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Intelligent Ventilation newsletter articles
Test your IntelliVence (Vol 18 Issue 1)26.02.2021
This patient is receiving noninvasive ventilation with pressure support. What does the spike at the beginning of inspiration on both the pressure and flow waveforms mean?
NIV, pressure support, overshoot, inspiratory pressure, pressure ramp, compliance, resistance, inspiratory flow, cycling
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Mitigating lung damage using rapid estimation of mechanical power24.02.2021
It is currently understood that VILI is a consequence of stress and strain placed upon lung tissue during mechanical ventilation [1]. The severity of stress and strain induced is commonly estimated by monitoring airway pressure and tidal volumes the patient is receiving.
VILI, lung damage, mechanical power, driving pressure, tidal volume, airway pressure, lung protective ventilation, volume control, pressure control, inspiratory hold, plateau pressure, EMR, electronic medical record
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Bedside tip: How to estimate mechanical power in volume- and pressure-control ventilation24.02.2021
As our understanding of VILI grows, there is a greater focus on mechanical power (MP) as a potential predictor of negative outcomes.
mechanical power, VILI, lung damage, pressure control, volume control, bedside, plateau pressure
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Assessing lung recruitability in ARDS16.11.2020
Acute respiratory distress syndrome (ARDS) is characterized by lung collapse that decreases the size of the aerated lung (baby lung concept [1]), resulting in decreased respiratory system compliance and impaired oxygenation.
recruitment, recruitability, potential, ARDS, lung collapse, early-onset, CT scan, lung imaging, pressure flow curve, PV curve, PV tool, PEEP setting, hysteresis, hysteresis ratio, recruitment-to-inflation ratio, R/I ratio
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Test your IntelliVence (Vol 17 Issue 5)16.11.2020
This patient is intubated and ventilated using pressure support (PS) mode. Why is the shape of the flow and pressure waveforms abnormal?
flow starvation, pressure support, flow waveform, pressure waveform, early cycling, inspiration, expiration, pressure ramp
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Bedside tip: How to recognize increases in expiratory filter resistance07.09.2020
It is well known that expiratory filters can become clogged with humidity and particles from nebulized medications trapped in the filter media (1).
RCexp, resistance, compliance, filter resistance, filter, occlusion, trending, expiratory flow, expiratory resistance, inspiratory resistance
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Test your IntelliVence (Vol 17 Issue 4)07.09.2020
This issue we're bringing you a new way to test your IntelliVence!
crossword
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Expiratory filter resistance07.09.2020
In these days of COVID-19, hospitals are experiencing increased volumes of mechanically ventilated patients. Additionally, institutions are struggling with equipment and supply shortages. Concerns about spreading COVID-19 between patients and healthcare workers have prompted increased consideration of controlling the exhaled gas from the ventilator by utilizing filters in the expiratory limb of the ventilator circuit.
filter, expiratory filter, filter resistance, filter obstruction, occlusion, expiratory resistance
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Can we predict the failure of HFNC in patients with acute hypoxemic respiratory failure?16.07.2020
The coronavirus pandemic has stretched many hospitals’ resources to the limit. Patients are requiring respiratory support on an unprecedented scale and a possible – or in some cases very real – shortage of ventilators is forcing institutions to weigh up the risks and benefits of alternative forms of therapy.
High flow, nasal cannula, hfnc, hfot, intubation, failure, conventional oxygen, face mask, standard oxygen, oxygen therapy, ROX index, respiratory rate, SpO2, FiO2
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Test your IntelliVence (Vol 17 Issue 3)16.07.2020
This intubated patient is being ventilated in P-CMV mode. What does the waveform show us?
expiratory flow, passive patient, tracheomalacia, instability, trachea, pssive expiration, collapse, restrict
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Bedside tip: How to set high flow oxygen therapy16.07.2020
High flow oxygen therapy combines several physiologic effects: Improved oxygenation, reduced inspiratory effort and work of breathing, improved lung mechanics, increased end-expiratory lung volumes (EELV), probably due to the positive end-expiratory pressure (PEEP) effect, increased carbon dioxide (CO2) clearance by washout of anatomic dead space, and improved comfort (1, 2).
high flow oxygen therapy, HFOT, settings, oxygenation, PEEP, flow
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Test your IntelliVence (Vol 17 Issue 2)11.05.2020
This intubated patient is suffering from COVID-19 pneumonia and is currently in the weaning phase of mechanical ventilation. What can we see from the pressure waveform?
p0.1, pressure drop, weaning, spontaneous, P-SILI, lung injury, self-inflicted
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Patient self-inflicted lung injury11.05.2020
Facilitating spontaneous efforts in those patients under light sedation is an important part of mechanical ventilation in the ICU.
P-SILI, patient self-inflicted lung injury, VILI, venilator induced lung injury, higher peep, spontaneous breathing, safe breathing, moderate ARDS, severe ARDS
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Driving pressure in ARDS patients02.04.2020
ARDS is characterized by lung collapse and consolidation leaving just a small portion of aerated lung remaining, which is at risk of ventilator-induced lung injuries (baby-lung concept).
driving pressure, lung safe, limiting driving pressure, hospital mortality, ARDS
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Individualized ventilation to protect the lung?05.03.2020
The application of general rules and guidelines for ventilator settings such as tidal volume may not be of benefit to every patient. A more individualized approach to treating the diseased lung may be safer for the lung and result in better outcomes. Today’s advanced technology supports this approach by allowing the clinician to set targets, then automatically adjusting ventilation settings according to each individual patient’s condition and lung characteristics.
closed loop ventilation, lung protection, lung protective, driving pressure, tidal volume, mechanical power, VILI, lung injury, INTELLiVENT, ASV
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Post-extubation respiratory failure: Is high flow nasal oxygen enough to prevent reintubation?20.12.2019
The process of separating patients from the ventilator after prolonged periods of invasive mechanical ventilation typically involves three steps: Firstly, screening the readiness-to-wean criteria, secondly, conducting a spontaneous breathing trial and thirdly, judging whether a patient will be able to maintain ventilation after extubation.
extubation, failure, reintubation, HFNO, high flow oxygen, NIV, high-risk, oxygen
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Test your IntelliVence (Vol 16, Issue 5)20.12.2019
This intubated patient was suffering from acute pancreatitis complicated by ARDS. What do the waveforms show us?
esophageal pressure, PEEP, pancreatitis, ARDS, atelectrauma, waveforms
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Should cuffed endotracheal tubes be the first-line choice for intubation in pediatric intensive care?07.11.2019
Tracheal intubation practice and safety in international and North American PICU’s were recently compared by means of a prospective, multicenter pediatric tracheal intubation database (1). A total of 10,510 tracheal intubations were reported and analyzed between the years 2014 and 2017.
cuffed tubes, endotracheal, pediatric, PICU, intubation, newborns, reintubation, leakage airway obstruction
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Test your IntelliVence (Vol 16 Issue 4)07.11.2019
Why is the volume curve not returning to zero?
leaks, cuff pressure, tracheal tube, positive flow, volume curve, flow curve
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Bedside tip - Managing cuff pressure in children intubated with cuffed tubes07.11.2019
The choice of tube size for uncuffed tubes is commonly made according to Cole`s formula (Age/4 + 4 mm); for cuffed tubes a size 0.5 mm smaller is recommended. The cuff pressure needs to be sufficient to avoid leakage during mechanical ventilation, and also to completely seal the airway and prevent micro-aspiration (thus preventing ventilator-associated pneumonia).
cuffed tubes, intubation, cuff size, cuff pressure, adjustment, leakage, pressure test, IntelliCuff
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Double triggering - Diagnosis, differentiation, and resolution08.07.2019
A mismatch within the patient-ventilator interface is a phenomenon which commonly occurs with invasively and noninvasively mechanically ventilated patients. The term “dyssynchrony” implies an abnormality of the expected synchrony between patient and ventilator.
asynchronies, dyssynchronies, double triggering, missed effort, ineffective effort, inspiratory effort, inspiratory time, waveforms, PES, flow, volume
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Bedside tip: How to diagnose and avoid ineffective efforts08.07.2019
An ineffective effort is defined as a patient effort that is unable to trigger the delivery of a mechanical breath.
Ineffective effort, trigger threshold, waveforms, autoPEEP, pressure support, expiratory trigger sensitivity, ETS
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Test your IntelliVence (Vol 16 Issue 3)08.07.2019
Which patient/ventilator dyssynchrony is present here (blue arrow)?
ineffective effort, patient effort, airway pressure, expiratory flow, waveform, pleural pressure, PES
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Applied physiology at the bedside: Volumetric capnography23.04.2019
Volumetric capnography is the graphical representation of the partial pressure of carbon dioxide (CO2) versus exhaled volume. This measurement is made noninvasively at every breath by a combination of flow and CO2 sensors, which are positioned together at the Y-piece of the ventilator circuit and well synchronized. Volumetric capnography provides much more information than time capnography, primarily about the metabolism, cardiovascular function, ventilation, and ventilation/perfusion (V̇/Q̇) ratio.
volumetric capnography, CO2, PETCO2, ventilation perfusion, ventilation perfusion ratio, ventilation perfusion mismatching, deadspace, cardiovascular function, metabolism, VDaw, alveolar ventilation, CO2 production, VCO2, V'CO2
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Test your IntelliVence (Vol 16 Issue 2)23.04.2019
The volumetric capnography loop displayed is from a passive patient ventilated in PC mode. What does its shape tell us?
volumetric capnography, airway deadspace, PEEP, ventilation perfusion ratio, airway resistance, ventilation perfusion mismatching
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Bedside tip: Using volumetric capnography to set PEEP23.04.2019
PEEP is used to keep the lung aerated and prevent lung collapse at the end of expiration. However, PEEP may over-distend the normally aerated lung and impair lung perfusion. Therefore, any change in PEEP may affect the overall ventilation/perfusion ratio in an unpredictable way.
volumetric capnography, setting PEEP, PEEP, ventilation perfusion ration, recruitment, VeCO2
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Bedside tip: Achieving effective ventilation using volumetric capnography18.02.2019
Ventilation is effective when it removes CO2 at a rate that maintains a normal or a targeted pH.
effective ventilation, volumetric capnography, paco2, petco2, co2 production, co2 elimination, minute ventilation, tidal volume, dead space, alveolar ventilation, V'alv, V'CO2
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Tidal volume and lung-protective strategy in non-ARDS patients18.02.2019
Mechanical ventilation is a lifesaving technique, but one that potentially has important complications. According to several experimental and clinical studies, mechanical ventilation has great potential to augment and initiate injury to the lungs and respiratory muscles (1, 2).
low tidal volumes, lung protection, lung-protective ventilation, non-ARDS, non-injured lung, VILI, lung injury, driving pressure, tidal volume, lung stress, lung strain
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Test your IntelliVence (Vol 16 Issue 1)18.02.2019
The patient is being ventilated in volume assist control mode. What does the change of shape of the pressure curve represent?
flow starvation, inspiratory pressure, flow, pressure curve, inspiratory effort, decrease
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Test your IntelliVence (Vol 15 Issue 6)07.01.2019
This intubated patient is being ventilated in PSIMV+ mode. What kind of asynchrony is visible in the breath marked by the cursor?
Delayed cycling, cycling, flow curve, asynchrony, PSIMV
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Bedside tip: Initial settings for the most important NIV parameters in children19.12.2018
The success of NIV depends on the right choice of equipment and adjustment of the settings to suit each individual child. In this Bedside Tip, we show you the initial settings for the most important parameters when applying NIV therapy in children.
NIV, parameters, pediatric, peak pressure, ETS, pressure support, TI, PEEP, inspiratory trigger, ramp
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NIV for acute respiratory distress in children19.12.2018
In children, it is not uncommon that the rapid progression of respiratory failure with decompensation of the gas exchange may lead to a life-threatening situation. If applied early enough, noninvasive ventilation (NIV) can help stop this progression and thus avoid intubation with invasive mechanical ventilation and the complications that come with it.
NIV, pediatric, PARDS, acute respiratory failure, HFNC, children, PICU, pneumonia, bronchiolitis
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Bedside Tip: How to measure esophageal pressure correctly19.10.2018
A recent physiological study demonstrated that esophageal pressure estimates the pleural pressure at mid-thorax at all levels of PEEP. Therefore, an absolute measurement of esophageal pressure is useful for setting PEEP and monitoring transpulmonary pressure.
esophageal pressure measurement, how to measure, positioning, esophageal balloon, esophageal catheter, inflation, balloon filling, verification, occlusion test
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What are we assessing with esophageal pressure measurement19.10.2018
Esophageal pressure measurement is an advanced form of monitoring for mechanically ventilated patients in order to assess transpulmonary pressure and the risk of ventilator-induced lung injuries (VILI), as well as optimize ventilator settings (1, 2). However, there have been concerns about the validity of esophageal pressure to assess pleural pressure (3).
esophageal pressure, measurement, pleural pressure, esophageal balloon, VILI, end-inspiratory, end-expiratory, balloon insertion, inflation, esophageal catheter, transpulmonary pressure, lung stress
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Test your IntelliVence (Vol 15 Issue 5)19.10.2018
This intubated patient is ventilated in pressure-support mode. What is the explanation for the sudden increase in esophageal pressure?
quiz, esophageal pressure, esophageal contraction, peristalsis, catheter placement, balloon inflation, pressure, esophageal pressure measurement
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Monitoring respiratory mechanics in the prone position14.08.2018
Esophageal pressure measurement can be used to guide ventilator management in severe ARDS patients, and this strategy has been shown to improve oxygenation, lung compliance and possibly survival when compared with standard practice.
prone position, esophageal pressure, measurement, pes, peso, VILI, respiratory mechanics, oxygenation, PEEP, transpulmonary pressure measurement, TPM
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Bedside tip: Assessing lung recruitability08.08.2018
The percentage of potentially recruitable lung varies widely among ARDS patients, and zones of collapsed and consolidated alveoli in the most dependent lung frequently require airway opening pressures of more than 35–40 cmH2O to recruit (1).
recruitment, recruitability, hysteresis, assessing, assessment, p/v curve, pressure volume, recruitment maneuver, supine, prone, prone position, PEEP
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Test your IntelliVence (Vol 15 Issue 4)08.08.2018
Why is the current volumetric capnogram loop different from the reference loop?
pulmonary embolism, capnography, volumetric capnography, dead space, VDalv, PetCO2, capnogram
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Bedside tip: Using measured airway mechanics in pediatrics12.06.2018
The expiratory time constant (RCexp) is measured breath-by-breath on all Hamilton Medical ventilators. As RCexp is the product of compliance and resistance, this single variable gives us an overview of the overall respiratory mechanics.
Rcexp, respiratory mechanics, compliance, resistance, time constant, settings, flow interruption, restriction, obstructive condition, mixed disease, pediatric
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Recommendations for mechanical ventilation of critically ill children12.06.2018
Common clinical practice in pediatric mechanical ventilation is largely based on personal experience or what has been adopted from adult and neonatal studies. There is a fundamental lack of clinical evidence to support the daily practice of pediatric mechanical ventilation, due in part to the extensive variability in lung size, maturity and range of acute and chronic respiratory conditions existing in all age groups of children.
pediatrics, airway mechanics, respiratory system, oxygenation, targets, inspiratory time, frequency, pressure, tidal volume, PEEP, guideline
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Monitoring respiratory mechanics in mechanically ventilated patients30.04.2018
The term respiratory mechanics describes the mechanical properties of the respiratory system that is inflated during mechanical ventilation. Monitoring respiratory mechanics is useful for diagnosing the lung condition, assessing the evolution and severity of the lung impairment, and adjusting ventilator settings.
respiratory mechanics, monitoring, time constant, rcexp, expiratory time constant,
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Test your IntelliVence (Vol 15 Issue 2)25.04.2018
This patient is passive and ventilated in pressure-control mode. Why is the flow curve shaped this way?
pressure control mode, flow limitation, COPD, expiratory flow, bicompartmental expiration, choke point, brochospasm
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Bedside tip: How to use the expiratory time constant25.04.2018
The expiratory time constant (RCEXP) is a dynamic measurement of respiratory mechanics measured breath-by-breath on all Hamilton Medical ventilators.
rcexp, time constant, expiratory time constant, compliance, resistance, monitoring, respiratory mechanics
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Test your IntelliVence (Vol 15 Issue 1)20.03.2018
Why is the flow shape different for the second breath? The patient is ventilated in pressure-support mode with no backup respiratory rate (RR).
auto triggering, inspiratory effort, esophageal pressure, pressure, flow, slope, inspiratory flow, asynchrony, mechanical breath
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Bedside tip: How to set expiratory trigger sensitivity (ETS)22.02.2018
Optimal patient-ventilator synchrony is of prime importance, as asynchronies lead to increased work of breathing and patient discomfort, and are also associated with higher mortality and prolonged mechanical ventilation (1, 2, 3).
ets, expiratory trigger, inspiratory trigger, expiratory trigger sensitivity, asynchrony, delayed cycling, late cycling, trigger adjustment, double triggering, IntelliSync
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Clinical practice guidelines for use of noninvasive ventilation for acute respiratory failure22.02.2018
The use of noninvasive ventilation (NIV) has increased considerably over the last two decades and is now widespread in the acute-care setting for management of acute respiratory failure (ARF). A guideline committee selected 11 questions relating to the clinical application of NIV for various etiologies of ARF based on their perceived clinical importance, and assessed the evidence currently available to develop corresponding recommendations [1].
NIV, guidelines, acute respiratory failure, ARF, noninvasive, noninvasive ventilation, weaning, asthma, post-extubation, respiratory failure, chest trauma, palliative care, post-operative, de novo ARF, immunocompromised, cardiogenic pulmonary edema, pulmonary edema, hypercapnia, hypercapnic, COPD exacerbation, respiratory acidosis
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Test your IntelliVence (Vol 14 Issue 5)19.12.2017
Why is the end-expiratory flow positive (above baseline)?
NIV, noninvasive ventilation, leak compensation, end-expiratory flow, leak rate
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High flow oxygen therapy after planned extubation19.12.2017
Oxygenation and ventilation impairment after planned extubation is frequent. Post-extubation respiratory management aims to decrease the risk of early acute respiratory failure and reintubation, which is associated with a poor prognosis (1).
high flow oxygen therapy, HFOT, extubation, oxygenation impairment, reintubation, post-extubation respiratory failure, high-risk patients, NIV, non invasive ventilation
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Test your IntelliVence (Vol 14 Issue 4)02.10.2017
What causes this temporary stop in breathing?
Cheyne stokes, CSR, apnea, stop breathing
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Bedside tip: How to perform a recruitment maneuver02.10.2017
A recruitment maneuver (RM) is a transient increase in transpulmonary pressure applied to reaerate the collapsed lung.
recruitment, recruitment maneuver, ARDS, PEEP, sustained inflation, PV Tool
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Clinical practice guidelines for mechanical ventilation in adult patients with ARDS02.10.2017
Acute respiratory distress syndrome (ARDS) is characterized by an inflammatory pulmonary edema resulting in severe hypoxemia. The recent LUNG SAFE study showed that ARDS is common in the ICU, occurring in 10% of all patients admitted (1).
ARDS, VILI, guideline, mechanical ventilation, mortality, tidal volume, inspiratory pressure, prone positioning, HFOV, PEEP, recruitment maneuvers, ECMO, recruitment
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Bedside tip: How to select SpO2 targets30.08.2017
In mechanically ventilated patients, SpO2 targets are selected according to the previous lung condition and the actual severity of the disease.
spo2, spo2 targets, ARDS, normal lung, hypercapnia, brain injury, PEEP
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Bedside tip: How to measure driving pressure30.08.2017
Airway driving pressure is associated with clinical outcomes in ARDS, post-surgical, and normal-lung patients, and is a measure of the strain applied to the respiratory system and the risk of ventilator-induced lung injuries. Evidence suggests we should keep driving pressure below 14 cmH2O. But how can we measure it?
driving pressure, hold maneuver, end-expiratory, end-inspiratory, plateau pressure, PEEP, ASV
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Bedside tip: How to wean with ASV®30.08.2017
The American Thoracic Society and the American College of Chest Physicians recently provided recommendations to help optimize liberation from mechanical ventilation in adult ICU patients (1). They suggest using a ventilator liberation protocol and performing spontaneous breathing trials (SBTs) with modest inspiratory pressure support (5-8 cmH2O). So how do we implement these recommendations using the Adaptive Support Ventilation (ASV) mode?
weaning, wean, ASV, recommendations, liberation, protocol, criteria, readiness-to-wean
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Clinical practice guidelines for weaning critically ill adult patients from mechanical ventilation29.08.2017
Due to the complications associated with mechanical ventilation, clinicians should implement strategies to liberate patients from mechanical ventilation as soon as the underlying cause for mechanical ventilation has sufficiently improved, and the patient is able to maintain spontaneous breathing unassisted.
Weaning, guidelines, liberate, liberation, recommendations, protocol, mechanical, ventilation
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Findings from the "Lung Safe" ARDS Epidemiology Study29.08.2017
The Lung Safe study Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries (1) evaluated the recognition, incidence, mortality and management of ARDS in 450 ICU’s in 50 countries. The results of the study may be somewhat surprising in comparison to common perceptions.
ARDS, study, epidemiology, lung safe, criteria
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Acute Respiratory Distress Syndrome In the Adult and Pediatric Population29.08.2017
Acute Respiratory Distress Syndrome (ARDS) is a potentially devastating clinical disorder, affecting critically ill patients of all ages. Hypoxemic respiratory failure is a common characteristic, requiring invasive or non-invasive mechanical ventilation. Mechanical ventilation provides critical support while clinical interventions and recovery time allow potential resolution of the acute disease process. However, clinically inappropriate techniques utilizing mechanical ventilation can further precipitate lung injury and possibly delay or prevent recovery.
ALI, acute lung injury, ARDS, distress syndrome
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Hyperoxemia in the ICU29.08.2017
Hyperoxemia can be defined as an increase in arterial oxygen partial pressure (PaO2) to a level greater than 120 mmHg (16 kPa) (1, 2). It is considered to be moderate for levels ranging between 120 and 200 mmHg, and severe if PaO2 exceeds 200 mmHg (27 kPa) (3). Hyperoxemia is caused by hyperoxia (an increase in oxygen) and occurs in 22% to 50% of mechanically ventilated patients in the ICU (1, 3-6).
hyperoxemia, hypoxia, hyperoxia, mortality, PaO2, SpO2, pulse oximetry, oxygenation, closed loop, Intellivent
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Test your IntelliVence (Vol 14 Issue 3)29.08.2017
What causes the distortions of pressure and flow during the second breath?
triggering, reverse triggering, muscle contractions, insufflation, double inspiration
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Test your IntelliVence (Vol 14 Issue 2)29.08.2017
Why are there oscillations in the pressure and flow waveforms?
oscillations, pressure waveform, flow waveform, proximal airways, distal airways, secretions
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Test your IntelliVence (Vol 14 Issue 1)13.07.2017
What does this small bump at the beginning of expiration represent?
expiration, premature, cycling, cycles, inspiratory, effort, insufflation, trigger sensitivity
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