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MECHANICAL VENTILATION INDICATION 1.Hypoxemia:FiO2>0.6,PaO2350

2.Hypercapnia:PaCO2>55(&pH

MECHANICAL VENTILATION INDICATION 6.Unstable ventilatory drive:apnea

7.Prophylactic mechanical ventilation:

post-op, mutiple trauma operation

major ,multiple organs failure

8.Closed head injury:IICP

9.Flailed chest:multiple rib fr.

10.Obstructive airway disease

(Homecare)(intensive)

(Homecare) (intensive)

CPAPSS/TTPC

-- iron lung,cuirass,body suit.

:

(body suit)

neuromuscular or chest wall disorder, COPD (

-CPAPBiPAP

1.(non-invasive ventilator)

:-.,

-

-

-

2.

( High Frequency Positive Pressure

Ventilation, HFPPV ) ( High Frequency Percussive Ventilation,

HFPV ) ( High Frequency Jet Ventilation, HFJV ) ( High Frequency Flow Interruption, HFFI ) ( High Frequency Oscillatory Ventilation,

HFOV )

Trigger:

Limit:limit

Cycle:

Trigger

Time trigger:

rate

Flow trigger:

continuous flow(e.g.6L/min)

flow sensitivity (e.g.3L/min)

airway flowbaseline

Trigger

pressure trigger

pressure sensitivity

(e.g.-1~2cmH2O)PAWbaseline

Sensitivityauto-

trigger

Cycle Time cycle

, Flow cycle

flowinitial flow%

(e.g.PSV=25%) Volume cycle

volume (e.g. Assist volume ventilation)

E.g. VCV, IMV Pressure cycle

pressure

(e.g.IPPB)

Mode of MV

Volume Ventilation --Control mechanical ventilation(CMV)/Volume-controlVC

--Intermittent Mechanical VentilationIMVSynchronized Intermittent Mechanical Ventilation SIMV

Pressure Ventilation --pressure support

--pressure control

--Noninvasive positive pressure ventilationNIPPV

Biphasic positive airway pressureBiPAP

Continuous positive airway pressure CPAP

Mode of MV

Dual Control Modes

--VAPS,VS,PRVC,APV,Auto-Flow

Alternative methods of ventilator support

--IRV,APRV,Bi-phasic,ATC,ASV

Mode of MV

Control mechanical ventilation(CMV)

-- time trigger, volume or pressure, no effort at Pt.

Mode of MV

Assist-control Ventilation( A/C)

-- Time or Pt trigger

Assisted vs. Controlled

Time (sec)

Assisted Controlled Pressure (cmH20)

Volume Ventilation

Set the volume delivered during the mandatory breath

VV guarantees volume (C,R V)

Lung worsens,peak and alveolar P. overdistention

change flow pattern

High volume give high peak and plateau P.

Flow controlled, Time or Pt trigger, volume limit, Volume cycle

Volume Ventilation

egIICPIatrogenic hyperventilationIICP

alveolar overdistensionpneumothoraxARDS

Controlled Mode

(Volume-Targeted Ventilation)

Preset VT

Volume Cycling

Dependent on

CL & Raw

Time (sec)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Preset Peak Flow

Time triggered, Flow limited, Volume cycled Ventilation

IMV

Time trigger

continuous (neonatal) or demand flow

--tidal volumetidal volume

SIMV

-- Pt or time trigger

--a.

b.

Pressure Ventilation (PV)

Preset a pressure, P. limit ventilation(PCV, PSV)

Vt :

P, Ti, TC (R, C), continuous flow rate (initial flow P.

waveform shape)

Pressure Ventilation (PV)

Tidal volume

Tidal volume and Minute ventilation

Controlled Mode

(Pressure-Targeted Ventilation)

Press

ure

Flow

Volume

(L/min)

(cm H2O)

(ml)

Time (sec)

Time-Cycled

Set PC level

Time Triggered, Pressure Limited, Time Cycled Ventilation

Pressure supported Ventilation

sensitivity

Patient-triggered, pressure-limited, flow-cycled.

Tidal volume

SIMV mode

PSV

Time (sec)

Flow (L/m)

Pressure (cm H2O)

Volume (mL)

Flow Cycling

Set PS level

Patient Triggered, Flow Cycled, Pressure limited Mode

The end of inspiration(PSV)

Decrease of peak flow to specific threshold

Above the fixed PSV level (1 to 3 cmH2O), sudden exp. effort from patient

A time end of the insp.

(PSV 1. 2. 3.

Flow

FlowPeak airway pressureGas distribution

FlowPeak airway pressureGas distributionauto-PEEP

CPAP

sleep apnea

CPAPPEEP

PEEP

CPAP

CPAP

Time (sec)

CPAP level

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

BiPAP

PSV mode

Flow-triggered,pressure-limited,flow or time- cycled.

Pressure Curve Examples

CPAP

BiPAP

Dual mode

PRVCVSVAPSAPV----

Volume ventilationpressure ventilation

Inverse Ratio Ventilation (IRV)

Techniques to increase I / E ratio

(1) VCIRV

-- slowing the flow rate flow cycle

-- use a inspiratory pause time cycle

(2) PCIRV

-- increase Ti time cycle

Improving PaO2 with IRV

Higher mean Paw

By the short Te end exp. P.(intrinsic P.)

Improved distribution due to low mean insp.

flow

Physiologic effect

-- intrapulmonary shunt, improved V/Q

matching, dead space ventilation

Airway Pressure Release Ventilation

(APRV)

(1)(hight CPAP)

(2)(lower CPAP)

(3)(pressure release time)

(4)(frequency of release)

Airway Pressure Release Ventilation

(APRV)

APRV

PhighMAP and (within lung protection peak alveolar pressure)PhighPSWOB & Vt

PlowPCO2 (typically not a problem)

Plow level (Downs)

hold release timelung collapse

Airway Pressure Release Ventilation

(APRV)

APRV CPAP

lower level

(effort)APRV PCIRV

PCIRV APRV

APRV PIP CPAP level

CPAP level

( BIPAPBiphasic intermittent positive pressure)

APRV

BIPAPI/E rationAPRV

PhighPlow

PCV

BIPAP* allows Spontaneous Breathing

during the Mandatory Stroke Reduction of the

invasivness of Ventilation

Reduction of Sedation

One Ventilation Mode from Intubation to Weaning

More comfortable for the Patient

Fewer Alarms (easier handling)

PC

V

Spontaneous

Breathing

BIPA

P

BIPAP /(:

nebulizertracheal gas insufflation)

BIPAP ( PCV+ ) Drager Evita 4 NPB 840

BiLevel

BIPAP BiPAPBIPAPBiPAP

( BIPAPBiphasic intermittent positive pressure)

APRV versus BIPAP different

philosophies

BIPAP

Pinsp

CPAP

Ventilation

Phigh

Plow

APRV

Airway Pressure Release Ventilation (APRV)

:PaO2?

PaCO2?

:weaning??

Automatic Tube Compensation (ATC)

ATC

1. ET-tube

2. Pt

3. air trapping (

)

Automatic Tube Compensation (ATC)

Setting the size of tube

amount of compensation

( 100% or partially )

Mandatory Minute Ventilation (MMV)

mode weaning

(MV)

MV MV

MV MV

MV

MV

MMV pt close-

loop ventilation

Adaptive Support ventilatioASV

ASV Hamilton Galileo

PCV PSV

ASV

(Y-piece)

( ventilation

target Vt RR)

Adaptive Support ventilatioASV

ASV:

1.

2.

3.

4.

ASV3:

1.(%MV)

2.high pressure alarm

3 Pt

Adaptive Support ventilatioASV

SPO2:(set:%MV120%)

:1.,?

2.PaCO2,?

3.PaO2/SpO2,,?

!