1. Non Invasive Ventilation and Mechanical Ventilation in the ER
September 27, 2016
Shane Barclay MD

2. Remember
This is about using a ventilator in a rural Emergency Department to stabilize patients and/or to maintain them while awaiting transfer. This is NOT about ICU ventilation. The Ventilator is a means of support, not a cure for any condition.

3. So why the fear and confusion about Ventilators ?

4. A/C
I:E ratio
PaCO2
IPAP
FiO2
SIMV
Tidal Volume
Plateau Pressure
BiPAP
Residual Volume
BIPAP
A-a gradient
PaO2
Forced Vital Capacity
PEEP
NIV
EPAP RR
ARDS
IBW

6. “The good thing…”
We are only going to be using a ventilator to quickly turn a sick patient around, say with Pulmonary edema.
Or we are going to intubate a patient and call for the helicopter.
So we don’t need to know most of the dials, modes, settings etc on the vent.
Knowing all this can be helpful, but not essential.

7. Is the most important slide. Contains all the information you need.
The “ NEXT SLIDE”
Is the most important slide. Contains all the information you need.

8. All you need to know ! Asthma/COPD Acute Pulm Edema, Pneumonia, OD, …
everything except Asthma/COPD
CO /- O Type 2
O2 +/- CO Type 1
Mode: S/T
PEEP 5 cm H2O
IPAP(PSV) cm H2O (max 20)
FiO2 100%
Rate 14 (Backup Rate)
Mode: S/T
PEEP O cm H2O
IPAP (PSV) cm H2O (max 20)
FiO2 40%
Rate 14 (Backup Rate)
NIV/BPAP
Mechanical
Ventilation
Mode: A/C Volume
Vt 6-8 cc/kg IBW
RR 18 bpm
PEEP 5 cm H2O - initially
FiO2 100% - initially
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO or SaO2 90%
Mode: A/C Volume
Vt 8 cc/kg IBW
RR 10 bpm
PEEP O-4 cm H2O
FiO2 40%
Goal: keep pH above 7.1

9. So let’s start with Non Invasive Ventilation - NIV
APE, Pneumonia), OD, …
everything except Asthma/COPD
Asthma/COPD
CO /- O2
O2 +/- CO2
Mode: S/T
PEEP 5 cm
IPAP (PSV) 5- 10
FiO2 100%
(Backup) Rate 14
Mode: S/T
PEEP O cm
IPAP (PSV)
FiO2 40%
(Backup) Rate 14
NIV/BPAP

10. Non Invasive Ventilation - NIV
Definition: The provision of ventilator support through the patient’s upper airway using a mask or similar device.

12. Contraindications for NIV
Patient obtunded, can’t protect their airway.
Facial deformity.
Excessive secretions ie pneumonia.
Respiratory arrest.
pH < 7.2 (may indicate need for intubation).
Thick beard. Can be a relative contraindication.

13. ‘Types’ of Respiratory Failure
Type 1 – failure of Oxygenation = HYPOXIA (“injury”) e.g.: Acute Pulmonary Edema (APE) Pneumonia, Atelectasis, ….
Type 2 – failure of Ventilation = HYPERCAPNIA
(“respiratory muscle fatigue” or “obstruction”)
e.g.: COPD, Asthma
Both Type 1 and 2 can be treated with non invasive or invasive (intubation) ventilation depending on patient condition

14. How do you tell Type 1 vs 2 ?
1. Patient history – ie CHF, asthmatic, pneumonia, lung trauma etc. 2. PaO2 : < 60 mmHg, likely Type 1 or Oxygenation failure 3. PaCO2 > 50 mmHg and pH > 7.3, likely Type 2 or Ventilation Failure (acute vs chronic) 4. EtCO2 ? EtCO2 = PaCO2 ABG is the gold standard for both determining hypoxia and hypercapnia.

15. ‘Types’ of Respiratory Failure
Remember
Patients can obviously have combined failure!

16. Non Invasive Ventilation - NIV
Positive NIV –Also called Non Invasive Positive pressure Ventilation (NIPPV) We’re going to call it just NIV

17. Non Invasive Ventilation - NIV
As we shall see in future slides, with NIV you can use “one level” positive pressure – ie PEEP or EPAP or “Bilevel” positive pressure – i.e. IPAP and EPAP
Don’t worry, PEEP, EPAP and IPAP will be explained later!
For patients in the ER, we will be using “Bilevel” positive pressure settings on the Ventilator.

18. Type 1 - Oxygenation Failure Pulmonary Edema, Pneumonia,…
Problem is getting oxygen ‘through’ the obstruction to the alveoli.
The way to fix this is to keep the alveoli ‘open’ during expiration to allow time for the oxygen to get into the vascular system.
Easiest way to do this is to provide continuous pressure into the lung, especially during expiration. (often referred to as ‘splinting’ the alveoli)

20. Oxygenation Failure Pulmonary Edema, Pneumonia
Think of being a passenger in a special car that can go from 0 to 5 or 15 kph within a second and slow down to whatever speed in 1 second. If the car goes continuously at 5 kph, and you stick you head out the window that is ‘continuous pressure’ - CP
Since it is positive pressure, we can call it:
Continuous Positive Pressure.
We can specify that the pressure is going into the airways, so lets call it : Continuous Positive Airway Pressure – ie CPAP.

21. CPAP
CPAP merely delivers continuous positive pressure which is useful during expiration. This allows oxygen transfer in the alveoli. The amount of pressure delivered we call the: Positive End Expiratory Pressure - PEEP
Since it is during expiration, we could also call it:
Expiratory Positive Airway Pressure – or EPAP
So basically:
CPAP = PEEP = EPAP
(conceptually, not mathematically)

22. Back to the special car!

23. Back to the special car! Stick your head out the window again.
Now when you breathe in the car goes up to 15 kph. When you breath out the car drops down to 5 kph.
You are now having ‘bi level’ pressure.
When you breath in, it is ‘Inspiratory Positive Airway Pressure’ (IPAP)
When you breath out, it is ‘Expiratory Positive Airway Pressure (EPAP)

24. So back to Types of Respiratory Failure
Type 1 – failure of oxygenation = Hypoxemia Acute Pulmonary Edema Pneumonia Type 2 – failure of ventilation = Hypercapnia COPD Asthma

25. Type 1 Failure – Oxygenation
The patient needs PEEP – keep the alveoli open to allow O2 exchange. We could use various ‘modes’ on a ventilator to deliver this: CPAP - but used only if Pt very awake/alert S (spontaneous) – used if Pt breathing spontaneously with a good rate S/T (spontaneous/timed) – used if Pt breathing spontaneously but we want to ensure a rate with a set IPAP and EPAP

26. Type 1 Failure – Oxygenation
In everyday use treating Type 1 (and Type 2) failure with NIV, most people use the S/T mode because it ensures that if the patient does start to tire out, their respirations will be maintained at a guaranteed rate (i.e. Timed)

27. Type 2 Failure – Ventilation failure
In this type of respiratory failure there is a problem with the patient’s respiratory muscles tiring out. i.e. they can’t ventilate themselves.
In this scenario, the patient needs inspiratory help
So if the patient is awake and breathing, we can use “Bilevel” ventilation. We want both ‘Inspiratory Positive Airway Pressure’ (sometimes call “Pressure Support Ventilation – PSV) along (maybe) with ‘Expiratory Positive Airway Pressure’
This is called IPAP (PSV) and EPAP respectively.

28. Type 2 Failure – Ventilation failure
Since we want IPAP and EPAP, we can use BiLevel NIV using the ST Mode
So for both Type 1 and Type 2 Respiratory Failure all we need to know is how to set up the S/T Mode!
Then if we want we can ‘finesse’ some of the settings or easier yet, call the RT!

29. A quick word on Terminology
BiPAP vs BIPAP vs Bi level vs BPAP ?
BiPAP and BIPAP are registered trade names from Ventilator companies.
So we should actually be using the terms “Bi Level” or “BPAP”
Or make it really simple and call anyone on a mask as getting Non Invasive Ventilation (NIV)!

30. Treating Type 1 and 2 Respiratory Failure
So if you are unsure, the easiest thing to do is if using NIV for which ever type of failure, use “BPAP” – with the ventilator mode set on S/T.
If you are a purest though, for Oxygenation failure, you really only need PEEP – so you could actually set the IPAP to equal EPAP
For Ventilation failure, you really need IPAP, which is using the S/T mode and setting the PEEP very low or zero – why?

31. Asthmatics and COPD
These patients often have ‘air trapping’ due to inability to exhale fully.
They have what is called ‘auto PEEP’ - i.e. when they exhale they don’t empty their lungs, which functionally acts as a PEEP.
If we go and add PEEP via the ventilator, we can worsen the degree of inflation and if on mechanical ventilation can even induce a pneumothorax.
Therefore be cautious with PEEP when treating asthmatics

32. To Summarize NIV then
Patients needing NIV with Acute Pulmonary Edema or Pneumonia 1. Use S/T mode with IPAP and EPAP
Patients needing NIV with COPD or Asthma
1. Use S/T mode with IPAP and EPAP
or 2. Use S/T mode but with low/nil EPAP setting,
or call the RT

33. NIV APE, Pneumonia), OD, … Asthma/COPD CO2 +/- O2 O2 +/- CO2 Mode: S/T
everything except Asthma/COPD
Asthma/COPD
CO /- O2
O2 +/- CO2
Mode: S/T
PEEP 5 cm
IPAP (PSV) 5- 10
FiO2 100%
(Backup) Rate 14
Mode: S/T
PEEP O cm
IPAP (PSV)
FiO2 40%
(Backup) Rate 14
NIV/BPAP

34. OK? … NOW !
So to summarize, one more time…any patient coming in with respiratory distress, regardless of type, cause, etiology etc,
as you get your ABG, lab, CXR etc, you can start up the Ventilator and set the mode to S/T with the previous settings.

35. Sedation ?
Explain to patient what is going to happen regarding the air ‘rushing’ in. Most patients can tolerate this. However for those that can’t … Fentanyl?

36. QUESTIONS ?

37. Invasive Ventilation aka Mechanical Ventilation
OK, so you tried NIV and the patient got worse, or the patient came in being bagged. Now you have to set up for mechanical ventilation.

38. All you need to know ! APE, Pneumonia, OD, … Asthma/COPD PEEP 5 cm
everything except Asthma/COPD
Asthma/COPD
CO /- O2
O2 +/- CO2
Mechanical
Ventilation
Mode: A/C Volume
Vt 6-8 cc/kg IBW
RR 18 bpm
PEEP 5 cm
FiO2 100%
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO or SaO2 90%
Mode: A/C Volume
Vt 8 cc/kg IBW
RR 10 bpm
PEEP O-4 cm
FiO 40%
Goal: keep pH above 7.1

39. A mention on ‘Modes’ on the Ventilator
Although the Ventilator has many ‘Modes’, for ALL intubated patients with respiratory failure, we can use what is called ASSIST/CONTROL (A/C).
The ‘control’ is that we set the rate, volume etc.
The assist part is if the patient is able or does take an extra breath, that is fine.
The ventilator will give an additional breath at whatever parameters we have set.

40. All you need to know ! APE, Pneumonia, OD, … Asthma/COPD CO2 +/- O2
everything except Asthma/COPD
Asthma/COPD
CO /- O2
O2 +/- CO2
Mechanical
Ventilation
Mode: A/C Volume
Vt 8 cc/kg IBW
RR 10 bpm
PEEP O-4 cm
FiO 40%
Goal: keep pH above 7.1

41. So lets talk about the Asthma/COPD Patient
GOAL – give the patient time to exhale. These patients are CO2 retainers. The Respiratory Rate is what will treat the CO2

42. COPD/Asthma Respiratory Rate (RR) = ventilation (CO2)
Mode: use Assist Control (AC) – Volume
Only FOUR settings you have to consider:
Tidal Volume (Vt) = lung protection
Respiratory Rate (RR) = ventilation (CO2)
FiO2 = oxygenation
PEEP (EPAP) = oxygenation

43. COPD/Asthma 4 settings – Vt, RR, Fi02,PEEP
Tidal Volume (Vt) – think of this as “lung protection”.
Use 8 cc/kg (ideal body wt., not the Pt’s actual body wt.)
This setting should not be altered to fix ventilation.
It should only be changed for lung protection,
ie to prevent barotrauma.

44. Ideal Body Weight Height 5 5’1 5’2 5’3 5’4 5'5 5’6 5’7” 5’8” 5’9”
5’10”
5’11” 6’
6’1”
6’2”
6’3”
6’4”
Male Kg 52 53 55 57 59 61 63 65 66 68 70 72 74 76 78 79 81
Female 49 50 54 60 62 64 67 75 77

45. COPD/Asthma 4 settings – Vt, RR, Fi02/PEEP
2. Rate (RR) = Ventilation. RR is most important setting. Initially set at 10. These patients are going to be Hypercapnic. Adjust rate to keep pH > 7.0 to 7.1 A quick mention of I:E ratio

46. I:E Ratio Inspiratory:Expiratory Ratio
Normal 1 : 1.5 (ie 1 second inspiration, 1.5 seconds expiration)
For asthmatic/COPD we may want a long expiration time to help ‘blow off CO2’.
On the Trilogy vent, the Inspiratory time will usually be set to 0.8 – 1 sec.
To increase the I:E ratio, turn DOWN the Inspiratory Time.

47. COPD/Asthma 4 settings – Vt, RR, Fi02, PEEP
3. and 4. FiO2/PEEP =Oxygenation Start at 100% FiO2 but can drop in 5 minutes to 40% and set PEEP to O-4 Wait minutes then do ABG (or VenousBG) Then call the Resp Tech Oxygenation goal- PaO mmHg or SpO %

48. A quick word on PEEP
Some authors recommend that for asthmatics the PEEP can be zero.
The ‘settings’ in previous slides shows PEEP as “0 – 4”.
The reason is that our ventilator (Trilogy) can go only as low as 4 cm Hg.
This is fine and is not deleterious for patients.

49. A quick word on FiO2
Although you can start someone on an FiO2 of 100%, it is NOT a good thing to leave them on this for a long time.
An FiO2 of 100% for several hours can damage the lungs.
Usually one can step down the FiO2 to ~ 40 % and maintain oxygenation.
Remember, if the O2 Sats are not where you want, use the PEEP to help oxygenate.

51. Now -Ventilation for ‘Everyone Else’
Mode: use Assist Control (AC) – Volume
Only FOUR settings you have to consider:
Tidal Volume (Vt) = lung protection
Respiratory Rate (RR) = ventilation (CO2)
3 & 4. FiO2/PEEP = oxygenation (the most important setting)

52. All you need to know ! APE, Pneumonia, OD, … Asthma/COPD CO2 +/- O2
everything except Asthma/COPD
Asthma/COPD
CO /- O2
O2 +/- CO2
Mechanical
Ventilation
Mode: A/C Volume
Vt 6-8 cc/kg IBW
RR 18 bpm
PEEP 5 cm/FiO2 100%
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO or SaO2 90%
Mode: A/C Volume
Vt 8 cc/kg IBW
RR 10 bpm
PEEP O-4 cm
FiO 40%
Goal: keep pH above 7.1

53. Now -Ventilation for ‘Everyone Else’
Mode: use Assist Control (AC) – Volume
Only FOUR settings you have to consider:
Tidal Volume (Vt) = lung protection cc/kg IBW
Respiratory Rate (RR) = ventilation
3 & 4. FiO2/PEEP = oxygenation % and 5

54. Go back to your settings! 4 settings – Vt, RR, Fi02/PEEP
Tidal Volume (Vt) – think of this as “lung protection”.
Use 6-8 cc/kg (ideal body wt., not actual Pt’s body wt.)
This setting should not be altered to fix ventilation.
It should only be changed for lung protection,
ie to prevent barotrauma.

55. 4 settings – Vt, RR, Fi02, PEEP
Tidal Volume (Vt) – Use 6-8 cc/kg (ideal body wt.)
In healthy patients a ‘normal’ lung volume can be up to 10 cc/kg
But in ‘injured’ lungs, (i.e. filled with fluid, mucus, blood etc) the volumes are going to be WAY less than 10 cc/kg.
Therefore we need much smaller volumes.

57. Lung Volumes The worse the lungs appear on CXR, the lower the volume.
Patients with ARDS can go as low as 4 cc/kg
Remember, maximum lung volumes are around 10 cc/kg.
Resting lung volumes are around 4-5 cc/kg.

58. 4 settings – Vt, RR, Fi02/PEEP
2. Rate (RR) = Ventilation Initially set at , adjust based on CO2 and ventilation needs. i.e. if CO2 high – increase RR – ‘blow off CO2’ if CO2 low – decrease RR Try to keep patient mildly hypercarbic. Remember: EtCO2 does not equal PaCO2 You can use Venous Blood Gases.

59. 4 settings – Vt, RR, Fi02/PEEP
3 & 4. FiO2/PEEP =Oxygenation Start at 100% FiO2 and PEEP of 5 Wait 15 – 30 minutes then do ABG (or VBG) Then call the Resp Tech or… set the FiO2 to 40% and start titrating based on following ARDSnet chart (next slide) Oxygenation goal- PaO mmHg or SpO %

60. FiO2/PEEP Chart - ARDSnet
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
PEEP 5 8 10 12 14 16 18
18-24

61. FiO2/PEEP Chart
FiO2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
PEEP 5 8 10 12 14 16 18
18-24
So you have now set things to FiO2 of 40% (.4) and a PEEP of 5.
If the SpO2 is say 75, then you move one step up to FiO2 0.4 and PEEP of 8. Then after a minute or so check the SpO2.
You keep going up by steps until you get to your goal of SpO2 90 +/-

62. A Quick Word on Oxygen Sats.
There is this thing called “Oxygen Saturation Lag”

63. A Quick Word on Oxygen Sats.
In a healthy patient, how long does it take from when you change something to a patients oxygenation/ventilation for it to change the SpO2 ?
Minimum 30 seconds.
If the patient is hypotensive
30-60 seconds.
If poorly oxygenated, hypotensive and hypothermic
2 minutes or more.

64. Sedation
1. Start with analgesia – ie fentanyl or morphine 2. Then ? Add sedation – midazolam, Ativan, etc For more on this see the Power Point on Ventilator Sedation on the LMHER website under “Ventilators in the ER”

65. QUESTIONS ?

66. Using your ventilator

67. Breathing Circuit connection – connect tubing here
Connect exhalation tubing to lowest outlet
Connect wall oxygen line
AC power outlet

68. Alarm Indicator and Audio Pause Button Magic Handshake Button
Start/Stop Button
Up and Down Buttons
Down also Magic Handshake Button
Left and Right Buttons

69. To Set up the Settings Push and hold the Alarm and the Down Button
This will turn on the panel without turning on the Vent.
This will allow you to set all the settings
without all the noise, air blowing etc.
Alarm - Magic Handshake Button
Note: the ‘magic handshake’ will only work with the Vent plugged in to wall outlet. This is to ensure battery life
Down - Magic Handshake Button

70. Note: The Filter is for trapping the patient’s exhalation gases
Note: The Filter is for trapping the patient’s exhalation gases. It does NOT connect to the ETT/LMA/King tube.
Remember to hook in line CO2 monitor here between tubing and ETT (not shown in this picture)

71. Port for suction catheter to go down.
Clear T piece adaptor
ETT suction connector
Medication nebulizer

72. Blue MDI adaptor (i.e. for salbutamol puffer)

73. QUESTIONS ?

74. Trouble shooting with Mechanical Ventilation (A/C)
1. PaO2 is too low: increase PEEP +/- increase FiO2 2. PaCO2 is too high: increase respiratory rate. 3. PaCO2 is too low: decrease respiratory rate

75. Trouble shooting with Mechanical Ventilation (A/C)
Low PaO2, BP crashing, patient fighting the vent? Disconnect the vent and bag the patient Check for kinked or blocked tube, mainstem intubation… EDE check for Pneumothorax CXR

76. Trouble shooting with Mechanical Ventilation (A/C)
Asthmatic Patient, with same Low PaO2, BP crashing, patient fighting the vent, wheezing, abdominal muscles contracting on exhalation, distended neck veins Disconnect the vent and bag the patient EDE check for Pneumothorax CXR
= Auto PEEP

77. Trouble shooting with Mechanical Ventilation (A/C)
NEVER hesitate to call for help via the Respiratory Techs.

78. For NIV

79. Size of Mask for NIV
3 Sizes: small, medium and large – should cover the nose and mouth.
Mask should be tight enough to seal, but not so tight as to cause pressure sores. You should be able to fit two fingers under the mask straps.
Men with beards: can use lubricant or gel to help seal the mask.
IPAP > 17 – 20 will usually lead to excessive leaks.

80. Then fit the mask. Advise the patient what is going to happen
Push the start button on the ventilator

81. Some NIV “Pre-sets” on the Trilogy
Trigger type Auto Trak Rise time 3 sec Ramp length 5 minutes Ramp Start pressure 4 cm H2O Circuit Disconnect 20 seconds Apnea Alarm 30 seconds Apnea Rate 10 bpm

82. A/C mode “Pre- sets” Flow Pattern Ramp Circuit Disconnect 30 seconds
Low Insp P Alarm 8 cm H2O
High Insp P Alarm 40 cm H2O
Apnea alarm off
Leave all these as is.

83. Philips Trilogy 202 Ventilator
APE, Pneumonia, OD, …
everything except Asthma/COPD
Asthma/COPD
CO /- O2 Type 2
O2 +/- CO2 Type 1
Mode: S/T
PEEP 5 cmH2O
IPAP (PSV) 5-10 cm H2O
FiO2 100%
(Backup) Rate 14
Mode: S/T
PEEP O cm H2)
IPAP (PSV) cm H2O
FiO2 40%
(Backup) Rate 14
NIV/BPAP
Mechanical
Ventilation
Mode: A/C Volume
Vt 6-8 cc/kg IBW
RR 18 bpm
PEEP 5 cm H2)
FiO2 100%
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO or SaO2 90%
Mode: A/C Volume
Vt 8 cc/kg IBW
RR 10 bpm
PEEP O-4 cmH2O
FiO 40%
Goal: keep pH above 7.1

84. LTV 1000 Ventilator APE, Pneumonia, OD, … Asthma/COPD
everything except Asthma/COPD
Asthma/COPD
CO /- O2 Type 2
O2 +/- CO2 Type 1
Mode: SIMV/CPAP
Set Breath rate to - - (or will be in SIMV)
PEEP: 5 cm H20 (max 15) (*)
PSV (IPAP): 10 cm H20 (max 20)
Fi02: 100% initial
Mode: SIMV/CPAP
PEEP: O – 5 cm H20
IPAP: cm H2O (max 20)
FiO2: 100% initially
NIV/BPAP
Mechanical
Ventilation
Mode: A/C Volume
Set “Sensitivity” to 3 (**)
Tidal Volume (Vt): 6-8 cc/kg IBW
Resp. Rate: 18 bpm
PEEP: 5 cm H2O
FiO2: 100% initial
IFR: lpm
After 5 min, do ABG, follow ARDSnet chart
Goal: PaO mmHg or SaO2 90%
Mode: A/C Volume
Tidal Volume (Vt): 8 cc/kg (***)
Resp. Rate: 10 bpm
PEEP: O-4 cm H2O
FiO2: 40 %
IFR: 80 – 100 lpm
Goal: Keep pH above 7.1

85. QUESTIONS ?