Mechanical ventilation in trauma

Peter J. Papadakosa, Marcin Karczb and Burkhard Lachmannc

a
Department of Anesthesiology, Surgery and
Neurosurgery, bDepartment of Anesthesiology,
University of Rochester, Rochester, New York, USA
and cDepartment of Anesthesiology and Operative
Intensive Care, Charite Universitats Median Berlin,
Campus Verchow Klinikum Humbolt University, Berlin,
Germany
Correspondence to Peter J. Papadakos, MD, FCCM,
Director, Critical Care Medicine, Department of
Anesthesiology, Surgery and Neurosurgery, University
of Rochester, Rochester, NY 14642, USA
E-mail: Peter_Papadakos@URMC.Rochester.edu
Current Opinion in Anaesthesiology 2010,
23:228–232
Purpose of review
The purpose of this review is to evaluate new concepts in mechanical ventilation in
trauma. We begin with the keystone of physiology prior to embarking on a discussion of
several new modes of mechanical ventilation. We will discuss the use of noninvasive
ventilation as a mode to prevent intubation and then go on to airway pressure release
ventilation, high-frequency oscillatory ventilation, and computer-based, closed loop
ventilation.
Recent findings
The importance of preventing further injury in mechanical ventilation lies at the heart of
the introduction of several new strategies of mechanical ventilation. New modes of
ventilation have been developed to provide lung recruitment and alveolar stabilization at
the lowest possible pressure.
Summary
The old modes of continuous positive airway pressure and bilevel positive airway
pressure have been actively introduced in clinical practice in the case of trauma patients.
Used with proper pain management protocols, there has been a decrease in the
incidence of intubation in blunt thoracic trauma. Airway pressure release ventilation has
been gaining a role in the management of thoracic injury and may lead to less incidence
of physiologic trauma to mechanically ventilated patients. High-frequency oscillatory
ventilation has been shown to be effective in patient care by its ability to open and recruit
the lung in trauma patients and in those with acute respiratory distress syndrome but it
may not have a role in patients with inhalational injury. Closed loop ventilation is a
technology that may better control major pulmonary parameters and lead to more rapid
titration from the ventilator to spontaneous breathing.

Keywords
airway pressure release ventilation, atelectasis, closed loop ventilation, high-frequency
oscillatory ventilation, mechanical ventilation, pulmonary trauma

Curr Opin Anaesthesiol 23:228–232

ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907

sors are the iatrogenic effects of intubation and the effects

Introduction
Owing to the evolution of emergency medical services
(EMS) throughout the world, a growing number of
patients present to both the operating room and the
ICU after sustaining massive chest trauma. The majority
of these patients are young and thus in their most
productive years [1]. Pulmonary dysfunction is now
being recognized as a major contributor to the loss of
productivity [2].
Pulmonary dysfunction in trauma patients is multifactor-
ial and may be the result of direct contusion of the lung
tissue, lung injury by fractured ribs, loss of chest wall
function, fat embolism to the lung from long bone frac-
tures, aspiration of blood or gastric contents and the
consequences of the activation of the systemic inflam-
matory response syndrome (SIRS) of shock, reperfusion,
and transfusion therapy [3,4]. In addition to these stres-
0952-7907 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
of mechanical ventilation, which include barotrauma and
biotrauma and the syndrome of ventilator-associated
pneumonia. An important thrust has been in research
on how mechanical ventilation modulates a number of
physiologic responses.
The purpose of this work is to review and highlight
some of the new contributions in mechanical ventilation
such as lung recruitment, closed loop management,
and physiologic principles of ventilator-associated injury
in trauma patients. Clinicians can greatly improve their
care of patients as they develop an understanding of
how the presenting injury and the basic support provided
by mechanical ventilation interact and can affect out-
come. New technology, such as computer controlled
closed loop technology, is being introduced in the care
of these patients. The syndrome of posttraumatic venti-
lator-associated pneumonia in these patients and the
DOI:10.1097/ACO.0b013e328336ea6e

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

development of such new syndromes as postventilation
emphysema in severe lung trauma affect long-term care
in these patients.
Physiology in mechanical ventilation
Injury due to mechanical ventilation has been historically
attributed to excess pressure, barotraumas [5,6] or volu-
trauma [7], applied to the lung patenchyma. Over the last
few years, it has become clear that mechanical ventilation
creates shear stresses at the interface between open and
closed lung regions, that is, atelectrauma [8,9,10] via
cyclic opening and closing, and activation of a cellular
inflammatory response, that is, biotrauma [11].
Pulmonary injury will greatly affect the force-bearing
structure, which is a skeleton composed of a fibrous
network made up of elastin and collagen that are
embedded in the extracellular matrix. There are two
fiber systems that connect at the alveolar level, one
originating from the hilum and the other from the visceral
pleura in the periphery [12]. Pulmonary contusion with
interalveolar hemorrhage will affect this fiber system and
may cause rupture of the structure and generalized lung
inflammation [13]. This breakdown in the structure will
also lead to atelectasis, which may not respond to recruit-
ment and stabilization procedures [14].
The standard of using physiological tidal volumes in the
range of 6–8 ml/kg and limiting the inspiratory plateau
has now been widely accepted in patients with acute
respiratory distress syndrome (ARDS) [15,16]. This
reduction in tidal volume may result in alveolar dere-
cruitment if not enough positive end-expiratory pressure
(PEEP) is applied to prevent alveolar collapse. The use
of high PEEP to compensate for this derecruitment may
be associated with excessive lung parenchyma stress and
strain [17]. This may impact the most on a highly injured
lung after traumatic lung injury. This has led to inves-
tigations to find ideal recruitment maneuvers [18] and
how they affect oxygenation and how they modulate
epithelial and endothelial damage, and how this affects
distal organs.
The ideal recruitment maneuver, along with its period-
icity, duration, and optimal inspiratory pressure, still
needs to be elucidated, especially in patients with pul-
monary injury secondary to trauma.
The level of PEEP used to stabilize alveolar beds has
been studied in a systematic review and meta-analysis
[19] evaluating how this standard treatment can be an
independent variable that can have an impact on
mortality. A high PEEP strategy may have a clinically
relevant independent mortality benefit. Despite a
possible increase in biotrauma, the benefits seem to far
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Mechanical ventilation in trauma Papadakos et al. 229
outweigh potential risks. PEEPs in the range of 14–
16 cmH2O may be useful in patients with severe lung
injury. This supports observations made in our trauma
population [20] and other groups [21], which showed
positive effects with stepwise titration of PEEP to higher
levels.
The use of recruitment and PEEP may have a special role
in brain-injured multitrauma patients who develop
neurologic pulmonary edema [22,23]. The use of PEEP
in these patients to produce recruitment may have few
adverse effects on intracranial pressure (ICP) in the
majority of patients but may have adverse effects in other
patients without severe injury. This PEEP effect must be
considered along with oxygenation and hemodynamics
[24]. High-frequency ventilation may have a special role
in this select patient population [25].
Another important new development in mechanical
ventilation is how even short periods of routine mech-
anical ventilation can affect the physical structure of the
diaphragm [26]. In this investigation, 18–69 h of com-
plete diaphragmatic inactivity and mechanical venti-
lation resulted in marked atrophy of human diaphragm
myofibers. These results have a marked implication in
multiple trauma patients with multisystem injuries, who
will have prolonged mechanical ventilation due to the
nature of their injuries. A prospective, international study
reported that 39% of patients in ICUs are mechanically
ventilated for a median duration of 7 days [27].
These current concepts suggest that diaphragm atrophy,
which is found in patients with SIRS, sepsis, or
barotrauma–volutrauma, should be associated with an
inflammatory-cell infiltrate or increased proinflammatory
cytokines. Neither of these findings, however, was evi-
dent in the diaphragm fibers examined in this study in
which patients showed decreased cross-sectional areas of
slow-twitch and fast-twitch fibers, decreased glutathione
concentration, a 100% increase in active caspase-3
expression, and a 200% higher ratio of astrogin-7 mes-
senger RNA.
Modes of mechanical ventilation
There has been an explosion in the modes of mechanical
ventilation available in ICUs throughout the world. The
majority of trauma patients are managed with pressure-
controlled modes, which have been a mainstay in the
treatment of severe lung injury since they were first
described at the University of Rochester in 1960 [28].
Basic physiology serves as the rationale for the use of
pressure-controlled ventilation [29]. Several new strat-
egies have gained widespread use in trauma patients,
including noninvasive ventilation, airway pressure
 230 Trauma and transfusion
release ventilation (APRV), and high-frequency oscil-
lation.
Noninvasive ventilation may reduce the need to intubate
patients with chest trauma-related hypoxemia [30]. It is
well known that patients with blunt thoracic trauma are
at increased risk of developing hypoxemic respiratory
failure, which may or may not be associated with hyper-
capnia. Hypoxemia in these patients is due to V/Q
mismatching and right to left shunt because of lung
contusion, atelectasis, inability to clear secretions, and
pneumothorax and/or hemothorax, all of which are com-
mon in trauma patients. After the use of analgesia, which
is fundamental in the management, the goal is to prevent
intubation. Continuous positive airway pressure (CPAP),
applied either by face mask, helmet or nasal mask, has
been tried in these patients in order to avoid the com-
plications related to endotracheal intubation, mainly
ventilator-associated pneumonia [31,32]. It is, therefore,
important that noninvasive ventilation, which has been
shown to be a safe technique, be used early in blunt
thoracic trauma to prevent acute respiratory failure.
Further investigations are necessary to find ideal
parameters to titrate noninvasive ventilation to prevent
atelectasis.
APRV is a pressure-limited, time-cycled mode of venti-
lation which has entered the trauma theater over the last
few years [33,34]. APRV allows unrestricted spon-
taneous breathing in any phase of the mechanical venti-
lator cycle. The degree of ventilator support with APRV
is determined by the duration of both CPAP levels and
the mechanically delivered tidal volume (VT) [35]. Tidal
volume depends mainly on respiratory compliance and
the difference between CPAP levels. In principle,
changes in ventilatory demand do not alter the level of
mechanical support during APRV. When there is no
spontaneous breathing, APRV resembles conventional
pressure-controlled, time-cycled mechanical ventilation.
This mode of ventilation may offer the ability to achieve
recruitment of atelectatic lung, a common problem in
blunt thoracic trauma, and improve oxygenation while
maintaining an acceptable peak airway pressure. In one of
the first studies in trauma, APVR significantly improved
oxygenation in a wide variety of trauma patients [36]. It
did so with the ability to reduce peak airway pressures,
thus preventing barotrauma.
High-frequency oscillation ventilation (HFOV) is a venti-
latory method that theoretically achieved all of the goals
of classic lung protection used in the ARDS Net trial [37].
HFOV uses a constant mean airway pressure over which
small tidal volumes are superimposed at a high respirat-
ory frequency [38]. Application of this constant mean
airway pressure allows maintenance of alveolar recruit-
ment with lower peak airway pressures (limiting baro-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
trauma) and avoiding low end-expiratory pressure (avoid-
ing alveolar collapse). In patients with severe pulmonary
contusions, the early use of HFOV was well tolerated and
led to a rapid improvement in the oxygenation index and
the PaO2/FIO2 ratio (P/F) [39]. HFOV has had a role in
the management of ARDS and severe lung injury, which
are common in trauma patients. This mode has been
expanded from a rescue mode to a mainstream therapy,
which has a role in trauma management [40].
HFOV has played a major role in inhalational burn injury
management [41]. Smoke inhalation injury, which is
frequently associated with burn trauma, poses a unique
set of potential challenges to the implementation of
HFOV. These challenges include the presence of diffuse
airway narrowing and increases in airway resistance,
hypercapnia, copious secretion production, and the need
for frequent bronchoscopy and delivery of a variety of
nebulized inhalational agents such as heparin, N-acetyl-
cysteine, and bronchodilators. New data suggest that
HFOV may not be the optimal rescue ventilation
modality in patients with ARDS in whom there has been
smoke inhalation injury.
Closed loop mechanical ventilation
With the introduction of complex computer sensors and
data analysis in mechanical ventilators, systems now are
entering clinical practice to provide closed loop control of
mechanical ventilation [42]. Closed loop technology is
now used to both titrate oxygenation and facilitate venti-
lator discontinuation or to escalate therapy to facilitate
minute ventilation (VE) [43,44]. Closed loop control of
inspired oxygen concentration has been introduced in the
management of trauma patients [45,46]. The systems for
oxygenation are designed to monitor oxygen saturation
via pulse oximetry (SpO2) and to adjust inspired oxygen
concentration (FIO2) while maintaining normal oxygen
saturation (SpO2) in the range of 94  2% [45]. The
results of this trial demonstrated effectiveness of the
controller at maintaining the target SpO2. This may have
clinical use in the hospital to decrease FIO2 below 0.40
and decrease hyperoxemia. Another great advantage of
this system is to prevent hypoxemia during transport,
which is a common event in the care of trauma patients
who may need various diagnostic scans in the first few
days after admission.
Closed loop ventilation is gaining a major role and will
aid in ventilator-discontinuation guidelines based on
the weaning-readiness screening and daily spontaneous
breathing trials [47]. Adaptive support ventilation (ASV) is
also a technique capable of automated weaning [48,49].
ASV can choose initial ventilator settings and escalate
ventilatory support when ventilation targets are not met.
ASV uses a VE target, based on predicted body weight and a

clinician-set percentage of the predicted VE. The technol-
ogy is based on the minimum work of breathing algorithm
first described by Otis et al. [50]. In patients who had ‘fast
track’ surgery, ASV shortened the time to extubation [51].
The role of ASV is under investigation in trauma patients
who may meet the need to enter weaning protocols.
Conclusion
Mechanical ventilation and an understanding of the
underlying physiology of blunt thoracic trauma play an
important role in the management of complex multi-
trauma. The importance of recruitment and stabilization
cannot be overstated. Atelectasis in pulmonary contusion
is a common finding. This can affect surfactant function
and immune function in injured lungs leading to venti-
lator-associated pneumonia.
There has been an increase in recruitment-based modes
of ventilation in the management of patients with non-
invasive ventilation such as CPAP and bilevel positive
airway pressure (BIPAP) as aids to recruitment in spon-
taneously breathing patients. Noninvasive support has
been integrated into the treatment of many medical
diseases, both acute and chronic. It may be an excellent
adjunct along with integrated pain control protocols to
prevent intubation in patients with chest trauma. By
preventing intubation in these patients, we may be able
to decrease ICU length of stay and also prevent
respiratory complications.
Several new modes of ventilation such as APRV and
HFOV have been introduced in the care of complex
thoracic injury and respiratory failure. These modes
aim to be lung protective modalities that control tidal
volumes and interalveolar pressures. These modes may
gain roles in preventing ventilator-induced lung injury in
patients requiring prolonged support due to severe poly-
trauma. HVOF has had a long history in the management
of bronchopleural fistulas and massive air leaks in pene-
trating trauma, along with independent lung ventilation
[4]. Anesthesiology, with its long history of using double
lumen tubes and independent lung ventilation in trauma,
is an ideal starting point for the use of these modes in
complex trauma patients.
These modes are all based on physiologic principles of
lung recruitment with APRV being a true lung protective
mode, based on limiting peak airway pressures. We must
all be aware of the importance of the effects of mechan-
ical ventilation not only on oxygenation but also on
physiologic responses. Owing to the unique direct trauma
of lung due to blunt injury to the skeleton of the lung, we
may be able to prevent long-term pulmonary disability in
young patients. Thus, ongoing investigations on lung
protective modes are mandated.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Mechanical ventilation in trauma Papadakos et al. 231
The ultimate new technology in pulmonary management
in trauma patients may be the introduction of closed
loop ventilation in which computers control the level of
ventilator support and the concentration of oxygen.
These new modes may be unimportant in decreasing
diaphragmatic dysfunction and wasting, which has been
recently described.
Ongoing research and development has ballooned and
clinicians must remain ahead of the curve as we try to use
physiologically based mechanical ventilation technology.
Acknowledgement
The authors have no conflicts of interest. No external funding was
provided for the writing of this article to any of the authors.
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