Ventilator setting

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Mechanical Ventilation
Ventilator Setting


Mechanical Ventilation

Non Invasive Invasive

Non Invasive: Ventilatory support that is given without
establishing endotracheal intubation or tracheostomy is
called Non invasive mechanical ventilation
Invasive: Ventilatory support that is given through endo-
tracheal intubation or tracheostomy is called as Invasive
mechanical ventilation


Non invasive

Negative pressure Positive pressure
Producing Neg. pressure Delivering air/gas with
intermittently in the pleural positive pressure to the
space/ around the thoracic cage airway

e.g.: Iron Lung BiPAP & CPAP


Invasive
Positive Pressure

Pressure Volume Time cycle
cycle cycle

Pressure Cycle:A pre determined and preset pressure
terminates inspiration. Pressure is constant and
volume is variable.
Volume Cycle:A pre determined and preset volume -
on completion of its delivery , terminates the
inspiratio. Pressure is variable and volume is constant.


Ventilator Settings Terminology

•A/C: Assist-Control
•IMV: Intermittent Mandatory Ventilation
•SIMV: Synchronized Intermittent
Mandatory Ventilation
•Bi-level/Biphasic: Non-inversed Pressure
Ventilation with Pressure Support (consists of
2 levels of pressure)


Ventilator Settings Terminology
(con’t)

•PRVC: Pressure Regulated Volume Control
•PEEP: Positive End Expiratory Pressure
•CPAP: Continuous Positive Airway
Pressure
•PSV: Pressure Support Ventilation
•NIPPV: Non-Invasive Positive Pressure
Ventilation


Noninvasive Bilateral Positive
Airway Pressure Ventilation (BiPAP)
• BiPAP is a noninvasive form of mechanical ventilation
provided by means of a nasal mask or nasal prongs, or a
full-face mask.

• The system allows the clinician to select two levels of
positive-pressure support:

• An inspiratory pressure support level (referred to as
IPAP)

• An expiratory pressure called EPAP (PEEP/CPAP
level).


‫)‪(Adaptive Support Ventilation‬‬
‫‪ASV‬‬
‫• اﯾﻦ ﻣﺪ ھﻮﺷﻤﻨﺪ ﺗﻨﻔﺴﯽ ﺑﯿﻤﺎران را از وﺿﻌﯿﺖ ﮐﺎﻣ ً ﻏﯿﺮ ﻓﻌﺎل ﺗﺎ ﮐﺎﻣ ً ﻓﻌﺎل‬
‫ﻼ‬ ‫ﻼ‬
‫ﺑﺼﻮرت ﺗﻄﺒﯿﻖ ﭘﺬﯾﺮ وﻧﺘﯿﻠﮫ ﻣﯿﮑﻨﺪ.وزن ﺑﯿﻤﺎر ﮐﮫ ﻣﺒﯿﻦ ﺣﺠﻢ دﻗﯿﻘﮫ ای ﻣﯽ‬
‫ﺑﺎﺷﺪ ﺑﮫ ﻋﻨﻮان ﭘﺎراﻣﺘﺮ ورودی ﺑﮫ دﺳﺘﮕﺎه داده ﻣﯿﺸﻮد و دﺳﺘﮕﺎه ﺑﺎ ﺳﻨﺠﺶ‬
‫وﺿﻌﯿﺖ ﺗﻨﻔﺴﯽ ﺑﯿﻤﺎر و ﭘﺮدازش اﻃﻼﻋﺎت ‪Respiratory Rate‬و ‪Tidal‬‬
‫‪ volume‬را ﺑﺼﻮرت اﺗﻮﻣﺎﺗﯿﮏ و ﭘﯿﻮﺳﺘﮫ ﺗﻨﻈﯿﻢ ﻣﯽ ﻧﻤﺎﯾﺪ.‬
‫• در اﯾﻦ ﻣﺪ ﻣﻘﺎدﯾﺮ ‪ Peep‬و 2‪ Fio‬ﺑﺎ ﺗﻮﺟﮫ ﺑﮫ ﻣﯿﺰان اﮐﺴﯿﮋﻧﺎﺳﯿﻮن ﺑﯿﻤﺎر‬
‫ﺗﻮﺳﻂ اﭘﺮاﺗﻮر ﺗﻨﻈﯿﻢ ﻣﯿﮕﺮدﻧﺪ.‬
‫• از آﻧﺠﺎ ﮐﮫ ﻣﺪ ‪ ASV‬ﻋﻤﻞ وﻧﺘﯿﻼﺳﯿﻮن ﺑﯿﻤﺎر را ﺑﺼﻮرت ﺧﻮدﮐﺎر اﻧﺠﺎم‬
‫ﻣﯽ دھﺪ در ﻧﺘﯿﺠﮫ ﻧﯿﺎز زﯾﺎدی ﺑﮫ اﻧﺠﺎم ﻋﻤﻠﯿﺎت ﺗﻮﺳﻂ اﭘﺮاﺗﻮر ﻧﻤﯽ ﺑﺎﺷﺪ‬

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‫‪Airway Pressure Release‬‬
‫)‪Ventilation(APRV‬‬
‫• دو ﺳﻄﺢ ﻣﺘﻔﺎوت از ‪) CPAP‬دم وﺑﺎزدم(ﺗﻨﻈﯿﻢ ﻣﯽ ﺷﻮﻧﺪ ﺑﺮای‬
‫دوره ھﺎﯾﯽ از زﻣﺎن ، ﮐﮫ اﺟﺎزه ﻣﯽ دھﻨﺪ ﺗﻨﻔﺲ ھﺎی ﺧﻮد ﺑﺨﻮد‬
‫در اﯾﻦ دو ﺳﻄﺢ اﺗﻔﺎق ﺑﯿﻔﺘﺪ.‬
‫• ‪ APRV‬ﺗﻨﻔﺲ ﺧﻮد ﺑﺨﻮد اﺳﺖ و ﻣﺪی اﺳﺖ ﮐﮫ ﺑﺮای ﺑﺎز ﻧﮕﮫ‬
‫داﺷﺘﻦ آﻟﻮﺋﻮﻟﮭﺎ ﺑﮫ ﮐﺎر ﻣﯽ رود ﺑﺪون آﻧﮑﮫ ﻓﺸﺎر ‪ PIP‬اﻓﺰاﯾﺶ‬
‫ﯾﺎﺑﺪ.ﭼﻮن اﻓﺰاﯾﺶ ﻓﺸﺎر ﻣﻨﺠﺮ ﺑﮫ ﺑﺎروﺗﺮوﻣﺎ ﻣﯽ ﺷﻮد.‬
‫‪P high=PSV‬‬
‫‪P low=PEEP‬‬
‫• در اﯾﻦ اﻟﮕﻮ ﺑﯿﻤﺎر ﺑﺎﯾﺴﺘﯽ از ﻧﻈﺮ ھﯿﭙﺮ ﮐﺎﭘﻨﯽ ﻣﺎﻧﯿﺘﻮر ﺷﻮد.‬


Ventilator Setting ‫• ﺗﻨﻈﯿﻢ وﻧﺘﯿﻼﺗﻮر‬
– Tidal Volume
– Breath Per Minutes (RR)
– I:E ratio
– Flow Wave Pattern
– Fio2
– Sigh
– Trigger or Sensitivity
• Pressure Trigger
• Flow Trigger ( Flow By)
– Peak Flow
– Peep
– Plateau ( Pause)
– O2 Flash
– Nebulizer


Tidal Volume
6-10cc/kg (IBW) ‫ﺣﺠﻢ ﺟﺎري‬ •
6cc/kg ARDS ‫در‬ •
6-8 cc/kg COPD ‫در‬ •
8-10 cc/kg ‫در ﺑﯿﻤﺎري ﻧﻮروﻣﻮﺳﻜﻮﻟﺮ ﯾﺎ ﭘﺲ از ﻋﻤﻞ ﺟﺮاﺣﻲ‬ •
.‫ 53 ﺑﺎﺷﺪ‬cmH2O ‫ﻓﺸﺎر ﭘﻼﺗﻮ ﺑﺎﯾﺴﺘﻲ ﻛﻤﺘﺮ از‬ •


For adult patients and older children:-
With COPD

• A reduced tidal volume
• A reduced respiratory rate

For infants and younger children:-

• A small tidal volume
• Higher respiratory rate


‫)‪Breath Per Minutes (RR‬‬
‫ﺗﻌﺪاد ﺗﻨﻔﺲ و ﺣﺠﻢ ﺟﺎري ﺗﻌﯿﯿﻦ ﻛﻨﻨﺪه ﺗﮭﻮﯾﮫ دﻗﯿﻘﮫاي ھﺴﺘﻨﺪ.‬ ‫•‬
‫ﺗﻌﺪاد ﺗﻨﻔﺲ ٢١ ﺗﺎ ٥١ در دﻗﯿﻘﮫ ﺗﻨﻈﯿﻢ ﻣﻲﻛﻨﯿﻢ ﺗﺎ ﺗﮭﻮﯾﮫ دﻗﯿﻘﮫاي 01-7‬ ‫•‬
‫‪ L/Min‬ﺣﺎﺻﻞ ﺷﻮد. اﮔﺮ ﺣﺠﻢ ﺟﺎري ﭘﺎﺋﯿﻦ و ‪ PH‬ھﻢ ﭘﺎﺋﯿﻦ اﺳﺖ ‪RR‬‬
‫ﺑﺎﻻﺗﺮي ﻧﯿﺎز اﺳﺖ.‬
‫ﺗﻌﺪاد ﺗﻨﻔﺲ ﻃﻮري اﻧﺘﺨﺎب ﺷﻮد ﺗﺎ ‪ PH‬و 2‪ PaCO‬ﻣﻨﺎﺳﺐ ﺑﺎﺷﺪ.‬ ‫•‬
‫ﺗﻌﺪاد ﺗﻨﻔﺲ زﯾﺎد ﻣﻨﺠﺮ ﺑﮫ ‪ Auto-peep‬ﻣﻲﺷﻮد.‬ ‫•‬
‫ﺗﮭﻮﯾﮫ دﻗﯿﻘﮫاي ﺑﺎﻻ )‪ (>10L/Min‬ﻣﻨﺠﺮ ﺑﮫ ﻓﻀﺎي ﻣﺮده ﻣﻲﺷﻮد.‬ ‫•‬


In a patient with head injury,
• Respiratory alkalosis may be required to
promote cerebral vasoconstriction, with a
resultant decrease in ICP.

• In this case, the tidal volume and respiratory rate
are increased ( hyperventilation) to achieve the
desired alkalotic pH by manipulating the PaCO2.


In a patient with COPD

• Baseline ABGs reflect an elevated PaCO2 should
not hyperventilated. Instead, the goal should be
restoration of the baseline PaCO2.

• These patients usually have a large carbonic acid
load, and lowering their carbon dioxide levels
rapidly may result in seizures.


‫‪I:E ratio‬‬
‫زﻣﺎن دم ﺑﺎ ‪ VT ،flow‬و اﻟﮕﻮي ﺟﺮﯾﺎن ﺗﻌﯿﯿﻦ ﻣﻲﺷﻮد.‬ ‫•‬
‫زﻣﺎن ﺑﺎزدم ﺑﺎ زﻣﺎن دم و ﺗﻌﺪاد ﺗﻨﻔﺲ ﺗﻌﯿﯿﻦ ﻣﻲﺷﻮد.‬ ‫•‬
‫زﻣﺎن ﺑﺎزدم ﺑﺎﯾﺴﺘﻲ ﺑﯿﺸﺘﺮ از زﻣﺎن دم ﺑﺎﺷﺪ.‬ ‫•‬
‫اﮔﺮ ‪ ) BP‬در ﭘﺎﺳﺦ ﺑﮫ ﺗﮭﻮﯾﮫ ﻣﻜﺎﻧﯿﻜﻲ ﯾﺎ ‪ (Auto-PEEP‬زﻣﺎن‬ ‫•‬
‫ﺑﺎزدم ﺑﺎﯾﺪ ﻃﻮﻻﻧﻲ ﺷﻮد ) ‪ flow‬ﺑﺎﻻﺗﺮ، ﺣﺠﻢ ﺟﺎري ﭘﺎﺋﯿﻨﺘﺮ، ﺗﻌﺪاد‬
‫ﺗﻨﻔﺲ ﻛﻤﺘﺮ(‬
‫زﻣﺎن دم ﻃﻮﻻﻧﻲ، ﻓﺸﺎر ﻣﺘﻮﺳﻂ راه ھﻮاﺋﻲ را اﻓﺰاﯾﺶ داده و ﺳﺒﺐ‬ ‫•‬
‫ﺑﮭﺘﺮ ﺷﺪن 2‪ PaO‬ﻣﻲﺷﻮد.‬
‫زﻣﺎن دم ﻃﻮﻻﻧﻲ ﻧﯿﺎز ﺑﮫ ﻣﻮﻧﯿﺘﻮرﯾﻨﮓ ھﻤﻮدﯾﻨﺎﻣﯿﻚ و ‪Auto-PEEP‬‬ ‫•‬
‫دارد.‬

‫2‪Fio‬‬
‫• ﺗﮭﻮﯾﮫ ﻣﻜﺎﻧﯿﻜﺎل را ﺑﺎ 1=2‪ Fio‬ﺷﺮوع ﻛﻨﯿﺪ.‬
‫• ﺑﺎ اﺳﺘﻔﺎده از ﭘﺎﻟﺲ اﻛﺴﻲﻣﺘﺮ ﻣﯿﺰان 2‪ Fio‬را ﻛﺎھﺶ دھﯿﺪ.‬
‫• ﻧﺎﺗﻮاﻧﻲ در ﻛﺎھﺶ 2‪ Fio‬ﺑﮫ ﻛﻤﺘﺮ از 6.0 ﻧﺸﺎﻧﮫ وﺟﻮد ﺷﻨﺖ‬
‫اﺳﺖ.‬


• In adult patients the initial FiO2 may be set at 100%
• until arterial blood gases can document adequate
oxygenation.

• An FiO2 of 100% for an extended period of time can be
dangerous ( oxygen toxicity) but it can protect against
hypoxemia

• For infants, and especially in premature infants, high
levels of FiO2 (>60%) should be avoided.

• Usually the FIO2 is adjusted to maintain an SaO2 of
greater than 90% (roughly equivalent to a PaO2 >60 mm
Hg).

• Oxygen toxicity is a concern when an FIO2 of greater
than 60% is required for more than 25 hours


‫‪Peep‬‬
‫اﺳﺘﻔﺎده از ‪ Peep‬اﻛﺴﯿﮋﻧﺎﺳﯿﻮن را اﻓﺰاﯾﺶ ﻣﻲدھﺪ. ﻣﻌﻘﻮل اﺳﺖ ﻛﮫ از ‪peep‬‬ ‫•‬
‫ﺣﺪاﻗﻞ ٣ ﺗﺎ ٥ ﺳﺎﻧﺘﯿﻤﺘﺮ آب در ﺷﺮوع ﺗﮭﻮﯾﮫ ﻣﻜﺎﻧﯿﻜﻲ اﺳﺘﻔﺎده ﺷﻮد.‬
‫‪ Peep‬را ﻃﻮري ﺗﻨﻈﯿﻢ ﻛﻨﯿﺪ ﺗﺎ ﺳﻄﺢ ﻣﻮرد ﻧﻈﺮ اﻛﺴﯿﮋﻧﺎﺳﯿﻮن ﺑﺪﺳﺖ آﯾﺪ.‬ ‫•‬
‫در ﺑﯿﻤﺎران ﺑﺎ ‪ Peep ،COPD‬را ﺟﮭﺖ ﺑﮭﺒﻮد ﺗﻮاﻧﺎﯾﻲ ﺑﯿﻤﺎر در ﺗﺮﯾﮕﺮ ﻛﺮدن‬ ‫•‬
‫وﯾﻨﯿﻼﺗﻮر ﻣﻲﺗﻮان ﺑﻜﺎر ﺑﺮد.‬
‫در ﺑﯿﻤﺎران ﺑﺎ ﻧﺎرﺳﺎﺋﻲ ﺑﻄﻦ ﭼﭗ ‪ Peep‬ﻣﻲ ﺗﻮاﻧﺪ ﺑﺎ ﻛﺎھﺶ ﺑﺎزﮔﺸﺖ ورﯾﺪي‬ ‫•‬
‫و اﻓﺘﺮﻟﻮد ﺑﻄﻦ ﭼﭗ ﻋﻤﻠﻜﺮد ﻗﻠﺒﻲ را ﺑﮭﺒﻮد ﺑﺨﺸﺪ.‬
‫در ﺳﻄﻮح ﺑﺎﻻي ‪ Peep‬ﺣﺠﻢ ﺟﺎري را ﻛﺎھﺶ دھﯿﺪ.‬ ‫•‬
‫‪ Peep‬در ﺑﯿﻤﺎري رﯾﻮي ﯾﻜﻄﺮﻓﮫ اﻛﺴﯿﮋﻧﺎﺳﯿﻮن را ﻛﺎھﺶ ﻣﻲ دھﺪ زﯾﺮا ﺳﺒﺐ‬ ‫•‬
‫ﺷﯿﻔﺖ ﺧﻮن ﺑﮫ رﯾﮫاي ﻛﮫ وﻧﺘﯿﻠﮫ ﻧﻤﻲ ﺷﻮد ﻣﻲﮔﺮدد.‬


‫‪Flow Wave Pattern‬‬
‫ﻃﺮح ﻣﺮﺑﻌﻲ ) ‪(square‬‬ ‫•‬
‫ﻃﺮح ﺳﯿﻨﻮﺳﻲ )‪(Sinusoidal‬‬ ‫•‬
‫ﻃﺮح ﺻﻌﻮدي )‪(Accelerating‬‬ ‫•‬
‫ﻃﺮح ﻧﺰوﻟﻲ )‪(Decelerating‬‬ ‫•‬
‫ﺣﺎﻟﺘﮭﺎي ﻣﻮج ‪ flow‬ﺣﺪاﻛﺜﺮ ﻓﺸﺎر راه ھﻮاﺋﻲ )‪ (PIP‬و ﻓﺸﺎر ﻣﺘﻮﺳﻂ راه‬ ‫•‬
‫ھﻮاﺋﻲ )‪ (Paw‬ﻣﺨﺘﻠﻔﻲ اﯾﺠﺎد ﻣﻲﻛﻨﻨﺪ. در اﻧﺘﺨﺎب ﻧﻮع ‪ flow‬ﺑﺎﯾﺪ در ﻧﻈﺮ‬
‫داﺷﺖ ﻛﮫ ‪ PIP‬ﻣﮭﻤﺘﺮ اﺳﺖ ﯾﺎ ‪.Paw‬‬
‫ﻣﻮج ﻣﺮﺑﻊ و ﻣﻮج اﻓﺰاﯾﺶ ﯾﺎﺑﻨﺪه از ﻟﺤﺎظ ﺧﺼﻮﺻﯿﺎت ﺷﺒﯿﮫ ﯾﻜﺪﯾﮕﺮﻧﺪ و از‬ ‫•‬
‫ﻃﺮﻓﻲ ﻣﻮج ﻛﺎھﺶ ﯾﺎﺑﻨﺪه و ﻣﻮج ﺳﯿﻨﻮﺳﻲ ﻧﯿﺰ ﺷﺒﯿﮫ ھﻢ ﻣﻲ ﺑﺎﺷﻨﺪ.‬
‫در ﻣﻮج ﻣﺮﺑﻊ و اﻓﺰاﯾﺶ ﯾﺎﺑﻨﺪه ﻣﯿﺰان ‪ ) PIP‬ﺑﻄﻮر ﻣﺘﻮﺳﻂ 5.62( و ‪) Paw‬‬ ‫•‬
‫6.4( ﻣﻲ ﺑﺎﺷﺪ. در ﻣﻮج ﻛﺎھﺶ ﯾﺎﺑﻨﺪه و ﺳﯿﻨﻮﺳﻲ ‪ ) PIP‬ﺑﻄﻮر ﻣﺘﻮﺳﻂ ٢٢(‬
‫و ‪ (٥)paw‬ﻣﻲﺑﺎﺷﺪ.‬

● Peak Airway Pressure:-

• In adults if the peak airway pressure is
persistently above 45 cmH2O, the risk of
barotrauma is increased and efforts should be
made to try to reduce the peak airway pressure.

• In infants and children it is unclear what level of
peak pressure may cause damage. In general,
keeping peak pressures below 30 is desirable.


‫‪Sigh‬‬
‫• ھﺪف از دم ﻋﻤﯿﻖ ﻣﻘﺎﺑﻠﮫ ﺑﺎ اﻧﺴﺪاد راھﮭﺎي ھﻮاﺋﻲ ﻛﻮﭼﻚ اﺳﺖ ﻛﮫ‬
‫ﻣﻤﻜﻦ اﺳﺖ در ﺻﻮرت اراﺋﮫ ﺣﺠﻢ ﺟﺎري ﯾﻜﻨﻮاﺧﺖ ﺑﺮوز ﻧﻤﺎﯾﺪ.‬
‫• ﺣﺠﻢ ‪ ٥/١ sigh‬ﺗﺎ ٢ ﺑﺮاﺑﺮ ﺣﺠﻢ ﺟﺎري و ﺗﻌﺪاد آن ٤ ﺗﺎ ٦‬
‫ﻣﻲﺑﺎﺷﺪ.‬
‫• در ﺣﺠﻢھﺎي ﺟﺎري ﺑﺎﻻ ﯾﺎ ﺑﻜﺎرﮔﯿﺮي ‪ peep‬ﻧﯿﺎزي ﺑﮫ ‪sigh‬‬
‫ﻧﯿﺴﺖ.‬


● Sensitivity(trigger Sensitivity)
• The sensitivity function controls the amount of patient
effort needed to initiate an inspiration

• Increasing the sensitivity (requiring less negative force)
decreases the amount of work the patient must do to
initiate a ventilator breath.

• Decreasing the sensitivity increases the amount of
negative pressure that the patient needs to initiate
inspiration and increases the work of breathing.


‫)‪Pressure Trigger(sensitivity‬‬
‫ﺗﻨﻈﯿﻢ ﺣﺴﺎﺳﯿﺖ ﻧﻤﺎﯾﺎﻧﮕﺮ ﻣﻘﺪار اﻓﺖ ﻓﺸﺎر در زﯾﺮ ﺧﻂ ﭘﺎﯾﮫ ) اﻧﺘﮭﺎي ﺑﺎزدم(‬ ‫•‬
‫اﺳﺖ ﻛﮫ ﺑﯿﻤﺎر ﺑﺎﯾﺴﺘﻲ در ﻣﺪار وﻧﺘﯿﻼﺗﻮر اﯾﺠﺎد ﻛﻨﺪ ﺗﺎ ﻣﻮﺟﺐ ﺗﺤﺮﯾﻚ دﺳﺘﮕﺎه‬
‫ﺟﮭﺖ اراﺋﮫ ﺣﺠﻢ ﺟﺎري ﺗﻨﻈﯿﻤﻲ ﺑﺮ روي آن ﺷﻮد.‬
‫ﺑﺎ ﺗﻨﻈﯿﻢ ﺻﺤﯿﺢ ﻛﻠﯿﺪ ﺣﺴﺎﺳﯿﺖ، ﻣﻲﺗﻮان ﭘﺎﺳﺦ ﺗﮭﻮﯾﮫاي دﺳﺘﮕﺎه را ﺑﺎ ﻛﻮھﺶ‬ ‫•‬
‫ﺗﻨﻔﺴﻲ ﺑﯿﻤﺎر ھﻤﺎھﻨﮓ ﻧﻤﻮد.‬
‫ﻣﻘﺪار آن از ٠/٥- ﺗﺎ ٠١- ﺳﺎﻧﺘﯿﻤﺘﺮ آب ﻗﺎﺑﻞ ﺗﻨﻈﯿﻢ اﺳﺖ.‬ ‫•‬
‫ﻣﻘﺪار ﺗﻨﻈﯿﻢ ﺑﺎﯾﺴﺘﻲ٥/ ١-٥ /٠ﺳﺎﻧﺘﯿﻤﺘﺮ آب زﯾﺮ ‪ baseline‬ﺑﺎﺷﺪ.‬ ‫•‬
‫در ﻣﺪ ‪ SIMV‬ﻓﺸﺎر ﻣﻨﻔﻲ ﻻزم ﺑﺮاي ﺗﺤﻮﯾﻞ دم اﺟﺒﺎري ﺗﻮﺳﻂ وﻧﺘﯿﻼﺗﻮر‬ ‫•‬
‫ﻧﺒﺎﯾﺪ از ١- ﺗﺎ ٢- ﺳﺎﻧﺘﯿﻤﺘﺮ آب ﺑﯿﺸﺘﺮ ﺑﺎﺷﺪ زﯾﺮا ھﺪف از ﺗﻨﻈﯿﻢ ﺣﺴﺎﺳﯿﺖ در‬
‫ﻣﺪ ‪ SIMV‬ھﻤﺎھﻨﮓ ﻛﺮدن دم اﺟﺒﺎري ﺑﯿﻤﺎر ﺑﺎ ﺷﺮوع دم ارادي اﺳﺖ.‬


‫)‪Flow Trigger ( Flow By‬‬
‫‪ Base flow‬ﺑﺮاﺑﺮ ﺑﺎ ﺗﮭﻮﯾﮫ دﻗﯿﻘﮫاي ﺑﯿﻤﺎر و ‪ sense flow‬ﻧﺼﻒ ‪ base‬ﯾﺎ‬ ‫•‬
‫ﺣﺪاﻗﻞ ١.‬
‫‪ Base flow‬ﺑﺮاﺑﺮ ﺗﮭﻮﯾﮫ دﻗﯿﻘﮫ اي ﺑﯿﻤﺎر و ‪ ١-٣ sense‬ﻟﯿﺘﺮ زﯾﺮ ‪base‬‬ ‫•‬
‫‪flow‬‬
‫وزن ﻛﻤﺘﺮ از ٥٢ ﻛﯿﻠﻮﮔﺮم ‪ ١ sense‬ﻟﯿﺘﺮ در دﻗﯿﻘﮫ ) ‪(small patient‬‬ ‫•‬
‫وزن ٥٢ ﺗﺎ ٠٥ ﻛﯿﻠﻮﮔﺮم ‪ ٢ sense‬ﻟﯿﺘﺮ در دﻗﯿﻘﮫ‬ ‫•‬
‫وزن ﺑﯿﺸﺘﺮ از ٠٥ ﻛﯿﻠﻮﮔﺮم ‪ ٣ sense‬ﻟﯿﺘﺮ در دﻗﯿﻘﮫ ) ﺑﺰرﮔﺴﺎﻻن(‬ ‫•‬
‫ﺣﺪاﻗﻞ ‪ ٥ baseflow‬ﻟﯿﺘﺮ در دﻗﯿﻘﮫ و ﺣﺪاﻛﺜﺮ آن ٠٢ ﻟﯿﺘﺮ در دﻗﯿﻘﮫ. اﮔﺮ‬ ‫•‬
‫‪ base flow‬زﯾﺎد ﺑﺎﺷﺪ ﻣﻮﺟﺐ اﻓﺰاﯾﺶ ‪ Peep‬و اﻓﺰاﯾﺶ ﻓﺸﺎر راه ھﻮاﺋﻲ‬
‫ﻣﻲﺷﻮد.‬


‫)‪Plateau ( Pause‬‬
‫در اﯾﻦ روش در ﭘﺎﯾﺎن دم درﯾﭽﮫ ﺑﺎزدﻣﻲ ﻣﺴﺪود ﺷﺪه، ھﻮا ﺑﮫ ﻣﺪت ﻛﺴﺮي از‬ ‫•‬
‫ﺛﺎﻧﯿﮫ در رﯾﮫ ھﺎ ﻣﺘﻮﻗﻒ ﻣﯿﮕﺮدد. اﯾﺠﺎد وﻗﻔﮫ در اﻧﺘﮭﺎي دم ﻣﻮﺟﺐ ﺣﻔﻆ ﺑﺎد‬
‫ﺷﺪﮔﻲ رﯾﮫھﺎ ﺑﺮاي ﯾﻚ دوره زﻣﺎﻧﻲ اﺧﺘﺼﺎﺻﻲ ) ﻣﻌﻤﻮﻻ ﻛﻤﺘﺮ از ٢ ﺛﺎﻧﯿﮫ(‬
‫ﻣﻲﺷﻮد.‬
‫ﺗﻮﻗﻒ ھﻮا در اﻧﺘﮭﺎي دم ﺑﮫ اﻧﺘﺸﺎر ﺑﯿﺸﺘﺮ ھﻮا در ﻗﺴﻤﺘﮭﺎي ﻣﺤﯿﻄﻲ رﯾﮫ ﻛﻤﻚ‬ ‫•‬
‫ﻣﻲﻛﻨﺪ و ﻣﻮﺟﺐ ﻛﺎھﺶ ﻧﻮاﺣﻲ ﺗﮭﻮﯾﮫ، ﻓﻀﺎي ﻣﺮده و ﺷﻨﺖ ﺷﺪه ﺑﮫ ﺑﮭﺒﻮد‬
‫ﺗﺒﺎدل ﮔﺎزي ﺑﯿﻦ ﺧﻮن ﻛﺎﭘﯿﻠﺮي و ھﻮاي داﺧﻞ آﻟﻮﻟﮭﺎ ﻛﻤﻚ ﻣﻲﻛﻨﺪ.‬
‫زﻣﺎن وﻗﻔﮫ دﻣﻲ ﺑﮫ زﻣﺎن دم اﺿﺎﻓﮫ ﺷﺪه و از زﻣﺎن ﺑﺎزدم ﻛﺎﺳﺘﮫ ﻣﻲﺷﻮد.‬ ‫•‬
‫اﺳﺘﻔﺎده از وﻗﻔﮫ اﻧﺘﮭﺎي دﻣﻲ اﺟﺎزه ﻣﻮﻧﯿﺘﻮرﯾﻨﮓ ﻛﻤﭙﻠﯿﺎﻧﺲ و ﻣﻘﺎوﻣﺖ را ﻣﻲ‬ ‫•‬
‫دھﺪ.‬
‫ﻓﺸﺎر ﭘﻼﺗﻮ ﻣﻨﻌﻜﺲ ﻛﻨﻨﺪه ﻓﺸﺎر داﺧﻞ آﻟﻮﺋﻮﻟﻲ اﺳﺖ ﻛﮫ از آن ﺟﮭﺖ ﻛﻤﭙﻠﯿﺎﻧﺲ‬ ‫•‬
‫اﺳﺘﺎﺗﯿﻚ اﺳﺘﻔﺎده ﻣﻲﺷﻮد.‬


‫‪Peak Flow‬‬
‫ﺳﺮﻋﺖ ﺟﺮﯾﺎن ھﻮا در ﻃﻮل دم ﻛﮫ ﺑﺮ ﺣﺴﺐ ﻟﯿﺘﺮ در دﻗﯿﻘﮫ ﻣﺤﺎﺳﺒﮫ ﻣﻲﺷﻮد.‬ ‫•‬
‫ﺗﻨﻈﯿﻢ ‪ Peak flow‬ﺑﺎ ﺗﻮﺟﮫ ﺑﮫ ﺗﻌﺪاد ﺗﻨﻔﺲ ﺑﯿﻤﺎر در دﻗﯿﻘﮫ و ﺣﺠﻢ ﺟﺎري‬ ‫•‬
‫ﺗﻨﻈﯿﻤﻲ ﺑﺮ روي دﺳﺘﮕﺎه اﺳﺖ. راﺑﻄﮫ ‪ flow‬ﺑﺎ زﻣﺎن دم و ﺣﺠﻢ ﺟﺎري ﺑﮫ‬
‫ﺻﻮرت ‪VT=F×Ti‬‬
‫‪ Flow‬زﯾﺎد ﻣﻨﺠﺮ ﺑﮫ ﻛﻮﺗﺎه ﺷﺪن زﻣﺎن دم، اﻓﺰاﯾﺶ ‪ PIP‬و ﺗﻮزﯾﻊ ﻛﻢ ﮔﺎز در‬ ‫•‬
‫رﯾﮫ ﻣﻲﮔﺮدد.‬
‫‪ Flow‬ﻛﻢ ﻣﻨﺠﺮ ﺑﮫ ﻛﺎھﺶ ‪ ،PIP‬ﺗﻮزﯾﻊ ﺑﮭﺘﺮ ﮔﺎز در رﯾﮫ، اﻓﺰاﯾﺶ ‪،Paw‬‬ ‫•‬
‫ﻃﻮﻻﻧﻲ ﺷﺪن زﻣﺎن دم، ﻛﻮﺗﺎه ﺷﺪن زﻣﺎن ﺑﺎزدم و ‪ ،air trapping‬اﺛﺮات‬
‫ﻧﺎﻣﻄﻠﻮب ﺑﺮ روي ﺳﯿﺴﺘﻢ ﻗﻠﺒﻲ-ﻋﺮوﻗﻲ‬
‫‪ Flow‬ﺑﺎﯾﺴﺘﻲ ﻃﻮري ﺗﻨﻈﯿﻢ ﺷﻮد ﻛﮫ ﻧﺴﺒﺖ دم ﺑﮫ ﺑﺎزدم از٥/ ١:١ ﺗﺎ ٤:١‬ ‫•‬
‫ﺷﻮد. ‪ Flow‬ﺑﺮ ﺣﺴﺐ ﻧﯿﺎز ﺑﯿﻤﺎر ﺑﺎ دﻗﺖ ﺗﻨﻈﯿﻢ ﺷﻮد.‬


Ensuring humidification and
thermo regulation
• All air delivered by the ventilator passes through the
water in the humidifier, where it is warmed and
saturated.

• Humidifier temperatures should be kept close to body
temperature 35 ºC- 37ºC.

• In some rare instances (severe hypothermia), the air
temperatures can be increased.

• The humidifier should be checked for adequate water
levels


‫‪Alarm system‬‬
‫• ‪ : Alarm system‬ﺷﺪت آﻻرم ﻣﺘﻨﺎﺳﺐ ﺑﺎ وﺧﺎﻣﺖ‬
‫اﺧﺘﻼل اﯾﺠﺎد ﺷﺪه ﻣﻲ ﺑﺎﺷﺪ.‬
‫– ﺷﻨﯿﺪاري‬
‫– دﯾﺪاري‬
‫• آﻻرم اﻛﺴﯿﮋن‬
‫– در ﺣﺪ ﺑﺎﻻﺗﺮ و ﭘﺎﯾﯿﻦ ﺗﺮ از2‪ FIO‬ﺗﻨﻈﯿﻢ ﻣﻲ ﺷﻮد‬
‫– ﻋﻠﻞ:‬
‫• ﺗﻐﯿﯿﺮ ﻋﻤﺪي 2‪FIO‬‬
‫• ﺧﻄﺎي آﻧﺎﻟﯿﺰور اﻛﺴﯿﮋن‬
‫• اﺷﻜﺎل در ﻣﻨﺒﻊ اﻛﺴﯿﮋن‬


‫• آﻻرم ﻓﺸﺎر‬
‫– ‪:High pressure limit‬‬
‫• ٠١ ‪ cm H2O‬ﺑﺎﻻﺗﺮ از ‪ PIP‬ﺗﻨﻈﯿﻢ ﻣﻲ ﺷﻮد‬
‫• ﻋﻠﻞ:‬
‫اﻧﺴﺪاد راه ھﻮاﯾﻲ‬ ‫–‬
‫ﻛﺎھﺶ ﻛﻤﭙﻠﯿﺎﻧﺲ رﯾﮫ: ﭘﻨﻮﻣﻮﺗﻮراﻛﺲ, ‪ ,ARDS‬آﺗﻠﻜﺘﺎزي, اﺳﻜﺎر ﺳﻮﺧﺘﮕﻲ‬ ‫–‬
‫ھﻨﮕﺎم ‪sigh‬‬ ‫–‬
‫‪ ,gaging‬ﺳﺮﻓﮫ ﻛﺮدن‬ ‫–‬
‫‪Fighting‬‬ ‫–‬
‫– ‪:Low pressure limit‬‬
‫• ٥-٠١‪ cmH2O‬ﭘﺎﯾﯿﻦ ﺗﺮ از ‪PIP‬ﺗﻨﻈﯿﻢ ﻣﻲ ﺷﻮد‬
‫• ﻋﻠﻞ:‬
‫– ﻗﻄﻊ ارﺗﺒﺎط ﺑﯿﻤﺎر از وﻧﺘﯿﻼﺗﻮر‬
‫– وﺟﻮد ﻧﺸﺖ در ﺳﯿﺴﺘﻢ‬


:Low oxygen pressure alarm •
‫– ﻋﻠﺖ ﭘﺎﯾﯿﻦ ﺑﻮدن ﻓﺸﺎر در ﻣﻨﺒﻊ اﻛﺴﯿﮋن وﻧﺘﯿﻼﺗﻮر ﻣﻲ ﺑﺎﺷﺪ‬
:Low air pressure alarm •
‫– ﻋﻠﺖ ﭘﺎﯾﯿﻦ ﺑﻮدن ﻓﺸﺎر ھﻮاي ﻓﺸﺮده و ﯾﺎ ﺧﺮاﺑﻲ ﻛﻤﭙﺮﺳﻮر‬
‫دﺳﺘﮕﺎه ﻣﻲ ﺑﺎﺷﺪ‬
:Low PEEP/CPAP alarm •
PEEP/CPAP ‫ ﭘﺎﯾﯿﻦ ﺗﺮ از ﻣﯿﺰان‬cmH2O٥-٣ –
‫– ﻋﻠﺖ وﺟﻮد ﻧﺸﺖ در ﻣﺪار ﺗﮭﻮﯾﮫ ﻣﻲ ﺑﺎﺷﺪ‬


‫• ‪: Volume alarm‬‬
‫– ‪Low exhaled tidal volume or minute‬‬
‫‪ventilation‬‬
‫• ٠١% ﻛﻤﺘﺮ از ‪ T.V‬و ﯾﺎ‪VE‬ﺗﻨﻈﯿﻢ ﻣﻲ ﺷﻮد‬
‫• ﻋﻠﻞ:‬
‫– ﻧﺸﺖ در ﺳﯿﺴﺘﻢ ﺗﻨﻔﺴﻲ‬
‫– ﻛﺎھﺶ ﻛﻤﭙﻠﯿﺎﻧﺲ و ﯾﺎ اﻓﺰاﯾﺶ ﻣﻘﺎوﻣﺖ رﯾﻮي در ‪ mode‬ﻓﺸﺎري‬
‫– ﻣﺮﻃﻮب ﺷﺪن ‪flow sensor‬‬
‫– ‪High exhaled tidal volume or minute‬‬
‫‪ventilation‬‬
‫• ٥١-٠١ % ﺑﺎﻻﺗﺮ از ‪ T.V‬و ﯾﺎ‪VE‬ﺗﻨﻈﯿﻢ ﻣﻲ ﺷﻮد‬
‫• ﻋﻠﻞ:‬
‫اﻓﺰاﯾﺶ ﺗﻌﺪاد ﺗﻨﻔﺲ ﯾﺎ ﺣﺠﻢ ﺟﺎري‬ ‫–‬
‫ﺗﻨﻈﯿﻢ ﻧﺎﻣﻨﺎﺳﺐ وﻧﺘﯿﻼﺗﻮر‬ ‫–‬
‫ﺗﻨﻈﯿﻢ اﺷﺘﺒﺎه ﻛﻠﯿﺪ ﺣﺴﺎﺳﯿﺖ‬ ‫–‬
‫وﺟﻮد آب در ﻟﻮﻟﮫ ھﺎي وﻧﺘﯿﻼﺗﻮر‬ ‫–‬


‫• ‪High/low respiratory rate alarm‬‬
‫– ﻋﻠﺖ ﺗﻐﯿﯿﺮ ﺗﻌﺪاد ﺗﻨﻔﺲ ﺑﯿﻤﺎر از ﺣﺪود ﺗﻌﯿﯿﻦ ﺷﺪه‬
‫• ‪Apnea alarm‬‬
‫– زﻣﺎﻧﻲ ﻓﻌﺎل ﻣﻲ ﺷﻮد ﻛﮫ در ﻣﺪت زﻣﺎن ﺗﻨﻈﯿﻢ ﺷﺪه )ﻣﻌﻤﻮﻻ ٠٢ ﺛﺎﻧﯿﮫ(‬
‫ھﯿﭻ ﮔﻮﻧﮫ ﺗﻼش ﺗﻨﻔﺴﻲ اﻧﺠﺎم ﻧﺸﻮد‬
‫– ﻋﻠﻞ:‬
‫• ﻋﺪم ﺗﻼش ﺗﻨﻔﺴﻲ ﺑﯿﻤﺎر‬
‫• ﺷﻞ ﺷﺪن راﺑﻂ ﻣﺮﺑﻮط ﺑﮫ ‪flow sensor‬‬
‫• ‪I:E ratio alarm‬‬
‫– ﻋﻠﺖ ﺗﻨﻈﯿﻢ ﻧﺎﻣﻨﺎﺳﺐ وﻧﺘﯿﻼﺗﻮر ﻣﻲ ﺑﺎﺷﺪ‬
‫• ‪Inoperative ventilator/machine failure alarm‬‬
‫– ﻋﻠﻞ:‬
‫• ﻗﻄﻊ ﺑﺮق‬
‫• اﻓﺖ ﻓﺸﺎر اﻛﺴﯿﮋن ﯾﺎ ھﻮا‬
‫• اﺧﺘﻼل در ﻋﻤﻠﻜﺮد ﺳﺨﺖ اﻓﺰاري وﻧﺘﯿﻼﺗﻮر‬


Common terms
• PIP = Peak Inspiratory Pressure
• Peep = Positive End Expiratory Pressure
• Frequency = rate of ventilation (20 – 40 bpm)
• I – time = Inspiratory time (.2 - .8 seconds)
• MAP = Mean airway pressure
• Tidal Volume = amount of air inhaled in a single
breath
• Minute Ventilation


Neonatal Ventilation
• Time Cycled and Pressure Limited
Ventilation
– Inspiration is stopped when the selected
inspiratory time has been reached
– PIP is the maximum amount of pressure exerted
on the patient’s airway during the inspiration
– Initial values = 16-20 cmH20 of PIP
– Good chest rise and Good breath sounds


Neonatal Ventilation
• Peep = Positive pressure maintained in the
patient’s airway during expiration
– Prevents collapsed alveoli
– Increases FRC
– Improves compliance
– Improves oxygenation
– Decreases intrapulmonary shunting
– Allows for lower PIPs to be used


CPAP vs PEEP
• Same distending alveolar pressure
• PEEP is used in conjunction with ventilator
rate
• CPAP is used in spontaneously breathing
patient


Methods of administering CPAP
• Endotracheal Tube
– Patent airway, airway clearance
– Disadvantage: plugging, malacia, infection
• Nasal Prongs
– Decrease infection, no malacia
– Disadv. = plugging,pressure necrosis, gastric distention
• Nasopharyngeal
– Pressure necrosis, infection
• Face Mask
– Temporary measure prior to intubation or for apnea episode


Most popular method
• High flow nasal cannula


MAP

• Most powerful influence on oxygenation
• Average pressure exerted on the airway and
lungs for the entire breath cycle
• Affected by: PIP,PEEP,I-Time, Rate
• High levels can lead to decreased CO,
pulmonary hypoperfusion and barotrauma


Target Values: MAP

Mean Airway Pressure
• Average pressure exerted on the airways from the start of
one inspiration until the next
• Is affected by IT, PIP, Rate, and PEEP
• Baro/Volutrauma seen with values above 12 cmH2O
• It is the most powerful influence on oxygenation!


Indications for Vent Support
• Respiratory Failure
– Hypoxemic respiratory failure
• PaO2 less than 50 on FIO2 greater than 60
– Hypercapnic respiratory failure
• PaCO2 greater than 50 and pH less than 7.25
– Mixed respiratory failure
• Both hypoxemia and hypercapnia


Target Values: ABGs
• pH: 7.25 – 7.45
• PaCO2: 35-55 mmhg
– Increased chances of intracranial bleed if above
55 mmhg
• PaO2: 50 – 70 mmhg
– Capillary is 35 – 50 mmhg


Initial Setting on neonatal vent
• Time cycled – Pressure Limited ventilator
– PIP set 15 – 20 cm H20
– Peep set 3 – 5 cm H2O
– Rate set 20 – 40 bpm
– Flow set 6 – 8 lpm
– I time set .3 - .5 seconds for LBW and .5 - .8
seconds for larger infants


Settings
• PIP – good chest excursion, good lung
aeration

• Vt in pressure control = PIP – PEEP

• Vt in pressure control changes with change
in compliance and resistance


Blood gas analysis
• Normal values (1 hr age, not ventilated)
– Preterm: pH 7.28-7.32, PCO2 35-45, PO2 50-80
– Term: pH 7.30-7.35, PCO2 35-45, PO2 80-95

• Remember! O2 content determined mostly
by SpO2 and Hb%.


Ventilator settings
• PEEP:
– affects MAP (PO2), affects VT (PCO2)
depending on position on P-V curve

Volume
PEEP PIP

Pressure
– older infants (e.g. BPD) tolerate higher levels
of PEEP (6-8 cm H2O) better
– RDS: minimum 2-3, maximum 6 cm H2O.


Ventilator setting

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Ventilator setting