how to ventilate icu patient dr mohammed bahzad mbbs.frcpc,fccp,fccm head of critical care...

How To Ventilate ICU How To Ventilate ICU PatientPatient

Dr Mohammed Bahzad Dr Mohammed Bahzad MBBS.FRCPC,FCCP,FCCMMBBS.FRCPC,FCCP,FCCM

Head Of Critical Care Department Head Of Critical Care Department Mubarak Alkbeer HospitalMubarak Alkbeer Hospital

AimsAims

Get oxygen inGet oxygen in Get carbon dioxide outGet carbon dioxide out Minimize adverse effectsMinimize adverse effects Maximize patient comfortMaximize patient comfort

Case ACase A

60 kg male60 kg male Post operative – complicated wipel Post operative – complicated wipel

procedureprocedure No previous lung or heart diseaseNo previous lung or heart disease Still paralyzedStill paralyzed

Make the ventilator fit the Make the ventilator fit the patientpatient

ModeMode

Non-invasiveNon-invasive InvasiveInvasive

– Assist controlAssist control– Pressure controlPressure control– SIMVSIMV– (Pressure support)(Pressure support)

Pick a mode you understand and are Pick a mode you understand and are familiar withfamiliar with

Assist controlAssist control

Set tidal volumeSet tidal volume Inspiratory-expiratory cyclingInspiratory-expiratory cycling

– Time cycledTime cycled Time is setTime is set Ventilator adjusts flow to deliver set tidal volume in Ventilator adjusts flow to deliver set tidal volume in

the set timethe set time

– Volume cycledVolume cycled

Assist controlAssist control

Breaths:Breaths:– Ventilator initiated (control breaths)Ventilator initiated (control breaths)– Patient initiated (assist breaths)Patient initiated (assist breaths)– Set minimum frequencySet minimum frequency

Characteristics of each inspiration are the Characteristics of each inspiration are the samesame– Not affected by whether breath is control breath Not affected by whether breath is control breath

or an assist breathor an assist breath

700 ml

-70

70 l/min

50 cmH2O

Assist controlAssist control

Pressure

Flow

Volume

T

700 ml

-70

70 l/min

50 cmH2O

Assist controlAssist control

Pressure

Flow

Volume

T

Assist controlAssist control

SetSet– Minimum respiratory rateMinimum respiratory rate

Patient’s spontaneous respiratory rate < set rate Patient’s spontaneous respiratory rate < set rate ventilator gives additional control breaths to make ventilator gives additional control breaths to make up differenceup difference

Patient’s spontaneous rate > set rate Patient’s spontaneous rate > set rate no control no control breathsbreaths

Volume controlVolume control

SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume

Volume controlVolume control

SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume– Inspiratory time or I:E ratioInspiratory time or I:E ratio– Inspiratory pause timeInspiratory pause time

Volume controlVolume control

Longer inspiratory timeLonger inspiratory time– Improved oxygenationImproved oxygenation

Higher mean airway pressureHigher mean airway pressure Re-distributionRe-distribution

– Lower peak airway pressureLower peak airway pressure More time available to deliver set tidal volumeMore time available to deliver set tidal volume

Shorter inspiratory timeShorter inspiratory time– Less risk of gas trapping and PEEPLess risk of gas trapping and PEEPii

– Less effect on cardiovascular systemLess effect on cardiovascular system

Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time

NomenclatureNomenclature

Time

Vol

ume

Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time

NomenclatureNomenclature

Time

Vol

ume

Inspiratory flow time

Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time

NomenclatureNomenclature

Time

Vol

ume

Inspiratory pause time

Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time

NomenclatureNomenclature

Time

Vol

ume

Inspiratory time

Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time

NomenclatureNomenclature

Time

Vol

ume

Inspiratory time Expiratory time

Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time

NomenclatureNomenclature

Time

Vol

ume

Respiratory cycle time

I:E as a ratio & inspiratory pause time I:E as a ratio & inspiratory pause time as a percentageas a percentage

Time

Vol

ume

6 secs

1 2

10%

I:E as a ratio & inspiratory pause time I:E as a ratio & inspiratory pause time as a percentageas a percentage

Time

Vol

ume

3 secs

1 2

10%

Respiratory rate

Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate

Time

Vol

ume

6 secs

2 secs 4 secs

0.5 s

Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate

Time

Vol

ume

3 secs

2 secs

0.5 s

Respiratory rate withoutchanging Inspiratory time orinspiratory flow

1 sec

Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate

Time

Vol

ume

3 secs

2 secs

1.5 s

inspiratory flow1 sec

Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate

Time

Vol

ume

3 secs

1 sec

0.5 s

Absolute inspiratory time2 sec

Time

Vol

ume

3 secs

2 secs

0.5 s

Respiratory rate withoutchanging inspiratory flow orinspiratory pause time

1 sec

Inspiratory flow time as a function of Inspiratory flow time as a function of flow rate, absolute pause timeflow rate, absolute pause time

Inspiratory flow time as a function of Inspiratory flow time as a function of flow rate, absolute pause timeflow rate, absolute pause time

Time

Vol

ume

3 secs

1 sec

0.5 s

inspiratory flow2 sec

Inspiratory flow time as a function of Inspiratory flow time as a function of flow rate, absolute pause timeflow rate, absolute pause time

Time

Vol

ume

3 secs

0.8 sec

0.3 s

inspiratory pause time2.2 sec

Volume controlVolume control

SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume– Inspiratory time or I:E ratioInspiratory time or I:E ratio

Directly/indirectlyDirectly/indirectly

– Inspiratory pause timeInspiratory pause time Directly/indirectlyDirectly/indirectly

– PEEPPEEP

Assist controlAssist control

AdvantagesAdvantages– Relatively simple to setRelatively simple to set

– Guaranteed minimum Guaranteed minimum minute ventilationminute ventilation

– Rests muscles of Rests muscles of respiration (if properly respiration (if properly set)set)

DisadvantagesDisadvantages– Not synchronizedNot synchronized– Patient may “lead” Patient may “lead”

ventilatorventilator– Inappropriate triggering Inappropriate triggering

may result in excessive may result in excessive minute ventilationminute ventilation

lung compliance lung compliance alveolar pressure with risk alveolar pressure with risk of barotraumaof barotrauma

– Often requires sedation to Often requires sedation to achieve synchrony. achieve synchrony.

Pressure controlPressure control

Pressure preset assist/control ventilationPressure preset assist/control ventilation Similar to volume control except pressure is Similar to volume control except pressure is

presetpreset

PEEP

PC above PEEP

Pre

ssure

Flow

Time

Time

Time

Volu

me

PEEP

PC above PEEP

Pre

ssure

Flow

Time

Time

Time

Volu

me

Normal inspiratory time Short inspiratory time

Pressure controlPressure control

AdvantagesAdvantages– Relatively simpleRelatively simple

– Avoids high inspiratory Avoids high inspiratory pressurespressures

– Rests muscles of Rests muscles of respirationrespiration

– Improved oxygenationImproved oxygenation

DisadvantagesDisadvantages– Not synchronizedNot synchronized

– Inappropriate triggering Inappropriate triggering may may excessive minute excessive minute ventilationventilation

– Change in lung compliance Change in lung compliance or resistance or resistance change in change in tidal volumetidal volume

– Often requires sedationOften requires sedation

Pressure supportPressure support

NomenclatureNomenclature– Inspiratory assistInspiratory assist– Assisted spontaneous breathingAssisted spontaneous breathing

Pressure supportPressure support

PEEP

PS above PEEP

Pre

ssu

reFl

ow

Volu

me

Maximum inspiratory

flowSet % of maxinspiratory flow

Pressure supportPressure support

AdvantagesAdvantages– Simple to setSimple to set– Avoids high inspiratory Avoids high inspiratory

pressurespressures– Better patient-Better patient-

ventilator synchronyventilator synchrony– Unloads respiratory Unloads respiratory

musclesmuscles

DisadvantagesDisadvantages– No apnoea back-up in No apnoea back-up in

older ventilatorsolder ventilators

– Change in lung Change in lung compliance or compliance or resistance resistance change in change in tidal volumetidal volume

Pressure supportPressure support

Pressure support of 3.5-14.5 cmHPressure support of 3.5-14.5 cmH22O O required to overcome the additional work required to overcome the additional work of breathing due to breathing through ETT of breathing due to breathing through ETT and demand valveand demand valve

Patients who require pressure support of < Patients who require pressure support of < 6 cmH6 cmH22O can probably be extubatedO can probably be extubated

SIMV (& pressure support)SIMV (& pressure support)

SIMV almost always combined with SIMV almost always combined with pressure supportpressure support

SIMVSIMV

Patient receives a minimum number of Patient receives a minimum number of mandatory breathsmandatory breaths

Able to breath in between these breathsAble to breath in between these breaths– ± pressure support breaths± pressure support breaths

SIMVSIMV

Pressure

Flow

PEEP

Time

Trig Trig

Time

Mandatory breath

SIMVSIMV

Pressure

Flow

PEEP

Time

Trig Trig

Time

Pressure support breath

Mandatory breathsMandatory breaths

Volume control breathsVolume control breaths– Set tidal volumeSet tidal volume

Pressure control breathsPressure control breaths– Set pressureSet pressure

Mandatory breathsMandatory breaths

Synchronized with patients inspiratory Synchronized with patients inspiratory effortsefforts

TriggeringTriggering

Effect of triggering depends on its timingEffect of triggering depends on its timing– Close to time that a mandatory breath is due Close to time that a mandatory breath is due

(during SIMV period)(during SIMV period) ⇒⇒synchronized mandatory breathsynchronized mandatory breath

– Other times (during spontaneous period)Other times (during spontaneous period) ⇒⇒pressure support breathpressure support breath

SIMV period

T T

Spontaneous period

SIMV period Spontaneous period

SettingsSettings

FFiiOO22

SIMV rateSIMV rate– =mandatory breath rate=mandatory breath rate

SIMV period (some ventilators)SIMV period (some ventilators) Tidal volume (or inspiratory pressure)Tidal volume (or inspiratory pressure) I:E ratioI:E ratio Pressure supportPressure support PEEPPEEP

Volume controlVolume control

SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume– Inspiratory time or I:E ratioInspiratory time or I:E ratio

Directly/indirectlyDirectly/indirectly

– Inspiratory pause timeInspiratory pause time Directly/indirectlyDirectly/indirectly

– PEEPPEEP

SIMV & PSSIMV & PS

AdvantagesAdvantages– Better patient-Better patient-

ventilator synchronyventilator synchrony

– Guaranteed minimum Guaranteed minimum minute ventilationminute ventilation

DisadvantagesDisadvantages– Complicated modeComplicated mode

What mode?What mode?

Largely apnoeic patientLargely apnoeic patient– Control of minute ventilation importantControl of minute ventilation important

Assist controlAssist control

– Control of peak pressure importantControl of peak pressure important Pressure controlPressure control

Intermittent spontaneous breathsIntermittent spontaneous breaths– SIMVSIMV

Regular spontaneous breaths, improving conditionRegular spontaneous breaths, improving condition– Pressure supportPressure support

Case ACase A

60 kg male60 kg male Post operative – complicated wipel Post operative – complicated wipel

procedureprocedure No previous lung or heart diseaseNo previous lung or heart disease Still paralyzedStill paralyzed

54

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

!

12-25 15:32

Charles Gomersall 2003

ModeVolume Control

AutomodeAdmitpatient

Nebulizer Status

Additionalvalues

Set ventilation mode Volume control Automode

Ti =1.33 s (33%)

Tidal volume

500

Resp. Rate

12

PEEP

5

O2 conc.

100

I:E

1:2.0

T. pause

10

T. Insp. rise

5

Trigger sensitivity

V

Basic I:E Trigger

.

Cancel Accept

.

AssessAssess

Chest movementChest movement Breath soundsBreath sounds SaturationSaturation

pH 7.23

PaCO2 8.1 kPa (61 mmHg)

PaO2 54.9 kPa (413 mmHg)

HCO3- 26 mmol/l

Base excess +3

Saturation 100%

)V-(V xRR nventilatio Alveolar DT

Increasing alveolar ventilationIncreasing alveolar ventilation

Increase tidal volumeIncrease tidal volume

Increase respiratory rateIncrease respiratory rate– Increase risk of gas trappingIncrease risk of gas trapping

Flow x resistance(Volume/compliance) + PEEP

58

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

!

12-25 15:32

Charles Gomersall 2003

ModeVolume Control

AutomodeAdmitpatient

Nebulizer Status

Additionalvalues

Basic I:E Trigger

.Additionalsettings

700 ml

-70

70 l/min

50 cmH2O

RecordingPpeak

Pplat

Pmean

PEEP

RR

O2

Vee

I:E

MVe

MVi

VTi

VTe

34

28

12

5

12

100

0

1:2.0

6.0

6.1

501

471

Moderately high Pplat

59

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

!

12-25 15:32

Charles Gomersall 2003

ModeVolume Control

AutomodeAdmitpatient

Nebulizer Status

Additionalvalues

Set ventilation mode Volume control Automode

Ti =1.33 s (33%)

Tidal volume

500

Resp. Rate

15

PEEP

5

O2 conc.

50

I:E

1:2.0

T. pause

10

T. Insp. rise

5

Trigger sensitivity

V

Basic I:E Trigger

.

Cancel Accept

.

Resp rate

FiO2

Case ACase A

Patient starts to wake upPatient starts to wake up Triggering ventilator frequentlyTriggering ventilator frequently

– some breath stackingsome breath stacking Change to pressure support modeChange to pressure support mode

61

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

!

12-25 15:32

Charles Gomersall 2003

ModeVolume Control

AutomodeAdmitpatient

Nebulizer Status

Additionalvalues

Set ventilation mode Pressure support

PS above PEEP

15

PEEP

5

O2 conc.

40

T. Insp. rise

5

Insp. cycle off

5

Trigger sensitivity

V

Basic I:E Trigger

.

Cancel Accept

.

Other settingsOther settings

Trigger sensitivityTrigger sensitivity sensitivity preferablesensitivity preferable

Flow triggering generally more sensitive than Flow triggering generally more sensitive than pressure triggeringpressure triggering

flow or flow or pressure pressure sensitivity sensitivity

AssessAssess

Chest movementChest movement Respiratory rate & effortRespiratory rate & effort SaturationSaturation

Respiratory rateRespiratory rate Tidal volumeTidal volume SynchronySynchrony Blood gasesBlood gases

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

ModeVolume Control

AutomodeAdmitpatient

Nebulizer Status

.

40

AssessAssess Ppeak (cmH2O)

2040

Pmean 12PEEP

RR (b/min)

O2 (%)46

MVe (l/min)

7.18.5

VTi 701VTe 693

Additionalsettings

Additionalvalues

5

10

34

Case BCase B

72 year old, 60 kg man with history of 72 year old, 60 kg man with history of asthmaasthma

Presents with severe bilateral pneumoniaPresents with severe bilateral pneumonia

Pressure control modePressure control mode FiOFiO22 1.0 1.0

Insp pressure 10 above PEEP 5Insp pressure 10 above PEEP 5 RR 20RR 20 I:E= 1:2I:E= 1:2

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

ModePressure Control

AutomodeAdmitpatient

Nebulizer Status

.

100

Case BCase B Ppeak (cmH2O)

1540

Pmean 12PEEP

RR (b/min)

O2 (%)100

MVe (l/min)

4.18.5

VTi 201VTe 193

Additionalsettings

Additionalvalues

5

20

94

Pressure control modePressure control mode FiOFiO22 0.6 0.6

Insp pressure 20 above PEEP 5Insp pressure 20 above PEEP 5 RR 20RR 20 I:E= 1:2I:E= 1:2

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

ModePressure Control

AutomodeAdmitpatient

Nebulizer Status

.

60

Case BCase B Ppeak (cmH2O)

2540

Pmean 12PEEP

RR (b/min)

O2 (%)66

MVe (l/min)

8.18.5

VTi 501VTe 493

Additionalsettings

Additionalvalues

5

20

54

Case BCase B

pH 7.43

PaCO2 5.1 kPa (38 mmHg)

PaO2 6.9 kPa (52 mmHg)

HCO3- 22 mmol/l

Base excess

-2

Saturation 84%

Look for causes of desaturationLook for causes of desaturation

Chest movementChest movement Breath soundsBreath sounds Ventilator malfunctionVentilator malfunction CXRCXR

Options ?Options ? FiOFiO22

inspiratory pressure inspiratory pressure inspiratory timeinspiratory time PEEPPEEP

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

ModePressure Control

AutomodeAdmitpatient

Nebulizer Status

.

60

Improving oxygenationImproving oxygenation Ppeak (cmH2O)

2540

Pmean 12PEEP

RR (b/min)

O2 (%)66

MVe (l/min)

8.18.5

VTi 501VTe 493

Additionalsettings

Additionalvalues

5

20

54

Mean alv pre

Options ?Options ? FiOFiO22

inspiratory pressureinspiratory pressure inspiratory timeinspiratory time PEEPPEEP

Startbreath

O2

breathsExp.hold

Insp.hold

Mainscreen

Menu

Quickstart

Alarmprofile

Save Trends

i

ModePressure Control

AutomodeAdmitpatient

Nebulizer Status

.

60

Improving oxygenationImproving oxygenationPpeak (cmH2O)

2540

Pmean 12PEEP

RR (b/min)

O2 (%)66

MVe (l/min)

8.18.5

VTi 501VTe 493

Additionalsettings

Additionalvalues

5

20

54

Re-assessRe-assess

Pulse oximetryPulse oximetry Arterial blood gasArterial blood gas

SummarySummary

Chose the mode that fits the patientChose the mode that fits the patient Set the ventilator to achieve your aimsSet the ventilator to achieve your aims Often more than one way to achieve your Often more than one way to achieve your

aimsaims– Select the method with the least adverse effectsSelect the method with the least adverse effects

Thank You