous breath is supported till the target volume is achieved

Page 20: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Non-invasive ventilation (NIV)

Page 21: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Nasal

Nasal pillow

Facial

Total face

Page 22: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Helmet

Nasal prong device

Page 23: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Exhalation device (used if there is no decidated expiratory limb)

Whisper-Swivel II, RespironicsPlateau valve

1. In mask2. In circuit

a. Whisper-Swivelb. Whisper-Swivel IIc. Plateau valve

Whisper-Swivel

Page 24: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Key terms in NIV

CPAP = continuous positive airway pressure

BiPAP = IPAP

(inspiratory) EPAP

(expiratory)

Page 25: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Clinical conditions

Page 26: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Scenario 1: COPD

M/80: 60 pack-year smoking history, c/o SOB for 3 days

Page 27: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

COPD: Ventilation requirements

NIV: very useful, start with this mode unless there is profuse sptum

IPPV Set a lower rate to allow for longer time for

expiration PEEP 5 or above, adjust according to

autoPEEP

Page 28: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Scenario 2: Asthma

M/20: Non-smoker, c/o wheezing and SOB for 3 days

Page 29: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Status asthmaticus: pathophysiology

Smooth muscle hypertrophy and spasm

Inflamed airway Thick bronchial cast

Page 30: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Asthma: Requirements

NIV may not be useful IPPV setting:

High resistance Low freq and small volume Long expiratory time Zero PEEP Allow pCO2 to rise (permissive hypercapnia), allow

pH around 7.2 Muscle relaxation Manual assisted expiration

Page 31: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Scenario 3: Acute pulmonary edema

M/60: DM, ECG: ST elevations

Page 32: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

APO requirements

NIV (both CPAP or BiPAP) useful IPPV

Low volume (6 – 8 ml/kg PBW) Higher freq High PEEP High FiO2

Page 33: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Scenario 4: Neuromuscular disease

Page 34: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Problems

Removal of secretions Ventilatory pump failure Progressive atelectasis Increasing oxygen requirement Decreasing MIP and VC

Page 35: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern
Page 36: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern
Page 37: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Choice of ventilatory support

Noninvasive positive-pressure ventilation If reversibility is expected over hours to days, e.g.

mild LRTI in chronic neuromuscular disease as polymyositis or MG; Problem: secretion retention

Intermittent positive pressure ventilation via endotracheal tube Larger tidal volumes (12 – 14 ml) may be better

tolerated and maximize stimulaton of surfatantproduction

PEEP: use physiological PEEP (3- 5 cm H2O) MV adjusted for desired pH Tracheostomy for failure to wean within 3 weeks

Page 38: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Summary

Major concepts in respiratory physiology General concepts of noninvasive and

invasive ventilation Different modes of mechanical

ventilation: VC, PC, CPAP + PS, SIMV Settings for different clinical scenarios:

COPD, asthma, APO, neuromuscular disease

Page 39: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Invasive ventilatorysettings in various conditions

Page 40: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Non-invasive ventilation

Page 41: Mechanical Ventilation Principles and Practices · Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern

Thank you


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