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1
Aubin, Paul F. AutoCAD MEP 2011. [Clifton Park, NY]: Autodesk Press, 2011.
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2
Kreit, John W. y John A. Kellum. Mechanical Ventilation. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.001.0001.
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Mechanical Ventilation—Physiology and Practice provides a comprehensive review of the physiological principles underlying mechanical ventilation, as well as practical approaches to the management of patients with respiratory failure. The book explains instrumentation and terminology, ventilator modes and breath types, ventilator alarms, how to write ventilator orders, and how to diagnose and correct patient–ventilator asynchrony. It also discusses the physiological assessment of the mechanically ventilated patient and the diagnosis and management of dynamic hyperinflation, and describes how to manage patients with the acute respiratory distress syndrome (ARDS), severe obstructive lung disease, and right ventricular failure; how to “wean” patients from the ventilator; and how and when to use noninvasive ventilation.
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Lei, Yuan. Introduction. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.003.0001.
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The ‘Introduction’ chapter presents the concept of the entire ventilator system, whose understanding is crucial for the clinician performing mechanical ventilation. Mechanical ventilation is a risky, expensive, and error-prone therapy, the author asserts, which is why it is so important to understand not just the clinical application of ventilation, but also the equipment used in ventilation therapy. Furthermore, the ventilator must be viewed within the context of the larger ventilation system. This chapter defines the book’s audiences and discusses its value to them.
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Oliver, Charles M. y S. Ramani Moonesinghe. Setting rate, volume, and time in ventilatory support. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0093.
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Ventilator rate, volume, and time parameters are interrelated directly, mechanically, and physiologically, and interactions between intrinsic pulmonary physio-mechanics, pathology and the effects of mechanical ventilation complex. The physiological consequences of mechanical ventilation and risks of ventilator-induced trauma may be exacerbated by lung pathology. Programming of ventilator parameters should be considered within the context of an individualized ventilatory strategy to achieve adequate gas exchange, while minimizing attendant risks of mechanical ventilation. Recommended strategies should be modified within accepted limits to mitigate disease-specific risks. Parameters should subsequently be titrated against blood gas- and ventilator-derived targets, and other clinical variables.
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Fanelli, Vito y V. Marco Ranieri. Failure to ventilate in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0100.
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Mechanical ventilation is an efficacious therapy to respiratory failure because it improves gas exchange and rests respiratory muscles. During controlled mechanical ventilation, a patient’s inspiratory muscles are resting and the ventilator delivers a preset tidal volume through the generation of inspiratory flow, overcoming resistive and elastic thresholds of the respiratory system. During assisted ventilation, the same goal is reached through an interplay between the patient’s inspiratory muscles and ventilator. Every perturbation of this interaction causes patient ventilator asynchrony and exposes to the risk of failure to ventilate. Patient–ventilator asynchrony may occur at each stage of assisted breath Signs of patient’s discomfort, the use of accessory muscles, tachycardia, hypertension, and assessment of flow and airway pressure traces displayed on modern ventilators, helps to detect asynchronies. Prompt recognition and intervention to improve patient–ventilator interaction may expedite liberation from mechanical ventilation, and reduce intensive care unit and length of hospital stay.
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Lei, Yuan. Medical Ventilator System Basics: A clinical guide. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.001.0001.
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Medical Ventilator System Basics: A clinical guide—unlike books that focus on clinical applications, or that provide specifics about individual ventilator models, this is a practical guide about the equipment used for positive pressure mechanical ventilation. This book provides the information a clinician needs every day: how to assemble a ventilator system, how to determine appropriate ventilator settings, how to make sense of monitored data, how to respond to alarms, and how to troubleshoot ventilation problems. The book applies to all ventilators based on the intermittent positive pressure ventilation (IPPV) operating principle. In a systematic and comprehensive way, the book steps the user through the ventilator system, starting with its pneumatic principles to an explanation of the anatomy and physiology of respiration. It describes the system components, including the ventilator, breathing circuit, humidifier, and nebulizer. The book then introduces ventilation modes, starting with an explanation of the building blocks of breath variables and breath types. It describes the major ventilator functions, including control parameters, monitoring, and alarms. Along the way the book provides much practical troubleshooting information. Clearly written and generously illustrated, the book is a handy reference for anyone involved with mechanical ventilation, clinicians and non-clinicians alike. It is suitable as a teaching aid for respiratory therapy education and as a practical handbook in clinical practice.
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Waldmann, Carl, Neil Soni y Andrew Rhodes. Respiratory therapy techniques. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199229581.003.0001.
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Oxygen therapy 2Ventilatory support: indications 6IPPV—description of ventilators 8IPPV—modes of ventilation 10IPPV—adjusting the ventilator 12IPPV—barotrauma 14IPPV—weaning techniques 16High-frequency ventilation 18Positive end-respiratory pressure 22Continuous positive airway pressure ventilation (CPAP) 24Recruitment manoeuvres 26Prone position ventilation 28...
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Kreit, John W. Ventilator Modes and Breath Types. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0005.
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Ventilator Modes and Breath Types describes, compares, and contrasts the different modes and breath types that are available on intensive care unit ventilators. The chapter first covers the various ventilator modes: continuous mandatory ventilation, synchronized intermittent mandatory ventilation, spontaneous ventilation, and bi-level ventilation. Then it turns to a discussion of the various mechanical breath types: volume control, pressure control, adaptive pressure control, pressure support, and finally, adaptive pressure support. It also provides practical advice about how and when to use each mode–breath type combination. Eight Boxes in the chapter discuss each breath type, and list each type’s features, and its clinician-set parameters.
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Masip, Josep, Kenneth Planas y Arantxa Mas. Non-invasive ventilation. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0025.
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During the last 25 years, the use of non-invasive ventilation has grown substantially. Non-invasive ventilation refers to the delivery of positive pressure to the lungs without endotracheal intubation and plays a significant role in the treatment of patients with acute respiratory failure and in the domiciliary management of some chronic respiratory and sleep disorders. In the intensive and acute care setting, the primary aim of non-invasive ventilation is to avoid intubation, and it is mainly used in patients with chronic obstructive pulmonary disease exacerbations, acute cardiogenic pulmonary oedema, or in the context of weaning, situations in which a reduction in mortality has been demonstrated. The principal techniques are continuous positive airway pressure and bilevel pressure support ventilation. Whereas non-invasive pressure support ventilation requires a ventilator, continuous positive airway pressure is a simpler technique that can be easily used in non-equipped areas such as the pre-hospital setting. The success of non-invasive ventilation is related to the adequate timing and selection of patients, as well as the appropriate use of interfaces, the synchrony of patient-ventilator, and the fine-tuning of the ventilator.
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Masip, Josep, Kenneth Planas y Arantxa Mas. Non-invasive ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0025_update_001.
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During the last 25 years, the use of non-invasive ventilation has grown substantially. Non-invasive ventilation refers to the delivery of positive pressure to the lungs without endotracheal intubation and plays a significant role in the treatment of patients with acute respiratory failure and in the domiciliary management of some chronic respiratory and sleep disorders. In the intensive and acute care setting, the primary aim of non-invasive ventilation is to avoid intubation, and it is mainly used in patients with chronic obstructive pulmonary disease exacerbations, acute cardiogenic pulmonary oedema, or in the context of weaning, situations in which a reduction in mortality has been demonstrated. The principal techniques are continuous positive airway pressure and bilevel pressure support ventilation. Whereas non-invasive pressure support ventilation requires a ventilator, continuous positive airway pressure is a simpler technique that can be easily used in non-equipped areas such as the pre-hospital setting. The success of non-invasive ventilation is related to the adequate timing and selection of patients, as well as the appropriate use of interfaces, the synchrony of patient-ventilator, and the fine-tuning of the ventilator.
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Masip, Josep, Kenneth Planas y Arantxa Mas. Non-invasive ventilation. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0025_update_002.
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During the last 25 years, the use of non-invasive ventilation has grown substantially. Non-invasive ventilation refers to the delivery of positive pressure to the lungs without endotracheal intubation and plays a significant role in the treatment of patients with acute respiratory failure and in the domiciliary management of some chronic respiratory and sleep disorders. In the intensive and acute care setting, the primary aim of non-invasive ventilation is to avoid intubation, and it is mainly used in patients with chronic obstructive pulmonary disease exacerbations, acute cardiogenic pulmonary oedema, or in the context of weaning, situations in which a reduction in mortality has been demonstrated. The principal techniques are continuous positive airway pressure and bilevel pressure support ventilation. Whereas non-invasive pressure support ventilation requires a ventilator, continuous positive airway pressure is a simpler technique that can be easily used in non-equipped areas such as the pre-hospital setting. The success of non-invasive ventilation is related to the adequate timing and selection of patients, as well as the appropriate use of interfaces, the synchrony of patient-ventilator, and the fine-tuning of the ventilator.
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Kreit, John W. Patient–Ventilator Interactions and Asynchrony. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0011.
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Patient–Ventilator Interactions and Asynchrony describes what happens when the patient and the ventilator do not work together in an effective, coordinated manner. Effective mechanical ventilation requires the synchronized function of two pumps: The mechanical ventilator is governed by the settings chosen by the clinician; the patient’s respiratory system is controlled by groups of neurons in the brain stem. Ideally, the ventilator simply augments and amplifies the activity of the respiratory system. Asynchrony between the ventilator and the patient reduces patient comfort, increases work of breathing, predisposes to respiratory muscle fatigue, and may even impair oxygenation and ventilation. The chapter describes the causes and consequences of patient–ventilator asynchrony during ventilator triggering and the inspiratory phase of the respiratory cycle and explains how to adjust ventilator settings to improve patient comfort and reduce the work of breathing.
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Lee, Jan Hau y Ira M. Cheifetz. Respiratory Failure and Mechanical Ventilation. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199918027.003.0006.
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This chapter on respiratory failure and mechanical ventilation provides essential information about how to support children with severe respiratory disorders. The authors discuss multiple modes of respiratory support, including high-flow nasal cannula oxygen, noninvasive ventilation with continuous positive airway pressure and bilevel positive airway pressure, as well as conventional, high-frequency, and alternative modes of invasive ventilation. The section on invasive mechanical ventilation includes key information regarding gas exchange goals, modes of ventilation, patient–ventilator interactions, ventilator parameters (including tidal volume, end-expiratory pressure, and peak plateau pressure), extubation readiness testing, and troubleshooting. The authors also provide the new consensus definition of pediatric acute respiratory distress syndrome. Also included are multiple figures and indispensable information on adjunctive therapies (inhaled nitric oxide, surfactant, prone positioning, and corticosteroids) and respiratory monitoring (including capnography and airway graphics analysis).
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Bauman, Kristy A. y Robert C. Hyzy. Volume-controlled mechanical ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0095.
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The goal of mechanical ventilation is to achieve adequate gas exchange while minimizing haemodynamic compromise and ventilator-associated lung injury. Volume-controlled ventilation can be delivered via several modes, including controlled mechanical ventilation, assist control (AC) and synchronized intermittent mandatory ventilation (SIMV). .In volume-controlled modes, the clinician sets the flow pattern, flow rate, trigger sensitivity, tidal volume, respiratory rate, positive end-expiratory pressure, and fraction of inspired oxygen. Patient ventilator synchrony can be enhanced by setting appropriate trigger sensitivity and inspiratory flow rate. I:E ratio can be adjusted to improve oxygenation, avoid air trapping and enhance patient comfort. There is little data regarding the benefits of one volume-controlled mode over another. In acute respiratory distress syndrome, low tidal volume ventilation in conjunction with plateau pressure limitation should be employed as there is a reduction in mortality with this strategy. This chapter addresses respiratory mechanics, modes and settings, clinical applications, and limitations of volume-controlled ventilation.
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Kreit, John W. How to Write Ventilator Orders. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0008.
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How to Write Ventilator Orders provides step-by-step instructions on how to write ventilator orders—how to choose appropriate settings immediately after intubation; how to adjust ventilator settings throughout the course of the patient’s illness; and when weaning the patient from mechanical ventilation—how to write orders for spontaneous breathing trials. For writing initial ventilator orders, we discuss: choosing a mode of mechanical ventilation, choosing the type of mechanical breath, selecting settings based on the type of mechanical breath, and specifying other basic settings. Next, the chapter covers recommended adjustments to settings in cases of high PaO2 and SpO2, low PaO2 andSpO2, and respiratory acidosis and alkalosis. A table at the end of the chapter shows the orders needed to perform an on-ventilator spontaneous breathing trial.
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Lei, Yuan. Ventilator System Concept. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.003.0004.
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‘Ventilator System Concept’ develops the idea that the equipment for mechanical ventilation is a ventilator system with six essential parts. Using a simple balloon model, it explains the operating principle and composition of a ventilator system, and it describes how the system generates intermittent positive airway pressure. The chapter ends by describing the conditions required for a ventilator system to function properly.
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Nava, Stefano y Luca Fasano. Ventilator Liberation Strategies. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199653461.003.0039.
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The weaning process should ideally begin as soon as the patient is intubated and continue through the treatment of the cause inducing acute respiratory failure. Weaning includes the assessment of readiness to extubate, extubation, and post-extubation monitoring; it also includes consideration of non-invasive ventilation which has been shown to reduce the duration of invasive mechanical ventilation in selected patients. Weaning accounts for approximately 40% of the total time spent on mechanical ventilation and should be achieved rapidly, since prolonged mechanical ventilation is associated with increased risk of complications and mortality and with increased costs. During mechanical ventilation, medical management should seek to correct the imbalance between respiratory load and ventilatory capacity (reducing the respiratory and cardiac workload, improving gas exchange and the ventilatory pump power). Ventilator settings delivering partial ventilatory pump support may help prevent ventilator-induced respiratory muscles dysfunction. Daily interruption of sedation has been associated with earlier extubation. Critically ill patients should be repeatedly and carefully screened for readiness to wean and readiness to extubate, and objective screening variables should be fully integrated in clinical decision making.
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Soar, Jasmeet y Jerry P. Nolan. Artificial ventilation in cardiopulmonary resuscitation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0060.
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When cardiac arrest occurs, cardiopulmonary resuscitation (CPR) should be started with chest compressions first. The use of ventilations is determined by the training of rescuers, their ability and willingness to provide rescue breaths, patient characteristics, and the underlying cause of the cardiac arrest. Trained rescuers should give two ventilations after every 30 compressions, or once the airway is secured with a tracheal tube, ventilate the patient at 10 breaths/min without any pause in chest compressions. Rescuers who are unable or unwilling to provide effective ventilation, while awaiting expert help should use compression-only CPR. Ventilations are needed for the treatment of cardiac arrest in children, when arrest is from a primary respiratory cause, or during a prolonged cardiac arrest. Choice of ventilation technique depends on rescuer skills and the airway used. Effective oxygenation and ventilation can be maintained during CPR with a tidal volume of approximately 500 mL given over an inspiratory time of 1 second. Rescuers should give supplemental oxygen in as high a concentration as possible during CPR in order to rapidly correct tissue hypoxia. Once restoration of a spontaneous circulation has been achieved the inspired oxygen should be adjusted to maintain oxygen saturation between 94 and 98%.
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Lei, Yuan. Basic Concepts. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.003.0002.
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‘Basic Concepts’ explains seven important physical concepts that are required to understand how a positive pressure ventilator system works: pressure, volume, flow, time, resistance, compliance, and time constant. A positive pressure ventilator system is a pneumatic device based on the operating principle of intermittent positive pressure ventilation (IPPV).
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Kreit, John W. Acute Respiratory Distress Syndrome (ARDS). Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0012.
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Acute Respiratory Distress Syndrome reviews the definitions, causes, pathophysiology, and management of this relatively common, life-threatening disorder. This chapter describes how to ensure adequate tissue oxygen delivery while minimizing ventilator-induced lung injury and provides an in-depth review of how to determine the optimum level of positive end-expiratory pressure (PEEP). The first topic addressed is the precipitating factors and pathophysiology of acute respiratory distress syndrome. Next the chapter turns to mechanical ventilation, and covers the subjects of adequate oxygenation, ventilator-induced lung injury, ancillary therapies, ventilatory therapies, and high I:E ventilation. The topics addressed in the area of non-ventilatory therapies include: prone positioning of the patient, neuromuscular blockade, inhaled vasodilators, and extracorporeal membrane oxygenation (ECMO).
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Muders, Thomas y Christian Putensen. Pressure-controlled mechanical ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0096.
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Beside reduction in tidal volume limiting peak airway pressure minimizes the risk for ventilator-associated-lung-injury in patients with acute respiratory distress syndrome. Pressure-controlled, time-cycled ventilation (PCV) enables the physician to keep airway pressures under strict limits by presetting inspiratory and expiratory pressures, and cycle times. PCV results in a square-waved airway pressure and a decelerating inspiratory gas flow holding the alveoli inflated for the preset time. Preset pressures and cycle times, and respiratory system mechanics affect alveolar and intrinsic positive end-expiratory (PEEPi) pressures, tidal volume, total minute, and alveolar ventilation. When compared with flow-controlled, time-cycled (‘volume-controlled’) ventilation, PCV results in reduced peak airway pressures, but higher mean airway. Homogeneity of regional peak alveolar pressure distribution within the lung is improved. However, no consistent data exist, showing PCV to improve patient outcome. During inverse ratio ventilation (IRV) elongation of inspiratory time increases mean airway pressure and enables full lung inflation, whereas shortening expiratory time causes incomplete lung emptying and increased PEEPi. Both mechanisms increase mean alveolar and transpulmonary pressures, and may thereby improve lung recruitment and gas exchange. However, when compared with conventional mechanical ventilation using an increased external PEEP to reach the same magnitude of total PEEP as that produced intrinsically by IRV, IRV has no advantage. Airway pressure release ventilation (APRV) provides a PCV-like squared pressure pattern by time-cycled switches between two continuous positive airway pressure levels, while allowing unrestricted spontaneous breathing in any ventilatory phase. Maintaining spontaneous breathing with APRV is associated with recruitment and improved ventilation of dependent lung areas, improved ventilation-perfusion matching, cardiac output, oxygenation, and oxygen delivery, whereas need for sedation, vasopressors, and inotropic agents and duration of ventilator support decreases.
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Kahn, Jeremy M. The Role of Long-Term Ventilator Hospitals. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199653461.003.0004.
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Long-term ventilator facilities play an increasingly important role in the care of chronically critically ill patients in the recovery phase of their acute illness. These hospitals can take several forms, depending on the country and health system, including �step-down� units within acute care hospitals and dedicated centres that specialize in weaning patients from prolonged mechanical ventilation. These hospitals may improve outcomes through increased clinical experience at applying protocolized weaning approaches and specialized, multidisciplinary, rehabilitation-focused care; they may also worsen outcomes by fragmenting the episode of acute care across multiple hospitals, leading to communication delays and hardship for families. Long-term ventilator facilities may also have important �spillover effects�, in that they free ICU beds in acute care hospitals to be filled with greater numbers of acute critically ill patients. Current evidence suggests that mortality of chronically critically ill patients is equivalent between acute care hospitals and specialized weaning centres; however, mechanical ventilation may be longer and cost of care higher in patients who remain in acute care hospitals. Given the rising incidence of prolonged mechanical ventilation and capacity constraints on acute care ICUs, long-term ventilator hospitals are likely to serve a key function in critical illness recovery.
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Abuella, Gihan y Andrew Rhodes. Mechanical ventilation. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0024.
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Mechanical ventilation is used to assist or replace spontaneous respiration. Gas flow can be generated by negative pressure techniques, but it is positive pressure ventilation that is the most efficacious in intensive care. There are numerous pulmonary and extrapulmonary indications for mechanical ventilation, and it is the underlying pathology that will determine the duration of ventilation required. Ventilation modes can broadly be classified as volume- or pressure-controlled, but modern ventilators combine the characteristics of both in order to complement the diverse requirements of individual patients. To avoid confusion, it is important to appreciate that there is no international consensus on the classification of ventilation modes. Ventilator manufacturers can use terms that are similar to those used by others that describe very different modes or have completely different names for similar modes. It is well established that ventilation in itself can cause or exacerbate lung injury, so the evidence-based lung-protective strategies should be adhered to. The term acute lung injury has been abolished, whilst a new definition and classification for the acute respiratory distress syndrome has been defined.
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Grounds, Robert O. y Andrew Rhodes. Mechanical ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0024_update_001.
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Mechanical ventilation is used to assist or replace spontaneous respiration. Gas flow can be generated by negative pressure techniques, but it is positive pressure ventilation that is the most efficacious in intensive care. There are numerous pulmonary and extrapulmonary indications for mechanical ventilation, and it is the underlying pathology that will determine the duration of ventilation required. Ventilation modes can broadly be classified as volume- or pressure-controlled, but modern ventilators combine the characteristics of both in order to complement the diverse requirements of individual patients. To avoid confusion, it is important to appreciate that there is no international consensus on the classification of ventilation modes. Ventilator manufacturers can use terms that are similar to those used by others that describe very different modes or have completely different names for similar modes. It is well established that ventilation in itself can cause or exacerbate lung injury, so the evidence-based lung-protective strategies should be adhered to. The term acute lung injury has been abolished, whilst a new definition and classification for the acute respiratory distress syndrome has been defined.
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Beduneau, Gaëtan, Jean-Christophe M. Richard y Laurent Brochard. Prolonged Respiratory Insufficiency and Ventilator Dependence in the ICU. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199653461.003.0014.
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The process of separation or weaning from mechanical ventilation can be arbitrarily separated into three categories: (1) simple weaning when patients are separated from the ventilator after the first attempt of unsupported spontaneous breathing. This usually represents slightly more than half of the patients; (2) difficult weaning when up to three attempts or 1 week is necessary to successfully separate the patient from the ventilator; (3) prolonged weaning for the remaining patients. This last group represents between 6 and 20% of the ICU population arriving at the stage of weaning and carries a considerable human and economic cost. A global approach, including measures to optimize psychological status, nutritional support, and sleep, is essential in the management of these patients, and referral to specialized weaning centres may be helpful. Muscle weakness is a very frequent finding in patients undergoing prolonged mechanical ventilation and may be worsened by excessive sedation, prolonged immobilization, and the use of controlled mechanical ventilation modes. It follows that approaches that include sedation sparing, early mobilization, and the transition to spontaneous breathing are likely to be beneficial.
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Lei, Yuan. Mechanical Ventilation Modes. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.003.0008.
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‘Mechanical Ventilation Modes’ seeks to shed light on this hotly debated topic, one that is complicated by ventilator manufacturers’ non-standardized terminology. The chapter looks at conventional modes, adaptive modes, and biphasic modes, which it classifies based on the mechanical breath types in each mode. It includes a comparison chart of the terminology used for common modes on popular IPPV ventilators. Using their signature waveforms, the author describes the assist/control, SIMV, and pressure support ventilation or PSV modes. It defines the modes by their application of spontaneous breaths and mandatory breaths. It continues with a discussion of adaptive modes and biphasic modes. It ends by discussing how to select the appropriate ventilation mode.
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Dhand, Rajiv y Michael McCormack. Bronchodilators in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0033.
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Inhaled beta-agonists and anticholinergic agents, as well as systemically administered methylxanthines, are frequently employed to achieve bronchodilation in critically-ill patients. Inhaled agents are given by pressurized metered dose inhaler (pMDI), nebulizer, or dry powder inhaler. In ventilator-supported patients, aerosolized agents are generally only administered by pMDI or nebulizer. The ventilator circuit, artificial airway, and circuit humidity complicate the delivery of aerosolized agents, and there is a wide variability in drug delivery efficiency with various bench models of mechanical ventilation. Aerosolized drug by pMDI is affected by the use of spacer devices, synchronization of pMDI actuation and ventilator breath delivery, and appropriate priming of the pMDI device. The efficiency of aerosolized drug delivery by jet nebulization is also affected by device placement in the circuit, as well as by a number of other factors. Several investigators have demonstrated comparable efficiency of aerosol delivery with mechanically-ventilated and ambulatory patients when careful attention is given to the technique of administration. Appropriate administration of aerosolized bronchodilators in patients receiving invasive or non-invasive positive pressure ventilation produces significant therapeutic effects.
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Kennedy, Veronica. Ventilation tubes. Editado por John Phillips y Sally Erskine. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198834281.003.0071.
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Masip, Josep, Kenneth Planas y Arantxa Mas. Non-invasive ventilation. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0025_update_003.
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During the last 25 years, the use of non-invasive ventilation has grown substantially. Non-invasive ventilation refers to the delivery of positive pressure to the lungs without endotracheal intubation and plays a significant role in the treatment of patients with acute respiratory failure and in the domiciliary management of some chronic respiratory and sleep disorders. In the intensive and acute care setting, the primary aim of non-invasive ventilation is to avoid intubation, and it is mainly used in patients with chronic obstructive pulmonary disease exacerbations, acute cardiogenic pulmonary oedema, immunocompromised or in the context of weaning, situations in which a reduction in mortality has been demonstrated. The principal techniques are continuous positive airway pressure, bilevel pressure support ventilation and more recently, high flow nasal cannula. Whereas non-invasive pressure support ventilation requires a ventilator, the other two techniques are simpler and can be easily used in non-equipped areas by less experienced teams, including the pre-hospital setting. The success of non-invasive ventilation is related to an adequate timing, proper selection of patients and interfaces, close monitoring as well as the achievement of a good adaptation to patients’ demand.
30
Garner, Justin y David Treacher. Intensive care unit and ventilation. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199657742.003.0009.
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Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are characterized by rapidly developing hypoxaemic respiratory failure and bilateral pulmonary infiltrates on chest X-ray. ALI/ARDS are a relatively frequent diagnosis in protracted-stay patients in the intensive care unit. The pathology is a non-specific response to a wide variety of insults. Impaired gas exchange, ventilation-perfusion mismatch, and reduced compliance ensue. Mechanical ventilation is the mainstay of management, along with treatment of the underlying cause. Mortality remains very high at around 40%. The condition is challenging to treat. Injury to the lungs, indistinguishable from that of ARDS, has been attributed to the use of excessive tidal volumes, pressures, and repeated opening and collapsing of alveoli. Lung-protective strategies aim to minimize the effects of ventilator-induced lung injury. Use of low tidal volume ventilation has been shown to improve mortality. Emerging ventilatory therapies include high-frequency oscillatory ventilation and extracorporeal membrane oxygenation.
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Kreit, John W. Ventilator Alarms—Causes and Evaluation. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0006.
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When a patient is intubated and placed on mechanical ventilation, the clinician must write a series of ventilator orders. It’s important to recognize though, that several other parameters are typically set by the respiratory therapist without direct physician input. The most important are the critical values that will trigger a ventilator alarm. ICU ventilators constantly monitor many machine and patient-related variables, including airway pressure, flow rate, volume, and respiratory rate, and it seems like there’s an alarm for almost everything. While it’s true that some alarms are of little or no significance, others may indicate an important and potentially life-threatening problem. Ventilator Alarms—Causes and Evaluation describes important ventilator alarms and how each is set and triggered. It also reviews how to determine the cause of each ventilator alarm and how to correct the identified problems.
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Lucangelo, Umberto y Massimo Ferluga. Pulmonary mechanical dysfunction in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0084.
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In intensive care units practitioners are confronted every day with mechanically-ventilated patients and should be able to sort out from all the data available from modern ventilators to tailored patient ventilatory strategy. Real-time visualization of pressure, flow and tidal volume provide valuable information on the respiratory system, to optimize ventilatory support and avoiding complications associated with mechanical ventilation. Early determination of patient–ventilator asynchrony, air-trapping, and variation in respiratory parameters is important during mechanical ventilation. A correct evaluation of data becomes mandatory to avoid a prolonged need for ventilatory support. During dynamic hyperinflation the lungs do not have time to reach the functional residual capacity at the end of expiration, increasing the work of breathing and promoting patient-ventilator asynchrony. Expiratory capnogram provides qualitative information on the waveform patterns associated with mechanical ventilation and quantitative estimation of expired CO2. The concept of dead space accounts for those lung areas that are ventilated but not perfused. Calculations derived from volumetric capnography are useful indicators of pulmonary embolism. Moreover, alveolar dead space is increased in acute lung injury and its value decreased in case of positive end-expiratory pressure (PEEP)-induced recruitment, whereas PEEP-induced overdistension tends to increment alveolar dead space.
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Chatburn, Robert L. y Eduardo Mireles-Cabodevila. Design and function of mechanical ventilators. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0092.
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This chapter presents a new approach to understanding the design and function of mechanical ventilators. Mechanical ventilators have become so complex that a practical classification system or taxonomy is required to compare and contrast treatment options. This chapter describes the 10 fundamental maxims from which we construct a taxonomy to describe each mode of mechanical ventilation. This method provides a framework for the comparison of published studies of mechanical ventilation, gives consistency in education and clinical practice. It also allows comparisons between different ventilator manufacturers and, most importantly, it provides a framework to match modes to specific patient needs.
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Aguirre-Bermeo, Hérnan y Jordi Mancebo. Pressure support ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0097.
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Pressure support ventilation (PSV) is one of the most common ventilatory modalities used in intensive care units. PSV is an assisted, pressure-limited, and flow-cycled ventilatory mode. The ventilator provides assistance when the patient makes a breathing effort, and when inspiratory flow reaches a certain threshold level, cycling to exhalation occurs. PSV unloads respiratory muscle effort, while allowing the patient to retain control over the respiratory rate and tidal volume. Withdrawal from mechanical ventilation should be performed with a gradual reduction of levels of support until extubation. Asynchronies can be present during PSV and are typically associated with high levels of support. A closed-loop modality, which adjusts support levels to keep the patient in a ‘comfort zone’, has been designed to assist in the withdrawal of mechanical ventilation. It performs at least as well as experienced medical staff and could be useful in specific groups of patients.
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Lei, Yuan. Special Ventilation Functions. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.003.0010.
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‘Special Ventilation Functions’ examines those hard-to-classify features such as standby; sigh; temporary oxygen enrichment or 100% O2; apnoea backup or apnoea ventilation; and tube resistance compensation, also known as tube compensation or automatic tube compensation. It describes each function in depth, including indications for use and details on typical implementations, providing examples from popular ventilators.
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Kreit, John W. Discontinuing Mechanical Ventilation. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0015.
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Discontinuing Mechanical Ventilation provides clear, step-by step instructions on how to liberate or “wean” the patient from the ventilator. It explains how to determine when the patient is ready to begin the weaning process, how to perform a spontaneous breathing trial, and how to determine if the patient is ready for extubation, including such considerations as whether the patient is at risk for post-extubation laryngeal edema; whether the patient will be able to effectively clear secretions from the airways following extubation; and determining if the patient has a “difficult airway” should the need for re-intubation arise. The chapter also provides a step-by-step approach to the difficult-to-wean patient, covering topics such as how to assess ventilatory ability and demand; determine the cause(s) of increased demand, impaired ability, or both; treat the causes of increased demand and impaired ability; and determine when to perform a tracheostomy.
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Kreit, John W. Noninvasive Mechanical Ventilation. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0016.
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Although so-called invasive ventilation can be life-saving, it can also cause significant morbidity. It has long been recognized that positive pressure ventilation can also be delivered “non-invasively” to critically ill patients through several different types of “interfaces” (usually a tight-fitting face mask). Noninvasive Mechanical Ventilation explains when and how to use noninvasive ventilation to treat patients with respiratory failure. It provides a detailed explanation of how noninvasive (bi-level) ventilators differ from the standard ICU ventilators, describes the available modes and breath types as well as the indications and contraindications for noninvasive ventilation, and explains how to initiate, monitor, and adjust noninvasive ventilation.
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Laffey, John G. y Brian P. Kavanagh. Hypercapnia in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0086.
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Hypercapnia is a central component of current ‘protective’ ventilator management. Hypercapnia, and the associated acidosis, has potentially important biologic effects on immune responses, injury and repair. Arterial carbon dioxide tension PaCO2 is tightly governed under physiological conditions and small elevations rapidly increase spontaneous minute ventilation. In the mechanically-ventilated patient, elevated PaCO2 usually reflects reduced elimination. This can be because tidal volume or respiratory rate delivered by the ventilator are reduced, or because of the diseased lung per se. Hypercapnia has many effects that are clinically obvious, but research over the last decade reveals important consequences on inflammatory and cellular mechanisms that are not apparent at the bedside.
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Martin-Loeches, Ignacio y Antonio Artigas. Respiratory support with positive end-expiratory pressure. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0094.
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Positive-end-expiratory pressure (PEEP) is the pressure present in the airway (alveolar pressure) above atmospheric pressure that exists at the end of expiration. The term PEEP is defined in two particular settings. Extrinsic PEEP (applied by ventilator) and intrinsic PEEP (PEEP caused by non-complete exhalation causing progressive air trapping). Applied (extrinsic) PEEP—is usually one of the first ventilator settings chosen when mechanical ventilation (MV) is initiated. Applying PEEP increases alveolar pressure and volume. The increased lung volume increases the surface area by reopening and stabilizing collapsed or unstable alveoli. PEEP therapy can be effective when used in patients with a diffuse lung disease with a decrease in functional residual capacity. Lung protection ventilation is an established strategy of management to reduce and avoid ventilator-induced lung injury and mortality. Levels of PEEP have been traditionally used from 5 to 12 cmH2O; however, higher levels of PEEP have also been proposed and updated in order to keep alveoli open, without the cyclical opening and closing of lung units (atelectrauma). The ideal level of PEEP is that which prevents derecruitment of the majority of alveoli, while causing minimal overdistension; however, it should be individualized and higher PEEP might be used in the more severe end of the spectrum of patients with improved survival. A survival benefit for higher levels of PEEP has not been yet reported for any patient under MV, but a higher PaO2/FiO2 ratio seems to be better in the higher PEEP group.
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Kreit, John W. Right Ventricular Failure. Editado por John W. Kreit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190670085.003.0014.
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Right ventricular (RV) failure is common in the ICU. Chronic RV failure is most often due to long-standing left ventricular (LV) systolic or diastolic failure or other causes of chronic pulmonary hypertension. Acute RV failure can result from massive pulmonary embolism, ARDS, RV infarction, and acute LV failure. Finally, acute-on-chronic RV failure can be precipitated by any disorder that leads to an abrupt rise in pulmonary vascular resistance (PVR) and RV afterload. Right Ventricular Failure provides an in-depth review of the adverse hemodynamic effects of mechanical ventilation and PEEP in patients with right ventricular failure. The chapter explains the effect of positive pressure ventilation and PEEP on pulmonary vascular resistance and RV afterload and describes how to adjust the ventilator to minimize these hemodynamic effects.
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Amato, Marcelo y Andreas Wolfgang Reske. Ventilator trauma in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0101.
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Ventilator trauma refers to complications of mechanical ventilation, which have an impact on morbidity and mortality. Two major forms of ventilator trauma may be distinguished—an acute form related to rupture of airspaces causing air-leak syndrome and a subacute form causing protracted inflammatory responses. A key feature of mechanically-ventilated lungs is the presence of non-aerated and unstable regions due to atelectasis, oedema, or consolidation. Because of mechanical interdependence, pressures acting in non-uniformly expanded lungs at the boundaries between non-aerated and aerated lung may be a multiple of the apparent transpulmonary pressure. The resulting effects have been reported to precipitate or contribute to ventilator-induced lung injury (VILI). The engineering terms stress and strain were recently proposed for better definition of risk-constellations for VILI. Because the aerated lung volume is positively correlated to compliance, driving-pressure can aid in identifying disproportionate combinations of tidal volumes and compliance.
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MacIntyre, Neil R. Indications for mechanical ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0091.
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Mechanical ventilation is indicated when the patient’s ability to ventilate the lung and/or effect gas transport across the alveolar capillary interface is compromised to point that harm is imminent. In practice, this means addressing one or more of three fundamental pathophysiological processes—loss of proper ventilatory control, ventilatory muscle demand-capability imbalances, and/or loss of alveolar patency. A fourth general indication involves providing a positive pressure assistance to allow tolerance of an artificial airway in the patient unable to maintain a patent and protected airway. The decision to initiate mechanical ventilation usually involves an integrated assessment that should include mental status, airway protection capabilities, ventilatory muscle load tolerance, spontaneous ventilatory pattern, and signs of organ dysfunction from either acidosis and/or hypoxaemia. Providing mechanical ventilatory assistance can be life-sustaining, but it is associated with significant risk, including ventilator-induced lung injury, infection, and need for sedatives/paralytics, and must be applied only when indications justify the risk.
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Cordioli, Ricardo Luiz y Laurent Brochard. Respiratory system compliance and resistance in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0074.
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Under mechanical ventilation, monitoring of respiratory mechanics is fundamental, especially in patients with abnormal mechanics. In order to appropriately set the ventilator, clinicians need to understand the relationship between pressure, volume and flow. To move air in and out the thorax, energy must be dissipated against elastic and resistive forces. Elastance is the pressure to volume ratio and necessitates an end inspiratory occlusion to measure the so-called plateau pressure. Resistance is the ratio between pressure dissipated and mean gas flow. Finally, the total positive end expiratory pressure must be measured with an end expiratory occlusion. Volume-controlled ventilation is the recommended mode to assess respiratory mechanics of a passive patient. Clinicians must be aware that both chest wall and lung participate in forces imposed by the respiratory system. An oesophageal catheter can estimate pleural pressure, and used to partition the respective role of the lung and the chest wall.
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Lei, Yuan. Lung Ventilation: Natural and Mechanical. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198784975.003.0003.
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‘Lung Ventilation: Natural and Mechanical’ describes the processes of respiration and lung ventilation, focusing on those issues related directly to mechanical ventilation. The chapter starts by discussing the anatomy and physiology of respiration, and the involvement of the lungs and the entire respiratory system. It continues by introducing the three operating principles of mechanical ventilation. It then narrows its focus to intermittent positive pressure ventilation (IPPV), the operating principle of most modern critical care ventilators, explaining the pneumatic process of IPPV. The chapter ends by comparing natural and mechanical/artificial lung ventilation.
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Hedenstierna, Göran y Hans Ulrich Rothen. Physiology of positive-pressure ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0088.
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During positive pressure ventilation the lung volume is reduced because of loss of respiratory muscle tone. This promotes airway closure that occurs in dependent lung regions. Gas absorption behind the closed airway results sooner or later in atelectasis depending on the inspired oxygen concentration. The elevated airway and alveolar pressures squeeze blood flow down the lung so that a ventilation/perfusion mismatch ensues with more ventilation going to the upper lung regions and more perfusion going to the lower, dependent lung. Positive pressure ventilation may impede the return of venous blood to the thorax and right heart. This raises venous pressure, causing an increase in systemic capillary pressure with increased capillary leakage and possible oedema formation in peripheral organs. Steps that can be taken to counter the negative effects of mechanical ventilation include an increase in lung volume by recruitment of collapsed lung and an appropriate positive end-expiratory pressure, to keep aerated lung open and to prevent cyclic airway closure. Maintaining normo- or hypervolaemia to make the pulmonary circulation less vulnerable to increased airway and alveolar pressures, and preserving or mimicking spontaneous breaths, in addition to the mechanical breaths, since they may improve matching of ventilation and blood flow, may increase venous return and decrease systemic organ oedema formation (however, risk of respiratory muscle fatigue, and even overexpansion of lung if uncontrolled).
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Spoletini, Giulia y Nicholas S. Hill. Non-invasive positive-pressure ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0090.
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Non-invasive ventilation (NIV) has been increasingly used over the past decades to avoid endotracheal intubation (ETI) in critical care settings. In selected patients with acute respiratory failure, NIV improves the overall clinical status more rapidly than standard oxygen therapy, avoids ETI and its complications, reduces length of hospital stay, and improves survival. NIV is primarily indicated in respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema and associated with immunocompromised states. Weaker evidence supports its use in other forms of acute hypercapnic and hypoxaemic respiratory failure. Candidates for NIV should be carefully selected taking into consideration the risk factors for NIV failure. Patients on NIV who are unstable or have risk factors for NIV failure should be monitored in an intensive or intermediate care units by experienced personnel to avoid delay when intubation is needed. Stable NIV patients can be monitored on regular wards.
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Cuartero, Mireia y Niall D. Ferguson. High-frequency ventilation and oscillation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0098.
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High-frequency oscillatory ventilation (HFOV) is a key member of the family of modes called high-frequency ventilation and achieves adequate alveolar ventilation despite using very low tidal volumes, often below the dead space volume, at frequencies significantly above normal physiological values. It has been proposed as a potential protective ventilatory strategy, delivering minimal alveolar tidal stretch, while also providing continuous lung recruitment. HFOV has been successfully used in neonatal and paediatric intensive care units over the last 25 years. Since the late 1990s adults with acute respiratory distress syndrome have been treated using HFOV. In adults, several observational studies have shown improved oxygenation in patients with refractory hypoxaemia when HFOV was used as rescue therapy. Several small older trials had also suggested a mortality benefit with HFOV, but two recent randomized control trials in adults with ARDS have shed new light on this area. These trials not show benefit, and in one of them a suggestion of harm was seen with increased mortality for HFOV compared with protective conventional mechanical ventilation strategies (tidal volume target 6 mL/kg with higher positive end-expiratory pressure). While these findings do not necessarily apply to patients with severe hypoxaemia failing conventional ventilation, they increase uncertainty about the role of HFOV even in these patients.
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König, Matthias W. y John J. McAuliffe. Difficult Ventilation During Laparoscopic Fundoplication. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199764495.003.0023.
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An ever-increasing number of surgical procedures are now performed via the laparoscopic approach, and it is estimated that about 60% of abdominal surgeries in children can be performed laparoscopically today. The creation of a pneumoperitoneum has significant effects on the respiratory system, particularly in small children. Further, laparoscopic procedures have the potential for unique complications not typically seen with conventional “open” surgical techniques.
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Schweickert, William D. y John P. Kress. Physical and Occupational Therapy in the ICU. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199653461.003.0043.
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Mechanically ventilated patients in the ICU are commonly immobilized for prolonged time periods due to factors that include the underlying illness, encephalopathy, or sedation. In this setting, severe ICU-acquired weakness is common and may represent both a cause and consequence of immobilization. Physical and occupational therapy is feasible in ICU patients, even very early during mechanical ventilation. This intervention requires a coordinated effort between physicians, nurses, respiratory therapists, and the physical/occupational therapy team. Early physical and occupational therapy can lead to improved strength and functional status, reduced ventilator days and length of stay, and fewer days of ICU delirium.
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Fanelli, Vito, Lucia Mirabella, Stefano Italiano, Michele Dambrosio y V. Marco Ranieri. Sleep-Promoting Strategies. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199653461.003.0041.
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The architecture of sleep is profoundly altered in critically ill patients. Up to 60% of ICU survivors report poor sleep quality or sleep deprivation. Sleep in ICU patients is characterized by a longer onset and a poorer sleep efficiency, as demonstrated by the prevalence of light sleep (N1 and N2 stages), a reduction or absence of deep phase (N3 stage) and REM sleep, and increased sleep fragmentation. The amount of total sleep time (TST) in 24-hour period is generally preserved, but this reflects abnormal daytime sleep (up to the 40–50% of TST) with short periods of nocturnal sleep. Disruption of sleep architecture has deleterious consequences on the homeostasis of cardiovascular, respiratory, and nervous systems, exposing patients to an increased risk of myocardial infarction, prolonged mechanical ventilation, and cognitive dysfunction. Factors associated with sleep disruption in the ICU include noise, lighting, nursing care interventions, pain, discomfort, mechanical ventilation, medications, and delirium. Although clinical trials are lacking, potentially valuable approaches to ameliorate sleep quality in the ICU include reducing noise and pain, promoting patient ventilator synchrony, and managing delirium.