LEARNING OBJECTIVES:

KNOWLEDGE:

Students should be able to describe:

• The major indications for intubation.
• The difference between pressure and volume cycled ventilators.
• Typical initial adult ventilator settings.
• How to assess the adequacy of these initial ventilator settings.
• The role of non-invasive mask ventilation in managing patients with acute on chronic respiratory failure secondary to COPD.
• The management of hypoxemia in ARDS.
  • Hypoxemic Respiratory Failure secondary to low-pressure pulmonary edema (i.e., ARDS).
  • Hypoxemic Respiratory Failure secondary to high-pressure pulmonary edema (i.e., CHF).
  • Status Asthmaticus
• Weaning strategies.
• Calculations of the A-a gradient, pH changes in response to acute changes in PaCO2, static compliance, and arterial oxygen content.

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SKILLS:

Students should be able to:

HISTORY AND PHYSICAL EXAM:

• Perform a focused evaluation of the mechanically ventilated patient with an emphasis on assessing potential complications as well as patient comfort.

LABORATORY INTERPRETATION:

• Appropriately interpret the ABG and CXR in mechanically ventilated patients, and be capable of interpreting the various dials and alarms on the ventilator.

COMMUNICATION SKILLS:

• Succinctly present data relevant to the evaluation of the mechanically ventilated patient to members of the health care team and in addition gain experience discussing the patient care plan with the patient and family.

BASIC AND ADVANCED PROCEDURES:

• Reliably perform oral-pharyngeal and endotracheal suctioning as well as extubation.

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.

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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
• respect the competent patient's right to d/c mechanical ventilation

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REFERENCES:

Mechanical Ventilation Principles

• Mechanical Ventilatory Support. Harrison 's Textbook of Medicine. 15 th Edition. New York : McGraw Hill, 2001, pp 1526-1531.
• Mechanical Ventilatory Support, in Harrison 's On-Line:
  http://harrisons.accessmedicine.com/server-java/Arknoid/amed/harrisons/co_chapters/ch266/ch266_p01.html
• 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.

Weaning

• 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.
• Esteban A, Frutos F, Tobin MJ, Alia I, Solsona J, Valverde I, Fernandez R, DeLaCal MA, Benito S, Tomas R, Carriedo D, Macias S, Blanc J: A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995:332:345-50.

CPAP/BiPAP

• 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.
• 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.

Mechanical Ventilation in Specific Disease States

• UpToDate ® has very nice succinct summaries of treatment strategies for Non-Cardiogenic Pulmonary Edema (i.e. ARDS), Cardiogenic Pulmonary Edema, and Status Asthmaticus.