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Berlin
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MECHANICAL VENTILATION
AND WEANING
Volume Editors:
Jordi Mancebo, MD Alvar Net, MD
Associate Professor of Medicine Professor of Medicine
Hospital de la Sante Creu i Sant Pau Hospital de la Sante Creu i Sant Pau
Servei de Medicina Intensiva Servei de Medicina Intensiva
Barcelona, Spain Barcelona, Spain
Laurent Brochard, MD
Professor of Medicine
H6pital Henri Mondor
Service Reanimation Medicale
Creteil, France
Series Editor:
Jean-Louis Vincent, MD, PhD, FCCM, FCCP
Head, Department of Intensive Care
Erasme University Hospital
Brussels, Belgium
With 85 Figures and 26 Tables
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Springer
lordi Mancebo, MD Alvar Net, MD
Associate Professor of Medicine Professor of Medicine
Hospital de la Sante Creu i Sant Pau Hospital de la Sante Creu i Sant Pau
Servei de Medicina Intensiva Servei de Medicina Intensiva
Av. S.A. Maria Claret 167 Av. S.A. Maria Claret 167
08025 Barcelona, Spain 08025 Barcelona, Spain
Laurent Brochard, MD Series Editor:
Professor of Medicine lean-Louis Vincent, MD, PhD, FCCM, FCCP
Service Reanimation Medicale Head, Department of Intensive Care
H6pital Henri Mondor Erasme University Hospital
51, Av. Du Mal de Lattre de Tassigny Route de Lennik 808
F-94010 Creteil cedex, France B-1070 Brussels, Belgium
Cataloging-in-Publication Data applied for
Die Deutsche Bibliothek -CIP-Einheitsaufnahme
Mechanical ventilation and weaning: with 26 tables I vol. ed.: lordi Mancebo .... -New York; Berlin;
Heidelberg; Hong Kong; London; Milan; Paris; Tokyo: Springer, 2003
(Update in intensive care medicine)
ISBN-13: 978-3-540-44181-6 e-ISBN-13: 978-3-642-56112-2
DOl: 10.1007/978-3-642-56112-2
Printed on acid-free paper.
Hardcover edition © 2002 Springer-Verlag Berlin Heidelberg.
Softcover edition © 2003 Springer-Verlag Berlin Heidelberg.
All rights reserved. This work may not be translated or copied in whole or in part without the written per
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and Merchandise Marks Act, may accordingly be used freely by anyone.
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press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors
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material contained herein.
Production managed by PRO EDIT GmbH, Heidelberg, Germany.
Typeset by TBS, Sandhausen, Germany.
9 8 7 6 5 4 3 2 1
ISSN 1610-4056
ISBN-13: 978-3-540-44181-6 SPIN 10891982
Springer-Verlag New York Berlin Heidelberg
A member of BerteismannSpringer Science+Business Media GmbH
Foreword
Do we really need a new book on mechanical ventilation? Initially, I
thought: certainly not! This field of medicine is indeed moving rapid
ly, but clinicians have been given several excellent books in the recent
past. However, when I went through this one, I was struck by a strong
feeling ofj amais vu. Indeed, it is focused mainly on new, difficult, prac
tical issues such as complications of mechanical ventilation (Serrano,
Esteban), patient -ventilator interaction, weaning, non -invasive ventila
tion,or artificial intelligence. Most of the members of the ventilator fan
club are here, from Europe - a strong contributor - to North America,
tracing an unexpected map where the capitals are St. Paul, Winnipeg,
Barcelona, Creteil, Nashville, Boston and Pavia.
Subtleties of assisted modes are explained, including the still exotic
PAY (Younes), from some very trivial but essential issues - what to do
when the patient fights the ventilator (Tobin) - to the most sophisticat
ed physiopathology (Sassoon). One major section is devoted to wean
ing. Weaning-induced cardiac failure is revisited (Jubran, Ferrer), as are
all predictive tests (Mancebo, Epstein, Fernandez). Many of those who
have recently contributed the most in this field are there: Ely and
Epstein, who taught us that systematic and repetitive use of algorithms
is better than plain medical judgement; Betbese, who interpreted
unplanned extubations; Tobin and Jubran, who did the same for shal
low breathing. Another highlight is non-invasive ventilation, the new
paradigm that is expanding so rapidly these days. The magic triangle
here is clearly Creteil-Barcelona-Pavia. Finally, the opening to the
future is represented by the fascinating knowledge-based system,
recently implemented into a ventilator, which achieves the most ancient
dream of ventilator users, an intelligent, auto-controlled machine ....
Creteil F. Lemaire
Contents
Mechanical Ventilation in Acute Respiratory Failure:
What We Have Learnt and What We Still Need to Learn
(f. Mancebo)
2 Controlled Mechanical Ventilation. . . . . . . . . . . . . . . . . . . . . 13
(f.]. Marini)
3 Proportional Assist Ventilation . . . . . . . . . . . . . . . . . . . . . . . . 39
(M. Younes)
4 Influence of Ventilator Performance
on Assisted Modes of Ventilation ...................... 74
(f.-C Richard and L. Breton)
5 Application of Tracheal Gas Insufflation
for Critical Care Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
(L. Blanch, G. Murias, P. V. Romero,
R. Fernandez, and A. Nahum)
6 What a Clinician Should Do When a Patient
"Fights the Ventilator" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 100
(CG. Alex, P.]. Fahey, and M.]. Tobin)
7 Critical Illness Polyneuropathy
and Critical Illness Myopathy. . . . . . . . . . . . . . . . . . . . . . . .. 118
(C Serrano-Munuera and 1. Illa)
8 Factors Associated with Mortality
in Mechanically Ventilated Patients .................... 133
(F. Frutos Vivar, 1. Alia Robledo,
and A. Esteban de la Torre)
9 Pathophysiology of Weaning-Associated
Respiratory Failure ................................. 152
(CS.H. Sassoon, A. Manka, and K.G. Chetty)
VIII Contents
10 Rapid Shallow Breathing: Causes and Consequences. . . . .. 161
(A. Jubran)
11 Cardiopulmonary Interactions and Gas Exchange
During Weaning from Mechanical Ventilation ........... 169
(M. Ferrer, J. Roca, and R. Rodriguez-Roisin)
12 Weaning-Induced Cardiac Failure 184
(A. Jubran)
13 Physiopathological Determinants
of Patient-Ventilator Interaction
and Dyssynchrony During Weaning ................... 193
(C.S.H. Sassoon, IS. Gallacher, and A. Manka)
14 Weaning Criteria: Physiologic Indices
in Different Groups of Patients. . . . . . . . . . . . . . . . . . . . . . .. 203
(I. Vallverdu and J. Mancebo)
15 How Should We Interpret Weaning-Predictive Indices? . . .. 216
(S.K. Epstein)
16 Timing and Criteria for Beginning Weaning. . . . . . . . . . . .. 239
(R. Fernandez)
17 The Importance of Clinical Algorithms
to Facilitate Weaning and Extubation .................. 248
(E. W. Ely)
18 Strategies for Implementation
of Weaning Algorithms in the Clinical Arena ............ 264
(E. W. Ely)
19 The Role of Muscle Training
and Rehabilitation During Weaning. . . . . . . . . . . . . . . . . . .. 279
(G.c. Piaggi, E. De Mattia, and S. Nava)
20 The Role of Noninvasive Mechanical Ventilation
in Facilitating Weaning and Extubation. . . . . . . . . . . . . . . .. 290
(S. Nava and S. Karakurt)
21 Expanding Horizons of Noninvasive Ventilation ......... 298
(L. Brochard and f. Mancebo)
22 Unplanned Extubation .............................. 313
(A.J. Betbese and J. Mancebo)
Contents IX
23 Extubation Failure: Can It Be Prevented or Predicted? . . . .. 322
(S.K. Epstein)
24 Continuous Positive Airway Pressure
in the Hypoxemic Patient ............................ 336
(A. Delclaux, L. Brochard, and J. Mancebo)
25 Closed-Loop Systems for Mechanical Ventilation. . . . . . . .. 348
(L. Brochard and M. Dojat)
rcu:
26 Tracheostomy in the Why, When and How? ......... 360
(E. L'Her and L. Brochard)
Subject Index ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 375
List of Contributors
Charles G. Alex
Associate Professor of Medicine, Division of Pulmonary and Critical Care
Medicine, Loyola University of Chicago Stritch School of Medicine,
Department of Veterans Affairs, Edward Hines Jr. Hospital, Hines, Illinois, USA
Inrnaculada Alia Robledo
Assistant Physician, Intensive Care Unit, University Hospital of Getafe,
Madrid, Spain
A.J. Betbese
Servei de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau,
Av. S.A. Maria Claret 167,08025 Barcelona, Spain
Lluis Blanch
Intensive Care Department, Hospital de Sabadell, Corporacio Parc Tauli,
Parc Tauli sin, 08208 Sabadell, Spain
Lucie Breton
Service de Reanimation Medicale, H6pital Charles Nicolle, 1 rue de Germont,
76031 Rouen Cedex, France
Laurent Brochard
H6pital Henri Mondor, Service Reanimation Medicale,
51 Avenue Du Mal de Lattre de Tassigny, 94010 Cniteil, France
Kota G. Chetty
Department of Medicine, Veterans Affairs Medical Center,
and the University of California, Irvine, California, USA
Christophe Delclaux
Servei de Medicina Intensiva, Hospital de Sant Pau,
Universitat Autbnoma de Barcelona,
Av. S.A.M. Claret 167,08025 Barcelona, Spain
Michel Dojat
Inserm U492, H6pital Henri Moudor, 94010 Creteil, France
E. Wesley Ely
Division on Allergy, Pulmonary, and Critical Care Medicine, The Vanderbilt
University Medical Center, 913 Oxford House, Nashville, TN 37232-4760, USA
XII List of Contributors
Scott K. Epstein
New England Medical Center, Box 369,750 Washington St., Boston, MA 02111, USA
Andres Esteban de la Torre
Head of Department, Intensive Care Unit, University Hospital of Getafe,
Madrid, Spain
Patrick J. Fahey
Professor of Medicine, Chief, Department of Medicine,
Department of Veterans Affairs, Edward Hines, Jr. Hospital, Associate Chairman,
Department of Medicine, Loyola University of Chicago Stritch School of Medicine,
Hines, Illinois, USA
Rafael Fernandez
Intensive Care Service, Hospital de Sabadell,
Parc Tauli sIn, 08208 Sabadell, Spain
Miquel Ferrer
UVIR. Servei de Pneumologia, Institut Clinic de Pneumologia i Cirurgia
Toracica, Hospital Clinic, Villarroel 170,08036 Barcelona, Spain
Fernando Frutos Vivar
Assistant Physician, Intensive Care Unit, University Hospital of Getafe,
Madrid, Spain
T. Scott Gallacher
Department of Medicine, Veterans Affairs Medical Center,
and the University of California, Irvine, California, USA
Isabel IlIa
Neuromuscular Division, Department of Neurology,
Hospital de la Sta. Creu i St. Pau, C/Sant Antoni Ma Claret, 167,
08025 Barcelona, Spain
AmalJubran
Division of Pulmonary and Critical Care Medicine, Edward Hines Jr.,
Veterans Affairs Hospital and Loyola University of Chicago Stritch School
of Medicine, Hines, IL 60141, USA
Sait Karakurt
Marmara University Hospital, Pulmonary and Critical Care Medicine,
81110 Istanbul, Turkey
Erwan L'Her
Reanimation et Urgences Medicales, CHU de la Cavale Blanche, Brest, France
Jordi Mancebo
Servei de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau,
Av. S.A. Maria Claret 167,08025 Barcelona, Spain
Albana Manka
Department of Medicine, Veterans Affairs Medical Center,
and the University of California, Irvine, California, USA
John J. Marini
Director of Pulmonary/Critical Care, St. Paul-Ramsey Medical Center,
640 Jackson Street, St. Paul, MN 55101-2595, USA
