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Humidification of respired gases during mechanical ventilation: mechanical considerations.

Humidification of inspired gases during mechanical ventilation remains a standard of care. Optimal humidity is an elusive target and is not clearly defined in the literature. The choice of a humidification device cannot be made solely on the basis of moisture output, however. The clinician must consider the effects of the device on gas exchange and spontaneous breath-ing. The author's group has used the data reviewed here to modify their previous algorithm for choosing a humidification device (see Fig. 2). Humidification requirements for noninvasive ventilation need further study.

Algorithms↗

Phase locking of the respiratory rhythm in cats to a mechanical ventilator.

Mechanical ventilation of paralyzed, pentobarbital-anesthetized adult cats was performed while recording phrenic nerve activity. The periodic changes in lung volume owing to mechanical ventilation affected the rhythm of central respiratory activity, resulting in a variety of regular and irregular patterns of coupling between respiratory system output, monitored by phrenic activity, and the mechanical ventilator. Phase-locked patterns, in which phrenic burst onset occurred at specific and repetitive phase(s) of the mechanical ventilator, with ratios of ventilator frequency: phrenic burst frequency of 1:2, 1:1, 3:2, 2:1, and 3:1 were observed. Regular and irregular patterns occurred over specific ranges of frequency and volume of the mechanical ventilator. A careful study was made of the 1:1 phase locking as the frequency and inflation volume of the mechanical ventilator were changed. The inspiratory time (TI) was defined as the interval between the time when phrenic activity began to rise and the onset of its rapid decline, and the expiratory time (TE) as the time between inspirations. In the 1:1 phase-locking region, as the frequency of the ventilator was increased both TI and TE decreased, and the phase of phrenic onset in the ventilator cycle changed. During ventilation with frequencies higher than the intrinsic phrenic frequency (initial burst frequency of phrenic activity with the ventilator turned off) inspiratory activity was prematurely terminated by lung inflation (Hering-Breuer inspiratory inhibitory reflex). During ventilation with frequencies lower than the intrinsic phrenic frequency, the onset of phrenic activity was delayed (TE was prolonged) by lung inflation (Hering-Breuer expiratory promoting reflex).

Animals↗

[Mechanical ventilation in pediatrics (III). Weaning, complications and other types of ventilation. Compications of mechanical ventilation].

Mechanical ventilation can produce multiple complications. The most important acute complications are mechanical problems (respirator failure, problems with the connections and circuit, incorrect parameters or alarms), problems in the airway (disconnection, extubation, mal-positioning of the endotracheal tube, leaks, nose erosions, obstruction of the endotracheal tube due to secretions or kinking, mainstem bronchus intubation, bronchospasm, postextubation croup), pulmonary complications (ventilator-induced lung injury with barotrauma, volutrauma and biotrauma), hemodynamic complications, nosocomial infections (tracheobronchitis, pneumonia, otitis, sinusitis), failure of adjustment of the respirator to the patient, and nutritional complications. The most important chronic problems are subglottal stenosis, chronic pulmonary injury, and psychological alterations.

Barotrauma↗

Principles of mechanical ventilation.

Mechanical ventilation is an enormous undertaking for a veterinary hospital in general and for any patient in particular. It is a team effort requiring large amounts of space, supplies, labor, and time. It requires committed owners and clinicians who communicate clearly with each other. It also requires a significant financial commitment initially from the hospital to obtain the equipment and expertise and then from the owner to maintain the patient. All members of the patient care team should have a basic understanding of respiratory physiology and ventilator mechanics. Clear goals for therapy and end points should be established. If they cannot be met, the goals should be reassessed in light of changes in patient condition. Weaning may be difficult and long, but once successful, it is most rewarding for the patient, family, clinician, and team.

Animals↗

Conventional mechanical ventilation.

Mechanical ventilation has become a very common and well-accepted practice in modern intensive care units. The use of the mechanical ventilator has progressed from being a support system during surgery and for acutely ill patients to being used in both moderate and long-term life support in patients with inadequate ventilation. The sophistication of modern ventilators and the ability of trained respiratory therapists and nursing personnel have permitted this technology to explode. This is occurring at a time when there are still many controversies about the relative benefits and modes of action of conventional ventilation. As newer techniques are developed, it is mandatory that the application of these techniques be tempered with controlled clinical trials, documenting their effectiveness. The beneficial effects of new modalities must be documented as mechanical ventilation expands from use in the intensive care unit to use in standard medical wards and the patient's home. In these latter two settings, the vigilance of an intensive care unit is absent and the simplest method will be preferable. The requirement to demonstrate efficacy of new techniques with adequate studies is especially necessary now as the economics of health delivery have come under increasing scrutiny. Even more important than new technologies may be the efficacy of prolonged mechanical ventilation. A recent study by Spicher and White evaluated the outcome in 250 patients ventilated for 10 days or more at the Hershey Medical Center (Pennsylvania State University). The mortality, morbidity, and disability in patients in this study population requiring prolonged ventilation were extremely high. As these studies have pointed out, further evaluations of predictors of meaningful survival are necessary to avoid unnecessary human suffering and to best use limited resources.

Biopsy↗

[Modalities of mechanical ventilation].

Mechanical ventilation improves the symptoms and reduces complications of acute respiratory failure. Recent advances in microprocessor technology have increased the sophistication of mechanical ventilators, thus leading to new ventilation modalities. This article describes the ventilation modalities available, grouping them as conventional, alternative and new modalities. Conventional ventilation includes the most widely used modalities, alternative ventilation includes less frequently used modalities, and new ventilation modalities include recently introduced options that are available on the latest-generation mechanical ventilators.

Critical Care↗

Intraocular pressure and mechanical ventilation.

Mechanical ventilation increases superior vena cava pressure and should theoretically increase episcleral venous pressure and intraocular pressure (IOP). A Keeler Pulsair Non Contact Tonometer was used to measure the IOP's of six subjects with no history of glaucoma or ocular hypertension. At 30 min of supine mechanical ventilation of tidal volume with low (7 to 15 cm H2O) peak inspiratory pressures, the IOP's were no different than at the end of a 30-min control period of supine spontaneous ventilation. However, using high (60 cm H2O) peak inspiratory pressures for 1 min after tidal volume ventilation, IOP's were 32.7% higher than at the end of the supine spontaneous ventilation control period (p < 0.05). Patients requiring long-term mechanical ventilation at high peak inspiratory pressures may be at increased risk of vision impairment secondary to machine-induced increase of IOP.

Adult↗

[Pathophysiological basis of mechanical ventilation].

Mechanical ventilation is required if ventilatory insufficiency is present. This is typically indicated by hypercapnea. Hypoxemia occurs secondary to hypoventilation. Usually overload of the respiratory muscles (ventilatory pump) will be the underlying mechanism, for the most part caused by acute or chronic disease. In case of sole hypoxemia mechanical ventilation will only be indicated if the oxygen-content (equals oxygen saturation x haemoglobin x 1.39) drops below a critical threshold or if ventilatory pump failure is imminent on account of the underlying disease (eg. pneumonia). The background of our recommendations is to avoid potential damage caused by mechanical ventilation. Especially high inspiratory pressures and oxygen concentrations can be harmful to the lung. Therefore every case has to evaluated for individual target parameters of ventilation. The use of the oxygen-content instead of the arterial oxygen pressure as the target parameter will usually lead to a more careful ventilation. Cardiogenic pulmonary oedema is an exception to this rule since inspiratory positive pressure and PEEP will result in improved diffusion as well as reduction of preload and work of breathing. In recent years progress has been made on the field of ventilation access especially in severe and acute cases. Non-invasive ventilation is superior to invasive ventilation in patients with exacerbated COPD since it improves outcome effectively. This is being caused by a decline in ventilator associated pneumonias, most likely because non-invasive ventilation allows patients to clear their secretions by coughing, resulting in improved lung clearance. Controlled ventilation allows optimal unloading of the respiratory muscles which have been overloaded by the underlying disease. Application of a controlled ventilation mode in acute disease will usually require some kind of sedation. Assisted ventilation will result in improved gas exchange but only incomplete unloading of respiratory muscles and therefore delayed restitution. Permanent controlled ventilation under sedation for a prolonged period (days) requires intermittent periods of assisted- or spontaneous breathing in order to avoid atrophy of the respiratory muscles. This review summarizes background information on the nature of the derangement, the relation between oxygen supply and consumption under special consideration of respiratory muscle insufficiency and impact of different ventilation modes.

Acute Disease↗

Normal plasma-urine osmolality relationship in preterm infants on positive pressure mechanical ventilation.

Mechanical ventilation with positive pressure has been implicated in the inappropriate release of vasopressin. To examine whether such a phenomenon occurs in infancy, 26 preterm neonates with Respiratory Distress Syndrome were studied. Simultaneous urine and plasma were collected for osmolality determination during mechanical ventilation with positive end expiratory pressure of 4-8 cmH2O. Results were plotted onto our previously described nomogram. The data show normal distribution of plasma to urine osmolality ratio in 25 out of 26 infants. These results do not support the common belief that positive pressure mechanical ventilation in the newborn with RDS provokes inappropriate secretion of vasopressin.

Humans↗

Progress in mechanical ventilation.

Mechanical ventilation is a life-supporting process employed in the management of respiratory failure. Over the years, our understanding of the pathophysiology of lung injury has greatly improved, and has aided the technological development of ventilatory modes that are more patient 'sensitive' and less traumatizing to the lungs. This review will discuss the fundamental modes of mechanical ventilation, and present current concepts regarding patient-ventilator interaction that either promote lung healing and weaning from positive pressure ventilation or delay recovery because of the injudicious use of ventilatory modalities that are incapable of meeting the ventilatory demands of the patient on a breath-by-breath basis. In addition, the current strategy for mechanical ventilation in acute lung injury and acute respiratory distress syndrome will be summarized.

Journal Article↗

[Lung damage due to mechanical ventilation].

Mechanical ventilation in both children and adults is still associated with development of lung injury, both short term and long term. In particular, ventilation with high tidal volumes and low positive end-expiratory pressures (PEEP) contributes significantly to development of lung injury. Suggested preventive measures consist of limiting peak inflation pressures, preventing high tidal volumes, and applying high PEEP to prevent alveolar collapse. Recent studies have demonstrated that mechanical ventilation, via stretch of lung tissue, results in an inflammatory reaction in the lungs. This is known as biotrauma. The degree of inflammation depends on the ventilator settings and mode of ventilation. This inflammatory reaction may not be limited to the lungs but, via inflammatory mediators, may cause multiple organ dysfunction as well. Future research needs to be concentrated on how to modify this ventilator induced inflammatory reaction in order to prevent lung injury as well as systemic injury.

Acute-Phase Reaction↗

[Definitions in mechanical ventilation].

Mechanical ventilation can be defined as the technique through which gas is moved toward and from the lungs through an external device connected directly to the patient. The clinical objectives of mechanical ventilation can be highly diverse: To maintain gas exchange, to reduce or substitute respiratory effort, to diminish the consumption of systemic and/or myocardiac O2, to obtain lung expansion, to allow sedation, anesthesia and muscle relaxation, and to stabilize the thoracic wall, etc. Ventilation can be carried out by negative extrathoracic pressure or intermittent positive pressure. According to the cycling mechanism, positive-pressure ventilators are classified as pressure-cycled, flow-cycled, or mixed, and according to the type of flow in continuous-flow ventilators, as intermittent flow or constant basic flow. Finally, high-frequency ventilators are classified according to their high-frequency mechanism as intermittent positive pressure, oscillatory high-frequency and high-frequency jet ventilators.

Child↗

Mechanical ventilation with air-oxygen mixtures during total intravenous anaesthesia. An evaluation of the Penlon Nuffield Series 400 ventilator.

Mechanical ventilation with air-oxygen mixtures during total intravenous anaesthesia is discussed with the associated problem of obtaining a medically suitable source of air in British rooms. Independently powered ventilators capable of entraining filtered room air were thought to be the best solution. The Penlon Nuffield Series 400 ventilator was modified and assessed for use in this mode. An entrainment adapter and circuit was devised which allowed the ventilator to entrain more than sufficient ambient air, premixed with added oxygen for patient ventilation even under adverse conditions. The entrainment system ensured good mixing of the entrained air and oxygen and allowed accurate determination of oxygen concentration in the patient system using a suitable nomogram and without an oxygen analyser. An assessment of one-way patient valves was also undertaken. The Laerdal valve was found to be the most suitable for use with the system described.

Air↗

[Mechanical ventilation in pediatrics (III). Weaning, complications and other types of ventilation. Weaning from mechanical ventilation].

Weaning from mechanical ventilation can be defined as the process that allows the transition from mechanical ventilation to spontaneous breathing. This process can account for a significant proportion of total ventilation time and failure to resume spontaneous breathing affects patient outcome. Thus, to ensure maximum success, patient readiness for weaning and extubation should be evaluated through the following steps: the patient must fulfill pre-established clinical and ventilatory support criteria for extubation, the patient should be observed during a breathing trial on minimal or no ventilatory support, and variables used to predict weaning success should indicate a favorable outcome. Breathing trials are usually conducted while the patient breathes spontaneously through a T-tube system or through the ventilator circuit on minimal ventilatory support. Neither of these methods has proved superior to the other. The best prognostic indicator of weaning outcome is clinical assessment of respiratory effort. Once mechanical ventilation is discontinued, it may be necessary to treat post-extubation complications or even to resume ventilatory support.

Humans↗

Economics of mechanical ventilation.

Mechanical ventilation is a life-saving medical advance. It has allowed many patients who previously would have died as a result of acute respiratory failure to survive. It has also created a population of patients who are unable to recover completely from their acute illness and who require prolonged mechanical ventilator support. The care for these patients raises many ethical, legal, social, economic, and medical issues. Data are needed to adequately meet the challenges of the ventilator-dependent patients in the future.

Home Care Services↗

Diaphragmatic nitric oxide synthase is not induced during mechanical ventilation.

Mechanical ventilation (MV) is associated with diaphragmatic oxidative stress that contributes to both diaphragmatic atrophy and contractile dysfunction. However, the pathways responsible for oxidant production in the diaphragm during MV remain unknown. To address this issue, we tested the hypothesis that diaphragmatic nitric oxide synthase (NOS) activity is elevated during MV, resulting in nitration of diaphragmatic proteins. Rats were mechanically ventilated for 18 h, and time-matched, anesthetized but spontaneously breathing animals served as controls. Protein levels of endothelial NOS, inducible NOS, and neuronal NOS were measured in diaphragms from all animals. 3-Nitrotyrosine levels were also measured as an index of protein nitration, and S-nitrosothiol levels were measured as a marker of nitric oxide reactions with molecules containing sulfhydryl groups. Levels of nitrates and nitrites were measured as markers of stable end products of nitric oxide metabolism. Finally, as a marker of oxidative stress, diaphragmatic levels of reduced GSH were also analyzed. MV did not promote an increase in diaphragmatic protein levels of endothelial NOS or neuronal NOS. Moreover, inducible NOS was not detected in the diaphragms of either experimental group. Consistent with these findings, MV did not elevate diaphragmatic 3-nitrotyrosine levels in any subcellular fraction of the diaphragm, including the cytosolic, mitochondrial, membrane, and insoluble protein fractions. Moreover, prolonged MV did not elevate diaphragmatic levels of S-nitrosothiols, nitrate, or nitrite. Finally, prolonged MV significantly reduced diaphragmatic levels of GSH, which is consistent with diaphragmatic oxidative stress. Collectively, these data reveal that MV-induced oxidative stress in the diaphragm is not due to increases in nitric oxide production by NOS.

Animals↗

Outcomes of pediatric mechanical ventilation.

Mechanical ventilation is one of the most commonly used life-support technologies in the PICU, is an absolute indicator of the need for PICU care, and adds considerably to the cost of intensive care. Patients with chronic disease account for a large proportion of admissions to the PICU and of patients undergoing cardiovascular surgery and neurosurgery. Although the average length of use of mechanical ventilation in the PICU is about 5 days, there is tremendous variability in the length of ventilation (SD approximately 9 days). Survival among ventilated patients varies greatly and depends mostly on the nature and severity of the underlying disease.

Adolescent↗

[Humidification and aspiration of the respiratory tract in patients with mechanical ventilation].

Mechanical ventilation through endotracheal prosthesis, suppresses the nose functions and stops elimination of secretions. It is mandatory to heat artificially, humidify insufflated gas and to suction tracheobronchial secretions. Heating humidifiers are very efficient for the first purpose but heat and moisture exchangers, a little less efficient, seem to be a good alternative as they are easiest to use and offer a good bacterial protection. Tracheobronchial suctioning has to be carried out at least each four hours and at the best as soon as adventitious sound are heard in the chest. Suction catheters have to be atraumatic; vacuum has to be between -200 to -400 cm H2O; catheter have not to be pushed further than the carina; suction hypoxemia can be reduced by shortening suction maneuver, by using suction catheter with little diameter, by conducting the suction on mechanical ventilation.

Arrhythmias, Cardiac↗