Absolute Basics of

Mechanical Ventilation

Dr David Howell
Consultant in Intensive Care, Respiratory
and Acute Medicine

Aims and Objectives

Define Positive Pressure Mechanical Ventilation
Explain Continuous Mandatory Ventilation (CMV)
Explain Synchronised Mandatory Ventilation (SIMV)
Explain Pressure Support Ventilation (PSV)
Explain Basic Ventilator Settings
Not a Talk on Physiology of Mechanical Ventilation

What you Encounter

Positive Pressure Mechanical Ventilator

Lots of Monitors and Knobs to Turn

Some are More Complicated than Others

Invasive support
Advanced
Ventilation

Tracheostomy
Prone Position
Nitric Oxide
Long Term
Weaning/Individual
plan

Weaning

Standard
Ventilation

Optimising the
Pt for weaning

Suctioning

Weaning
Screen/standard
protocol

Intubation
Humidification
Wake, Warm
& Wean
Non-Invasive
Ventilation

Oxygen
Therapy

Mask CPAP

Non-invasive support

Extubation
Decannulation

NIV vs. Invasive Mechanical Ventilation

NIV is defined as ventilatory support provided via

a tight fitting mask or similar interface as opposed
to invasive support, which is provided via a
laryngeal mask, endotracheal tube or
tracheostomy tube.
Tight fitting masks deliver can CPAP, BIPAP or NIV
via the mechanical ventilator.

Indications for Mechanical Ventilation

The work of breathing usually accounts for 5%
of oxygen consumption (V02).
In the critically ill patient this may rise to 30%.
Invasive mechanical ventilation eliminates the
metabolic cost of breathing.

Indications for Mechanical Ventilation

Inadequate oxygenation (not corrected by supplemental
O2 by mask).
Inadequate ventilation (increased PaCO2).
Retention of pulmonary secretions (bronchial toilet).
Airway protection (obtunded patient, depressed gag
reflex).

Intubation

Bare Essentials for Intubation

ALSOBLEED
1 Airway: oral Guedel airway to lift tongue off posterior
pharynx to facilitate mask ventilation during pre-intubation
phase.
2 Liquids: stop feed and aspirate ng tube.
3 Suction: extremely important to avoid pulmonary
aspiration.
4 Oxygen: preoxygenate patient and ensure a source of O2
with a delivery mechanism (ambu-bag and mask) is available.

Bare Essentials for Intubation

ALSOBLEED
5 Bougie: to facilitate tube insertion in more difficult airway.
6 Laryngoscope: have a long and short blade available.
7 Endotracheal tube: for average adult, cuffed oral
endotracheal tube 7.0 for women and 8.0 for men.
8 End tidal CO2: to confirm correct position of tube.
9 Drugs: an induction agent, muscle relaxant, sedative are
usually required.

Principles of Mechanical Ventilation

PEEP

ET tube
Ventilator Tubing
Major Airways

Alveoli

Principles of Mechanical Ventilation

Positive pressure ventilation involves delivering a
mechanically generated breath to get O2 in and CO2
out.
Gas is pumped in during inspiration (Ti) and the patient
passively expires during expiration (Te).
The sum of Ti and Te is the respiratory cycle or breath.

Flow

Pressure

Principles of Mechanical Ventilation

Ti

Te

Ti

Te

Principles of Mechanical Ventilation

In the fully ventilated patient, positive pressure breaths
are delivered either as preset volume or pressure
continuous mandatory breaths (CMV) breaths.
The mechanical ventilator triggers the breath and
switches from inspiration to expiration when the preset
volume, pressure (or time) is achieved/delivered.
During CMV the patient takes no spontaneous breaths.
CMV is usually used in theatre and in very unwell ICU
patients.

Principles of Mechanical Ventilation

Volume control

Pressure control

Tidal volume is preset

Inspiratory Pressure is preset

Usually 500 mls

Usually 15-20 cm H20

Airway Pressure is Variable Tidal Volume is Variable

Principles of Mechanical Ventilation

Mandatory breaths are delivered during inspiration, to
generate a tidal volume (Vt), at a set rate (f), the quotient
of which is the minute volume (MV).
Minute Volume = Tidal Volume x frequency
In volume control ventilation, an inspiratory flow rate is
also set.
The ratio of the time spent in inspiration:expiration (I:E
ratio) is usually 1:2.

Principles of Mechanical Ventilation

Pressure Control Breath

Flow

Pressure

Volume Control Breath

Ti

Te

Ti

Te

Principles of Mechanical Ventilation

Mechanically ventilated patients usually receive
positive end-expiratory pressure (PEEP), to overcome
the loss of physiological PEEP provided by the larynx
and vocal cords.
PEEP is delivered throughout the respiratory cycle and
is synonymous to CPAP, but in the intubated patient.
Standard PEEP setting is 5 cm H20.
Sedation is often required to prevent ventilator-patient
asynchrony.

Basic Settings on the Ventilator

Tidal Volume
Pressure controlled breath (15-20 cm H20)
Volume controlled breath (500 mls)
Rate (frequency) (10-12 breaths/minute)
Positive end expiratory pressure (PEEP) (5 cm H20)
FiO2 (0.21-1)
Peak airway pressure (PAP)

Principles of Mechanical Ventilation

Why is the peak airway pressure (PAP) important?
Ventilator Induced Lung Injury (VILI).
Mechanical ventilation is injurious to the lung.
Aim PAP< 35 cm H20.

Principles of Mechanical Ventilation

Volume Breath

Pressure Breath

Flow

Pressure

35 cm H20

Ti

Te

Ti

Te

Pneumothorax

Principles of Mechanical Ventilation

Dont forget that the peak airway pressure

will also include the PEEP that is added

Principles of Mechanical Ventilation

Once stabilised on CMV, the level of ventilatory support
may be reduced (weaning).
This can be done by providing a mixture of synchronised
intermittent mandatory breaths (SIMV) and spontaneously
triggered pressure supported breaths (PSV).

Principles of Mechanical Ventilation

Ventilator assisted breaths are synchronized with the
patients breathing to prevent the possibility of a
mechanical breath on top of a spontaneous breath.
However, the patients attempt at a breath would not be
enough to generate an adequate tidal volume on its own,
hence the term pressure support.

Principles of Mechanical Ventilation

Pressure support is only delivered during inspiration
and the patients attempt at breathing triggers the breath
rather than the ventilator.
A standard level of pressure support delivered in
inspiration is 20 cm H20

SIMV and Pressure Support Ventilation

Ventilator

Patient

Principles of Mechanical Ventilation

As patients improve, mandatory breaths are
withdrawn and receive pressure-supported breaths
alone.
Finally, as tidal volumes improve, the level of
pressure support is reduced and then withdrawn so
patients breathe spontaneously with PEEP alone.
Extubation can now be contemplated.
Spontaneous modes of breathing should always be
encouraged as respiratory muscle function is
maintained

Pressure Support Ventilation

Patient

Patient

Successful Weaning and Extubation

To succeed, the initiating cause of respiratory failure,
sepsis, fluid and electrolyte imbalance and nutritional
status should all be treated or optimised.
Failure to wean is associated with:
Ongoing high V02.
Muscle fatigue.
Inadequate drive.
Inadequate cardiac reserve.

Successful Weaning and Extubation

Weaning screens exist to help select patients for
extubation.
In the unsupported patient, if f/Vt is >100, extubation
is likely to be unsuccessful.
There is some evidence to support extubation to NIV,
particularly in patients with COPD.

Basic Ventilatory Modes: Summary

Continuous Mandatory Ventilation (CMV)
Pressure control
Volume control
No spontaneous breathing
Ventilator triggers breath
Synchronised intermittent mandatory ventilation
(SIMV)/Pressure Support Ventilation (PSV)
Pressure control (SIMV)
Volume control (SIMV)
Some spontaneous breathing is allowed (PSV)
Mixture of ventilator and patient triggered breaths

Basic Ventilatory Modes: Summary

Pressure Support Ventilation (PSV)

Spontaneous breathing with inspiratory support
All patient triggered breaths

PEEP/CPAP (5 cm H20)
Entirely spontaneous breathing
Consider extubation

Basic Ventilatory Modes: Summary

CMV

PSV
PEEP
SIMV
PSV

Mandatory

Overlap

Spontaneous

Standard Ventilator Settings

MORITE
Mode
O2
Respiratory Rate
Inspiratory Action
Inspiratory Time
Expiratory Action

Standard Ventilator Settings

MORITE
Mode
O2

CMV, Volume Control

0.5 (50% 02)

Respiratory Rate
Inspiratory Action
Inspiratory Time
Expiratory Action
Be Aware

12/minute
Set Vt at 500 mls
Set I:E ratio 1:2
Set PEEP at 5 cm H20
PAP 35 cm H2O

Spontaneously Ventilating Patient Failing Conventional Therapy

Consider

CPAP on Ward

Optimise

NIV
BIPAP
on ICU

Patient Position

Humidification

BIPAP on Ward

Patient Requiring Basic Invasive Mechanical Ventilation

CMV (VCV or PCV)

Escalation

IMV (VCV or PCV)

PSV

PEEP/CPAP

De-escalation