Mechanical Ventilation (MV)

1. Mechanical Ventilation(MV) 8/09/2011 jk

2. Ventilation/Volume Exchange • The movement of gas in and out of the lungs • Marker of effectiveness = PaCO2 • Marker of efficiency = Minute Ventilation • VA = RR (Vt – Vd ) • VA= Alveolar ventilation – gas reaching profused alveoli • Vt =Tidal Volume • Vd = Dead Space Ventilation (part of breath that does not reach profused alveoli

3. Ventilation/Volume Exchange PT = (V*E) + (Q*R) PT = total pressure change needed to displace a breath Actions V = Displaced volume Q = Gas flow through airways Impedance factors E = Elastic recoil of the system R = Resistance (Frictional forces) opposing gas flow

4. Ventilation/Volume Exchange PT = (V*E) + (Q*R) • An  in any of these factors  the total pressure change needed to displace a breath • In spontaneous breathing, PT is developed by the inspiratory muscles, primarily the diaphragm • When load (PT) is great than capacity (inspiratory muscle strength) ventilatory failure ensues

5. EXTERNAL RESPIRATION • The movement of gas across membranes • Effectiveness measured by PaO2 • Marker of efficiency = PaO2/FiO2 • PaO2 of more than 500 on100% O2 is normal • PaO2 < 300 on 100% = Acute lung injury • PaO2 < 200 on 100% is one criteria for ARDS

6. Factors Affecting the Rate of Gas Movement Across the A/C Membrane The rate of diffusion is directly related to the difference in the partial pressure of gas on either side of the membrane Clinical Intervention Increasing FiO2 Blood Flow O2 O2 O2 O2

7. Factors Affecting the Rate of Gas Movement Across the A/C Membrane Clinical Intervention Thinning A/C Membrane The rate of diffusion is directly related to the membrane’s permeability characteristics for the gas Blood Flow O2 O2 O2 O2

8. Factors Affecting the Rate of Gas Movement Across the A/C Membrane The rate of diffusion is directly related to the total surface area available for diffusion Clinical Intervention Improving Ventilation to Perfusion (V/Q) matching, often by increasing lung size Blood Flow O2 O2 O2 O2 O2 O2 O2

9. External Respiration • O2 Very sensitive to changes in membrane characteristics and surface area • Beyond increasing oxygen dose, improving ventilation to perfusion matching, often through lung distention, is most often used to improve oxygenation during mechanical ventilation. • Distention therapy is best reflected in mean airway pressure.

10. V/Q Mismatch

11. Sources of V/Q Mismatch • Restrictive processes: • ↓lung size creating airway instability • Loss of airway patency • Alveolar collapse • ↓ O2’s ability to reach perfused alveolar/capillary membranes • Disruption in blood distribution in the lung • Positive pressure breathing causing ventilation to displace in areas of low perfusion (The lung is moving the chest) • Results in V/Q mismatch and ↓ SaO2, which is non-responsive to ↑ O2 dose (refractory hypoxemia)

12. Ventilation Distribution in Positive Pressure (PPB) vs. Spontaneous, Non-pressure Assisted Breathing (SB) The chest is moving the lung • During SB, pleural pressure drop favors high perfusion regions, promoting ↑V/Q matching The lung is moving the chest • During PPB, there is no pleural pressure drop, so ventilation go to the areas of least resistance, often, the areas of lowest perfusion, promoting ↑V/Q mismatching

13. Improving O2 diffusion Beyond ↑ oxygen dose, ↑ V/Q matching is most often used: • Traditionally through lung distention via PEEP/CPAP • Distention therapy is best reflected in mean airway pressure (MAP). • Additional options include • Proning/positioning • Unilateral lung ventilation • Inverse I:E ventilation • Spontaneous, non positive pressure assisted, ventilation

14. Indications for Positive Pressure Therapy (Lung Distention) • Respiratory failure (Type 1) - Hypoxemia (↓PaO2) refractory to oxygen therapy

15. Indication for Mechanical Ventilation • Ventilatory failure (Type 2 Respiratory Failure)- Impending or frank Hypercapnia (↑PaCO2) with or without

16. General Goals of Mechanical Ventilation/Positive Pressure Therapy • CO2 Clearance (Exchange) • Volume Exchange • Oxygenation • Surface area manipulations (Distention) • FiO2 (Adjusted if other approaches ineffective)

17. Non-Invasive Approach

18. Distention Therapy - CPAP • CPAP: Continuous Positive Airway Pressure • Does not directly assist with inspiration, therefore is not technically a form of mechanical ventilation. • Pressure setting directly impact resting lung size and airway stability – improving V/Q matching

19. Distention Therapy – CPAPIndication • Obstructive sleep apnea • Refractory hypoxemia without Hypercapnia

20. Exchange Techniques – NIPPV (BiPAP) • NIPPV Non-invasive positive pressure ventilation • CPAP with additional pressure applied during inspiration • Is therefore a form of mechanical ventilation

21. Exchange Techniques – NIPPV (BiPAP) • Goal of Therapy • Reduce Work of Breathing (Accessory Muscle • Rest) • Improve Pulmonary Mechanics • Augment Alveolar Ventilation

22. Exchange Techniques – NIPPV (BiPAP) Setting • IPAP: Inspiratory Pressure (Normally 10-30 cmH2O) • EPAP (Same as CPAP): Expiratory Pressure (Normally 4-10 cmH2O) • The difference between IPAP and EPAP setting determines the “size of the breath” or level or inspiratory assistance.

23. Disease Processes that may benefit from NIPPV • Chronic Ventilatory Failure • Obstructive Airways Disease • COPD • CF • Restrictive Lung Disease • Neuromuscular Disease • Interstitial Lung Disease • Overlap Syndromes • Central Sleep Apnea • Central Alveolar Hypoventilation • Obesity Hypoventilation • OSA with COPD and Pulmonary HTN

24. Disease Processes that may benefit from NIPPV • Acute Respiratory Failure • COPD Exacerbation • Auto-immune disease • Cardiogenic Pulmonary Edema • Status Asthmaticus • Neuromuscular Disease

25. Contraindications of CPAP/NIPPV • Complete Respiratory Failure • Unstable Hypotension • Unstable Arrhythmia • High risk of Emesis/Aspiration • Active GI Bleed • Unstable airway Relative: • Recent Facial Trauma/Surgery • Anxiety

26. Interface Selection The KEY to Success!!

27. Nasal Interface

28. Oral/nasal Interfaces

29. Limitations • Risk of aspiration • Leaks • Limited effectiveness of inline medication delivery • Inappropriate delay in intubation • Morbidity and Mortality increase with delay in intubation

30. Take-Home Points • NIPPV is not a replacement for ETI and CMV • COPD and Auto-immune process may be exceptions • Can be very effective on an Acute and Chronic basis • Proper Interface is paramount to success • Patient education and flexibility will improve compliance

31. Invasive Mechanical Ventilation

32. MODES/TRIGGERING How the Breath is Started/ level of Machine supported Breaths • Control (guaranteed)– fixed rate, no Pt assisting • Assist – Ventilator responses to pt effort by providing a machine delivered breathe without guaranteed frequency • Assist/Control – Guaranteed minimum rate with Pt’s ability to ↑ machine delivered breaths as needed • Spontaneous – Pt initiated breathe. Volume based on pt/ventilator interaction. No guarantee of frequency or volume • Intermittent Mandatory Ventilation - Provides a periodic guaranteed breathe, with all additional breathing preformed spontaneously

33. CyclingHow the Breath is Stopped(Ordered) • Volume – how much gas is delivered • Time – how long inspiration lasts The interplay between volume and time = Flow • Pressure – how much pressure is used Cycling method ordered is the independent variable, and the others are the dependent variables.

34. Method of MV Often based on need • Oxygen delivery (via distention and V/Q matching) • Often used in ARDS or Acute Lung Injury • CO2 clearance ( via exchange) • Most common during post-op recovery

35. Goals of MV in ARDS/Acute Lung Injury Deliver enough oxygen to tissues to met aerobic needs (lactic acid) • Clear enough CO2 to maintain life • Avoid lung stress More than this is not helpful

36. Avoiding Lung Stress Peak Airway Pressure (PIP) Total force required to deliver breath (∆Pt) • Pressure required to flow gas through airways (V*R), • Is not transmitted to alveolar wall • Does not in itself indicate ↑risk of barotrauma • Pressure required to distend lung (V*E)

37. Avoiding Lung Stress Plateau Pressure (Pplat) • Force required to distend lung • Measured in static conditions • In ARDS, static pressures <30 cmH2O, when associated with Vt of 6 ml/Kg IBW were associated with better outcomes • Values >35 cmH2O, regardless of Vt size, were associated with poorer outcomes

38. Volume Exchange (Ventilation) Orientated Techniques

39. Volume Cycled Ventilation • Most common method of MV – often falsely called assist/control, after the triggering method. • Requires ordered volume based on ideal body wt • generally 6 to 10 ml/kg depending on lung mechanics. • Stiffer lungs require smaller volume to avoid injury. • Independent Variable = volume • Dependents = time and pressure

40. Volume Cycled Ventilation Advantage • Reproducible volumes ↑likelihood of constant ventilation (CO2 exchange) Disadvantage • Lack of volume adjustments with changing lung mechanics may ↑ risk of barotrauma. • Difficult to control mean airway pressure. (Distention) • Positive pressure breathing increases V/Q mismatch (lung is moving chest)

41. Synchronized Intermittent Mandatory Ventilation (SIMV) • Provides a periodic machine delivered breath, with all other breathing preformed spontaneously. • Once thought to help with ventilatory muscle training. • Research suggests it does not reduce work of breathing and may promote muscle discoordination. • Order requires a volume/pressure and rate

42. SIMV Advantage • Limits machine delivered breaths and therefore may control hyperventilation. Example: Hiccups triggered the ventilator. Disadvantages • Fixed number of machine breathes ↓ likelihood of constant ventilation (CO2 exchange) in the face of changing ventilatory requirements. • Difficult to control mean airway pressure. (Distention)

43. Pressure Support Advantage • Seems to be more effective at reducing work of breathing and promoting muscle coordination than IMV. • Self adjusting flows able to respond to pt’s breathing pattern. Disadvantages • No guaranteed volume or frequency • Difficult to control mean airway pressure. (Distention) • May increase V/Q mismatch (lung is moving chest)

44. Distending Techniques

45. Lung Surface Area Restrictive processes: • Reduce lung surface area and creates airway instability • Reduces oxygen’s ability to reach the alveolar/capillary membrane • Results in decreased blood oxygen levels

46. Distending Techniques • Focuses on improving oxygenation by ↑average lung volume/surface area • ↑ Mean Airway Pressure (Pma) (and therefore average lung volume) by: • Increasing resting lung size via PEEP/CPAP • Increasing inspiratory time (breath holding) • Increasing delivered volume (not popular at this time)

47. PEEP AND CPAPAdjusting Resting Lung Volumes • Restrictive processes reduce lung surface area and creates airway instability • reduces O2’s ability to reach alveolar/capillary membrane • results in decreased blood oxygen levels. • Traditional method of counter-acting: • continuous lung pressurization > atmospheric pressure, even during exhalation, to ↑resting lung size (FRC).

48. PEEP AND CPAPAdjusting Resting Lung Volumes PEEP • Lung pressurization during the expiratory phase of mechanical delivered breathe it is called Positive End Expiratory Pressure CPAP • Lung pressurization during the expiratory phase during spontaneously breathing, it is called Continuous Positive Airway Pressure (CPAP). • ATS guidelines suggest using the lowest level of PEEP/CPAP needed to achieve a saturation response • Both add to plateau pressure and therefore increases risk of lung injury.

49. Recruitment Maneuvers • Temporary hyperinflation of the lung to determine if it is possible to open lung units to improve oxygenation. Common approach – 40 cmH2O of CPAP for 40 seconds. • Can cause drop in blood pressure and heart rate. • Saturations often fall during the maneuver • Should avoid in patient with or at risk of pneumothorax.

50. PEEPAdjusting Resting Lung Volumes Advantage • ↑resting lung size with possible ↑ in oxygenation Disadvantage • Only effective in homogeneous restrictive processes • May effect blood pressure, cardiac output and urine output • Contributes to barotrauma • If used when not indicated, may ↓ Oxygenation • If positive pressure delivered tidal breath ↑ V/Q mismatch. (the lung is moving the chest)