Cardiogenic pulmonary

edema/ARDS/Bronchopneumonia?
Type I or Classic “Hypoxemic”
Respiratory Failure

• Type I ARF is the most common form of respiratory failure and is

defined by PaO2 < 60 mm Hg, with normal or decreased PaCO2.
Type II or “Hypercapnic”
Respiratory Failure
• Type II ARF (PaCO2 > 45 mm Hg) represents the failure of the lungs to
remove a sufficient amount of CO2 and is characterized by decreased
alveolar minute ventilation. An increase in PaCO2 leads to hypoxemia
because CO2 displaces O2 and effectively reduces the alveolar partial
pressure of oxygen (PAO2).
Type III or “Perioperative”
Respiratory Failure
• Type III respiratory failure is synonymous with perioperative
respiratory failure and is related to atelectasis of the lung. It is often a
consequence of abnormal abdominal and chest wall mechanics in the
setting of surgery or trauma, especially with intrapleural or
subdiaphragmatic pathologies.
• As a result, type III ARF shares features with both type I (hypoxemic)
and type II (hypercapnic) ARF.
Type IV or “High-demand”
Respiratory Failure

• Type IV respiratory failure is related to an inability of (normal or

relatively normal lungs) to keep up with increased ventilatory
demands associated with systemic hypermetabolism (e.g., secondary
to sepsis).
 CAUSES OF ARTERIAL
HYPOXEMIA
• 1. Reduced fraction of inspired oxygen (FiO2) or partial pressure of
• oxygen (e.g., breathing at elevation)
• 2. Hypoventilation (e.g., central respiratory depression,
neuromuscular
• weakness, and chest wall deformity)
• 3. Diffusion impairment
• 4. Ventilation/perfusion mismatch
• 5. Presence of a pulmonary shunt
Reduced Alveolar Oxygenation
and Hypoventilation

• Alveolar oxygenation (PAO2) is defined by the equation:

• PAO2 = FiO2(Patm− PH2O)− PaCO2/RQ
• PAO2= 0.21(760-47)-40/0.8=100 mmHg
Alveolar partial pressure of O2
Ventilation/Perfusion Mismatch
and Shunting
• The most common cause of hypoxemia is ventilation/perfusion
mismatch,specifically when areas of reduced alveolar ventilation have
relatively preserved or even supranormal levels of blood perfusion.
• Typically, alveolar filling or collapse (due to edema, pneumonia,
hemorrhage,tumor, or atelectasis) results in unventilated or poorly
ventilated areas of lung.
V/Q mismatch
Shunt equation
Pneumonia
Pneumonia CT
 Cardiogenic pulmonary
edema/ARDS/Bronchopneumonia?
ARDS
MECHANICAL VENTILATORS
• Breaths can be initiated (triggered) by patient effort (assisted breaths)
or by the machine timer (controlled breaths)
• Breath delivery algorithms from modern mechanical ventilators can
be broken into five basic breaths based upon trigger, target, and cycle
criteria: (1) volume control (VC); (2) volume assist (VA); (3) pressure
control (PC); (4) pressure assist (PA); and (5) pressure support (PS)
• 1. Ventilator breath delivery is characterized by the trigger, target, and cycle
variables.
• 2. The interaction of a positive-pressure breath and respiratorysystem
mechanics is summarized by the equation of motion:
• Airway pressure = (Flow × Resistance) + (Volume/System Compliance) + PEEP
• 3. The goal of positive pressure mechanical ventilation is to provide adequate
gas exchange while protecting the lung from overdistention and recruitment-
derecruitment injury.
• 4. Positive pressure mechanical ventilation in obstructive lung disease poses
the additional risk of producing overdistention from air trapping.
Settings
1. Trigger mode and sensitivity
2. Respiratory rate
3. Tidal Volume
4. Positive end-expiratory pressure (PEEP)
5. Flow rate
6. Inspiratory time
7. Fraction of inspired oxygen
Trigger
• There are two ways to initiate a ventilator-delivered breath: pressure
triggering or flow-by triggering
• When pressure triggering is used, a ventilator-delivered breath is initiated if
the demand valve senses a negative airway pressure deflection (generated by
the patient trying to initiate a breath) greater than the trigger sensitivity.
• When flow-by triggering is used, a continuous flow of gas through the
ventilator circuit is monitored. A ventilator-delivered breath is initiated when
the return flow is less than the delivered flow, a consequence of the patient's
effort to initiate a breath
Tidal Volume
• The tidal volume is the amount of air delivered with each breath. The
appropriate initial tidal volume depends on numerous factors, most
notably the disease for which the patient requires mechanical
ventilation.
Respiratory Rate
• An optimal method for setting the respiratory rate has not been
established. For most patients, an initial respiratory rate between 12
and 16 breaths per minute is reasonable
Positive End-Expiratory Pressure (PEEP)
• Applied PEEP is generally added to mitigate end-expiratory alveolar
collapse. A typical initial applied PEEP is 5 cmH2O. However, up to 20
cmH2O may be used in patients undergoing low tidal volume
ventilation for acute respiratory distress syndrome (ARDS)
Flow Rate
• The peak flow rate is the maximum flow delivered by the ventilator
during inspiration. Peak flow rates of 60 L per minute may be
sufficient, although higher rates are frequently necessary. An
insufficient peak flow rate is characterized by dyspnea, spuriously low
peak inspiratory pressures, and scalloping of the inspiratory pressure
tracing
Inspiratory Time: Expiratory Time
Relationship (I:E Ratio)
• During spontaneous breathing, the normal I:E ratio is 1:2, indicating
that for normal patients the exhalation time is about twice as long as
inhalation time.
• If exhalation time is too short “breath stacking” occurs resulting in an
increase in end-expiratory pressure also called auto-PEEP.
• Depending on the disease process, such as in ARDS, the I:E ratio can
be changed to improve ventilation
Fraction of Inspired Oxygen
• The lowest possible fraction of inspired oxygen (FiO2) necessary to
meet oxygenation goals should be used. This will decrease the
likelihood that adverse consequences of supplemental oxygen will
develop, such as absorption atelectasis, accentuation of hypercapnia,
airway injury, and parenchymal injury
Modes of Ventilation: The Basics
• Assist-Control Ventilation Volume Control
• Assist-Control Ventilation Pressure Control
• Pressure Support Ventilation
• Synchronized Intermittent Mandatory Ventilation Volume Control
• Synchronized Intermittent Mandatory Ventilation Pressure Control
Assist Control Ventilation
• A set tidal volume (if set to volume control) or a set pressure and time
(if set to pressure control) is delivered at a minimum rate
• Additional ventilator breaths are given if triggered by the patient
Pressure Support Ventilation
• The patient controls the respiratory rate and exerts a major influence
on the duration of inspiration, inspiratory flow rate and tidal volume
• The model provides pressure support to overcome the increased work
of breathing imposed by the disease process, the endotracheal tube,
the inspiratory valves and other mechanical aspects of ventilatory
support.
Synchronized Intermittent Mandatory
Ventilation
• Breaths are given are given at a set minimal rate, however if the patient chooses
to breath over the set rate no additional support is given
• One advantage of SIMV is that it allows patients to assume a portion of their
ventilatory drive
• SIMV is usually associated with greater work of breathing than AC ventilation and
therefore is less frequently used as the initial ventilator mode
• Like AC, SIMV can deliver set tidal volumes (volume control) or a set pressure and
time (pressure control)
• Negative inspiratory pressure generated by spontaneous breathing leads to
increased venous return, which theoretically may help cardiac output and
function
Goals of mechanical ventilation
• Primary goals of mechanical ventilation are adequate
oxygenation/ventilation, reduced work of breathing, synchrony of
vent and patient, and avoidance of high peak pressures
• Set initial FIO2 on the high side, you can always titrate down
• Initial tidal volumes should be 8-10ml/kg, depending on patient’s
body habitus. If patient is in ARDS consider tidal volumes between 5-
8ml/kg with increase in PEEP
Goals of mechanical ventilation
• Use PEEP in diffuse lung injury and ARDS to support oxygenation and
reduce FIO2
• Avoid choosing ventilator settings that limit expiratory time and cause
or worsen auto PEEP
• When facing poor oxygenation, inadequate ventilation, or high peak
pressures due to intolerance of ventilator settings consider sedation,
analgesia or neuromuscular blockage
Trouble Shooting the Vent
• High peak pressure differential:

High Peak Pressures High Peak Pressures

Low Plateau Pressures High Plateau Pressures
Mucus Plug ARDS
Bronchospasm Pulmonary Edema
ET tube blockage Pneumothorax
Biting ET tube migration to a single
bronchus
Effusion
 Weaning
• Gradual reduction of ventilatory support either by decreasing the
number of machine breaths on IMV or by decreasing the amount of
pressure suport on PSV
• When the patient has recovery adequately from respiratory failure
• Clinical assessment are needed to determine when the patient is
ready for discontinuation of ventilatory support and extubation
• Prolonged mech vent: airway trauma, VAP, increased cardiac
morbidity, death
 Weaning criteria
• Adequate oxigenation
• Hemodynamic stability
• No myocardial ischemia or hypotension
• No significant acid-base disturbance
• Adequate mental status
• Stable metabolic status
• Able to initiate an inspiratory effort