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Pathophysiology of Respiratory

Pathophysiology of Respiratory
Failure and
Failure and
Use of Mechanical Ventilation
Use of Mechanical Ventilation
Puneet Katyal, MBBS, MSHI
Puneet Katyal, MBBS, MSHI
Ognjen Gajic
Ognjen Gajic
, MD
, MD
Mayo Clinic, Rochester, MN, USA
Mayo Clinic, Rochester, MN, USA
Definition
Definition
n n Chest wall (including Chest wall (including
pleura and pleura and
diaphragm) diaphragm)
n n Airways Airways
n n Alveolar Alveolar capillary capillary
units units
n n Pulmonary circulation Pulmonary circulation
n n Nerves Nerves
n n CNS or Brain Stem CNS or Brain Stem
n n
Respiratory failure is a syndrome of inadequate
Respiratory failure is a syndrome of inadequate
gas exchange due to dysfunction of one or more
gas exchange due to dysfunction of one or more
essential components of the respiratory system:
essential components of the respiratory system:
Respiratory System
Respiratory System
L
u
n
g
:

A
l
v
e
o
l
a
r

U
n
i
t

Brain
Spinal cord
Nerves
Intercostal
muscles
Chest wall
Airway
Pleura
Diaphragm
Epidemiology
Epidemiology
n n
Incidence: about 360,000 cases per year in the
Incidence: about 360,000 cases per year in the
United States
United States
n n
36% die during hospitalization
36% die during hospitalization
n n
Morbidity and mortality rates increase with age
Morbidity and mortality rates increase with age
and presence of comorbidities
and presence of comorbidities
Classification
Classification
n n Type I or Hypoxemic (PaO2 <60 at sea level): Type I or Hypoxemic (PaO2 <60 at sea level): Failure of Failure of
oxygen exchange oxygen exchange
n n Increased shunt fraction (Q Increased shunt fraction (Q
S S
/Q /Q
T T
) )
n n Due to alveolar flooding Due to alveolar flooding
n n Hypoxemia refractory to supplemental oxygen Hypoxemia refractory to supplemental oxygen
n n Type II or Type II or Hypercapnic Hypercapnic (PaCO2 >45): (PaCO2 >45): Failure to Failure to
exchange or remove carbon dioxide exchange or remove carbon dioxide
n n Decreased alveolar minute ventilation (V Decreased alveolar minute ventilation (V
A A
) )
n n Often accompanied by hypoxemia that corrects with Often accompanied by hypoxemia that corrects with
supplemental oxygen supplemental oxygen
Classification
Classification
n n Type III Respiratory Failure: Type III Respiratory Failure: Perioperative Perioperative respiratory respiratory
failure failure
n n Increased Increased atelectasis atelectasis due to low functional residual capacity due to low functional residual capacity
( (FRC FRC) in the setting of abnormal abdominal wall mechanics ) in the setting of abnormal abdominal wall mechanics
n n Often results in type I or type II respiratory failure Often results in type I or type II respiratory failure
n n Can be ameliorated by anesthetic or operative technique, Can be ameliorated by anesthetic or operative technique, posture posture, ,
incentive incentive spirometry spirometry, post , post- -operative analgesia, attempts to lower operative analgesia, attempts to lower
intra intra- -abdominal pressure abdominal pressure
n n Type IV Respiratory Failure: S Type IV Respiratory Failure: Shock hock
n n Type IV describes patients who are Type IV describes patients who are intubated intubated and ventilated and ventilated
in the process of resuscitation for shock in the process of resuscitation for shock
n n Goal of ventilation is to stabilize gas exchange and to unload t Goal of ventilation is to stabilize gas exchange and to unload the he
respiratory muscles, lowering their oxygen consumption respiratory muscles, lowering their oxygen consumption
Classification
Classification
n n
Respiratory failure may be
Respiratory failure may be
n n Acute Acute
n n Chronic Chronic
n n Acute on chronic Acute on chronic
n n E.g.: acute exacerbation of advanced COPD E.g.: acute exacerbation of advanced COPD
Pathophysiology:
Pathophysiology:
Mechanisms
Mechanisms
n n
Hypoxemic failure
Hypoxemic failure
n n Ventilation/Perfusion (V/Q) mismatch Ventilation/Perfusion (V/Q) mismatch
n n Shunt Shunt
n n Exacerbated by low mixed venous O2 (SvO2) Exacerbated by low mixed venous O2 (SvO2)
n n
Hypercapnic
Hypercapnic
failure
failure
n n Decreased minute ventilation (MV) relative to Decreased minute ventilation (MV) relative to
demand demand
n n Increased dead space ventilation Increased dead space ventilation
Pathophysiology:
Pathophysiology:
Etiologic Categories
Etiologic Categories
n n
Nervous system
Nervous system
failure (Type II)
failure (Type II)
n n Central Central
hypoventilation hypoventilation
n n Neuropathies Neuropathies
n n
Muscle (pump)
Muscle (pump)
failure (Type II)
failure (Type II)
n n Muscular dystrophies Muscular dystrophies
n n Myopathies Myopathies
n n
Neuromuscular
Neuromuscular
transmission failure
transmission failure
(Type II)
(Type II)
n n Myasthenia gravis Myasthenia gravis
n n
Airway failure
Airway failure
(Type II)
(Type II)
n n Obstruction Obstruction
n n Dysfunction Dysfunction
Pathophysiology:
Pathophysiology:
Etiologic Categories
Etiologic Categories
n n Chest wall and pleural Chest wall and pleural
space failure (Type II) space failure (Type II)
n n Kyphoscoliosis Kyphoscoliosis
n n Morbid obesity Morbid obesity
n n Pneumothorax Pneumothorax
n n Hydrothorax Hydrothorax
n n Hemothorax Hemothorax
n n Alveolar unit failure Alveolar unit failure
(Type I) (Type I)
n n Collapse Collapse
n n Flooding: edema, blood, Flooding: edema, blood,
pus, aspiration pus, aspiration
n n Fibrosis Fibrosis
n nPulmonary vasculature failure (Type I) Pulmonary vasculature failure (Type I)
n nPulmonary embolism Pulmonary embolism
n nPulmonary hypertension Pulmonary hypertension
Causes
Causes
n n Type I respiratory failure Type I respiratory failure
n n Pneumonia Pneumonia
n n Cardiogenic Cardiogenic pulmonary edema pulmonary edema
n n Pulmonary edema due to increased hydrostatic pressure Pulmonary edema due to increased hydrostatic pressure
n n Non Non- -cardiogenic pulmonary edema cardiogenic pulmonary edema
n n Pulmonary edema due to increased permeability Pulmonary edema due to increased permeability
n n Acute lung injury (ALI) Acute lung injury (ALI)
n n Acute respiratory distress syndrome (ARDS) Acute respiratory distress syndrome (ARDS)
n n Pulmonary embolism (see also type IV respiratory failure) Pulmonary embolism (see also type IV respiratory failure)
n n Atelectasis (see also type III respiratory failure) Atelectasis (see also type III respiratory failure)
n n Pulmonary fibrosis Pulmonary fibrosis
Causes
Causes
n n Type II respiratory failure Type II respiratory failure
n n Central hypoventilation Central hypoventilation
n n Asthma Asthma
n n Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD)
n n Hypoxemia and Hypoxemia and hypercapnia hypercapnia often occur together often occur together
*Neuromuscular and chest wall disorders Neuromuscular and chest wall disorders
n n Myopathies Myopathies
n n Neuropathies Neuropathies
n n Kyphoscoliosis Kyphoscoliosis
n n Myasthenia gravis Myasthenia gravis
n n Obesity Hypoventilation Syndrome Obesity Hypoventilation Syndrome
Causes
Causes
n n Type III respiratory failure Type III respiratory failure
n n Inadequate post Inadequate post- -operative analgesia, upper abdominal operative analgesia, upper abdominal
incision incision
n n Obesity, Obesity, ascites ascites
n n Pre Pre- -operative tobacco smoking operative tobacco smoking
n n Excessive airway secretions Excessive airway secretions
n n Type IV respiratory failure Type IV respiratory failure
n n Cardiogenic Cardiogenic shock shock
n n Septic shock Septic shock
n n Hypovolemic Hypovolemic shock shock
Diagnosis: History
Diagnosis: History
n n Sepsis suggested by fever, chills Sepsis suggested by fever, chills
n n Pneumonia suggested by cough, sputum production, Pneumonia suggested by cough, sputum production,
chest pain chest pain
n n Pulmonary embolus suggested by sudden onset of Pulmonary embolus suggested by sudden onset of
shortness of breath or chest pain shortness of breath or chest pain
n n COPD exacerbation suggested by history of heavy COPD exacerbation suggested by history of heavy
smoking, cough, sputum production smoking, cough, sputum production
n n Cardiogenic pulmonary edema suggested by chest pain, Cardiogenic pulmonary edema suggested by chest pain,
paroxysmal nocturnal dyspnea, and orthopnea paroxysmal nocturnal dyspnea, and orthopnea
Diagnosis: History
Diagnosis: History
n n
Noncardiogenic edema suggested by the
Noncardiogenic edema suggested by the
presence of risk factors including sepsis,
presence of risk factors including sepsis,
trauma, aspiration, and blood transfusions
trauma, aspiration, and blood transfusions
n n
Accompanying sensory abnormalities or
Accompanying sensory abnormalities or
symptoms of weakness may suggest
symptoms of weakness may suggest
neuromuscular respiratory failure as would the
neuromuscular respiratory failure as would the
history of an ingestion or administration of
history of an ingestion or administration of
drugs or toxins.
drugs or toxins.
n n
Additional exposure history may help diagnose
Additional exposure history may help diagnose
asthma, aspiration, inhalational injury and some
asthma, aspiration, inhalational injury and some
interstitial lung diseases
interstitial lung diseases
Diagnosis: Physical Findings
Diagnosis: Physical Findings
n n Hypotension usually with signs of poor perfusion Hypotension usually with signs of poor perfusion
suggests severe sepsis or massive pulmonary embolus suggests severe sepsis or massive pulmonary embolus
n n Hypertension usually with signs of poor perfusion Hypertension usually with signs of poor perfusion
suggests cardiogenic pulmonary edema suggests cardiogenic pulmonary edema
n n Wheezing suggests airway obstruction: Wheezing suggests airway obstruction:
n n Bronchospasm Bronchospasm
n n Fixed upper or lower airway pathology Fixed upper or lower airway pathology
n n Secretions Secretions
n n Pulmonary edema ( Pulmonary edema ( cardiac asthma cardiac asthma ) )
Diagnosis: Physical Findings
Diagnosis: Physical Findings
n n
Stridor suggests upper airway obstruction
Stridor suggests upper airway obstruction
n n
Elevated jugular venous pressure suggests right
Elevated jugular venous pressure suggests right
ventricular dysfunction due to accompanying
ventricular dysfunction due to accompanying
pulmonary hypertension
pulmonary hypertension
n n
Tachycardia and arrhythmias may be the cause
Tachycardia and arrhythmias may be the cause
of cardiogenic pulmonary edema
of cardiogenic pulmonary edema
Diagnosis: Laboratory Workup
Diagnosis: Laboratory Workup
n n ABG ABG
n n Quantifies magnitude of gas exchange abnormality Quantifies magnitude of gas exchange abnormality
n n Identifies type and chronicity of respiratory failure Identifies type and chronicity of respiratory failure
n n Complete blood count Complete blood count
n n Anemia may cause cardiogenic pulmonary edema Anemia may cause cardiogenic pulmonary edema
n n Polycythemia suggests may chronic hypoxemia Polycythemia suggests may chronic hypoxemia
n n Leukocytosis, a left shift, or leukopenia suggestive of Leukocytosis, a left shift, or leukopenia suggestive of
infection infection
n n Thrombocytopenia may suggest sepsis as a cause Thrombocytopenia may suggest sepsis as a cause
Diagnosis: Laboratory Workup
Diagnosis: Laboratory Workup
n n
Cardiac serologic markers
Cardiac serologic markers
n n Troponin, Creatine kinase Troponin, Creatine kinase- - MB fraction (CK MB fraction (CK- -MB) MB)
n n B B- -type natriuretic peptide (BNP) type natriuretic peptide (BNP)
n n
Microbiology
Microbiology
n n Respiratory cultures: sputum/tracheal Respiratory cultures: sputum/tracheal
aspirate/ aspirate/broncheoalveolar broncheoalveolar lavage (BAL) lavage (BAL)
n n Blood, urine and body fluid (e.g. pleural) cultures Blood, urine and body fluid (e.g. pleural) cultures
Diagnostic Investigations
Diagnostic Investigations
n n
Chest radiography
Chest radiography
n n Identify chest wall, pleural and lung parenchymal Identify chest wall, pleural and lung parenchymal
pathology and distinguish disorders that cause pathology and distinguish disorders that cause
primarily V/Q mismatch (clear lungs) vs. Shunt primarily V/Q mismatch (clear lungs) vs. Shunt
(intra (intra- -pulmonary shunt with opacities present) pulmonary shunt with opacities present)
n n
Electrocardiogram
Electrocardiogram
n n Identify arrhythmias, ischemia, ventricular Identify arrhythmias, ischemia, ventricular
dysfunction dysfunction
n n
Echocardiography
Echocardiography
n n Identify right and/or left ventricular dysfunction Identify right and/or left ventricular dysfunction
Diagnostic Investigations
Diagnostic Investigations
n n Pulmonary function tests/bedside spirometry Pulmonary function tests/bedside spirometry
n n Identify obstruction, restriction, gas diffusion abnormalities Identify obstruction, restriction, gas diffusion abnormalities
n n May be difficult to perform if critically ill May be difficult to perform if critically ill
n n Bronchoscopy Bronchoscopy
n n Obtain biopsies, brushings and BAL for histology, cytology Obtain biopsies, brushings and BAL for histology, cytology
and microbiology and microbiology
n n Results may not be available quickly enough to avert Results may not be available quickly enough to avert
respiratory failure respiratory failure
n n Bronchoscopy may not be safe in the Bronchoscopy may not be safe in the if critically ill if critically ill
Respiratory Failure:
Respiratory Failure:
Management
Management
n n
ABC
ABC

s
s
n n Ensure airway is adequate Ensure airway is adequate
n n Ensure adequate supplemental oxygen and assisted Ensure adequate supplemental oxygen and assisted
ventilation, if indicated ventilation, if indicated
n n Support circulation as needed Support circulation as needed
Respiratory Failure:
Respiratory Failure:
Management
Management
n n Treatment of a specific cause when possible Treatment of a specific cause when possible
n n Infection Infection
n n Antimicrobials, source control Antimicrobials, source control
n n Airway obstruction Airway obstruction
n n Bronchodilators, glucocorticoids Bronchodilators, glucocorticoids
n n Improve cardiac function Improve cardiac function
n n Positive airway pressure, diuretics, vasodilators, Positive airway pressure, diuretics, vasodilators,
morphine, morphine, inotropy inotropy, revascularization , revascularization
Respiratory Failure:
Respiratory Failure:
Management
Management
n n
Mechanical ventilation
Mechanical ventilation
n n Non Non- -invasive (if patient can protect airway and is invasive (if patient can protect airway and is
hemodynamically stable) hemodynamically stable)
n n Mask: usually orofacial to start Mask: usually orofacial to start
n n Invasive Invasive
n n Endotracheal tube (ETT) Endotracheal tube (ETT)
n n Tracheostomy Tracheostomy if upper airway is obstructed if upper airway is obstructed
Respiratory Failure
Secure airway
Supplemental oxygen as needed
Treat underlying condition
Need for endotracheal
intubation or tracheostomy?
Invasive mechanical
ventilation
Non-invasive
mechanical ventilation
Yes
No
Fails
Indications for Mechanical
Indications for Mechanical
Ventilation
Ventilation
n n Cardiac or respiratory arrest Cardiac or respiratory arrest
n n Tachypnea or bradypnea with respiratory fatigue or Tachypnea or bradypnea with respiratory fatigue or
impending arrest impending arrest
n n Acute respiratory acidosis Acute respiratory acidosis
n n Refractory hypoxemia Refractory hypoxemia (when the P
a
O
2
could not be
maintained above 60 mm Hg with inspired O
2
fraction
(F
I
O
2
)>1.0)
n n Inability to protect the airway associated with depressed levels Inability to protect the airway associated with depressed levels
of consciousness of consciousness
Indications for Mechanical
Indications for Mechanical
Ventilation
Ventilation
n n Shock associated with excessive respiratory work Shock associated with excessive respiratory work
n n Inability to clear secretions with impaired gas exchange Inability to clear secretions with impaired gas exchange
or excessive respiratory work or excessive respiratory work
n n Newly diagnosed neuromuscular disease with a vital Newly diagnosed neuromuscular disease with a vital
capacity <10 capacity <10- -15 mL/kg 15 mL/kg
n n Short term adjunct in management of acutely increased Short term adjunct in management of acutely increased
intracranial pressure (ICP) intracranial pressure (ICP)
Invasive vs. Non
Invasive vs. Non
-
-
invasive
invasive
Ventilation
Ventilation
n n
Consider non
Consider non
-
-
invasive ventilation particularly
invasive ventilation particularly
in the following settings:
in the following settings:
n n COPD exacerbation COPD exacerbation
n n Cardiogenic pulmonary edema Cardiogenic pulmonary edema
n n Obesity hypoventilation syndrome Obesity hypoventilation syndrome
n n Noninvasive ventilation may be tried in selected Noninvasive ventilation may be tried in selected
patients with asthma or non patients with asthma or non- -cardiogenic hypoxemic cardiogenic hypoxemic
respiratory failure respiratory failure
Goals of Mechanical
Goals of Mechanical
Ventilation
Ventilation
n n
Improve ventilation by augmenting respiratory
Improve ventilation by augmenting respiratory
rate and tidal volume
rate and tidal volume
n n Assistance for neural or muscle dysfunction Assistance for neural or muscle dysfunction
n n Sedated, comatose or paralyzed patient Sedated, comatose or paralyzed patient
n n Neuropathy, myopathy or muscular dystrophy Neuropathy, myopathy or muscular dystrophy
n n Intra Intra- -operative ventilation operative ventilation
n n Correct respiratory acidosis, providing goals of lung Correct respiratory acidosis, providing goals of lung- -
protective ventilation are met protective ventilation are met
n n Match metabolic demand Match metabolic demand
n n Rest respiratory muscles Rest respiratory muscles
Goals of Mechanical
Goals of Mechanical
Ventilation
Ventilation
n n
Correct hypoxemia
Correct hypoxemia
n n High F High F
I I
O O
2 2
n n Positive end expiratory pressure (PEEP) Positive end expiratory pressure (PEEP)
n n
Improve cardiac function
Improve cardiac function
n n Decreases preload Decreases preload
n n Decreases afterload Decreases afterload
n n Decreases metabolic demand Decreases metabolic demand
Permissive Hypercapnia
Permissive Hypercapnia
n n
Ventilation strategy that allows P
Ventilation strategy that allows P
a a
CO
CO
2 2
to rise
to rise
by accepting a lower alveolar minute ventilation
by accepting a lower alveolar minute ventilation
to avoid specific risks:
to avoid specific risks:
n n Dynamic hyperinflation ( Dynamic hyperinflation ( auto auto- -peep peep ) and ) and
barotrauma in patients with asthma barotrauma in patients with asthma
n n Ventilator Ventilator- -associated lung injury, in patients with, or associated lung injury, in patients with, or
at risk for, ALI and ARDS at risk for, ALI and ARDS
n n
Contraindicated in patients with increased
Contraindicated in patients with increased
intracranial pressure such as head trauma
intracranial pressure such as head trauma
Mechanical Ventilation
Correct Hypoxemia Optimize cardiac function
Correct respiratory
acidosis*
F

I

O

2

,

P
E
E
P

RR, TV
P
r
e
l
o
a
d
,

A
f
t
e
r
l
o
a
d
,

M
e
t
a
b
o
l
i
c

d
e
m
a
n
d

Meet increased
metabolic
demand
* Avoid ventilator induced lung injury and dynamic hyperinflation
Hyperventilation may be used as a short
term adjunct to treat acutely elevated ICP
Enhance Ventilation *
Assistance for neural and/or
muscle dysfunction
Other Issues to Consider When
Other Issues to Consider When
Initiating Mechanical Ventilation
Initiating Mechanical Ventilation
n n
Do not wait for frank respiratory acidosis
Do not wait for frank respiratory acidosis
especially with evidence of:
especially with evidence of:
n n Inability to protect airway Inability to protect airway
n n Persistent or worsening tachypnea (respiratory rate Persistent or worsening tachypnea (respiratory rate
>35/minute) >35/minute)
n n Respiratory muscle fatigue Respiratory muscle fatigue
n n
Always consider risks and benefits of initiation
Always consider risks and benefits of initiation
and continuation of mechanical ventilation
and continuation of mechanical ventilation
Other Issues in Intubated &
Other Issues in Intubated &
Mechanically Ventilated
Mechanically Ventilated
Patients
Patients
n n Always elevate the head of the bed >30 Always elevate the head of the bed >30 and use ulcer and use ulcer
and DVT prophylaxis, unless contraindicated and DVT prophylaxis, unless contraindicated
n n Use lung protective ventilation strategy for patients Use lung protective ventilation strategy for patients
with Acute Lung Injury (TV ~ 6 ml/kg ideal body with Acute Lung Injury (TV ~ 6 ml/kg ideal body
weight, Plat pressure < 30 cmH weight, Plat pressure < 30 cmH
2 2
O) O)
n n Modify ventilator settings primarily to achieve patient Modify ventilator settings primarily to achieve patient- -
ventilator synchrony. If this fails, use the least amount ventilator synchrony. If this fails, use the least amount
of sedation required to achieve comfort and avoid of sedation required to achieve comfort and avoid
unnecessary neuromuscular blockade unnecessary neuromuscular blockade
Other Issues in Intubated &
Other Issues in Intubated &
Mechanically Ventilated
Mechanically Ventilated
Patients
Patients
n n
Monitor patient comfort, gas exchange,
Monitor patient comfort, gas exchange,
mechanics, and ventilator waveforms daily, or
mechanics, and ventilator waveforms daily, or
more frequently if indicated
more frequently if indicated
n n
When minimal settings are required for
When minimal settings are required for
oxygenation (F
oxygenation (F
I I
O
O
2 2
<55%, PEEP<8) and
<55%, PEEP<8) and
patient is hemodynamically stable, perform a
patient is hemodynamically stable, perform a
spontaneous breathing trial daily
spontaneous breathing trial daily
References
References
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continuous positive airway pressure therapy: support of a new mo continuous positive airway pressure therapy: support of a new modality for improving dality for improving
the prognosis and survival of patients with advanced congestive the prognosis and survival of patients with advanced congestive heart failure. heart failure. Heart Heart
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n n Plant P., Owen J., Elliott M. (2000). Early use of non Plant P., Owen J., Elliott M. (2000). Early use of non- -invasive ventilation for acute invasive ventilation for acute
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a a multicentre randomised multicentre randomised controlled trial. controlled trial. The Lancet, Volume 355, Issue 9219, p 1931 The Lancet, Volume 355, Issue 9219, p 1931- -
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tidal volumes as compared with traditional tidal volumes for acu tidal volumes as compared with traditional tidal volumes for acute lung injury and the te lung injury and the
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