Mechan|ca|

Venn|atory
Support
Curtis N. Sessler, MD, FCCP, FCCM
Orhan Muren Professor of Medicine
Virginia Commonwealth University Health System
Director, Center for Adult Critical Care
Medical College of Virginia Hospitals
csessler@vcu.edu
ACCP Pulmonary Board Review Course
San Antonio, TX
August 29, 2013
Mechan|ca| Venn|atory
Support
Curtis N. Sessler, MD, FCCP, FCCM

No potential conflicts of interest to disclose
ACCP Pulmonary Board Review Course
San Antonio, TX
August 29, 2013
Mechan|ca| Venn|atory Support:
Cb[ecnves
A|phabet Soup
of Mechan|ca| Venn|anon
SIMV
AC
PSV
PEEP
APRV
PCV
PRVC
PAV
VAPS
NAVA
NPPV
CMV
HELP
MV: Conceptua| Iramework
S
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P
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2
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1
2

Cxygenanon
oxygenauon by
ercenL C2 (l.e. 40)
- or fracuon, llC2 (l.e. 0.4)
Cpenlng alveoll wlLh
osluve end-explraLory
pressure (LL) or
mean alrway pressure
(MA), esp lf dluse
lung dlsease (l.e. A8uS)
MonlLor oxygenauon
aC2/llC2 rauo
SpC2
Venn|anon
ulerenL breaLhs Lypes, how Lhey are puL LogeLher
8reaLhs
CharacLerlsucs: 3 1s: 1argeL, 1rlgger, 1ermlnauon
Common breaLh Lypes: ConLrolled, AsslsLed,
SupporLed
venL modes
1ypes of breaLhs
SeL raLe
Common modes
- AsslsL conLrol
- SlMv
- SponLaneous /
Sv
C|ass|hcanon of Venn|anon:
8reath De||very 1arget
Volume
You set:
Tidal volume
Peak flow
Flow pattern
Delivery of the
breath stops when
set volume delivered
(termination signal)
Airway pressure may
vary with effort, lung
mechanics
Pressure
You always set:
Inspiratory pressure
(Pplateau PEEP)
Inspiratory time depends
on breath type
(termination signal)
You set inspiratory time for
mandatory breaths
Patients effort determines
inspiratory time in
spontaneous breath
Volume may vary
C|ass|hcanon of Venn|anon:
S|gna| to In|nate 8reath (1r|gger)
1lmed (coottolleJ or venulaLor lnluaLed)
8ased upon seL raLe of mooJototy bteotbs
- l.e. lf raLe = 10/mln, Lhen umed breaLh every 6 sec
auenL lnluaLed
lnsplraLory eorL generaLes a ln alrway pressure or
ln lnsplraLory ow LhaL exceeds a pre-seL Lhreshold
- Lhls Lrlggers Lhe venulaLor Lo dellver a breaLh
1ype of breaLh (l.e. mooJototy or spootooeoos)
depends upon mode and umlng
- MandaLory = AsslsLed breaLh
- SponLaneous = SupporLed breaLh
C|ass|hcanon of Venn|anon:
S|gna| to 1erm|nate 8reath
1ermlnauon crlLerla (also called cycllng) can be pre-seL
or dependenL upon pauenL eorL
lot o MooJototy bteotb, yoo set ctltetlo.
volume-cycled: lnsplrauon LermlnaLed aer preseL
udal volume dellvered
1lme-cycled, based on pre-seL lnsplraLory ume
lot o 5pootooeoos bteotb, poueot e[ott Jetetmloes
tetmloouoo
ressure-supporLed sponLaneous breaLh: ow-
cycled, ow decreases Lo a seL (usually 23) of
peak ow raLe and breaLh ls LermlnaLed
1rad|nona| C|ass|hcanon of
Venn|ator 8reaths
Cycllng mechanlsm (Lermlnauon of lnsplrauon)
volume-cycled: lnsplrauon LermlnaLed aer preseL udal
volume dellvered (l.e. volume-LargeLed AC or SlMv)
ressure-cycled: lnsplrauon LermlnaLed when preseL
maxlmum pressure reached
llow-cycled: lnsplrauon LermlnaLed when ow raLe
reached, such as ow decreased Lo 23 of peak ow
(l.e. Sv)
1lme-cycled: lnsplrauon LermlnaLed aer preseL
lnsplraLory ume (l.e. pressure-LargeLed AC or SlMv)
8reath 1ypes 8ased on In|nanon
(1r|gger) and 1erm|nanon
uesnon 1
Whlch of Lhe followlng sLaLemenLs regardlng Lhe
characLerlsuc of a pressure supporLed breaLh ls
Lrue?
A. 1he cllnlclan seLs Lhe lnsplraLory ume
8. 1he pauenL deLermlnes Lhe lnsplraLory pressure
C. 1he cllnlclan seLs Lhe raLe
u. 1he breaLh ls LermlnaLed when lnsplraLory ow
decreases Lo a seL Lhreshold
uesnon 1
Whlch of Lhe followlng sLaLemenLs regardlng Lhe
characLerlsuc of a pressure supporLed breaLh ls
Lrue?
A. 1he cllnlclan seLs Lhe lnsplraLory ume
8. 1he pauenL deLermlnes Lhe lnsplraLory pressure
C. 1he cllnlclan seLs Lhe raLe
>> u. 1he breaLh ls LermlnaLed when lnsplraLory ow
decreases Lo a seL Lhreshold
Mode of Venn|anon:
Integranon of 8reath 1ypes
AsslsL ConLrol (AC)
SeL mlnlmum raLe: all are MandaLory
(ConLrolled or AsslsLed), all exLra breaLhs are
AsslsLed
Synchronlzed lnLermluenL MandaLory venulauon
(SlMv)
SeL raLe: all are MandaLory (ConLrolled or
AsslsLed), all exLra breaLhs are SponLaneous
(SupporLed) breaLhs
SponLaneous / ressure SupporL venulauon (Sv)
All are SupporLed breaLhs
uesnon 2
A pauenL venulaLed ln volume-LargeLed asslsL-conLrol
mode wlLh seL raLe of 12 /mln & udal volume of 300 ml
develops pulmonary edema and LoLal resp raLe Lo 30/
mln. Whlch of Lhe followlng changes ln venulauon wlll
occur?
A. 1he number of sponLaneous pressure-supporLed breaLhs
wlll lncrease Lo 18 breaLhs/mln
8. 1he udal volume wlll decrease
C. 1he peak alrway pressure wlll lncrease
u. All breaLhs wlll become conLrolled breaLhs
uesnon 2
A pauenL venulaLed ln volume-LargeLed asslsL-
conLrol mode wlLh seL raLe of 12 /mln & udal
volume of 300 ml develops pulmonary edema
and LoLal resp raLe Lo 30/mln. Whlch of Lhe
followlng changes ln venulauon wlll occur?
A. 1he number of sponLaneous pressure-supporLed
breaLhs wlll lncrease Lo 18 breaLhs/mln
8. 1he udal volume wlll decrease
>> C. 1he peak alrway pressure wlll lncrease
u. All breaLhs wlll become conLrolled breaLhs
Mode of Venn|anon:
Integranon of 8reath 1ypes
AsslsL conLrol
volume or pressure
SlMv
volume or pressure
SponLaneous (pressure supporL)
ressure conLrol venulauon
ressure-AC wlLhouL Lrlggered (asslsLed) breaLhs
C-lnverse rauo venulauon (C-l8v)
- long lnsplraLory ume
8|Leve| Venn|anon ]
A|rway ressure ke|ease Venn|anon (AkV)
SeL low LL and hlgh LL (plaLeau) levels
auenL Lakes sponLaneous breaLhs, whlch can be
pressure supporLed (g 1)
uurauon of low LL and hlgh LL can be ume-
based or synchronlzed wlLh pauenL eorL
A|rway ressure
ke|ease Venn|anon
Airway
Pressure
Flow
Greater D|sp|acement of Lower
D|aphragm w|th Spontaneous 8reaths
Froese
Anesthesiology
1974;41:242
C|ass|c AkV
50% of Peak Flow
Tlow = 0.7 sec
Peak Flow
8|Leve| w|th 1|ow > 1 Sec
Note: complete exhalation
AkV Concerns: AutoLL & 1|da|
Vo|ume Creep
Incomplete emptying (i.e. autoPEEP)
300
350
400
450
500
550
600
650
700
10pm 2am 6am 10am
Tidal volume
6 ml/kg PBW
A|rway ressure ke|ease
Venn|anon (AkV) for AkDS
Classlc A8v lncreases rlsk of auLo-LL
Pyperlnauon, less eecuve venulauon
Conslder: seL a mlnlmal 1low > 1 sec (A8v llLe)
A8v & 8lLevel rlsk of excesslve udal volumes
8lsk lncreased lf sponLaneous breaLhs supporLed wlLh
Sv or Lube comp, Conslder: sponL breaLhs wlLh no
supporL, SeL alarms for udal volume > 7-8 ml/kg 8W
Can oxygenauon, buL beuer alLernauves
Absence of evldence for ouLcome beneL vs
convenuonal modes ln Lhe modern era
ressure kegu|ated Vo|ume
Contro| (kVC)
Also called volume conLrol plus (vC+),
AuLollow, adapuve-pressure conLrol,
adapuve supporL venulauon
8reaLhs are mandaLory (asslsLed or conLrolled),
pressure llmlLed, ume cycled, 8u1.
Cllnlclan seLs goal udal volume, and Lhe venulaLor
reseLs pressure uslng lasL few breaLhs Lo dellver
goal udal volume

kVC ] VC+
ressure kegu|ated Vo|ume Contro|
(kVC) Venn|anon
A
B
C
D
E
Asynchony () results in small breath (A), so pressure d (B)
resulting in excessively large breath (C), so next pressure is
reduced (D) resulting in breath near target size (E)
ressure kegu|ated Vo|ume Contro|
(kVC) Venn|anon
Asynchrony (muluple Lrlggers) can confuse Lhe
sysLem
Vo|ume-Assured ressure Support
(VAS)
Slmllar Lo 8vC, excepL applled Lo sponLaneous
breaLhs
Lach breaLh ls pauenL Lrlggered, pressure llmlLed,
ow cycled, 8u1
lnsplraLory pressure ls ad[usLed by Lhe venulaLor
Lo achleve goal udal volume
SLrong eorL = lower lnsplraLory pressure
Weak eorL = hlgher lnsplraLory pressure
ropornona| Ass|st Venn|anon (AV): Cru|se
Contro| for the Venn|ator?
ConcepL: changlng pressure Lo perform venulaLor
work proporuonal Lo pauenL eorL
ressure-LargeLed, pauenL Lrlggered, ow cycled
ressure changes breaLh-Lo-breaLh
8ased upon measured changes ln elasLance (1/
compllance), reslsLance, and ow demand
Plgher ow or volume g hlgher pressure
Av seL Lo overcome a selecLed of work of breaLhlng
SafeLy semngs wlLh hlgh pressure, hlgh volume
Lecnve Venn|anon: Integranon of
anent & Venn|ator: NAVA
T
o
b
i
n
,

M
J
.

N

E
n
g
l

J

M
e
d

2
0
0
1
;
3
4
4
:
1
9
8
6
-
9
6

Neura||y Ad[usted Venn|atory Ass|st
(NAVA): D|aphragm |s Dr|ver
ConcepL: venulaLor applles pressure LhroughouL
lnsplrauon ln proporuon Lo elecLrlcal acuvlLy of
Lhe dlaphragm (LAdl) by Lrans-esophageal LMC
Ad[usL proporuon of asslsLance
ressure LargeLed, pauenL Lrlggered, varlable
cycllng (Lermlnauon) - 70 peak LAdl or ow/aw
Less asynchrony Lhan wlLh Sv colombo et ol. loteoslve cote
MeJ 2008, J4.2010-18
NAVA
Pressure

Flow

Volume

Edi
Comp||canons of
Mechan|ca| Venn|anon
Cxygen 1oxlclLy
8aroLrauma
uynamlc
hyperlnauon
venulaLor assoclaLed
lung ln[ury (vALl)
vA
SLress ulcer
1racheomalacla
vocal cord Lrauma
1rauma Lo llp, nose,
LeeLh, eLc
unplanned exLubauon
L1 Lube malposluon
1racheosLomy
bleedlng, eLc
Mon|tor|ng Mechan|ca| Venn|anon
FLOW
PRESSURE
Alarms
Output data
Minute
ventilation
Total rate
Peak pressure
Flow-time and
pressure-time
graphics
Venn|ator Graphics
flow
pressure
exhaled CO
2
volume
Time
OUT
IN
uesnon 3. What venn|ator mode |s th|s?
A) AC, 8) SIMV, C) spontaneous
flow
pressure
exhaled CO
2
volume
uesnon 3. What venn|ator mode |s th|s?
8) SIMV
flow
pressure
exhaled CO
2
volume
Lecnve Venn|anon: Integranon of
anent & Venn|ator
T
o
b
i
n
,

M
J
.

N

E
n
g
l

J

M
e
d

2
0
0
1
;
3
4
4
:
1
9
8
6
-
9
6

4. Wh|ch panent-venn|ator
asynchrony |s present?
A. uouble Lrlggerlng
8. lneecuve Lrlggerlng
C. llow asynchrony
u. AuLo-Lrlggerlng
4. Wh|ch panent-venn|ator
asynchrony |s present?
A. uouble Lrlggerlng
>> 8. lneecuve Lrlggerlng
C. llow asynchrony
u. AuLo-Lrlggerlng
C|ass|hcanon of anent-Venn|ator
Interacnons & Common Asynchron|es
1rlgger
lneecuve Lrlgger
uouble Lrlgger
8reaLh dellvery
llow asynchrony
Cycllng Lo exhalauon
uelayed Lermlnauon
remaLure
Lermlnauon
Lxhalauon
lnLrlnslc LL
C|ass|hcanon of anent-Venn|ator
Interacnons & Common Asynchron|es
1rlgger
lneecuve Lrlgger
uouble Lrlgger
8reaLh dellvery
llow asynchrony
Cycllng Lo exhalauon
uelayed Lermlnauon
remaLure
Lermlnauon
Lxhalauon
lnLrlnslc LL
Ineecnve 1r|gger
Ineecnve 1r|gger Demonstrated by
Lsophagea| ressure
N
i
l
s
e
s
t
u
e
n

&

H
a
r
g
e
t
t
.

R
e
s
p
i
r

C
a
r
e

2
0
0
5
;

5
0
:
2
0
2

Flow



Pairway




Peso
Doub|e 1r|gger
Doub|e 1r|gger
Demonstrated by Lsophagea| ressure
N
i
l
s
e
s
t
u
e
n

&

H
a
r
g
e
t
t
.

R
e
s
p
i
r

C
a
r
e

2
0
0
5
;

5
0
:
2
0
2

Peso
Doub|e 1r|gger: Common w|th Low
1|da| Vo|ume Venn|anon
P
o
h
l
m
a
n

C
r
i
t

C
a
r
e

M
e
d

2
0
0
8
;
3
6
:
3
0
1
9
-
3
0
2
3

Stacked breaths averaged 10.1 ml/kg PBW (1.6
x set Vt)

Less common with higher set Vt
C|ass|hcanon of anent-Venn|ator
Interacnons & Common Asynchron|es
1rlgger
lneecuve Lrlgger
uouble Lrlgger
8reaLh dellvery
llow asynchrony
Cycllng Lo exhalauon
uelayed Lermlnauon
remaLure Lermlnauon
Lxhalauon
lnLrlnslc LL
Increased Work w|th I|ow
Asynchrony
N
i
l
s
e
s
t
u
e
n

&

H
a
r
g
e
t
t
.

R
e
s
p
i
r

C
a
r
e

2
0
0
5
;

5
0
:
2
0
2

I|ow Asynchrony
SIMV volume-targeted + PS (breaths 1 & 4)
Max flow = 40 L/min
I|ow Asynchrony:
Flow Asynchrony
SIMV volume-targetted + PS (breath 3)
Max flow = 60 L/min (breaths 1, 2, 4)
I|ow Asynchrony:
Flow Asynchrony
SIMV volume-targetted + PS (breath 2)
Max flow = 70 L/min (breaths 1, 3)
2
C|ass|hcanon of anent-Venn|ator
Interacnons & Common Asynchron|es
1rlgger
lneecuve Lrlgger
uouble Lrlgger
8reaLh dellvery
llow asynchrony
Cycllng Lo exhalauon
uelayed Lermlnauon
remaLure
Lermlnauon
Lxhalauon
lnLrlnslc LL
Cyc||ng Asynchrony:
De|ayed 1erm|nanon
Active exhalation during ventilator breath airway
pressure (A) and produces expiratory flow (B)
Cyc||ng Asynchrony:
De|ayed 1erm|nanon
LMG kevea|s Lxp|ratory Lort
8efore 8reath 1erm|nanon
R
a
c
c
a

e
t

a
l
.

R
e
s
p
i
r

C
a
r
e

C
l
i
n

2
0
0
5
;
1
1
:
2
2
5
-
2
4
5

De|ayed 1erm|nanon: Corrected
w|th Shorter Insp|ratory 1|me
C|ass|hcanon of anent-Venn|ator
Interacnons & Common Asynchron|es
1rlgger
lneecuve Lrlgger
uouble Lrlgger
8reaLh dellvery
llow asynchrony
Cycllng Lo exhalauon
uelayed Lermlnauon
remaLure
Lermlnauon
Lxhalauon
lnLrlnslc LL
Intr|ns|c LL
When exhalauon
LermlnaLes before
equlllbrauon
beLween alrway
(aw) and alveolar
(alv) pressures, end-
explraLory ow
(arrow) perslsLs, and
LoLal LL exceeds
seL value, produclng
dynamlc
hyperlnauon
Marini J. Am J Respir Crit
Care Med 2011;184:756
Palv
Flow
Does not reach baseline
before next breath
Auto-PEEP
Lxp|ratory ause to Create
No I|ow and & Ca|cu|ate LLI
1
2
3 4
Lxp|ratory hase:
Intr|ns|c LL
Also called AuLo-LL, CcculL LL
ulmculL Lo recognlze, measure, & conLrol
Consequences can lnclude hypoLenslon,
baroLrauma, work of breaLhlng, pauenL-
venulaLor asynchrony, venulauon
lf worsenlng alrow obsLrucuon (bronchospasm,
secreuons) lL can become abrupLly llfe-LhreaLenlng
Marini J. Am J Respir Crit Care Med 2011;184:756
Dynam|c nyper|nanon
Bronchospasm, mucus plugging
Airflow obstruction
Delayed / incomplete alveolar emptying
Auto PEEP
Ineffective triggering
Flattened diaphragm
Hemodyamic compromise
If pressure-targeted, tidal volumes
If volume-targeted, plateau pressure
The ART and SCIENCE of
Weaning from Mechanical
Ventilation
Liberation From the Ventilator

Ventilator Discontinuation and Extubation
Lv|dence-based Gu|de||ne for Wean|ng
& D|sconnnu|ng Venn|atory Support
Daily screen performed by RN & RT: must
pass all
Some reversal of cause for ventilatory support
Adequate oxygenation (paO2/FiO2 > 150-200 torr,
PEEP < 5-8 cmH2O, FiO2 < .04-.05) ; pH > 7.25
Hemodynamically stable; no (or minimal) pressors
Can initiate inspiratory effort
Spontaneous breathing trial
Airway patency, ability to protect airway
ACCP/SCCM/AARC Task Force. Chest 2001; 120:375S
Common Components of Wean|ng
rotoco|s
Parameter Measures
Medical stability shock, pressors, pH
Mental status i.v. sedatives, sedation scale
Oxygenation FiO2, PEEP, PaO2:FiO2
Lung mechanics RSBI, pH
Endurance SBT
Airway patency Cuff-leak test
Miscellaneous Condition improving, cough,
sputum
Lect of a Sedanon rotoco| on
Duranon of Mechan|ca| Venn|anon
RCT: 321 ventilated pts
RN protocol focused on
less infusion rx: fentanyl,
lorazepam
Protocol reduced
continuous infusion
Protocol: independent
predictor of MV LOS
Similar reintubation
rates: P 8.6%, C 13%
0
5
10
15
20
MV
LOS
ICU
LOS
Hosp
LOS
Control Protocol
0
2
4
6
8
10
12
14
Tracheostomy
Days
% Patients
Brook et al. Crit Care Med 1999; 27:2609-15
* * * *
* p < .05
Spontaneous 8reath|ng 1r|a|:
1he |vota| 1est
Test of breathing for 30-120 min with minimal
ventilatory support
Variables in SBT
Ventilatory support: T-tube or flow-by, < 5 cm
H2O CPAP, PSV, or automatic tube compensation
Duration of SBT: 30min, 60min, or 120min
Termination criteria: RR > 35 bpm x > 5 min,
SaO2 < 90%, HR > 140 bpm or sustained HR
change > 20% higher or lower, SBP > 180 or < 90
mmHg, increased anxiety or diaphoresis
Automanc 1ube Compensanon
(1ube Comp): Smart SV?
Alrway reslsLance ls proporuonal Lo lengLh x 1/
radlus
4
, lncreases wlLh lncreased ow

CperaLor lnpuLs pauenLs ldeal body welghL, Lube
Lype (L11 vs Lrach), Lube lnLernal dlameLer, and
humldlcauon Lype
1he compuLer ln Lhe venulaLor calculaLes Lhe
Lube compensauon conunuously and ad[usLs
Lhe pressure Lo maLch Lhe pauenLs lnsplraLory
ow raLe every 3 ms
Menta| Status, Sputum Vo|ume &
Cough Strength |n Wean|ng
rospecuve observauonal sLudy of 88 pauenLs who
passed 30-60mln S81
3 8lsk facLors for fallure
oor cough (peak ow < 60 lpm)
Peavy endoLracheal secreuons (> 2.3ml/h)
unable Lo do all 4 Lasks (open eyes, follow wlLh eyes,
grasp hand, suck ouL Longue)
lf 2/3 presenL, 71 sensluve,
81 speclc for fallure (72h)
Salam et al. Intensive Care Med 2004; 30:1334-9
anents red|cnon of Lxtubanon
Success
rospecuve observauonal sLudy of 211 Mv
pauenLs who compleLed S81
auenLs asked abouL Lhelr condence ln
remalnlng exLubaLed
CondenL pauenLs had 90 success
non-condenL pauenLs had 43 success
LxLubauon success assoclaLed wlLh pauenL
predlcuon C8 = 9.2 (3.7-22.4)
Perren et al. Intensive Care Med 2010; 36:2045-52
1roub|eshoonng Wean|ng
D|mcu|ty
unresolved preclplLaung
process
8everslble alrway
obsLrucuon
L1 Lube reslsLance
Lxcesslve secreuons
8esplraLory depressanL
drugs
MeLabollc alkalosls
LlecLrolyLe lmbalance
Pemodynamlc lnsLablllLy
lschemlc hearL dlsease
lnfecuon
lmpalred menLal sLaLus
MalnuLrluon /
overfeedlng
unrecognlzed
neuromuscular problem
sychologlcal facLors
uesnon S
Whlch of Lhe followlng lndlcauons for
nonlnvaslve posluve pressure venulauon has Lhe
hlghesL level of evldence?
A .Cardlogenlc pulmonary edema
8. Pypercapnlc resplraLory fallure from asLhma
C. LxLubauon fallure
u. Pypoxemlc resplraLory fallure from pneumonla
uesnon S
Whlch of Lhe followlng lndlcauons for
nonlnvaslve posluve pressure venulauon has Lhe
hlghesL level of evldence?
>> A .Cardlogenlc pulmonary edema
8. Pypercapnlc resplraLory fallure from asLhma
C. LxLubauon fallure
u. Pypoxemlc resplraLory fallure from pneumonla
Non|nvas|ve os|nve ressure
Venn|anon
v vla ughLly mng mask
Mask lnLerface requlres sLable
hemodynamlc, noL comaLose
AdvanLages: less sedauon, uprlghL
posLure, avoldance of Lranslaryngeal
& nasal Lubes
Ad[usL lnsplraLory and explraLory
pressures Lo achleve gas exchange
Close monlLorlng necessary
lf noL lmprovlng wlLhln 2h - lnLubaLe
NV: Lv|dence-8ased
kecommendanons
8ecommended (1A)
Severe CCu exacerbauon (pP < 7.33)
Cardlogenlc pulmonary edema
- no shock or ACS requlrlng revascularlzauon
SuggesLed (28-2C)
lmmunocompromlsed hypoxemlc 8l (2C)
osL-op resplraLory fallure (2C)
- abdomlnal, lung resecuon
laclllLauon of exLubauon ln hlgh-rlsk or CCu
- 8uL AvClu lf low-rlsk pauenL wlLhouL CCu
Keenan et al. Can Med Assoc J 2011
NV: red|ctors of Ia||ure
CCu
Alr leaklng
Severely lll
Asynchrony
CCS < 11
oor Lolerance
pP < 7.23
88 > 33/mln
Pypoxemlc 8esp
lall
ALl/A8uS
Severely lll
MeLabollc acldosls
/l < 130 (173 for
A8uS) aer 1h of
nv
neumonla
Shock
Hill et al. Crit Care Med 2007;35:2402-7
NV: Mon|tor|ng
auenL
Mask comforL
1olerance
8esp dlsLress
88, vS
Accessory muscle
use
Abdomlnal
paradox
venulaLor
Alr leak
Adequacy of lA
(vL), LA
L-venL synchrony
SpC2, A8C (2 hr)
Semng
lCu Lo sLarL
Suu lf sLable
Hill et al. Crit Care Med 2007;35:2402-7
Mechan|ca| Venn|anon |n the ICU:
1he 8ouom L|ne
8aslc concepLual sLrucLure helps recognlze breaLh
characLerlsucs (3 1s), common breaLh Lypes, and
common modes
AdapL venulauon Lo pauenL
Alrow obsLrucuon: lncrease expL ume
A8uS: low udal volume / lung proLecuve
venulauon
Avold compllcauons of posluve pressure
venulauon
Mechan|ca| Venn|anon |n the ICU:
1he 8ouom L|ne
MonlLorlng venulaLor graphlcs can asslsL ln
deLecung auLoLL and pauenL-venulaLor
asynchronles
use a sLrucLured muludlsclpllnary approach Lo
llberauon from venulauon
1rlal of nonlnvaslve venulauon when approprlaLe