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Conflict of Interest Declaration

I receive royalties for two books on critical care


published by McGraw-Hill

I do not receive financial support for research from any


pharmaceutical, biotechnology or medical device company

I do not serve as a consultant to or on the advisory board of


any company
In early 2017, New York University organized a symposium to celebrate the 60th anniversary
of the Nobel Prize awarded to Andre Cournand and Dickinson Richards, the last
North American clinicians to receive the award
The following lecture is the presentation I made at this symposium
Cournand and Richards made seminal observations concerning
the effect of positive-pressure ventilation on cardiac output
Cournand and Richards made seminal observations concerning the effect of positive-pressure
ventilation on cardiac output, yet the link between physiology and mechanical ventilation is best
made by a concept of another Frenchman: Claude Bernard’s milieu intérieur
Cournand and Richards seminal observations effect of positive-pressure ventilation on cardiac output,
yet the link between physiology and mechanical ventilation is best made by a concept of
another Frenchman: Claude Bernard’s milieu intérieur
Claude Bernard during experiment with collaborators
in laboratory of Collège de France

Léon-Augustin L'hermitte, 1844-1925


Laboratory of Physiology, Sorbonne University, Paris (1889)

Cournand and Richards seminal observations … yet link between physiology and mechanical ventilation
is best made by a concept of another Frenchman: Claude Bernard’s milieu intérieur
Acute Respiratory Failure
Patients consented
to photo display

Patients admitted to the ICU exemplify par excellence a disturbance in this milieu
J Appl Physiol 1951;4:77

Although respiratory failure is defined conventionally in terms of abnormal arterial blood gases –
hypoxia, hypercapnia – these are rarely the reasons for institution of mechanical ventilation
Fritz Rohrer, 1988-1926
Rohrer F. In: Handbuch der normalen und pathologischen
Physiologie. Springer, Berlin,1925, vol 2, p 70-127 University of Bern
Instead, mechanical ventilation is typically instituted because of disturbances in the
framework first articulated by Rohrer, and subsequently developed by Fenn, Otis and Rahn:
derangements in respiratory mechanics leading to marked increases in work of breathing
Photo taken in 1963

Arthur Otis Hermann Rahn


1913 -2008 1912-90

Wallace Fenn
1893-1971

Instead, mechanical ventilation is typically instituted because of disturbances in the framework


first articulated by Rohrer, and subsequently developed by Fenn, Otis and Rahn:
derangements in respiratory mechanics leading to marked increases in work of breathing
Inspiratory Effort in Acute Respiratory Failure

AJRCCM 1997;155:906

In patients who develop acute respiratory failure, inspiratory effort increases ~ 4 times
above the normal value, and the increase is 6-fold in some patients
ARRD 1982;126:9

In such patients, the respiratory muscles account for 20% of total oxygen consumption
– and more than 50% in some patients ARRD 1982;126:9
ARRD 1982;126:9

In such patients, the respiratory muscles account for 20% of total oxygen consumption
– and more than 50% in some patients ARRD 1982;126:9
NEJM 1994;330:1056

The overriding objective of mechanical ventilation is to decrease oxygen cost of


breathing, enabling precious oxygen stores to be rerouted from the respiratory
muscles to other vulnerable tissue beds
NEJM 2001;344:1986

Patient work during mechanical ventilation is primarily determined by a physician's ability


to align cycling of the machine with the rhythm of the patient's respiratory centers
The rhythm of breathing, however, exhibits considerable breath-to-breath variability
1954 Engstrom
Ventilator

In the 1950s, 60s and even 70s, neuromuscular blockers were administered to prevent
patients from bucking against cycling of the ventilator
Schematic Representation of Internal Operation of ICU Ventilator

In: Tobin, Principles and Practice of Mechanical Ventilation, 3rd ed, 2012, p67

Today, almost all ventilator modes are “cycled-on” by a patient triggering the pneumatic
system that delivers flow
Cycling-Rhythm Alignment

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

Problems in aligning the cycling of a ventilator with a patient's own rhythm of breathing
may arise at three points: cycling-on function (triggering), post-trigger inflation, and cycling-off
Cycling-Rhythm Alignment

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

Problems in aligning the cycling of a ventilator with a patient's own rhythm of breathing may arise at 3 points: cycling-on
(triggering), post-trigger inflation (flow delivery), and cycling-off function (inspiration: expiration switchover)
Cycling-Rhythm Alignment

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

Problems in aligning the cycling may … arise at three points: cycling-on function (triggering), post-trigger
inflation, and cycling-off function (inspiration:expiration switchover)
Respiratory Motor Output and Ventilator Unloading

For a given trigger sensitivity, patient respiratory motor output determines the delay
between onset of inspiratory effort and onset of ventilator unloading
Low Drive and Delayed Ventilator Assistance

Flow

Paw

Pes

When respiratory drive is low, assistance may not begin until well into a patient’s
inspiratory time, thereby causing the ventilator to cycle almost completely out of phase
with the patient’s respiratory cycle
Output Flow-Control Valve

In: Tobin, Principles and Practice of


Mechanical Ventilation, 3rd ed, 2012, p69
When patient inspiratory effort opens the demand valve, the
inspiratory neurons do not suddenly switch off, and a patient may expend
considerable inspiratory effort throughout the remainder of inflation
Respiratory Motor Output and Ventilator Unloading

Tobin NEJM 2001;344:1986

When patient inspiratory effort opens the demand valve, the inspiratory neurons do
not suddenly switch off, and a patient may expend considerable inspiratory
effort throughout the remainder of inflation
Intrinsic PEEP impedes Ventilator Triggering

Flow, L/m
Pes, cm H2O Paw, cm H2O

PEEPi
PEEPi = 0.5 cmH2O 10.6 cmH2O

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

The patient on the right exhibits a considerable delay between the onset of
inspiratory effort, signaled by the vertical blue line, and the onset of flow delivery
by the ventilator, signaled by the vertical red line
Intrinsic PEEP impedes Ventilator Triggering

Flow, L/m
Pes, cm H2O Paw, cm H2O

PEEPi
PEEPi = 0.5 cmH2O 10.6 cmH2O

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

The patient had to decrease esophageal pressure by more than 10 cm H2O,


overcoming the level of intrinsic PEEP, in order to successfully trigger flow
delivery by the ventilator
Failure to Trigger

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

Among patients receiving a high level of ventilator assistance, a quarter to a third of


patient inspiratory efforts may fail to trigger the machine
Failure to Trigger

Rate = 16

Rate = 28

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871


In this patient, the respiratory centers are firing 28 times per minute whereas the
ventilator is cycling only 16 times per minute. That is, 43% of the patient’s inspiratory
efforts fail to trigger ventilator assistance.
Failure to Trigger

Rate = 16

Rate = 28

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

the respiratory centers are firing 28/min whereas ventilator is cycling only 16 times per minute.
That is, 43% of the patient’s inspiratory efforts fail to trigger ventilator assistance
Double Triggering

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

Some patients exhibit double triggering, where the ventilator produces two inflations
within a single inspiratory effort made by the patient
Double Triggering

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

Here, esophageal pressure falls and remains negative for more than 1 second,
whereas duration of mechanical inflation is 0.6 second
Double Triggering

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

The longer duration of neural inspiration as compared with mechanical inflation causes the
ventilator to deliver a 2nd breath before there’s time for exhalation, producing breath stacking
Double Triggering

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

In this patient, arrowheads signal 4 incidents of double triggering; the width of the Pes
swing is roughly equivalent to duration of patient neural inspiratory time
Double Triggering

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

On the bottom tracing, patient neural inspiratory time in the double-triggered breaths
– width of the Pes swing – is substantially longer than in the normally triggered breaths
Triggering Peculiarities

Some might think that these triggering peculiarities are no more than arcane quirks;
on the contrary, they have major significance and contribute to patient mortality when
they go unrecognized
Low versus High Tidal Volume in ARDS

1.0

Survival
Low, 6 ml/kg
Proportion Surviving

0.8
69%
0.6 60%
Control, 12 ml/kg
0.4

n=861 (p<0.007)
0.2

0
0 20 60 100 140 180
Days after Randomization NEJM 2000;342:1301

Consider mechanical ventilation in patients with ARDS, where a tidal volume of 6 ml/kg
has been shown to lower mortality
Tidal Volume in ARDS

This setting is so widely accepted that it has become


de rigueur in protocolized management
Tidal Volume in ARDS

Principles and Practice of Mechanical Ventilation, 3rd ed, 2012, p141


Protocol advocates, ungrounded in physiology, do not recognize
that low tidal volume is necessarily accompanied by shortening
of mechanical inspiratory time; and once mechanical TI becomes less
than neural TI, double triggering is inevitable
Tidal Volume in ARDS

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

…accompanied by shortening of mechanical TI; and once mechanical inspiratory time


becomes less than neural inspiratory time, double triggering is inevitable
Low versus High Tidal Volume in ARDS

1.0

Survival
Low, 6 ml/kg
Proportion Surviving

0.8
69%
0.6 60%
Control, 12 ml/kg
0.4

n=861 (p<0.007)
0.2

0
0 20 60 100 140 180
Days after Randomization NEJM 2000;342:1301

Protocol enthusiasts believe they’re delivering a tidal volume of 6 ml/kg, but the patient
is receiving 12 ml/kg – a setting proven to increase mortality
There is simply no substitute for deep understanding
and clinical wisdom when taking care of patients

Dickinson W. Richards, MD
1895-1973
Inspiratory Flow Demand

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871


When patients are initially connected to a ventilator, inspiratory flow is typically set at some
default value, such as 60 L/min; many critically ill patients have elevated respiratory motor
output and the flow setting may not be sufficient to meet patient flow demands
Inspiratory Flow Demand

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871


The flow setting at 60 L/min in this patient produced marked negative deflection in airway
pressure (the triggering effort); subsequent extensive scalloping of the pressure contour
signifies that delivered flow was insufficient to meet the patient's high demand
Inspiratory Flow Demand

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871


A flow setting at 90 L/min resulted in a small negative deflection in airway pressure and
a smooth convex pressure contour, signifying that flow satisfied patient respiratory
motor output
Inspiratory Flow Demand

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871


The swings in esophageal pressure were smaller at flow of 90 L/min, signifying
greater unloading of the respiratory muscles
Cycling-Rhythm Alignment

Tobin et al, Comprehensive Physiology (Handbook of Physiology) 2012;2:2871

The next point in the respiratory cycle at which problems may arise is at the switchover
between inspiration and expiration
Inspiration-Expiration Switchover

Neuronal
firing

During pressure support, the algorithm for "cycling-off" of mechanical inflation is based
on a decrease in flow to 25% of the peak value
Inspiration-Expiration Switchover

Neuronal
firing

In patients with COPD who have a prolonged time constant, more time will be required
to reach this threshold
Inspiration-Expiration Switchover

Neuronal
firing

The expiratory neurons become impatient and start to fire, causing contraction of the
expiratory muscles during mechanical inflation
Inspiration-Expiration Switchover

Pes, cm H2O
Time, sec

We became aware of this problem by looking at the contour of esophageal pressure


in patients with COPD receiving pressure support
Inspiration-Expiration Switchover

Esophageal
pressure

Pes, cm H2O

Time, sec

Halfway during inflation, esophageal pressure is higher than calculated chest-wall recoil
pressure (the dashed tracing), indicating expiratory muscle recruitment
Expiratory Muscle Recruitment during Inflation

Transversus abdominis
EMG (arbitrary units)

To obtain more direct evidence, we inserted needle electrodes into the transversus
abdominis
Expiratory Muscle Recruitment during Inflation

Transversus abdominis
EMG (arbitrary units)

This patient with COPD receiving pressure support activated his expiratory muscles about
half way during mechanical inflation – an under-appreciated form of fighting the ventilator
Cycling-Rhythm Alignment

Ventilator

Subject 1
phase angle (θ): 60°

Subject 2
phase angle (θ): -45°

The most precise way to quantify a discrepancy in timing of ventilator cycling versus
rhythmical activity of a patient's respiratory centers is to measure phase angle (θ)
Cycling-Rhythm Alignment

Ventilator

Subject 1
phase angle (θ): 60°

Subject 2
phase angle (θ): -45°

If, for example, the major expiratory muscle, the transversus abdominis, starts to contract
before completion of mechanical inflation, phase angle will have negative units
Cycling-Rhythm Alignment

We employed a Starling resistor to induce airflow limitation in


healthy subjects and wire electrodes to obtain EMG recordings
of the diaphragm and transversus abdominis
Cycling-Rhythm Alignment

All subjects exhibited non-triggering efforts when ventilated with


pressure support
Cycling-Rhythm Alignment

Phase angle of non-triggering attempts was significantly more negative than


phase angle of attempts that successfully triggered the ventilator
Cycling-Rhythm Alignment

This means that the length of time that the expiratory muscles had been
active before cycling-off of mechanical inflation was longer for
non-triggering attempts than for triggering attempts
Cycling-Rhythm Alignment

The longer the time that mechanical inflation continues into neural expiration,
the shorter will be the time available for unopposed expiratory flow, causing
elastic recoil to rise and increasing the likelihood of non-triggering
Sleep during Mechanical Ventilation

By ablating behavioral stimuli, sleep might be expected to


enhance respiratory muscle rest during mechanical ventilation
Sleep during Mechanical Ventilation

But again physiological mechanisms intervene


Sleep during Mechanical Ventilation
Assist Control Pressure Support

Horizontal bars on top signify


arousals and awakenings

We undertook polysomnography in critically ill patients receiving


assist-control and pressure support
Sleep during Mechanical Ventilation
Assist Control Pressure Support

Horizontal bars on top signify


arousals and awakenings

During pressure support, this patient had repeated central apneas


Sleep during Mechanical Ventilation

Apneas per hour

Assist Control Pressure Support

More than half the patients developed central apneas during pressure
support, but no apneas during assist-control
Arousals plus Awakenings per hour

p<0.05

54 79

Assist Pressure
Control Support

Sleep fragmentation was greater during pressure support than during assist-control:
79 versus 54 events per hour
Arousals plus Awakenings per hour

p<0.05

54 79

Assist Pressure
Control Support

This level of sleep fragmentation is equivalent to that experienced by patients with


obstructive sleep apnea who have excessive daytime sleepiness and impaired cognition
Sleep during Mechanical Ventilation
Assist Control Pressure Support

Horizontal bars on top signify


arousals and awakenings

Disturbed sleep during pressure support was related to the development of central
apneas, which, in turn, was related to the difference between end-tidal PCO2 and
the apnea threshold
Sleep during Mechanical Ventilation

PETCO2 minus apnea threshold, mm Hg

Central apneas per hour

Disturbed sleep during pressure support was related to the development


of central apneas, which, in turn, was related to the difference
between end-tidal PCO2 and the apnea threshold
Sleep during Mechanical Ventilation
Arousals plus Awakenings per hour
Apneas per hour
90 p<0.01
75

60
50

30
79 44
25
0

Pressure PS plus
Support Dead Space 0
Pressure PS plus
Support Dead Space

The addition of dead space increased PCO2 by 4.3 mm Hg and decreased central apneas
(from 53 to 4 per hour), and decreased the sum of arousals and awakenings from
79 to 44 events per hour
Sleep during Mechanical Ventilation
Arousals plus Awakenings per hour
Apneas per hour
90 p<0.01
75

60
50

30
79 44
25
0

Pressure PS plus
Support Dead Space 0
Pressure PS plus
Support Dead Space

The addition of dead space increased PCO2 by 4.3 mm Hg, decreased central apneas
(from 53 to 4 per hour), and decreased the sum of arousals and awakenings from
79 to 44 events per hour
Physiologic Basis of Mechanical Ventilation

Tobin NEJM 2001;344:1986

In summary, understanding of respiratory physiology is fundamental to achieving optimal


synchronization of respiratory muscle groups with ventilator cycling and achieving
muscle rest, which is the primary reason mechanical ventilation is instituted
Dr. E. B. Mer
Dr. Protocol
Some physicians, however, do not relish a physiological (individualized) approach
to mechanical ventilation, and prefer “Making Everything Easier” guidelines
While mechanical ventilation saves many lives, it is also responsible for many deaths
Accordingly, it is critical to get patients off the ventilator at the earliest possible time
Getting Patients off the Ventilator

This task demands greater wisdom and cognitive skill than is required for adjusting
settings on the ventilator
60-80% of Ventilated Patients Tolerate First Weaning Attempt
100
Extubated
Reintubated
Percentage 80

60

76% 68%
40

20

16%
0
n = 456 n = 546
Brochard et al AJRCCM 1994 Esteban et al NEJM 1995

Randomized trials on weaning techniques reveal that physicians are inherently slow
at initiating the weaning process
Weaning-Predictor Tests

Weaning predictor tests consist of physiological measurements that alert


a physician that a ventilated patient might be able to come off the ventilator
sooner than the physician otherwise thinks
In this study, we developed a new weaning predictor test, frequency-to-tidal
volume ratio, f/VT
Rapid Shallow Breathing Index

Ventilator
stopped

Rapid shallow breathing is present when


f/VT exceeds 100 breaths/min/liter
e.g., f = 30 breaths/min
VT = 0.30 liter

When the f/VT ratio exceeds 100, rapid shallow breathing is present
f/VT Threshold
N Engl J Med 1991;324:1445

A f/VT ratio of 100 performed superiorly to other weaning predictors in forecasting which
patients would successfully tolerate a T-tube trial vs. patients who would fail a T-tube trial
f/VT: Predicting Weaning-Extubation Outcome
Yang & Tobin, 1991 Jacob et al, 1997
Gandia & Blanco, 1992 Krieger et al, 1997
Sassoon & Mahutte, 1993 Rivera & Weissman et al, 1997
Yang, 1993 Farias et al, 1998
Mohsenifar et al, 1993 Vallverdu et al, 1998
Lee et al, 1996 Thiagarajan et al, 1999
Capdevila et al, 1995 Zeggwagh et al, 1999
Epstein, 1995 Maldonado et al, 2000
Chatila et al, 1996 Uusaro et al, 2000
Dojat et al, 1996 Khamiees et al, 2001
Leitch et al, 1996 Smina et al, 2003
Mergoni et al, 1996 Conti et al, 2004
Bouachour et al, 1996 Fernandez et al, 2004
Baumeister et al, 1997 Jiang et al, 2004
Гологорский et al, 1997

Since our original report, the accuracy of f/VT in predicting weaning outcome has been
evaluated by more than 27 groups of investigators, making it the most reevaluated
phenomenon in critical care
Positive Predictive Value ranges from 0.53 to 0.98
1.0

Positive Predictive Value


0.8

0.6

0.4

0.2

0.0

Some investigators reported that f/VT was unreliable in predicting


weaning outcome
Positive Predictive Value as a Function of Pretest Probability
1.0

0.8
Positive Predictive Value

0.6

Weighted r = 0.86
0.4 p < 0.0001

0.2

0.0
0.0 0.2 0.4 0.6 0.8 1.0
Pretest Probability of Success

Once the “non-supportive” data are analyzed using a Bayesian framework,


anchored on pretest probability, they unwittingly confirm the reliability of f/VT
Weaning Trial
Patient consented
to photo display

If f/VT is less than 100, the physician proceeds with a weaning trial using
one of two methods: intermittent unassisted breathing (zero vent support,
as with T-tube trial seen here) or gradual reduction in ventilator assistance
Weaning-Predictor Tests
Patient consented
to photo display

Weaning predictors are not done to forecast a failed weaning trial, but in order to alert a
physician that a patient might tolerate a weaning trial sooner than the physician otherwise thinks
and move that weaning trial earlier in time and shorten the overall of duration mechanical ventilation
Weaning-Predictor Tests
Patient consented
to photo display

Weaning predictors are not done to forecast a failed weaning trial, but in order to alert a physician
that a patient might tolerate a weaning trial sooner than the physician otherwise thinks
and move that weaning trial earlier in time and shorten the overall of duration mechanical ventilation
Weaning-Predictor Tests

In: Tobin, Principles and Practice of Mechanical Ventilation, 3rd ed, 2012, p1308

Weaning predictors are not done to forecast a failed weaning trial, but in order to alert a physician that a
patient might tolerate a weaning trial sooner than the physician otherwise thinks and move that
weaning trial earlier in time and shorten the overall of duration mechanical ventilation
AJRCCM 1994;150:896
In 1994, Brochard published the first RCT of different weaning methods, showing that
IMV was the worst technique
AJRCCM 1994;150:896
One arm in the Brochard RCT was T-tube trials combined with assist-control, but the
duration of rest between each failed T-tube trial could be as brief as 1 hour
Transdiaphragmatic twitch pressure

At this time, Franco Laghi had data showing that recovery from diaphragmatic fatigue
required at least 24 hours of rest
This was the motivation behind the incorporation of a 24-hour rest arm in an RCT
conducted by the Spanish Lung Failure Collaborative Group
Our study revealed that T-tube trials combined with 24 hours of rest weaned patients
3 times faster than did IMV and 2 times faster than did pressure support
JAMA 2013;309:671

The most difficult group of patients to wean is those


JAMA requiring prolonged ventilation
2013;309::671
in a long-term acute care hospital (LTACH)
Trach Collar versus Pressure Support
1.0

Proportion of patients remaining


on mechanical ventilation
0.8

Pressure
0.6 support

0.4

0.2
Trach collar

p = 0.016
0.0
0 5 10 15 20 25 30 35 40 45
Weaning duration (days) JAMA 2013;309:671
In a randomized trial, we found that intermittent unassisted breathing (using a tracheostomy
collar) resulted in 1.43 times faster removal of the ventilator than did pressure support
Randomized Controlled Trials of Weaning Techniques

The superior outcome with unassisted breathing arms (T-tube, trache collar) in our
two RCTs is best explained on the basis of physiology
Pressure Support vs Unassisted Breathing

Pressure Support Unassisted Breathing

Tobin et al, Comprehensive Physiology (Handbook of Physiology)2012;2:2871

The superior outcome with the unassisted-breathing arm (T-tube, trache collar) in our
two RCTs is best explained on the basis of physiology
Pressure Support vs Unassisted Breathing

Pressure Support Unassisted Breathing

Tobin et al, Comprehensive Physiology (Handbook of Physiology)2012;2:2871

During trach-collar or T-piece trial, the amount of respiratory work is determined solely
by the patient – the ventilator cannot do any work
Evaluation of Patient Weanability
Trach-Collar or T-piece Wean

Respiratory Pump Ventilator

During trach-collar or T-piece trial, the amount of respiratory work is


determined solely by the patient – the ventilator cannot do any work
Evaluation of Patient Weanability
Trach-Collar or T-piece Wean

Respiratory Pump Ventilator

As such, a physician observing a patient breathe on a T-piece or trach


collar has a completely clear view of the patient's respiratory capabilities
Evaluation of Patient Weanability
Pressure-Support Wean

Respiratory
Ventilator
system

During pressure-support weaning, a clinician's ability to judge


weanability is clouded because the patient is receiving
ventilator assistance
Methodology to Quantify Pressure-Time Product during Pressure Support

Onset Inspiratory Effort

8 Chest-wall recoil
pressure
Pes, cm H2O

4
Esophageal
0 pressure

-4
0 2 4 6
Time, sec
Jubran et al, AJRCCM 1995;152:129
… andit is extremely difficult to distinguish between how much work the patient is doing
and how much work the ventilator is doing, even when esophageal pressure is being
monitored – and impossible without esophageal pressure monitoring
Methodology to Quantify Pressure-Time Product during Pressure Support

Onset Inspiratory Effort

8 Chest-wall recoil
pressure
Pes, cm H2O

4
Esophageal
0 pressure

-4
0 2 4 6
Time, sec
Jubran et al, AJRCCM 1995;152:129
… andit is extremely difficult to distinguish between how much work the patient is doing
and how much work the ventilator is doing, even when esophageal pressure is being
monitored – and impossible without esophageal-pressure monitoring
Evaluation of Patient Weanability
Pressure-Support Wean

Patient Ventilator
work work

It may be that the ventilator is doing a moderate amount of work


Evaluation of Patient Weanability
Pressure-Support Wean

Patient
Ventilator
work work

Or the ventilator is doing a large amount of work


Evaluation of Patient Weanability
Pressure-Support Wean

Patient Ventilator
work
work

Or the ventilator is doing very little work


Evaluation of Patient Weanability
Pressure-Support Wean

By physical examination, and even by looking at airway pressure


tracings on the monitor, it is impossible to estimate how much work
a patient is performing while receiving pressure support
Evaluation of Patient Weanability

Trach-Collar or T-piece Wean Pressure-Support Wean

Patient Ventilator
work work

Because of the impossibility of guesstimating work of breathing during pressure support,


clinicians are more likely to accelerate the weaning process in patients who perform
unexpectedly well during a T-piece trial or trach-collar challenge than when a low level
of pressure support is being used
Readiness of a Patient for Extubation
PS 0 PS 5 PS 10

Time (sec)

Tobin et al, Comprehensive Physiology (Handbook of Physiology)2012;2:2871


Many physicians think weaning is complete when they reach pressure support of 5-7 cmH2O,
often combined with PEEP 5 cmH2O, and extubate patients from these settings
Readiness of a Patient for Extubation
PS 0 PS 10

Time (sec)

Tobin et al, Comprehensive Physiology (Handbook of Physiology)2012;2:2871


When assessing a patient’s readiness for extubation, a physician needs to guesstimate
patient work of breathing
Decrease in Patient Work of Breathing Compared with Extubated State

Patient work of breathing, Percent 1%

Extubated CPAP 0, PS 0
(FlowBy)

Compared with work of breathing in the extubated state, breathing through the ventilator
circuit (with CPAP of 0 and pressure support of 0) decreases patient work by about 1%
Decrease in Patient Work of Breathing Compared with Extubated State

Patient work of breathing, Percent 1%

31-38 40%

Extubated CPAP 0, PS 0 PS 5 CPAP 5


ARRD 1991;143:469 (FlowBy)
AJRCCM 1995;152:129

In contrast, CPAP of 5 decreases patient work of breathing by 40%


Pressure support of 5 decreases patient work of breathing by 30-40%
Decrease in Patient Work of Breathing Compared with Extubated State

Patient work of breathing, Percent 1%

31-38 40%

Extubated CPAP 0, PS 0 PS 5 CPAP 5


ARRD 1991;143:469 (FlowBy)
AJRCCM 1995;152:129

In contrast, CPAP of 5 decreases patient work of breathing by 40%


Pressure support of 5 decreases patient work of breathing by 30-40%
Decrease in Patient Work of Breathing Compared with Extubated State

Patient work of breathing, Percent 1%

31-38 40%

Extubated CPAP 0, PS 0 PS 5 CPAP 5


ARRD 1991;143:469 (FlowBy)
AJRCCM 1995;152:129

When evaluating a patient’s readiness for extubation, the thing you most want to avoid is:
A decrease in patient work of breathing compared to what it will be following extubation
Decrease in Patient Work of Breathing Compared with Extubated State

Patient work of breathing, Percent 1%

31-38 40%

Extubated CPAP 0, PS 0 PS 5 CPAP 5


ARRD 1991;143:469 (FlowBy)
AJRCCM 1995;152:129

When evaluating a patient’s readiness for extubation, the thing you most want to avoid is:
A decrease in patient work of breathing compared to what it will be following extubation
Readiness of a Patient for Extubation
Patient consented
to photo display

AJRCCM
2012;185:349
The vast majority of patients can cope with a 40-60% increase in work of
breathing at the point of extubation – but a fragile patient may not
Decrease in Patient Work of Breathing Compared with Extubated State

Patient work of breathing, Percent 1%

31-38 40%

Extubated CPAP 0, PS 0 PS 5 CPAP 5


ARRD 1991;143:469 (FlowBy)
AJRCCM 1995;152:129
To extubate a fragile patient directly from CPAP of 5
or from pressure support of 5 is to risk killing that patient
Patient consented
to photo display

In conclusion: over the breadth of my


pulmonary and critical care practice, ….
no area demands greater
Conclusion: Over the breadth of my pulmonary and critical care practice,
understanding of physiological principles than ventilator management, and the need for
physiological understanding is greatest in facilitating expeditious weaning while minimizing the risk of death
Physiologic Basis of Mechanical Ventilation
PS 0

Time (sec)

Over the breadth of my practice, no area demands greater understanding of physiological principles than
ventilator management, and the need for physiological understanding is greatest when
facilitating expeditious weaning and extubation while minimizing the risk of death