CHAPTER 207

MECHANICAL VENTILATION
Joe Esherick

Modern mechanical ventilation was developed out of necessity • High plateau pressures (>30  cm H2O) lead to increased risk
during the polio epidemic of the 1930s. The original machines were of barotrauma (e.g., pneumothorax, pneumomediastinum,
negative-pressure ventilators, known as “iron lungs.” These devices pneumopericardium).
soon became obsolete with the development of positive-pressure • Inadequate head elevation predisposes to ventilator-associated
ventilators during the 1950s. The advent of positive-pressure ven- pneumonia.
tilation ushered in the era of modern-day surgery, anesthesia, and • High positive end-expiratory pressure (PEEP) levels can decrease
critical care medicine. cardiac output, leading to hypotension, and can increase intra-
Mechanical ventilators assist in the oxygenation and ventilation cranial pressure.
of patients. Ventilators improve pulmonary gas exchange and aim • High tidal volume (VT > 10 mL/kg predicted body weight) ven-
to reverse hypoxemia and acute respiratory acidosis. Mechanical tilation may cause ventilator-induced lung injury and acute renal
ventilation also unloads the respiratory muscles and therefore sig- failure.
nificantly decreases the body’s oxygen consumption in both shock • Prolonged mechanical ventilation predisposes to
and respiratory failure. Although positive-pressure ventilation can • Stress gastric ulcers
aid in pulmonary mechanics, it can also lead to ventilator-induced • Subglottic stenosis and tracheomalacia
lung injury if improperly applied. • Sinusitis
• Decubitus pressure ulcers
CLASSIFICATION OF MECHANICAL • Intensive care unit psychosis
VENTILATION
All modern ventilators use positive-pressure ventilation. Positive- TECHNIQUE
pressure ventilation can be administered noninvasively (e.g., bilevel
positive airway pressure [BiPAP] or continuous positive airway pres-
Modes of Ventilation
sure [CPAP] machines); however, this chapter focuses on positive- There are four main modes of ventilation: controlled mode, assist-
pressure ventilation delivered by an endotracheal or tracheostomy control (AC) mode, synchronized intermittent mandatory ventila-
tube. tion (SIMV) mode, and support mode (Table 207-1). Each of these
modes is subclassified into volume-cycled or pressure-cycled methods
INDICATIONS of ventilation.
• Inability to protect one’s airway Controlled Mode
• Hypoxic respiratory failure Controlled ventilation (or intermittent mandatory ventilation) is
• Hypercapnic respiratory failure restricted to use in heavily sedated or paralyzed patients. It is the
• Cardiac arrest principal mode of ventilation used for general anesthesia in the
operating room. This mode will deliver a preset VT at a specified
CONTRAINDICATIONS rate independent of patient effort. The advantage to its use is that
the clinician controls with absolute certainty the patient’s minute
Advanced directives specifying no intubation or resuscitation are
ventilation. However, the disadvantage is that heavy sedation
the contraindications for mechanical ventilation.
is required to prevent the development of patient–ventilator
dyssynchrony.
EQUIPMENT AND SUPPLIES
Assist-Control Mode
• Ventilator
• Ballard suction catheter Assist-control ventilation is capable of both assisted ventilation and
• Suction canister and suction tubing controlled ventilation. If patients are spontaneously breathing, the
• Yankauer suction tip ventilator will synchronize with a patient-initiated breath and
• Bite block or oral airway thereby assist ventilation. If the patient fails to initiate a breath
• Heat and moisture exchanger within a given time (as determined by the preset ventilator rate),
• Ventilator circuit tubing the machine will provide a controlled breath. AC mode can be
• Metered-dose inhaler adapter volume-cycled (volume control), pressure-cycled, (pressure control),
• Bag-valve-mask device or a hybrid of the two (pressure-regulated volume control).
With volume control (VC) ventilation, each AC breath delivers
a preset VT. In other words, both assisted breaths and controlled
PRECAUTIONS breaths receive a preset VT regardless of the pressure required. The
• Using inadequate sedation may lead to patient–ventilator machine ensures that the patient will receive a minimum number
dyssyn­chrony. of breaths per minute, based on the set ventilator rate, even in the

1415
1416 HOSPITALIST

TABLE 207-1  Modes of Ventilation

Synchronized Intermittent
Controlled Assist-Control Mandatory Ventilation Support

Pressure of volume preset Pressure of volume preset Usually volume preset Usually pressure preset
Use in paralyzed patient Use as an initial ventilatory mode Use in spontaneously breathing Use only in spontaneously breathing patient
patient with adequate respiratory drive
Patient receives mandatory preset Patient receives mandatory Patient receives mandatory preset Patient receives no mandatory preset
ventilator rate preset ventilator rate ventilator rate ventilator rate
All breaths are ventilator initiated All spontaneous breaths are Spontaneous breaths are not All spontaneous breaths are ventilator
ventilator assisted ventilator assisted assisted
No spontaneous breathing problems Can be used as a weaning mode Can be used as a weaning mode
From Lapinsky SE, Slutsky AS: Ventilator management. In Wachter RM (ed): Hospital Medicine, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 173–182,
Figure 23.1.

absence of patient effort. An advantage is that this mode requires may be applied to aid respiratory mechanics and achieve an
less patient sedation. However, AC cannot limit the respiratory rate adequate VT.
of patients who have a high spontaneous respiratory rate. Patients
with obstructive lung disease (e.g., chronic obstructive pulmonary
disease [COPD], status asthmaticus) and a rapid respiratory rate may
Ventilator Settings and Terminology
develop air trapping. Air trapping can cause auto-PEEP and poten- • Inspiratory time: The inspiratory time (IT) can be adjusted to
tially barotrauma. change the inspiratory–expiratory (I:E) time ratio. The normal
With pressure control (PC) ventilation, the ventilator delivers I:E ratio is 1 : 2. A decreased IT is often helpful for conditions
gas at a flow rate necessary to achieve a preset peak pressure. As in requiring a prolonged expiratory time, such as severe broncho-
VC, the ventilator synchronizes with patient effort, when present, spasm (e.g., COPD, asthma exacerbations). An increased IT may
and ensures a minimum ventilatory rate. In PC ventilation the peak be indicated for severe hypoxia refractory to high PEEP levels. A
inspiratory pressure (PIP) remains constant, but its major disadvan- significantly prolonged IT is usually very uncomfortable, typically
tage is that the VT varies from breath to breath depending on requires heavy sedation, and may lead to auto-PEEP.
the dynamic lung compliance; therefore, the VT can fall to very • Triggering sensitivity: The triggering sensitivity is the amount of
low levels if the lungs are stiff, which can compromise the minute negative pressure/flow needed to trigger a ventilator-assisted
ventilation. breath. This is set in all ventilator modes while watching patient
Pressure-regulated volume control (PRVC) is a hybrid between effort. The aim is to achieve optimal patient comfort.
VC and PC. PRVC is essentially a volume-cycled mode of ventila- • Positive end-expiratory pressure: PEEP is applied by regulating the
tion with gas flow characteristics similar to those of PC ventilation. pressure in the expiratory limb of the ventilator circuit. The goal
The ventilator will deliver a preset tidal volume with each breath of PEEP is to keep the alveoli open after expiration to increase
using a decelerating flow curve. PRVC allows the delivery of a preset the surface area available for gas exchange. In addition, PEEP can
VT at lower peak and mean airway pressures compared with VC. recruit lung volume by opening closed alveoli; it also raises intra-
The primary disadvantage for all modes of AC ventilation is the thoracic pressure, which can decrease cardiac preload. High levels
potential for developing auto-PEEP. At the same minute ventila- of PEEP (>10 cm H2O) can improve oxygenation so that lower
tion, auto-PEEP occurs with fairly equal frequency in VC, PC, and levels of inspired oxygen (FIO2) can be administered. Further-
PRVC. See the discussion of auto-PEEP, later, for more details. more, a high level of PEEP is often needed during lung-protective
ventilation in patients ventilated either for acute respiratory dis-
tress syndrome (ARDS) or for acute lung injury. PEEP must be
Synchronized Intermittent Mandatory Ventilation Mode
used with extreme caution in shock states or if there is any evi-
Synchronized intermittent mandatory ventilation is a mode of ven- dence of increased intracranial pressure because high levels of
tilation that ensures a preset minimum number of “machine breaths” PEEP can worsen both of these conditions.
while allowing spontaneous patient breaths in between. The venti- • Auto-PEEP: Auto-PEEP occurs when there is inadequate time for
lator waits for a preset time, allowing the patient to breathe spon- expiration. It causes an increase in the functional residual capac-
taneously, and then delivers a “machine breath” synchronized with ity and raises intrathoracic pressure, increasing the risk of baro-
patient inspiratory effort. The main difference between the AC and trauma. Volume-cycled AC modes have a higher risk of auto-PEEP
SIMV modes is that every breath in the AC mode is ventilator compared with the SIMV modes of ventilation. Additional risk
assisted, whereas only a minimum number of breaths per minute are factors include severe bronchospasm, high respiratory rates, and
ventilator assisted in SIMV. SIMV can be administered in VC, PC, a high I:E time ratio.
or PRVC mode; therefore, the ventilator mode can be set as SIMV/ • Tidal volume: A preset VT is used for all volume-cycled modes of
VC, SIMV/PC, or SIMV/PRVC. If necessary, pressure support (PS) ventilation (VC or PRVC). The ventilator displays both an inspi-
or PEEP can be added to assist spontaneous breathing in the SIMV ratory VT and an expiratory VT, which should be the same unless
mode. the circuit is occluded or has a leak. VT should be monitored
closely when ventilating in PS mode.
• Peak inspiratory pressure: The PIP is the maximal airway pressure
Pressure Support Mode
experienced by the patient. The PIP is a measure of dynamic lung
The PS mode is used solely for spontaneously breathing patients. compliance and is a pressure preset in PC mode. The PIP levels
All breaths in this mode are patient-initiated breaths and can vary in volume-cycled ventilation depending on the breath-to-
be augmented by varying degrees of PS. The least amount of PS breath changes in dynamic lung compliance. Causes of a high PIP
that should be added is 6 to 10 cm H2O to overcome the resistance are described later in the discussion of high airway pressures in
of the endotracheal or tracheostomy tube. Higher PS levels the Ventilator Complications section.
 207  ——  MECHANICAL VENTILATION 1417

• Plateau pressure: The plateau pressure (PPLAT) is the airway pres- Rules of Thumb for Mechanical Ventilation
sure measured after an end-inspiratory hold. This pressure reflects
the static lung compliance and is a barometer for the risk of • Adjust ventilation by changing minute volume, to modify the
barotrauma. Every effort should be made to keep the PPLAT partial pressure of arterial carbon dioxide (PaCO2) and pH:
30 cm H2O or less. A patient with a high PPLAT may require a
lower VT (if ARDS), increased sedation (if patient–ventilator Minute volume = respiratory rate × tidal volume (liters)
dyssynchrony), loop diuretics (if congestive heart failure),
or an investigation for abdominal compartment syndrome or • Methods to improve oxygenation are as follows:
pneumothorax. • Increase FIO2 or PEEP first.
• Fraction of inspired oxygen: The FIO2 can vary from 0.21 (room • Increase the IT for refractory hypoxia.
air) to 1.0. The initial ventilator settings typically start with an • Keep PPLAT no greater than 30 cm H2O.
FIO2 between 0.8 and 1.0 until adequate oxygenation is ensured. • Avoid ventilating with VT greater than 10 mL/kg (predicted body
Prolonged administration of an FIO2 greater than 0.6 can lead to weight [PBW]).
oxygen toxicity through formation of oxygen free radicals; there- • Typical VT is 6 to 8 mL/kg (PBW).
fore, every effort is made to wean the FIO2 level down to at least • PBW for men (kg) = 50 + (2.3 × [height in inches – 60]).
0.6 as quickly as possible. • PBW for women (kg) = 45.5 + (2.3 × [height in inches – 60]).
• Avoid paralytics (if possible) because of concerns over critical
illness polyneuropathy.
Initiating Mechanical Ventilation • Sedation during mechanical ventilation should include agents
The steps involved in the initiation of mechanical ventilation and that provide anxiolysis, analgesia, and, ideally, amnesia. Sedation
required monitoring are outlined in Box 207-1. The initial mode of should be titrated to an accepted sedation scale (e.g., the Ramsey
ventilation is usually the AC mode. scale) and continuous sedation should be interrupted on a daily
basis.
• Opiate and benzodiazepine combination.
• Opiate and propofol combination.
• Ketamine and benzodiazepine combination.
Box 207-1.  Initiating Mechanical Ventilation
Weaning from Mechanical Ventilation
1. Choose the mode of ventilation
• AC if very limited patient effort or heavy sedation (VC Weaning from mechanical ventilation involves the transition from
or PRVC) full ventilatory support to spontaneous breathing, and then to even-
• SIMV if some respiratory effort or patient–ventilator tual extubation (Fig. 207-1). There have been numerous approaches
dyssynchrony on AC to ventilator weaning, but none as successful as daily spontaneous
2. Settings for oxygenation breathing trials (SBT). Patients who pass an SBT can be successfully
• Initial FIO2 0.8 to 1.0, adjust according to SaO2 extubated 85% of the time.
• Initial PEEP 5 cm H2O, adjust according to FIO2 Patients should be assessed on a daily basis as to whether
• Aim for SaO2 ≥90%, PaO2 ≥60 mm Hg they are ready for an SBT; in part, this consists of clinicians inter-
• Aim to titrate FIO2 ≤0.6 rupting continuous sedation on a daily basis. Patients should meet
3. Settings for ventilation the following criteria to be ready for an SBT: (1) awake, cooperative,
• Tidal volume: 6 to 10* mL/kg predicted body weight and able to follow commands; (2) clinically stable and preferably
• Ventilator rate: 12 to 16/min, adjust based on PaCO2 off vasopressor medications; (3) the underlying disease leading
and pH (consider initial rate of 20 to 24 in ARDS) to intubation has sufficiently resolved; (4) good gag reflex and a
• Keep plateau pressure ≤30 cm H2O strong cough; (5) minimal pulmonary secretions; (6) spontaneous
4. Additional ventilator settings respirations with a PEEP less than 5 to 8  cm H2O; (7) a partial
• Triggering sensitivity: adjust to minimize patient effort pressure of arterial oxygen (PaO2)/FIO2 ratio of at least 150 to 200;
• I:E ratio: initially 1 : 2, decrease inspiratory time for (8) a pH of at least 7.25; and (9) a rapid shallow breathing index
severe bronchospasm and can increase inspiratory time (RSBI) of less than 105. The RSBI is checked by placing the patient
for refractory hypoxia on CPAP of 5 cm H2O with a PS of 0 cm H2O for 3 minutes and
• Pressure support: if SIMV mode, can adjust between 6 determining the average respiratory rate divided by the VT (in
to 20 cm H2O titrated to patient comfort liters). Patients who have an RSBI greater than 105 fail an SBT
5. Monitoring 95% of the time.
• Continuous cardiopulmonary monitor If the aforementioned criteria are met, an SBT should be
• Ventilator: tidal volume, minute volume, airway performed daily. An SBT can be performed with the patient either
pressures, serial arterial blood gases on a CPAP level of 5  cm H2O and PS of 6 to 8  cm H2O or on a
• ETCO2 monitors desirable for ventilator weaning T-piece with an FIO2 no greater than 0.4 to 0.5. Watch the patient
for 30 to 120 minutes and terminate the SBT if the patient develops
AC, assist-control; ARDS, acute respiratory distress syndrome; any of the following signs of intolerance: respiratory rate greater
ETCO2, end-tidal carbon dioxide; FIO2, fraction of inspired oxygen; than 35/min, arterial oxygen saturation (SaO2) less than 90%,
I:E, inspiratory–expiratory time ratio; PaCO2, partial pressure arterial PaO2 less than 60 mm Hg, heart rate greater than 140/min, systolic
carbon dioxide; PaO2, partial pressure arterial oxygen; PEEP, positive blood pressure greater than 180  mm Hg or less than 90  mm Hg,
end-expiratory pressure; SaO2, arterial oxygen saturation; SIMV, agitation, diaphoresis, increased work of breathing, or a VT less
synchronized intermittent mandatory ventilation; VC, volume than 325 mL (or less than 4 mL/kg PBW). After 30 to 120 minutes,
control; PRVC, pressure-regulated volume control.
*Desire tidal volume 6 to 8 mL/kg predicted body weight.
an arterial blood gas can be drawn to ensure adequate oxygenation
Adapted from Lapinsky SE, Slutsky AS: Ventilator management. and ventilation. A PaCO2 greater than 50  mm Hg (or a greater
In Wachter RM (ed): Hospital Medicine, 2nd ed. Philadelphia, than 10  mm Hg increase) or a PaO2 less than 55  mm Hg (on
Lippincott Williams & Wilkins, 2005, pp 173–182, Figure 23.2. FIO2 = 0.4) would be additional reasons to continue mechanical
ventilation.
1418 HOSPITALIST

Patient is ready for a spontaneous breathing trial if

the following criteria are met:
• Awake, cooperative, and follows commands
• Good gag reflex
• Strong cough
• Minimal secretions
• Hemodynamically stable off vasopressors
• The underlying disease leading to intubation has resolved
• Hemoglobin ≥8 g/dL
• Spontaneously breathing on PEEP <5 to 8
• PaO2/FIO2 ratio ≥150–200 (or SaO2 ≥90% with FIO2 ≤0.4)
• Systemic pH ≥7.25
• Minute ventilation <15 L/minute
• Rapid shallow breath index <105

Spontaneous breathing trial (SBT) Resume mechanical ventilation

• Settings: T-piece or PEEP 5 cm H2O and PS 6 to 8 cm H2O • Search for causes of failure
• Duration: 30 to 120 minutes Daily SBT Malnutrition
• Patient passes SBT if trials Electrolyte abnormalities
RR ≤35 Cardiopulmonary disease
HR <120 to 140/minute Mucous plugging
SBP >90 and <180 mm Hg Oversedation
SaO2 ≥90% or PaO2 ≥55 mm Hg on FIO2 ≤0.4 Neurologic dysfunction
VT ≥4 mL/kg predicted body weight or ≥325 mL (in Fails SBT Underlying disease necessitating mechanical
adults) ventilation has not sufficiently resolved
PaCO2 increase <10 mm Hg • Resume a nonfatiguing mode of ventilation
Absence of agitation, diaphoresis, or increased work of
breathing

Daily ventilator weaning

• Pressure support weaning
Extubate if successful SBT PEEP 5 to 8 cm H2O
PS 6 to 20 cm H2O to keep respiratory rate
<30/minute
Gradually wean PS by 2 to 4 cm H2O as
tolerated
• If patient is unable to tolerate PS ventilation, use
SIMV mode
Slowly reduce backup rate as tolerated

Figure 207-1  Weaning and liberation from mechanical ventilators. FIO2, fraction of inspired oxygen; HR, heart rate; PaCO2, partial pressure of arterial
carbon dioxide; PaO2, partial pressure of arterial oxygen; PEEP, positive end-expiratory pressure; PS, pressure support; RR, respiratory rate; SaO2, arterial
oxygen saturation; SBP, systolic blood pressure; SIMV, synchronized intermittent mandatory ventilation; VT, tidal volume. (Adapted from MacIntyre NR, Cook
DJ, Ely EW Jr, et al: Evidence-based guidelines for weaning and discontinuing ventilatory support. Chest 120[6 Suppl]:375S–395S, 2001.)

• Low airway pressures: A low airway pressure usually means a leak

VENTILATOR COMPLICATIONS in the ventilator circuit. This can be caused by the patient
• High airway pressures: A high airway pressure can be divided into becoming disconnected from the ventilator, a loose tubing con-
conditions associated with a high PIP or conditions associated nection, or a large cuff leak.
with a high PPLAT. The conditions associated with a high PIP, • Hypotension: The causes of hypotension in a ventilated patient
but an unchanged PPLAT, include aspiration, bronchospasm, or can be divided into ventilator-related causes, patient-related
endotracheal tube obstruction (kinking or secretions). Condi- causes, and medication-induced hypotension. The ventilator-
tions that have an elevation in both the PIP and PPLAT include related causes include high PEEP levels, the development of
“bucking the ventilator,” pulmonary edema, pneumothorax, auto-PEEP, or a tension pneumothorax. Patient-related causes
auto-PEEP, severe abdominal distention, ARDS, or chest wall include hypovolemia, a worsening shock state (e.g., septic, car-
noncompliance. “Bucking the ventilator” may be caused by inad- diogenic, anaphylactic), abdominal compartment syndrome, a
equate sedation, paroxysms of coughing, or patient–ventilator massive pulmonary embolus, unstable arrhythmia, or a massive
dyssynchrony. myocardial infarction. Finally, medication-induced hypotension
• Barotrauma: Barotrauma is defined as lung injury due to high may be caused by excessive sedation (e.g., opiates, propofol, ben-
mean airway pressures. It occurs when there is an alveolar leak zodiazepines), medication hypersensitivity response, or the exces-
causing one of the following clinical conditions: pneumomedias- sive use of antihypertensives.
tinum, pneumopericardium, pneumothorax, or subcutaneous • Reversible causes of hypoxia: The reversible causes of hypoxia in a
emphysema. Those at highest risk for barotrauma have one of the ventilated patient can be remembered by the mnemonic CDSPIES
following conditions: very stiff lungs (e.g., in ARDS); severe bron- (Box 207-2). Causes of chronic hypoxia are not included as eti-
chospasm; PPLAT greater than 30 cm H2O; use of a high IT; the ologies. Splinting applies only to spontaneous breathing in a
development of auto-PEEP; and VT greater than 10 mL/kg PBW. support mode when the VT is limited by pain.
 207  ——  MECHANICAL VENTILATION 1419

pressure ulcers of the occiput, sacrum, and heels. Frequent turning

Box 207-2.  Reversible Causes of Hypoxia is imperative.
in Ventilated Patients • Venous thromboembolism: Mechanical ventilation is a risk factor
for venous thromboembolism. All ventilated patients should
C Congestive heart failure receive prophylactic heparin or sequential compression stockings
D Drugs (oversedation leading to hypoventilation in to minimize the risk of a deep venous thrombosis.
spontaneously breathing patients) • Stress gastric ulcers: Mechanical ventilation for longer than 48
S Secretions or splinting (leading to atelectasis in hours places patients at risk for a stress ulcer. Therefore, hista-
spontaneously breathing patients) mine type 2 blockers or proton pump inhibitors should be admin-
P Pneumothorax istered as prophylaxis against the development of a stress gastric
I Infection (ventilator-associated pneumonia) ulcer.
E Embolism (pulmonary embolism) • Ventilator-associated pneumonia: Patients who have required
S Spasm (bronchospasm) mechanical ventilation for longer than 48 hours are at risk for a
ventilator-associated pneumonia. The risk of ventilator-associated
pneumonia can be decreased by performing the following inter-
ventions: raise the head of the bed to 45 degrees, avoid gastric
• High respiratory rates: The most common causes of a high respira- overdistention, minimize ventilator circuit changes/manipulation,
tory rate in a ventilated patient are inadequate sedation, hypoxia, drain ventilator circuit condensate on a regular basis, use appro-
and anxiety. Other causes include a profound metabolic acidosis priate hand disinfection before patient care, consider kinetic bed
with a compensatory stimulus to hyperventilate, neurogenic therapy for prolonged mechanical ventilation, and administer
hyperventilation, a pulmonary embolus, and toxic overdoses twice-daily oral care with chlorhexidine rinses. Selective gut
that stimulate the medullary respiratory center (e.g., salicylate decontamination has a role in trauma patients. Other promising
overdose). interventions include endotracheal tubes with either low-volume/
• Apnea: The most common cause of apnea in a ventilated patient high-compliance cuffs or those that allow for continuous subglot-
is oversedation or the use of paralytics. Other potential causes tic suctioning.
include a central nervous system catastrophe or central sleep
apnea.
• Ventilator-induced lung injury: Ventilator-induced lung injury
results either from shear stress or from overdistention injury.
POSTPROCEDURE MANAGEMENT
Shear stress is caused by the repetitive opening and collapsing of • Check a daily chest radiograph in all endotracheally intubated
alveoli. Overdistention injury results from the prolonged applica- patients.
tion of high-VT ventilation (VT >10 mL/kg PBW). Overdisten- • Assess ventilator settings frequently and adjust accordingly.
tion injury is especially common if there are areas of normal and • Ensure the patient is receiving interventions to prevent decubitus
diseased lung; the normal lung will be preferentially ventilated ulcers, gastric ulcers, a ventilator-associated pneumonia, or a deep
and therefore is at risk of overinflation. Conditions associated venous thrombosis and assess daily for vent complications.
with poor lung compliance, like ARDS, are at highest risk for • Assess patients daily for potential to wean or discontinue ventila-
ventilator-induced lung injury, and therefore are indications for tory support.
the use of lung-protective ventilation (Table 207-2).
• Self-extubation: Self-extubation can occur for several reasons.
First, it can be the inadvertent consequence of moving the
patient without adequate attention to the airway. It can also
CPT/BILLING CODES
occur as a result of inadequate sedation or loose restraints in an 94002 Ventilation assist and management; hospital inpatient/
agitated patient. observation, initial day
• Decubitus pressure ulcers: Patients who have been mechanically 94003 Ventilation assist and management; hospital inpatient/
ventilated for a prolonged period are at risk for development of observation, subsequent days

TABLE 207-2  Protocol for Lung-Protective Ventilation

1.  Assist-control mode with FIO2 = 100%
2.  VT = 8 mL/kg predicted body weight (PBW)
PBW for men (kg) = 50 + [2.3 × (height in inches − 60)]
PBW for women (kg) = 45.5 + [2.3 × (height in inches − 60)]
Decrease VT 1 mL/kg PBW every 1 to 2 hr until VT = 6 mL/kg PBW
3.  Initial respiratory rate typically 12 to 16/min, but can increase up to 35/min
4.  Initial PEEP 5 to 8 cm H2O, and adjust based on PEEP-FIO2 algorithm (see below)
5.  Adjust PEEP and FIO2 to keep PaO2 > 55 mm Hg or SaO2 > 88%
6.  Decrease VT as low as 4 mL/kg PBW if PPLAT >30 cm H2O despite adequate suctioning and sedation
7.  Allow permissive hypercapnia and may use sodium bicarbonate to keep pH > 7.15
PEEP-FIO2 Algorithm for Lung-Protective Ventilation
FIO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 1.0 1.0 1.0
PEEP* 5 5 8 8 10 10 10 12 14 14 14 16 18 18 20 22 24
FIO2, fraction of inspired oxygen; PaO2, partial pressure of arterial oxygen; PEEP, positive end-expiratory pressure; PPLAT, plateau pressure; SaO2, arterial oxygen
saturation; VT, tidal volume.
*PEEP measured in cm H2O.
Adapted from Brower RG, Lanken PN, MacIntyre N, et al, for the ARDS Clinical Trials Network: Higher versus lower positive end-expiratory pressures in patients
with the acute respiratory distress syndrome. N Engl J Med 351:327–336, 2004; and Brower RG, Matthay MA, Morris A, et al, for the ARDS Clinical Trials Network:
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. N Engl J Med 342:1301–
1308, 2000.
1420 HOSPITALIST

94004 Ventilation assist and management; nursing home, per day 785.59 Shock, other (hypovolemic, anaphylactic)
(94002 to 94004 not to be reported with E/M services 99201–99499) 786.09 Hypercapnia
94005 Home ventilator management care plan oversight; in 799.02 Hypoxia
home or assisted living, within a calendar month, ≥30 799.1 Respiratory arrest
minutes
(94005 code not to be reported with 99339–99340 or 99374–99378)
SUPPLIERS
(See contact information online at www.expertconsult.com.)
ICD-9-CM DIAGNOSTIC CODES Maquet Critical Care AB
Puritan Bennett
276.2 Acidosis Siemens
276.3 Alkalosis
276.4 Acid-base mixed disorder
427.5 Cardiac or cardiorespiratory arrest BIBLIOGRAPHY
428.1 Congestive heart failure, left-sided Brower RG, Matthay MA, Morris A, et al, for the ARDS Clinical Trials
491.20 Chronic obstructive bronchitis, without exacerbation Network: Ventilation with lower tidal volumes as compared with tradi-
491.21 Chronic obstructive bronchitis, with or without emphy- tional tidal volumes for acute lung injury and acute respiratory distress
sema, with acute exacerbation syndrome. N Engl J Med 342:1301–1308, 2000.
492.8 Emphysema, NOS Lapinsky SE, Slutsky AS: Ventilator management. In Wachter RM (ed):
493.01 Asthma, extrinsic with status asthmaticus Hospital Medicine, 2nd ed. Philadelphia, Lippincott Williams & Wilkins,
493.90 Asthma, unspecified with status asthmaticus 2005, pp 173–182.
518.5 Pulmonary insufficiency following trauma and surgery MacIntyre NR: Assist-control mechanical ventilation. In Fink MP,
518.81 Acute respiratory failure, NOS Abraham E, Vincent J-L, Kochanek P (eds): Textbook of Critical Care,
5th ed. Philadelphia, Saunders, 2005, pp 497–518.
518.82 Respiratory distress, acute
MacIntyre NR, Cook DJ, Ely EW Jr, et al: Evidence-based guidelines
518.83 Respiratory failure, chronic for weaning and discontinuing ventilatory support. Chest 120(6 Suppl):
780.01 Coma 375S–395S, 2001.
785.50 Shock, unspecified, without mention of trauma Markowitz DH, Irwin RI: Mechanical ventilation: Initiation and discontinu-
785.51 Shock, cardiogenic ation. In Irwin RI, Rippe JM (eds): Manual of Intensive Care Medicine,
785.52 Shock, septic 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 301–311.