The document describes the anatomy and components of a ventilator, including filters, valves, monitors, and modes of breath delivery such as volume control, pressure control, and pressure support ventilation. It discusses factors that affect aerosol drug delivery to mechanically ventilated patients and compares different ventilator modes, noting that no single new mode has been proven superior for improving patient outcomes. The goals of setting the ventilator are also summarized.

1. Anatomy of the Ventilator Dean Hess PhD RRT Associate Professor of Anesthesia Harvard Medical School Assistant Director of Respiratory Care Massachusetts General Hospital Editor in Chief Respiratory Care

2. air O 2 filter filter PATIENT Microprocessor (mode and breath delivery) inspiratory valve(s) (flow, volume, pressure, F I O 2 ) expiratory valve (PEEP) humidifier electrical power atmosphere monitors & alarms

3. expired gas humidifier ventilator patient Aerosolized drug (nebulizer or MDI) filter dead space gas compression bias flow suction

4. Anesthesiology 2006;104:39

5. Crit Care Med 2007;35:260 VAP Crit Care Med 2007;35:260 Closed suction is cost-effective because the same catheter can be used multiple times; even for multiple days.

7. Crit Care Med 2007; 35:2843

14. Equation of Motion Volume Ventilation E = 1/C X X P MUS + P AW = E V + R V . fixed volume and flow increased effort decreased airway pressure fixed pressure increased effort increased flow and tidal volume P MUS + P AW = E V + R V . Pressure Ventilation

15. Flow Dys-synchrony: VCV

16. Improved Synchrony

17. PCV 20 cm H 2 O, PEEP 10 cm H 2 O; Pplat 30 cm H 2 O transpulmonary pressure = 45 cm H 2 O -15 cm H 2 O Active inspiratory effort ↑↑ V T

18. Transpulmonary Pressure ventilator support patient effort

19. Kallet, Respir Care 2005;50:1623

20. Dys-Synchrony with PCV Kallet, Respir Care 2005;50:1623

22. Mireles-Cabodevila, Cleve Clin J Med 2009;76:417

25. Pressure Support Ventilation Adjustable rise time Adjustable flow cycle

27. Volume-Control vs Pressure Control Evidence for better outcomes with either volume-control or pressure-control is lacking VCV PCV PSV Tidal volume Fixed Variable Variable Inspiratory flow Fixed Variable Variable Airway pressure Variable Fixed Fixed Inspiratory time Fixed Fixed Variable Rate Minimum set Minimum set Not set

29. PCV+ (Drager); Bilevel (PB 840) Patroniti, Anesthesiology 2002; 96:788

31. SIMV flow airway pressure esophageal pressure volume spontaneous breath spontaneous breaths mandatory breath

32. Ventilator Modes Continuous Mandatory Ventilation (CMV) Continuous Spontaneous Ventilation (CSV) Intermittent Mandatory Ventilation (SIMV) VCV PCV Dual Control PCIRV APRV CPAP PSV PAV NAVA VCV MMV Dual Control Bilevel Dual Control Automode ASV PCV

34. Setting the Ventilator Ventilator-Induced Lung Injury Gas Exchange Patient Comfort Hemodynamics