Cooley/DeBakey
Joint Session
Michael A. Norman, MD,
FACS
Presented at the Joint
Session of the Denton
A. Cooley Cardiovascular
Surgical Society and the
Michael E. DeBakey
International Surgical
Society; Austin, Texas,
10–13 June 2010
Section Editor:
Joseph S. Coselli, MD
From: Division of Surgery,
Michael E. DeBakey
Department of Surgery,
Baylor College of Medicine,
Houston, Texas 77030
Address for reprints:
Michael A. Norman, MD,
FACS, Division of Surgery,
Michael E. DeBakey
Department of Surgery,
Baylor College of Medicine,
Suite 404D, One Baylor
Plaza, Houston, TX 77030
E-mail:
mnorman@bcm.edu
© 2010 by the Texas Heart ®
Institute, Houston
Texas Heart Institute Journal
Ventilator Management
in the Surgical
Intensive Care Unit
I
nvasive mechanical ventilation at its most basic level provides support for intubat-
ed patients during critical illness. Along with this goes the ability to affect pulmo-
nary gas exchange, to relieve respiratory distress, and to improve lung expansion.
Adult Respiratory Distress Syndrome (ARDS) was first described in the late 1960s
as a constellation of respiratory failure, cyanosis refractory to supplemental oxygen,
decreased lung compliance, noncardiogenic pulmonary edema, and bilateral pulmo-
nary infiltrates.1 Each year, approximately 150,000 new cases of ARDS arise in both
medical and surgical patients, and, in some series, the mortality rate continues to be
as high as 30%.2 Since its initial description by Ashbaugh and colleagues,1 ARDS is
now recognized not just as an isolated pulmonary process, but as the result of a sys-
temic inflammatory response to sepsis that leads to the development of pulmonary
edema. The American-European Consensus Conference on ARDS met in 1994 and
defined ARDS as a constellation involving the following hallmarks 3:
1) Acute onset of symptoms;
2) Ratio of arterial oxygen to fraction of inspired oxygen (Pao2/FIo2) <200 mmHg;
3) Bilateral infiltrates on frontal chest radiograph; and
4) Pulmonary artery wedge pressure ≤18 mmHg (or no clinical evidence of left atri-
al hypertension).
It has further been recognized that the disease process can be broken down into
multiple components that ultimately end in tissue damage at the alveolar level. As a re-
sult of inflammatory mediators, leukocytes adhere to the basement membrane, move
across it, and then degranulate, triggering microvascular thrombosis and ultimately
increasing pulmonary vascular resistance, increasing shunt, decreasing compliance,
and worsening V/Q mismatch.
In the late 1990s, the ARDSnet study 4 showed an 8.8% absolute mortality de-
crease when a lower (6 mL/kg body weight) tidal volume and plateau pressure (Pplat
≤30 cmH2O) was used for mechanical ventilation—compared with a traditional (12
mL/kg body weight) tidal volume and plateau pressure (Pplat ≤50 cmH2O). In addi-
tion, study investigators found deceased ventilator length of stay, lower interleukin-6
(IL-6) levels in the blood, and less multisystem organ failure.4
Current goals seen in the literature focus on limiting lung damage (by preventing
overdistention of stiff lung), limiting cyclical collapse, reopening alveolar units, and
maximizing oxygen delivery. Two modes of mechanical ventilation are very useful for
these goals: bilevel ventilation and airway pressure release ventilation (APRV). These
fall under the “open lung” concept of ventilation, which focuses on the following 5:
1) Pressure control to limit airway pressures and prevent overdistention, as well as
to prevent the cyclical opening and closing of alveolar units;
2) Manipulation of the inspiratory:expiratory ratio with use of inverse-ratio venti-
lation, which enables higher mean airway pressure and the recruitment of col-
lapsed alveoli; and
3) The ability of the patient to breathe spontaneously, which results in increased pa-
tient comfort and synchrony with the ventilator.
Bilevel ventilation sets a range for positive end-expiratory pressure (from PEEPHigh
to PEEPLow). Inspiratory and expiratory times can be manipulated as well, enabling
Ventilator Management in the Surgical ICU 681
inverse-ratio ventilation in which short expiratory times
enable ventilation and longer inspiratory times encour-
age recruitment of alveoli, thus facilitating oxygenation.
Bilevel ventilation and APRV are essentially 2 levels of
continuous positive airway pressure that allow a mix-
ture of spontaneous and ventilator-mandated breaths.
These 2 pressure levels are the PEEPHigh and PEEPLow
settings. The timing of the cycle is referred to as time
high (TH ) and time low (TL ). The difference between
PEEPHigh and PEEPLow serves as the driving force for ven-
tilation and can be adjusted to deliver a tidal volume of
6 to 8 cc/kg in accordance with the ARDSnet guide-
lines (Fig. 1). As alveoli are recruited and the lungs be- Fig. 2 The upper (gray arrow) and lower (red arrow) inflection
come more compliant, this number might need to be points on a pressure–volume curve are shown. Above the upper
adjusted so that excessive tidal volumes are avoided. A inflection point, where the curve flattens out, there is a risk of
tidal volume that maintains a pH of greater than 7.25 is alveolar overdistention. At pressures less than the lower inflection
point, some alveoli will not remain open during the respiratory
sufficient in most patients. The PEEPLow setting is deter- cycle. In this graph, green represents inspiration and yellow rep-
mined, ideally, by identifying the inflection point on a resents expiration. Reproduced by permission of Diane McCabe,
pressure–volume curve, so that alveolar collapse is pre- RRT, RCP (Ben Taub General Hospital, Houston).
vented (Fig. 2). Paw = airway pressure; VT = tidal volume
Beyond lung-protective ventilator measures, there
are techniques that involve positioning the patient in
a manner that reduces V/Q mismatch. These are rota-
tional (or kinetic) therapy and prone positioning. Rota- ry pressure needed to open collapsed alveoli, decrease
tional therapy involves turning the patient at least 42° to the end-expiratory pressure needed to keep alveoli open,
each side for variable periods of time, which can help to and reduce the cyclical opening and closing of alveoli.
open atelectatic lung segments. Some of the beneficial
effects of rotational or prone positioning may be con- References
sequent to relieving compression from the heart. Albert
and Hubmayr 6 found that up to 40% of the left lung 1. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute res­
piratory distress in adults. Lancet 1967;2(7511):319-23.
is under the heart when the patient was supine, versus 2. Navarrete-Navarro P, Ruiz-Bailen M, Rivera-Fernandez R,
less than 1% when prone. Relieving the compression Guerrero-Lopez F, Pola-Gallego-de-Guzman MD, Vazquez-
of the viscera on the lungs may decrease the inspirato- Mata G. Acute respiratory distress syndrome in trauma pa-
tients: ICU mortality and prediction factors. Intensive Care
Med 2000;26(11):1624-9.
3. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hud-
son L, et al. The American-European Consensus Conference
on ARDS. Definitions, mechanisms, relevant outcomes, and
clinical trial coordination. Am J Respir Crit Care Med 1994;
149(3 Pt 1):818-24.
4. Ventilation with lower tidal volumes as compared with tra-
ditional tidal volumes for acute lung injury and the acute res­
piratory distress syndrome. The Acute Respiratory Distress
Syndrome Network. N Engl J Med 2000;342(18):1301-8.
5. Stawicki SP, Goyal M, Sarani B. High-frequency oscillatory
ventilation (HFOV) and airway pressure release ventilation
(APRV): a practical guide. J Intensive Care Med 2009;24(4):
215-29.
6. Albert RK, Hubmayr RD. The prone position eliminates
compression of the lungs by the heart. Am J Respir Crit Care
Fig. 1 The PEEPHigh and PEEPLow settings are shown. The differ- Med 2000;161(5):1660-5.
ence between the 2 settings creates the driving pressure for
ventilation. Inspiration occurs during PEEPHigh time, and expiration
occurs when the lungs deflate during PEEPLow time. Throughout
the respiratory cycle, the patient is able to breathe spontaneously
as depicted. Reproduced by permission of Diane McCabe, RRT,
RCP (Ben Taub General Hospital, Houston).
APRV = airway pressure release ventilation; PEEP = positive
end-expiratory pressure

682 Ventilator Management in the Surgical ICU Volume 37, Number 6, 2010