Mechanical Ventilation facts

8/13/2019 Mechanical Ventilation facts

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Mechanical ventilationFrom Wikipedia, the free encyclopediaJump to: navigation , search

For the use in architecture and climate control, see Ventilation (architecture) .

Mechanical ventilation Intervention

Diagram of an endotracheal tube used in mechanicalventilation. The tube is inserted into the trachea in

order to provide air to the lungs.

A) Endotracheal tube which sits in the trachea. B)Inflatable Cuff which facilitates the inflation of the

balloon at the end of the tube to allow it to sitsecurely in the airway. The balloon can also be

deflated via this cuff upon extubation. C) Trachea

D) EsophagusICD-9: 93.90 96.7

MeSH D012121

OPS-301 code: 8-71

In medicine , mechanical ventilation is a method to mechanically assist or replacespontaneous breathing . This may involve a machine called a ventilator or the

breathing may be assisted by a registered nurse , physician , respiratorytherapist , paramedic or other suitable person compressing a bag or set of bellows.

There are two main divisions of mechanical ventilation: invasive ventilation and non-invasive ventilation .[1] There are two main modes of mechanical ventilation within thetwo divisions: positive pressure ventilation, where air (or another gas mix) is pushedinto the trachea , and negative pressure ventilation, where air is essentially sucked intothe lungs.

Contents

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1 Medical uses 2 Associated risk

o 2.1 Complications 3 Application and duration

o 3.1 Negative pressure machines o 3.2 Positive pressure

3.2.1 Transairway pressure 4 Types of ventilators

o 4.1 Mechanical ventilators 5 Breath delivery

o 5.1 Trigger o 5.2 Cycle o 5.3 Limit

6 Breath exhalation 7 Dead space 8 Modes of ventilation 9 Modification of settings

o 9.1 Weaning from mechanical ventilation 10 Respiratory monitoring 11 Artificial airways as a connection to the ventilator 12 Ventilation formulas

o 12.1 Alveolar Ventilation o 12.2 Arterial PaCO2 o 12.3 Alveolar volume o

12.4 Estimated physiologic shunt equation 13 History 14 References 15 External links

Medical uses[ edit ]

Respiratory therapist examining a mechanically ventilated patient on an IntensiveCare Unit.

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Mechanical ventilation is indicated when the patient's spontaneous ventilation isinadequate to maintain life. It is also indicated as prophylaxis for imminent collapse ofother physiologic functions, or ineffective gas exchange in the lungs. Becausemechanical ventilation only serves to provide assistance for breathing and does notcure a disease, the patient's underlying condition should be correctable and shouldresolve over time. In addition, other factors must be taken into consideration becausemechanical ventilation is not without its complications ( see below )

Common medical indications for use include:

Acute lung injury (including ARDS , trauma) Apnea with respiratory arrest, including cases from intoxication Chronic obstructive pulmonary disease (COPD ) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO

2) > 50 mmHg and pH < 7.25, which may be due to paralysis ofthe diaphragm due to Guillain-Barré syndrome , myasthenia gravis , spinalcord injury, or the effect of anaesthetic and muscle relaxant drugs

Increased work of breathing as evidenced by significant tachypnea , retractions,and other physical signs of respiratory distress

Hypoxemia with arterial partial pressure of oxygen ( Pa O 2) < 55 mm Hg with supplemental fraction of inspired oxygen ( Fi O 2) = 1.0

Hypotension including sepsis , shock , congestive heart failure Neurological diseases such as muscular dystrophy and amyotrophic lateral

sclerosis

Associated risk[ edit ]

Barotrauma — Pulmonary barotrauma is a well-known complication of positive pressure mechanical ventilation .[2] This includes pneumothorax , subcutaneousemphysema , pneumomediastinum , and pneumoperitoneum .[2]

Ventilator-associated lung injury — Ventilator-associated lung injury (VALI) refersto acute lung injury that occurs during mechanical ventilation. It is clinically

indistinguishable from acute lung injury or acute respiratory distresssyndrome (ALI/ARDS) .[3]

Diaphragm — Controlled mechanical ventilation may lead to a rapid type ofdisuse atrophy involving the diaphragmatic muscle fibers, which can develop withinthe first day of mechanical ventilation .[4] This cause of atrophy in the diaphragm is

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also a cause of atrophy in all respiratory related muscles during controlled mechanicalventilation .[5]

Motility of mucocilia in the airways — Positive pressure ventilation appears toimpair mucociliary motility in the airways. Bronchial mucus transport was frequentlyimpaired and associated with retention of secretions and pneumonia .[6]

Complications [edit ]

Mechanical ventilation is often a life-saving intervention, but carries many potentialcomplications including pneumothorax , airway injury, alveolar damage, andventilator-associated pneumonia .[7] Other complications include diaphragm atrophy,decreased cardiac output, and oxygen toxicity. One of the primary complications that

presents in patients who are mechanically ventilated is acute lung injury (ALI)/acuterespiratory distress syndrome (ARDS). ALI/ARDS are recognized as significantcontributors to patient morbidity and mortality .[8]

In many healthcare systems prolonged ventilation as part of intensive care is a limitedresource (in that there are only so many patients that can receive care at any givenmoment). It is used to support a single failing organ system (the lungs) and cannotreverse any underlying disease process (such as terminal cancer). For this reason therecan be (occasionally difficult) decisions to be made about whether it is suitable tocommence someone on mechanical ventilation. Equally many ethical issues surroundthe decision to discontinue mechanical ventilation .[9]

Application and duration [edit ]

It can be used as a short term measure, for example during an operation or criticalillness (often in the setting of an intensive care unit ). It may be used at home or in anursing or rehabilitation institution if patients have chronic illnesses that require long-term ventilatory assistance. Due to the anatomy of the human pharynx , larynx , and esophagus and the circumstances for which ventilation is needed, additionalmeasures are often required to secure the airway during positive pressure ventilationin order to allow unimpeded passage of air into the trachea and avoid air passing intothe esophagus and stomach. Commonly this is by insertion of a tube into thetrachea which provides a clear route for the air. This can be either an endotrachealtube , inserted through the natural openings of mouth or nose ora tracheostomy inserted through an artificial opening in the neck. In othercircumstances simple airway maneuvres , an oropharyngeal airway or laryngeal maskairway may be employed. If the patient is able to protect their own airway and non-

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invasive ventilation or negative-pressure ventilation is used then an airwayadjunct may not be needed.

Negative pressure machines [edit ]

An iron lungMain article: Negative pressure ventilator

The iron lung , also known as the Drinker and Shaw tank, was developed in 1929 andwas one of the first negative-pressure machines used for long-term ventilation. It wasrefined and used in the 20th century largely as a result of the polio epidemic thatstruck the world in the 1940s. The machine is effectively a large elongated tank , whichencases the patient up to the neck. The neck is sealed with a rubber gasket so that the

patient's face (and airway) are exposed to the room air.

While the exchange of oxygen and carbon dioxide between the bloodstream and the

pulmonary airspace works by diffusion and requires no external work, air must bemoved into and out of the lungs to make it available to the gas exchange process. Inspontaneous breathing, a negative pressure is created in the pleural cavity by themuscles of respiration, and the resulting gradient between the atmospheric

pressure and the pressure inside the thorax generates a flow of air.

In the iron lung by means of a pump, the air is withdrawn mechanically to produce avacuum inside the tank, thus creating negative pressure. This negative pressure leadsto expansion of the chest, which causes a decrease in intrapulmonary pressure, andincreases flow of ambient air into the lungs. As the vacuum is released, the pressureinside the tank equalizes to that of the ambient pressure, and the elastic coil of thechest and lungs leads to passive exhalation. However, when the vacuum is created, theabdomen also expands along with the lung, cutting off venous flow back to the heart,leading to pooling of venous blood in the lower extremities. There are large portholesfor nurse or home assistant access. The patients can talk and eat normally, and can seethe world through a well-placed series of mirrors. Some could remain in these ironlungs for years at a time quite successfully.

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Today, negative pressure mechanical ventilators are still in use, notably with the poliowing hospitals in England such as St Thomas' Hospital in London and the JohnRadcliffe in Oxford . The prominent device used is a smaller device known asthe cuirass . The cuirass is a shell-like unit, creating negative pressure only to the chestusing a combination of a fitting shell and a soft bladder. Its main use is in patientswith neuromuscular disorders who have some residual muscular function. However, itwas prone to falling off and caused severe chafing and skin damage and was not usedas a long term device. In recent years this device has re-surfaced as amodern polycarbonate shell with multiple seals and a high pressure oscillation pump inorder to carry out biphasic cuirass ventilation .

Positive pressure [edit ]

Neonatal mechanical ventilator

The design of the modern positive-pressure ventilators were mainly based ontechnical developments by the military during World War II to supply oxygen tofighter pilots in high altitude. Such ventilators replaced the iron lungs as safeendotracheal tubes with high volume/low pressure cuffs were developed. The

popularity of positive-pressure ventilators rose during the polio epidemic in the 1950sin Scandinavia and the United States and was the beginning of modern ventilationtherapy . Positive pressure through manual supply of 50% oxygen through

a tracheostomy tube led to a reduced mortality rate among patients with polio andrespiratory paralysis. However, because of the sheer amount of man-power requiredfor such manual intervention, mechanical positive-pressure ventilators becameincreasingly popular.

Positive-pressure ventilators work by increasing the patient's airway pressure throughan endotracheal or tracheostomy tube. The positive pressure allows air to flow into the

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airway until the ventilator breath is terminated. Subsequently, the airway pressuredrops to zero, and the elastic recoil of the chest wall and lungs push the tidalvolume — the breath — out through passive exhalation.

Transairway pressure [edit ]

PTA =Transairway pressure PAO = Pressure at airway opening PALV = Pressure in alveoli

Types of ventilators [edit ]

SMART BAG MO Bag-Valve-Mask Resuscitator

Ventilators come in many different styles and method of giving a breath to sustainlife. There are manual ventilators such as bag valve masks and anesthesia bags requirethe user to hold the ventilator to the face or to an artificial airway and maintain breathswith their hands. Mechanical ventilators are ventilators not requiring operator effortand are typically computer controlled or pneumatic controlled.

Mechanical ventilators [edit ]

Mechanical ventilators typically require power by a battery or a wall outlet (DC orAC) though some ventilators work on a pneumatic system not requiring power.

Transport ventilators — These ventilators are small, more rugged, and can be powered pneumatically or via AC or DC power sources.

Intensive-care ventilators — These ventilators are larger and usually run onAC power (though virtually all contain a battery to facilitate intra-facilitytransport and as a back-up in the event of a power failure). This style ofventilator often provides greater control of a wide variety of ventilation

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parameters (such as inspiratory rise time). Many ICU ventilators alsoincorporate graphics to provide visual feedback of each breath.

Neonatal ventilators — Designed with the preterm neonate in mind, these area specialized subset of ICU ventilators which are designed to deliver thesmaller, more precise volumes and pressures required to ventilate these

patients. Positive airway pressure ventilators (PAP ) — These ventilators are

specifically designed for non-invasive ventilation . This includes ventilators foruse at home for treatment of chronic conditions such as sleep apnea or COPD .

Breath delivery[ edit ]

Trigger [edit ]

The trigger is what causes a breath to be delivered by a mechanical ventilator. Breathsmay be triggered by a patient taking their own breath, a ventilator operator pressing amanual breath button, or by the ventilator based on the set breath rate and mode ofventilation.

Cycle [edit ]

The cycle is what causes the breath to transition from the inspiratory phase to theexhalation phase. Breaths may be cycled by a mechanical ventilator when a set timehas been reached, or when a preset flow or percentage of the maximum flow deliveredduring a breath is reached depending on the breath type and the settings. Breaths canalso be cycled when an alarm condition such as a high pressure limit has beenreached, which is a primary strategy in pressure regulated volume control .

Limit [edit ]

Limit is how the breath is controlled. Breaths may be limited to a set maximum circuit pressure or a set maximum flow.

Breath exhalation[ edit ]

Exhalation in mechanical ventilation is almost always completely passive. Theventilator's expiratory valve is opened, and expiratory flow is allowed until the

baseline pressure (PEEP ) is reached. Expiratory flow is determined by patient factorssuch as compliance and resistance.

Dead space[ edit ]

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Mechanical dead space is defined as the volume of gas re-breathed as the result of usein a mechanical device.

Example of calculation for mechanical dead space

Simplified version

Modes of ventilation[ edit ]

Main article: Modes of mechanical ventilation

Mechanical ventilation utilizes several separate systems for ventilation referred to asthe mode. Modes come in many different delivery concepts but all modes fall into oneof three categories; volume cycled, pressure cycled, spontaneously cycled. Theselection of which mode of mechanical ventilation to use for a given patient isgenerally based on the familiarity of clinicians with modes and the equipmentavailability at a particular institution .[10]

Modification of settings[ edit ]In adults when 100% Fi O 2 is used initially, it is easy to calculate the next Fi O 2 to be used and easy to estimate the shunt fraction. The estimated shunt fractionrefers to the amount of oxygen not being absorbed into the circulation. In normal

physiology, gas exchange (oxygen/carbon dioxide) occurs at the level of the alveoli inthe lungs. The existence of a shunt refers to any process that hinders this gasexchange, leading to wasted oxygen inspired and the flow of un-oxygenated blood

back to the left heart (which ultimately supplies the rest of the body withunoxygenated blood).

When using 100% Fi O 2, the degree of shunting is estimated by subtracting the measured Pa O 2 (from an arterial blood gas ) from 700 mmHg. For each difference of 100 mmHg, theshunt is 5%. A shunt of more than 25% should prompt a search for the cause of thishypoxemia, such as mainstem intubation or pneumothorax , and should be treated

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accordingly. If such complications are not present, other causes must be sought after,and PEEP should be used to treat this intrapulmonary shunt. Other such causes of ashunt include:

Alveolar collapse from major atelectasis Alveolar collection of material other than gas, such as pus from pneumonia ,

water and protein from acute respiratory distress syndrome , waterfrom congestive heart failure , or blood from haemorrhage

Weaning from mechanical ventilation [edit ]

Withdrawal from mechanical ventilation — also known as weaning — should not bedelayed unnecessarily, nor should it be done prematurely. Patients should have theirventilation considered for withdrawal if they are able to support their own ventilationand oxygenation, and this should be assessed continuously. There are severalobjective parameters to look for when considering withdrawal, but there is no specificcriteria that generalizes to all patients.

Trials of spontaneous breathing have been shown to accurately predict the success ofspontaneous breathing .[11]

Respiratory monitoring[ edit ]

Main article: respiratory monitoring

Respiratory mechanics monitor

One of the main reasons why a patient is admitted to an ICU is for delivery ofmechanical ventilation. Monitoring a patient in mechanical ventilation has manyclinical applications: Enhance understanding of pathophysiology, aid with diagnosis,guide patient management, avoid complications and assessment of trends .[12]

Most of modern ventilators have basic monitoring tools. There are also monitors thatwork independently of the ventilator, which allow to measure patients after theventilator has been removed, such as a T tube test.

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Artificial airways as a connection to the ventilator[ edit ]

Main article: Artificial airway

There are various procedures and mechanical devices that provide protection againstairway collapse, air leakage, and aspiration:

Face mask — In resuscitation and for minor procedures under anaesthesia, aface mask is often sufficient to achieve a seal against air leakage. Airway

patency of the unconscious patient is maintained either by manipulation of the jaw or by the use of nasopharyngeal or oropharyngeal airway . These aredesigned to provide a passage of air to the pharynx through the nose or mouth,respectively. Poorly fitted masks often cause nasal bridge ulcers, a problem forsome patients. Face masks are also used for non-invasive ventilation inconscious patients. A full face mask does not, however, provide protectionagainst aspiration.

Tracheal intubation is often performed for mechanical ventilation of hours toweeks duration. A tube is inserted through the nose (nasotracheal intubation) ormouth (orotracheal intubation) and advanced into the trachea . In most casestubes with inflatable cuffs are used for protection against leakage andaspiration. Intubation with a cuffed tube is thought to provide the best

protection against aspiration. Tracheal tubes inevitably cause pain andcoughing. Therefore, unless a patient is unconscious or anaesthetized for otherreasons, sedative drugs are usually given to provide tolerance of the tube. Other

disadvantages of tracheal intubation include damage to the mucosal lining ofthe nasopharynx or oropharynx and subglottic stenosis . Supraglottic airway — a supraglottic airway (SGA) is any airway device which

is seated above and outside the trachea, as an alternative to endotrachealintubation. Most devices work via masks or cuffs which inflate to isolate thetrachea for oxygen delivery. Newer devices feature esophageal ports forsuctioning or ports for tube exchange to allow intubation. Supraglottic airwaysdiffer primarily from tracheal intubation in that they do not prevent aspiration.After the introduction of the laryngeal mask airway (LMA) in 1998,supraglottic airway devices have become mainstream in both elective and

emergency anesthesia .[13]

There are many types of SGAs available includingthe Esophageal-tracheal Combitube (ETC), Laryngeal tube (LT), and theobsolet eEsophageal obturator airway (EOA).

Cricothyrotomy — Patients who require emergency airway management, inwhom tracheal intubation has been unsuccessful, may require an airwayinserted through a surgical opening in the cricothyroid membrane . This is

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similar to a tracheostomy but a cricothyrotomy is reserved for emergencyaccess .[14]

Tracheostomy — When patients require mechanical ventilation for severalweeks, a tracheostomy may provide the most suitable access to the trachea. Atracheostomy is a surgically created passage into the trachea . Tracheostomytubes are well tolerated and often do not necessitate any use of sedative drugs.Tracheostomy tubes may be inserted early during treatment in patients with

pre-existing severe respiratory disease, or in any patient who is expected to bedifficult to wean from mechanical ventilation, i.e., patients who have littlemuscular reserve.

Mouthpiece — Less common interface, does not provide protection againstaspiration. There are lipseal mouthpieces with flanges to help hold them in

place if patient is unable.

Ventilation formulas[ edit ]Alveolar Ventilation [edit ]

Arterial PaCO2 [edit ]

Alveolar volume [edit ]

Estimated physiologic shunt equation [edit ]

History [edit ]

The Roman physician Galen may have been the first to describe mechanicalventilation: "If you take a dead animal and blow air through its larynx [through areed], you will fill its bronchi and watch its lungs attain the greatestdistention. "[15] Vesalius too describes ventilation by inserting a reed or cane into

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the trachea of animals .[16] In 1908 George Poe demonstrated his mechanical respirator by asphyxiating dogs and seemingly bringing them back to life .[17]

References[ edit ]

1. ^ Cabrini L, Landoni G, Zangrillo A (2011). "Noninvasive ventilation failure:the answer is blowing in the leaks.". Respir Care 56 (11): 1857 – 8.doi :10.4187/respcare.01565 . PMID 22035827 .

2. ^ a b Parker JC, Hernandez LA, Peevy KJ (1993). "Mechanisms of ventilator-induced lung injury". Crit Care Med 21 (1): 131 – 43. doi :10.1097/00003246-199301000-00024 . PMID 8420720 .

3. ^ "International consensus conferences in intensive care medicine: Ventilator-associated Lung Injury in ARDS. This official conference report wascosponsored by the American Thoracic Society, The European Society of

Intensive Care Medicine, and The Societé de Réanimation de LangueFrançaise, and was approved by the ATS Board of Directors, July 1999" . Am. J. Respir. Crit. Care Med. 160 (6): 2118 – 24. December1999 .doi :10.1164/ajrccm.160.6.ats16060 . PMID 10588637 .

4. ^ Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, etal. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanicallyventilated humans". N Engl J Med 358 (13): 1327 – 35. doi :10.1056/NEJMoa070447 . PMID 18367735 .

5. ^ De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I,Boussarsar M, et al. (2002). "Paresis acquired in the intensive care unit: a

prospective multicenter study". JAMA 288 (22): 2859 – 67. doi :10.1001/jama.288.22.2859 . PMID 12472328 . 6. ^ Konrad F, Schreiber T, Brecht-Kraus D, Georgieff M (1994). "Mucociliary

transport in ICU patients". Chest 105 (1): 237 – 41.doi :10.1378/chest.105.1.237 . PMID 8275739 .

7. ^ Hess DR (2011). "Approaches to conventional mechanical ventilation of the patient with acute respiratory distress syndrome". Respir Care 56 (10): 1555 – 72. doi :10.4187/respcare.01387 . PMID 22008397 .

8. ^ Hoesch, Robert; Eric Lin, Mark Young, Rebecca Gottesman, Laith Altaweel,Paul Nyquist, Robert Stevens (February 2012). "Acute lung injury in critical

neurological illness". Critical care medicine 40 (2): 587 – 593. doi :10.1097/CCM.0b013e3182329617 . PMID 21946655 .

9. ^ O'Connor HH (2011). "Prolonged mechanical ventilation: are you a lumperor a splitter?". Respir Care 56 (11): 1859 – 60. doi :10.4187/respcare.01600 .PMID 22035828 .

10 . ̂ Esteban A, Anzueto A, Alía I, Gordo F, Apezteguía C, Pálizas F et al.(2000). "How is mechanical ventilation employed in the intensive care unit? An

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12 . ̂ Tobin MJ (2006). Principles and Practice of Mechanical Ventilation (2nded.). McGraw Hill.

13 . ̂ Cook T, Howes B (December 2011). "Supraglottic airway devices: recentadvances" . Contin Educ Anaesth Crit Care 11 (2): 56 – 61.doi :10.1093/bjaceaccp/mkq058 .

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17 . ̂ "Smother Small Dog To See it Revived. Successful Demonstration of anArtificial Respiration Machine Cheered in Brooklyn. Women in the Audience,

But Most of Those Present Were Physicians. The Dog, Gathered in from theStreet, Wagged Its Tail." . New York Times . May 29, 1908, Friday. Retrieved2007-12-25. "An audience, composed of about thirty men and three or fourwomen, most of the men being physicians, attended a demonstration of Prof.George Poe's machine for producing artificial respiration in the library of theKings County Medical Society, at 1,313 Bedford Avenue, Brooklyn, last night,under the auspices of the First Legion of the Red Cross Society."
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