SMART

VENTILATION
: Mechanical
Ventilation 101 Prof K U Tobi
A Mechanical
Ventilator
• Mechanical ventilation is any method
of breathing assistance in which a
machine supports a patient's
breathing.
• Mechanical ventilatory support is
among the commonest indications for
admission to the intensive care unit
(I.C.U.)
 • Introduction
• Characteristics of an ideal ventilator
• Indications for Mechanical Ventilation
Outline and • SMART Ventilation

Learning
- Setting
- Mode

Objectives -
-
Adjuvants
Release
- Troubleshooting
• Initiation of Mechanical Ventilation
 • The mechanical ventilator can be a life-saving device if
used "smartly" or a death box if otherwise. There is a
need to understand the indication for ventilatory
support, the ventilator workings and patient-ventilator
interaction.
• "SMART" ventilation is an acronym which means:
- Setting
Introduction - Mode
- Adjuvant
- Release or Weaning
- Troubleshooting.
• SMART ventilation aims to target Specific, Measurable,
Achievable, Reproducible and Time-bound goals to
restore normal respiratory physiology.
 • Versatile i.e. tidal volume up to 1500mls and
respiratory rate 60/minute and facilities for
other ventilator modes.
• Economical, simple, portable and robust
Characteristics • Nebulisation of drugs possible.
of an ideal • Inspiration and airway pressure monitoring
ventilator: • Long-lasting
“VENTILATE” • Alarm systems e.g. disconnect alarms, high
airway pressure alarms
• Easy to clean and sterilize.
 Indications for mechanical ventilation

• The primary indication for mechanical ventilation

is a respiratory failure; however, the indication for
respiratory support, the underlying condition must
be reversible, or weaning may be impossible.
Specific indications include: the “4Hs”
Hypoxaemic respiratory failure due to, for example
acute respiratory distress syndrome (ARDS) with
ABG values of PaO2< 8kpa (60mmHg)
Hypercapnic respiratory failure with and PaCO2
>8kpa (60mmHg)
Hypoventilation with respiratory rate
<5cycles/minute, tidal volume <5ml/kg
Hyperventilation with respiratory rate
>35cycles/minute
 • Before initiating mechanical ventilation for a patient, some
settings must be fed into the ventilator. These settings should be
patient- and condition-specific. Appropriate settings must be
ensured for optimal ventilatory output and favourable patient
outcomes. These include:
Respiratory rate: The rate set will depend on the tidal volume,
type of lung pathology, and the target PaCO2. for example, 8-12

SMART: breaths/minute for patients with normal lung physiology, 6-8 for
patients with obstructive lung disease and 12-20 for patients
with restrictive lung disease.
Setting Tidal Volume (T.V.): The appropriate initial tidal volume depends
on numerous factors, most notably the disease for which the
patient requires mechanical ventilation. All tidal volumes are
expressed as ml/kg of ideal or Predicted body weight. For all
adults with normal lungs, tidal volume is set at 6-8 mL/kg (based
on ideal body weight).
Flow rate: The usual setting is 40-100 litres per minute, and the
peak flow rate is the maximum flow the ventilator delivers
during inspiration. The flow rate is adjusted in a specific
condition.
 Inspiratory time (I): The normal I: E ratio is 1:2. Depending on the disease
process, such as ARDS, the I: E ratio can be changed to improve
ventilation. Occasionally, inverse ratio ventilation (IRV) may be desired.
Fractional inspired concentration of oxygen (Fi02): Ranges from 21% to
100%. At the initiation of ventilatory support, it is recommended that the
FiO2 be set at 1.0 (100%). Once the patient is stabilized, the FiO2 can be
reduced based on pulse oximetry and arterial blood gas values. The FiO2
should only be as high as is necessary to keep the PaO2 in the desired

SMART: range.
Positive End Expiratory Pressure (PEEP): Physiological PEEP is 4-5 cmH2O.

Setting The setting of PEEP also depends on the patient's lung pathology. For
instance, you could start 'Z.E.E.P.' or zero PEEP in severe asthma.
However, in pulmonary oedema /ARDS, a much higher PEEP, such as 8-10
cmH2O, may be required.
Pressure Limit: Pressure limit protects against barotrauma; thus, a plateau
pressure not exceeding 35 cm H2O is usually recommended. A higher
pressure generated may be an indication of an obstructed airway which
may be due to mucus or secretion.
Trigger: The triggering setting determines the patient's effort to initiate an
inspiratory breath on the ventilator. Note that flow triggering is a better
setting for patients who can breathe spontaneously because it reduces
the work of breathing.
 SMART: Setting

S.No. SETTING FUNCTION USUAL PARAMETERS

Number of breaths delivered by the

 1. Respiratory Rate (RR) Usually 6-20 breaths per minute
ventilator per minute

Volume of gas delivered during each

 2. Tidal Volume (VT) Usually 6-10ml/kg
ventilator breath

Amount of oxygen delivered by 21% to 100%; usually set to keep

 3. Fractional Inspired Oxygen (FiO2)
ventilator to patient PaO2 > 60 mmHg or SaO2 > 90%

Length of inspiration compared to Usually 1:2 or 1:1.5 unless inverse

 4. Inspiratory:Expiratory (I:E) Ratio
length of expiration ratio ventilation is required

Maximum amount of pressure the 10-20 cm H2O above peak inspiratory

 5. Pressure Limit
 SMART: Modes of Ventilation

• Broadly classified into controlled and assisted mode

ventilation.
 Assisted mode ventilation is the most commonly
employed in the I.C.U. This is designed to work with the
patient's respiratory effort. The patient's inspiratory effort
is detected, triggering the ventilator to boost the
inspiratory breath.
 Controlled mandatory ventilation: CMV completely
controls the patient's ventilation, and the patient CANNOT
generate spontaneous breaths, volumes, or flow rates in
this mode, which can either be volume-controlled or
pressure controlled.
- The volume-controlled ventilation (CMV) indications
include patient bucking or fighting the ventilator, tetanus,
convulsive disorders, and crushed chest injury.
- With Pressure Controlled Ventilation (PCV), the ventilator
delivers pressure-limited, time-cycled breaths with a
preset inspiratory pressure.
 •Assist-Controlled mode (A/C): All •Pressure support ventilation
delivered breaths, whether (P.S.V.): Supports spontaneous
mandatory or patient-triggered, breathing of patients by
will be delivered by the ventilator augmenting each inspiratory
according to the set parameters. effort at a preset inspiratory
SMART: This mode is used for patients
who can initiate a breath but
have weakened respiratory
pressure level. It applies pressure
plateau to the patient airway
Modes of muscles.
•Intermittent Mandatory
during spontaneous breathing.
•Adaptive Support Ventilation
Ventilation ventilation: The ventilator
delivers a preset number of time-
(ASV): Patient's data, e.g. body
weight and percentage minute
volume, are fed into the
cycle mandatory breaths and
allows the patient to breathe ventilator. The ventilator selects
spontaneously in between and provides the frequency,
•Synchronized Intermittent inspiratory time, I:E and sets the
Mandatory Ventilation (S.I.M.V.): high-pressure limit for mandatory
Prevents breath stacking, as and spontaneous breaths.
mandatory breaths are •Proportional Assisted Ventilation
synchronized with spontaneous (PAV): Assists patient’s ventilation
breaths. in proportion to the patient's
•Mandatory Minute Ventilation effort inspiratory flow, volume
(MMV): The ventilator measures and pressure are variable, and
patient’s minute volume and, pressure support changes
delivers it as mandatory breaths according to elastance, airflow
in btw spont breaths.. resistance, and patient demand.
 SMART: Modes of
Ventilation
• Volume Assured Pressure Support Ventilation (VAPS): Incorporates
inspiratory pressure support ventilation and conventional volume-assisted
cycles to provide optimal inspiratory flow during assisted or controlled
ventilation. Desired tidal vol and pressure support are preset.
• Pressure Regulated Volume Control Ventilation (P.R.V.C.): Achieves volume
support while keeping P.I.P. at the lowest level. This is achieved by altering
peak and inspiratory time in response to changing airway or compliance
characteristics. At constant flow, P.I.P. increases, which increases airflow
resistance; thus, decreasing flow reduces airflow resistance. To compensate
for lower flow, inspiratory time is prolonged.
• Airway Pressure Release Ventilation (APRV): Similar to CPAP as the patient
can breathe spontaneously. Airway pressure is maintained at moderately high
levels (15-20cmH2O) throughout most of the respiratory cycle, with brief
periods of low pressure to allow lung deflation. Increased pressure ensures
alveolar recruitment and oxygenation, and brief deflation allows CO2
excretion without alveolar collapse.
 • The following mnemonic  Low Volume Ventilation: Lower
facilitates recollection of some of Tidal Volume ventilation reduces
these adjuvants, "P.H.I. L.I.P.E.":. ventilator-induced lung injury
(V.I.L.I), barotrauma, volutrauma,
 Positive End Expiratory Pressure atelectrauma, and biotrauma.
(PEEP): Basically, PEEP does not
allow airway pressure to return to  Prone Ventilation: Typically
SMART: zero at the end of expiration.
Therapeutic PEEP usually ranges
reserved as a rescue treatment
option for severe acute respiratory
Adjuvants of from 10-30cm H2O in adults.
 High-frequency ventilation (HFV)
distress syndrome (ARDS). This
method of ventilation requires
adequate sedation and muscle
Ventilation delivers a small volume of gas
between 1-3ml/kg tidal volume at
a very rapid rate which may range
paralysis. Regular arterial blood gas
must be done to assess the degree
of oxygenation. Attention must be
from 60-180 breaths/minute. paid to the pressure areas to
There are three types of HFV, prevent pressure ulcers.
namely: H.F.P.P.V.: 60-
110breaths/min, H.F.J.V.: 110-  Extracorporeal membrane
600breaths/min and H.F.O.V.: 600- oxygenation (ECMO): This external
3000breaths/min artificial circuit carries venous blood
from the patient to a gas exchange
 Inverse Ratio Ventilation (IRV): device where the blood is
reverses the typical inspiratory: oxygenated, and carbon dioxide
expiratory ratio. IRV intends to removed. The oxygenated blood is
improve oxygenation by increasing then returned to the patient via a
the mean airway pressure (M.A.P.) central vessel.
and inspiratory time. Normal I: E is
1:1.5 to 1:3. But in IRV, I: E may
range from 2:1 to 4:1
 • Weaning off the ventilator is • The process of weaning
gradual withdrawal of From Full Control to SIMV: SIMV-
machine support to allow PSV reduces the need for sedation
the patient resume during the weaning process and it
spontaneous breathing. The facilitates the process of weaning.
SMART: framework for a safe
weaning process in our units
From SIMV-PSV to CPAP: It reduces
the mandatory breaths and allows
Release or is: When the patient is no
longer a GHOST, i.e.
consistent pressure support, which
encourages each spontaneous
Weaning G.C.S.>13/15
breathing with adequate ventilation.
The success of this step determines
Haemodynamic stability: a successful pass to a more
M.A.P.>65mmHg and no supportive mode like CPAP.
longer on inotrope From CPAP to Extubation: evaluate
Oxygenation is improved: RR Spontaneous Breathing Trial (SBT) by
<35/min; FiO2 <0.5, determining the Rapid Shallow
Breath Index, aka Tobin's index.
SPO2>90% and Disconnect the patient from the
PEEP<10cmh2O; tidal ventilator and attach a Wright
volume>5ml/kg, vital spirometer to obtain this index. A
capacity >10ml/kg. result greater than 105 virtually
Spontaneous breathing rules out readiness for weaning. In
adequate with intact the absence of a Wright Spirometer,
reflexes (gag and cough determine Tobi’s index with the
patient on CPAP with low-pressure
reflexes) support (below 10), physiological
Temperature <37.5o C PEEP and FiO2 < 50%.
 • Failure to wean off the ventilator is the failure to pass a
spontaneous breathing trial (S.B.T.). It also means the
requirement for endotracheal intubation within 48 hours
following extubation for a patient on a mechanical
ventilator.
• Some of the reversible causes of failure to wean have
been grouped into a mnemonic "WHEANS NOT":
Wheezing
Failure to Heart diseases, e.g. L.V.H.
wean off the Electrolyte deraignment, e.g. hypokalaemia
Anxiety
ventilator Nutritional insufficiency
Sepsis, e.g. ventilator-associated pneumonia
Opioids use (prolonged)Thyroid disease
 Patient assessment: This Haemodynamic instability:
includes assessing the need Some causes are
for urgent resuscitation, hypovolaemia secondary
SMART: the patient's airway, to a reduction in venous
Troubleshooting adequate and bilateral return exacerbated by
chest movement and the
patient's level of positive intrathoracic
oxygenation, pressure, drug-induced
haemodynamic status or vasodilation and
agitation. myocardial depression and
Hypoxia: In assessing the tension pneumothorax.
patient's hypoxia, follow Agitation: An increase in
this mnemonic, "DOPE”, i.e.
patient agitation and dis-
-Displaced ETT synchrony on the
-Obstructed (kinked or ventilator could be
bitten tube, mucous plug,
etc.) secondary to overall
-Pneumothorax, patient discomfort or
-Esophageal intubation. secondary to feelings of air
hunger.
  The Ventilators Alarms: These are - High Respiratory Rate Alarm
various alarm systems, including (HRRA.): evaluate the patient
high or low-pressure alarms. for anxiety, pain, respiratory
- High Airways Pressure Alarm distress and
SMART: (HAPA): Some causes include confusion/agitation. Verbal
communication is essential in
Troubleshooting inappropriate setting on the
ventilator, displaced or I.C.U. even if the patient
obstructed tubes and circuits. doesn't speak: Reassure the
Others are increased airway patient.
resistance due to bronchospasm, - Apnoea Alarm (AA): The A.A.
and reduced chest or lung can be triggered by three
compliance, e.g. abnormal chest factors viz: Patient,
wall or pneumothorax Endotracheal tube or
- Low-pressure or low-exhaled tidal Ventilator Circuit. If the patient
volume alarm (LAPA.) indicates is not breathing, the alarm will
tubing disconnection or air leak. be triggered by exceeding the
First, verify that the ventilator apnea interval. There may be
tubing is intact and the an accidental extubation, or
connections are tight; reconnect the ventilator circuit might be
and tighten tubing at disconnected from the patient.
connections, drainage, and access
points..
 • Ensure the indication • Enter initial ventilator setting
for ventilatory support (“SMART”) e.g.
is reversible FiO2=1.0 initially then reduce
Initiating • Obtain consent from gradually.
Mechanical relatives or patients if PEEP=5cmH2O
conscious
Ventilation • Obtain baseline ABG
Tidal volume=7-10ml/kg
Inspiratory
before initiating MV pressure=20cmH2O,
• Ensure adequate Frequency =10-15 cycles /min
supply of gas /oxygen,
proper working of the PSV/ASB=20cmH2O
ventilator. I:E ratio=1:2
• Select mode of Flow trigger=2l/min
ventilation: assist or Pressure trigger=-1 to-
control mode 3cmH2O.
Conclusion and
Questions
 • Karin Deden , Ventilation modes in intensive care, • Christopher D Jackson, Zab Mosenifar. Mechanical
HEADQUARTERS Dräger Medical GmbH Moislinger Ventilation. Medscape Updated: Sep 15, 2020
Allee 53–55 23558 Lübeck, Germany www.draeger.com
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