Chapter 295: Mechanical Ventilatory Support

MECHANICAL VENTILATORY SUPPORT

Mechanical ventilation (MV) is used to assist or replace spontaneous breathing. It is implemented with special devices that can support ventilatory function and improve oxygenation through the application of high-oxygen-content gas and positive pressure. The primary indication for initiation of MV is respiratory failure, of which there are two basic types: (1) hypoxemic, which is present when arterial O₂ saturation (SaO₂) <90% occurs despite an increased inspired O₂ fraction and usually results from ventilation-perfusion mismatch or shunt; and (2) hypercarbic, which is characterized by elevated arterial carbon dioxide partial pressure (PCO₂) values (usually >50 mmHg) resulting from conditions that decrease minute ventilation or increase physiologic dead space such that alveolar ventilation is inadequate to meet metabolic demands. When respiratory failure is chronic, neither of the two types is obligatorily treated with MV, but when it is acute, MV may be lifesaving.

INDICATIONS

The most common reasons for instituting MV are acute respiratory failure with hypoxemia (acute respiratory distress syndrome, heart failure with pulmonary edema, pneumonia, sepsis, complications of surgery and trauma), which accounts for ~65% of all ventilated cases, and hypercarbic ventilatory failure—e.g., due to coma (15%), exacerbations of chronic obstructive pulmonary disease (COPD; 13%), and neuromuscular diseases (5%). The primary objectives of MV are to decrease the work of breathing, thus avoiding respiratory muscle fatigue, and to reverse life-threatening hypoxemia and progressive respiratory acidosis.

In some cases, MV is used as an adjunct to other forms of therapy. For example, it is used to reduce cerebral blood flow in patients with increased intracranial pressure. MV also is used frequently in conjunction with endotracheal intubation for airway protection to prevent aspiration of gastric contents in otherwise unstable patients during gastric lavage for suspected drug overdose or during gastrointestinal endoscopy. In critically ill patients, intubation and MV may be indicated before the performance of essential diagnostic or therapeutic studies if it appears that respiratory failure may occur during those maneuvers.

TYPES OF MECHANICAL VENTILATION

There are two basic methods of MV: noninvasive ventilation (NIV) and invasive (or conventional mechanical) ventilation (MV).

Noninvasive Ventilation

NIV has gained acceptance because it is effective in certain conditions, such as acute or chronic respiratory failure, and is associated with fewer complications—namely, pneumonia and tracheolaryngeal trauma. NIV usually is provided with a tight-fitting face mask, a nasal mask similar to that used for treatment of sleep apnea and in some cases with the use of a helmet or a hood. NIV has proved highly effective in patients with respiratory failure arising from exacerbations of COPD. It is most frequently implemented as bilevel positive airway pressure ventilation or pressure-support ventilation (PSV). Both modes, which apply a preset positive pressure during inspiration and a lower pressure during expiration, are well tolerated ...