Monitoring patients receiving mechanical ventilator support has four general goal :

1. Assuring that the ventilator is operating as designed and set up by the vlinician
2. Providing information to the clinicians to facilitate appropriate adjusments to the
ventilator
3. Controlling automatic feedback systems ( including alarms ) on the ventilator
4. Providing information that might allow prediction of outcome

Common monitoring techniques are the direct clinical examination, assessments of gas
exchange, and pressure / flow / volume measurements in the ventilator circuitry, which are
reviewed in the first portion of this chapter ( 1-3 ). The second portion of this chapter reviews
several new techniques that are either under investigation or have recently been introduced and
may address some of the shortcomings of currently available strategies.

Conventional Monitoring of Patients Receiving Mechanical Ventilation
a. Clinical Evaluation
During the course of mechanical ventilator support, eliciting symptoms may be difficult
because of the presence of artificial airways and altered mental status from drugs or
disease. Neverthcless, symptoms of dyspnea, pain and cough are important indicators of
patient status and evidence for these should be sought through both direct and indirect
assessments ( table 13-1 )

Table 13 1 Symptoms Evaluation of Petient Requiring Mechanical Ventilation

Careful physicial examination of the respiratory system of the critically ill patient
receiving mechanical ventilation is often challenging but remains a vital undertaking.
Abnormalities of the respiratory system often present in a nonspecific manner, but patterns of
findings may aid in the diagnosis.
Careful inspection may reveal important findings ( table 13-2 ). Palpation of the chest
may also be a useful examination tool. During palpation of the chest, the examiner may asses for
changes in tactile fremitus. Increased fremitus suggest parenchymal consolidation. Decreased
fremitus suggests either pleural fluid or hyperinflated parenchyme. Percussion may also be
useful to assess for consolidation, pleural disease, or pneumothorax. Although the breath sounds
may be obscured by mechanical ventilation, auscultation remains a useful tool, the listener may
hear the usual array of adventitious sound and can easily assess for the absence of the absence of
breath sounds indicative of a pneumothorax.

Evaluation Of Gas Exchange
One principal goal of monitoring the mechanically ventilated patient is to ensure
adequate oxygen delivery to the tissues. Oxygen delivery ( DO2 ) is related to the cardiac output
(Q) and arterial oxygen concentration ( Ca02 ) using Equation 13 1. The Cao2 in turn is related
to haemoglobin level ( Hb ), Oxyhemoglobin concentration ( or percent saturation : SaO2 ) , and
the partial pressure of oxygen ( PO2 ) Through Equation 13-2 :
DO2 = Q x CaO2 = Q x ( 1,34 x Hb x SaO2 ) x 10
CaO2 = ( 1.34 x Hb x SaO2 ) + ( 0,003 x PO2 )

The PO2 and SaO2 are usually measured from direct analysis of arterial blood. Arterial
blood gas analysis for acid base status ( Paco2 and pH ) is also criticial to monitor in
mechanically ventilated petients. The pH affects many biologic functions, and Psco2 is inversely
proportional to the minute ventilation provided by the mechanical ventilator.
Because analysis of the arterial blood gases is a cornerstone of respiratory monitoring in
the mechanically ventilated patient, it is essential to use a consistent, straightforward method of
analysis. Modern blood gas analyzers use various electrodes and light absorption techniques to
provides and light absorption techniques to provide values for Po2, Pco2, and pH. It is important
to correct these measured values for the patients temperature. Modern analyzer also can measure
various forms of haemoglobin such as carbonhemoglobin and methemoglobin. Carbonmeglobin
is useful for diagnosis of carbon monoxide intoxication. Methemoglobin is an alternate form of
hemoglobin with reduced oxygen binding capacity that is typically or the use of oxidant drugs
Older analyzer did not measure SaO2 directly and instead plotted Po2 against an ideal
oxygen-hemoglobin dissociation curve to generate an expected SaO2. Caution must be used in
interpreting calculated values for SaO2 because many factors in critically ill patients may create
a difference between true SaO2 and this epected SaO2 ( e.g pH, temperature, abnormal
hemoglobin binding, and alternate forms of hemoglobin
It is important to remember that sampling of aterial blood reflect only one point in time
and is not reflection of gas exchange over time. Moreover, intermittent blood gas sampling is
complicated by several potential sampling and measurement errors ( e.g. air bubbles mixed with
the sample during transportations or temporary storage, and anylyzer calibration factor ). In
addition to these errors, frequent blood gas sampling exposes health care personnel to blood and
it increses the considerable amount of blood used for testing in critically ill patient.
In an effort to avoid many of these problems, technology has been developed for
continuous intra-arterial blood gas monitoring. Continuos blood gas monitoring is currently
achieved by placement of a catheter with a sensor in the intravascular space. The two main
sensing modalities used are the fiberoptic ( optode ) and electrochemical ( electrode ) systems.
Both systems have shown promise in laboratory and animal testing, but several problems have
limited widespread clinical application. For example, during periods of circulatory failure,
peripheral blood flow is stagnant, thus likely leading to lower Po2, Higher Pco2, and lower pH
than expected. In addition, the catheter may touvh the arterial and tissue values. Similar to other
intravascular devices, these catheters may be thrombogenic and the waveform may be altered by
patient and user interactions. Finally, these indwelling devices are costly,
An alternative to actual blood sampling for SaO2 is the pulse oximeter. Using the
differential absorption of red and infrared light of oxyhemoglobin and deoxyhemoglobin, the
pulse oximeter generates ad estimate of arterial oxygen saturation ( SpO2 ) from light beams
applied to the surface of the skin. In general, the SpO2 correlates reasonably well with SaO2.
However, because of the sigmoid shape of the oxyhemoglobin dissociation shpe of the
oxyhemglobin dissociatioin curve, a 4 % error in an SpO2 reading of 95% could leave the range
of underlying Po2 as large as 100mmHg. Furthermore, the use of pulse oximetry traditionlally
calibrates with healthy volunteers, which may not translate accurately in the setting of critical
illness. Second, because of the inappropriate nature of exposing healthy volunteers to more
severe hypoxemia, calibration is only done to an SpO2 of 70 % , thus leaving pulse oximeters
less reliable at lower SpO2. In addition to severe hypoxia, pulse oximetry is also uneable to
detect hyperoxia because the oxyhemoglobin desaturation curve is flat at high Po2 and further
increases in Po2 lead to minimal, if any, increses in SaO2 or SpO2.

Mechanical Ventilator Device Monitor
Modern electronic and microprocessor based mechanical ventilator systems have
considerable internal monitoring of electronic and pneumatic function that are designed to assure
safe operation. Modern mechanical ventilators also routinely have mean airway pressure ( Paw)
and flow (V) sensor in the circuitry that continuously monitor and display data for clinical use. In
addition to these direct measurements, many derived values (e.g, inspired and exhaled volumes,
minute ventilation, inspiratory to expiratory ratio ( I/E ) usully are available also. Most
modern ventilators also have oxygen sensors in the circuitry to assure delivery of desired FIO2,
ande some ventilators may also have analyzers for exhaled CO2 and inhaled therapeutic gases
such as NO or heliox. The exhaled CO2 analyzer may have particular value as a back up
disconnect alarm.
In addition to routinely monitored values, modern ventilators can also make calculations
after various maneuvers. The most common maneuvers are the vital capacity, SBT, maximal
inspiratory mouth pressure (PI max ), measurements of respiratory system mechanics, and
estimates of intrinsic positive end expiratory pressure ( PEEPi)
The vital capacity requires a maximal voluntary expiratory effort from total lung capacity
by the patient, and the exhaled volume is measured by the ventilator. The SBT is done with
either minimal or no ventilator assistance and the spontaneous ventilation along with the
frequency to tidal volumes (f/Vt) measured by th ventilator. The negative inspiratory force is
measured by occluding the inspiratory circuit for at least 20 second and rhen measuring the
negative pressure the patient can generate.
Commonly measured respiratory system mechanics are airway resistance and respiratory
system compliance. These are measured using a constant flow controlled breath with an end
inspiratory pause ( i.e, no patient effort ). The distending pressure ( peak airway pressure ) (
Ppeak ), expiratory pressure (PEEP), V, compliance of the respiratory system (CRS ) in Equation
(13-3) and tidal volume (Vt) measurements obtained during such a breath are used to calculate
total airway resistance (Raw) in equation 13-4
CRS =Vt/Pplat PEEP ( 13-3 )
Raw = ( Ppeak Pplat ) / V ( 13-4 )
A more sophisticated way to assess respiratory system mechanics using these signals is
to generates a quasistic pressure volume (PV) plot. However, this requires a heavily sedated or
paralyzed patient to allow multiple Pplat determinations to be plotted over the entire range of
lung volumes. A modification on this approach is the use of a very slow inspiratory flow ( <10
L/min during a single breath from functional residual capacity to total lung capacity.
Conceptually, the PV plot can determine when significant overdistention is developing ( upper
inflection point ).
PEEPi develops when the expiratory time is inadequate to fully empty the lungs. During
controlled mechanical ventilation (i.e. no patient effort ), PEEPi canbe suspected when
expiratory flow is still occurring at the initiation of the next breath, and it can be measured
during the expiratory hold maneuver.
Alarms can be used on virtually any component of the ventilator or circuit. Alarm
strategies should be prioritized based on two factors :
1. The rapidity at which an adverse event develops ( either mechanical function of the
machine or patient status )
2. The rapidity at which a clinical response is required

Three levels of monitoring and alarms thus exist :
1. High level : rapidly developing events requiring an immediate respons ( e.g., patient
disconnect, gas supply failure )
2. Moderate level : Rapidly developing events that require a prompt, but not necessarily
immediate respons (e.g. oxygens blende failure, loss of PEEP )
3. Low level : slowly developing events that do not necessarily require a clinical response (
eg., worsening lung compliance )

In general, high-level monitoring and alarm condition require redundant,
continuous monitoring with high priority alarms ( and even automated responses ).
Moderate and low-level monitoring and alarm condition require less intensive setups.
A consensus group has recommended the use of various monitors and alarm
systems in specific clinical settings. These are summarized in tables 13-3 and 13-4

Using Monitored Information To Guide Ventilator Management
To provide adequate support yet minimize ventilator induced lung injury ( VILI ),
mechanical ventilation goals must involve tradeoffs. Spesificially, the need for potentially
injurious pressures, volumes and supplemental O2 must be weighed against the benefit of gas
has occurred over the last benefits of gas exchange support and muscle unloading. To this end, a
rethinking of gas exchange goals has occurred over the last decade, and now pH goals as low
7.15 tp 7.20 and PO2 goal as low as 55 mmHg are often considered acceptable if the lung can
protected from VILI. Ventilator settings thus selected to provide at least this level of gas
exchange support while at the same time meeting two mechanical goals :
1. Providing enough PEEP to maintain recruitment of the recruitable alveoli at end
exhalation
2. Avoiding a PEEP-Vt combination that unnecessarily overdistend healthier lung region at
end inspiration.
These goals embody the concept of a lungvprotective mechanical ventilator strategy, and these
principles guide current recommendations for the management of parenchymal and obstructive
lung disease.
In acute respiratory failure from parenchymal lung injury, either volumes or pressure
targeted assist control modes are often used initially to assure adequate unloading of ventilator
muscle. Tidal volumes should initially starte at 6 ml/kg ( ideal body weight), but increase may be
needed if unacceptable gas exchange or discomfort is pressurent. These increase, however,
should be limited to the minimum necessary to achive gas exchange or comfort while keeping
the airway Pplat less than 30 to 35 cm H2O ( accounting for any effects of excessive
extrathoracic stiffness. Rate should be adjusted to maintain pH goals. I/E ratios are generally
kept less than 1:1 to assure comfort.
Although PEPP levels can be set according to mechanical properties of the lung ( e.g
best compliance or the lower inflection point on quasistic pressure volume relationships ).
These procedures are difficult to do routinely. In practice, the PEEP FIO2 tables used in the
two large national institute of health acute respiratory distress syndrome ( NIH ARDS ) Network
trials seem similar in efficacy and provide a reasonable approach to balancing expiratory
pressure and supplemental oxygen. ( Table 13-5 )
In acute respiratory failure from obstructive lung disease, many of the priciples used for
the management of parenchymal disease noted above are also applicable. Spesifically, the
pressure or volumes targeted assist control mode tends to be used initially for near total
unloading of ventilator muscle ; Vt is kept low to avoid VILI in the lung. Also, moderate
hypercapnia should be tolerated if needed to keep thes tidal volumes and Pplat low.
The obstructive lung disease patient, however, poses additional problems because of the
likelihood of PEEPi development with consequent overdistention and breath triggering delays.
To minimize air trapping and PEEPi, particular effort is required to minimize inspiratory time
and maximize expiratory time. This may require even further reduction in Vt and respiratory rate
than what might be used in parenchymal lung injury, with consequently more severe permissive
hypercapnia. Another way to reduce the I/E ratio is to increace the inspiratory flow. Although
this is reasonable, there is the theoretical risk of rapidly (but transiently) overdistending healthy
lung units at the start of inspiration
PEEP and FIO2 requirements are often lower in obstructive lung disease patients, but the
approach described in table 13-5 is still reasonable. In the obstructive lung disease patient,
applied PEEP may serve an additional role to unload the imposed breathtriggering load imposed
by PEEP. This can be more carefully addressed using esophageal pressure measurements as
described below
In the patient with nonpulmonary causes of respiratory failure (e.g. neuromuscular
diseases, respiratory depressant drugs), the goals of mechanical ventilator support are relatively
straightforward. Pressure or volume targeted assist control modes are almost always needed
because of the patients generally unreliable respiratory drive. Because the lungs are relatively
normal, there seems to be less risk of regional overdistention. Thus, Vt larger than 6 mL/Kg
(ideal body weight) could be applied if needed for comfort and/or gas exchange
provided that the plateau pressure did not exceed the low-to mid -20 cm H2O range.
PEEP-FIO2 needs are generally low in these nonpulmonary processes but the approach outlined
in Table 13-4 still seems reasonable.
As respiratory failure stabilizes and begins to reverse, clinical attention shifts to the
ventilato withdrawal process. Unfortunately, many large clinical trials have clearly demonstrated
that current assessment/management strategies are not optimal, and considerable delay in
ventilator withdrawal is the consequence. Increased cost and exposure to pressure and infection
result. Attempts to increase withdrawal with consequent airway loss, aspiration, and ventilatory
muscle fatique.
A recent evidence-based task force(17) has recommended a two-step assessment process
:
1. Consider a patient a candidate for withdrawal if the lung injury is stable/resolving: the
gas exchange is adequate with low PEEP/Fio2 requirements; hemodynamics are
stable without a need for vasopressors; and the patient can initiate spontaneous
breaths. In patient meeting all requitments, proceed to the step below. In those not
meeting all four requirements, leave on current ventilator settings and reassess 24
hours later.
2. In patients meeting all the requirements in the step above, do an SBT using a T-
piece, constant positive airway pressure, or 5 cm H2O pressure support for 30 to 120
minutes. Assessments should include the ventilator pattern, gas exchange,
hemodynamics, and comfort. Patients passing this trial should be considered for
immediate ventilator withdrawal. Patients failing this trial must return to mechanical
ventilator support for the next 24 hours and the be reassessed.
In general, the goal in managing ventilatory support in patients who have failed an SBT is
to provide a stable, comfortable level of support that avoids underloading and
overloading ventilator muscles (17). To meet this goal, complete muscle immobility, as
provided during controlled ventilation, should be avoided because atrophy and delayed
fatique recovery are theoretical risks. More appropriate is the use of pressure-targeted
partial support modes. These are set by applying the minimum inspiratory pressure
needed to keep the patient comfortable, generally manisfested by a spontaneous
respiratory rate less than 30 and minimal signs of dyspnea. Cycle criteria can either be
flow (pressure support) or time (pressure assist). Backup control rates are rarely
necessary and the PEEP-FIO2 approach outlined in table 13-5 again seems reasonable.
It is important to assure that these supported/assisted breaths are initiated
promptly in accordance with patient demand. Accordingly, sensitive and responsive
triggering systems as well as synchronous flow delivery should be assured by assessing
both patient effort visually and through analysis of the pressure and flow graphics (Figure
13-3). Finally, it is important to reemphasize that this is a 24 hour management strategy:
the SBT must be used daily.


Never Approaches To Monitoring Mechanical Ventilation
Although clearly effective, the common monitoring techniques described above provide
little information about many important physiologic variables. For example, lung stretch
is only superficially assessed by measurements of circuit pressure and Vt, lung
requitment is only indirectly assessed by arterial oxygenation, and mechanical loads on
patient muscles have no direct monitoring technique.

Assessing Ventilator Function With Esophageal And Tracheal Measurements.
Esophageal Pressure and Tracheal Pressure To Assess Respiratory System Mechanics. As noted
above, the stretch across the lung at end inspiration is commonly assessed by the measurememnt
of Pplat(9,10) an important assumption made during this standard approach is that this Pplat is
primaly measured by alveolar distention. Recall, however, that chest wall compliance (Ccw) can
also affect Pplat. In many patients, Ccw can also affect Pplat. In many patients, Ccw is usually
several times greater than Cl such that it has little impact on Pplat. In patients with abnormal
chest wall mechanics (e.g. massive obesity, anasarca, chest wall injury, surginal dressings),
however, Ccw can be quite poor and can have profound effects on Pplat (6,7). Under these
conditions, the assumption that Pplat represents only lung properties does not hold
Figure 13-3. Pressure volume plots depicting various patient-ventilator interactions for a
constant tidal volume. In each plot, volume is on the vertical axis and pressure is on the
horizontal axis. Machine pressure generated in the circuit/airway are depicted by solid lines to
the right: esophageal pressure (pleura Pressures) are depicted by dashed lines to the left. The
solid-angled line directed upward and to the right from the origin reflects passive inflation
esophageal pressure (chest wall compliance). The shaded are reflects patient work. Breath A
depicts a normally loaded spontaneous (unsupported/unassisted) breath. Breath B depicts an
abnormally loaded spontaneous breath. Breath C depicts a machine-controlled breath in this
abnormal patient. Breath D depicts a synchronous-assisted breath designed to near totally unload
this abnormal patient (only triggering load is is evident). Breath E depicts a synchronous-assisted
breath designed to partially unload this abnormal patient. Under these circumstances, synchrony
is defined as a smooth airway pressure application that converts the patients loading pattern to a
more normal configuration (i.e resembling breath A). Breath F depicts a dyssynchronous-assisted
breath in this abnormal patient. High pressure patient loads exit through much of this breath
because of inappropriate ventilator flow delivery and resultant inappropriate circuit/airway
pressure generation

Pes is monitored from a pressure sensorplaced in midesophagus and is a reasonable
approximation of pleural pressure (8-13). During a passive positive pressure inflation, pes
reflects pressure on the other side of the alveolus and in front of the chest wall. It thus can be
used as a reference value for Pplat to give true transalveolar lung stretching pressure.
Tracheal pressure is monitored from a pressure sensor in the trachea distal to the articial
airway. Because of this, tracheal pressure can be used to separate the resistance imposed by the
articial airay from, the patients airway resistance. These uses of PES and tracheal pressure in
assessing respiratory system mechanicsin more detail are summarized in Table 13-7

Esophageal Pressure (Along with Mean Airway Pressure) to Assess Mechanical Loads.
Mechanical load is measured by the amount of ventilarory and by the various resistance and
compliance elements of the respiratory system and is expressed as either a pressure time product
(PTP) or a work (W) value. The PTP is the integral of pressure change over (PTP = Pdt
(integration of pressure over time): the work is calculated as the integral of pressure change over
(W-PdV) (integration of volume over time).
In figure 13-3, both Paw and Pes are plotted overtime for three breaths (spountaneous,
controlled and interactive). Integrating these plot thus yields the PTP as a reflection of load on
the ventilator and/or the patient. These same mechanical properties could also be depicted by
integrating pressure over volume as work.

Esophageal Pressure to Assess and Manage Triggering Loads Imposed by PEEPi. As noted
above, in a patient with severe obstructive lung disease, flow limited airway segments can
produce significant PEEPi (13,16). This high-end expiratory alveolar pressure can the serve as an
inspiratory threshold load for triggering the next breath. The amount of the PEEPi triggering load
can be readily estimated from esophageal pressure tracing. In a patient with no PEEPi, the
initiation of effort (i.e., the drop in the esophageal pressure) isaccompanied by simultaneous drop
in airway pressure and increace in flow from the circuitry. In contrast, in a patient with PEEPi
(Figure 13-4), a similar effort reflected by a drop in the esophageal pressure

Figure 13-4 Pressure time products (PTPs) as an index of mechanical load. Pictured are three
breaths of similar flow/volume with both airway and pleural (esophageal) pressure plotted over
time. The integral of pressure over time is the PTP (shaded areas). During a controlled breath (no
patient activity, left panel A), all the load is borne by the ventilator (light shading). The PTP
from the airway reflects the load imposed by the total respiratory system load imposed by the
total respiratory system and the PTP from esophagus reflects that potion of the respiratory
system load imposed by the chest wall. During a spontaneous breath (unassisted patient activity,
right panel C), all the load is borne by the patient (dark shading). The pressure from the
esophagus under these conditions can either be referenced to atmospheric pressure (the end
expiratory value) or to a passive esopjageal pressure tracing from a controlled breath of similar
flow/volume(dotted line). The PTP from the former approach reflects only the load imposed by
the lung: the PTP from the latter approach reflects the loads from the total respiratory system.
Note that given the same compliances, resistances and breath flow/volume, the respiratory
system PTP from the control Breath A is equal to the respiratory system PTP from the
spontaneous Breath C. during interactive breaths, (patients and ventilator both active, middle
panel B, load is shared by the patient and the ventilator. The proportion of load borne by the
patient and by the ventilator can be measured by superimposing a controlled breath (dotted
lines) of similar flow/volume on the interactive breath (solid lines). (Paw = mean airway
pressure: Pes = esophageal pressure. (from Maclntyre NR. Ventilator monitors, displays and
alarms. In: Maclntyre NR, Branson RD, eds. Mechanical Ventilation. Philadelphia: WB
Saunders: 2000: with permission

tracting is not accompanied by a simultaneous drop in airway pressure or increase in flow until
the PEEPi level (in this patient almost 25 cm H2O) has been exceeded by the effort. Note that
under these circumstances, assitional PEEP, by balancing the PEEPi, reduces the inspiratory
threshold load (Figure 13-5)
Visual Techniques To Asses Regional Lung Recruitment And Distention
Raising the end-expiratory lung volume (EELV) with PEEP (either applied PEEP or PEEPi) has
long been the major focus of the therapy for lung injury that produces atelectasis
and`parenchymal infiltrates (18). As noted above, the most common guide to the PEEP setting is
the Po2 improvement that occurs with better ventilation/perfusion relationships (see Table 13-5).
This simple gas exchange approach to PEEp settings, however, ignores an important
pathophysiologic effect of parenchymal lung injury. Specifically, because parenchymal lung
injury is often quite heterogeneous, an optimal expiratory pressure setting with appropriate
restoration of EELV in one unit may be an excessive expiratory pressure application with
overdistention in healthier regions. Minimizing ventilator induced lung injury and still providing
adequate gas exchange may thus involve expiratory pressure settings that are not associated with
the best values for PO2. Supporting this concept is the observation in NIH ARDS Network Trial
of ventilator management strategies: this trial showed that the small Vt approach, which
produced the best mortality outcome, was associated with less recruitment and a lower
Pao2/FIO2 ratio than the higher Vt approach (15).
A conceptually more attractive approach would thus be to develop ways to assess
regional behavior in the lung. Radiologic approaches using computed tomography (CT) offer
such an approach as regional recruitment and/or overdistention can be visualized (19). This type
of assessment, however, is complex and expensive and thus does not lend itself as an intensive
care unit monitoring tool. However, electrical impedance tomography (EIT) is a variation on the
radiologic approach that might have bedside applicability (20). EIT uses electrical impedance
from an array of electrodes around the chest to contruct a two-dimensional cross-sectional image
that can distinguish air from fluid. EIT images thus have the potential to distinguish atelectatic,
normal, and perhaps overdistended regions. The image resolution, however, is considerably less
than CT scanning and only one cross-sectional plane of the chest can be seen. It thus remains to
be seen if EIT will have clinical usefulness.

INERT AND SOLUBLE GAS BEHAVIOR TO ASSESS VENTILATION/ PERFUSION
RELATIONSHIPS
A very sophisticated way of assessing ventilation/perfusion relationships is the multiple inert gas
elimination technique (MIGET) (21). This involves the administration of sixinert gases of
different solubilities and analyzing gas and blood samples over a period of time. The retention
and excretion of these gases can then be used to contruct a 50 unit lung model having
ventilation/perfusion relationships ranging from zero (shunt) to in finity (dead space). This
technique has been used in many physiologic experiments, both in animals and humans, to
quantify ventilation/perfusion distribution changes as a function of various interventions. For
example, the MIIGET technique has been used in models of respiratory failure to demonstrate
how ventilation/perfusion distributions will change wth different PPV ventilator patterns,
different PEEP settings, application of perflubron, and other techniques (21).
In concept, this technique might help assess the optimal EELV. The goal would be to
apply expiratory pressure and increase lung volume as long as ventilator/perfusion relationships
were being made better. When regions of ventilation/perfusion units would be detected.
Although physiologically fascinating and conceptually attractive, this is cumbersome to
use and requires expensive


Figure 13-5 PEEPi from flow limited airways producing an inspiratory threshold triggering load.
Plotted are flow (V), volume (v), circuit/airway pressure (paw) and esophageal pressure (Pes)
over time. A patient effort in the left panel is reflected by the decrease in Pes (left arrow). Note,
however, that no simultaneous drop in circuit pressure or flow occurs until almost 0,5 seconds
has passed and the Pes has decreased almost 25 cm H2O (right arrow). This represents an PEEPi
level of at least 25 cm H2O that must be overcome by the inspiratory muscles before this patient
demand can be sensed in the ventilator circuitry (triggering threshold load). In the right panel, 20
cm H2O applied PEEP has been given. This level of PEEP does not eliminate the trapped gas in
the lung, but it does help equilibrate the expiratory pressures throughout the lung and circuitry.
Because of this, the patient effort to change circuit pressure/flow to trigger an assisted breath
becomes considerably less. Note that the applied PEEP under these circumstances has not
appreciably changed the peak pressure or the tidal volume. (Paw = mean airway pressure, PEEP
= positive end expiratory pressure: PEEpi = instrinsic positive end expiratory pressure, Pes =
esophageal pressure).

Equipment; therefore, it is unsuitable for true monitoring. Moreover, the ventilator settings
established with this technique have not been studied in any meaningful outcome way

SUMMARY

Monitoring mechanically ventilated patients is critical to assure safe and effective mechanical
ventilator includes regular clinical assessments, arterial blood gas analysis and respiratory system
mechanics. Alarms are essential components of monitoring, and their application depends on the
importance of monitored clinical/mechanical events and the speed required for the appropriate
response. Current monitoring strategies are not ideal for assessing such things as the risks for
VILI, patient-ventilator synchrony, inflammation, oxygen transport, and musle loading.
Monitoring innovations are thus needed and could involve more sophisticated analyses of
existing signals as well as the development of entirely new approaches.