Teaching Module

Manoj Dalmia, MD
BIDMC Anesthesia Resident

The objective of this module is to develop a
solid understanding of the different modes of
ventilation utilized in the care of surgical
patients and other ventilator-related
considerations.

By the end of this lesson, the learner should be
able to demonstrate and explain the difference
between the two most common modes of
controlled ventilation: volume control and
pressure control.

You have a 28 yo female patient who is
scheduled to undergo an inguinal hernia repair
under general anesthesia. She has a past
medical history significant for asthma, snoring
(no definitive dx of OSA), GERD, and a recent
URI which she said resolved over a week ago.
She is 64 inches tall and weighs 110 kg. Her
vital signs in the preoperative holding area are
as follows: BP 135/87, HR 90, RR 16, and SpO2
99%.

Given her body habitus and reflux history, you
decide intubating this patient would be the
safest way to manage her airway. Would you
choose a volume control or pressure control
ventilation strategy with this patient? Why?
 VOLUME CONTROL PRESSURE CONTROL

Tidal volume constant
Tidal volume variable

Peak airway pressure
Peak airway pressure

variable constant

Pressure will increase
Tidal volume will

(to set limit) to maintain increase/decrease if
tidal volume peak pressures
decrease/increase
 VOLUME- PRESSURE –
TARGETED TARGETED

Decreased compliance ↑ Pressure ↓ Volume

Increased compliance ↓ Pressure ↑ Volume

Pneumothorax ↑ Pressure ↓ Volume

Bronchospasm ↑ Pressure ↓ Volume

Pleural effusion ↑ Pressure ↓ Volume

Increased patient effort ↓ Pressure ↑ Volume

Decreased patient effort ↑ Pressure ↓ Volume

Adjust the volume under a volume control
setting and make note of the change in airway
pressures during each mechanical breath

Adjust the pressure under a pressure control

setting and make note of the change in tidal
volumes during each mechanical breath

*Observe the differences noted with surgical

pressure on the abdomen during the case

Which mode of ventilation would be most
suitable in our patient?

Volume control
 Obesity
decreased compliance
 Abdominal surgery
further decreased
compliance/↑ airway pressures with manipulation
of the abdomen
 Able to maintain constant minute ventilation
 With pressure control, minute ventilation could be
extremely variable
 *By far, most common mode used in adults

Volume control is most common mode of
ventilation used in adults
 Tidal volume constant, pressure variable

Pressure control
 Pressure constant, tidal volume variable
 Specific instances where it may be preferable over volume
control
 Eg. small children
concern for barotrauma (limits peak
inflating pressure) plus setting anesthesia ventilators to
deliver accurate small tidal volumes is difficult because of
the proportionately large compression volume loss in the
ventilator and circuit
You’re now ready for the next lesson, nice job ☺

By the end of this lesson, the learner should be
able to demonstrate and explain the difference
between the two modes of controlled
ventilation most commonly utilized in ICU
settings: assist-control (A/C) ventilation and
synchronized intermittent mandatory
ventilation (SIMV).

At the end of the inguinal hernia repair, you
notice that the peak airway pressures for your
patient begin to rise significantly. In addition,
the slope of Phase 2 on the EtCO2 curve begins
to increase. You listen to the patient and notice
diffuse expiratory wheezes bilaterally. In
addition, you notice a diffuse rash and swelling
of the patient’s face. Her BP drops to 90/40, her
HR increases to 110, and her SpO2 drops to
92% with an FiO2 of 1.0.

You become concerned about an anaphylactic
reaction but are unsure of the source.
Regardless, you correctly make the decision to
immediately treat the patient with epinephrine,
steroids, and beta-2 agonists. She is transferred
to the ICU intubated till her reaction resolves.
As her condition improves, she is switched
over to assist-control ventilation but you are
curious why this is chosen over SIMV.

Both control modes of ventilation (either
volume or pressure-controlled)

Both allow for patient-triggered breaths
between minimum programmed mandatory
rate
 Ensures minimum minute ventilation achieved

Both modes have their advocates and
detractors

If the ventilator senses a spontaneous breath
(negative airway pressure), the ventilator triggers
and delivers a full tidal volume to the patient
 May adjust sensitivity of trigger

Patient determines ventilatory rate though

minimum back-up rate set to ensure a minimum
minute ventilation

*Most commonly used mode of ventilation utilized

in ICUs worldwide
http://emedicine.medscape.com/article/304068-overview
 ADVOCATES DETRACTORS

Patients with normal
“Trigger” issues
respiratory centers able to  If trigger too sensitive, may
hyperventilate
auto-regulate respiratory  If trigger not sensitive enough,
rate breathing may become

May prevent atrophy of dysynchronous
 If respiratory center not normal,
ventilatory muscles may be inappropriate to use
compared to pure
Each positive-pressure breath
controlled modes of ↑ intrathoracic pressure and
ventilation subsequently ↓ venous

Decreased work of return/CO
breathing compared to
In those with obstructive
SIMV airway disease, it may worsen
air-trapping and breath-
stacking

Allows combination of spontaneous, unsupported
breathing with a minimum mandatory back-up
rate

“Window” of breathing opportunity

 Time in which a patient may breathe spontaneously
 If ventilator does not sense effort during this “window”,
then a positive pressure controlled breath is delivered

*Original intent: allow respiratory muscles to rest

during controlled breaths and work during
spontanous respirations
 (does not hold true – see continued discussion)
http://emedicine.medscape.com/article/304068-overview
 ADVOCATES

Spontaneous breathing
may improve V/Q
matching (Figure 83-8)

Negative intrathoracic
pressure during
spontaneous breaths
improves venous
return/CO
Effect of spontaneous ventilation and positive-pressure ventilation on gas distribution in a
supine subject. During spontaneous ventilation (A) diaphragmatic action distributes most
ventilation to the dependent zones of the lungs, where perfusion is greatest. The result is
good matching of ventilation to perfusion. During positive-pressure ventilation (B)
because the diaphragm is doing little to no contraction, ventilation is primarily distributed
to nondependent lung, increasing the level of ventilation to perfusion mismatch.
(Reprinted from Wilkens RL, Stoller JK, Scamlon CC. Egan’s Fundamentals of Respiratory
Care. 8th ed. St. Louis, MO: Mosby, 2003:972, with permission from Elsevier.)
 DETRACTORS

Work of breathing
excessive (see figure)
 Has been shown that work
of breathing not decreased
during mandatory breaths
as originally thought
 Delays extubation
compared w/ PS and SBT
Inspiratory work per unit volume (work per liter [Wp/L]) done by the
(see Lesson 3) patient during assisted cycles (open bars) and spontaneous cycles
(reverse cross-hatched bars). Wp/L increased with decreasing

Greater likelihood of synchronized intermittent mandatory ventilation percentage for both
types of breath. Wp/L for spontaneous breaths tended to exceed Wp/L
dysynchrony versus A/C for machine-assisted breaths. (Marini JJ, Smith TC, Lamb VJ. External
work output and force generation during synchronized intermittent
mechanical ventilation. Am Rev Respir Dis 1988;138:1169. © American
Thoracic Society)

Both A/C and SIMV are control modes of
ventilation that allow for patient triggered
breaths

Assist control – greatest benefit is decreased

work of breathing compared to SIMV

SIMV – greatest benefit is possible

improvement in V/Q matching and improved
CO compared to A/C
You’re now ready for the next lesson, nice job ☺

By the end of this lesson, the learner should be
able to understand the pressure-support
ventilator mode and its utility in weaning
patients from a ventilator.

After a 24-hr period in the ICU, your patient’s
anaphylactic reaction has resolved. The ICU
team would like to wean the patient from the
ventilator and she has done well on assist-
control ventilation. As a result, they have
placed the patient on pressure-support
ventilation with starting settings of FiO2 0.50,
PS 10, PEEP 5.

Closest mode to true assist ventilation
 Lowers work of breathing
 Requires stable ventilatory drive

No true back-up rate

Similar to Pressure A/C but major difference is

mechanism that terminates inspiration
 A/C → inspiration terminated by time
 PS → inspiration terminated by decreasing gas flow
 Tracheal flow decreases to ~25% → breath terminated

Allows patient greatest control over ventilation
 Patient triggers each breath
 End of breath based on demand of patient

TV varies with each breath, may adjust PS level

 Weaning is accomplished by decreasing PS level and
gradually transferring increased work to patient till
PS ~5
 Extubation typically successful at this level
http://emedicine.medscape.com/article/304068-overview

Pressure support ventilation is ideal mode for
ventilator wean
 Lowers work of breathing
 Allows patient to gradually increase work of
breathing as tolerated with eventual goal for
extubation
 Patient triggers each breath
You’re now ready for the next lesson, nice job ☺

By the end of this lesson, the learner should be
able to state the criteria to conduct a
spontaneous breathing trial (SBT), what defines
failure of a SBT, and which factors may
contribute to ventilator dependence in difficult-
to-wean patients.

The patient has done extremely well on
pressure support ventilation and does not look
to be in much respiratory distress. Her current
settings are FiO2 of 40%, PS of 5, and PEEP of
0. Her RR is 18. Her ABG results are as follows:
7.41/158/38/26/0. Her VS are similar to her
preoperative state. The ICU team has decided
to initiate a SBT with goal of extubation.

Criteria
 Improvement in factors that led to ventilator
dependence in the first place
 Assessment of oxygenation
 PaO2/FiO2 ≥ 150 mmHg
 PEEP ≤ 8 cm H2O
 FiO2 ≤ 0.5
 pH ≥ 7.25
 Hemodynamic stability (low-dose vasopressors OK)
 Spontaneous (duh!) respirations

Patient typically performs SBT for 30-120
minutes and does not meet any of the
following criteria to be considered for
extubation:
 RR > 35 breaths/minute
 HR > 140 or a sustained ↑ of 20% from baseline
 SBP > 180 mmHg or DBP > 90 mmHg
 ↑ anxiety
 ↑ diaphoresis

Other parameters used include:
 RR < 25 breaths per minute
 TV > 5 cc/kg
 VC > 10 cc/kg
 Negative inspiratory force (NIF) < -25 cmH2O
 *Rapid shallow breathing index (RSBI)
 = RR/Vt < 105
 Though used in many institutions, has not proven
universally successful in identifying those ready to
wean
*WHEANS NOT

Wheezing

Heart disease

Electrolyte imbalance

Anxiety, aspiration, alkalosis

Neuromuscular weakness

Sepsis, sustained sedation

Nutritional deficits

Obesity, opioid overdose

Thyroid disease

*Anesthesiology by Longnecker, et al

There are specific criteria that have been created to
determine whether a patient is a candidate for a SBT
(though the clinical picture must still be taken into
account)
 NIF and RSBI, though still commonly used, have not been
consistently shown to be great predictors of ability to wean

Remember the mnemonic “WHEANS NOT” when

considering which patients may be a difficult ventilator
wean!
 What characteristics does this patient have that may make her a
difficult wean?

*Think about possible scenarios which would make a

patient an appropriate candidate for a SBT.
You’re now ready for the next lesson, nice job ☺

By the end of this lesson, the learner should be
able to understand the use of non-invasive
positive pressure ventilation (NIPPV) in
facilitating the transition to unsupported
spontaneous respirations.

The patient successfully passes her SBT and the
decision is made to extubate her. Over the next
2 hours, the patients becomes progressively
tachypneic. The ICU team draws a blood gas
with the patient on RA (prior to putting on a
nonrebreather) which demonstrates the
following: pH 7.51, PaO2 80, and PaCO2 30.
The team wants to avoid reintubating this
patient and decides to see how the patient
responds to NIPPV.

Primary mechanism after surgery…
 V/Q mismatch secondary to development of
atelectasis!
 Positioning
 Absorption atelectasis
 Diaphragm weakness/dysfunction
 Incisional pain leading to impaired secretion clearance

Goal: increase FRC!

 How can this be accomplished?

Continuous Positive Airway Pressure (CPAP)

Bi-Level Positive Airway Pressure (BiPAP)


Delivers a predetermined and constant stream
of pressure through a tight-fitting mask that
essentially “stents” the airway open
 Effective for reducing atelectatic areas
 Effective for patients with obstructive sleep apnea
CPAP breaks this
cycle at this point!
 PROS CONS

Safe and effective
Headaches

Skin irritation

Compact and portable
Stomach bloating

Nasal congestion

Many do not tolerate
continuous positive
pressure, esp. awake!

Two levels of pressure
 Inspiratory Positive Airway Pressure
 High amount of pressure on inhalation
 Expiratory Positive Airway Pressure
 Low positive pressure on exhalation

Usually prescribed when a patient does not

tolerate CPAP or has additional respiratory
issues
 PROS CONS

Safe and effective
Headaches

Skin irritation

Better tolerated due to
Stomach bloating
variation in inspiratory
Nasal congestion
and expiratory
Not compact/portable
pressures

Requires constant
supervision of pressure
settings

In many instances, NIPPV can effectively
improve V/Q mismatch

CPAP
continuous stream of pressure

throughout respiratory cycle, stents the airway
open, portable

BiPAP
increased pressure on inspiration,

less on expiration, better tolerated than CPAP
but requires constant supervision of pressures
You’re now ready for the next lesson, nice job ☺

By the end of this lesson, the learner should be
able to understand ventilator-induced lung
injury (VILI).

Your 28 yo patient did fantastic and was able to
be discharged to the floor 2 days after her
initial admission to the ICU. Luckily, she did
not incur any injury from her time on the
ventilator (unlike one of the other unfortunate
patients in the ICU).

What is ventilator-induced lung injury?


Definition
 An increase in the permeability of the alveolar
capillary membrane, the development of pulmonary
edema, the accumulation of neutrophils and protein
within the lung parenchyma and airway, the
disruption of surfactant production, and a decrease
in lung compliance.

“Volutrauma” – injury due to excessive volume

Barotrauma – injury due to excessive pressure

“Atelectrauma” – recruitment/derecruitment
injury
Comparison of lungs excised from rats ventilated with peak pressure of 14 cm H2O, zero positive end-expiratory
pressure (PEEP); peak pressure 45 cm H2O, 10 cm H2O PEEP; and peak pressure 45 cm H2O, zero PEEP (left to
right). The perivascular groove is distended with edema in the lungs from rats ventilated with peak pressures of 45
cm H2O, 10 cm H2O PEEP. The lung ventilated at 45 cm H2O peak pressure zero PEEP is grossly hemorrhaged.
(Webb HH, Tierney D. Experimental pulmonary edema due to intermittent positive pressure ventilation, with high
inflation pressure protection by positive end expiratory pressure. Am Rev Respir Dis 1974;110:556–565. © American
Thoracic Society.)
Congratulations! You’re done! Nice job ☺