Students should be able to describe:
- The major indications for intubation.
- The role of non-invasive mask ventilation in managing patients with acute on chronic respiratory failure secondary to COPD.
- The difference between pressure and volume cycled ventilators.
- Typical initial adult ventilator settings.
- How to assess the adequacy of these initial ventilator settings.
- An understanding of how to calculate and interpret Airways Resistance and Respiratory System Compliance.
- Ventilator strategies and rescue strategies for the management of patients suffering from ARDS.
- An approach to Weaning including a knowledge of the Loyola weaning protocol.
Students should be able to:
HISTORY AND PHYSICAL EXAM:
- Recognize the symptoms and signs of impending respiratory failure.
- Succinctly present data relevant to the evaluation of the mechanically ventilated patient to members of the health care team.
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
Mechanical Ventilation Principles
- Tobin MJ: Mechanical ventilation. N Engl J Med 1994:330:1056-60.
- 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.
- 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
- 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
- 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
- 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
Esteban A, et al. Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation. NEJM 2004;350:2452-60.
F/U editorial by Truwit JD and Bernard GR. Noninvasive Ventilation – Don’t Push Too Hard. NEJM 2004;350:2512-15.
- A meta-analysis describing the benefit of CPAP/BiPAP in exacerbations of COPD.
- 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.
- 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
- Jakob, et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA 2012; 307(100):1151-1160