Ventilation Techniques - A practical workshop

Presented at ANZCA 2015 by

Dr Chris Thompson, Senior Staff Specialist
Royal Prince Alfred Hospital

Goals of the workshop Loss of ventilation skills

• Improve ventilation awareness and skills • Anaesthetists have lost some of their ventilation
• Learn how to use a modern ventilator to skills as the ventilators used
fix ventilation problems. in some anaesthetic machines are 20 years behind
those in ICU. However, other machines have
Skills ventilators that are better than ever
• Most patients are healthy and so anaesthetists
• Mask and bagging skills
have become deskilled in mask and bagging
• Can’t intubate, can’t ventilate skills
ventilation
• Anaesthetists use high inspired oxygen to mask
Questions
poor ventilation in the patient
• Are you, as an anaesthetist, comfortable dealing • The advent of the LMA has meant that it is not
with sick patients who have unique challenges? necessary to intubate if it is too hard to introduce
• Can anaesthetists do as good a job as Intensivists an ETT
in looking after patient’ lungs? • The failure in the CICO is actually a failure in
ventilation on the most part
• Breathing is required for control of carbon dioxide
• Oxygen given in recovery is to deal with the failure
to return the patient to normal
oxygenation and breathing after the anaesthetic

Ordinary respiratory care in the anaesthesia

Improve environment

Ventilation •
•
100% oxygen on induction and emergence
Apnoea on induction

Awareness •
•
ETT paralysis
Patient lying flat
• If there are respiratory problems, the patient is
sent to ICU
• Opioid analgesia
• High flow Hudson mask
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• If the patient has a low SpO2 then increase the the APL valve, which increases the work of
FiO2 breathing
• High FiO2/I:E ratio of 1:2/5cmH2O PEEP • Dräger machines – same as an ICU circuit,
• IPPV – 700mls TV and 10 breaths per minute whereby on inspiration the gas comes
• These contribute to lung collapse and bad directly from the ventilator and in expiration the
outcomes patient only needs to blow off against the PEEP
• Instead of increasing oxygen to solve ventilation valve
problems, anaesthetists should deal with the root • The lung itself has a normal respiratory rate of 15.
cause The elastic work is used to overcome lung
• Results in trying to establish ventilation after the stiffness, while the air flow work overcomes
patient has become apnoeic and the tongue has resistance. The respiratory rate should be
caused obstruction. increased for stiff lungs and decreased for airway
resistance
Multi-modal solution • Lung collapse makes the lung smaller and
resistance is increased. Stiffer lungs increase the
• Lung recruitment
pressure within the lung which can result in the
• Reduced tidal volume
anaesthetist ventilating the stomach by accident
• Reasonable amount of PEEP
while bagging the patient. The anaesthetic
• Results in
machine is able to provide ventilation with
o Decrease in atelectasis/ARDS
accuracy if Pressure support is used
o Wound infection
• In pressure support mode, the inspiratory effort is
o Decrease days in ICU
detected by looking at a flow trigger. The machine
o Decrease need for non-invasive ventilation
sees air going in and when using Dräger
machines, an arrow is shown on the flow curve.
Total lung care
The machine increases airway pressure and gas
• Plan ahead flows into the lungs. The airway pressure increase
• Less than 70% oxygen on induction and is set by the anaesthetist as the pressure support
emergence value. The machine watches the air flow curve
• Sit the patient up on induction and emergence until it is 25% of peak air flow. Once it has fallen
• Pressure support on induction and emergence to 25% the pressure support is released. The
• Non-invasive ventilation through a mask to pressure support is dynamically adjusting the
decrease obstruction during induction duration of the increase to match what the patient
• Avoid ETT/paralysis requires. It adapts to the patient’s lung mechanics
• Small tidal volumes at a quicker rate e.g. 500mls x and breathing pattern
13 breaths Settings
• PEEP 5- 10cmH2O (optimised) o Inspired pressure delta of 5-8cmH2O with a
• I:E ratio at 1:1 (individualised) to lower airway Dräger machine, may need more
pressure for better distribution of with a GE machine. It should be adjusted to
ventilation the desired tidal volume
• FiO2 of 30-40% o Flow trigger should be 5L/min for adults and 2-
• Recruitment ventilation 3L/min for children or tachypnoeic adults
• Full reversal o Rise time – 0.3 seconds for an adult, however,
• Early extubation for gasping adults or children it should be
• Minimise lung soiling by removing the ETT with brought down
the cuff inflated o PEEP/CPAP – 5-8 cmH2O
• Minimise post-operative FiO2 o Apnoea response time- dependent upon the
• Don’t blow off all the patient’s CO2 resting respiratory rate, is self-triggering in
Dräger’s pressure support mode. If the
Pressure Support respiratory rate is set a 15 breaths per minute
then the trigger will be at 6 seconds
• Most anaesthetic ventilators can be used to recruit o I:E ratio – should be 1:1, inspiration must follow
and use Pressure Support straight on from expiration togive the lowest
• GE machines – patient must breath through the CO2. Inspiration and expiration should be
soda lime and the bag and must exhale through
 VENTILATION TECHNIQUES - A practical workshop | 3

symmetrical in time. There should be constant • Optimise PEEP/CPAP to best lung compliance or
air flow. best PaO2
o Compliance – with a normal compliance curve, • Use pressure based ventilation modes
10cmH2O of PEEP will get approximately • Extubate sitting up with PEEP and the ETT cuff
800mls of tidal volume. In a collapsed lung, inflated
anaesthetist will need to recruit to try and fix
the altered compliance. Optimal mechanical Improving Oxygenation
PEEP is where compliance is best. This is
• Recruit lungs
where there is the best tidal volume increase
• Optimise PEEP
for the smallest pressure change
• Monitor compliance
o PEEP optimisation
• Re-recruit prn
 Step PEEP up in a constant manner and
• I:E ratio 1:1 with optimal inspiratory and expiratory
look at the tidal volume change
times
 The tidal volume will get bigger until the
• Give inotropes, if needed, to give optimal PEEP
lung is overstretched, then the tidal
volume will decrease. Optimal PEEP has
Extubation Strategies
the maximum tidal volume.
Method • Maintain PEEP/CPAP at all times
 Pressure control mode o Wean using pressure support with PEEP
 Slow rate o Don’t bag and leave apnoeic to induce
 I:E ratio of 1:1 respiration
 Step PEEP up to around 20cmH2O • Recruit lung just before extubation
(30cmH2O for obese patients) • Extubate sitting up with PEEP
 Hold for 30 seconds o As little oxygen as possible
 Maintain ventilation o ETT cuff inflated
 Treat hypotension o Awake as possible
 Step PEEP up and back gradually o Good analgesia
 Result is that the lungs become more o Fully reversed
elastic and can be recruited as this • Minimise opioid, use blocks/ketamine
method is implemented • Patient should be able to breath well in air
 Tidal volume increase relates to extent of
lung collapse Summary

Minimising airway pressure • Lung collapse and increased work of breathing

is normal during anaesthesia but need not be
• Great for laparoscopy to decrease carbon • Pressure support makes breathing easier
dioxide • Recruitment, optimal PEEP and other open
• Low tidal volume, high rate lung strategies improve lung function,
• Recruit the lung by optimising PEEP reduce work of breathing and improve
• Optimise inspiratory and expiratory time (1:1 outcomes
ratio) • Great ventilation skills are not difficult to learn
• Monitor compliance over time and recruit prn
• Use volume-preset pressure modes if available

Preventing lung collapse

• Avoid apnoeic episodes in 100% oxygen and

consider inducing with pressure support and
CPAP
• Perform recruitment manoeuvers
o 30-40cmH2O over 15-20 cmH2O of PEEP
o Hold for 10 breaths or 30 seconds
• Monitor compliance and re-recruit if needed