Respiratory failure

Invasive mechanical
ventilation
Simon V Baudouin

Abstract
The majority of patients admitted to level 3 critical care facilities will need
invasive ventilatory support. Over half of these will suffer from acute res-
piratory failure, with smaller proportions having exacerbations of chronic
obstructive pulmonary disease (COPD), coma of various causes and neu-
romuscular diseases. Patients with respiratory failure can be divided into
two groups on the basis of ventilation requirements. Those with acute
respiratory distress syndrome (ARDS) have stiff lungs, while the major
problem in COPD and asthma is increased airways resistance. In ARDS,
the ‘recruitment’ and maintenance of open alveoli is important in order to
improve oxygenation. In COPD and asthma, oxygenation is not usually a
major problem but incomplete lung emptying is common, leading to gas
trapping and increased intrathoracic pressures. Experimental and clini-
cal studies show that ventilation can cause and exacerbate lung injury.
Ventilation strategies which aim to reduce this ­damage have therefore
been widely adopted. They are based on ­ deliberate ­ under-ventilation
(using relatively low tidal volumes) with the acceptance of hypercapnia.
Such strategies have been shown to improve clinical outcome in ARDS.
Approximately 50% of patients needing prolonged ventilation will leave
hospital with survival mostly determined by the severity of the original
illness and the previous health status of the patient.
Keywords acute lung injury; acute respiratory distress syndrome; chronic
obstructive pulmonary disease; mechanical ventilation; tracheostomy;
ventilator-induced lung injury
Figure 1 A modern microprocessor-
controlled mechanical ventilator.
Pressure and volume waveforms can
be monitored. The control interface
is complex with a large number of
controlled and measured variables
simultaneously displayed.
receive non-elective ventilation will have developed some form of
acute or acute-on-chronic respiratory failure. Large multinational
surveys suggest that approximately 66% of ventilated patients will
have acute respiratory failure, 15% coma, 13% acute exacerba-
tions of COPD and 5% neuromuscular disorders (Figure 2).
Indications for ventilation
The identification of critically ill patients at a stage before the
occurrence of respiratory arrest has been a major aim of the
recent Outreach programmes in the UK. Patients who require
ventilating develop a common pattern of physiological deteriora-
tion. This will include a combination of:

Conditions requiring invasive mechanical ventilation

The effectiveness of mechanical ventilation, both invasive (by
endotracheal intubation) and non-invasive (by negative pressure Neuromuscular
ventilation), was established during the polio epidemics which problems 5%
spread throughout Europe and North America in the late 1950s Adult respiratory
and early 1960s. Since then, indications for ventilation have distress syndrome 11%
expanded with the concentration of invasive ventilation services Heart failure 11%
in highly-staffed critical care units and, in some parts of Europe,
Pneumonia 11%
respiratory care units.
Modern ventilators have become very complex (Figure 1), but Sepsis 11%
their principal purpose remains straightforward, namely to provide Postoperative
a substitute for the respiratory muscle pump.1 Most patients who complications 11%
Trauma 11%
Coma 16%
Simon V Baudouin MD FRCP is Senior Lecturer in Critical Care Medicine
and Honorary Consultant Physician at the Royal Victoria Infirmary, Chronic obstructive
pulmonary disease 13%
Newcastle upon Tyne, UK. He trained in respiratory and general
medicine at the Brompton and King’s College Hospitals, London, and
in Critical Care Medicine, as a JACIT trainee, at the Leeds Teaching Source: Esteben A, et al. Am J Respir Crit Care Med 2000; 161: 1450–8.
Hospitals. His research interests include acute lung injury, and the
genetics of sepsis. Competing interests: none declared. Figure 2

MEDICINE 36:5 250 © 2008 Elsevier Ltd. All rights reserved.

 Respiratory failure

• increasing respiratory rate

• asynchronous respiratory pattern Ventilatory support terminology
• a change in mentation and level of consciousness
• frequent oxygen desaturation despite increasing oxygen Term Explanation
­concentration
• hypercapnia and respiratory acidosis Continuous positive Not a form of ventilation as the
• circulatory problems, including hypotension and atrial airway pressure (CPAP) treatment does not have an
­dysrhythmias. inspiratory/expiratory cycle. Can
Decisions about the initiation of invasive ventilation can be dif- be used only on a spontaneously
ficult and early discussion with critical care colleagues is essen- breathing patient
tial. Appropriateness of ventilatory support may also be an issue Positive end-expiratory The addition of an above-atmospheric
requiring discussion with the patients and their ­families. pressure (PEEP) pressure to the expiratory cycle of
a ventilated breath. Fulfils the same
function as CPAP in the spontaneously
Initiation of ventilation in the critically ill breathing patient
The transition period from an awake and self-ventilating patient Controlled breath A pre-set, machine-delivered breath
to full, controlled invasive ventilation can be very difficult in that cannot be altered by the patient
the severely ill. Most patients will either be on the verge of, Assisted breath A machine-driven breath that is
or have already developed, failure of other organ systems. A initiated (triggered) by patient effort.
pre-­intubation combination of hypovolaemia, prior ischaemic Synchronized Usually a volume pre-set mode which
heart disease and cardiovascular depression secondary to ­sepsis intermittent mandatory allows spontaneous breathing to occur
is ­ common. Anaesthetic induction agents produce circulatory ventilation (SIMV) between machine triggered breaths.
depression, as does positive-pressure ventilation, by ­ reducing Pressure-controlled A pressure pre-set mode of controlled
venous return to the heart. As a result of all these factors, peri- ventilation (PCV) ventilation. Both inspiratory and
intubation hypotension is common. Large-volume cannulae expiratory pressure (equivalent to
need to be in place before intubation, and rapid infusion of vol- PEEP) is pre-set
Pressure support A patient-triggered form of ventilation.
ume expanders may be needed following induction. Volume-
ventilation (PSV) Following a patient-initiated breath,
resistant hypotension may require inotrope bolus or infusion.
tidal volume is augmented by the
Finally, cessation of spontaneous ventilation leads to very rapid
machine-driven pre-set airway
desaturation in these patients, due to their marginal respiratory
pressure. Expiration may be flow-
reserve and circulatory problems. The airway needs to be rap-
or time-triggered. Often used in
idly secured following induction of anaesthesia. This is most
conjunction with PCV to allow
likely to be achieved by an experienced and senior member of
spontaneous breaths and as a
the critical care team working in an appropriately equipped area
weaning mode
of the hospital.
Assisted, synchronized A different term for PSV
breathing (ASB)
Types of ventilator and principles of ventilation
The aim of ventilation is to achieve a sufficient minute volume Table 1
(tidal volume × rate) to produce adequate CO2 removal and gas In practice, either ventilation mode can be used successfully
exchange. Separate high pressure air and oxygen supplies are on most patients and modern, micropressor-controlled machines
needed as ventilators mix air and oxygen to achieve FiO2 greater can be rapidly switched from one type to the other.
than the 21% available in room air. Ventilator technology is
increasingly complex (Table 1), but a division into those where Basic and advanced ventilation
volume is the main set parameter and those which use a pres- Despite the apparent complexity of modern ventilators, many
sure pre-set is useful. In volume pre-set machines, rate and tidal patients can be successfully managed on simple settings.
volume are used to determine minute volume delivered. Airway A straightforward postoperative patient would be set on synchro-
pressure will then be a consequence of the set volume and total nized ­ intermittent mandatory ventilation (SIMV mode; Table 1)
compliance of the system. The main advantage of this type of with a rate of 10–14 breaths per minute, a tidal volume of about 10
machine is guaranteed minute volume in the face of changing ml/kg body weight and an inspiratory:expiratory time ratio of 1:2.
lung mechanics (e.g. sudden onset of pulmonary oedema). How- The fraction of inspired oxygen (FiO2) would be adjusted to give a
ever, airway pressures may rise to unacceptable levels. brain oxygen saturation (SO2) in the mid-90s. Adequacy of ventila-
In pressure pre-set machines the volume of gas delivered in tion would subsequently be confirmed with arterial blood gases.
each machine-driven breath (tidal volume) is determined by the More complex settings are needed for those with signifi-
driving pressure of the gas and the compliance of the system cant lung disease. In simple terms, two broad categories can be
into which the gas is injected. This includes the chest, chest wall ­distinguished:
and machine/tubing interface. Pre-setting airway drive pressure • patients with stiff lungs (acute respiratory distress syndrome
prevents excessive airway pressures developing, but at the cost (ARDS), diffuse pneumonia, pulmonary oedema)2,3
of unpredictable volume delivery. • patients with increased airflow resistance (asthma, COPD).4

MEDICINE 36:5 251 © 2008 Elsevier Ltd. All rights reserved.

 Respiratory failure
In the first group, oxygenation may be very difficult due to
marked pulmonary shunting. Oxygenation can often be improved
by increasing tidal volume or mean airway pressures. However,
there is increasing evidence, both experimentally and from more
recent clinical trials, that high tidal volume/mean airway pres-
sure strategies cause a pattern of ventilator-induced lung injury
(VILI) indistinguishable from ARDS.5
A recent multi-centre study compared two different modes
of ventilation in over 800 patients with ARDS.2 Survival in the
group which received a lower tidal volume ventilation strategy
was significantly improved. The inevitable consequence of the
deliberate under-ventilation approach was the development of
significant hypercapnia with a respiratory acidosis apparently
well tolerated. The target saturation of oxygen in arterial blood
(SaO2) of 89–93% was also lower than that often used in current
practice. Low tidal volumes (around 6 ml/kg) and the avoidance
of airway pressures in excess of 30 cm H2O in ventilating this
group have, therefore, been recommended.
Greater use of both positive end-expiratory pressure (PEEP)
and intermittent lung recruitment manoeuvres are also being
increasingly used to improve oxygenation. Both approaches aim
to ‘recruit’ previously collapsed alveoli and then maintain them
as open, gas-exchanging units. Setting PEEP remains a mostly
empirical process with one recent multicentre trial using a simple
table of adjustment based on FiO2. The optimal PEEP level to use
in lung injury remains uncertain. Experimental studies suggest
that PEEP protects against lung injury. However, one large multi-
centre clinical trial found no difference in outcome when two
different levels of PEEP were compared in ARDS. More complex
approaches to adjusting PEEP using bedside recordings of lung
mechanics are possible and are the subject of active research.
In patients with increased airflow resistance, oxygenation is
usually relatively easy to maintain. Gas trapping, due to slow
lung emptying, is a major problem and very high airway pres-
sures can quickly develop. Ventilator settings that prolong expi-
ration are often used in addition to limiting airway pressures. In
severe cases, it may even be necessary to transiently discontinue
ventilation to allow lung emptying to occur and airway pressures
to fall. Attempts to rapidly normalize arterial carbon dioxide
pressure (PaCO2) will lead to gas trapping with barotrauma, and
permissive hypercapnia is often employed.
Weaning, tracheostomy and outcomes
Most ventilated patients can be rapidly and successfully weaned.
However, 5–10% of all patients admitted to intensive care units
will require a prolonged (more than 3 weeks) period of venti-
lation.6 These patients are older, have pre-existing respiratory
and other chronic medical problems, have been more severely ill
and may have underlying chronic neurological conditions. The
majority will have a tracheostomy performed for ease of man-
agement. The indication for and timing of tracheostomy remains
controversial, although a recent systematic review found some
evidence in favour of early tracheostomy. A large multi-centre
study comparing outcome in early tracheostomy against late
tracheostomy is currently being conducted in the UK. Pending
these results, current practice would be to perform the procedure
between 7 to 14 days in patients where prolonged ventilation
seemed likely.
MEDICINE 36:5
Other, evidence-based approaches to weaning are useful.
A number of North American studies have found that non-
doctor-driven weaning protocols reduce ventilation time although
their translation to European practice remains untested. Both
repeated daily trials of spontaneous breathing through a ‘T-piece’
circuit, and gradual reduction of ventilatory assist using pressure
support ventilation (PSV) have been shown to be superior to
SIMV in weaning. Finally, only awake co-operative patients can
be weaned and there is strong evidence that daily cessation of
sedation improves weaning and outcome in the critically ill.
Between 2 and 5% of all ventilated patients will need long-term,
machine-based respiratory assistance for at least part of the day.
These patients should be assessed by a team with experience in the
care and management of long-term ventilation. They may require
further investigations, and chronic neuromuscular diseases need
to be excluded. It is possible to support such ventilator-assisted
individuals in out-of-hospital environments, including their own
homes, but this involves specialist expertise and a multidisciplinary
team. These services are best provided by regional domiciliary ven-
tilation units and there are a number of these in the UK.
Hospital survival of patients requiring prolonged invasive
mechanical ventilation is in the region of 50%, although 3-year
survival may be well below 30%. Outcome is mostly determined
by the initial severity of illness, the number of other organs that
fail, and previous health status. ◆
References
1 Tobin MJ. Advances in mechanical ventilation. N Engl J Med 2001;
344: 1986–96.
2 The Acute Respiratory Distress Syndrome Network. Ventilation with
lower tidal volumes as compared with traditional tidal volumes for
acute lung injury and the acute respiratory distress syndrome.
N Engl J Med 2000; 342: 1301–08.
3 Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory
distress syndrome: a clinical review. Lancet 2007; 369: 1553–64.
4 Davidson AC. The pulmonary physician in critical care. 11: critical
care management of respiratory failure resulting from COPD. Thorax
2002; 57: 1079–84.
5 Tremblay LN, Slutsky AS. Ventilator-induced lung injury: from the
bench to the bedside. Intensive Care Med 2006; 32: 24–33.
6 Baudouin SV, Davidson C, Elliott MW, et al. National Patients Access
Team Critical Care Programme: weaning and long term ventilation.
London: Department of Health, 2002.
Practice points
• Multiple organ dysfunction commonly develop in patients
requiring invasive mechanical ventilation
• Ventilator strategies using low tidal volumes with airway
pressure limitation have been shown to improve survival in
two recent randomised trials in ARDS
• High tidal volumes and airway pressures cause a ventilator-
induced lung injury which is similar to ARDS
• Weaning from invasive ventilation is best achieved by a
protocolized approach involving frequent trials of sedation
cessation with spontaneous or assisted breathing
252 © 2008 Elsevier Ltd. All rights reserved.