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Comprehensive Guide to Mechanical Ventilation: Indications, Types, and Management Strategies

This resource provides an in-depth overview of mechanical ventilation (MV) techniques and their clinical indications. It covers essential topics such as hypoxemia, acute respiratory acidosis, and controlled hyperventilation. Various types of MV, including assist-control and synchronized intermittent mandatory ventilation, are discussed alongside their settings and modes. For effective patient management, it includes protocols on sedation, neuromuscular blockade, pressure control settings, and troubleshooting tips. This guide is critical for healthcare professionals managing critically ill patients requiring respiratory support.

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Comprehensive Guide to Mechanical Ventilation: Indications, Types, and Management Strategies

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  1. MECHANICAL VENTILATION KENNEY WEINMEISTER M.D.

  2. INDICATIONS FOR MV • Hypoxemia • Acute respiratory acidosis • Reverse ventilatory muscle fatigue • Permit sedation and/or neuromuscular blockade • Decrease systemic or myocardial oxygen consumption

  3. INDICATIONS CONTINUED • Reduce intracranial pressure through controlled hyperventilation • Stabilize the chest wall • Protect airway • Neurologic impairment • airway obstruction

  4. TYPES OF CONVENTIONAL MV • Timed cycled • Home ventilators • Pressure cycled • Pressure controlled • Volume cycled • Flow cycled • Pressure support

  5. VOLUME VENTILATION • Controlled mechanical ventilation CMV • Assist-control AC • Synchronized intermittent mandatory ventilation SIMV • Which mode?

  6. VENTILATOR SETTINGS • Tidal volume • 10 to 15 mL/kg • Respiratory rate • 10 to 20 breaths/minute • normal minute ventilation 4 to 6 L/min • Fraction of inspired oxygen • Flow rate and I:E ratio

  7. PRESSURE SUPPORT VENTILATION • Flow cycled • preset pressure sustained until inspiratory flow tapers to 25% of maximal value • Comfortable • Used mainly as a weaning mode • Wean pressure until equivalent to air way resistance • peak - plateau pressure

  8. PRESSURE CONTROLED VENTILATION • Pressure cycled • Volume varies with lung mechanics • Minute ventilation is not assured • Improves oxygenation • recruitment of alveoli • Lessens volutrauma?

  9. SETTINGS FOR PRESSURE CONTROL VENTILATION • Inspiratory pressure • I:E ratio • 1:2, 1:1, 2:1, 3:1 • Rate • FIO2 • Peep

  10. PRESSURE REGULATED VOLUME CONTROLLED • Ventilate with pressure control • Preset volume • Inspiratory pressure is adjusted breath to breath • Minute ventilation is maintained

  11. INDICATIONS FOR PEEP • ARDS • Stabilize chest wall • Physiologic peep • Decrease Auto-peep?

  12. CONTRAINDICATIONS FOR PEEP • Increased intracranial pressure • Unilateral pneumonia • Bronchoplueral fistulae

  13. PEEP • Increases FRC • Recruits alveoli • Improves oxygenation • Best Peep • based on lower inflection of pressure volume curve

  14. TROUBLE SHOOTING VOLUME VENTILATION • High pressure alarm • Breath sounds • CXR • Low tidal volume • disconnected • Desaturation

  15. TROUBLE SHOOTING PRESSURE VENTILATION • Low tidal volumes or minute ventilation • Desaturation • Breath sounds • Patient agitation • CXR

  16. Sedation in Mechanically Ventilated Patients • Benzodiazepines • Opioids • Neuroleptics • Propofol • Ketamine • Dexmedetomidine

  17. Benzodiazepines • Lorazepam • Half-life 12 to 15 hours • Major metabolite inactive • Midazolam • Half-life 1-4 hours, increased in cirrhosis, CHF, obesity, elderly • Active metabolite

  18. Opioid • Morphine • Fentanyl • Hydromorphone

  19. Neuroleptics • Haloperidol • Mild agitation .5mg to 2mg • Moderate agitation 2 to 5 mg • Severe 10 to 20 mg • Side Effects • Acute dystonic reactions • Polymorphic VT • Neuroleptic malignant syndrome

  20. Propofol • Side Effect • Hypotension • Bradycardia • Anticonvulsant • Expensive • Use short term

  21. Ketamine • Dissociative anesthetic state • Direct cardiovascular stimulant • Brochodilator • Side Effects • Dysphoric reactions • increased ICP

  22. Dexmedetomidine • Centrally acting alpha 2 agonist • Approved for 24 hours or less • Side Effects • Hypotension • Bradycardia • Atrial fibrillation

  23. Maintenance of Sedation • Titrate dose to ordered scale • Motor Activity Assessment Scale MAAS • Sedation-Agitation Scale SAS • Ramsay • Rebolus prior to all increases in the maintenance infusion • Daily interruption of sedation

  24. NEUROMUSCULAR BLOCKING AGENTS • Difficult to asses adequacy of sedation • Polyneuropathy of the critically ill • Use if unable to ventilate patient after patient adequately sedated • Have no sedative or analgesic properties

  25. Neuromuscular Blocking Agents • Depolarizing • Bind to cholinergic receptors on the motor endplate • Nondepolarizing • Competitively inhibit Ach receptor on the motor endplate

  26. Depolarizing NMBASuccinylcholine • Rapid onset less than 1 minute • Duration of action is 7-8 minutes • Pseudocholinesterase deficiency • 1 in 3200 • Side Effects • Hyperthermia, Hyperkalemia, arrhythmias • Increased ICP

  27. Nondepolarizing Agents • Pancuronium • Drug of choice for normal hepatic and renal function • Atracurium or Cisatracurium • Use in patients with hepatic and/or renal insufficiency • Vecuronium • Drug of choice for cardiovascular instability

  28. No bubble is so iridescent or floats longer than that blown by the successful teacher.Sir William Osler

  29. MV IN OBTRUCTIVE AIRWAY DISEASE • Decrease barotrauma • related to mean airway pressure • Increase I:E • decrease TV and/or increase flow • Minimize auto-peep • auto-peep shown to cause most barotrauma • Permissive hypercapnea

  30. ARDS • Set peep to pressure shown at lower inflection point of pressure volume curve • Tidal volumes set below upper inflection point of pressure volume curve • Use pressure control ventilation early • Minimize volutrauma

  31. Ventilation With Lower Tidal Volumes • Tidal volume: 6 ml/kg • Male 50 + 0.91(centimeters of height-152.4) • Female 45.5+0.91(centimeters of ht - 152.4) • Decrease or Increase TV by 1ml/kg to maintain plateau pressure 25 to 30. • Minimum TV 4ml/kg • PaO2 55 - 88 mm Hg. Sats 88 to 95% • pH 7.3 to 7.45

  32. CASE EXAMPLE • 34 y/o female admitted with status asthmaticus and respiratory failure • You are called to see patient for inability to ventilate • Tidal volume 800 cc, FIO2 100%, AC 12 Peep 5 cm • PAP 70, returned TV 200 cc

  33. Case example continued • Examine patient • CXR • Sedate • Assess auto-peep • Increase I:E • Lower PAP and MAP • Reverse bronchospasm & elect. Hypovent.

  34. CONCLUSION • Three options for ventilation • volume, pressure, flow • Peep, know when to say no • Always assess to prevent barotrauma • ventilate below upper inflection point • assess static compliance daily • monitor for auto-peep

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