HMC/UW Lung Day

May 29, 2009

Selected References:

What I’ve Learned about Mechanical Ventilation

David J Pierson MD

Metnitz PG, Metnitz B, Moreno RP, et al; SAPS 3 Investigators. Epidemiology of mechanical ventilation: analysis of the SAPS 3 database. Intensive Care Med. 2009 May;35(5):816-25.

Study of how mechanical ventilation was carried out in 13,322 patients admitted to 299 intensive care units ICUs in 35 countries. The variation in nearly every variable studied was substantial. For example, in Australasia, nearly 70% of patients were managed on either SIMV or SIMV+PSV; in Northern Europe, 85% were managed on either PCV or PSV; in North America, nearly 70% were managed on either CMV or assist-control.

Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008 Nov 13;359(20):2095-104.

This study found that adjusting PEEP using esophageal pressure measurements to determine transpulmonary pressure, which resulted in PEEP levels on average 7 cm H₂O higher than in the control group managed according to the ARDS Net PEEP-FIO₂ ladder, was associated with better oxygenation (by P/F ratio) and compliance. Other studies have shown better oxygenation with higher PEEP but no improvement in outcomes, so further, larger studies need to be done before this more invasive approach can be recommended for general clinical use.

Kallet RM. The legacy of the NIH ARDS Net. Respir Care 2009 Jul;54(7):in press.

A comprehensive review of the findings of the various multicenter trials on the management of acute lung injury and ARDS carried out to date by the ARDS Net.

Hill NS, Brennan J, Garpestad E, Nava S. Noninvasive ventilation in acute respiratory failure. Crit Care Med. 2007 Oct;35(10):2402-7.

State-of-the-art review of efficacy of NIV in different clinical settings. Its use is urged, with level “A” evidence, in COPD exacerbations, acute cardiogenic pulmonary edema, acute hypoxemic respiratory failure in immunocompromised patients, and as a bridge to weaning in intubated COPD patients. The usefulness of NIV in other settings is less clear, and in extubation failure it may actually be harmful.

Hess DR. How to initiate a noninvasive ventilation program: bringing the evidence to the bedside. Respir Care. 2009 Feb;54(2):232-43; discussion 243-5.

This is the best article I know of on how to make NIV work in your institution. NIV can save lives and decrease hospital costs but there is a substantial learning curve and making it really work requires a multidisciplinary effort as well as some system changes.

Hough CL. Neuromuscular sequelae in survivors of acute lung injury. Clin Chest Med. 2006 Dec;27(4):691-703

A review of the increasing evidence for neuromuscular weakness as a major complication of critical illness, particularly ARDS.

Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008 Oct 8;300(14):1685-90.

In many ICUs patients with critical illness are kept in bed until they leave the unit. However, mobilizing them much earlier improves several important outcomes, including decreased complications and lower costs.

Epstein SK. Weaning from ventilatory support. Curr Opin Crit Care. 2009 Feb;15(1):36-43.

A good recent review.