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KEY POINTS

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KEY POINTS

  1. The goals of mechanical ventilation are to provide safe gas exchange, decrease the work of breathing, improve patient–ventilator interactions, minimize iatrogenic injury, and promote liberation from mechanical ventilation in a timely manner.

  2. Mechanical ventilation is indicated in individuals who are unable to sustain normal gas exchange as a result of established or impending respiratory failure from hypoxemia, hypercapnia, or both; airway problems, and to provide support to individuals undergoing general anesthesia.

  3. A ventilator mode can be classified by specifying the control variable, breath sequence, and targeting scheme.

  4. Conventional modes of ventilatory support include continuous mandatory ventilation, assist-control ventilation, intermittent mandatory ventilation and synchronized intermittent mandatory ventilation, and pressure support ventilation.

  5. Alternative modes of ventilatory support include dual control modes, such as volume-assured pressure support or pressure augmentation, volume support ventilation or variable pressure support ventilation, pressure-regulated volume control and auto mode ventilation.

  6. Nonconventional modes of ventilatory support include airway pressure release ventilation, proportional assist ventilation, adaptive support ventilation, neurally adjusted ventilatory assist, and high-frequency ventilation including high-frequency oscillatory ventilation and high-frequency percussive ventilation.

  7. Monitoring during mechanical ventilation includes measurement of peak and plateau pressures, intrinsic positive end-expiratory pressure, and work of breathing.

  8. Prerequisites prior to conducting a spontaneous breathing trial include partial or complete recovery of conditions that resulted in respiratory failure; adequate oxygenation with low PEEP, that is, PaO2/FIO2 more than 200, PEEP ≤ 8 cm H2O, and FIO2 ≤ 0.5; absence of severe acidosis (pH ≥ 7.25); hemodynamic stability with minimal or no vasopressor support; and presence of spontaneous inspiratory effort.

  9. Noninvasive positive pressure ventilation avoids complications of invasive ventilation (eg, trauma, cardiac arrhythmias, hypotension, volutrauma, and ventilator-associated pneumonia).

  10. Indications for noninvasive positive pressure ventilation include acute hypercapnic respiratory failure in the setting of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema and immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure.

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INTRODUCTION

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Mechanical ventilation may prove to be life-saving in patients with acute respiratory failure. The use of mechanical ventilation has evolved over the years from the application of positive pressure with bellows to negative-pressure deployment with devices like the tank respirator to the modern day complex microprocessor-controlled positive-pressure devices. In recent years, new modes of mechanical ventilation have been devised for the purpose of enhancing patient comfort, minimizing patient-ventilator dyssynchrony, reducing lung injury, and automatically escalating or deescalating ventilatory support as needed. Regardless of these advancements, the goals of mechanical ventilation remain the same: providing safe gas exchange; decreasing the work of breathing (WOB); improving patient–ventilator interactions; minimizing iatrogenic injury; improving patient-ventilator interactions; and promoting liberation from mechanical ventilation in a timely manner.1,2,3 Nonetheless, it must be pointed out that there is limited data to show that newer modes of mechanical ventilation reduce morbidity and mortality over conventional modes of mechanical ventilation.4

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INDICATIONS OF MECHANICAL VENTILATION

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Mechanical ...

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