CoverArticle
CE Continuing Education
Mechanical Ventilation
of Patients With Acute
Respiratory Distress
Syndrome and Patients
Requiring Weaning
The Evidence
Guiding Practice
Suzanne M. Burns, RN, MSN, RRT, ACNP, CCRN
M echanical ventilation is
one of the most commonly used tech-
nologies in critical care. Despite the
prevalence of ventilators, care plan-
ning is heavily influenced by anecdote
and clinical preference. A vast array
of ventilator modes and mode options
exist, and claims of what works and
what does not abound. Critical care
nurses knowledge and understand-
ing of mechanical ventilation are cen-
tral to ensuring patients safe passage
from the acute stage of ventilation to
weaning. Of key importance is the
use of evidence that may improve
patients outcomes. To that end, in
14 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
this article, I discuss the science
related to mechanical ventilation in
patients with acute respiratory dis-
tress syndrome (ARDS) and in
patients who require weaning.
The Acute Stage of Ventilation:
Supplying Ventilation to the
Lungs in Patients With ARDS
The acute stage of ventilation is
described as that stage at which the
patients require a high level of venti-
latory support and their hemody-
namic status is often unstable.1-5 A
variety of volume and pressure modes
of ventilation are used in an effort to
* This article has been designated for CE credit.
A closed-book, multiple-choice examination fol-
lows this article, which tests your knowledge of
the following objectives:
1. Identify lung-protective strategies in acute
respiratory distress syndrome (ARDS)
2. Describe the benefits of low-tidal-volume
ventilation in ARDS
3. Discuss evidence-based guidelines of
mechanical ventilation in ARDS
Author
Suzanne M. Burns is a professor of
nursing and an advanced practice nurse
in the medical intensive care unit at the
University of Virginia in Charlottesville.
To purchase reprints, contact The InnoVision Group,
101 Columbia, Aliso Viejo, CA 92656. Phone, (800)
809-2273 or (949) 362-2050 (ext 532); fax, (949)
362-2049; e-mail, reprints@aacn.org.
improve oxygenation, ventilation,
and acid-base status. The results of
recent research in patients with ARDS
are dramatically affecting how we
use mechanical ventilation in such
patients and how clinical end points
of mechanical ventilation are selected.
The concept of lung-protective
strategies, which include low-tidal-
volume ventilation, positive end-
expiratory pressure (PEEP), and
prone positioning of patients, has
emerged along with a renewed inter-
est in the potential efficacy of high-
frequency oscillation. A discussion
focused on the evidence related to
the use of such therapies follows.
Are Volume or Pressure Modes
Better for Patients With ARDS?
Investigators6-11 have shown that
animals with induced ARDS, treated
with mechanical ventilation with
traditional (ie, large) ventilator
volumes experience more lung injury
than do similar animals treated with
mechanical ventilation with lower
ventilator volumes.6,7 In these animals,
plateau pressures of 35 cm H2O or
greater for 72 hours resulted in alve-
olar fractures and increased alveolar
flooding.8-11 The term volutrauma was
coined to describe injuries due to the
large traditional volumes, although
questions remained about whether
the tidal volumes or the resultant dis-
tending (plateau) pressures were actu-
ally responsible for the lung injury.
Because the potential for volutrauma
in humans was recognized, recom-
mendations for the use of smaller
tidal volumes began to emerge12,13
and studies in humans followed.14-16
In a study by Hickling et al,14 a
total of 53 patients with ARDS were
treated with mechanical ventilation at
low volumes (7 mL/kg) in an attempt
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
to maintain peak airway pressures less
than 30 cm H2O. Hospital mortality
for the patients was significantly
lower than the mean mortality pre-
dicted on the basis of on Acute
Physiology and Chronic Health Eval-
uation II scores. After this study, the
ARDS Network16 reported on the
results of a randomized controlled
trial designed to compare clinical
outcomes of patients with ARDS
who were assigned to low-volume
(6 mL/kg) versus traditional-volume
(12 mL/kg) ventilation. The study
was stopped after a preliminary
analysis of 861 patients indicated
that mortality in the low-tidal-volume
group was significantly lower than
that in the control group (31.0% vs
39.8%, P = .007). Of interest, the
plateau pressures when the tidal vol-
ume of 6 mL/kg was used were in
the range of 26 to 30 cm H2O.16 This
pressure was far lower than the
plateau pressure (<35 cm H2O) that
had been suggested as potentially
lung protective in the animal studies.
But, the ARDS Networks study16
has been criticized. For example, some
have noted that volumes between 6
and 12 mL/kg (ie, 7, 8, 9, 10, and
11 mL/kg) were not tested, yet those
volumes may be more reflective of
common practice patterns. Others
contended that the control group
assignment of 12 mL/kg was exces-
sively high and that the principle of
scientific equipoise (ie, that genuine
uncertainty exists about what treat-
ment is best) may have been vio-
lated. Rubenfeld et al17 and Weinert
et al18 subsequently examined prac-
tice patterns in the selection of tidal
volume at academic institutions
where clinicians were aware of the
results of the ARDS Networks study.
Their results17,18 indicated that com-
CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 15
monly selected tidal volumes were
not in the range of 6 mL/kg but were
rather in a higher range, findings
that somewhat dispelled the validity
of the concerns.
Regardless, questions persist
about the effect of tidal volumes from
7 to 11 mL/kg and about the use of
pressure modes to control plateau
pressures in patients with ARDS.19,20
Because pressure modes of ventila-
tion have characteristics that make
them attractive for use in patients
with noncompliant lungs, many
wonder if pressure-targeted ventila-
tion might be a comparable substi-
tute for volume-targeted ventilation
in patients with ARDS. Some of the
characteristics of pressure-targeted
ventilation are discussed next.
The decelerating flow pattern
associated with pressure modes is
thought to provide better gas distribu-
tion than volume ventilation does.21-23
In addition, plateau pressure can be
reliably limited by using pressure
modes. Although some might assume
that using pressure ventilation in
patients with stiff lungs (in order to
ensure a low plateau pressure) might
result in outcomes similar to those
found in the ARDS Networks trial,
much remains to be determined. For
example, volumes delivered with
pressure ventilation are affected by
compliance (lung and chest wall)
and resistance. Using a plateau pres-
sure to ensure lung protection may
not ensure volumes comparable to
the tidal volume of 6 mL/kg used in
the ARDS Networks study.
The superiority of selected new
pressure modes, such as pressure-
release ventilation, for use in ARDS
also has not been established. Ran-
domized controlled trials comparing
the modes with low-volume targeted
ventilation will be necessary before
the new pressure modes can be widely
endorsed.
To date, the study by the ARDS
Network,16 in which tidal volumes of
6 mL/kg were used, is the only study
that has demonstrated a change in
mortality. Until the effects of other
modes of mechanical ventilation on
the outcomes of patients with ARDS
are clarified, the use of low-volume
targeted ventilation rather than
pressure-targeted ventilation is the
suggested ventilatory strategy for
protecting the lungs of these patients.
Until the effects of other modes of
mechanical ventilation on the outcomes
of patients with ARDS are clarified, the
use of low-volume targeted ventilation
rather than pressure-targeted ventilation
is the suggested ventilatory strategy for
protecting the lungs of these patients.
What About PEEP Levels?
In a randomized controlled trial
of patients with ARDS, Amato et al24
studied outcomes associated with
different levels of PEEP. The optimal
level was determined by measuring
lung compliance at increasing levels
of PEEP. A level just above the lower
inflection point (that level that
resulted in an increase in compliance
with a given level of PEEP) was
selected as the lung recruitment PEEP
for the intervention group. Findings
of the study suggested that levels of
PEEP of about 14 to 16 cm H2O (ie,
higher than levels generally selected)
were necessary to prevent derecruit-
ment (lung closure).
Unfortunately, measurement of
the inflection point at the bedside is
16 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
technically difficult, and this method
is unlikely to be widely used in clini-
cal practice. Although the results of
Amato et al24 suggest that PEEP levels
of 14 to 16 cm H2O are required to
open the lung in patients with ARDS,
definitive methods for determining
the appropriate level of required PEEP
are unknown.
In the ARDS Network study,16 an
algorithmic approach was used to
assign levels of PEEP. Unfortunately,
auto-PEEP (occult PEEP due to inad-
equate expiratory time) also occurred
in many of the patients (eg, those with
high respiratory rates and high
minute volumes), making accurate
assessment of the total level of PEEP
difficult. Some have suggested that
the auto-PEEP may have recruited
the lung, perhaps contributing to
the beneficial outcomes described
by the investigators.25
How best to apply PEEP to recruit
the lung and prevent derecruitment
is not yet clear. Regardless, an under-
standing of these concepts is helpful
for focusing clinical interventions.
Recruiting the Lungs
and Keeping Them Open
(Preventing Derecruitment)
In patients with ARDS, noncom-
pliant lungs tend to collapse, and once
collapsed, high inflation pressures
are necessary to reopen the lungs.
Knowledge of how the lungs in
patients with ARDS inflate during
mechanical ventilation is essential to
our understanding of recruitment.
Computed tomography scans of
patients with ARDS have improved
our understanding of the alveolar
filling patterns associated with
ARDS.26,27 Once thought to be
homogeneous, the pattern of alveo-
lar filling in ARDS is actually hetero-
geneous. Some areas of the lung are
open and others are closed. In the
areas of aerated lung, the entire
brunt of a tidal volume breath is
experienced by the compliant (and
open) lung tissue. Unfortunately,
this small area of the lung (also
called baby lung) is at increased
risk of injury from overdistention
and the shear forces of repetitive
opening and closing with tidal
breathing. The stress on the lungs
from the tidal breath may be an
important mechanism associated
with volutrauma.
The closed lung parenchyma of
patients with ARDS cannot be
recruited without applying a critical
opening pressure (ie, a pressure high
enough to open closed alveoli). Fur-
ther, once opened, the lung tissue is
at risk of closing again (derecruitment)
if optimal levels of PEEP or other
strategies are not applied. Thus the
concepts of lung recruitment and
derecruitment are integrally related.
The use of PEEP levels from 14 to
16 cm H2O, as described by Amato
et al,24 is suggested as one way to open
the lungs. Another method is to pro-
vide periodic episodes of super-high
levels of PEEP. Referred to as 40/40
or 60/60 maneuvers (eg, 40 cm H2O
of PEEP for 40 seconds), these tech-
niques have been used in a number
of studies, but they are associated
with a risk of barotrauma.24,27-29
Once the Lungs Are Opened,
How Are They Kept Open?
Unfortunately, it is unclear how
to select a level of PEEP to stabilize
ventilation once a recruitment maneu-
ver is completed.30-32 Although moni-
toring the effects of the selected
settings on oxygenation and ventila-
tion is a generally accepted way of
deciding if the settings are preventing
derecruitment over time, oxygenation
may not be the best indicator. Oxy-
genation, traditionally used to assess
the adequacy of PEEP, is unreliable
because the increase in oxygenation
may be the result of either recruit-
ment or redistribution of blood flow
to aerated areas of the lung (thus
decreasing the shunt and improving
oxygenation). Identification of a
PEEP level that recruits lung and
prevents repetitive opening injury
associated with tidal breathing is
thus an elusive clinical goal.
Investigators have used com-
puted tomography to compare lung
recruitment when different ventilatory
maneuvers are used.27,33 Although
this method is accurate, it is imprac-
tical for use in most clinical settings
and widespread use of it is unlikely.
Theoretically, another way to assess
recruitment is to increase the level
of PEEP and monitor the difference
between the plateau pressure and
the PEEP level. If the addition of
PEEP results in recruitment of lung,
the plateau pressure should not
change; however, if PEEP is adding
to alveolar overdistention, the plateau
pressure will increase.
Although we have learned much
about the effectiveness of PEEP in
treating ARDS, much remains to be
18 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
elucidated. To date, definitive meth-
ods of applying PEEP to ensure lung
protection and to prevent derecruit-
ment have not been clearly identified.
Regardless, arbitrary selection of a
PEEP level is unlikely to accomplish
the goal.
Other Ways to Recruit the Lungs:
What About High-Frequency
Oscillation and Prone
Positioning of Patients?
Unlike traditional ventilatory
modes, high-frequency oscillation
does not require bulk movement of
volume in and out of the lungs; rather,
a bias flow of gases is provided and
an oscillator disperses the gases
throughout the lung at very high
frequencies in what has been called
augmented dispersion. The lungs
are recruited and a mean airway
pressure sufficient to cause a chest
vibration (or wiggle) is maintained.34
Although some think that this mode
of ventilation may recruit the lungs
and prevent tidal stress (damage due
to tidal volume and repetitive open-
ing of the stiff alveoli), to date only a
single randomized controlled trial
has been completed. The Multicen-
ter Oscillatory Ventilation for Acute
Respiratory Distress Syndrome
Trial34 was designed to test the safety
and efficacy of a specific ventilator
for high-frequency oscillation. The
results indicated a positive but non-
significant trend in 30-day mortality
in patients receiving mechanical
ventilation with high-frequency
oscillation. Unfortunately, the tidal
volumes in the control group were
not maintained in the protective
range, a situation that makes it diffi-
cult to interpret the results. An addi-
tional concern is that patients
generally require heavy sedation and
often require paralytic agents to
ensure compliance with high-fre-
quency oscillation.
Prone positioning is useful in
recruiting lung tissue. Studies in
animal models and patients with
ARDS in the prone position have
revealed a number of responsible
mechanisms.35-45 Blood flow and gas
distribution in the lungs are affected
by gravity. When patients are supine,
the alveoli in the dependent parts of
the lungs (ie, the back) fill with fluid
and collapse. When patients are
turned to the prone position, the
effect of gravity is reversed and lung
tissue is recruited.35 In addition,
pleural pressures are more uniform
in the dorsal than in the ventral
position, so lung recruitment is
enhanced.36-41 The third mechanism
is a mechanical one. With prone
positioning, the heart rests against
the sternum (rather than against the
lungs) and the abdomen moves
away from the lungs.38,42-44 As much
as a third of the posterior part of the
lungs may be recruited when
patients are prone.42 Last, the ante-
rior part of the chest, normally the
most mobile part of the chest, is
slightly restricted when patients are
prone. Consequently, when the
lungs are ventilated in a patient who
is prone, the air is redistributed
more evenly throughout the chest,
including the dependent regions.45
The effect of prone positioning
of patients on outcomes in ARDS is
as yet unclear. Although our under-
standing of how prone positioning
improves lung recruitment is fairly
good, to date the only randomized
controlled trial of prone positioning
in patients with ARDS did not show
a change in mortality.46 Patients in
the study were maintained in a
prone position for at least 6 hours a
day for 10 days. The study was done
before the results of the ARDS study
on ventilation with low lung vol-
umes were published,27 however, so
volumes were not controlled. Of
interest, in the sickest cohort of
patients in the study, patients with a
ratio of PaO2 to fraction of inspired
oxygen of less than 88 (a ratio <200
is defined as ARDS), those assigned
to the prone position had a better
10-day survival rate than did those
who remained supine.
Perhaps the most important fact
associated with positioning patients
prone is that it is a relatively safe
intervention compared with other
techniques (albeit a time- and effort-
intensive one) that recruits lung and
assists with drainage of secretions.47,48
Although studies are needed to defin-
itively determine the importance of
prone positioning in the management
of ARDS, the use of this position
may be less risky than use of some
of the other recruitment maneuvers
described.
What Ventilation, Oxygenation,
and Acid-Base Thresholds
Should Be Used With Protective
Ventilatory Strategies?
Use of low-volume ventilation
may result in significant hypercar-
bia.7,14,15,49-53 In the past, ventilator set-
tings were adjusted to attain eucarbia
and a normal pH. Because the goal
is to protect the lung, such an end
point may not be possible. Instead,
the goal should be to ensure that
volutrauma does not occur. Because
low-volume ventilation results in
decreased alveolar ventilation, hyper-
carbia is expected. Called permissive
hypercarbia, the goal for acid-base
status is to maintain a reasonable
20 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
pH (approximately 7.25).7,14,15,49-53
Bicarbonate infusions may be used if
necessary in patients whose pH is
lower and thought to be potentially
harmful.14-16,49 Although it is generally
tolerated well in most patients, per-
missive hypercarbia is not appropri-
ate for all patients. Examples include
patients with elevated intracranial
pressures and patients with some
cardiac conditions.51-53
The Weaning Stage of
Mechanical Ventilation
The weaning stage of mechanical
ventilation is described as that time
when the patients physiological sta-
tus is stable and progressive libera-
tion from mechanical ventilation is
possible.1-5 Various mechanical venti-
latory modes and methods are used
to ensure an expeditious process.
Recent research on weaning has elu-
cidated the importance of approaches
in which protocols and comprehen-
sive multidisciplinary processes of
care delivery are used.
Recent research on weaning has
elucidated the importance of approaches
in which protocols and comprehensive
multidisciplinary processes of care
delivery are used.
Mechanical Ventilation in the
Weaning Stage: What Works?
To date, no mode of weaning has
been shown to be superior to the
others, yet how the various methods
of weaning are used does seem to
make a difference in clinical outcomes.
In randomized controlled trials by
Brochard et al54 and Esteban et al,55
patients were selected on the basis
of entry criteria that established the
subjects readiness to be weaned. If
patients met the readiness criteria,
they were assigned to a 2-hour spon-
taneous breathing trial during which
they were monitored for signs of
intolerance to the trial. If signs of
intolerance emerged, the weaning
trial was classified as a failure and
the patient was randomly assigned
to a weaning protocol. In the study
by Esteban et al,55 patients who suc-
cessfully sustained the 2-hour trial
were extubated; the reintubation
rate was 20%.
The protocol methods to which
patients were randomly assigned
included pressure-support ventila-
tion, intermittent mandatory venti-
lation, and spontaneous breathing
trials. Although Brochard et al54
found that pressure-support ventila-
tion resulted in faster weaning and
Esteban et al55 found that spontaneous
breathing trials once per day were
superior, both groups of investigators
used similar protocols for assessing
weaning readiness, advancing wean-
ing trials, and defining success (tol-
erance) or failure (intolerance). The
results of those 2 studies54,55 stimu-
lated interest in testing the efficacy
and safety of weaning protocols.
In studies by Ely et al56 and
Kollef et al,57 patients were randomly
assigned either to a weaning protocol
managed by a nurse and respiratory
therapist or to a traditional weaning
plan designed by a physician. Com-
pared with weaning according to the
physicians plan, weaning via the pro-
tocol resulted in significantly shorter
durations of mechanical ventilation
in both studies and a significantly
shorter stay in the intensive care unit
(ICU) in the study by Kollef et al.57
The usefulness of protocols in
decreasing variation in processes of
care is not restricted to weaning trials.
The use of sedatives in patients receiv-
ing mechanical ventilation has been
associated with prolonged duration
of mechanical ventilation and pro-
longed stays in the ICU and hospital.57
In randomized controlled trials, the
algorithmic management of sedation58
and use of a protocol to wean patients
off infusions of sedatives59 resulted
in significantly shorter duration of
mechanical ventilation and shorter
stays in the ICU and in the hospital.
The use of protocols is linked to
improved outcomes. However, the
results of a study by Ely et al60 suggest
that protocols must be applied care-
fully. Ely et al sought to implement a
protocol for weaning in surgical units
that involved spontaneous breathing
trials. The protocol had been previ-
ously tested in a study of patients in
a medical ICU and coronary care
unit.56 Components of the protocol
included a weaning readiness screen-
ing, a spontaneous breathing trial,
and end points for stopping the trial.
Educational sessions were used to
update clinicians about the study,
and respiratory care practitioners
implemented the protocol. The spon-
taneous breathing trials were imple-
mented only 10% of the time initially,
but implementation increased to 30%
with additional educational sessions.
One of the major reasons for the lack
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
of compliance with the protocol was
that the protocol was not managed
by any specific person (as it had been
during the original study).60
Other methods of improving
weaning outcomes for patients treated
with mechanical ventilation include
systematic comprehensive initiatives
in which multiple evidence-based
interventions are applied together in
a single approach.61-68 The interven-
tions include clinical pathways, meth-
ods for evaluating progress, specific
elements of care (eg, deep vein pro-
phylaxis, nutrition, mobility) and
protocols for weaning trials. Two
prospective system initiatives indicate
the effectiveness of the more compre-
hensive approaches.
Smyrnios et al67 designed a large-
scale multidisciplinary approach to
care of patients receiving mechanical
ventilation in a medical ICU, a surgi-
cal ICU, and a coronary care unit. The
initiative consisted of using a weaning
algorithm and a nurse clinician to
ensure compliance with the processes
of care. Duration of mechanical ven-
tilation, length of stay in the ICU,
and length of stay in the hospital all
improved significantly when the care
initiative was used. Financial gains
also occurred; however, mortality
was not affected.
In another study,68 all adult
patients in 5 critical care units (med-
ical ICU, coronary care unit, thoracic-
cardiovascular ICU, surgical-trauma
ICU, and neurological ICU) who
required mechanical ventilation for
more than 3 consecutive days were
managed and monitored by 4
advanced practice nurses for 1 year.
The process consisted of an evidence-
based clinical pathway, protocols
for weaning trials and sedation
management, and a standardized
CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 21
weaning assessment tool (Burns Wean
Assessment Program). Results of the
intervention were compared with out-
comes prospectively collected before
implementation of the approach.
The findings included significant
reductions in duration of mechanical
ventilation, lengths of stay in the ICU
and hospital, and mortality in the
managed group. The beneficial out-
comes were attributed to the man-
agement and monitoring of the
process by the advanced practice
nurses and the systematic multidis-
ciplinary evidence-based approach
to care of the patients.
Conclusions and Summary
To achieve the best outcomes, we
must have an in-depth understand-
ing of the evidence related to appro-
priate use of mechanical ventilation
in patients with ARDS and in
patients who require weaning. We
have learned much from studies con-
ducted in such patients, yet many
questions about how best to apply
the therapy remain unanswered.
Low-volume lung ventilation is asso-
ciated with decreased mortality as
applied in the ARDS Networks
study.16 Until additional studies of
other modes (pressure modes and
high-frequency oscillation) indicate
comparable outcomes, use of low-
volume ventilation in patients with
ARDS should be encouraged. Unfor-
tunately, questions still abound
related to how we might best recruit
the lungs and keep them open (eg,
optimal levels of PEEP, prone posi-
tioning).
In the area of weaning, evidence
indicates that it is not the mode used
but rather the method, specifically
the use of protocols, that results in
improved clinical outcomes. Further,
outcomes are likely to be improved
by multidisciplinary system initia-
tives that provide systematic evidence-
based care.
References
1. Burns SM, Clochesy J, Goodnough-
Hanneman SK, Ingersoll GE, Knebel AR,
Shekleton ME. Weaning from long-term
mechanical ventilation. Am J Crit Care.
1995;4:4-22.
2. Knebel AR, Shekleton ME, Burns SM,
Clochesy JM, Goodnough-Hanneman SK,
Ingersoll GL. Weaning from mechanical
ventilation: concept development. Am J Crit
Care. 1994;3:416-420.
3. Goodnough-Hanneman SK, Ingersoll GL,
Knebel AR, Shekleton ME, Burns SM,
Clochesy JM. Weaning from short-term
mechanical ventilation: a review. Am J Crit
Care. 1994;3:421-443.
4. Burns SM, Ryan B, Burns JE. The weaning
continuum: use of Apache III, BWAP, TISS,
and WI scores to establish stages of wean-
ing. Crit Care Med. 2000;28:2259-2267.
5. Knebel A, Shekleton MD, Burns S, Clochesy
JM, Hanneman SK. Weaning from mechani-
cal ventilatory support: refinement of a
model. Am J Crit Care. 1998;7:149-152.
6. Dreyfuss D, Basset G, Soler P, Saumon G.
Intermittent positive-end expiratory pres-
sure hyperventilation with high inflation
pressures produces pulmonary microvascu-
lar injury in rats. Am Rev Respir Dis.
1985;132:880-884.
7. Tremblay L, Valenza F, Ribeiro SP, Li J, Slut-
sky AS. Injurious ventilatory strategies
increases cytokines and c-fos m-RNA
expression in an isolated rat lung model.
J Clin Invest. 1997;99:944-952.
8. Dreyfuss D, Saumon G. The role of tidal vol-
ume, FRC and end-inspiratory volume in
the development of pulmonary edema fol-
lowing mechanical ventilation. Am Rev
Respir Dis. 1993;148:1194-1203.
9. Dreyfus D, Saumon G. Ventilator induced
lung injury. Am J Respir Crit Care Med.
1998;157:294-323.
10. Dreyfuss D, Soler P, Bassett G, Saumon G.
High inflation pressure pulmonary edema.
Am Rev Respir Dis. 1988;137:1159-1164.
11. Fu Z, Costello ML, Tsukimoto K, et al. High
lung volume increases stresss failure in pul-
monary capillaries. J Appl Physiol.
1992;73:123-133.
12. Slutsky AS. Consensus conference on
mechanical ventilationJanuary 28-30,
1993 at Northbrook, Illinois, USA: part 1.
European Society of Intensive Care Medi-
cine, the ACCP and the SCCM. [published
correction appears in Intensive Care Med.
1994;20:378]. Intensive Care Med.
1994;20:64-79.
13. Slutsky AS. Consensus Conference on
Mechanical VentilationJanuary 28-30,
1993 at Northbrook, Illinois, USA: part 2.
Intensive Care Med. 1994;20:150-162.
14. Hickling KG, Henderson SJ, Jackson R. Low
mortality associated with low volume
pressure-limited ventilation with permissive
hypercapnia in severe adult respiratory dis-
tress syndrome. Intensive Care Med.
1990;16:372-377.
22 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
15. Hickling K. Low volume ventilation with
permissive hypercapnia in the adult respira-
tory distress syndrome. Clin Intensive Care.
1992;3:67-78.
16. The Acute Respiratory Distress Syndrome
Network. Ventilation with lower tidal vol-
umes as compared with traditional tidal vol-
umes for acute lung injury and the acute
respiratory distress syndrome. N Engl J Med.
2000;342:1301-1307
17. Rubenfeld G, Caldwell E, Hudson L. Publi-
cation of study results does not increase use
of lung protective ventilation patients with
acute lung injury [abstract]. Am J Respir Crit
Care Med. 2001;163:A295.
18. Weinert CR, Gross CR, Marinelli WA.
Impact of randomized trial results on acute
lung injury ventilator therapy in teaching
hospitals. Am J Respir Crit Care Med.
2003;167:1304-1309.
19. Stewart TE, Meade MO, Cook DJ, et al. Eval-
uation of a ventilation strategy to prevent
barotrauma in patients at high risk for acute
respiratory distress syndrome: Pressure-
and Volume-Limited Ventilation Strategy
Group. N Engl J Med. 1998;338:355-361.
20. Rappaport SH, Shpiner R, Yoshihara G, et
al. Randomized, prospective trial of pres-
sure-limited versus volume-controlled ven-
tilation in severe respiratory failure. Crit
Care Med. 1994;22:22-32.
21. MacIntyre NR. Respiratory function during
pressure support ventilation. Chest.
1986;89:677-683.
22. Brochard L, Pluskwa F, Lemaire F. Improved
efficacy of spontaneous breathing with
inspiratory pressure support. Am Rev Respir
Dis. 1987;136:411-415.
23. Davis K, Branson RD, Campbell RS, Porem-
bka DT. Comparison of volume control and
pressure control ventilation: is flow waveform
the difference? J Trauma. 1996;41:808-814.
24. Amato MBP, Barbas CSV, Medeiros DM, et
al. Effect of a protective-ventilation strategy
on mortality in the acute respiratory dis-
tress syndrome. N Engl J Med. 1998;338:
347-354.
25. de Durante G, del Turco M, Rustichini L, et
al. ARDSNet lower tidal volume ventilatory
strategy may generate intrinsic positive end-
expiratory pressure in patients with acute
respiratory distress syndrome. Am J Respir
Crit Care Med. 2002;165:1271-1274.
26. Gattinoni L, Presenti A, Torresin A, et al.
Adult respiratory distress syndrome profiles
by computed tomography. J Thorac Imaging.
1986;1:25-30.
27. The ARDS Clinical Trials Network; National
Heart, Lung and Blood Institute; National
Institutes of Health. Effects of recruitment
maneuvers in patients with acute lung
injury and acute respiratory distress syn-
drome ventilated with high positive end-
expiratory pressure. Crit Care Med.
2003;31:2592-2597.
28. Fujino Y, Goddon S, Dolhnikoff M, Hess D,
Amato MB, Kacmarek RM. Repetitive high-
pressure recruitment maneuvers required
to maximally recruit lung in a sheep model
of acute respiratory distress syndrome. Crit
Care Med. 2001;29:1579-1586.
29. Foti G, Cereda M, Sparacino ME, et al.
Effects of periodic lung recruitment maneu-
vers on gas exchange and respiratory
mechanics in mechanically ventilated acute
respiratory distress syndrome (ARDS)
patients. Intensive Care Med. 2000;26:501-507.
30. Marini JJ. Recruitment maneuvers to
achieve an open lung: whether and how?
Crit Care Med. 2001;29:1647-1648.
31. Lachmann B. Open up the lung and keep
the lung open. Intensive Care Med.
1992;18:319-321.
32. Amato MBP, Barbas CSV, Medeiros DM, et
al. Beneficial effects of the open lung
approach with low distending pressures in
acute respiratory distress syndrome. Am J
Respir Crit Care Med. 1995;152:1835-1846.
33. Gattinoni L, Pesanti A, Avalli L, Rossi F,
Bombino M. Pressure volume curve of total
respiratory system in acute respiratory fail-
ure: computed tomographic scan study. Am
Rev Respir Dis. 1987;136:730-736.
34. Derdak S, Mehta A, Stewart TE, et al. High-
frequency oscillatory ventilation for acute
respiratory distress syndrome in adults. Am
J Respir Crit Care Med. 2002;166:801-808.
35. Messerole E, Peine P, Wittkopp S, Marini JJ,
Albert RK. The pragmatics of prone posi-
tioning. Am J Respir Crit Care Med.
2002;165:1359-1363.
36. Pappert D, Rossaint R, Slama K, Gruning T,
Falke KJ. Influence of positioning on ventila-
tion-perfusion relationships in severe adult
respiratory distress syndrome. Chest.
1994;106:1511-1516.
37. Gattinoni L, Pelosi P, Vitale G, Presenti A,
DAndrea L, Mascheront D. Body position
changes redistribute lung computer tomo-
graphic density in patients with acute respi-
ratory failure. Anesthesiology. 1991;74:15-25.
38. Pelosi P, Turbiolo D, Mascheroni D, et al.
Effects of the prone position on respiratory
mechanics and gas exchange during acute
lung injury. Am J Respir Crit Care Med.
1998;157:387-389.
39. Wiener CM, Kirk W, Albert RK. The prone
position reverses the gravitational distribu-
tion of perfusion in dog lungs with oleic
acid-induced injury. J Appl Physiol.
1990;68:1386-1392.
40. Lamm WJE, Graham MM, Albert RK. Mech-
anism by which the prone position improves
oxygenation in acute lung injury. Am J Respir
Crit Care Med. 1994;150:184-193.
41. Beck KC, Vettermann J, Rehder K. Gas
exchange in dogs in the prone and supine
positions. J Appl Physiol. 1992;72:2292-2297.
42. Albert RK, Hubmayr RD. The prone posi-
tion eliminates compression of the lungs by
the heart. Am J Respir Crit Care Med.
2000;161:1660-1665.
43. Hoffman EA. Effect of body orientation on
regional lung expansion: a computed tomo-
graphic approach. J Appl Physiol. 1985;
59:468-480.
44. Wiener CM, McKenna WJ, Myers MJ, Laven-
dar JP, Hughes JM. Left lower lobe ventila-
tion is reduced in patients with cardiomegaly
in the supine but not the prone position. Am
Rev Respir Dis. 1990;141:150-155.
45. Albert RK. Editorial: for every thing
(turnturnturn..). Am J Respir Crit Care
Med. 1997;155:393-394.
46. Gattinoni L, Tognoni G, Pesenti A, et al.
Effect of prone positioning on the survival
of patients with acute respiratory failure.
N Engl J Med. 2001;345:568-573.
47. Douglas WW, Rehder K, Beynen FM,
Sessler AD, Marsh HM. Improved oxygena-
tion in patients with acute respiratory fail-
ure: the prone position. Am Rev Respir Dis.
1977;115:559-567.
48. Curley MAQ. Prone positioning of patients
 with acute respiratory distress syndrome: a care setting. Crit Care Med. 2001;29:297-303.
systematic review. Am J Crit Care. 1999;8: 66. Henneman E, Dracup K, Ganz T, Molayeme
397-405. O, Cooper CB. Using a collaborative wean-
49. Menitove SM, Golring RA. Combined venti- ing plan to decrease duration of mechanical
lator and bicarbonate strategy in the man- ventilation and length of stay in the inten-
agement of status asthmaticus. Am J Med. sive care unit patients receiving long-term
1983;74:889-901. mechanical ventilation. Am J Crit Care.
50. Darioli R, Perret C. Mechanical controlled 2002;11:132-140.
hypoventilation in status asthmaticus. Am 67. Smyrnios NA, Connolly A, Wilson MM, et
Rev Respir Dis. 1984;129:385-387. al. Effects of a multifaceted, multidiscipli-
51. Tuxen D. Permissive hypercapnia. In: Tobin nary, hospital-wide quality improvement
MJ, ed. Principles and Practice of Mechanical program on weaning from mechanical ven-
Ventilation. New York, NY: McGraw Hill; tilation. Crit Care Med. 2002;30:1224-1230.
1994:371-392. 68. Burns SM, Earven D, Fisher C, et al. Imple-
52. Bidani A, Tzouanakis AE, Cardenas VJ, mentation of an institutional program to
Zwischenberger JB. Permissive hypercapnia improve clinical and financial outcomes of
in acute respiratory failure. JAMA. patients requiring mechanical ventilation:
1994;272:957-962. one year outcomes and lessons learned. Crit
53. Bellomo R, Mclaughlin P, Tai E, Parkin G. Care Med. 2003;31:2752-2763.
Asthma requiring mechanical ventilation: a
low morbidity approach. Chest. 1994;105:
891-896.
54. Brochard L, Ranes A, Benito S, et al. Com-
parison of three methods of gradual with-
drawal from ventilatory support during
weaning from mechanical ventilators. Am J
Respir Crit Care Med. 1994;150:896-903.
55. Esteban A, Frutos F, Tobin MJ, et al. A com-
parison of four methods of weaning
patients from mechanical ventilation:
Spanish Lung Failure Collaborative Group.
N Engl J Med. 1995;332:345-350.
56. Ely EW, Baker AM, Dunagan DP, et al.
Effect on the duration of mechanical venti-
lation of identifying patients capable of
breathing spontaneously. N Engl J Med.
1996;335:1964-1969.
57. Kollef MH, Shapiro SD, Silver P, et al. A
randomized, controlled trial of protocol-
directed versus physician-directed weaning
from mechanical ventilation. Crit Care Med.
1997;25:567-574.
58. Brook AD, Ahrens TS, Schaff R, et al. Effect
of a nursing-implemented sedation protocol
on the duration of mechanical ventilation.
Crit Care Med. 1999;27:2609-2615.
59. Kress JP, Pohlman AS, OConnor MF, Hall JB.
Daily interruption of sedative infusions in crit-
ically ill patients undergoing mechanical ven-
tilation. N Engl J Med. 2000;342:1471-1477.
60. Ely EW, Bennett PA, Bowton DL, Murphy
SM, Florance AM, Haponick EF. Large-scale
implementation of a respiratory therapist-
driven protocol for ventilator weaning. Am J
Respir Crit Care Med. 1999;159:439-436.
61. Cohen IL, Bari N, Strosberg MA, et al.
Reduction of duration and cost of mechani-
cal ventilation in an intensive care unit by
use of a ventilatory management team. Crit
Care Med. 1991;19:1278-1284.
62. Rudy FB, Daly BJ, Douglas S, Montenegro
HD, Song R, Dyer MA. Patient outcomes for
the chronically critically ill: special care unit
versus intensive care unit. Nurs Res.
1995;44:324-331.
63. Kite-Powell D, Sauban D, Ideno KT, et al.
Optimizing outcomes in ventilator-depend-
ent patients: challenging critical care prac-
tice. Crit Care Nurs Q. 1996;19:77-90.
64. Burns SM, Marshall M, Burns JD, et al.
Design, testing and results of an outcomes
managed approach to patients requiring
prolonged ventilation. Am J Crit Care.
1998;7:45-57.
65. Henneman E, Dracup K, Ganz T, Molayeme
O, Cooper C. Effect of a collaborattive wean-
ing plan on patient outcome in the critical

CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 23

Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017
CE Test Test ID C054: Mechanical Ventilation in Patients With Acute Respiratory Distress Syndrome and Patients Requiring Weaning:
The Evidence Guiding our Practice
Learning objectives: 1. Identify lung-protective strategies in acute respiratory distress syndrome (ARDS) 2. Describe the benefits of low-tidal-volume
ventilation in ARDS 3. Discuss evidence-based guidelines of mechanical ventilation in ARDS
1. Which of the following is not a lung-protective strategy in the 7. Low-tidal-volume ventilation may result in which of the following?
management of acute respiratory distress syndrome (ARDS)? a. Hypocarbia
a. Low-tidal-volume ventilation b. Eucarbia
b. Positive end-expiratory pressure (PEEP) c. Hyperventilation
c. Lateral positioning of patients d. Hypercarbia
d. High-frequency oscillation
8. The goal for acid-base status in ARDS is to
2. Which of the following tidal volumes contributed maintain a pH at which of the following levels?
to a lower mortality rate in the ARDS Networks study? a. 7.15
a. 4 mL/kg b. 7.25
b. 6 mL/kg c. 7.35
c. 8 mL/kg d. 7.45
d. 10 mL/kg
9. Permissive hypercarbia should be avoided in which of the following?
3. Which of the following PEEP levels may be a. Increased intracranial pressure
benef icial in preventing alveolar closure in ARDS? b. Decreased intracranial pressure
a. 10 to 12 cm H2O c. Acute lung injury
b. 12 to 14 cm H2O d. ARDS
c. 14 to 16 cm H2O
d. 16 to 18 cm H2O 10. Which of the following is not a component of a weaning protocol?
a. Assessing weaning readiness
4. Which of the following mechanisms of prone b. Advancing spontaneous weaning trial
positioning is benef icial in recruiting lung in ARDS? c. Tolerance criteria
a. Low pleural pressure d. Failure criteria
b. Elevation of the diaphragm
c. Low tidal volume
11. The use of a weaning protocol has been
d. Reversed gravity
associated with which of the following?
a. Decreased morbidity
5. Which of the following PaO2 to fraction of
b. Decreased use of paralytics
inspired oxygen ratios is indicative of ARDS?
c. Decreased use of sedation
a. Less than 200
d. Decreased ventilator days
b. Less than 250
c. Less than 300
d. Less than 350

6. Which of the following is a goal of low-tidal-volume ventilation?

a. Increased oxygenation
b. Eucarbia
c. Decreased volutrauma
d. Normal pH

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. a 2. a 3. a 4. a 5. a 6. a 7. a 8. a 9. a 10. a 11. a
b b b b b b b b b b b
c c c c c c c c c c c
d d d d d d d d d d d
Test ID: C054 Form expires: August 1, 2007. Contact hours: 2.0 Fee: $12 Passing score: 8 correct (73%) Category: A Test writer: John P. Harper, RN, MSN, BC
Program evaluation Name Member #
Yes No
Objective 1 was met Address
Objective 2 was met City State ZIP
Objective 3 was met
Content was relevant to my Country Phone
Mail this entire page to: nursing practice
My expectations were met E-mail
AACN This method of CE is effective RN Lic. 1/St RN Lic. 2/St
101 Columbia for this content
The level of difficulty of this test was: Payment by: Visa M/C AMEX Discover Check
Aliso Viejo, CA 92656 easy medium difficult
To complete this program, Card # Expiration Date
(800) 899-2226 it took me hours/minutes. Signature

24 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017

Mechanical Ventilation of Patients With Acute Respiratory Distress Syndrome and
Patients Requiring Weaning: The Evidence Guiding Practice
Suzanne M. Burns
Crit Care Nurse 2005;25 14-23
Copyright 2005 by the American Association of Critical-Care Nurses
Published online http://ccn.aacnjournals.org/
Personal use only. For copyright permission information:
http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

Subscription Information
http://ccn.aacnjournals.org/subscriptions/
Information for authors
http://ccn.aacnjournals.org/misc/ifora.xhtml

Submit a manuscript
http://www.editorialmanager.com/ccn

Email alerts
http://ccn.aacnjournals.org/subscriptions/etoc.xhtml

Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published
bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949)
362-2049. Copyright 2016 by AACN. All rights reserved.

Downloaded from http://ccn.aacnjournals.org/ by AACN on October 26, 2017