Common Modes of Mechanical Ventilation

Breath
Breath
Flow
Wean
Mode
I:E
NIPPV
Type
Trigger
(LPM)
Mode
CMV
Vol.
Timer
Set
N
Full
N
ACV
Vol.
Timer/Pt.
Set
N
Full
N
Depends on
IMV
Vol.
Timer
Set
Y
N
spont. pattern
Depends on
SIMV
Vol.
Timer/Pt.
Set
Y
N
spont. pattern
PSV
Pr.
Pt.
Var.
Y
Patient set
Y
PCV
Pr.
Timer/Pt.
Var.
N
Full
N
BiPAP
Pr.
Timer/Pt.
Set
N
Patient set
Y
Modes of Ventilation Index
CMV = Controlled Mechanical Ventilation or Continuous Mandatory
Breath Trigger
ACV = Assist-Control Ventilation
IMV = Intermittent Mandatory Ventilation
SIMV = Synchronized IMV
PSV = Pressure Support Ventilation
PCV = Pressure Control Ventilation
CiPAP = Bi-level Positive Airway Pressure
*1. CPAP (continuous positive airway pressure) is an elevated
baseline pressure throughout a spontaneous inspiratory and
expiratory cycle that does not provide alveolar ventilation. PEEP
(positive end-expiratory pressure) may be used with all vent. modes
for improved oxygenation, improved lung compliance, FRC, shunt
fraction and redistribution of lung water. PS (pressure support) may
be added to spontaneous respiratory efforts.
*2. Spontaneous breaths are patient-cycled and patient-triggered.
Mandatory breaths are always machine/time cycled and/or triggered.
IMV and SIMV allow unassisted spontaneous respirations.
*3. Weaning modes refers to those methods that will allow patients
to gradually share and to eventually assume completely, the work of
breathing. May also consider progressive T-piece trials.
*4. I:E = Inspiratory:Expiratory ratio - I:E range 1:5 to 5:1. I:E ratio >
1:1, requires the use of Inverse Ratio Ventilation (IRV) and may
require sedation and paralysis.
*5. NIPPV = Noninvasive positive pressure ventilation: Requiring the

use of either nasal pillows, nasal mask or facial mask for delivery of
CPAP, BiPAP, Pressure Support or Volume-cycled ventilatory support.
Clinical indications may include COPD exacerbation, acute pulmonary
edema, neuromuscular disease, control of breathing disorders (OSAS,
OHS) or thoracic cage deformity. Complications of NIPPV may
include leaks at interface, skin abrasion/ulceration, conjunctivitis,
aerophagia with possible risk of aspiration, claustrophobia, patient
intolerance, rhinitis, nasal drying and transient periods of hypoxemia
with removal of nasal/facial apparatus.
*6. Dynamic hyperinflation or pulmonary air trapping during
mechanical ventilation occurs when there is insufficient expiratory
time to allow the lungs to decompress to their FRC or relaxation
volume before the next tidal volume inspiration. This alteration of
normal lung mechanics may produce an auto-PEEP effect an
increased end-respiratory elastic recoil pressure. Auto-PEEP may
occur with or without dynamic hyperinflation. Clinically, it may occur
with COPD, asthma, or other ventilatory patterns incorporating
shortened expiratory times. Corrective measures may include
reduction of airflow obstruction, and/or expiratory time with flow
rate. Addition of external PEEP may help ventilator triggering in
patients with dynamic hyperinflation.

Complications of Mechanical Ventilation

1. Ventilator malfunction;
2. Cardiovascular: venous return, C.O., hypotension;
3. Oxygen toxicity;
4. Pulmonary barotrauma: PTX, subcutaneous emphysema,
pneumopericardium - peritoneum -mediastinum, BPF, air embolism,
interstitial emphysema, air cysts; Barotrauma may be minimized by
keeping Plateau pressure < 35 cm H2O.
5. Pulmonary mechanics(*6): Dynamic hyperinflation, auto-PEEP;
6. Nosocomial pneumonia (see Pul. Care II);
7. Airway: sinusitis, epistaxis (traumatic), glottic-subglottic stenosis,
tracheal injury (ulceration, malacia, dilatation, granulation tissue),
vocal cord/s injury (edema, paralysis, phonation dysfunction);
8. Tracheostomy: Tracheal injury (ulceration, stenosis, malacia,
granulation tissue), tracheo-innominate artery erosion with
hemorrhage;
9. Misc: Pulmonary embolism, DVT, stress gastritis, psychological
stress -anxiety -depression, sleep deprivation, ICP, patient-ventilator
asynchrony, ETT misplacement, inadvertent ETT dislocation due to
cuff leak, inadvertent extubation, atelectasis worsening hypoxemia,
free water retenfion Na+.

End-Tidal CO2 Monitoring (Capnometry)

The continuous measurement of the partial pressure of PaCO2 in exhaled gas. The
ETCO2 is equivalent to fhe PaCO2 in arterial, end-capillary blood of normal lungs.
ETCO2 measurements may provide clinical evaluation of pulmonary gas exchange,
carbon dioxide production, cardiac performance (cardiac output) and ventilator-patient
management problems. ETCO2: C.O., cardiac arrest, right or left mainstem
intubation, ETT obstruction, esophageal intubation, unexpected extubation, leak around
ETT cuff, pt. disconnection from ventilator, general anesthesia, hypothermia, PE,
ARDS ( shunt fraction), PEEP; ETCO2: Hypermetabolism (Sepsis, Hyperthermia,
Pain), rebreathing, mechanical dead space. ETCO2 monitoring may be useful when
evaluating a patient with survival potential with CPR and/or assessing the weaning
status during mechanical ventilation.
*PaCO2 = kVCO2/VE (1 -VD/VT) or (kVCO2 / VA)
Oxygen Delivery System (FIO2)
A) Nasal: 1-6 LPM (1L = 3% FIO2)
B) VentiMask: 24,28,31,35,40, 50%
C) Face Mask: 35-60%
D) Partial Rebreather: 60-90%
E) Partial Non-Rebreather: 90-100%
F) Trach Colla:24,28,31,35,40,50%
Respiratory Nubulization Medications
A) Bronchodilators (Sympathomimetic): Isoetharine (Bronkosol) Unit - Dose (0.08%,
0.1%, 0.17%, 0.25%); Metaproterenol (Alupent) Unit-Dose (0.4%, 0.6%); Albuterol
Unit-Dose (0.083%) Albuterol Inhalation Solution (0.5%): 0.5 ml + 2.5 ml NS-Full
strength or 0.25 ml + 2.5 ml NS -1/2 strength; Racepinephrine (Racemic Epinephrine)
Solution (2.25%): 0.5 ml + 2.5 ml NS - may also be used for post-intubation stridor or
croup. (Anticholinergic): lpratropium (Atrovent) Unit-Dose (0.02% - 2.5 ml);
B) Mucolytics: Dornase Alfa (Pulmozyme) Unit-Dose (2.5 ml); Acetylcysteine
(Mucomyst) (10%, 20%): 4 cc of Mucomyst 10% or 2cc of Mucomyst 20%;
C) Asthma - Anti-inflammatory: Cromolyn (Intal) Unit-Dose (2 ml-20 mg);
D) Misc.: 10% NaCl via USN for sputum induction; Xylocaine (Lidocaine) Solution
(4%): 5 ml dose - may be used for local anesthesia of the upper airway.
Pulmonary Function Physiology
PFT values vary in the population and are influenced by age, sex, wt., ht. and race.
Normal values will depend upon predicted reference equations. General guidelines:
Obstruction: FEV1/FVC >= 70% = N; 60-69% = Mild; 40-59% = Mod.; 30-39% =
Severe; <30% = Very severe. Restriction: VC >= 80% = N; 60-79% = Mild; 50-59% =
Mod.; 35- 49% = Severe; <35% = Very severe. Use TLC instead of VC if obstruction is
present.

Lung Volumes
Normal

Obstruction

Restriction

Spirometry