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How To Ventilate ICU Patient. Dr Mohammed Bahzad MBBS.FRCPC,FCCP,FCCM Head Of Critical Care Department Mubarak Alkbeer Hospital. Aims. Get oxygen in Get carbon dioxide out Minimize adverse effects Maximize patient comfort. Case A. 60 kg male

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How To Ventilate ICU Patient


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how to ventilate icu patient

How To Ventilate ICU Patient

Dr Mohammed Bahzad MBBS.FRCPC,FCCP,FCCM

Head Of Critical Care Department Mubarak Alkbeer Hospital

slide2
Aims
  • Get oxygen in
  • Get carbon dioxide out
  • Minimize adverse effects
  • Maximize patient comfort
case a
Case A
  • 60 kg male
  • Post operative – complicated wipel procedure
  • No previous lung or heart disease
  • Still paralyzed
slide5
Mode
  • Non-invasive
  • Invasive
    • Assist control
    • Pressure control
    • SIMV
    • (Pressure support)
  • Pick a mode you understand and are familiar with
assist control
Assist control
  • Set tidal volume
  • Inspiratory-expiratory cycling
    • Time cycled
      • Time is set
      • Ventilator adjusts flow to deliver set tidal volume in the set time
    • Volume cycled
assist control7
Assist control
  • Breaths:
    • Ventilator initiated (control breaths)
    • Patient initiated (assist breaths)
    • Set minimum frequency
  • Characteristics of each inspiration are the same
    • Not affected by whether breath is control breath or an assist breath
assist control8
Assist control

T

50 cmH2O

Pressure

70 l/min

Flow

-70

700 ml

Volume

assist control9
Assist control

T

50 cmH2O

Pressure

70 l/min

Flow

-70

700 ml

Volume

assist control10
Assist control
  • Set
    • Minimum respiratory rate
      • Patient’s spontaneous respiratory rate < set rate  ventilator gives additional control breaths to make up difference
      • Patient’s spontaneous rate > set rate  no control breaths
volume control
Volume control
  • Set
    • Minimum respiratory rate
    • Tidal volume
volume control12
Volume control
  • Set
    • Minimum respiratory rate
    • Tidal volume
    • Inspiratory time or I:E ratio
    • Inspiratory pause time
volume control13
Volume control
  • Longer inspiratory time
    • Improved oxygenation
      • Higher mean airway pressure
      • Re-distribution
    • Lower peak airway pressure
      • More time available to deliver set tidal volume
  • Shorter inspiratory time
    • Less risk of gas trapping and PEEPi
    • Less effect on cardiovascular system
setting i e inspiratory flow time pause time15
Setting I:E, inspiratory flow time, pause time
  • Nomenclature

Inspiratory flow time

Volume

Time

setting i e inspiratory flow time pause time16
Setting I:E, inspiratory flow time, pause time
  • Nomenclature

Inspiratory pause time

Volume

Time

setting i e inspiratory flow time pause time17
Setting I:E, inspiratory flow time, pause time
  • Nomenclature

Inspiratory time

Volume

Time

setting i e inspiratory flow time pause time18
Setting I:E, inspiratory flow time, pause time
  • Nomenclature

Inspiratory time

Expiratory time

Volume

Time

setting i e inspiratory flow time pause time19
Setting I:E, inspiratory flow time, pause time
  • Nomenclature

Respiratory cycle time

Volume

Time

i e as a ratio inspiratory pause time as a percentage21
I:E as a ratio & inspiratory pause time as a percentage

3 secs

1

2

 Respiratory rate

10%

Volume

Time

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

6 secs

2 secs

4 secs

0.5 s

Volume

Time

absolute inspiratory time inspiratory flow time as a function of flow rate23
Absolute inspiratory time, inspiratory flow time as a function of flow rate

3 secs

2 secs

1 sec

 Respiratory rate withoutchanging Inspiratory time orinspiratory flow

0.5 s

Volume

Time

absolute inspiratory time inspiratory flow time as a function of flow rate24
Absolute inspiratory time, inspiratory flow time as a function of flow rate

3 secs

2 secs

1 sec

 inspiratory flow

1.5 s

Volume

Time

absolute inspiratory time inspiratory flow time as a function of flow rate25
Absolute inspiratory time, inspiratory flow time as a function of flow rate

3 secs

1 sec

2 sec

 Absolute inspiratory time

0.5 s

Volume

Time

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

3 secs

2 secs

1 sec

 Respiratory rate withoutchanging inspiratory flow orinspiratory pause time

0.5 s

Volume

Time

inspiratory flow time as a function of flow rate absolute pause time27
Inspiratory flow time as a function of flow rate, absolute pause time

3 secs

1 sec

2 sec

 inspiratory flow

0.5 s

Volume

Time

inspiratory flow time as a function of flow rate absolute pause time28
Inspiratory flow time as a function of flow rate, absolute pause time

3 secs

0.8 sec

2.2 sec

 inspiratory pause time

0.3 s

Volume

Time

volume control29
Volume control
  • Set
    • Minimum respiratory rate
    • Tidal volume
    • Inspiratory time or I:E ratio
      • Directly/indirectly
    • Inspiratory pause time
      • Directly/indirectly
    • PEEP
assist control30
Advantages

Relatively simple to set

Guaranteed minimum minute ventilation

Rests muscles of respiration (if properly set)

Disadvantages

Not synchronized

Patient may “lead” ventilator

Inappropriate triggering may result in excessive minute ventilation

 lung compliance  alveolar pressure with risk of barotrauma

Often requires sedation to achieve synchrony.

Assist control
pressure control
Pressure control
  • Pressure preset assist/control ventilation
  • Similar to volume control except pressure is preset
slide33

PC above PEEP

Pressure

PEEP

Time

Flow

Time

Volume

Time

slide34

Normal inspiratory time

Short inspiratory time

PC above PEEP

Pressure

PEEP

Time

Flow

Time

Volume

Time

pressure control35
Advantages

Relatively simple

Avoids high inspiratory pressures

Rests muscles of respiration

Improved oxygenation

Disadvantages

Not synchronized

Inappropriate triggering may  excessive minute ventilation

Change in lung compliance or resistance  change in tidal volume

Often requires sedation

Pressure control
pressure support
Pressure support
  • Nomenclature
    • Inspiratory assist
    • Assisted spontaneous breathing
pressure support37

Maximum inspiratoryflow

Set % of maxinspiratory flow

Pressure support

PS above PEEP

Pressure

PEEP

Flow

Volume

pressure support38
Advantages

Simple to set

Avoids high inspiratory pressures

Better patient-ventilator synchrony

Unloads respiratory muscles

Disadvantages

No apnoea back-up in older ventilators

Change in lung compliance or resistance  change in tidal volume

Pressure support
pressure support39
Pressure support
  • Pressure support of 3.5-14.5 cmH2O required to overcome the additional work of breathing due to breathing through ETT and demand valve
  • Patients who require pressure support of < 6 cmH2O can probably be extubated
simv pressure support
SIMV (& pressure support)
  • SIMV almost always combined with pressure support
slide41
SIMV
  • Patient receives a minimum number of mandatory breaths
  • Able to breath in between these breaths
    • ± pressure support breaths
slide42
SIMV

Mandatory breath

Pressure

PEEP

Time

Flow

Time

Trig

Trig

slide43
SIMV

Pressure support breath

Pressure

PEEP

Time

Flow

Time

Trig

Trig

mandatory breaths
Mandatory breaths
  • Volume control breaths
    • Set tidal volume
  • Pressure control breaths
    • Set pressure
mandatory breaths45
Mandatory breaths
  • Synchronized with patients inspiratory efforts
triggering
Triggering
  • Effect of triggering depends on its timing
    • Close to time that a mandatory breath is due (during SIMV period)
      • ⇒synchronized mandatory breath
    • Other times (during spontaneous period)
      • ⇒pressure support breath
slide47

Spontaneous period

SIMV period

T

T

settings
Settings
  • FiO2
  • SIMV rate
    • =mandatory breath rate
  • SIMV period (some ventilators)
  • Tidal volume (or inspiratory pressure)
  • I:E ratio
  • Pressure support
  • PEEP
volume control50
Volume control
  • Set
    • Minimum respiratory rate
    • Tidal volume
    • Inspiratory time or I:E ratio
      • Directly/indirectly
    • Inspiratory pause time
      • Directly/indirectly
    • PEEP
simv ps
Advantages

Better patient-ventilator synchrony

Guaranteed minimum minute ventilation

Disadvantages

Complicated mode

SIMV & PS
what mode
What mode?
  • Largely apnoeic patient
    • Control of minute ventilation important
      • Assist control
    • Control of peak pressure important
      • Pressure control
  • Intermittent spontaneous breaths
    • SIMV
  • Regular spontaneous breaths, improving condition
    • Pressure support
case a53
Case A
  • 60 kg male
  • Post operative – complicated wipel procedure
  • No previous lung or heart disease
  • Still paralyzed
slide54

ModeVolume Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Set ventilation mode

12-25 15:32

Volume control 

Automode

Ti =1.33 s (33%)

Save

Trends

i

Basic

I:E

Trigger

.

Tidal volume

500

I:E1:2.0

Trigger sensitivityV

Resp. Rate12

T. pause10

Quickstart

PEEP5

T. Insp. rise5

Menu

Mainscreen

O2 conc.100

.

Additionalvalues

Cancel

Accept

!

Startbreath

O2breaths

Exp.hold

Insp.hold

54

 Charles Gomersall 2003

assess
Assess
  • Chest movement
  • Breath sounds
  • Saturation
increasing alveolar ventilation
Increasing alveolar ventilation
  • Increase tidal volume
  • Increase respiratory rate
    • Increase risk of gas trapping

(Volume/compliance) + PEEP

Flow x resistance

slide58

ModeVolume Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

12-25 15:32

Recording

Save

Trends

50 cmH2O

Ppeak

34

Pplat

28

Pmean

12

i

Basic

I:E

Trigger

PEEP

5

Moderately high Pplat

70 l/min

RR

12

O2

100

Vee

0

Quickstart

I:E

1:2.0

-70

Menu

700 ml

MVe

6.0

Mainscreen

MVi

6.1

VTi

501

VTe

471

.

Additionalsettings

Additionalvalues

!

Startbreath

O2breaths

Exp.hold

Insp.hold

58

 Charles Gomersall 2003

slide59

ModeVolume Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Set ventilation mode

12-25 15:32

Volume control 

Automode

Ti =1.33 s (33%)

Save

Trends

i

Basic

I:E

Trigger

.

Tidal volume

500

I:E1:2.0

Trigger sensitivityV

 Resp rate

Resp. Rate15

T. pause10

Quickstart

PEEP5

T. Insp. rise5

Menu

Mainscreen

O2 conc.50

.

Additionalvalues

Cancel

Accept

 FiO2

!

Startbreath

O2breaths

Exp.hold

Insp.hold

59

 Charles Gomersall 2003

case a60
Case A
  • Patient starts to wake up
  • Triggering ventilator frequently
    • some breath stacking
  • Change to pressure support mode
slide61

ModeVolume Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Set ventilation mode

12-25 15:32

Pressure support 

Save

Trends

i

Basic

I:E

Trigger

.

PS above PEEP

15

T. Insp. rise 5

Trigger sensitivityV

PEEP5

Insp. cycle off5

Quickstart

O2 conc. 40

Menu

Mainscreen

.

Additionalvalues

Cancel

Accept

!

Startbreath

O2breaths

Exp.hold

Insp.hold

61

 Charles Gomersall 2003

other settings
Other settings
  • Trigger sensitivity
    •  sensitivity preferable
      • Flow triggering generally more sensitive than pressure triggering
      •  flow or  pressure   sensitivity
assess63
Assess
  • Chest movement
  • Respiratory rate & effort
  • Saturation
assess64
Assess

ModeVolume Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Save

Trends

Ppeak (cmH2O)

40

20

  • Respiratory rate
  • Tidal volume
  • Synchrony
  • Blood gases

Pmean

12

i

PEEP

5

RR (b/min)

10

O2(%)

46

34

40

Quickstart

MVe (l/min)

8.5

Menu

7.1

Mainscreen

VTi

701

VTe

693

.

Additionalsettings

Additionalvalues

Startbreath

O2breaths

Exp.hold

Insp.hold

case b
Case B
  • 72 year old, 60 kg man with history of asthma
  • Presents with severe bilateral pneumonia
case b66
Case B

ModePressure Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Save

Trends

Ppeak (cmH2O)

40

15

  • Pressure control mode
  • FiO2 1.0
  • Insp pressure 10 above PEEP 5
  • RR 20
  • I:E= 1:2

Pmean

12

i

PEEP

5

RR (b/min)

20

O2(%)

100

94

100

Quickstart

MVe (l/min)

8.5

Menu

4.1

Mainscreen

VTi

201

VTe

193

.

Additionalsettings

Additionalvalues

Startbreath

O2breaths

Exp.hold

Insp.hold

case b67
Case B

ModePressure Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Save

Trends

Ppeak (cmH2O)

40

25

  • Pressure control mode
  • FiO2 0.6
  • Insp pressure 20 above PEEP 5
  • RR 20
  • I:E= 1:2

Pmean

12

i

PEEP

5

RR (b/min)

20

O2(%)

66

54

60

Quickstart

MVe (l/min)

8.5

Menu

8.1

Mainscreen

VTi

501

VTe

493

.

Additionalsettings

Additionalvalues

Startbreath

O2breaths

Exp.hold

Insp.hold

look for causes of desaturation
Look for causes of desaturation
  • Chest movement
  • Breath sounds
  • Ventilator malfunction
  • CXR
improving oxygenation
Improving oxygenation

ModePressure Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Save

Trends

Ppeak (cmH2O)

40

25

  • Options ?
    •  FiO2
    •  inspiratory pressure
    •  inspiratory time
    •  PEEP

Pmean

12

i

PEEP

5

RR (b/min)

20

O2(%)

66

54

60

Mean alv pre

Quickstart

MVe (l/min)

8.5

Menu

8.1

Mainscreen

VTi

501

VTe

493

.

Additionalsettings

Additionalvalues

Startbreath

O2breaths

Exp.hold

Insp.hold

improving oxygenation71
Improving oxygenation

ModePressure Control

Automode

Admitpatient

Nebulizer

Status

Alarmprofile

Save

Trends

Ppeak (cmH2O)

40

25

  • Options ?
    •  FiO2
    •  inspiratory pressure
    •  inspiratory time
    •  PEEP

Pmean

12

i

PEEP

5

RR (b/min)

20

O2(%)

66

54

60

Quickstart

MVe (l/min)

8.5

Menu

8.1

Mainscreen

VTi

501

VTe

493

.

Additionalsettings

Additionalvalues

Startbreath

O2breaths

Exp.hold

Insp.hold

re assess
Re-assess
  • Pulse oximetry
  • Arterial blood gas
summary
Summary
  • Chose the mode that fits the patient
  • Set the ventilator to achieve your aims
  • Often more than one way to achieve your aims
    • Select the method with the least adverse effects