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Journal of Pharmacy Practice

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Mechanical Ventilation : Introduction for the Pharmacy Practitioner


Michael J. Cawley
Journal of Pharmacy Practice 2011 24: 7 originally published online 30 November 2010
DOI: 10.1177/0897190010388145
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New York State Council of Health-system Pharmacists

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Critical Care Medicine

Mechanical Ventilation: Introduction


for the Pharmacy Practitioner

Journal of Pharmacy Practice


24(1) 7-16
The Author(s) 2011
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0897190010388145
http://jpp.sagepub.com

Michael J. Cawley, PharmD, RRT, CPFT1

Abstract
Mechanical ventilation is a common therapeutic modality required for the management of patients unable to maintain adequate
intrinsic ventilation and oxygenation. Mechanical ventilators can be found within various hospital and nonhospital environments
(ie, nursing homes, skilled nursing facilities, and patients home residence), but these devices generally require the skill of a
multidisciplinary health care team to optimize therapeutic outcomes. Unfortunately, pharmacists have been excluded in the
discussion of mechanical ventilation since this therapeutic modality may be perceived as irrelevant to drug utilization and the
usual scope of practice of a hospital pharmacist. However, the pharmacist provides a crucial role as a member of the
multidisciplinary team in the management of the mechanically ventilated patient by verifying accuracy of prescribed
medications, providing recommendations of alternative drug selections, monitoring for drug and disease interactions, assisting
in the development of institutional weaning protocols, and providing quality assessment of drug utilization. Pharmacists may
be intimidated by the introduction of advanced ventilator microprocessor technology, but understanding and integrating
ventilator management with the pharmacotherapeutic needs of the patient will ultimately help the pharmacist be a better
qualified and respected practitioner. The goal of this article is to assist the pharmacy practitioner with a better understanding
of mechanical ventilation and to apply this information to improve delivery of pharmaceutical care.
Keywords
mechanical ventilation, pharmacist

Introduction
Mechanical ventilators are medical devices that provide an artificial means of ventilatory support. They are routinely used in
various health care settings including hospitals, long-term care
facilities, ambulance, and mobile intensive care units (ICUs),
life flight, and helicopter transport. Also their routine use maintains patient independence during wheelchair ambulation and
within home environments suitable for patients with chronic
respiratory diseases. The technology of these medical devices
has progressed from rudimentary electronic controls to integrated microprocessor-controlled devices that respond and
adapt to patient ventilatory needs to optimize gas exchange.
Education of mechanical ventilation primarily occurs from
health care providers intimately involved with the bedside care
of the patient including pulmonary critical care physicians/
intensivists and other multidisciplinary team members including respiratory therapists and critical care nurses. Pharmacists
routinely encounter patients on mechanical ventilation and
require a better understanding of the terminology and fundamentals of ventilator settings, which may ultimately effect drug
therapy utilization. Limited data have been published in the
pharmacy literature discussing mechanical ventilation.1-3 The
inclusion of pharmacists during the discussion of the ventilator
plan of the patient provides expert knowledge of

pharmacological agent delivery including appropriate drug


selection, accurate dose and dose titration, and monitoring of
agents that may impede ventilator weaning outcomes.
This article will assist the pharmacy practitioner with a
better understanding to integrate and apply basic principles
of mechanical ventilation with pharmaceutical care delivery for
the mechanically ventilated patient.

History of Mechanical Ventilation


The history of mechanical ventilation can be traced back to the
term artificial respiration identified in Biblical, Egyptian
and Greek references. Artificial respiration continued to be
experimented with throughout history until the early 19th century, with the development of the iron lung. The iron lung
was the first practical mechanical ventilator device that
1
Philadelphia College of Pharmacy, University of the Sciences in Philadelphia,
Philadelphia, PA, USA

Corresponding Author:
Michael J. Cawley, Department of Pharmacy Practice and Pharmacy
Administration, Philadelphia College of Pharmacy, University of the Sciences
in Philadelphia, 600 South 43rd Street, Philadelphia, PA 19104, USA
Email: m.cawley@usp.edu

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Journal of Pharmacy Practice 24(1)

improved patient outcomes including patient survival during


the poliomyelitis epidemics in the mid-1950s.4,5 This device
was a airtight metal cylindrical tank that required the patient
to be placed inside in the supine position. The patients head
was exposed out of the device. Negative pressure then was generated with a mechanical pump to make the patients chest rise.
Although this device was lifesaving for many patients, it was
very clumsy and impractical based upon its crude mechanical
design. Other devices then spawned from this method of ventilation included cuirass devices which required the patient upper
torso to be encased into a crude shell or compartment that also
worked based upon the negative-pressure model. These devices
had limited utility but some models are still utilized around the
world for patients with neuromuscular diseases who require
ventilatory support.
In the 1970s, respiratory critical care medicine changed with
the advent of rudimentary computer microprocessor positivepressure ventilators. These devices including the Bennett
MA-I (Puritan-Bennett Corp., Kansas City, Missouri) and the
Ohio 560 (Ohio Medical Products, Madison, Wisconsin)
offered many advantages including ventilator mode selection,
fraction of inspired oxygen (FIO2) adjustment setting, intermittent physiological sigh breath to limit atelectasis, positive
end-expiratory pressure (PEEP), inspiratory humidification,
and multiple alarm systems. These devices had the ability for
the medical professional to change multiple ventilator parameters and interface with patient ventilatory requirements.
In the 20th century, mechanical ventilators are now
equipped with more advanced microprocessor controls which
augment pressure and flow waveforms to interface and synchronize with patient ventilatory requirements. These devices
will continue to evolve to provide the most advanced technology in the modern age of respiratory medicine.

adequate airway protection. Invasive delivery methods require


the introduction of an artificial device to be placed into the
upper airway (ie, endotracheal [ET], nasotracheal, or tracheostomy tube). Once the artificial airway is properly placed and
location verified by radiographic evidence, the patient may
now be initiated on mechanical ventilation.

Basics of Mechanical Ventilation


Pharmacists must first become familiar with common terminology and basic mechanical functioning associated with the use
of mechanical ventilators. Appendix A provides a summary
of mechanical ventilation terminology including abbreviations,
meanings, and definitions associated with the use of mechanical ventilators. Mechanical ventilator breaths are delivered to
the patient by an integration of both triggering (what initiates
the ventilator support breath) and cycling (what ends the ventilator support breath). Ventilator breaths are traditionally classified as volume, pressure, or time cycled. These forms of
cycling all occur when the inspiratory phase begins and gas
flows through the ventilator circuit into the patients lungs.
Volume cycling ends when a predetermined volume is delivered, pressure cycling ends when a predetermined pressuresensing mechanism in the ventilator reaches a preset level, and
time-cycling ends when a timing mechanism in the ventilator
reaches a preset duration. The final result is a ventilator breath
that is delivered with either volume or pressure. A more
detailed review of mechanical ventilation focused as a tutorial
for pharmacists can provide additional information.1
Traditionally, the first parameter that must be chosen for initial implementation of mechanical ventilation is the mode of
ventilation. Despite this fact, other basic parameters must be
clarified before explaining how the mode of ventilation is integrated with the following ventilator parameters.

Indications for Mechanical Ventilation


Mechanical ventilation is primarily required for patients unable
to maintain adequate alveolar ventilation, resulting in respiratory failure. Respiratory failure can be categorized as hypoxic
or hypercapnic. Hypoxic respiratory failure is inability of the
patient to maintain adequate oxygenation which is measured
by both the partial pressure of oxygen in the arterial blood
(PaO2) and the saturation of oxygen in arterial blood (SaO2).
Inability to correct tissue hypoxemia with the highest amounts
of FIO2 (100%) requires the need for positive pressure ventilation.
Hypercapnic respiratory failure is defined as the inability to
maintain adequate ventilation, or as an increased partial pressure
of carbon dioxide in the arterial blood (PaCO2). Increases in PaCO2
result in progressive respiratory acidosis, also require the need
for positive pressure ventilation. Other pulmonary parameters
for assessing the need for mechanical ventilation have been
published but are beyond the scope of this article.6,7
Mechanical ventilation may be administered by either an
invasive or a noninvasive delivery method. Invasive methods
are required for emergent situations in which airway access and
stabilization is required and for patients unable to maintain

Tidal Volume
The tidal volume is the volume of air inhaled then passively
exhaled in a normal respiratory cycle.8 The tidal volume breath
is set based upon the patients ideal body weight and has
traditionally ranged from 4 to 12 mL/kg.9 Data have also
recommended tidal volume variations including lower volumes
of 4 to 8 mL/kg for patients with restrictive lung disease to limit
peak alveolar pressures and 8 to 10 mL/kg for patients with
obstructive lung disease to limit air trapping.9 Lower tidal
volumes are also proposed for acute lung injury (ALI) and adult
respiratory distress syndrome (ARDS) to limit its effects in
causing barotrauma or volutrauma to alveoli.10 Despite controversy in determining the most optimum tidal volume setting,
most clinicians select an initial tidal volume of 5 to 10 mL/kg.

Respiratory Rate
The respiratory rate is the number of preset tidal volume
breaths the patient will receive per minute. Traditionally,
mechanical ventilator respiratory rates may range from 0 to

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Cawley

60 breaths/min. Clinicians initiating mechanical ventilation


may arbitrarily start the initial respiratory rate between 10 and
20 breaths/min. After approximately 20 to 30 minutes, an arterial blood gas sample would then be drawn from the patient. The
resulted PaCO2 and pH would require a change in the ventilator
respiratory rate. If the patient is experiencing hyperventilation
(# PaCO2), a decrease in the preset respiratory rate would be
warranted to raise the PaCO2; if hypoventilation is occurring
(" PaCO2), an increase in the preset respiratory rate would be
warranted to decrease the PaCO2.

Flow Rate
The inspiratory flow rate is the volume of gas that is delivered to
the patients lungs per unit of time. Inspiratory flow rate is
expressed in liters/minute and the setting can ultimately determine the inspiratory/expiratory (I:E) ratio of the respiratory cycle.
The normal I:E is 1:2, but patients with severe pulmonary
critical care illness (eg, ARDS) may require an inverse I:E of
2:1 or 4:1. A longer inspiratory time may be required to recruit
damaged or compromised pulmonary alveoli to improve
oxygenation and alveolar ventilation. The inspiratory flow rate
is traditionally started at 40 to 60 L/min but may require an
increase or decrease to achieve an optimal I:E ratio based upon
the patients pulmonary condition.

Fraction of Inspired Oxygen


The FIO2 is the percentage of oxygen that can be delivered to
the patient during a mechanical ventilator breath or patient
breath. The FIO2 can range from 21% (environmental or room
air) to 100%. During initial implementation of mechanical ventilation, the FIO2 is traditionally initiated at 100% if the
patients oxygenation status is unknown. Arterial blood gas
analysis is performed 20 to 30 minutes after the FIO2 change.
Repeated arterial blood gases would only be required to monitor the arterial PaCO2 and pH since these ventilation parameters
may be affected by changes in the respiratory rate. If the clinician is only concerned about the degree of hypoxemia, then
subsequent oxygenation monitoring can be done using a pulse
oximeter to measure the SaO2 in a noninvasive method. A disadvantage of this device is it may produce inconsistent results
in patients with compromised peripheral perfusion.
A common concern of oxygen therapy is the potential for
oxygen toxicity. Oxygen has shown to cause the formation of
oxygen metabolites and reactive mediators. Oxygen exposure
to an FIO2 of 40% or higher for up to 30 days is associated with
fibrinitic changes to the pulmonary system.11 Although data
has demonstrated that oxygen has some degree of inflicting
pulmonary changes, the use should not be discouraged for
patients who require treatment of arterial hypoxemia.

Positive End-Expiratory Pressure


PEEP refers to positive pressure that is maintained within the
lungs after the exhalation phase of a mechanical ventilator

breath. The primary role for PEEP is to increase the functional


residual capacity (FRC) of the alveoli. Increasing the FRC
increases the surface area of the alveoli, allowing greater surface area for oxygen to transfer into the pulmonary circulation.
The result is increasing oxygenation including improvements
in PaO2 and SaO2. PEEP is traditionally added for patients
unable to attain adequate PaO2 or SaO2 values on FIO2 concentrations greater than 50%. The value of adding PEEP is an
oxygen-sparing effect where the potential of oxygen toxicity
is decreased with the need of lower FIO2 requirements. PEEP
is usually begun at 5 cm H2O pressure and is increased in
2.5 cm H2O increments to achieve the optimum PaO2 goal.
PEEP levels usually range from 5 to 10 cm H2O but may
exceed greater than 20 cm H2O (super PEEP) for the most
critically ill patients.
PEEP improves oxygenation delivery but also has negative
adverse effects including potential for pneumothorax and
hemodynamic instability. Pneumothorax may develop due to
excessive intrathoracic pressure. Hemodynamic instability is
induced due to decreased cardiac venous return. Patients may
require greater pharmacological support to optimize hemodynamics during PEEP including aggressive fluid resuscitation
and/or vasopressor initiation.

Traditional Modes of Mechanical Ventilation


Despite the availability of several advanced modes of ventilator
support, there are still fundamental modes that all ventilators
have in common. The focus of this review is to focus on these
fundamental modes including assist-control ventilation (A/C),
synchronized intermittent mandatory ventilation (SIMV),
pressure-control ventilation (PCV), pressure-support ventilation (PSV), and continuous positive airway pressure (CPAP).
Noninvasive ventilation will discuss CPAP and bilevel positive
airway pressure (BiPAP). Figures 1 and 2 provide a basic
understanding of airway pressure waveforms created during
traditional modes of invasive and noninvasive mechanical
ventilation.

Assist-Control Ventilation
Assist-control (A/C) is one of the most common volume-cycled
modes selected for patients requiring invasive mechanical ventilation. During A/C, the clinician sets a predetermined tidal
volume and respiratory rate but the patient is able to selfinitiate additional tidal volume breaths. The self-initiated
breath occurs due to the negative pressure generated by the
patient within the ventilator tubing. To receive this selfinitiated breath, the clinician must set a triggering threshold
or sensitivity. The sensitivity is traditional set at 2 cm H2O
pressure. Once the patient inhales and reaches this preset sensitivity value, the ventilator will deliver the preset tidal volume
breath. If the patient is unable to generate a self-initiated breath
due to excessive pharmacological sedation or other physiological processes inhibiting or ceasing respiration, the patient is
guaranteed to receive the preset tidal volume and respiratory

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Journal of Pharmacy Practice 24(1)

+30
A/C

Note negative inspiratory(I) pressure to trigger


the assist-control breath.

0
I

5
+30
SIMV

0
I

SIMV

SIMV

SIMV

Note spontaneous breathing


(I -inspiration + E -expiration) between SIMV
breaths. Note negative pressure deflection
triggeredby the patient, which initiates the
SIMV breath.

+30
PCV

Note regular time intervals of machine pressure


control breaths.

0
5

+30
PSV

Note negative inspiratory pressure (I) initiating the


PSV breath. Downward arrow indicates the pressure
plateau of a PSV breath. Upward arrow indicates the
termination of the PSV breath.

Figure 1. Pressure waveforms of traditional modes of invasive positive pressure ventilation. A/C indicates assist-control ventilation; SIMV,
synchronized intermittent mandatory ventilation; PCV, pressure control ventilation; PSV, pressure support ventilation. Modified from reference 1.
+15
+5
*CPAP

Note CPAP (+5) is maintained during spontaneous


breathing.

IPAP

IPAP

IPAP

+15
+5
BiPAP

EPAP

EPAP

EPAP

Note IPAP (+15) is the PSV value and EPAP (+5) is


the CPAP value.

Figure 2. Pressure waveforms of traditional modes of noninvasive positive pressure ventilation. CPAP indicates continuous positive airway
pressure; BiPAP, bilevel positive airway pressure; IPAP, inspiratory positive airway pressure; EPAP, expiratory positive airway pressure; PSV,
pressure support ventilation; *CPAP is also used during invasive positive pressure ventilation as a ventilator weaning mode.

rate. If the patient is unable to generate an A/C breath, then the


mode would be referred to as control-mode ventilation (CMV).
CMV (eg, machine controlled) and A/C (eg spontaneous support) are technical variations of each other. CMV and A/C

deliver the same tidal volume and respiratory rate, but CMV
does not allow the patient to self-initiate a breath.
A/C mode is often started as the initial mechanical ventilator
mode due to simplicity and familiarity by clinicians. This mode

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11

is very effective but it does come with limitations in its use


including the potential for hyperventilation, resulting in
excessive minute ventilation. A preset tidal volume (mL) 
respiratory rate (breaths/minute or bpm) equals minute
ventilation (eg, 0.7 L  14 bpm 9.8 L/min). If the patient
begins to self-initiate additional tidal volume breaths due to
experiencing pain, anxiety, or other etiologies, the result
may be hyperventilation and respiratory alkalosis (eg, 0.7 L
 25 bpm 17.5 L/min). Clinicians that prefer limiting
pharmacological interventions to decrease respiratory drive
may consider changing the ventilator mode to SIMV.

Synchronized Intermittent Mandatory Ventilation


SIMV is another common volume-cycled mode of mechanical
ventilation. SIMV is similar to A/C in that the patient receives a
preset tidal volume and respiratory rate, but the key difference
is the patients own respiratory rate is synchronized with the
SIMV ventilator rate. As the patient receives the preset tidal
volume and respiratory rate, the patient is able to breathe at
their own tidal volume between each preset ventilator breath.
The result is the patient can spontaneously breathe between
each of the preset tidal volume supported breaths. Some clinicians prefer this mode since the ventilator not only delivers preset tidal volume breaths but allows the patient to contribute to
their own respiratory effort. Allowing the patient to contribute
to their own respiratory effort improves respiratory muscle
exercise and conditioning.12 A potential disadvantage of SIMV
is when the patient respiratory muscle conditioning is exceeding above and beyond what is capable for the patient. This will
lead to increased work of breathing, respiratory fatigue, and
ultimately respiratory failure, inhibiting weaning from
mechanical ventilation. Either limiting the patients time on
SIMV or adding PSV to SIMV may limit respiratory fatigue
and improve ventilator weaning outcomes.
Before the introduction of SIMV, IMV (Intermittent Mandatory Ventilation) was the primary mode of choice. IMV and
SIMV again are technical variations of each other. The only
difference between IMV and SIMV is that SIMV allows the
patients spontaneous breathing pattern to be synchronized with
the SIMV rate. Due to this advancement, SIMV has replaced
IMV in modern mechanical ventilators.

Pressure-Control Ventilation
PCV is a time-cycled pressure-cycled mode that provides a
constant pressure throughout the inspiratory phase. PCV is
often required for patients unable to maintain adequate oxygenation or ventilation goals during volume-controlled ventilation (A/C or SIMV) or may also be initiated in patients
experiencing increased peak airway pressures during volumecontrolled ventilation. The most critically ill pulmonary
patients including ARDS and ALI may require PCV to achieve
oxygenation and ventilatory goals. A major limitation of this
form of ventilation is it requires excessive sedation, and possible pharmacological paralysis, to optimize oxygenation and

ventilation. Also, there is always the potential for pulmonary


complications including pneumothorax due to excessive intrapulmonary pressures.

Pressure Support Ventilation


PSV provides a preset pressure assistance that is delivered
during each spontaneous patient breath. The primary purpose
of this mode of ventilation is to overcome airway resistance
of the ET tube and to decrease ventilator tubing dead space.
Both airway resistance and ventilator tubing dead space are
primary etiologies that lead to an increase in the work of
breathing. As a result, failure to wean from mechanical ventilation is increased. PSV can be used alone for weaning from
mechanical ventilation or it can be used in combination with
other modes (SIMV) to assist the patient during periods of
spontaneous breathing. If used alone, PSV is delivered with
each spontaneous patient breath. If used with SIMV, PSV
is only applied during spontaneous breaths taken between
ventilator-mandated breaths. Clinicians initially set the pressure support by increasing the pressure until the patient
achieves the desired expired tidal volume. If the patient
requires initial higher pressure support levels (eg, 20 cm
H2O), then progressive weaning of pressure support will be
required for removal of mechanical ventilation. Extubation
and removal of mechanical ventilation will be considered
once the patient is breathing comfortably and has reached a
final PSV level of 6 to 8 cm H2O.13

Continuous Positive Airway Pressure


CPAP is a preset pressure level that is maintained within the
pulmonary system throughout the respiratory cycle. CPAP
requires a patient to provide and maintain a continuous respiratory effort. This mode may be initiated in different ways based
upon the ventilator manufacturer but traditionally the ventilator
respiratory rate is set to 0 to prevent any controlled ventilator
breaths from being initiated. Once the respiratory rate is set
to 0 then CPAP is added. Levels of 5 cm H2O are traditionally
started to maintain physiological pulmonary pressure above
atmospheric pressure. CPAP can be either administered alone
or combined with PSV (eg, CPAP 5cm H2O PSV 10 cm
H2O). During spontaneous ventilation, the patient will receive
CPAP to maintain continuous airway pressure to optimize
alveolar ventilation and PSV to provide a present pressure level
during each spontaneous patient breath to decrease the work of
breathing. CPAP alone or with PSV are the primary ventilator
modes used to promote ventilator weaning and mechanical
ventilation discontinuation.

Advanced Modes of Mechanical


Ventilation
Mechanical ventilators have evolved to integrate both computer microprocessor technologies with ventilatory requirements for the patient. Many ventilator manufacturers have

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Journal of Pharmacy Practice 24(1)

incorporated new forms of advanced modes of mechanical


ventilation for their products. Unfortunately, there is limited
scientific data to support the routine use of these advanced
modes in daily clinical practice. Examples of advanced modes
of ventilation include biphasic intermittent positive airway
pressure, mandatory minute ventilation, proportional assist
ventilation, adaptive support ventilation, pressure regulated
volume control, high-frequency oscillatory ventilation, and
airway pressure release ventilation. Until more scientific data
are published in regard to the efficacy of one advanced mode
over another, these modes will continue to be used as rescue
therapy or when other traditional ventilator modes fail.

Modes of Noninvasive Mechanical


Ventilation
Noninvasive mechanical ventilation or noninvasive positive
pressure ventilation (NIPPV) is a form of ventilation initiated
for patients who require assistance in optimizing pulmonary
gas exchange including patient with obstructive sleep apnea,
respiratory failure induced by acute exacerbations of chronic
obstructive pulmonary disease (COPD), and acute respiratory
failure caused by acute pulmonary edema.14,15 NIPPV has the
advantages to avoid many of the complications of ET intubation including oversedation, airway trauma, and ventilatorassociated pneumonia.16,17 The primary form of NIPPV is
BiPAP because of its ability to integrate both inspiratory and
expiratory positive airway pressures to optimize pulmonary gas
exchange. A secondary NIPPV mode is CPAP. Both forms of
NIPPV require the patient to wear an anatomically appropriate
mask or nasal device. Patients require the skill of a respiratory
therapist to select and custom fit the best device to achieve and
maintain optimum performance and patient comfort.

Bilevel Positive Airway Pressure


BiPAP is a form of NIPPV that utilizes and cycles both inspiratory (I) and expiratory (E) pressure to achieve optimum ventilatory outcomes. The inspiratory pressure is considered the
PSV, and the expiratory pressure is the CPAP level. BiPAP
is clinically indicated for patients with chronic stable or progressive respiratory failure (preventing the need for ET intubation), which may include patients with COPD exacerbations,
acute pulmonary edema, asthma, pneumonia, or for patients
who refuse ET intubation.
Physician prescribing BiPAP may transcribe the written
orders with the following abbreviation format: BiPAP I10/E4.
The designation I10 refers to the inspiratory pressure (pressure
support) level of 10 cm H2O and E4 refers to the expiratory pressure (CPAP) level of 4 cm H2O. To begin BiPAP, the patient is
placed in a sitting position and inclined at approximately 45 . As
the inspiratory and expiratory pressures are initiated, the mask is
then gently placed over the patients nose or mouth and fitted for
comfort. Patients are usually started at an inspiratory pressure of
8 to 10 cm H2O and expiratory pressure of 4 to 6 cm H2O. The
BiPAP device can also be set for a backup mandatory ventilator

respiratory rate (4-12 bpm) for patients who may experience


apnea. Oxygen can be titrated into the BiPAP circuit between
0.5 and 6 L/min for patients requiring supplemental treatment for
tissue hypoxia.

Continuous Positive Airway Pressure


As previously discussed, CPAP is primarily used as a weaning
mode for patients during invasive mechanical ventilation but
can also be used as a very effective NIPPV strategy. CPAP traditionally has been implemented for common BiPAP pulmonary indications but is more commonly used for adult patients
with a diagnosis of moderate-to-severe obstructive sleep
apnea.18 Obstructive sleep apnea is primarily diagnosed with
nocturnal sleep study testing. The optimum CPAP pressure is
selected based upon the results of the sleep study test results,
which may have included periods of oxygen desaturation or
increased apnea periods. After the patient is custom fitted for
the appropriate mask or nasal device, the CPAP level is usually
initiated at 2.5 to 15 cm H2O. Oxygen may be titrated into the
CPAP circuit between 0.5 and 6 L/min for patients requiring
supplemental treatment for tissue hypoxia.
Both CPAP and BiPAP devices, although very effective, are
not without their limitations. The primary limitation of CPAP
devices is compliance with their use. Patients may discontinue
or abandon the use of their CPAP devices due to discomfort,
noise level, or potential discouragement of intimacy with a
sleeping partner. Compliance rates for utilizing nocturnal positive airway pressure vary throughout the literature based upon
the definition of adequate adherence. A comprehensive review
of CPAP literature published prior to 2003 found noncompliance rates to vary from 5% to 50%, with an average of 20%.19

Humidification
Inspired air enters through the nostrils and passes over the
warm ciliated mucous layer before passing into the nasopharynx. This process maintains a hydroscopic foundation to maintain mucous viscosity and assistance to transport foreign
inhaled material. During mechanical ventilation, patients may
require oxygen or other compressed air source gases. Since
these compressed gas sources are dry, they require humidification before delivery to the patient. Humidification is accomplished utilizing heated systems such as a heated pass over
humidification source or nonheated source such as a
heatmoisture exchange system. Both systems provide advantages and disadvantages. Heated pass over systems may potentially harbor and colonize bacterial organisms and require
frequent sterilization. Heatmoisture exchange systems which
are connected at the end of the ventilator tubing to the ET tube
may become occluded with pulmonary secretions, thus
resulting in increased airway pressures and work of breathing.

Alarms
Mechanical ventilators require safeguards to prevent malfunction and potential harm to the patient. These machines are

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13

equipped with a multitude of electronic alarms that must be set,


checked visually, and checked for auditory sound and documented. Respiratory care departments have specific protocols
to provide this safeguard. Alarms include low/high pressure,
apnea, patient disconnect, low/high FIO2, low/high respiratory
rate, and low/high minute volume.

Complications of Invasive and


Noninvasive Mechanical Ventilation
Invasive mechanical ventilation may be associated with numerous complications including mechanical, physiologic, and operator error. Mechanical complications include simple
malfunction of the device or improper setting of alarms. Physiologic complications include lung overinflation (volutrauma or
barotraumas), leading to pneumothorax, oxygen toxicity, health
care-associated pneumonia (hospital and ventilator), sinusitis,
gastrointestinal complications, neuromuscular weakness, delirium, and cardiovascular instability.1 Also, complications of the
artificial airway including hard and soft palate injuries, vocal
cord dysfunction or paralysis, soft tissue injury to the oral cavity,
tracheal stenosis, and self-extubation.20 Many of these complications are primarily caused by the inflatable cuff located at the
distal portion of the ET or tracheostomy tube. The ET cuff is a
low-pressure cuff device that is required to maintain an airtight
seal between the ET or tracheostomy tube and the tracheal soft
tissue. The cuff is inflated to a pressure range of 10 to 20 cm
H2O. Overinflation of this cuff or maintaining exceedingly high
pressures can cause increased pressure on tracheal capillaries
leading to ischemia and potentially tracheal stenosis or rupturing
of the cuff. ET or tracheostomy cuff rupture requires immediate
intervention for replacement. ET and tracheostomy tubes should
be checked periodically for proper function which includes
maintaining adequate cuff pressures.
Noninvasive mechanical ventilation complications may
occur particularly through mechanical or operator error, but
patients are able to respond and simply discontinue the use of
the device (CPAP or BiPAP) until properly serviced. Subtle
physiological complications can occur including drying out
of the nasal mucosa, abdominal distention and flatulence, and
tissue irritation due to improperly fitted mask or nasal device.

Aerosol Therapy
Patients receiving both invasive and noninvasive mechanical
ventilation may require aerosol therapy. Aerosol therapy may
be administered by an aerosol generator such as a jet nebulizer
or metered dose inhaler (MDI). Both aerosol delivery devices
may assist in the delivery of beta agonists, anticholinergics,
antimicrobials, or other pharmacological agents. Despite the
advantages and disadvantages of both devices, there are several
factors that influence drug delivery to the mechanically ventilated patient. For an in-depth review, the reader is referred to a
1997 publication by Dhand and Tobin.21
Although all host factors are important, it is unlikely that
they will change for most patients (eg, ET size, tidal volume,

pressure waveform, device including MDI or nebulizer). One


exception may include the introduction of humidification into
the ventilator circuit during aerosol administration. Data have
identified that the administration of heated humidified air during pharmacological aerosol delivery using a MDI can decrease
the amount of drug delivered to the smaller airways as much as
40%.21 Although significant decrease in the amount of drug
delivered to the smaller airways is evident, experts recommend
not shutting off heated humidification during aerosol MDI
treatment. Rationale includes forgetting to reinitiate the heated
aerosol, thus, potentially leading to pulmonary mucosa water
loss, exacerbating pulmonary mucous retention. Experts agree
that dosing of beta agonists and anticholinergic agents via MDI
should be increased to 4 to 6 puffs every 3 to 6 hours for stable
mechanically ventilated patients and higher doses may be
required for patients experiencing bronchospasm.22
MDI propellants are presently changing from chlorofluorocarbon (CFC) to hydrofluoroalkanes (HFA) due to effects of
depleting environmental ozone.23 HFA have demonstrated
similar drug deposition to the bronchi compared to CFC agents.
Optimization of drug delivery to the lower respiratory tract via
MDI is to add a spacer device approximately 15 cm from the
ET tube and coordinate the MDI actuation with the beginning
of ventilator inspiration.24 Connecting a nebulizer approximately 18 cm from the patient wye (connection from the end
of the ventilator tubing to the ET tube) also optimizes drug
delivery.25 The majority of adult ICUs prefer MDI over jet
nebulizer because of convenience, more consistent dosing, and
reduced chance of bacterial infection.26 In regard to pharmacoeconomics, older data have suggested MDIs to be more
cost-effective than jet nebulizers; however, this may not be true
in transitioning from CFC-MDIs to HFA-MDIs. Prospective
clinical trials are needed to assess this issue between HFA
MDIs and jet nebulizers in mechanically ventilated patients.

Weaning From Invasive Mechanical


Ventilation
Weaning and discontinuing of invasive mechanical ventilation
is the ultimate goal for the patient. Weaning indicates gradual
cessation of all mandated ventilator support. Traditionally, clinicians have chosen one of a variety of techniques either alone or
in combination for weaning a patient from invasive mechanical
ventilation including SIMV or IMV, CPAP, PSV, or a spontaneous breathing trial (SBT) administered once per day or intermittently several trials per day.27 SBT can be done by having the
patient breathe via a T-piece which allows the patient to be
disconnected from the ventilator and breathing through the ET
tube connected to a humidified oxygen supply. Another popular
SBT method is for the patient to interface with the ventilator
with low levels of PSV and CPAP (eg, PSV 5 cm H2O with
5 cm H2O CPAP). After initiation of a selected weaning method,
the patient is observed for signs and symptoms associated with
failure to wean from mechanical ventilation including increased
shortness of breath, tachycardia, diaphoresis, oxygen desaturation, hypertension, and increased anxiety. A patient who is able

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Journal of Pharmacy Practice 24(1)

to maintain comfort without any obvious signs of respiratory


distress or pulmonary decompensation may be considered a candidate for extubation and removal from mechanical ventilation.
Throughout the medical literature, weaning from mechanical
ventilation is discussed in relation to the ventilator mode or
adjusting ventilator parameters to improve chances of discontinuation. Weaning must also include a pharmacological weaning
component that includes discussion of sedatives, narcotic analgesics, and neuromuscular blocking agents (NMBAs). No universal
method has been devised to wean narcotic analgesics or sedatives
in patients receiving mechanical ventilation. Based upon the SBT
model, spontaneous awaking trials (SATs) have demonstrated
success as an alternative or adjunctive method for ventilator
weaning. This method discontinues all narcotic and sedative
agents daily to allow the patient to fully recover on their own. If
the patient is calm and comfortable, sedation is discontinued. If
a patient demonstrates respiratory distress, sedation may be reinitiated at half the previous dose. This is done daily until the patient
is able to achieve adequate criteria for removal of mechanical
ventilatory support without the need for continued sedative
agents. Recent data have demonstrated that when combining SBT
and SAT patients were 32% less likely to die at any instant during
the year compared to patients weaned with usual care and SBT.28
Other experts agree that the latest generation of weaning protocols
that combine SBT and SATs represent a streamlined, effective,
and safe approach to ventilator weaning and can be used for most
patients in the ICU.29 Although these methods have demonstrated
success, some clinicians may resist implementing these strategies
based upon a number of rationales including familiarity and success with previous weaning methods, acute patient agitation due
to sedative discontinuation leading to dysynchrony with mechanical ventilation which may precipitate a decrease in SaO2, hemodynamic instability, and potential patient self-extubation.
A committed ICU team is required if SBT and SAT are to be routinely utilized within the ICU environment. If the patient demonstrates improvement in their pulmonary status requiring to
lighten up the patients sedation, the following general rule for
weaning is recommended. Decrease the continuous infusion of
either or both narcotic analgesic or sedative by 10% to 25% per
day, with periodic bolus dosing as needed for breakthrough pain
or agitation.30 This strategy has been recommended but weaning
titration or implementing weaning protocols depends upon many
different factors including pharmacokinetic and pharmacodynamic of individual agents, degree of patient critical illness
including pulmonary, neurological, and nutritional status, and
ventilator plan of the patient. Weaning protocols have shown to
demonstrate superior outcomes compared to physician-directed
weaning.31 Patients entering the ICU requiring short-term intubation (24-48 hours) with no history of pulmonary disease routinely
are targeted for more aggressive downward titration or
discontinuation of narcotic analgesics and sedative infusions to
expedite extubation and discontinuation of mechanical ventilation.
Overuse or aggressive use of narcotic analgesics and/or sedatives can directly affect respiratory drive, leading to failure to
wean from mechanical ventilation. This may result in restarting
full ventilatory support in patients continued to be intubated or

patients who have been extubated may require reintubation or


initiation of NIPPV to maintain adequate oxygenation and ventilation. If patients demonstrate dyssynchrony with mechanical
ventilator support despite no obvious physical or mechanical ventilator dysfunction, then pharmacological agents must be
considered. Sedatives and/or analgesics can be administered
every 2 hours as needed to optimize patient comfort and acceptance of mechanical ventilation. Patients requiring dosing more
often than every 2 hours should be initiated on continuous infusions of either or both classes of agents.30 Pharmacists must be
vigilant in discussing with the patients nurse to maintain frequent
assessment of degree of agitation or sedation utilizing an appropriate sedation scoring system. Sedation scoring systems have
demonstrated that both sedatives and analgesics can be titrated
to predetermined end points.30 No sedation scoring system is
superior to another but one method should be chosen and utilized
in every critical care unit to optimize administration of sedatives.
Patients continuing to demonstrate dyssynchrony with
mechanical ventilation despite no physical or mechanical complications of mechanical ventilation and are receiving continuous infusions of narcotic analgesics and sedatives must be
assessed for delirium. Patients inadvertently treated with benzodiazepines for delirium may become more agitated and confused. Delirium can be assessed using the Confusion
Assessment Method (CAM) score. The CAM is a diagnostic tool
to assess delirium and can be utilized by nonpsychiatrists. It is
easy to use and has demonstrated effectiveness in clinical investigations.32 Although controversial, this tool can be completed at
the bedside by the nurse and can be completed in 2 minutes with
a 98% accuracy rate.30 Appropriate diagnosis of delirium can
then be treated with a typical antipsychotic such as haloperidol.
Haloperidol can be given as a bolus dose of 2 to 10 mg, with
repeated doses every 15 to 20 minutes, followed by 25% of the
loading dose scheduled every 4 to 6 hours.30
Pharmacists who understand and participate as a member of
the medical team in discussing the daily ventilator plan can
assist in assessment and weaning of narcotic analgesics and
sedatives. Pharmacists have a vital role in assisting the medical
team in the development of weaning protocols which include
optimizing drug selection, dose titration, and monitoring for
adverse effects to achieve ventilator weaning outcomes. Close
observation of drug utilization may limit potential adverse
effects including neurological and respiratory depression and
lead to successful mechanical ventilation independence.

Conclusion
Mechanical ventilation is a lifesaving and life-sustaining
modality that will continue to evolve. Pharmacists must be
included as a member of the medical team when discussing a
therapeutic ventilatory plan and in the development of ventilator
weaning protocols. Understanding the basic concepts of mechanical ventilation will assist the pharmacist practitioner when making
pharmacotherapeutic recommendations. As medical technology
evolves, pharmacist will continue to play a vital role in rational
drug management to optimize pharmacotherapeutic outcomes.

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Cawley

15
Table A1 (continued)

Appendix A
Table A1. Summary of Mechanical Ventilation Terminology
Abbreviation Meaning
Vt

VE

FIO2

CMV

A/C

IMV

SIMV

PCV

PEEP

CPAP

PSV

BiPAP

Abbreviation Meaning

Definition

IPAP

Inspiratory positive
airway pressure

EPAP

Expiratory positive
airway pressure

Amount of inspiratory pressure


preset and administered during
noninvasive mechanical ventilation. IPAP is equivalent to
PSV.
Amount of expiratory pressure
preset and administered during
noninvasive mechanical ventilation. EPAP is equivalent to
CPAP.

Definition

Tidal volume

Volume of gas inhaled or exhaled


during a normal respiratory
cycle.
Minute ventilation
Volume of gas exhaled in 1 minute
and is the product of tidal volume and respiratory rate.
Fraction of inspired
Percentage of oxygen that can be
oxygen
administered ranging from 21%
to 100%.
Control-mode
Time-cycled and volume-cycled
ventilation
mode of ventilator support
generating an inspiratory tidal
volume breath independent of
the patients respiratory effort.
Assist control
Volume-cycled mode of ventilator
support administering a
predetermined tidal volume and
respiratory rate such as controlmode ventilation, but the patient
may also trigger additional tidal
volume breaths above the
preset ventilator settings.
Intermittent mandaVolume-cycled mode of ventilator
tory ventilation
support in which a patient
receives a preset tidal volume
and respiratory rate but allows
the patient to breath spontaneously between predetermined ventilatory breaths.
Volume-cycled mode of ventilator
Synchronized intersupport similar to IMV but
mittent mandatory
prevents stacking of inspiraventilation
tory tidal volume breaths.
Pressure control
Time-cycled and pressure-cycled
ventilation
mode where a constant pressure is maintained throughout
the preset inspiratory time.
Maintains pressure held above
Positive endatmospheric pressure during
expiratory
the exhalation phase of a
pressure
mechanical initiated breath.
Continuous positive
Maintains constant pressure held
airway pressure
above atmospheric pressure
throughout the respiratory
cycle.
Pressure support
Provides preset inspiratory presventilation
sure assistance during each
spontaneous patient breath.
Bilevel positive airway Noninvasive positive pressure
pressure
ventilation that provides continuous positive airway pressures that cycles between a
preset high (inspiratory positive airway pressure [IPAP])
and low (expiratory positive
airway pressure [EPAP]).
(continued)

Declaration of Conflicting Interests


The author(s) declared no conflicts of interest with respect to the
authorship and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or
authorship of this article.

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