Mechanical Ventilation Articles

Apr 222017
 
ICU Physiology in 1000 Words: Weaning-Induced Cardiac Dysfunction & the Passive Leg Raise

Jon-Emile S. Kenny MD [@heart_lung] Reminder: Help me with my master’s thesis!  Please complete a learning module, and fill out this exceptionally brief survey! Perhaps the landmark trial elaborating an evolving cardiac dysfunction during the spontaneous breathing trial [SBT] is that of Lemaire and colleagues – published in 1988 [1].  One particularly memorable patient of [… read more]

Mar 202017
 
ICU Physiology in 1000 Words: Heliox & Mechanical Power

Jon-Emile S. Kenny MD [@heart_lung] Of the countless things taught to me by Dr. Chitkara at the Palo Alto VA Health Care System, one that sticks is the difference between density-dependent and viscosity-dependent airflow.  He often used the chronic bronchitic suffering through the viscous, humid New York City summers as a teaching example.  The importance [… read more]

Mar 012017
 
Are ventilator-associated pneumonia rates plummeting, or unchanged?

In 2008 hospitals were informed they would no longer be paid for treating hospital acquired infections like ventilator associated pneumonia. Miraculously, the rates of VAP (self-reported by hospitals to the Centers for Disease Control and Prevention) fell dramatically by 60 to 70% between 2006 and 2012, to less than one VAP per 1,000 ventilator days [… read more]

Feb 232017
 
The Normalization Fallacy: why much of "critical care" may be neither

By Scott Aberegg, MD, MPH Like many starry-eyed medical students, I was drawn to critical care because of the high stakes, its physiological underpinnings, and the apparent fact that you could take control of that physiology and make it serve your goals for the patient. On my first MICU rotation in 1997, I was so swept [… read more]

Feb 152017
 
Oxygen saturation in critical illness: could low-normal be best?

Oxygen is essential for life, but by forming superoxides and free radicals, supplemental oxygen can also inflict damage on lung and other body tissues. The sweet spot for oxygen delivery in critically ill patients is unknown, but increasing evidence suggests that when it comes to blood oxygen saturation during critical illness, “normal” levels might actually [… read more]

Feb 022017
 
CDC Releases Ventilator-Associated Events Criteria

A new term has been coined by the Centers for Disease Control and Prevention, ventilator-associated events (VAEs)¹. In 2011, the CDC convened a working group composed of members of several stakeholder organizations to address the limitations of the definition of ventilator-associated pneumonia (VAP) definition². The organizations represented in the Working Group include: the Critical Care [… read more]

Jan 112017
 
ICU Physiology in 1000 Words: Hidden Hemodynamics in Respiratory Mechanics

Jon-Emile S. Kenny MD [@heart_lung] Hemodynamic assessment, by any means, demands a shrewd familiarity with mechanical heart-lung interaction.  The two ventricles communicate in series and in parallel; each ventricle’s pressure-volume characteristics and loading conditions pulsate between systole and diastole.  And around the heart and pericardium lies the respiratory pump – the lungs within the thorax [… read more]

Nov 182016
 
Does intensive rehab and physical therapy in the ICU really help?

Every year, over a million people in the U.S. suffer respiratory failure requiring mechanical ventilation. They experience enormous catabolic stress, extended periods of inactivity, and usually go without their usual caloric intake. It’s no surprise that many are rendered profoundly debilitated by the experience. For many, this weakness and loss of muscle mass represents a second [… read more]

Sep 102016
 
Let’s Plan for Extubation in the Morning

Jon-Emile S. Kenny [@heart_lung] “Truth is like the sun, its value wholly depends upon our being at a correct distance away from it.” -Hjalmar Söderberg The evening is invigorating; the Stockholm Marathon has been run and cobblestoned cafés, concealed within winding, narrowed side-streets are in the throes of summer’s end.  I take a coffee and [… read more]

Jun 112016
 
ICU Physiology in 1,000 Words: ARDS - Part 3

Jon-Emile S. Kenny [@heart_lung] While parts 1 and 2 of this trilogy considered the mechanical power applied to the lung skeleton and the effects of lung inhomogeneity [i.e. ‘stress raisers’], respectively; this final installment will draw the reader towards the pulmonary vasculature as a key mediator of ventilator induced lung injury [VILI].  That the pulmonary [… read more]

May 012016
 
ICU Physiology in 1,000 Words: ARDS - Part 2

Jon-Emile S. Kenny [@heart_lung] Gattinoni and Quintel have, very recently, outlined their approach to managing the acute respiratory distress syndrome [ARDS] [1].  They argue that treatment of ARDS should minimize firstly, the mechanical power applied to the lungs – as described in part 1.  Secondly, Gattinoni and Quintel note that, in the treatment of ARDS, [… read more]

Apr 222016
 
ICU Physiology in 1,000 Words: ARDS - Part 1

Jon-Emile S. Kenny [@heart_lung] “Often, as new knowledge progresses, old knowledge is abandoned or forgotten.” -Luciano Gattinoni In a succinct and current treatise, Gattinoni and Quintel outline the modern management of the acute respiratory distress syndrome [ARDS] [1].  It is imperative, they reason, that treatment of ARDS minimizes firstly, the mechanical power applied to the [… read more]

Mar 182016
 
The Physiologically Difficult Airway – Part 2

Jon-Emile S. Kenny [@heart_lung] In part 2, I continue my commentary on this excellent review; part 1 may be found here.  In this post I will consider patients with severe metabolic acidosis and those with right ventricular [RV] dysfunction and/or failure. Severe Metabolic Acidosis In patients with severe metabolic acidosis, alveolar ventilation tends to be maximal [… read more]

Mar 112016
 
The Physiologically Difficult Airway – Part 1

Jon-Emile S. Kenny [@heart_lung] To celebrate the birthday of Dr. Erin Hennessey [@ErinH_MD] – my former co-fellow and current Stanford intensivist-anesthesiologist – I will interpret a relatively recent and terrifically high-yield overview of physiologically challenging intubations.  In this must-read survey, the authors highlight particularly troublesome intubations not from the classic, anatomical perspective, but from the [… read more]

Feb 172016
 
Recruitment Maneuvers & PEEP in the Morbidly Obese

Jon-Emile S. Kenny [@heart_lung] A recent study of applied respiratory physiology in the mechanically-ventilated, obese patient was published.  The ubiquitous focus on lung protective ventilation with “low” [physiological] lung volumes, and low plateau pressure may leave the obese patient susceptible to untoward respiratory embarrassment.  Excess abdominal and chest wall weight affect each of the following: [… read more]

Feb 132016
 
ICU Physiology in 1000 Words: Driving Pressure & Stress Index

By Jon-Emile S. Kenny [@heart_lung] The problem with the lung in the acute respiratory distress syndrome [ARDS] is not that it is stiff, but rather, that it is small [1].  In the 1980s, CT scans of the lungs of patients with ARDS revealed that the functional lung was attenuated in size and that dependent densities [… read more]

May 282015
 
Restricting calories by 50% during critical illness results in no harm

Everyone agrees that providing adequate nutrition in critical illness is vitally important. The problem is, no one knows for sure what “adequate” means. Caloric targets are not based on evidence from randomized trials with meaningful clinical outcomes. They emerge as consensus from educated guesses by researchers conducting physiology studies. One camp believes that extra calories should [… read more]

May 272015
 
High flow oxygen by nasal cannula saved lives over noninvasive ventilation

Noninvasive ventilation (NIV), often referred to by the trade name “BiPAP®,” can prevent intubation and save lives in patients with COPD exacerbations or pulmonary edema due to heart failure. Its proven benefits and low risk have led to NIV being used for patients in respiratory failure in virtually every acute care setting in the developed [… read more]

May 172015
 
SICU Basic Training (Video, Part 1)

Dr. Richard Savel, director of the surgical intensive care unit (SICU) at Maimonides Medical Center, Albert Einstein College of Medicine contributes this excellent educational video. Designed for an audience of SICU house staff, its content is applicable to non-surgical critically ill patients as well. Topics presented include shock; sepsis bundles; acid base status; metabolic acidosis; metabolic alkalosis; [… read more]

May 172015
 
The only VAP prevention method that saves lives is the one you’re not using

There’s always been doubt about the efficacy of the numerous “ventilator bundles” hospitals use to prevent ventilator-associated pneumonia (VAP). A provocative new analysis concludes that none of these methods save lives — except the one that almost no ICUs are using today. Healthcare associated pneumonias (HAP), especially ventilator-associated pneumonias (VAP), are associated with increased mortality, excess antibiotic use, lengthened hospital [… read more]