Mechanical Ventilation Principles and Practices
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1 Mechanical Ventilation Principles and Practices Dr LAU Chun Wing Arthur Department of Intensive Care Pamela Youde Nethersole Eastern Hospital 6 October 2009
2 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
3 Four important equations in respiratory medicine PaCO2 is measured in mm Hg, VCO2 in ml/min (STPD), and VA in L/min (BTPS); hence the units must be converted to mm Hg. This conversion is achieved by the constant,
4 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)
5 Invasive ventilation
6
7 ICU ventilators Viasys Avea Siemens Servo i Draeger Evita 4 Puritan Bennett 840 Have to be equipped with a noninvasive mode : leak-tolerant, use only the essential alarms
8 Hybrid ventilators Viasys Vela Bird VSO2
9 Home ventilators Respironics BiPAP Vision Versamed ivent Breas PV 102 Breas LTV 1000 Sirio NIV-S
10 Heated Humidifier
11 Heat and Moister exchanger (HME)
12
13
14 Key terms in Mechanical Ventilation Tidal volume Rate: breaths per minute Minute ventilation PEEP FiO2 I:E ratio, Inspiratory flow rate Pressure control pressure CPAP, Pressure support
15 Control mode 1 Assist Control Ventilation TV is set Rate is set Airway pressure varies with lung compliance Ventilator delivers a fixed volume (patient triggers or mandatory)
16 Control mode 2 Pressure 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)
17 VC PC
18 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
19 Control + Support mode Synchronized 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
20 Non-invasive ventilation (NIV)
21 Nasal Facial Nasal pillow Total face
22 Nasal prong device Helmet
23 Exhalation device (used if there is no decidated expiratory limb) 1. In mask 2. In circuit a. Whisper-Swivel b. Whisper-Swivel II c. Plateau valve Whisper-Swivel Plateau valve Whisper-Swivel II, Respironics
24 Key terms in NIV CPAP = continuous positive airway pressure BiPAP = IPAP (inspiratory) EPAP (expiratory)
25 Clinical conditions
26 Scenario 1: COPD M/80: 60 pack-year smoking history, c/o SOB for 3 days
27 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
28 Scenario 2: Asthma M/20: Non-smoker, c/o wheezing and SOB for 3 days
29 Status asthmaticus: pathophysiology Smooth muscle hypertrophy and spasm Inflamed airway Thick bronchial cast
30 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
31 Scenario 3: Acute pulmonary edema M/60: DM, ECG: ST elevations
32 APO requirements NIV (both CPAP or BiPAP) useful IPPV Low volume (6 8 ml/kg PBW) Higher freq High PEEP High FiO2
33 Scenario 4: Neuromuscular disease
34 Problems Removal of secretions Ventilatory pump failure Progressive atelectasis Increasing oxygen requirement Decreasing MIP and VC
35
36
37 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 surfatant production PEEP: use physiological PEEP (3-5 cm H2O) MV adjusted for desired ph Tracheostomy for failure to wean within 3 weeks
38 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
39 Invasive ventilatory settings in various conditions
40 Noninvasive ventilation
41 Thank you
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