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BASIC PRINCIPLES OF MECHANICALBASIC PRINCIPLES OF MECHANICAL
VENTILATION ANDVENTILATORVENTILATION ANDVENTILATOR
GRAPHICSGRAPHICS
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BASIC PRINCIPLES OF MECHANICALBASIC PRINCIPLES OF MECHANICAL
VENTILATIONVENTILATION
Regardless of the disease states he! a "atie!tfails to #e!tilate or o$%ge!ate ade&'atel% the"ro(le) lies i! * of + "atho"h%siologi,al fa,tors
*- I!,reased aira% resista!,e
.- Cha!ge i! l'!g ,o)"lia!,e
/- H%"o#e!tilatio!
0- V12 )is)at,h3- I!tra"'l)o!ar% sh'!ti!g
+- Di4'sio! defe,ts
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CONDITIONS LEADING TO AIRWAY RESISTANCEE)"h%se)aAsth)aBro!,hie,tasisPosti!t'(atio! o(str',tio!Foreig! (od%E!dotra,heal t'(e Co!de!satio! i! #e!t ,ir,'itALTBBro!,hiolitisE"iglottitis
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AIRWAY RESISTANCE AND WORK OF
BREATHINGAira% resista!,e < Ra> is P1 V
P9"ea? aira% "ress're6"latea' "ress're
V9:oI!,rease i! aira% resista!,e )ea!s i!,rease
i! or? of (reathi!g
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VENTILATOR@ FAILRE is fail're of l'!gs to
eli)i!ate CO.
OGENATION FAILRE is fail're of l'!g a!dheart to "ro#ide ade&'ate o$%ge! for)eta(oli, !eeds
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LUNG COMPLIANCE
Co)"lia!,e is l'!g e$"a!sio!
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LUNG COMPLIANCE CONT-Stati, ,o)"lia!,e re:e,ts the elasti,
"ro"erties of l'!g a!d,hest all
D%!a)i, ,o)"lia!,e re:e,ts the aira%resista!,e a!d the elasti,
"ro"erties of l'!g a!d,hest all
Co!ditio!s ,a'si!g ,ha!ge i! stati,
,o)"lia!,e i!#o?e si)ilar ,ha!ges i! d%!a)i,
,o)"lia!,e
here aira% resista!,e is the o!l%a(!or)alit% d%!a)i, ,o)"lia!,e ,ha!ge
i!de"e!de!tl%
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CLINICAL CONDITIONS THAT DECREASE THE
COMPLIANCE
T@PE OF COMPLIANC
1. STATIC
1. DYNAMIC
CONDITIONS
*- ATELECTASIS
.- ARDS/- P!e')othora$
0- O(esit%
3- Retai!ed se,retio!s
*- Bro!,hos"as)
.- i!?i!g of ET t'(e
/- Aira% o(str',tio!
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HIGH COMPLIANCEE)"h%se)a
S'rfa,ta!t thera"%
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VENTILATORY FAILURE
3 )e,ha!is)s lead to #e!tilator% fail're
*- H%"o#e!tilatio!
.- Persiste!t #e!tilatio! "erf'sio! )is)at,h/- Persiste!t i!tra"'l)o!ar% sh'!ti!g
0- Di4'sio! defe,t
3- Red',tio! i! PIO. i-e- i!s"ired o$%ge!te!sio!
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HYPOVENTILATIONCa'sed (% de"ressio! i! CNS
Ne'ro)'s,'lar disease
Aira% o(str',tio!I! a ,li!i,al setti!g h%"o#e!tilatio! is
,hara,terised (% a red',tio!of al#eolar#e!tilatio! a!d i!,rease i! arterial CO.
te!sio!
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VENTIATION PERFSION MISMATCHDisease "ro,ess hi,h ,a'ses o(str',tio! or
atele,tasis res'lt i! less o$%ge! (ei!g a#aila(leleadi!g to lo V12
P'l)o!ar% e)(olis) is a! e$a)"le that de,reases"'l)o!ar% "erf'sio! a!d high V12
T1T i! )e,ha!i,al #e!tilatio! i!,l'de i!,reasi!grate ; tidal #ol')e ; FiO.
T1t dire,ti!g toards re)o#i!go(str',tio!;re,r'iti!g atele,tati, =o!es a!d"re#e!ti!g ,los're
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INTRAPULMONARY SHUNTINGCa'ses refra,tor% h%"o$ia
!or)al sh'!t is less tha! *5
*56.5)ild sh'!t.56/5 sig!i7,a!t sh'!t
/5 ,riti,al a!d se#ere sh'!t
eg "!e')o!ia a!d ARDS
Classi, 2s12t9< C,O.6CaO.>1
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DIFFUSION DEFECT
TYPE1. Decrease ! "ress#re
$ra%e!&
'. T(c)e!!$ *+ A-C,e,ra!e
. Decrease s#r+acearea*+ A-C ,e,ra!e
/. I!s#0ce!& &,e *+%#s*!
CLINICAL CONDITIONS1. H$( a2&%e3 4re
c*,#s&*!
'. P#2,*!ar5 e%e,a a!%re&a!e% secre&*!s
. E,"(5se,a 3"#2,*!ar5 4r*ss
/. &ac(5car%a
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T%"es of a#efor)sT%"es of a#efor)sVol')e Modes Press're Modes
Vol')e Co!trol1 SIMV Press're Co!trol1PRVC
SIMV SIMV
Press're S'""ort1Vol')e S'""ort
Press'r
e
Flo
Vo
l')e
Press'r
e
Flo
Vol')e
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Press're1Ti)e S,alarPress're1Ti)e S,alar
I! Vol')e )odes;the sha"e ill (ea! e$"o!e!tialrise or a!a,,elerati!g ra)"for )a!dator%
(reaths-
I! Press're )odes; thesha"e ill (ere,ta!g'lar or s&'are-
This )ea!s that"ress're re)ai!s,o!sta!t thro'gho'tthe (reath ,%,le-
I! Vol')e )odes; addi!g a! i!s"irator% "a'se )a% i)"ro#e distri('tio! of #e
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Press're1Ti)e S,alarPress're1Ti)e S,alar
Air tra""i!g
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Press're1Ti)e S,alarPress're1Ti)e S,alar
The (aseli!e for the "ress're a#efor) i!,reases he! PEEP isadded-
There ill (e a !egati#e de:e,tio! J'st (efore the a#efor) ithatie!t tri ered (reaths-
3
*3
No "atie!t e4ort Patie!t e4ort
PEEP K3
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Press're1Ti)e S,alarPress're1Ti)e S,alar
AB
1
2
I!s"irator% "a'se
= MAP
* 9 Pea? I!s"irator% Press're . 9 Platea' Press're
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Press're1Ti)e S,alarPress're1Ti)e S,alar
I!,reased Aira%Resista!,e
De,reasedCo)"lia!,e
PIP
P"lat
PIP
P"lat
A. B.
A6A! i!,rease i! aira% resista!,e ,a'ses the PIP to i!,rease; ('t P"lat"ress're re)ai!s !or)al-B6A de,rease i! l'!g ,o)"lia!,e ,a'ses the e!tire a#efor) to i!,rease i!
si=e-The di4ere!,e (etee! PIP a!d P lat re)ai! !or)al-
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Vol')e1Ti)e S,alarVol')e1Ti)e S,alar
The Vol')e a#efor) ill ge!erall% ha#e a )o'!tai!"ea? a""eara!,e at the to"- It )a% also ha#e a "latea';or :atte!ed area at the "ea? of the a#efor)-
There ill also (e a "latea' if a! i!s"irator% "a'se set or i!s"irator% hold
)a!e'#er is a""lied to the (reath-
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Vol')e1Ti)e S,alarVol')e1Ti)e S,alar
Air6Tra""i!g or Lea?
If the e$halatio! side of the a#efor) does!8t ret'r! to (aseli!e; it
,o'ld (e fro) air6tra""i!g or there ,o'ld (e a lea?
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Flo1Ti)e S,alarFlo1Ti)e S,alar
I! Vol')e )odes; thesha"e of the a#efor)ill (e s&'are orre,ta!g'lar-
This )ea!s that :ore)ai!s ,o!sta!tthro'gho't the (reath,%,le-
I! Press're )odes;
the sha"e of thea#efor) ill ha#ea de,elerati!gra)" :o "atter!-
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Flo1Ti)e S,alarFlo1Ti)e S,alar
Air tra""i!g Flo a#efor) Sha"eI!s"irator% FloAs%!,hro!%
Triggeri!g E4ort
Ca! (e 'sed to assess
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Flo1Ti)e S,alarFlo1Ti)e S,alar
Vol')e Press're
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Flo1Ti)e S,alarFlo1Ti)e S,alar
The de,elerati!g :o "atter! )a% (e "referred o#er the ,o!sta!t :o
"atter!- The sa)e tidal #ol')e is deli#ered; ('t ith a loer "ea? "ress're-
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Flo1Ti)e S,alarFlo1Ti)e S,alar
A'to6Pee"
If e$"irator% :o does!8t ret'r! to (aseli!e (efore the !e$t (reath starts;
there8s a'to6PEEP "rese!t ; e-g- e)"h%se)a-
Start of !e$t (reath
E$"irator% :odoes!8t ret'r!
to (aseli!e
9 Nor)al
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Flo1Ti)e S,alarFlo1Ti)e S,alar
Bro!,hodilator Res"o!se
To assess res"o!se to (ro!,hodilator thera"%; %o' sho'ld see a! i!,rease i!"ea? e$"irator% :o rate-
The e$"irator% ,'r#e sho'ld ret'r! to (aseli!e soo!er-
Pea? E$"- Flo
I)"ro#ed Pea? E$"- Flo
ShorterE6ti)e
Lo!gerE6ti)e
Pre6Bro!,hodilator Post6Bro!,hodilator
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T%"es of a#efor)sT%"es of a#efor)sVol')e Modes Press're Modes
I! Press're Li)ited; Ti)e6,%,led )odes; i!s"irator% :o sho'ld ret'r! to(aseli!e- 6
Vol')e Co!trol1 SIMV Press're Co!trol1PRVC
SIMV SIMV
Press're S'""ort1Vol')e S'""ort
Press'r
e
Flo
Vo
l')e
Press'r
e
Flo
V
ol')e
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Noti,e the area of !o :o i!di,ated (% the red li!e- This is ?!o! as a =ero6:o state-
T%"es of a#efor)sT%"es of a#efor)s
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15 305
250
500
Press're1Vol')e Loo"sPress're1Vol')e Loo"s
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Press're1Vol')e Loo"sPress're1Vol')e Loo"s
Vol')e is "lotted o! the %6a$is; Press're o!the $6a$is-
I!s"irator% ,'r#e is '"ard; E$"irator% ,'r#e
is do!ard-S"o!ta!eo's (reaths go ,lo,?ise a!d
"ositi#e "ress're (reaths go ,o'!ter,lo,?ise-The (otto) of the loo" ill (e at the set PEEP
le#el- It ill (e at 5 if there8s !o PEEP set-If a! i)agi!ar% li!e is dra! do! the )iddle
of the loo"; the area to the right re"rese!tsi!s"irator% resista!,e a!d the area to the leftre"rese!ts e$"irator% resista!,e-
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Press're1Vol')e Loo"sPress're1Vol')e Loo"s
L'!g O#erdiste!tio!
Aira% O(str',tio!Bro!,hodilator Res"o!seRes"irator% Me,ha!i,s
OBFlo Star#atio!Lea?sTriggeri!g E4ort
Ca! (e 'sed to assess
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inspira
tion
expirati
on
15 305
D%!a)i,Co)"lia!,e
AA9I!s"irator%Resista!,e1Resisti#eOB
B
Press're1Vol')e Loo"sPress're1Vol')e Loo"s
(Cdyn)
The to" "art of the P1V loo" re"rese!ts D%!a)i, ,o)"lia!,e -Cd%! 9 #ol')e1"ress're
500
250
B= Exp.
Resistance/Elastic WOB
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Press're1Vol')e Loo"sPress're1Vol')e Loo"s
15 305
O#erdiste!tio!
beaking
Press're ,o!ti!'es to rise ith little or !o ,ha!ge i! #ol')e; ,reati!g a (ird
(ea?-Fi$ ( red',i! a)o'!t of tidal #ol')e deli#ered
500
250
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15 305
250
500
15 305
Press're1Vol')e Loo"sPress're1Vol')e Loo"s
I!,reased Co)"lia!,e De,reasedCo)"lia!,e
E$a)"le
E)"h%se)a;
E$a)"le ARDS; CHF;
Atele,tasis
500
250
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Poi!t of '""er i!:e,tio!
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Flo1Vol')e Loo"sFlo1Vol')e Loo"s
0
200 400 600
20
40
60
-20
-40
-60
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Flo1Vol')e Loo"sFlo1Vol')e Loo"s
Flo is "lotted o! the % a$is a!d #ol')e o! the $a$is
Flo #ol')e loo"s 'sed for #e!tilator gra"hi,s
are the sa)e as o!es 'sed for P'l)o!ar% F'!,tio!Testi!g;
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Flo1Vol')e Loo"sFlo1Vol')e Loo"s
Air tra""i!g
Aira% O(str',tio!Aira% Resista!,eBro!,hodilator Res"o!seI!s"1E$" Flo
Flo Star#atio!Lea?sater or Se,retio!a,,')'latio!
As%!,hro!%
Ca! (e 'sed to assess
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Flo1Vol')e Loo"sFlo1Vol')e Loo"s
0
200 400 600
20
40
60
-20
-40
-60
PEF
Start ofI!s"iratio!
Start ofE$"iratio!
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DIFFERENT FLO VOLME LOOPS
A; !or)al loo"
B s?i6slo" o(ser#er#ed i! e$"-Flo li)itatio!
C E$trathora,i, aira%o(str',tio! ith i!s"irator%a!d e$"irator% air :oli)itatio! see! i! s'(gloti,ste!osis a!d !arroe!dotra,heal t'(e
D I!trathora,i, i!s"irator%air:o li)itatio!as see! ith(a(ies ith i!tral')i!alo(str',tio!
E '!sta(le aira% egtra,heo)ala,ia
F Errati, air:o i! se,retio!s
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Flo1Vol')e Loo"sFlo1Vol')e Loo"s
0
200 400 600
20
40
60
-20
-40
-60
E$"irator%"ortio! of loo"does !otret'r! tostarti!g "oi!t;i!di,ati!g alea?-
A Lea?
If there is a lea?; the loo" ill !ot )eet at the starti!g "oi!t here i!halatio!
starts a!d e$halatio! e!ds- It ,a! also o,,'r ith air6tra""i!g-
9 Nor)al
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Air Tra""i!g
Ca'ses
I!s',ie!t e$"irator% ti)e
Earl% ,olla"se of '!sta(le al#eoli1aira%s d'ri!g e$halatio!
Ho to Ide!tif% it o! the gra"hi,s
Press're a#e hile "erfor)i!g a! e$"irator% hold; thea#efor) rises a(o#e (aseli!e-
Flo a#e the e$"irator% :o does!8t ret'r! to (aseli!e(efore the !e$t (reath (egi!s-
Vol')e a#e the e$"irator% "ortio! does!8t ret'r! to (aseli!e-
Flo1Vol')e Loo" the loo" does!8t )eet at the (aseli!e
Press're1Vol')e Loo" the loo" does!8t )eet at the (aseli!e
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Aira% Resista!,eAira% Resista!,e
Cha!gesCha!gesCa'ses
Bro!,hos"as) ETT "ro(le)s
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Co)"lia!,e Cha!gesCo)"lia!,e Cha!ges
De,reased ,o)"lia!,e Ca'ses
ARDS Atele,tasis A(do)i!al diste!sio!
CHF Co!solidatio! Fi(rosis H%"eri!:atio! P!e')othora$ Ple'ral e4'sio!
Ho to Ide!tif% it o! thegra"hi,s
Press're a#e PIP a!d"latea' (oth i!,rease
Press're1Vol')e loo" la%s)ore hori=o!tal
I!,reased ,o)"lia!,e Ca'ses
E)"h%se)a S'rfa,ta!t Thera"%
Ho to Ide!tif% it o! thegra"hi,s
Press're a#e PIP a!d"latea' (oth de,rease
Press're1Vol')e loo"Sta!ds )ore #erti,al
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Lea?sLea?s
Ca'ses E$"irator% lea? ETT ,'4 lea? ; ,hest t'(e lea?; BP 7st'la; NGt'(e i! tra,hea
I!s"irator% lea? loose ,o!!e,tio!s; #e!tilator )alf'!,tio!;fa'lt% :o se!sor
Ho to ID it Press're a#e De,reased PIP
Vol')e a#e E$"irator% side of a#e does!8t ret'r! to(aseli!e
Flo a#e PEF de,reased
Press're1Vol')e loo" e$" side does!8t ret'r! to the (aseli!e Flo1Vol')e loo" e$" side does!8t ret'r! to (aseli!e
Ho to 7$ it Che,? "ossi(le ,a'ses listed a(o#e
Do a lea? test a!d )a?e s're all ,o!!e,tio!s are tight
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As%!,hro!%As%!,hro!% Ca'ses
Air h'!ger Ne'rologi,al I!J'r% I)"ro"erl% set se!siti#it%
Ho to ID it Press're a#e "atie!t tries to i!hale1e$hale i! the )iddle of the
a#efor); ,a'si!g a di" i! the "ress're
Flo a#e "atie!t tries to i!hale1e$hale i! the )iddle of the a#efor);,a'si!g errati, :os1di"s i! the a#efor)
Press're1Vol')e loo" "atie!t )a?es e4ort to (reath ,a'si!g di"s i!loo" either I!s"1E$"-
Flo1Vol')e loo" "atie!t )a?es e4ort to (reath ,a'si!g di"s i! loo"either I!s"1E$"-
Ho to 7$ it Tr% i!,reasi!g the :o rate; de,reasi!g the I6ti)e; or i!,reasi!g the setrate to ,a"t're the "atie!t-
Cha!ge the )ode 6 so)eti)es ,ha!gi!g fro) "artial to f'll s'""ort illsol#e the "ro(le)
If !e'rologi,al; )a% !eed "aral%ti, or sedati#e AdJ'st se!siti#it%
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As%!,hro!%As%!,hro!%Flo Star#atio!
The i!s"irator% "ortio! of the "ress're a#e shos a s,oo"i!g or di"; d'eto i!ade&'ate :o-
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As%!,hro!%As%!,hro!%
F1V Loo" P1V Loo"
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Rise Ti)eRise Ti)e
The i!s"irator% rise ti)e deter)i!es thea)o'!t of ti)e it ta?es to rea,h the desiredaira% "ress're or "ea? :o rate-
sed to assess if #e!tilator is )eeti!g "atie!t8s de)a!d i! Press're S'""ort
)ode-I! SIMV rise ti)e (e,o)es a of the (reath , ,le-
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Rise Ti)eRise Ti)e
If rise ti)e is too fast; %o' ,a! get a! o#ershoot i! the"ress're a#e; ,reati!g a "ress're s"i?e- If this o,,'rs; %o'
!eed to i!,rease the rise ti)e- This )a?es the :o #al#eo"e! a (it )ore slol%-
If rise ti)e is too slo; the "ress're a#e (e,o)es ro'!dedor sla!ted; he! it sho'ld (e )ore s&'are- This ill de,reaseVt deli#er% a!d )a% !ot )eet the "atie!t8s i!s"irator%de)a!ds- If this o,,'rs; %o' ill !eed to de,rease the riseti)e to o"e! the #al#e faster-
too slotoo fast
"ress're s"i?e
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I!s"irator% C%,le O4I!s"irator% C%,le O4
The i!s"irator% ,%,le o4 deter)i!es he! the#e!tilator :o ,%,les fro) i!s"iratio! toe$"iratio!; i! Press're S'""ort )ode-
The :o6,%,li!g #aria(le is gi#e! di4ere!t !a)es de"e!di!g o! the t%"e of#e!tilator-
Also ?!o asI!s"irator% :oter)i!atio!;E$"irator% :o se!siti#it%;
I!s"irator% :o ,%,le ;E6,%,le et,
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I!s"irator% C%,le O4I!s"irator% C%,le O4
The (reath e!ds he! the #e!tilator dete,ts i!s"irator% :o has dro""ed to
a s"e,i7, :o #al'e-
I!s"iratio! e!ds
"ress're
:o
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I!s"irator% C%,le O4I!s"irator% C%,le O4
I! the a(o#e e$a)"le; the )a,hi!e is set to ,%,le i!s"iratio! o4 at /5 ofthe "atie!t8s "ea? i!s"irator% :o-
*55 of Patie!t8sPea? I!s"irator%Flo
Flow
*55
35
/5
3
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I!s"irator% C%,le O4I!s"irator% C%,le O4
A The ,%,le o4 "er,e!tage is too high; ,%,li!g o4 too soo!- This )a?es the(reath too s)all-
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So'r,esSo'r,es
Ra"id I!ter"retatio! of Ve!tilator a#efor)sVe!tilator a#efor) A!al%sis
S'sa! Pearso!
Golde! Mo)e!ts i! Me,ha!i,al Ve!tilatio! Ma&'et; i!,-
Ser#o6I Gra"hi,s Ma&'et; i!,-
te$t (oo? of "h%siolog%6 Ga!o!g Da#id Cha!g ,li!i,al a""li,atio! of )e,ha!i,al
#e!tilatio!
P'l)o!ar% f'!,tio! a!d gra"hi,s 6Golds)ith
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70/70
Tha!? @o'Tha!? @o'