Mechanical Ventilation Basics

Thirty seconds of history: When man first conceived of the idea of mechanical ventilation,
positive pressure ventilation was so un-intuitive that he never even gave it serious consideration.
As a result, the first attempts at ventilation support were manifested as what we now tongue in
cheek refer to as the iron lung, a east of a device in which a patient was confined, much like a
coffin !with much the same results" that would pull a negative pressure on the outside of the
chest for the purpose of pulling a negative pressure inside the chest# a $uite nole, and very
physiologic effort. %owever, can you imagine trying to take care of a critically ill patient
confined inside a o& through which you cannot peer' The results were less than promising' At
any rate, the idea of pushing air into the chest at a pressure that would e&pand the chest (ust
seemed so un-physiologic that it (ust couldn)t work. *t would seem that venous return to the right
side of the heart would e completely inhiited !which it transiently is'" and that cardiac output
would e all ut halted. !which it is not'". +ut work, it did. And the result was a ,oliath of a
machine with a control panel that rivaled a +oeing -.-. /ow, we must unravel this east down
to its asics and see the machine to which it has evolved today.
0irst, * think it important to understand that there are two asic methods of pushing that air into
the chest !and therefore, two asic types of ventilators": 1" 2olume ventilators !typically the si3e
of a refrigerator in their early years, and $uite comple& to set up, incredily e&pensive, ut whose
function asically hinged on the idea of choosing a set volume of air and then pushing that
volume into the chest with each reath" 4" 5ressure ventilators !$uite compact, aout the si3e of
an *2 pump, much simpler to set up, very ine&pensive, and whose function is ased upon
pushing air into the chest with a previously chosen pressure. 2olume ventilators are the most
common type we see in the intensive care units and pressure ventilators are the most common
type we see ehind the sheets in the 67 the anesthesiologists use during general anesthesia.
%owever, the newer ventilators are eginning to show up with volume and pressure features
lended into one unit. We)ll hear more aout this later.
6ver the last 89 years, we)ve done some significant fine tuning to this asic concept of pushing a
chosen volume of air into the chest with each reath, ut during the first 1: years of my medical
practice, volume ventilators had only one asic mode IMV !intermittent mandatory
ventilation"# a set numer of reaths given at regular intervals whether the patient wanted them
or not. Though it eat the heck out of dying, this mode gave ucking the ventilator its name
for ovious reasons. ;ater the rilliant idea of allowing the patient to trigger each of these
reaths was spawned SIMV !synchroni3ed intermittent mandatory ventilation". This made the
minute to minute tuning of the ventilator tremendously easier and instead of aout <9= of the
patients ucking the ventilator, the average decreased to aout .9=. And for many years *
en(oyed this da33ling piece of technology. >everal other attempts were made at e&panding the
feature set to these ventilators, ut most went the way of the >igh 2olume feature ?an attempt at
simulating the natural tendency of a human eing to take a sigh !large volume" reath from 4 to :
times@minuteA. +ut aout ten years ack, some guru made a really significant refinement to this
asic >*B2 setup. We now call it Assist Control. ;ater, we)ll deal in some depth with (ust
what this is and how it differs from >*B2. +ut first, T%C +A>*D>'
When a patient fails to ade$uately ventilate themselves, a code or near code situation often
develops, during which their heart rate !and ours" soars. Cveryone is tight sphincterd for the
several minutes it takes for us to get an airway estalished and attempt to figure out why the
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Mechanical Ventilation Basics
wheel ran off the cart. *t is on the heals of this terrifying event that the nurse or respiratory
therapist will often turn to you with the famous $uestion, What vent settings do you wantE *t
seems that this terrifying $uestion comes at a point when we are most stressed and least ale to
think straight. As a result, * have taken a very simplistic approach to teaching myself how to
weather this rief storm. There are three parts to the answer to the aove $uestion: 1" T%C
7ATC 4" T%C 0*64 8" T%C T*FA; 26;GBC
1" RATE: This one is easy. Cveryone gets a rate of 1: reaths per minute. 5eriod. Furing
the years of *B2, that didn)t work worth a s$uat. >*B2 helped some, ut even here more
than half the patients still re$uired some fiddling with the rate control setting during the
first few hours of vent support for reasons we)ll discuss shortly. %owever, one of the
features of Assist Dontrol mentioned aove all ut solved this prolem, although it has
more to do with the tidal volume !more on this in a minute". With Assist Dontrol, if you
set the rate at 1: and the patient wants to reath 4- times per minute, the Assist Dontrol
mode allows them to over reath the ventilator)s rate setting of 1: reaths y the
additional 14 reaths per minute. %erein lies the asic difference etween >*B2 and
Assist Dontrol. 0or the first 1: reaths !again, if that)s the rate you choose" oth methods
give the patient 1: reaths and oth methods allow the patient to take the additional 14
!or however many they desire" reaths. %owever, it)s the difference in how Assist
Dontrol handles T*FA; 26;GBC that makes it shine over >*B2. Allowing the patient
to determine the rate at which they seem most comfortale ypasses the vast ma(ority of
rate related prolems associated with mechanical ventilator support.
4" TIDAL VOLUME: *t is here where the asic difference etween >*B2 and Assist
Dontrol ecomes most evident. With >*B2, the patient gets 1: reaths !again if that)s
what you set" at the tidal volume you set. The same is true for Assist Dontrol. %owever,
during the additional 14 reaths !in this e&ample" with >*B2, the patient gets only
whatever tidal volume he can muster on his own. With Assist Dontrol, this is not the case.
The patient gets the set tidal volume not only with the initial set 1: reaths, ut also with
the additional patient initiated 14 reaths. With this in mind, we need a simple way to
select a reasonale tidal volume during the heat of the attle. 0or that, * use a simple ., :,
H approach. *n other words, .99 cc for small statured people, :99 cc for medium si3ed
people and H99 cc for large framed people. /ow if you wonder (ust how precise this
guessing process needs to e during these initial few minutes of vent support, (ust ear in
mind that these numers were in the range of :99 cc, -99 cc and I99 cc for the first 1:
years of my medical practice. %owever more recent research has concluded that the use
of much smaller tidal volumes administered at somewhat higher rates reflect much etter
outcomes !shorter length of stay, fewer days of ventilator support re$uired, lower
moridity@mortality, etc.". And (ust what do you do in this instance with the 4H8 pound
elderly lady who, at age 1< graduated from high school weighing an envious 11H lsE
Well, she)s simply a small lady in a ig package. +ut her lungs are the same si3e !if not a
it smaller" than they were when she weighed the 11H ls. >o, she gets a tidal volume of
.99 cc in spite of her heavy weight. /ow, * reali3e the literature says we should use lean
ody weight. /ot a one of us, if the truth were told, ever sits down with a calculator and
estimates the ody weight y this method. And in fact my ne&t assessment helps resolve
this prolem. %aving selected a tidal volume, most residents, when asked, What do you
do ne&tE, respond with, ,et some A+,)s. %owever, this omits a supremely important
step from the initial setup process. Jou should walk over to the patient)s edside, watch
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Mechanical Ventilation Basics
the patient for a moment, then take a hard look at the ventilator)s intimidating interface.
6n it somewhere, you will find a graphical representation of the volume of air you are
pushing in !the tidal volume" and the resultant pressure that volume generates when it)s
pushed in. That pressure is the key to knowing if you have guessed correctly on the tidal
volume. *t turns out that the pressure re$uired to ade$uately ventilate the average adult
!regardless of ody si3e'''" is in the range of 49 to 89 mm%g. >oooo, if the tidal volume
you have chosen generates a pressure in this range, you have accurately guessed at the
tidal volume and you don)t need a set of A+,)s to prove it. *f you find the average
reath-to-reath pressure to e less than 49 mm%g, you (ust turn up the tidal volume y
:9 cc or so. ;ikewise, if you find the pressures to e consistently aove 89 mm%g, you
turn down the tidal volume y :9 cc or so. This fine-tuning of the tidal volume allows
you to ma&imi3e the asic vent settings efore you ever draw the first set of A+,)s.
8" FIO2: Buch like the rate, * have a one si3e fits all approach to setting the 0*64. *f in
dout, start with 199=' %owever, if we (ust stop and think for (ust a few seconds, we
can easily reak patients with respiratory failure into two road categories# a" those
with roken necks, myasthenia gravis, ,uillain +arreK >yndrome, etc. i.e. nothing wrong
with their lungsL " those with primary respiratory failure# things like acute pulmonary
edema, asthma, D65F, pneumonia, near drowns, 5TC, etc. 0or the former group, * give
near room air settings, like for e&ample, 89=. To those in the latter group, * start with
high 0*64)s# like 199=. /ow, it)s true that with a little e&perience, you can fine tune
this latter 199= 0*64 approach and give some H9=, some <9= and some 199=. +ut it)s
not at all unreasonale to (ust use 199= if there is any $uestion in your mind until you get
the first set of A+,)s ack.
Bucking the Ventilator: *t has een my e&perience that working your way through the aove
asic setup will achieve ade$uate o&ygenation in aout <:= of folks with respiratory failure
re$uiring mechanical ventilation. %owever, there is another 19= or so that will test your
religion. These folks are the ones who, from the eginning, (ust keep ucking the ventilator.
To solve this prolem, we must understand what is most likely causing this phenomenon. To
illustrate the prolem, allow me to use an oversimplification. When you and * reathe in the
course of an average day, the length of time re$uired to take in a reath compared to the length
of time it takes to low it out is on the order of 4 to 1. *n other words, it takes twice as long to
take in a reath as it does to e&hale it. %owever, for most people who re$uire mechanical
ventilation support for respiratory failure, this ratio is reversed# something on the order of 1 to
4 or 1 to 8 or somewhere in etween !e.g. 1 to 4.H or 1. 4.8". /ow for the oversimplified
e&ample, let)s say it takes one second to push in the tidal volume we have set, and that it takes
two seconds for the reath to passively come out. 6ne plus two e$uals three. %ow many
ventilation cycles are possile in this scenario in one minuteE Well, si&ty divided y three !1
second to inhale M 4 two seconds to e&hale" is twenty. What if our imaginary patient is trying to
reathe twenty si& times per minuteE Well, during those additional si& reaths !4H minus 49",
the last reath has not had time to get out when the ventilator tries to push in another full tidal
volume' The result manifests itself in two ways. 1" The pressure generated y the partial reath
that hasn)t come out yet plus the full tidal volume eing pushed in pushes the pressure aove the
pressure alarm setting and the pressure alarm on the ventilator goes off. This alone, would not e
a ig deal, ut this high pressure that is generated y the stacking of reaths triggers the
person)s cough refle& and this then, causes the pressure alarm to go off a second time, and often
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Mechanical Ventilation Basics
results in repeated coughing. This reath stacking, pressure rise, coughing is what we call,
ucking the ventilator. /ow, how do we fi& itE Well, from the e&ample aove, you might
guess that we don)t have much control !like none" over the e&piratory part of the reathing cycle.
>o the only variale we can alter is the length of time re$uired to push in the chosen tidal
volume. We call this the inspiratory flow rate. +y increasing the inspiratory flow rate !pushing
in the reath faster", we can effectively alter the *@C ratio toward 1 to : or 1 to H effectively
allowing more ventilation cycles in the course of each minute of ventilation !e.g. if we started at
1@8.< and we increase the inspiratory flow rate y 19=, the effect might e to move the *@C ratio
to say 1 to ..:". +y moving this *@C ratio in such a fashion, we allow for more ventilaton cycles
in a given minute. *n practical terms, if you can keep the *@C ration in the 1@8 range in most
people, this will allow for a respiratory rate up into the high 49)s@minute# plenty of rate to
ade$uately overcome the dyspnea most patients with respiratory failure feel.
EE: With this fine tuning of the *@C ratio noted aove, we can ade$uately ventilate another :
to 19= of patients re$uiring mechanical ventilation. That last few percent can e a real challenge
!or, you might say, are y definition difficult to ventilate". >o, when you have done all of the
aove to ma&imi3e the efficacy@efficiency of the ventilator setup, what raits are left in the hat
if ade$uate o&ygenation is still not achievedE Well, there is 5CC5. +efore you (ump though,
you need to understand that not only will 5CC5 not help everyone with respiratory failure on
mechanical ventilatory support. There is a group that it will help and a group that 5CC5 will
actually worsen. *f you think a moment, you could proaly guess who the folks are that 5CC5
will worsen. *n addition to the hemodynamic effect of 5CC5 on right ventricular filling
pressures, it also has an aerodynamic effect that is e$ually disastrous when used in the wrong
patients. Nust who might these folks eE Well, perhaps those with the primary prolem of having
difficulty getting their last reath out. Asthmatics and folks with other forms of D65F, like
emphysema. *f you apply 5CC5 to them, the efficacy of their mechanical ventilation will actually
deteriorate'
+ut, who will 5CC5 helpE Those patients with water-in-the-lung, namely acute cardiac
pulmonary edema, A7F>, near drown victims, pneumonia !a locali3ed form of pulmonary
edema", etc.
/ow, do we ever get patients with mi&ed prolems# say, someone with D65F and D%0E 6r
D65F and pneumoniaE Dertainly. The prolem is that using 5CC5 in these patients will
typically help the water-in-the-lung prolem !pulmonary edema@D%0@A7F>" while e&acerating
their primary air trapping prolem !asthma@D65F" and the net effect is that the 5CC5 ought
you little if any e&tra mileage. /evertheless watching someone die efore our eyes often pushes
us to desperate measures# usually with poor results.
/ow let)s return to the hemodynamic effect of 5CC5 on right ventricular filling pressures. We
need to recall what the right ventricular filling pressures are# !Jou do rememer that the left
side of the heart does not pump what the right side does not send itE" Gnder normal
circumstances the right ventricular filling pressures are pretty low# in the range of minus five to
plus ten mm%g# fre$uently hovering around 3ero mm%g. 5CC5 is, Positive End Expiratory
Pressure. The prolem is that this positive pressure is not (ust applied at the end of the
e&piratory cycle as the title implies. *t is applied throughout the ventilator cycle''' That means
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Mechanical Ventilation Basics
that in order for the right side of the heart to fill with lood at its usual filling pressures, this
5CC5 must e overcome. At pressures approaching 19 mm%g, the 5CC5 fre$uently cannot e
overcome and the result is a dramatic reduction in left heart pressures !i.e. the systolic lood
pressure drops". This effect is not immediate and in fact, the way it typically happens is for you
to fiddle with the vent settings for an hour or so, finally settle on a setup that achieves ade$uate
o&ygenation and off to ed you go. Nust aout the time your head hits the pillow, you get a call
from the *DG nurse, Foctor, Bs. Nones) lood pressure is H9@.9' And what is your knee (erk
response to a drop in lood pressure in a dog sick patient you)ve (ust coded and intuatedE
2olume. 7ightE Wake up. >tand eside the ed and hear my voice screaming at you'
T%*/O'''''' Fo you give more volume to a patient you (ust selected for 5CC5 ecause they
had water-in-the-lungsE /oooooooooo''' 2asopressors. 7ightE /ooooooooo''' The left heart
cannot pump what the right heart does not send it' *t)s the 5CC5 that is the prolem. >o, always
start low !. to : mm%g" with 5CC5 and very cautiously increase it one or two mm%g at a time
until you achieve ade$uate o&ygenation and e ready for that phone call aout the patient)s lood
pressure dropping. +y the time you get up in the 19 mm%g range, you are going to get the call'
/ow, we are down to that last few percent of survivors that in spite of all the aove use of
technology are still fighting the ventilator and not ade$uately o&ygenated. This select group will
re$uire drastic measures# heavy sedation !*2 2ersedP or something similar" followed y a
neuromuscular locking agent !5avulonP, succinylcholine or something similar". 0rom here, all
the aove measures are ma&imi3ed. *n other words, if the 0*64 is not 199=, turn it up. >et the
*@C ratio optimi3ed to allow for the highest cycling rate you can achieve. *f the patient falls in the
water-in-the-lung category, optimi3e the 5CC5 to the point where it induces hypotension, then
ack it down 4 mm%g. *f these measures fail, you are ready to hang crepe with the patient)s
family ecause the curtains are aout to come down. Jou have done all you can do.
VE!TILATOR "EA!I!#:
6n a lighter note, for those who survived our efforts to this point, we have much etter odds of
getting them through it. %owever, the war is not over. We have won the first volley, ut many
more attles are to come. 6ver the ne&t day or two, our ventilation efforts are generally focused
on maintaining ade$uate o&ygenation while giving the patient time to recover from whatever
caused the initial insult !B*, sepsis, 5TC, pneumonia, etc.". +y the morning of the third day !if
not efore, in prolems like near drowns and drug overdoses, where the patient can often e
e&tuated the second morning" one should egin planning for the weaning process. This is most
often a mind game in which you walk in every morning, look at the patient and try to decide if
this is the day. There are many traditional predictors of weaning outcome that cumulatively are
used to make the decision whether the patient is ready to start the process. At this point * would
refer you to GpToFateP on the topic of 7apid >hallow +reathing *nde& !7>+*" and other
predictors !Work of +reathing *nde&, Binute 2entilation, Ba&imum *nspiratory 5ressure,
6cclusion 5ressures, etc". 6f all these, the 7>+* is proaly the est. *t is simple to perform and
* like simple approaches to comple& su(ects. %owever *)ll have to admit * gave up using it for a
yet simpler approach. *n my e&perience the two most useful predictors are: 1" The patient)s
mental status !is he awake, alert, has following eye movements, ale to communicate, etc." 4"
Ade$uate o&ygenation !*n some cases of respiratory failure, we are not (ust fretting over the 64
level, ut also may e attling hypercaria in D65F patients. These re$uire special measures
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Mechanical Ventilation Basics
discussed in more detail elow D65F with hypo&emia and hypercaria". The latter of these
is pretty straight ahead. Jou (ust look at the A+,)s and the 564 is either aove <9 or it)s not. *f
it)s not, they are proaly not ready for weaning. >imple enough. The assessment of the
patient)s mental and general physical status is a little more involved. * think it might e helpful
for you to visuali3e how * might go through assessing this former predictor of weaning success.
6n that second or third morning, as you enter the room, efore you ever touch !wake" the patient,
(ust stand there and watch them reath for a moment. *f the family is present, do it anyway. *s the
patient showing any evidence of struggling, any effort at reathing or triggering the ventilator. *f
they are, that)s a ad sign. 6nce you have oserved them for a moment, reach over and turn the
alarm on the ventilator off !*f you don)t know where the vent alarm is, ask the respiratory
therapist to show you so you will know the ne&t time." and disconnect the ventilator from the
endotracheal tue. /ow, (ust stand there and watch them reath for a couple of minutes or so.
*)ve found it helpful at that moment to turn my attention to any family present and spend a few
minutes talking with them, while keeping an oservant eye on the patient. +y the time you have
oserved them for a few minutes reathing on their own, off all ventilator support, and they are
not taking rapid shallow reaths and don)t look distressed, you have the asic information the
7>+* would tell you. 0rom this point, one need only give weaning a shot. *f, on the other hand
the person is working hard to reath, reathing faster and noticealy uncomfortale, it)s proaly
est to rest them on Assist Dontrol another day and try again tomorrow. *t)s important here to
understand that you don)t have to e successful at the weaning process a high percentage of the
time. *f you fail, all is not lost. Jou (ust try again the ne&t day. What you don)t want to do is go
day after day (ust following las, oserving, ut never giving weaning a try. Bost physicians are
too gun shy aout taking a shot at weaning early on in the course of mechanical ventilation. Try
and fail, ut try you do# every day'
Weaning the patient with COPD with hypoxemia and hypercarbia: This represents a uni$ue
suset of folks with ventilation failure that re$uires special consideration. 0olks with D65F are
particularly difficult to wean from mechanical ventilation, ut those with oth D65F and
chronic D64 retention are particularly challenging. 0irst must recogni3e that these patients have
a very different drive to reath than other people. Jou and * take our ne&t reath minute to
minute controlled completely y the D64 level in our lood. *f the D64 level rises, you reath
faster. %owever this is not the case with a person with D65F and chronic D64 retention. %is
drive to reath is hypo&emia. *n other words, he must be hypoxemic in order to keep reathing'
*n fact, this very feature of their e&istence is often what lands them on mechanical ventilation
support. They come to the hospital already hypercaric and somewhat somnolent as a result,
very hypo&emic !ut therefore reathing" and we have the knee (erk response of placing them on
H liters of 64. Their 564 improves and their drive to reath goes to the +ahamas' The ne&t step
is intuation. *t)s reversing this process where we really egin to stumle. *f you think aout it a
moment and ask yourself the $uestion, *f * had seen this person in Wal-Bart and checked a set
of A+,)s, what would have een ideal for themE Well how aout a p% of -.88 !almost
compensated", 5D64 of :9 to H9 !not enough to make them somnolent", and a 564 of H9 to -9
!low enough to leave them with a drive to reath". Why is it then, when we start the weaning
process, that we want to see a 564 of 199, 5D64 of 8: and a p% of -..9E *t makes no sense.
6ur goal during the weaning process should e, at est, their aseline !not normal" A+,)s. The
64 >AT)s should e aout << to I9=, not I:=. +y learning to accept these very anormal
values in this suset of patients with D65F and D64 retention, we can en(oy much greater
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Mechanical Ventilation Basics
success in the weaning process. They are still difficult to wean, ut with realistic e&pectations,
the process goes much smoother.
Weaning the average patient: The first step at weaning is to egin a stepwise reduction in the
0*64 support from 199= down toward .9=, generally in increments of 19 to 49=. *n the most
critically ill patients, this may take two or three days. *n most it can e accomplished in a day or
so. 6nce the 0*64 is in the .9 to :9= range, the ne&t ma(or step can e attempted. %aving
assessed your predictors of weaning success discussed aove and make the conscious decision
to take a shot at weaning, what is your ne&t stepE *t is simply to change from Assist Dontrol to
>*B2. *n doing so, you have effectively reduced the patient)s ventilation support y the
difference in their own tidal volume in all those reaths they were taken aove the set rate !in
this case, 1:". >o, if the person was reathing 4. times@min, on Assist Dontrol, they were getting
the full !say, for e&ample, :99 cc" set tidal volume for all 4. reaths. 6n >*B2, they will e
getting only what they can muster !say, for e&ample, 8<9 cc" for those additional I reaths !4.
-1: Q I" and the set :99 cc for the other 1: reaths. >o, you see that (ust changing from Assist
Dontrol to >*B2 reduces ventilation support in most patients. /ow you have your patient on
>*B2 with a set rate of 1: and reathing something more than that, say 4. times@min. The ne&t
step is to egin reducing the >*B2 rate. +ased upon how sick the patient has een, how alert
they are, how good their A+,)s look, you decrease the rate y aout 8 reaths per minute for the
first step !to 14@min". ;et an hour or two pass, check 64 >AT)s and if ade$uate, go down another
4 reaths per minute to 19 per minute. Wait another hour or two and repeat the process, reducing
the rate to < per minute. This is repeated in similar fashion down to aout . to H reaths per
minute and once at this level, if all has gone well, change the ventilation support to 0low +y.
At this setting, the patient is getting the set 0*64 !now down to the .9 to :9= range", ut the rate
and tidal volume of each reath are completely determined y the patient. *f 64 >AT)s remain
ade$uate !Bost would check A+,)s after a couple of hours or so on flow y to assess not (ust
the 564, ut the p% and 5D64 as well.", e&tuation can e e&ecuted. Jou may have noticed that
to this point, * have not mentioned 5ressure >upport. *t)s ecause * seldom use it. %owever, it
can e a very useful and alternative type of ventilation support to achieve successful weaning
from ventilation support. The method is very similar to weaning from >*B2 rate support. As
noted aove, once the 0*64 has een weaned down to the .9 to :9= range, once can simply turn
the >*B2 off !to 0low +y" and turn pressure support on to a level that will give the patient
appro&imately the same amount of ventilation support that >*B2 would have given at aout 14
reaths per minute. That numer turns out to e aout 14 to 1: mm%g of pressure support.
7ememer in thinking aout this how much pressure support would e e$uivalent to full Assist
Dontrol setting 4: mm%g of pressure support. >o, changing from Assist Dontrol in a patient
reathing 4. times per minute to pressure support at 1: mm%g would e the e$uivalent of
changing from Assist Dontrol to >*B2 at 1: reaths per minute. 0rom that point, you could
proaly guess how to use pressure support to wean down to flow y. After an hour or two on
pressure support at 1: mm%g, (ust turn the pressure support down to 14. Wait an hour or two,
and if 64 >AT)s are 6O, turn it down to 14 per minute. Then 19 per minute, then < per minute,
and so forth down to flow y with no pressure support. * think most pulmonologists would part
with me at this point. Bost would say that the resistance in the tuing !eing smaller in diameter
than the upper airway" would re$uire aout : mm%g of pressure support to overcome. And to
this statement, * would agree. >till * don)t use pressure support. *t has een my e&perience that if
the patient cannot handle : mm%g of pressure support caused y the line resistance, he is not
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Mechanical Ventilation Basics
ready to e e&tuated. The rare e&ception might e a patient with D65F and chronic D64
retention who lives with crossed or near crossed gasses, an occasional patient with severe
pulmonary firosis or some other lung disease where their asic metaolic state is so close to
death that they (ust have no margin for error. *n this select few, using a few mm%g of pressure
support to get them through that couple of hours on flow y might e warranted. Bost, however,
will do (ust fine with no pressure support. *f they struggle without it, you may well find yourself
in a few hours ack intuating them again# not a pleasant e&perience in any case. Bany
pulmonologists utili3e pressure support simultaneously with >*B2 in the process of weaning
from ventilation support. To me, it makes no sense to mi& the two in most cases. %owever, in
managing patients in concert with several pulmonologists now for many years, * know there are a
host of individuali3ed methods of achieving good results with all the aove discussed methods of
ventilation management that are $uite different from my own approach. And that is $uite 6O.
There is a pretty wide range of variance etween individual pulmonologists as well. By method
is (ust that# one method that works, and works $uite well. With e&perience, you will
undoutedly develop your own approach with which you ecome successful.
A. 7oert >heppard, B.F.
Associate 5rofessor of Bedicine
Firector, %ospitalist >ervices
Dollege of Dommunity %ealth >ciences
Gniversity of Alaama >chool of Bedicine
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