BMV - Dr. Hanu

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Ventilation
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JCCA-Sahid Hotel 2017
dr. Hanudjaja Subroto SpAn KIC
03/05/2018 1
INDICATIONS FOR MECHANICAL
VENTILATION
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HYPERCARBIA edit
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LIFE SUPPORT
03/05/2018 Chang W.David. Clinical Application of Mechanical Ventilation. 4th2 edition

GOAL OF MECHANICAL VENTILATION
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03/05/2018 3
PRECAUTION : COMPLICATIONS
• Barotrauma : Injury resulting from high
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intrapulmonary air pressures.
• Volutrauma : Direct injury to alveoli from
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overdistention of the lung.
• Biotrauma : Lung and distant organ injury
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inflammatory mediators into the air
spaces and the systemic circulation.
• Atelectrauma : Injury to alveoli resulting
from the cyclic collapse and opening of
atelectatic alveoli.
03/05/2018 4
TYPES OF VENTILATOR
• NEGATIVE PRESSURE
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• POSITIVE PRESSURE Non –invasive and Invasive
03/05/2018 5
MODES OF VENTILATOR
1. Spontaneous
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2. Positive end-expiratory pressure (PEEP)
3. Continious positive airway pressure (CPAP)
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4. Bilevel positive airway pressure (BiPAP)
5. Controlled mandatory ventilationsubtitle
(CMV)
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6. Assist/control (AC)
7. Intermittent mandatory ventilation (IMV)
8. Synchronized intermittent mandatory ventilation (SIMV)
9. Mandatory minute ventilation (MMV)
10. Pressure support ventilation (PSV)
03/05/2018 Chang W.David. Clinical Application of Mechanical Ventilation. 4th edition 6
MODES OF VENTILATOR
11. Adaptive support ventilation (ASV) 18. Airway pressure release ventilation
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12. Proportional assist ventilation (PAV) (APRV)
13. Volume-assured pressure support 19. Biphasic positive airway pressure
(VAPS)
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14. Pressure-regulated volume control
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20. Inverse ratio ventilation (IRV)
(PRVC) 21. Automatic tube compensation (ATC)
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22. Neurally adjusted ventilator assist (NAVA)
15. Adaptive pressure control (APC) 23. Hight-frequency oscillatory ventilation
16. Volume ventilation plus (VV+) (HFOV)
17. Pressure-controlled ventilation (PCV)
03/05/2018 7
Terminology
MECHANICAL BREATH VARIABLES
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BREATH SEQUENCE
03/05/2018 8
MODE
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FULL VS PARTIAL
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P/V-CV SIMV
A/C CPAP
03/05/2018 9
Control Mandatory Ventilation
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• Ventilator delivers a preset tidal
• Indications edit
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frequency Master title
2. Seizure
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1. Initial setting
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injury
RR 4. Apnea
VT MV
CMV
03/05/2018 10
Chang W.David. Clinical Application of Mechanical Ventilation. 4th edition
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03/05/2018 11
Assist/Control
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• Patient may increase
ventilator frequency edit Master
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Low effort requirement to initiate
(assist) in addition to Click
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flow
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preset mechanical
frequency (control) Complications
Alveolar hyperventilation
leading to respiratory
alkalosis
03/05/2018 12
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03/05/2018 13
Intermittent Mandatory Ventilation
• Ventilator deliver control Benefit
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breath (mandatory) and allows
the patient to breathe at any
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breathing
tidal volume
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Complications Master
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VT RRm/rrsp
Breath stacking leading
to barotrauma
IMV
03/05/2018 14
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03/05/2018 15
SIMV - Synchronized
Intermittent Mandatory Ventilation
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Indications
• Ventilator delivers either assisted To provide partial Vent
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patient at the
beginning of spontaneous breath or
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support
time-triggered mandatory breathe
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• Spontaneous breathing frequency Disadvantages
and tidal volume totally dependent
on the patient’s breathing support if too fast weaning, leading to
high of WOB, fatigue and
weaning failure
03/05/2018 16
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03/05/2018 17
Pressure Support
• To lower the work of
spontaneous breathing and
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augment a patient’s spontaneous edit
tidal volume
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 Spontaneous RR
RRsp  WOB
Ps
Minute
Ventilation
03/05/2018 18
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03/05/2018 19
Pulse Oximetry
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• Non invasive, Simple device, helpful and most frequency used to assess
patient’s oxygenation by Beer-Lambert Law and spectrophotometric
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• Works by emitting dualClick
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vascular
PaO2
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• Proper placement to obtain an accurate reading90% 60
• SpO2 >95 % ≈ paO2 >70%

80% 50
75% 40
70% 35
60% 30
50% 27
30 20
03/05/2018 20
CLINICAL APPLICATION OF PULSE OXIMETRY
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FACTORS THAT EFFECTS Click
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03/05/2018 21
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Noise Artifact
Motion Artifact
03/05/2018 22
ET CO2
• Non invasive, simple device to assess CO2 level in gas sample.
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When gas sample is collected at the end expiration : ETCO2
• Under normal conditions, the PaCO2 is higher 2 mmHg than
Pet CO2 Master
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03/05/2018 23
Normal waveform
MEASURED ET CO2
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03/05/2018 24
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03/05/2018 25
BGA – Henderson Hasselbalch
PRIMARY DISORDER PRIMARY DISTURBANCE PRIMARY
COMPENSATION
RESPIRATORY ACIDOSIS
PCO2
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HCO3 -
RESPIRATORY ALKALOSIS
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PCO2 HCO3-
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Renal HCO3 excretion
METABOLIC ACIDOSIS
HCO3- PCO2
Lung CO2 removal
METABOLIC ALKALOSIS
HCO3- PCO2
Lung CO2 retention
03/05/2018 26
Simple Lung Protective Strategy
• Low Tidal Volume  Permissive Hypercapnia
• PEEP Click
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 Pplat < 35
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Recent clinical trials have demonstrated that in patients with ARDS, protective
ventilatory strategies are associated with decreased serum cytokine levels, decreased
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levels of organ dysfunction, and decreased mortality ,edit Master
perhaps by text stylesmitigating
partially
the development of MODS.
Slutsky S. Arthur, Imai Yumiko. Applied Physiology in Intensive care 2, 3rd edition.
Ventilator-induced lung injury, cytokine, PEEP, and mortality : implication for practice
and for clinical trials
03/05/2018 27
PEEP
DECREASES THE PRESSURE THRESHOLD

FOR ALVEOLAR INFLATION
USEFUL
TO TREAT REFRACTORY
HYPOXEMIA
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(LOW PaO2)
NOT RESPONDING
TO HIGH FIO2)
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INCREASES FRC
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IMPROVES VENTILATION
3 types of alveoli in ARDS INCREASES V/Q

• CONSOLIDATED ALV
• RECRUITABLE ALV IMPROVES OXYGENATION
• NORMAL FUNCTIONAL ALV
DECREASES WOB
03/05/2018 28
INITIAL VENTILATOR SETTING
• DETERMINE :
1. MODE Click
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2. FREQUENCY
3. TIDAL VOLUME Master
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4. FIO2 Click to edit Master Click
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5. I : E ratio
6. inspiratory flow pattern
7. ALARM LIMIT
03/05/2018 29
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03/05/2018 30
MODE SELECTION
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03/05/2018 31
FREQUENCY
• NUMBER OF BREATHS PER MINUTE TO
MAINTAIN CO2 LEVEL
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• USUALLY SET BETWEEN 10-12/MIN edit
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COUPLED WITH 10-12 ML/KG TIDAL
VOLUME title
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• ESTIMATE MINUTE VOLUME
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TIDAL VOLUME
03/05/2018 32
Dubois chart - MV
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03/05/2018 33
TIDAL VOLUME
• Initial tidal volume : 10 – 12 ml/kg
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• Lower VT as 6 ml/kg : ARDS, to avoid barotrauma, minimize airway
pressure
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03/05/2018 34
FiO2
• Initially may be set at 100 %
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• Should be evaluated by BGA to maintain good level of PaO2
• FiO2 < 50% to avoid Oxygen Induced Lung Injury
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• ( 200 x 0.3 ) : 100 = 0.6 ( FiO2)
03/05/2018 35
I : E RATIO
• Ratio of Inspiratory time to expiratory time
• Between 1:1,5 and 1:3 Click
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• A larger i:e ratio to give more exhalation time (air trapping or auto
PEEP) Master
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• Inverse Ratio for refractory hypoxemia
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ARDS
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after fail to improve with PEEP
03/05/2018 36
CALCULATION ie Ratio
• Given RR 20, desire i:e ratio 1:2
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• Calculate : the I time needed for an ie ratio 1:2
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• since RR=20 Master
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• I time : I time :
Time of @breath x ( 1/sum of ie ratio) 4 x ( 1/ 1+2.5)
1.1248 sec
3 x ( 1 / 1+2 ) Exp time 4-1.1248 = 2.8752
1 second
03/05/2018 37
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CONSEQOUENCES MANAGEMENT AUTO PEEP

HYPOTENSION LENGTHEN EXPIRATORY TIME
INCREASE WOB STEROID
INCREASE INSPIRATORY PRESSURE BRONCHODILATOR
WORSEN OXYGENATION REDUCE TIDAL VOLUME
03/05/2018 38
ALARM SETTING
• Pass the diagnostic test
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• To alert the clinician to undesirable technical or patient event
• To detect failure of the airway pressure to return to the baseline value
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( it could be by airway obstruction, circuit obstruction or ventriculer )
• Volume alarm : to detect Click to edit Master
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supported breaths and spontaneous breaths
• Flow alarm : to detect high/low minute ventilation
• Time alarm : to detect high/low frequency, excessive or inadequate
inspiratory or expiratory time
• Inspired gas alarm : to detect in oxygenation concentration
03/05/2018 39
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03/05/2018 40
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03/05/2018 41
SUMMARY
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• Good to Knew the indication using Mechanical Ventilation, better if
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could intubate the pateint but best if how to set the Ventilator too
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• Many modes in ventilator but focus to master in several basic mode
its very helpful
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operates the mechanical ventilator, we must practise
03/05/2018 42
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03/05/2018 43
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03/05/2018 44
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03/05/2018 45

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dr. Hanudjaja Subroto SpAn KIC

03/05/2018 Chang W.David. Clinical Application of Mechanical Ventilation. 4th2 edition

• POSITIVE PRESSURE Non –invasive and Invasive

• SpO2 >95 % ≈ paO2 >70%

Click to edit Master Click

DECREASES THE PRESSURE THRESHOLD

3 types of alveoli in ARDS INCREASES V/Q

• ( 200 x 0.3 ) : 100 = 0.6 ( FiO2)

CONSEQOUENCES MANAGEMENT AUTO PEEP

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