LEARNING OBJECTIVES:

KNOWLEDGE:

Students should be able to describe:

1. The major indications for intubation.
2. The role of non-invasive mask ventilation in managing patients with acute on chronic respiratory failure secondary to COPD.
3. The difference between pressure and volume cycled ventilators.
4. Typical initial adult ventilator settings.
5. How to assess the adequacy of these initial ventilator settings.
6. An understanding of how to calculate and interpret Airways Resistance and Respiratory System Compliance.
7. Ventilator strategies and rescue strategies for the management of patients suffering from ARDS.
8. An approach to Weaning including a knowledge of the Loyola weaning protocol.

SKILLS:

Students should be able to:

HISTORY AND PHYSICAL EXAM:

• Recognize the symptoms and signs of impending respiratory failure.

COMMUNICATION SKILLS:

• Succinctly present data relevant to the evaluation of the mechanically ventilated patient to members of the health care team.

MANAGEMENT:

• Determine appropriate initial ventilator settings, be capable of responding to acute peak airway pressure alarms, and assess a patient’s ability to be weaned.

ATTITUDES/PROFESSIONAL BEHAVIORS:

Students should be able to:

• Show empathy for the mechanically ventilated patient and, specifically, be cognizant of the potential for patient discomfort
• Interact with the mechanically ventilated patient in a professional and personal fashion, despite the inherent communication difficulties

REFERENCES:

Mechanical Ventilation Principles

1. Tobin MJ: Mechanical ventilation. N Engl J Med 1994:330:1056-60.
2. http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/lecture/vent/case_f.htm A nice PowerPoint presentation available on LUMEN summarizing many aspects of mechanical ventilation.

Weaning

1. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995; 332:345-50. Prospective, randomized study found once daily or multiple daily trials of spontaneous breathing (T-piece or CPAP <5 cm) resulted in more rapid successful extubation than gradual weaning of pressure support or IMV. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7823995
2. Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150:896-903. Prospective, randomized study found weaning with pressure support mode superior to SIMV mode and T-piece trials. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7921460
3. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324:1445-50. Study in a VA population found the rapid shallow breathing index (RSBI = RR/Vtidal) was the single best predictor of weaning success (sensitivity 0.97, specificity 0.64).   http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2023603

CPAP/BiPAP

1. Keenan SP, et al.  Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation?  A systematic review of the literature.  Annals of Int Med 2003; 138(11); 861-871.   http://www.annals.org/issues/v138n11/pdf/200306030-00007.pdf
• A meta-analysis describing the benefit of CPAP/BiPAP in exacerbations of COPD.
2. Esteban A, et al.  Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation.  NEJM 2004;350:2452-60.
3. F/U editorial by Truwit JD and Bernard GR.  Noninvasive Ventilation – Don’t Push Too Hard.  NEJM 2004;350:2512-15.
   

ARDS

1. ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for ALI and ARDS. N Engl J Med. 2000;342:1301-8. Results of the ARMA study found the use of low (6 ml/kg predicted weight) rather than “standard” (12 ml/kg predicted weight) tidal volumes reduced mortality from 40 to 30%. These results form much of the basis for use of low- stretch/low tidal volume ventilation strategy in acute lung injury.
   http://content.nejm.org/cgi/content/abstract/342/18/1301
2. UpToDate® has very nice succinct summaries of treatment strategies for Non-Cardiogenic Pulmonary Edema (i.e. ARDS), Cardiogenic Pulmonary Edema, and Status Asthmaticus.

Sedation in the ICU

1. Jakob, et al.  Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials.  JAMA 2012; 307(100):1151-1160
2. http://jamanetwork.com/journals/jama/fullarticle/1105080

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