Modos de assistncia ventilatria:

Conceitos e ajuste dos parmetros

Dr. Antonio Roberto Carraretto, TSA-SBA

Professor Anestesiologia UFES
Membro Comisso de Educao Continuada SBA
Responsvel CET Integrado HUCAM
 Dia 14/09/2009

TERICO: Horrio: 09:30 s 09:50h

MODOS DE ASSISTNCIA
VENTILATRIA CONCEITOS E AJUSTE
DOS PARMETROS
ESTAO PRTICA: Horrio: 14h s 18h
MODOS DE VENTILAO, AJUSTES DE
PARMETROS E ANLISE DAS CURVAS

2
 Abreviaturas

VCV Ventilao Controlada a Volume

PCV Ventilao Controlada a Presso
PCV/AV Ventilao Controlada a Presso com Volume Assegurado
SIMV/V Ventilao Mandatria Intermitente Sincronizada
com Controle do Volume
SIMV/P Ventilao Mandatria Intermitente Sincronizada
com Controle da Presso
MMV Ventilao com Volume Minuto Mnimo
BIPV Ventilao Espontnea com Dois Nveis de Presso
CPAP Ventilao com Presso Positiva Contnua nas Vias Areas
PSV Ventilao com Suporte de Presso
PSV/AV Ventilao com Suporte de Presso e Volume Assegurado
VSV Ventilao Volumtrica com Suporte de Presso
VAPS Ventilao Volumtrica Assistida com Presso de Suporte

3
 Volume Controlado
Volume Controlled Ventilation

Presso Controlada
Pressure Controlled Ventilation

Ventilao com Presso de Suporte

Pressure Support Ventilation

Ventilao Mandatria Intermitente Sincronizada

Synchronized Intermittent Mandatory Ventilation

Ventilao com Presso Limitada

Pressure Limited Ventilation
4
 Variveis da Ventilao Mecnica

Quantidade de gs na unidade do
Fluxo tempo: L.min-1 ou L.s-1
Principal varivel para as trocas
Volume gasosas: O2 - CO2 mL
Resultado da distenso / retrao
Presso dos componentes: cmH2O
Durao do ciclo ventilatrio: (s)
Tempo
Relao entre o Tins e Texp: I:E

5
 Vlvulas de Controle: Fluxo e Presso

VENTILADOR
Vlvula
de
fluxo CIRCUITO RESPIRATRIO

Ramo inspiratrio
PACIENTE

Vlvula
de
exalao Ramo expiratrio

Transdutor
de presso Pva

CPU Fluxo
Transdutor
de fluxo

PAINEL
MONITOR DE
CONTROLES

6
 Tipos de Fluxo

Quantidade de gs na unidade do tempo:

Fluxo L.min-1 ou L.s-1

Senoidal Desacelerado Desacelerado 50% Constante

7
 Presso Inspiratria Mxima e de Plat

8
 Fluxo: Constante X Desacelerado
90 90

T (s)
Fluxo 0 T (s) 0

1000 1000

Volume 0
0
0 0
0 1 2 0 1 2

20 20

Presso 0
1 2
0
2
9 0 1
 Decelerating inspiratory flow waveform improves lung
mechanics and gas exchange in patients on intermittent
positive-pressure ventilation.

Fluxo: Constante X Desacelerado

da presso de pico
da resistncia respiratria total
do trabalho inspiratrio
da relao espao morto / volume corrente (VD/VT)
do gradiente alvlo-arterial O2
das Complacncias esttica e dinmica
da PaO2
Sem alteraes
PaCO2 - Dbito cardaco e hemodinmica

10 Al-Saady N, Bennett E D. Intensive Care Med. 11(2):68-75, 1985.

 VCV
ventilao controlada a volume

Volume
Pva Rva.Fluxo
Csr
 VCV

Volume
Pva Rva.Fluxo PEEP
Csr
12
 Ventilao Controlada a Volume - VCV

Presso
Inspiratria
Varivel

Fluxo
Constante

Senoidal
Desacelerado
Desacelerado 50%
Constante
13
 Pausa Inspiratria

Tempo (s) Distribuio do gs

% de Tins

4. Fechamento da Vlv. Ins.

1. Fechamento da Vlv. Exp. 5. Trmino do Fluxo Ins.
2. Abertura da Vlv. Ins.
3. Fluxo Inspiratrio

6. Abertura da Vlv. Exp.

Expirao

14
 Pausa Inspiratria (33%)

15
 VCV e VCV com PEEP

16
 PCV
ventilao controlada a presso

Volume
Pva Rva.Fluxo
Csr
 PCV

Volume
Pva Rva.Fluxo PEEP
Csr
18
 Ventilao Controlada a Presso - PCV

Presso
Inspiratria
Constante

Fluxo
Desacelerado

19
 Controle

VCV PCV

20
 PCV e PCV com PEEP

21
 Ventilao Presso Controlada x VCV
Vantagens

Pouca diferena em pacientes normais.

Estratgia protetora para pacientes graves.
Continuidade para pacientes j em uso.

Os estudos atribuem as vantagens da PCV a:

1. Fluxo desacelerado.
2. Estratgia protetora do controle da
presso.

22
 Ventilao Presso-Controlada
Vantagens

PACIENTES PEDITRICOS
Melhor proteo pulmonar

Compensao de distensibilidade (Compl)

Compensao de vazamentos

Sem influncia do fluxo de acoplamento

23
 Compensao de Complacncia / Vazamentos
Presso = 50 cmH2O

Sensor
Paciente 650 mL
500 mL

Volume
Adicional Ventilador
750 mL

24
 Fluxo de Acoplamento

25
 Ventilao Presso-Controlada x VCV
Desvantagens

Necessita de correo freqente do

Controle da Presso, com as alteraes
da complacncia e da resistncia, para
manter o Volume Minuto adequado.

26
 SIMV/V
ventilao mandatria intermitente
sincronizada com controle de volume
 Ventilao Mandatria Intermitente
Sincronizada - SIMV
Ajuste Primrio - Ajuste Secundrio

21 0.5 2P 4 30
VCV

600 ----- 8 24 -----

28
 SIMV/V

Respirao espontnea entre ciclos

mandatrios de Volume Controlado.
Os ciclos espontneos podem ter suporte
29 pressrico para auxlio a respirao.
 PSV
ventilao espontnea com
presso de suporte nas vias areas
 Ventilao com Presso de Suporte

Aplicar uma Presso de Suporte nas vias

areas, em um ciclo iniciado pelo paciente
(ventilao espontnea).
Fluxo inicial rpido, decrescente para
manter a presso.
Trmino fluxo com 25% do seu valor inicial.
Valores iniciais de 5 a 10 cmH2O.
Ajustar para manter volume adequado.
Compensa vazamentos - LMA

31
 Ventilao com Presso de Suporte - PSV

O paciente respira espontaneamente sobre

uma presso positiva mantida constante
pelo ventilador.
32
Ventilao de backup PCV.
 Volume Garantido com Limite de Presso

33
 Controle Duplo
Ciclado a Volume Limitado a Presso
Determinado - Operador
Frequncia ventilatria (mnima)

Volume minuto (alvo)

Presso (limite)

Calculado Ventilador
Variveis de Presso

Fluxo

34
 PCV/AV - Ventilao com Volume Assegurado (AV)
com Controle de Presso (PCV)

Auto-ajusta a menor presso inspiratria necessria para

atingir o volume corrente ajustado.
Adapta-se s propriedades mecnicas dos pulmes e trax.
Presso Inspiratria constante.
35 Fluxo Inspiratrio desacelerado.
 Modo Duplo Duplo Controle - Hbrido

Modo de PRESSO CONTROLADA que

automaticamente aumenta ou diminui a
presso, para alcanar o volume desejado.
Baseados no conceito de Closed-Loop.

Vantagens
Volume garantido.
Fluxo desacelerado (no controlado pelo
operador).

Desvantagem
Limite de presso como na VCV.
36
 PCV - Estudos em Anestesia
Estudo Comparativo dos Efeitos Hemodinmicos e Ventilatrios da
Ventilao Controlada a Volume ou a Presso, em Ces Submetidos
ao Pneumoperitnio.
Carraretto AR, Vianna PTG, Almeida AV, Ganem EM.
Rev Bras Anestesiol. 2005; 55: 6: 639-54

Alteraes Hemodinmicas durante o Pneumoperitnio em Ces

Ventilados com Volume e Presso Controlados.
Almeida AV, Ganem EM, Carraretto AR, Vianna PTG.
Rev Bras Anestesiol. 2003; 53: 6: 756-66

Efeitos do Pneumoperitnio sobre a Hemodinmica e Funo Renais

de Ces Ventilados com Volume e Presso Controlados.
Almeida AV, Ganem EM. Rev Bras Anestesiol. 2004; 54: 3: 343-60

Estudo comparativo dos efeitos hemodinmicos e ventilatrios da VCV

ou da VCP, em ces submetidos ao pneumoperitnio.
Carraretto AR Tese Mestrado, 2002

Influncia do modo ventilatrio no desempenho funcional dos enxertos

pulmonares ps transplante em modelo canino: VCV versus VCP.
37
Fortis EAF Tese Doutorado, 2003.
 Assunto j antigo

Bergman NA: Effects of varying inspiratory waveforms on gas

exchange. ANESTHESIOLOGY 1967; 28:390-5.
Sykes, M K; Lumley, J. The effect of varying inspiratory: expiratory
ratios on gas exchange during anaesthesia for open-heart surgery.
Br J Anaesth. 41(5):374-80, 1969 May.
Dammann JF, McAslan TC, Maffeo CJ: Optimal flow pattern for
mechanical ventilation of the lungs. 2. The effect of a sine versus
square wave flow pattern with and without an end-inspiratory pause
on patients. Crit Care Med 1978; 6:293-310.
Al-Saady, N; Bennett, E D. Decelerating inspiratory flow waveform
improves lung mechanics and gas exchange in patients on
intermittent positive-pressure ventilation. Intensive Care Med.
11(2):68-75, 1985.
Markstrom AM. et al. Ventilation with Constant Versus Decelerating
Inspiratory Flow in Experimentally Induced Acute Respiratory Failure.
Anesthesiology. 1996; 84: 882-9.
38
 Estudos Comparativos .

PCV VCV
Controle Presso Volume / Fluxo
Fluxo Varivel Controlado
Volume Varivel Garantido
Ppeak Controlada Alta
Pmean
Complacncia
VD/VT

39
 Estudos Comparativos ..

PCV VCV
Reduo PaCO2
Aumento PaO2
D(A-a)O2 -
Distribuio V -
Conforto
Preveno VILI
Uso PAC Graves
Uso ANESTESIA

40
 A cultura do VOLUME

41
Referncias Bibliogrficas
 Effects of short-term pressure-controlled ventilation on gas exchange,
airway pressures, and gas distribution in patients with acute lung
injury/ARDS: comparison with volume-controlled ventilation.

Chest. 2002 Oct;122(4):1382-8 - Erratum in: Chest. 2003 Jan;123(1):315

Prella M, Feihl F, Domenighetti G. Multidisciplinary ICU, Regional Hospital La Carit, 6600 Locarno,
Switzerland.
STUDY OBJECTIVES: The potential clinical benefits of pressure-controlled ventilation (PCV) over volume-
controlled ventilation (VCV) in patients with acute lung injury (ALI) or ARDS still remain debated. We
compared PCV with VCV in patients with ALI/ARDS with respect to the following physiologic end points:
(1) gas exchange and airway pressures, and (2) CT scan intrapulmonary gas distribution at end-
expiration. DESIGN: Prospective, observational study. SETTING: A multidisciplinary ICU in a
nonuniversity, acute-care hospital. PATIENTS: Ten patients with ALI or ARDS (9 men and 1 woman;
age range, 17 to 80 years). INTERVENTIONS: Sequential ventilation in PCV and VCV with a constant
inspiratory/expiratory ratio, tidal volume, respiratory rate, and total positive end-expiratory pressure;
measurement of gas exchange and airway pressures; and achievement of CT sections at lung base,
hilum, and apex for the quantitative analysis of lung densities and of aerated vs nonaerated zones.
RESULTS: PaO(2), PaCO(2), and PaO(2)/fraction of inspired oxygen ratio levels did not differ between
PCV and VCV. Peak airway pressure (Ppeak) was significantly lower in PCV compared with VCV (26
+/- 2 cm H(2)O vs 31 +/- 2 cm H(2)O; p < 0.001; mean +/- SEM). The surface areas of the nonaerated
zones as well as the total areas at each section level were unchanged in PCV compared with VCV,
except at the apex level, where there was a significantly greater nonaerated area in VCV (11 +/- 2 cm(2)
vs 9 +/- 2 cm(2); p < 0.05). The total mean CT number of each lung (20 lungs from 10 patients) was
similar in the two modes, as were the density values at the basal and apical levels; the hilum mean CT
number was - 442 +/- 28 Hounsfield units (HU) in VCV and - 430 +/- 26 HU in PCV (p < 0.005).
CONCLUSIONS: These data show that PCV allows the generation of
lower Ppeaks through the precise titration of the lung distending
pressure, and might be applied to avoid regional overdistension by
43 means of a more homogeneous gas distribution.
PMID: 12377869 [PubMed - indexed for MEDLINE]
 Pressure versus volume-controlled ventilation with a laryngeal
mask airway in paediatric patients.

Paediatr Anaesth. 2001 Nov;11(6):691-4. Links

Keidan I, Berkenstadt H, Segal E, Perel A.
Department of Anesthesiology and Intensive Care, Sheba Medical Center, Sackler School of Medicine, Tel-
Aviv University, Israel. keidan@shani.net
BACKGROUND: The utility of positive pressure ventilation with the laryngeal mask airway (LMA) in children
was described previously, but the possibility of gastric insufflation, related to high peak airway pressure,
continues to be a disadvantage. In this prospective study, inspiratory pressures, air leak and signs of
gastric insufflation were compared between volume-controlled ventilation (VCV) and pressure-controlled
ventilation (PCV) using an LMA. METHODS: Thirty-two ASA I patients, aged 4.5 +/- 4 years, who were
scheduled for elective procedures under combined general anaesthesia and caudal analgesia, were
enrolled. After inhalation induction and LMA insertion, each patient was randomly assigned to receive
successively PCV and VCV. Peak pressures (PCV) and tidal volumes (VCV) were changed in order to
achieve adequate ventilation [endtidal CO2 5-5.4 kPa (38-42 mmHg)]. RESULTS: Peak airway
pressures were significantly lower with PCV than VCV (14.1 +/- 1.6 cmH2O versus 16.7 +/- 2.3 cmH2O,
P < 0.001). No patient ventilated with PCV required peak pressure higher than 20 cmH2O compared
with six patients ventilated with VCV (P < 0.05). Haemodynamic parameters, expiratory tidal volume and
percent of leak were similar in both ventilatory modes and no signs of gastric insufflation were detected.
CONCLUSIONS: During general anaesthesia in children using
an LMA, PCV offers lower peak inspiratory airway pressures
while maintaining equal ventilation compared with VCV.
Although no signs of gastric insufflation were detected in both
groups, the lower pressures might be significant in patients with
reduced chest wall or lung compliance.
44
PMID: 11696145 [PubMed - indexed for MEDLINE]
 Cardiorespiratory effects of pressure-controlled ventilation with and
without inverse ratio in the adult respiratory distress syndrome.

Chest. 1993 Sep;104(3):871-5. - Comment in: Chest. 1993 Sep;104(3):664-5.

Merced A, Grani L, Teboul JL, Lenique F, Richard C.
Service de Ranimation Mdicale, Universit Paris-Sud, Hopital de Bictre, Le Kremlin Bictre, France.

To assess the cardiorespiratory effects of pressure-controlled ventilation (PCV) and pressure-controlled

inverse ratio ventilation (PC-IRV), we compared pressure-controlled ventilation with an inspiratory-to-
expiratory time ratio (I/E) of 1/2 (PCV) and of 2/1 (PC-IRV) to volume-controlled ventilation (VCV) with
an I/E of 1/2 in 10 patients suffering from the adult respiratory distress syndrome. In all modes, the
inspiratory oxygen fraction, tidal volume, respiratory rate, and total positive end-expiratory pressure
(PEEPt = applied PEEP + intrinsic PEEP) were kept constant. Each ventilatory mode was applied for 1
h in a randomized order. No significant differences in PaO2 were observed among the three modes. The
PaCO2 was lower (p < 0.05) in PC-IRV (39 +/- 4 mm Hg) than in PCV (43 +/- 5 mm Hg) and in VCV (45
+/- 5 mm Hg). The peak airway pressure was significantly lower in PC-IRV than in PCV (p < 0.05) and in
PCV than in VCV (p < 0.05), but plateau pressure was not different in the 3 modes. The mean airway
pressure (mPaw) was significantly higher (p < 0.05) in PC-IRV (21.4 +/- 0.7 cm H2O) than in PCV (17.1
+/- 0.7 cm H2O) and VCV (16.4 +/- 0.5 cm H2O). As a consequence of this increased mPaw, PC-IRV
induced a decrease in cardiac index (CI) (3.3 +/- 0.2 vs 3.7 +/- 0.2 L/min/m2 in VCV; p < 0.05) and
hence in oxygen delivery (DO2) (424 +/- 28 vs 469 +/- 38 ml/min/m2 in VCV; p < 0.05).

Our results suggest that neither PCV nor PC-IRV bring any benefit
over VCV in terms of arterial oxygenation. Moreover, the
increase in mPaw induced by PC-IRV may be deleterious to the
CI and DO2.
PMID: 8365303 [PubMed - indexed for MEDLINE]
45
 Reviso: Pressure-controlled versus volume-controlled
ventilation: does it matter?

Respir Care. 2002 Apr;47(4):416-24; discussion 424-6.

Campbell RS, Davis BR.
Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati College of Medicine,
Cincinnati, Ohio 45267, USA. robert.campbell@uc.edu
Volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) are not different ventilatory
modes, but are different control variables within a mode. Just as the debate over the optimal ventilatory
mode continues, so too does the debate over the optimal control variable. VCV offers the safety of a
pre-set tidal volume and minute ventilation but requires the clinician to appropriately set the inspiratory
flow, flow waveform, and inspiratory time. During VCV, airway pressure increases in response to
reduced compliance, increased resistance, or active exhalation and may increase the risk of ventilator-
induced lung injury. PCV, by design, limits the maximum airway pressure delivered to the lung, but may
result in variable tidal and minute volume. During PCV the clinician should titrate the inspiratory pressure
to the measured tidal volume, but the inspiratory flow and flow waveform are determined by the
ventilator as it attempts to maintain a square inspiratory pressure profile. Most studies comparing the
effects of VCV and PCV were not well controlled or designed and offer little to our understanding of
when and how to use each control variable. Any benefit associated with PCV with respect to
ventilatory variables and gas exchange probably results from the associated
decelerating-flow waveform available during VCV on many ventilators. Further, the
beneficial characteristics of both VCV and PCV may be combined in so-called dual-
control modes, which are volume-targeted, pressure-limited, and time-cycled. PCV
offers no advantage over VCV in patients who are not breathing spontaneously,
especially when decelerating flow is available during VCV. PCV may offer lower
work of breathing and improved comfort for patients with increased and variable
respiratory demand.
46 PMID: 11929615 [PubMed - indexed for MEDLINE]
 Comparison of volume control and pressure control
ventilation: is flow waveform the difference?

CONCLUSIONS: Both pressure control ventilation and

volume control ventilation with a decelerating flow
waveform provided better oxygenation at a lower
peak inspiratory pressure and higher mean airway
pressure compared to volume control ventilation
with a square flow waveform. The results of our
study suggest that the reported advantages of
pressure control ventilation over volume control
ventilation with a square flow waveform can be
accomplished with volume control ventilation with a
decelerating flow waveform.

Davis K Jr, Branson RD, Campbell RS, Porembka DT

47 J Trauma. 1996 Nov;41(5):808-14
 Effects of inspiratory flow waveforms on lung mechanics, gas
exchange, and respiratory metabolism in COPD patients during
mechanical ventilation.

CONCLUSIONS: The most favorable flow

pattern for ventilated patients with COPD
appeared to be the decelerating waveform.
There are possibilities for the improvement
of ventilation in these patients by selecting
an appropriate inspiratory flow.

Yang SC, Yang SP. Chest. 2002 Dec;122(6):2096-104

48
 Controle de Presso e PEEP

Altos Volumes causam leso.

PEEP promove proteo.
Leso pulmonar pr existente torna mais
vulnervel a VILI (Leses Induzidas por Ventilador).
SARA - algumas regies dos pulmes
recebem volumes elevados.
Repetido fechamento e reabertura -
estresse ao alvolo.

Leonard D Hudson - Editorial - JAMA 1999, 283: 77-78

49 Ulrich Rat al - Anesthesiology 1999; 91:1577 - 1586
 Randomized, prospective trial of pressure-limited versus
volume-controlled ventilation in severe respiratory failure (1)
Physiologic approach to mechanical ventilation(2)

PCV
Aumenta a complacncia
Melhora a troca gasosa

Reduz a presso inspiratria

(1) Rappaport SH et al. Crit Care Med 1994; 22:22-32.

50
(2) Hubmary RD, Abel MD, Rehder K. Crit Care Med 1990; 18:103-13.
 Ventilation with Constant Versus Decelerating Inspiratory Flow
in Experimentally Induced Acute Respiratory Failure.

Fluxo inspiratrio rpido (alto)

Aumento rpido e manuteno da
presso das vias areas
Transferncia rpida dos gases e
manuteno da presso alveolar por
maior tempo
Potencial para recrutar e melhorar a
distribuio dos gases
Aumento da eliminao do CO2

51 Markstrom AM. et al. Anesthesiology. 1996; 84: 882-9.

 PCV + Pneumoperitnio

Estudo Comparativo dos Efeitos Hemodinmicos e Ventilatrios

da Ventilao Controlada a Volume ou a Presso, em Ces
Submetidos ao Pneumoperitnio.
Carraretto AR, Vianna PTG, Almeida AV, Ganem EM.
Rev Bras Anestesiol. 2005; 55: 6: 639-54

Alteraes Hemodinmicas durante o Pneumoperitnio em

Ces Ventilados com Volume e Presso Controlados.
Almeida AV, Ganem EM, Carraretto AR, Vianna PTG.
Rev Bras Anestesiol. 2003; 53: 6: 756-66

Efeitos do Pneumoperitnio sobre a Hemodinmica e Funo

Renais de Ces Ventilados com Volume e Presso Controlados.
Almeida AV, Ganem EM. Rev Bras Anestesiol. 2004; 54: 3: 343-60

52
Muito Obrigado