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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
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
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
Cawley
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.
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
10
+30
A/C
0
I
5
+30
SIMV
0
I
SIMV
SIMV
SIMV
+30
PCV
0
5
+30
PSV
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
IPAP
IPAP
IPAP
+15
+5
BiPAP
EPAP
EPAP
EPAP
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.
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
Cawley
11
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
12
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
Cawley
13
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,
14
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.
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
Definition
Tidal volume
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
References
1. Cawley MJ. Mechanical ventilation: a tutorial for pharmacists.
Pharmacotherapy. 2007;27(2):250-266.
2. Cawley MJ, Skaar DJ, Anderson HL, et al. Mechanical ventilation
and pharmacological strategies for acute respiratory distress syndrome. Pharmacotherapy. 1998;18:140-155.
3. Barbarash RA, Smith LA, Godwin JE, et al. Mechanical ventilation. DICP Ann Pharmacother. 1990;24:959-970.
4. Baker BA. Artificial respiration: the history of an idea. Med Hist.
1971;15(4):336-351.
5. Drinker P, Shaw LA. Apparatus for prolonged administration of
artificial respiration: design for adults and children. J Clin Invest.
1929;7(2):229-247.
6. Spearman CB, Sheldon RL, Egan DF. Egans Fundamentals of
Respiratory Therapy. 4th ed. St. Louis, MO: CV Mosby Co;;
1982:493.
7. Geer RT. Mechanical ventilation. In: Fishman AP, ed. Pulmonary
Diseases and Disorders. New York: McGraw-Hill; 1980:1607.
8. Wilkens RL, Sheldon RL, Krider SJ. Clinical Assessment in
Respiratory Care. St. Louis, MO: CV Mosby Co; 1985:236-237.
9. Hess DR, Kacmarek RM. Essentials of Mechanical Ventilation.
2nd ed. New York: McGraw-Hill, 1996:120.
10. Slutsky AS. Mechanical ventilation: American College of Chest
Physicians consensus conference. Chest. 1993;104(6):
1833-1859.
11. Gould V, Tosco R, Wheelis R, et al. Oxygen pneumonitis in man:
ultrastructural observations on the development of alveolar
lesions. Lan Invest. 1972;26(5):499-508.
12. Giuliani R, Mascia L, Recchia F, et al. Patient-ventilator interaction
during synchronized intermittent mandatory ventilation. Effects of
flow triggering. Am J Respir Crit Care Med. 1995;151(1):1-9.
13. Tobin MJ. Medical progress: advances in mechanical ventilation.
N Engl J Med. 2001;344(26):1986-1996.
16
14. Ward NS, Dushay KM. Clinical concise review: mechanical ventilation of patients with chronic obstructive pulmonary disease.
Crit Care Med. 2008;36(5):1614-1619.
15. Moritz F, Brousse B, Gellee B, et al. Continuous positive airway
pressure versus bilevel noninvasive ventilation in acute cardiogenic pulmonary edema: a randomized multicenter trial. Ann
Emerg Med. 2007;50(6):666-675.
16. Anzueto A, Frutos-Vivar F, Esteban A, et al. Incidence, risk factors and outcomes of barotraumas in mechanically ventilated
patients. Intensive Care Med. 2004;30:612-619.
17. Pierson DJ. Complications associated with mechanical ventilation. Crit Care Clin. 1990;6:711-724.
18. Loube DI, Gay PC, Strohl KP, et al. Indications for positive airway
pressure treatment of adult obstructive sleep apnea patients: a consensus statement. Chest. 1999;115(3):863-866.
19. Engelman HM, Wild MR. Improving CPAP use by patients with the
sleep apnea/hypopnea syndrome. Sleep Med Rev. 2003;7(5):81-99.
20. Singer BD, Corbridge TC. Basic invasive mechanical ventilation.
Southern Med J. 2009;102(12):1238-1245.
21. Dhand R, Tobin MJ. Inhaled bronchodilator therapy in mechanically ventilated patients. Am J Respir Crit Care Med. 1997;
156(1):3-10.
22. Dhand R. Inhalation therapy with metered-dose inhalers and dry
powder inhalers in mechanically ventilated patients. Respir Care.
2005;50(10):1331-1344.
23. Food and Drug Administration. Use of ozone-depleting substances: removal of essential-use designation. Final rule. Fed
Regist. 2005;70(63):17167-17192.