Newer nonconventional modes of mechanical ventilation

Mechanical ventilation: Beyond the basics

ABSTRACT

Mechanical ventilation is rarely a simple matter. Skill and knowledge are required to operate the ventilator modes, choose the optimal settings, and understand many monitored variables. Supporting the patient safely and effectively is the top priority in providing mechanical ventilation. This article discusses mechanical ventilation in adults.

Complications and Pharmacologic Interventions of Invasive Positive Pressure Ventilation During Critical Illness

Objective: To review the fundamentals of invasive positive pressure ventilation (IPPV) and the common complications and associated pharmacotherapeutic management in order to provide opportunities for pharmacists to improve patient outcomes. Data Sources: A MEDLINE literature search (1950-December 2017) was performed using the key search terms invasive positive pressure ventilation, mechanical ventilation, pharmacist, respiratory failure, ventilator associated organ dysfunction, ventilator associated pneumonia, ventilator bundles, and ventilator liberation. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language original research and review reports were evaluated. Data Synthesis: IPPV is a common supportive care measure for critically ill patients. While lifesaving, IPPV is associated with significant complications including ventilator-associated pneumonia, sinusitis, organ dysfunction, and hemodynamic alterations. Optimization of pain and sedation management provides an opportunity for pharmacists to directly affect IPPV exposure. A number of pharmacotherapeutic interventions are related directly to prophylaxis against IPPV-associated adverse events or aimed at reduction of duration of IPPV. Conclusions: Enhanced knowledge of the common complications, associated pharmacotherapy, and monitoring strategies facilitate the pharmacist's ability to provide increased pharmacotherapeutic insight in a multidisciplinary intensive care unit setting.

Factors determining outcomes in adult patient undergoing mechanical ventilation: A "real-world" retrospective study in an Indian Intensive Care Unit

Background:

Characteristics of patients admitted to intensive care units with respiratory failure (RF) and undergoing mechanical ventilation (MV) have been described for particular indications and diseases, but there are few studies in the general Intensive Care Unit (ICU) population and even lesser from developing countries.

Objective:

This study aims to study clinical characteristics, outcomes, and factors affecting outcomes in adult patients with RF on MV admitted to ICU.

Methods:

A retrospective study of medical records of all patients admitted to ICU between January 1, 2015, and March 31, 2016. Patients receiving MV for more than 6 h were included in the study. Patients younger than 12 years were excluded. Data were recorded of all patients receiving MV during this period regarding demographics, indications for MV, type and characteristics of ventilation, concomitant complications and treatment, and outcomes. Data were recorded at the initiation of MV and daily all throughout the course of MV. The main outcome measure was all-cause mortality at the end of ICU stay.

Results:

Of the 500 patients admitted to the ICU during the period of the study, a total of 122 patients received MV (and were included in study) for mean (standard deviation [SD]) duration of 4 (3.4) days. The mean (SD) stay in ICU and hospital was 4.49 (3.52) and 6.4 (3.6), respectively. Overall mortality for the unselected general ICU patients on MV was 67.21% while that for ARDS patients was 76.1%. The main factors independently associated with increased mortality were (i) pre-MV factors: age, Apache II scores, heart failure (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.54–3.73; P < 0.001); (ii) patient management factors: positive end-expiratory pressure (OR, 2.69; 95% CI, 0.84–8.61; P < 0.001); (iii) Factors occurring over the course of MV: PaO₂/FiO₂ ratio < 100 (OR, 1.66; 95% CI, 0.67–4.11; P < 0.001) and development of renal failure (OR, 2.33; 95% CI, 2.05–2.42; P < 0.001) and hepatic failure (OR, 2.07; 95% CI, 1.91–2.24; P < 0.001) after initiation of MV.

Conclusions:

Outcomes of patients undergoing MV are dependent on various factors (including patient demographics, nature of associated morbidity, characteristics of the MV received, and conditions developing over course of MV) and these factors may be present before or develop after initiation of MV.

Advanced Modes of Mechanical Ventilation: Introduction for the Critical Care Pharmacist

Mechanical ventilation continues to be an evolving modality in the critical care environment. Technological advances in microprocessor-controlled ventilation integrated with the complexity of new ventilator modes has provided the multidisciplinary team opportunities to further improve the care of the critically ill ventilator patients. As members of the critical care multidisciplinary team, pharmacists require a basic understanding of both conventional and advanced modes of mechanical ventilation in order to assist in optimizing medication use and ultimately patient health-care outcomes. Pharmacists have a key responsibility to practice vigilance to maintain safe drug therapy use by preventing drug-drug or drug-disease interactions and optimal dose selection based upon pharmacokinetics and pharmacodynamics principles. Pharmacists also assist in the development of drug utilization guidelines and pharmacological ventilator-weaning protocols based upon evidence-based practice. The result of these responsibilities must include the continued longitudinal assessment and reporting of quality measures to assess ventilator weaning, time to liberation of mechanical ventilation, and length of care in intensive care unit. The purpose of this article is to provide the clinical pharmacist a guide to a basic understanding of advanced modes of mechanical ventilation in adults and to apply the knowledge gained to assist in the care of the critical care patients.

A Critical Review of Mechanical Ventilation Virtual Simulators: Is It Time to Use Them?

BACKGROUND

Teaching mechanical ventilation at the bedside with real patients is difficult with many logistic limitations. Mechanical ventilators virtual simulators (MVVS) may have the potential to facilitate mechanical ventilation (MV) training by allowing Web-based virtual simulation.

OBJECTIVE

We aimed to identify and describe the current available MVVS, to compare the usability of their interfaces as a teaching tool and to review the literature on validation studies.

METHODS

We performed a comparative evaluation of the MVVS, based on a literature/Web review followed by usability tests according to heuristic principles evaluation of their interfaces as performed by professional experts on MV.

RESULTS

Eight MVVS were identified. They showed marked heterogeneity, mainly regarding virtual patient's anthropomorphic parameters, pulmonary gas exchange, respiratory mechanics and muscle effort configurations, ventilator terminology, basic ventilatory modes, settings alarms, monitoring parameters, and design. The Hamilton G5 and the Xlung covered a broader number of parameters, tools, and have easier Web-based access. Except for the Xlung, none of the simulators displayed monitoring of arterial blood gases and alternatives to load and save the simulation. The Xlung obtained the greater scores on heuristic principles assessments and the greater score of easiness of use, being the preferred MVVS for teaching purposes. No strong scientific evidence on the use and validation of the current MVVS was found.

CONCLUSIONS

There are only a few MVVS currently available. Among them, the Xlung showed a better usability interface. Validation tests and development of new or improvement of the current MVVS are needed.

Clinical study on VATS combined mechanical ventilation treatment of ARDS secondary to severe chest trauma

The aim of the study was to investigate the clinical effects of microinvasive video-assisted thoracoscopic surgery (VATS) combined with mechanical ventilation in the treatment of acute respiratory distress syndrome (ARDS) secondary to severe chest trauma. A total of 62 patients with ARDS secondary to severe chest trauma were divided into the observation and control groups. The patients in the observation groups were treated with VATS combined with early mechanical ventilation while patients in the control group were treated using routine open thoracotomy combined with early mechanical ventilation. Compared to the controls, the survival rate of the observation group was significantly higher. The average operation time of the observation group was significantly shorter than that of the control group, and the incidence of complications in the perioperative period of the observation group was significantly lower than that of the control group (p<0.05). The average application time of the observation group was significantly shorter than that of the control group, and the incidence of ventilator-associated complications was significantly lower than that of the control group (p<0.05). In conclusion, a reasonable understanding of the indications and contraindications of VATS, combined with early mechanical treatment significantly improved the success rate of the treatment of ARDS patients secondary to severe chest trauma and reduced the complications.