Chest
Volume 104, Issue 6, December 1993, Pages 1833-1859
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accp consensus conference: Consensus Development Conference: Journal Article: Review
Mechanical Ventilation

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OBJECTIVES AND SPECIFIC RECOMMENDATIONS SECTION 1: OBJECTIVES OF CONSENSUS COMMITTEE

Although the concept of artificial respiration was recognized in the 16th century by Vesalius, it was not until the 20th century that mechanical ventilation became a widely used therapeutic modality. Over the past 30 years, and especially over the past decade, there has been an explosion of new ventilatory techniques that present a bewildering array of alternatives for the treatment of patients with respiratory failure. Unfortunately, although the number of options available to the clinician

SECTION 2: OBJECTIVES OF MECHANICAL VENTILATION

Mechanical ventilation and continuous positive airway pressure (CPAP) are methods of supporting intubated patients during illness, and are not, in and of themselves, curative or therapeutic. Indeed, in certain clinical settings, there may be effective alternative therapies that do not require intubation and mechanical ventilation. The fundamental objectives for ventilatory support in acutely ill patients may be viewed physiologically and clinically, as detailed below. The following objectives

Mechanical Ventilation for Specific Entities

Adult Respiratory Distress Syndrome (ARDS): Although it has been argued that patients with ARDS are now more severely ill than those encountered in the past, the failure of ARDS mortality to decrease during the past 15 to 20 years is disappointing, particularly in light of the many technical advances in ICU care. Criteria that selected a severely hypoxemic subset of patients with ARDS were established in the 1974 to 1977 ECMO clinical trial. Recent work indicates that the average survival of

Patient-Related Physiologic Principles

The response to mechanical ventilation is governed by several physiologic relationships. Two cardinal rules apply:

  • 1.

    Although the qualitative response of a given physiologic variable to manipulation of ventilator settings may be predictable, the quantitative response is highly variable and patient specific. Thus, an increase in PEEP or level of ventilation usually improves PaO2 at a given FIo2. However, the extent of improvement in any given patient may be large or small, and the short-term

SECTION 5: COMPLICATIONS OF MECHANICAL VENTILATION

Although mechanical ventilation offers vital life support, its use can result in untoward or life-threatening side effects.70 Many such hazards can be modified or avoided by appropriate attention to the technique of implementation. Interventions associated with mechanical ventilation include airway intubation, application of positive pressure to the respiratory system, provision of supplemental oxygen, imposition of unnatural breathing patterns, and the administration of sedative or paralytic

What Is It, and When Does It Begin?

Weaning has been defined as the process whereby mechanical ventilation is gradually withdrawn and the patient resumes spontaneous breathing.141 Within the daily vernacular of the ICU, most clinicians do not employ the term weaning in the strict sense, but rather they use it to include the overall process of discontinuing ventilator support. To enhance communication between investigators and clinicians, it may be wise to drop the term weaning, and replace it by a term such as discontinuation of

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    American College of Chest Physicians' Consensus Con ference, Northbrook, Illinois, January 28-30, 1993. Cosponsored by the Society of Critical Care Medicine, and the European Society of Intensive Care Medicine.

    Participants: Arthur S. Slutsky, M.D., F.C.C - Chairman: Toronto, Ontario, Canada; Laurent Brochard, M.D., Creteil, France; R. Philip Dellinger M.D., FCC.?, Columbia, Mo; John B. Downs, M.D., Tampa, Fla; TJames Gallagher, M.D., FCC.?, Gainesville, Fla; Luciano Gattinoni, M.D., Milan, Italy; Keith Hickling, M.D., Otago, New Zealand; Robert M. Kacmarek, Ph.D., R.R.T, Boston, Mass; Neil Maclntyre, M.D., F.C.C.?, Durham, NC; John j Marini, M.D., FCC.?, St. Paul, Minn; Alan H. Morrs M.D., F.C.C.?, Salt Lake City, Utah; Davidj Pierson, M.D., FCC.?, Seattle; Jean-Jacques Rouby, M.D., Ph.D., Paris, France; Martin J. Tobin, M.D., F.C.C.?, Chicago; and Magdy Younes, M.D., Manitoba, Canada

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