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John J. Marini Alain F. Broccard University of Minnesota Regions Hospital Minneapolis / St. Paul USA Advanced Mechanical Ventilation
Advanced Mechanical Ventilation Outline   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Consequences of Elevated Alveolar Pressure--1   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Partitioning of Alveolar Pressure is a Function  of Lung and Chest Wall Compliances Lungs are smaller and pleural pressures are higher when the chest wall is stiff.
Hemodynamic Effects of Lung Inflation   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hemodynamic Effects of Lung Inflation   With Low Lung Compliance, High Levels of  PEEP are Generally Well Tolerated.
Effect of lung expansion on pulmonary vasculature .  Capillaries that are embedded in the alveolar walls undergo compression even as interstitial vessels dilate. The net result is usually an increase in pulmonary vascular resistance, unless recruitment of collapsed units occurs.
Conflicting Actions of Higher Airway Pressure   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Gas Extravasation  Barotrauma
Diseased Lungs Do  Not Fully Collapse, Despite Tension Pneumothorax … and  They cannot always  be  fully  “opened” Dimensions of a fully  Collapsed  Normal  Lung
Tension Cysts
Tidally Phasic Systemic Gas Embolism   End-Expiration End-Inspiration
Consequences of Elevated Alveolar Pressure--2   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Recognized Mechanisms of Airspace Injury   “ Stretch” “ Shear” Airway Trauma
Mechanisms of Ventilator-Induced Lung Injury (VILI)   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
End-Expiration Tidal Forces  (Transpulmonary and Microvascular Pressures) Extreme   Stress/Strain Moderate   Stress/Strain Mechano signaling via integrins, cytoskeleton, ion channels inflammatory cascade Cellular Infiltration   and  Inflammation Rupture Signaling Marini / Gattinoni CCM 2004 Pathways to VILI
Microvascular Fracture in ARDS A Portal for  Gas & Bacteria? Hotchkiss  et al Crit Care Med  2002; 1  
The Problem of Heterogeneity   ,[object Object],[object Object],[object Object],[object Object]
Spectrum of Regional Opening Pressures  (Supine Position) Superimposed Pressure ( from Gattinoni ) Lung Units at Risk for Tidal  Opening & Closure = Inflated 0 Alveolar Collapse (Reabsorption) 20-60 cmH 2 O Small Airway Collapse 10-20 cmH 2 O Consolidation  Opening Pressure
Different lung regions may be overstretched or underinflated, even as measures of total lung mechanics appear within normal limits. Alveolar Pressure Lung Volume UPPER  LUNG TOTAL  LUNG LOWER  LUNG
Recruitment Parallels Volume As A  Function of Airway Pressure   Recruitment and  Inflation (%) Frequency Distribution of  Opening Pressures (%) Airway Pressure (cmH2O)
% Opening and Closing Pressures in ARDS 50 High pressures may be needed to open some lung units, but once open, many units stay open at lower pressure. Paw [cmH 2 O] 0 5 10 15 20 25 30 35 40 45 50 0 10 20 30 40 Opening pressure Closing  pressure From Crotti et al AJRCCM 2001.
Zone of ↑  Risk
Dependent to Non-dependent  Progression of Injury
Histopathology of VILI   Belperio et al, J Clin Invest Dec 2002; 110(11):1703-1716
Links Between VILI and MSOF   Biotrauma and Mediator De-compartmentalization Slutsky,  Chest  116(1):9S-16S
Airway Orientation in Supine Position
 
Prone Positioning Evens The Distribution of Pleural & Transpulmonary Pressures
Prone Positioning Relieves Lung Compression by the Heart   Supine Prone
Proning May Benefit the Most Seriously Ill ARDS Subset SAPS II Mortality Rate > 49 40- 49 31- 40 0 - 31 0.0 0.1 0.2 0.3 0.4 0.5 Quartiles of SAPS II Supine * p<0.05 vs Supine Prone *
Proning Helped Most in High V T  Subgroup At Risk For VILI   V T /Kg < 8.2 8.2- 9.7 9.7- 12 > 12  0.0 0.1 0.2 0.3 0.4 0.5 Mortality Rate Quartiles of V T  /Predicted body weight Supine * p<0.05 vs Supine Prone *
How Much Collapse Is Dangerous Depends on the Plateau   R = 100% 20 60 100 Pressure [cmH 2 O] 20 40 60 Total Lung Capacity [%] R = 22% R = 81% R = 93% 0 0 R = 0% R = 59% From Pelosi et al AJRCCM 2001 Some potentially recruitable units open only at high pressure More Extensive  Collapse But  Lower P PLAT Less Extensive  Collapse But  Greater P PLAT
Recruiting Maneuvers in ARDS   ,[object Object],[object Object],[object Object]
Theoretical   Effect of Sustained Inflation on Tidal Cycling   Rimensberger  ICM  2000 VOLUME (% TLC) Benefit from a recruiting maneuver is usually transient if PEEP remains   unchanged afterward.
Three Types of Recruitment Maneuvers S-C Lim, et al  Crit Care Med   2004
How is the Injured Lung Best Recruited?   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Severe Airflow Obstruction   ,[object Object],[object Object],[object Object],[object Object]
Auto-PEEP Adds To the Breathing Workload   The pressure-volume areas correspond to the inspiratory mechanical workloads of auto-PEEP (AP) flow resistance and tidal elastance.
Gas Trapping in Severe Airflow Obstruction   ,[object Object],[object Object],[object Object],[object Object]
 
Volume Losses in Recumbent Positions   Note that COPD patients lose much less lung volume than normals do, due to gas trapping and need to keep the lungs more inflated to minimize the severity of obstruction. Orthopnea may result.
PEEP in Airflow Obstruction   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Inhalation Lung Scans in the Lateral Decubitus Position for a Normal Subject and COPD Patient   Normal COPD No PEEP  PEEP 10  Addition of 10 cm H 2 O PEEP re-opens dependent airways in COPD
PEEP Flow Limitation “Waterfall”
Adding PEEP that approximates auto-PEEP may reduce the difference in pressure between alveolus (Palv) and airway opening, thereby lowering the negative pleural   (Pes) pressure needed to begin inspiration and trigger ventilation.
Adding PEEP Lessens the Heterogeneity of End-expiratory Alveolar Pressures and Even the Distribution of Subsequent Inspiratory Flow.
PEEP may offset  (COPD) or add to auto-PEEP (Asthma), depending on flow limitation. Note that adding 8 cmH2O PEEP to 10 cmH2O of intrinsic PEEP may either reduce effort (Pes, solid arrow) or cause further hyper-inflation (dashed arrow). Ranieri et al,  Clinics in Chest Medicine  1996; 17(3):379-94 ASTHMA COPD
Conventional Modes of Ventilatory Support The traditional modes of mechanical ventilation—Flow-regulated volume Assist Control (“Volume Control”, AMV, AC)) or Pressure-Targeted Assist Control (“Pressure Control”), Synchronized Intermittent Mandatory Ventilation (SIMV)—with flow or pressure targeted mandatory cycles), Continuously Positive Airway Pressure (CPAP) and Pressure Support can be used to manage virtually any patient when accompanied by adequate sedation and settings well adjusted for the patient’s needs.  Their properties are discussed in the “Basic Mechanical Ventilation” unit of this series.
Positive Airway Pressure Can Be Either Pressure or Flow Controlled—But Not Both Simultaneously   Dependent Variable Dependent Variable Set Variable Set Variable
Decelerating flow profile is an option in flow controlled ventilation  but a dependent variable in pressure control. Decelerating Flow Pressure Control Peak pressure is a function of flow; plateau pressure is not
Patient-Ventilator Interactions   ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pressure Support ‘off-switch’ is a set flow value or a set % of  peak inspiratory flow. The patient with airflow obstruction may need  to put on the brake with muscular effort to slow flow quickly enough  to satisfy his intrinsic neural timing.
Tapered inspiratory ‘attack’ rate and a higher percentage of peak flow off switch criterion are often more appropriate in airflow obstruction than are the default values in PSV. Airflow Obstruction
Although early flows are adequate, mid-cycle efforts may not be matched by Decelerating Flow Control (VCV). Pressure Controlled breaths (PCV) do not restrict flow. Since the flow demands of severely obstructed patients may be nearly unchanging in severe airflow obstruction , decelerating VCV may not be the best choice.
Interactions Between Pressure Controlled Ventilation and Lung Mechanics ,[object Object],[object Object],[object Object],[object Object]
Alveolar  Pressure Airway  Pressure Residual Flows
 
P aw  Reflects Effort and Dys-Synchrony During Constant Flow Ventilation Deformed Airway Pressure Waveforms
High Pressure Alarm Variable Tidal Volume or Pressure Limit Alarm During Pressure Control
What to Do When the Patent and Ventilator are “Out of Synch”?   ,[object Object],[object Object],[object Object],[object Object]
Advanced Interactive Modes of  Mechanical Ventilation   ,[object Object],[object Object],[object Object],[object Object],[object Object]
Combination “Dual Control” Modes   ,[object Object],[object Object],[object Object],[object Object]
Combination “Dual Control” Modes   ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pressure Regulated Volume Control Characteristics   ,[object Object],[object Object],[object Object]
Compliance Changes During Pressure Controlled Ventilation
PRVC Automatically Adjusts To Compliance Changes
Several modes allow the physician to allow for variability in patient efforts while achieving a targeted goal. Volume support monitors minute ventilation and tidal volume , changing the level of pressure support to achieve a volume target. Volume assured pressure support allows the patient to breathe with pressure support, supplementing the breath with constant flow when needed to achieve the targeted tidal volume within an allocated time.  Proportional assist (see later) varies pressure output in direct relation to patient effort.
Airway Pressure Release and Bi-Level Airway Pressure ,[object Object],[object Object],[object Object]
Inverse Ratio Airway Pressure Release (APRV), and Bi-Level (Bi-PAP)
Bi-Pap &Airway Pressure Release Characteristics ,[object Object],[object Object],[object Object],[object Object]
Unlike PCV, BiPAP Allows Spontaneous Breathing During Both Phases of Machine’s Cycle
Bi-Level Ventilation
Bi-Level Ventilation With Pressure Support
Modes That Vary Their Output to Maintain Appropriate Physiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Proportional Assist Ventilation (PAV) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Proportional Assist Amplifies Muscular Effort Muscular effort (P mus ) and  airway pressure assistance  (P aw ) are better matched  for  Proportional Assist (PAV) than for Pressure Support  (PSV).
Goals of Adaptive Support Ventilation ,[object Object],[object Object],[object Object],[object Object]
Adaptive Lung Ventilation ,[object Object],[object Object],[object Object],[object Object]
 
Neural Control of Ventilatory Assist (NAVA) ,[object Object],[object Object],[object Object]
Neural Control of Ventilatory Assist (NAVA) Neuro-Ventilatory Coupling Central Nervous System  Phrenic Nerve  Diaphragm Excitation  Diaphragm Contraction  Chest Wall and Lung Expansion  Airway Pressure, Flow and Volume New Technology Ideal Technology Current Technology Ventilator Unit
Electrode Array in Neurally Adjusted Ventilatory Assist (NAVA) Sinderby et al,  Nature Medicine ; 5(12):1433-1436
NAVA Provides Flexible Response to Effort Volume P AW D GM  EMG Sinderby et al,  Nature Medicine ; 5(12):1433-1436
Automatic Tube Compensation ,[object Object],[object Object],[object Object],[object Object],[object Object]
External and Tracheal Pressures Differ Because of Tube Resistance ATC offsets a fraction of tube resistance
Valve Control Maintains  Tracheal  Pressure During ATC Pressure Support Pressure Support ATC ATC Fabry et al, ICM 1997;23:545-552
ATC Adjusts Inspiratory Pressure to Need Postop Critically Ill
Discontinuation of Mechanical Ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Preparation: Factors Affecting Ventilatory Demand
 
The frequency to tidal volume ratio (or rapid shallow breathing index, RSBI) is a simple and useful integrative indicator of the balance between power supply and power demand. A rapid shallow breathing index < 100 generally indicates adequate power reserve. In this instance, the RSBI indicated that spontaneous breathing without pressure support was  not   tolerable, likely due in part to the development of gas trapping. Even when the mechanical requirements of the respiratory system can be met by adequate ventilation reserve, congestive heart failure, arrhythmia or ischemia may cause failure of spontaneous breathing.
Integrative Indices Predicting Success
Measured Indices Must Be Combined With Clinical Observations
Three Methods for Gradually Withdrawing Ventilator Support Although the majority of patients do not require gradual withdrawal of ventilation, those that do tend to do better with graded pressure supported weaning than with abrupt transitions from Assist/Control to CPAP or with SIMV used with only minimal pressure support.
Extubation Criteria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Advanced Mechanical Ventilation

  • 1. John J. Marini Alain F. Broccard University of Minnesota Regions Hospital Minneapolis / St. Paul USA Advanced Mechanical Ventilation
  • 2.
  • 3.
  • 4. Partitioning of Alveolar Pressure is a Function of Lung and Chest Wall Compliances Lungs are smaller and pleural pressures are higher when the chest wall is stiff.
  • 5.
  • 6. Hemodynamic Effects of Lung Inflation With Low Lung Compliance, High Levels of PEEP are Generally Well Tolerated.
  • 7. Effect of lung expansion on pulmonary vasculature . Capillaries that are embedded in the alveolar walls undergo compression even as interstitial vessels dilate. The net result is usually an increase in pulmonary vascular resistance, unless recruitment of collapsed units occurs.
  • 8.
  • 9. Gas Extravasation Barotrauma
  • 10. Diseased Lungs Do Not Fully Collapse, Despite Tension Pneumothorax … and They cannot always be fully “opened” Dimensions of a fully Collapsed Normal Lung
  • 12. Tidally Phasic Systemic Gas Embolism End-Expiration End-Inspiration
  • 13.
  • 14. Recognized Mechanisms of Airspace Injury “ Stretch” “ Shear” Airway Trauma
  • 15.
  • 16. End-Expiration Tidal Forces (Transpulmonary and Microvascular Pressures) Extreme Stress/Strain Moderate Stress/Strain Mechano signaling via integrins, cytoskeleton, ion channels inflammatory cascade Cellular Infiltration and Inflammation Rupture Signaling Marini / Gattinoni CCM 2004 Pathways to VILI
  • 17. Microvascular Fracture in ARDS A Portal for Gas & Bacteria? Hotchkiss et al Crit Care Med 2002; 1 
  • 18.
  • 19. Spectrum of Regional Opening Pressures (Supine Position) Superimposed Pressure ( from Gattinoni ) Lung Units at Risk for Tidal Opening & Closure = Inflated 0 Alveolar Collapse (Reabsorption) 20-60 cmH 2 O Small Airway Collapse 10-20 cmH 2 O Consolidation  Opening Pressure
  • 20. Different lung regions may be overstretched or underinflated, even as measures of total lung mechanics appear within normal limits. Alveolar Pressure Lung Volume UPPER LUNG TOTAL LUNG LOWER LUNG
  • 21. Recruitment Parallels Volume As A Function of Airway Pressure Recruitment and Inflation (%) Frequency Distribution of Opening Pressures (%) Airway Pressure (cmH2O)
  • 22. % Opening and Closing Pressures in ARDS 50 High pressures may be needed to open some lung units, but once open, many units stay open at lower pressure. Paw [cmH 2 O] 0 5 10 15 20 25 30 35 40 45 50 0 10 20 30 40 Opening pressure Closing pressure From Crotti et al AJRCCM 2001.
  • 23. Zone of ↑ Risk
  • 24. Dependent to Non-dependent Progression of Injury
  • 25. Histopathology of VILI Belperio et al, J Clin Invest Dec 2002; 110(11):1703-1716
  • 26. Links Between VILI and MSOF Biotrauma and Mediator De-compartmentalization Slutsky, Chest 116(1):9S-16S
  • 27. Airway Orientation in Supine Position
  • 28.  
  • 29. Prone Positioning Evens The Distribution of Pleural & Transpulmonary Pressures
  • 30. Prone Positioning Relieves Lung Compression by the Heart Supine Prone
  • 31. Proning May Benefit the Most Seriously Ill ARDS Subset SAPS II Mortality Rate > 49 40- 49 31- 40 0 - 31 0.0 0.1 0.2 0.3 0.4 0.5 Quartiles of SAPS II Supine * p<0.05 vs Supine Prone *
  • 32. Proning Helped Most in High V T Subgroup At Risk For VILI V T /Kg < 8.2 8.2- 9.7 9.7- 12 > 12 0.0 0.1 0.2 0.3 0.4 0.5 Mortality Rate Quartiles of V T /Predicted body weight Supine * p<0.05 vs Supine Prone *
  • 33. How Much Collapse Is Dangerous Depends on the Plateau R = 100% 20 60 100 Pressure [cmH 2 O] 20 40 60 Total Lung Capacity [%] R = 22% R = 81% R = 93% 0 0 R = 0% R = 59% From Pelosi et al AJRCCM 2001 Some potentially recruitable units open only at high pressure More Extensive Collapse But Lower P PLAT Less Extensive Collapse But Greater P PLAT
  • 34.
  • 35. Theoretical Effect of Sustained Inflation on Tidal Cycling Rimensberger ICM 2000 VOLUME (% TLC) Benefit from a recruiting maneuver is usually transient if PEEP remains unchanged afterward.
  • 36. Three Types of Recruitment Maneuvers S-C Lim, et al Crit Care Med 2004
  • 37.
  • 38.
  • 39. Auto-PEEP Adds To the Breathing Workload The pressure-volume areas correspond to the inspiratory mechanical workloads of auto-PEEP (AP) flow resistance and tidal elastance.
  • 40.
  • 41.  
  • 42. Volume Losses in Recumbent Positions Note that COPD patients lose much less lung volume than normals do, due to gas trapping and need to keep the lungs more inflated to minimize the severity of obstruction. Orthopnea may result.
  • 43.
  • 44. Inhalation Lung Scans in the Lateral Decubitus Position for a Normal Subject and COPD Patient Normal COPD No PEEP PEEP 10 Addition of 10 cm H 2 O PEEP re-opens dependent airways in COPD
  • 45. PEEP Flow Limitation “Waterfall”
  • 46. Adding PEEP that approximates auto-PEEP may reduce the difference in pressure between alveolus (Palv) and airway opening, thereby lowering the negative pleural (Pes) pressure needed to begin inspiration and trigger ventilation.
  • 47. Adding PEEP Lessens the Heterogeneity of End-expiratory Alveolar Pressures and Even the Distribution of Subsequent Inspiratory Flow.
  • 48. PEEP may offset (COPD) or add to auto-PEEP (Asthma), depending on flow limitation. Note that adding 8 cmH2O PEEP to 10 cmH2O of intrinsic PEEP may either reduce effort (Pes, solid arrow) or cause further hyper-inflation (dashed arrow). Ranieri et al, Clinics in Chest Medicine 1996; 17(3):379-94 ASTHMA COPD
  • 49. Conventional Modes of Ventilatory Support The traditional modes of mechanical ventilation—Flow-regulated volume Assist Control (“Volume Control”, AMV, AC)) or Pressure-Targeted Assist Control (“Pressure Control”), Synchronized Intermittent Mandatory Ventilation (SIMV)—with flow or pressure targeted mandatory cycles), Continuously Positive Airway Pressure (CPAP) and Pressure Support can be used to manage virtually any patient when accompanied by adequate sedation and settings well adjusted for the patient’s needs. Their properties are discussed in the “Basic Mechanical Ventilation” unit of this series.
  • 50. Positive Airway Pressure Can Be Either Pressure or Flow Controlled—But Not Both Simultaneously Dependent Variable Dependent Variable Set Variable Set Variable
  • 51. Decelerating flow profile is an option in flow controlled ventilation but a dependent variable in pressure control. Decelerating Flow Pressure Control Peak pressure is a function of flow; plateau pressure is not
  • 52.
  • 53. Pressure Support ‘off-switch’ is a set flow value or a set % of peak inspiratory flow. The patient with airflow obstruction may need to put on the brake with muscular effort to slow flow quickly enough to satisfy his intrinsic neural timing.
  • 54. Tapered inspiratory ‘attack’ rate and a higher percentage of peak flow off switch criterion are often more appropriate in airflow obstruction than are the default values in PSV. Airflow Obstruction
  • 55. Although early flows are adequate, mid-cycle efforts may not be matched by Decelerating Flow Control (VCV). Pressure Controlled breaths (PCV) do not restrict flow. Since the flow demands of severely obstructed patients may be nearly unchanging in severe airflow obstruction , decelerating VCV may not be the best choice.
  • 56.
  • 57. Alveolar Pressure Airway Pressure Residual Flows
  • 58.  
  • 59. P aw Reflects Effort and Dys-Synchrony During Constant Flow Ventilation Deformed Airway Pressure Waveforms
  • 60. High Pressure Alarm Variable Tidal Volume or Pressure Limit Alarm During Pressure Control
  • 61.
  • 62.
  • 63.
  • 64.
  • 65.
  • 66. Compliance Changes During Pressure Controlled Ventilation
  • 67. PRVC Automatically Adjusts To Compliance Changes
  • 68. Several modes allow the physician to allow for variability in patient efforts while achieving a targeted goal. Volume support monitors minute ventilation and tidal volume , changing the level of pressure support to achieve a volume target. Volume assured pressure support allows the patient to breathe with pressure support, supplementing the breath with constant flow when needed to achieve the targeted tidal volume within an allocated time. Proportional assist (see later) varies pressure output in direct relation to patient effort.
  • 69.
  • 70. Inverse Ratio Airway Pressure Release (APRV), and Bi-Level (Bi-PAP)
  • 71.
  • 72. Unlike PCV, BiPAP Allows Spontaneous Breathing During Both Phases of Machine’s Cycle
  • 74. Bi-Level Ventilation With Pressure Support
  • 75.
  • 76.
  • 77. Proportional Assist Amplifies Muscular Effort Muscular effort (P mus ) and airway pressure assistance (P aw ) are better matched for Proportional Assist (PAV) than for Pressure Support (PSV).
  • 78.
  • 79.
  • 80.  
  • 81.
  • 82. Neural Control of Ventilatory Assist (NAVA) Neuro-Ventilatory Coupling Central Nervous System  Phrenic Nerve  Diaphragm Excitation  Diaphragm Contraction  Chest Wall and Lung Expansion  Airway Pressure, Flow and Volume New Technology Ideal Technology Current Technology Ventilator Unit
  • 83. Electrode Array in Neurally Adjusted Ventilatory Assist (NAVA) Sinderby et al, Nature Medicine ; 5(12):1433-1436
  • 84. NAVA Provides Flexible Response to Effort Volume P AW D GM EMG Sinderby et al, Nature Medicine ; 5(12):1433-1436
  • 85.
  • 86. External and Tracheal Pressures Differ Because of Tube Resistance ATC offsets a fraction of tube resistance
  • 87. Valve Control Maintains Tracheal Pressure During ATC Pressure Support Pressure Support ATC ATC Fabry et al, ICM 1997;23:545-552
  • 88. ATC Adjusts Inspiratory Pressure to Need Postop Critically Ill
  • 89.
  • 90. Preparation: Factors Affecting Ventilatory Demand
  • 91.  
  • 92. The frequency to tidal volume ratio (or rapid shallow breathing index, RSBI) is a simple and useful integrative indicator of the balance between power supply and power demand. A rapid shallow breathing index < 100 generally indicates adequate power reserve. In this instance, the RSBI indicated that spontaneous breathing without pressure support was not tolerable, likely due in part to the development of gas trapping. Even when the mechanical requirements of the respiratory system can be met by adequate ventilation reserve, congestive heart failure, arrhythmia or ischemia may cause failure of spontaneous breathing.
  • 94. Measured Indices Must Be Combined With Clinical Observations
  • 95. Three Methods for Gradually Withdrawing Ventilator Support Although the majority of patients do not require gradual withdrawal of ventilation, those that do tend to do better with graded pressure supported weaning than with abrupt transitions from Assist/Control to CPAP or with SIMV used with only minimal pressure support.
  • 96.