02/26/2018 Compliance • C= V/P • Compliance comes from chest wall and lungs in a parallel circuit manner => • 1/200+ 1/200 = 1/100 • These compliance are not individual entities so change in compliance of chest wall will affect total compliance of the respiratory system and vice versa. Assist Control Ventilation • “Control” – set number of breaths are delivered • “Assist” – if patient wants to take a spontaneous breath, machine will aid in the process once minimum negative pressure is triggered. • Can be volume controlled or pressure control • VC-AC or VC-PC VC-AC • The tidal volume and the RR is set. • Machine will give whatever pressure is required to generate set tidal volume. • Tidal volume should be based on PBW (depends on height and gender). • ARDSNET study showed VILI is due to volutrauma and less barotrauma. • Recommend 4-6ml/kg of tidal volume. VC-AC (continued) • Plateau pressure – relates to static compliance and reflects pressure in the small airways and alveoli when there is no airflow • End Inspiratory Hold Maneuver for 0.5-1sec • Ideally Plateau Pressure should be 30-35 cm H2O. • Compliance and plateau pressure are inversely related. • In VC, machine turns off flow once the target tidal volume has been reached. VC-AC (continued) PC-AC • The driving pressure, the rate and the i-Time is set. • The driving pressure is the change in pressure that occurs during the course of a breath. • The normal I:E is 1:2 - 1:4 -- > breathing in takes 1 sec and exhaling takes 2 secs/4secs. • I:E >=1:1 reverse ventilation – refractory ARDS and must heavily sedate patient. PC-AC (Continued) • Driving pressure = base pressure at the end of expiration (PEEP) to a Peak Pressure and holds it for I-time and drops back to PEEP. • So the tidal volume generated by the driving pressure depends on the compliance. • The driving pressure should be set at whatever pressure generates a tidal volume of 6ml/kg. PC-AC (Continued) PC-AC (Continued) • Drawback is that compliance can change in critically ill patients, therefore generated tidal volumes may be erratic. • Be mindful of barotrauma due to high Peak pressures (PEEP + Driving Pressure) and should not exceed 30-35cm H2O. VC vs PC SIMV • Synchronized Intermittent Mandatory Ventilation • Similar to AC that ventilator is set to deliver a pre-set number of breaths. • Different from AC, if the machine detects the patient is trying to breath on their own, it will delay the machine breath and let patient breath on their own – “synchrony”. SIMV (continued) • Problem is that tidal volume is dependent on patient’s effort and strength and can be variable. • SIMV is therefore usually equipped with PS (pressure support – different from pressure control in AC). • PS is the pressure the ventilator applies whenever it detects the patient taking a breath on their own. SIMV (continued) • On SIMV, the rate (12-18) and tidal volume (6ml/kg) are set similar to AC. • Initial PS @ 10cm H2O and can be changed based on pulled tidal volumes. • As PS is decreased, patient can also be assessed for readiness of extubation. A graphical presentation of AC vs SIMV Triggering • Can be via change in pressure vs change in flow. • Pressure trigger requires PEEP to drop by a present amount. • Pressure triggers are difficult in a patient with COPD/Asthma or any condition with autopeep or dynamic hyper-inflation. Triggering (continued) • To make triggering easier, vents allow triggering to be initiated by inspiratory flow. • Flow triggering may be too sensitive (independent of PEEP) and can auto-cycle with oscillation from water or secretions. Conclusion • Ventilator is not a permanent solution. • Consider dynamic Hyperinflation/auto-PEEP if RR is increased and PaCO2 remains high. • Patient will come off the vent when ready – daily SBT with with T-piece or low level pressure support. References • The Ventilator Book; William Owens, MD. • The Little ICU Book; Paul Marino, MD. THE END