![]() Respiratory drive intact (ie not apneic or hypopneic when set rate removed from ventilator?) Head: Are they awake and conscious, able to protect their airway? Cough and gag intact, GCS >8. airway protection for mental status, lung disease, metabolic control etc) Head to toe approach, focusing on why they were intubated in the first place (i.e. Similarly, increasing the i time also leads to increased area under the curve and thus higher mean airway pressure and improved oxygenation. Hence, increasing the PEEP (and to a lesser extent PIP since more time is generally spent in expiration than inspiration) increases the mean airway pressure and thus improves oxygenation. PIP X itime/(itime + etime) + PEEP X e time/(itime + etime) or / (i time+e time) The pressure in inspiration multiplied by the relative amount of time spent in inspiration added to the pressure in expiration multiplied by the relative amount of time spent in expiration. Mean airway pressure can also be calculated fairly easily. Hence, maneuvers that improve mean airway pressure generally improve oxygenation (ie via alveolar recruitment). Mean airway pressure can be understood as the area under the curve (the integral) of the pressure vs. ![]() This is the average pressure in the respiratory system over time (taking into account both inhalation and exhalation) Primarily determined by mean airway pressure (P aw ) ( as opposed to PEEP as commonly noted by early trainees). Theoretically gives the advantages of both pressure control and volume control in that you guarantee a minute ventilation like volume control but also deliver the breath with a decelerating waveform like pressure control. Pressure Regulated Volume Control (PRVC or Volume Guarantee): Hybrid mode where you set a tidal volume and the ventilator looks at the last three breaths delivered to the patient and the pressures/volumes delivered and delivers a breath in a pressure control style (decelerating flow) attempting to achieve your set tidal volume. It also utilizes a square flow waveform that may be less comfortable. The disadvantage is that if there is a significant leak around the ETT, it cannot be used. The advantage is that minute ventilation is guaranteed. The more compliant the lung is, the less pressure is required to achieve the set tidal volume. Pressure (IP and PIP) becomes the dependent variable and thus depends on the patient's compliance and airway resistance. Volume Control (VC): You set the tidal volume and the ventilator delivers that volume. The major advantage of PC is that it utilizes a decelerating flow pattern which generally is more comfortable, achieves the same volume at lower peak airway pressures, and is preferred for non compliant lungs. Conversely, lungs that have improving compliance will have increasingly larger tidal volumes in pressure control mode. Hence, if a patient has lungs that are getting worse and stiff (reduced compliance), their tidal volumes will decrease. ![]() Tidal volume becomes the dependent variable and thus depends on the patient's compliance and airway resistance. Pressure Control (PC): You set the pressures (IP and PEEP). STEP 2: A second classification can then be made by what variable is controlled or set: Patients generally find controlling the duration of their own breaths (ie PS breaths) more comfortable than ventilator controlled duration (ie AC or IMV breaths). However, the difference is that pressure supported breaths are generally terminated (cycled) when the flow reaches a certain point (ie 30% of maximal) whereas a normal pressure control breath is terminated (cycled) by the set inspiratory time. SIMV Pressure Control with a pressure support that is equal to the IP is nearly assist control (all breaths, whether strictly mechanical or patient triggered spontaneous breaths, receive the same pressure). ![]() Hence, this is sometimes considered a weaning mode but is routinely used for the majority of patients in the PICU. Any spontaneous patient triggered breaths above this set rate receive the set pressure support only. Synchronized Intermittent Mandatory Ventilation (SIMV): The ventilator delivers the set number of breaths with the preset PIP or V t, and I t. Every breath, whether mechanical or spontaneous (patient triggered) results in a fully supported breath (still synchronized) STEP 1: Can be divided into the a mount of support the ventilator provides for the patientĪssist Control (AC): More support and control. ![]()
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