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Cournand and Richards seminal observations … yet link between physiology and mechanical ventilation
is best made by a concept of another Frenchman: Claude Bernard’s milieu intérieur
Acute Respiratory Failure
Patients consented
to photo display
Patients admitted to the ICU exemplify par excellence a disturbance in this milieu
J Appl Physiol 1951;4:77
Although respiratory failure is defined conventionally in terms of abnormal arterial blood gases –
hypoxia, hypercapnia – these are rarely the reasons for institution of mechanical ventilation
Fritz Rohrer, 1988-1926
Rohrer F. In: Handbuch der normalen und pathologischen
Physiologie. Springer, Berlin,1925, vol 2, p 70-127 University of Bern
Instead, mechanical ventilation is typically instituted because of disturbances in the
framework first articulated by Rohrer, and subsequently developed by Fenn, Otis and Rahn:
derangements in respiratory mechanics leading to marked increases in work of breathing
Photo taken in 1963
Wallace Fenn
1893-1971
AJRCCM 1997;155:906
In patients who develop acute respiratory failure, inspiratory effort increases ~ 4 times
above the normal value, and the increase is 6-fold in some patients
ARRD 1982;126:9
In such patients, the respiratory muscles account for 20% of total oxygen consumption
– and more than 50% in some patients ARRD 1982;126:9
ARRD 1982;126:9
In such patients, the respiratory muscles account for 20% of total oxygen consumption
– and more than 50% in some patients ARRD 1982;126:9
NEJM 1994;330:1056
In the 1950s, 60s and even 70s, neuromuscular blockers were administered to prevent
patients from bucking against cycling of the ventilator
Schematic Representation of Internal Operation of ICU Ventilator
In: Tobin, Principles and Practice of Mechanical Ventilation, 3rd ed, 2012, p67
Today, almost all ventilator modes are “cycled-on” by a patient triggering the pneumatic
system that delivers flow
Cycling-Rhythm Alignment
Problems in aligning the cycling of a ventilator with a patient's own rhythm of breathing
may arise at three points: cycling-on function (triggering), post-trigger inflation, and cycling-off
Cycling-Rhythm Alignment
Problems in aligning the cycling of a ventilator with a patient's own rhythm of breathing may arise at 3 points: cycling-on
(triggering), post-trigger inflation (flow delivery), and cycling-off function (inspiration: expiration switchover)
Cycling-Rhythm Alignment
Problems in aligning the cycling may … arise at three points: cycling-on function (triggering), post-trigger
inflation, and cycling-off function (inspiration:expiration switchover)
Respiratory Motor Output and Ventilator Unloading
For a given trigger sensitivity, patient respiratory motor output determines the delay
between onset of inspiratory effort and onset of ventilator unloading
Low Drive and Delayed Ventilator Assistance
Flow
Paw
Pes
When respiratory drive is low, assistance may not begin until well into a patient’s
inspiratory time, thereby causing the ventilator to cycle almost completely out of phase
with the patient’s respiratory cycle
Output Flow-Control Valve
When patient inspiratory effort opens the demand valve, the inspiratory neurons do
not suddenly switch off, and a patient may expend considerable inspiratory
effort throughout the remainder of inflation
Intrinsic PEEP impedes Ventilator Triggering
Flow, L/m
Pes, cm H2O Paw, cm H2O
PEEPi
PEEPi = 0.5 cmH2O 10.6 cmH2O
The patient on the right exhibits a considerable delay between the onset of
inspiratory effort, signaled by the vertical blue line, and the onset of flow delivery
by the ventilator, signaled by the vertical red line
Intrinsic PEEP impedes Ventilator Triggering
Flow, L/m
Pes, cm H2O Paw, cm H2O
PEEPi
PEEPi = 0.5 cmH2O 10.6 cmH2O
Rate = 16
Rate = 28
Rate = 16
Rate = 28
the respiratory centers are firing 28/min whereas ventilator is cycling only 16 times per minute.
That is, 43% of the patient’s inspiratory efforts fail to trigger ventilator assistance
Double Triggering
Some patients exhibit double triggering, where the ventilator produces two inflations
within a single inspiratory effort made by the patient
Double Triggering
Here, esophageal pressure falls and remains negative for more than 1 second,
whereas duration of mechanical inflation is 0.6 second
Double Triggering
The longer duration of neural inspiration as compared with mechanical inflation causes the
ventilator to deliver a 2nd breath before there’s time for exhalation, producing breath stacking
Double Triggering
In this patient, arrowheads signal 4 incidents of double triggering; the width of the Pes
swing is roughly equivalent to duration of patient neural inspiratory time
Double Triggering
On the bottom tracing, patient neural inspiratory time in the double-triggered breaths
– width of the Pes swing – is substantially longer than in the normally triggered breaths
Triggering Peculiarities
Some might think that these triggering peculiarities are no more than arcane quirks;
on the contrary, they have major significance and contribute to patient mortality when
they go unrecognized
Low versus High Tidal Volume in ARDS
1.0
Survival
Low, 6 ml/kg
Proportion Surviving
0.8
69%
0.6 60%
Control, 12 ml/kg
0.4
n=861 (p<0.007)
0.2
0
0 20 60 100 140 180
Days after Randomization NEJM 2000;342:1301
Consider mechanical ventilation in patients with ARDS, where a tidal volume of 6 ml/kg
has been shown to lower mortality
Tidal Volume in ARDS
1.0
Survival
Low, 6 ml/kg
Proportion Surviving
0.8
69%
0.6 60%
Control, 12 ml/kg
0.4
n=861 (p<0.007)
0.2
0
0 20 60 100 140 180
Days after Randomization NEJM 2000;342:1301
Protocol enthusiasts believe they’re delivering a tidal volume of 6 ml/kg, but the patient
is receiving 12 ml/kg – a setting proven to increase mortality
There is simply no substitute for deep understanding
and clinical wisdom when taking care of patients
Dickinson W. Richards, MD
1895-1973
Inspiratory Flow Demand
The next point in the respiratory cycle at which problems may arise is at the switchover
between inspiration and expiration
Inspiration-Expiration Switchover
Neuronal
firing
During pressure support, the algorithm for "cycling-off" of mechanical inflation is based
on a decrease in flow to 25% of the peak value
Inspiration-Expiration Switchover
Neuronal
firing
In patients with COPD who have a prolonged time constant, more time will be required
to reach this threshold
Inspiration-Expiration Switchover
Neuronal
firing
The expiratory neurons become impatient and start to fire, causing contraction of the
expiratory muscles during mechanical inflation
Inspiration-Expiration Switchover
Pes, cm H2O
Time, sec
Esophageal
pressure
Pes, cm H2O
Time, sec
Halfway during inflation, esophageal pressure is higher than calculated chest-wall recoil
pressure (the dashed tracing), indicating expiratory muscle recruitment
Expiratory Muscle Recruitment during Inflation
Transversus abdominis
EMG (arbitrary units)
To obtain more direct evidence, we inserted needle electrodes into the transversus
abdominis
Expiratory Muscle Recruitment during Inflation
Transversus abdominis
EMG (arbitrary units)
This patient with COPD receiving pressure support activated his expiratory muscles about
half way during mechanical inflation – an under-appreciated form of fighting the ventilator
Cycling-Rhythm Alignment
Ventilator
Subject 1
phase angle (θ): 60°
Subject 2
phase angle (θ): -45°
The most precise way to quantify a discrepancy in timing of ventilator cycling versus
rhythmical activity of a patient's respiratory centers is to measure phase angle (θ)
Cycling-Rhythm Alignment
Ventilator
Subject 1
phase angle (θ): 60°
Subject 2
phase angle (θ): -45°
If, for example, the major expiratory muscle, the transversus abdominis, starts to contract
before completion of mechanical inflation, phase angle will have negative units
Cycling-Rhythm Alignment
This means that the length of time that the expiratory muscles had been
active before cycling-off of mechanical inflation was longer for
non-triggering attempts than for triggering attempts
Cycling-Rhythm Alignment
The longer the time that mechanical inflation continues into neural expiration,
the shorter will be the time available for unopposed expiratory flow, causing
elastic recoil to rise and increasing the likelihood of non-triggering
Sleep during Mechanical Ventilation
More than half the patients developed central apneas during pressure
support, but no apneas during assist-control
Arousals plus Awakenings per hour
p<0.05
54 79
Assist Pressure
Control Support
Sleep fragmentation was greater during pressure support than during assist-control:
79 versus 54 events per hour
Arousals plus Awakenings per hour
p<0.05
54 79
Assist Pressure
Control Support
Disturbed sleep during pressure support was related to the development of central
apneas, which, in turn, was related to the difference between end-tidal PCO2 and
the apnea threshold
Sleep during Mechanical Ventilation
60
50
30
79 44
25
0
Pressure PS plus
Support Dead Space 0
Pressure PS plus
Support Dead Space
The addition of dead space increased PCO2 by 4.3 mm Hg and decreased central apneas
(from 53 to 4 per hour), and decreased the sum of arousals and awakenings from
79 to 44 events per hour
Sleep during Mechanical Ventilation
Arousals plus Awakenings per hour
Apneas per hour
90 p<0.01
75
60
50
30
79 44
25
0
Pressure PS plus
Support Dead Space 0
Pressure PS plus
Support Dead Space
The addition of dead space increased PCO2 by 4.3 mm Hg, decreased central apneas
(from 53 to 4 per hour), and decreased the sum of arousals and awakenings from
79 to 44 events per hour
Physiologic Basis of Mechanical Ventilation
This task demands greater wisdom and cognitive skill than is required for adjusting
settings on the ventilator
60-80% of Ventilated Patients Tolerate First Weaning Attempt
100
Extubated
Reintubated
Percentage 80
60
76% 68%
40
20
16%
0
n = 456 n = 546
Brochard et al AJRCCM 1994 Esteban et al NEJM 1995
Randomized trials on weaning techniques reveal that physicians are inherently slow
at initiating the weaning process
Weaning-Predictor Tests
Ventilator
stopped
When the f/VT ratio exceeds 100, rapid shallow breathing is present
f/VT Threshold
N Engl J Med 1991;324:1445
A f/VT ratio of 100 performed superiorly to other weaning predictors in forecasting which
patients would successfully tolerate a T-tube trial vs. patients who would fail a T-tube trial
f/VT: Predicting Weaning-Extubation Outcome
Yang & Tobin, 1991 Jacob et al, 1997
Gandia & Blanco, 1992 Krieger et al, 1997
Sassoon & Mahutte, 1993 Rivera & Weissman et al, 1997
Yang, 1993 Farias et al, 1998
Mohsenifar et al, 1993 Vallverdu et al, 1998
Lee et al, 1996 Thiagarajan et al, 1999
Capdevila et al, 1995 Zeggwagh et al, 1999
Epstein, 1995 Maldonado et al, 2000
Chatila et al, 1996 Uusaro et al, 2000
Dojat et al, 1996 Khamiees et al, 2001
Leitch et al, 1996 Smina et al, 2003
Mergoni et al, 1996 Conti et al, 2004
Bouachour et al, 1996 Fernandez et al, 2004
Baumeister et al, 1997 Jiang et al, 2004
Гологорский et al, 1997
Since our original report, the accuracy of f/VT in predicting weaning outcome has been
evaluated by more than 27 groups of investigators, making it the most reevaluated
phenomenon in critical care
Positive Predictive Value ranges from 0.53 to 0.98
1.0
0.6
0.4
0.2
0.0
0.8
Positive Predictive Value
0.6
Weighted r = 0.86
0.4 p < 0.0001
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
Pretest Probability of Success
If f/VT is less than 100, the physician proceeds with a weaning trial using
one of two methods: intermittent unassisted breathing (zero vent support,
as with T-tube trial seen here) or gradual reduction in ventilator assistance
Weaning-Predictor Tests
Patient consented
to photo display
Weaning predictors are not done to forecast a failed weaning trial, but in order to alert a
physician that a patient might tolerate a weaning trial sooner than the physician otherwise thinks
and move that weaning trial earlier in time and shorten the overall of duration mechanical ventilation
Weaning-Predictor Tests
Patient consented
to photo display
Weaning predictors are not done to forecast a failed weaning trial, but in order to alert a physician
that a patient might tolerate a weaning trial sooner than the physician otherwise thinks
and move that weaning trial earlier in time and shorten the overall of duration mechanical ventilation
Weaning-Predictor Tests
In: Tobin, Principles and Practice of Mechanical Ventilation, 3rd ed, 2012, p1308
Weaning predictors are not done to forecast a failed weaning trial, but in order to alert a physician that a
patient might tolerate a weaning trial sooner than the physician otherwise thinks and move that
weaning trial earlier in time and shorten the overall of duration mechanical ventilation
AJRCCM 1994;150:896
In 1994, Brochard published the first RCT of different weaning methods, showing that
IMV was the worst technique
AJRCCM 1994;150:896
One arm in the Brochard RCT was T-tube trials combined with assist-control, but the
duration of rest between each failed T-tube trial could be as brief as 1 hour
Transdiaphragmatic twitch pressure
At this time, Franco Laghi had data showing that recovery from diaphragmatic fatigue
required at least 24 hours of rest
This was the motivation behind the incorporation of a 24-hour rest arm in an RCT
conducted by the Spanish Lung Failure Collaborative Group
Our study revealed that T-tube trials combined with 24 hours of rest weaned patients
3 times faster than did IMV and 2 times faster than did pressure support
JAMA 2013;309:671
Pressure
0.6 support
0.4
0.2
Trach collar
p = 0.016
0.0
0 5 10 15 20 25 30 35 40 45
Weaning duration (days) JAMA 2013;309:671
In a randomized trial, we found that intermittent unassisted breathing (using a tracheostomy
collar) resulted in 1.43 times faster removal of the ventilator than did pressure support
Randomized Controlled Trials of Weaning Techniques
The superior outcome with unassisted breathing arms (T-tube, trache collar) in our
two RCTs is best explained on the basis of physiology
Pressure Support vs Unassisted Breathing
The superior outcome with the unassisted-breathing arm (T-tube, trache collar) in our
two RCTs is best explained on the basis of physiology
Pressure Support vs Unassisted Breathing
During trach-collar or T-piece trial, the amount of respiratory work is determined solely
by the patient – the ventilator cannot do any work
Evaluation of Patient Weanability
Trach-Collar or T-piece Wean
Respiratory
Ventilator
system
8 Chest-wall recoil
pressure
Pes, cm H2O
4
Esophageal
0 pressure
-4
0 2 4 6
Time, sec
Jubran et al, AJRCCM 1995;152:129
… andit is extremely difficult to distinguish between how much work the patient is doing
and how much work the ventilator is doing, even when esophageal pressure is being
monitored – and impossible without esophageal pressure monitoring
Methodology to Quantify Pressure-Time Product during Pressure Support
8 Chest-wall recoil
pressure
Pes, cm H2O
4
Esophageal
0 pressure
-4
0 2 4 6
Time, sec
Jubran et al, AJRCCM 1995;152:129
… andit is extremely difficult to distinguish between how much work the patient is doing
and how much work the ventilator is doing, even when esophageal pressure is being
monitored – and impossible without esophageal-pressure monitoring
Evaluation of Patient Weanability
Pressure-Support Wean
Patient Ventilator
work work
Patient
Ventilator
work work
Patient Ventilator
work
work
Patient Ventilator
work work
Time (sec)
Time (sec)
Extubated CPAP 0, PS 0
(FlowBy)
Compared with work of breathing in the extubated state, breathing through the ventilator
circuit (with CPAP of 0 and pressure support of 0) decreases patient work by about 1%
Decrease in Patient Work of Breathing Compared with Extubated State
31-38 40%
31-38 40%
31-38 40%
When evaluating a patient’s readiness for extubation, the thing you most want to avoid is:
A decrease in patient work of breathing compared to what it will be following extubation
Decrease in Patient Work of Breathing Compared with Extubated State
31-38 40%
When evaluating a patient’s readiness for extubation, the thing you most want to avoid is:
A decrease in patient work of breathing compared to what it will be following extubation
Readiness of a Patient for Extubation
Patient consented
to photo display
AJRCCM
2012;185:349
The vast majority of patients can cope with a 40-60% increase in work of
breathing at the point of extubation – but a fragile patient may not
Decrease in Patient Work of Breathing Compared with Extubated State
31-38 40%
Time (sec)
Over the breadth of my practice, no area demands greater understanding of physiological principles than
ventilator management, and the need for physiological understanding is greatest when
facilitating expeditious weaning and extubation while minimizing the risk of death