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Editorial Mechanical Ventilation
New Developments in Mechanical Ventilation
Daniel R Ouellette
Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, US
P ositive pressure ventilation was developed in the 1950s as a way to treat respiratory failure due to ventilatory insufficiency. While life-
saving, mechanical ventilation, especially when prolonged, can be associated with a host of complications. Current advances focus on
strategies to liberate patients from the ventilator. New guidelines have been published to aid practitioners in this area.
Keywords Mechanical ventilation, Critical
Illness, Respiratory Failure
Disclosure: Daniel R Ouellette has nothing to disclose in
relation to this article. This article is a short opinion piece
and has not been submitted to external peer reviewers.
Authorship: All named authors meet the International
Committee of Medical Journal Editors (ICMJE) criteria
for authorship of this manuscript, take responsibility
for the integrity of the work as a whole, and have
given final approval to the version to be published.
Open Access: This article is published under the
Creative Commons Attribution Noncommercial License,
which permits any noncommercial use, distribution,
adaptation, and reproduction provided the original
author(s) and source are given appropriate credit.
Received: March 2, 2017
Published Online: April 19, 2017
Citation: US Respiratory & Pulmonary Diseases,
2017;2(1):21–2 Corresponding Author: Daniel R Ouellette, Department
of Pulmonary and Critical Care Medicine, Henry Ford
Hospital, Detroit MI 48202, US. E: email@example.com
Support: No funding was received for
the publication of this article.
Dr. Bjorn Ibsen suggested to medical leaders in Copenhagen, during the 1952 polio epidemic,
that positive pressure ventilation might have beneficial effects in patients with polio afflicted with
respiratory failure primarily related to deficiencies in alveolar ventilation. 1 The success of positive
pressure mechanical ventilation in saving lives in the early 1950s led to widespread use of this
intervention, and helped to spur the development of the nascent field of critical care medicine.
Today, we understand that mechanical ventilation, as a therapy, represents a double-edged sword: on
the one hand, it is a life-saving treatment, but on the other, it is associated with a host of complications.
Critical care practitioners know that the duration of mechanical ventilation is directly associated with
the incidence of adverse effects. 2 Liberation of patients from mechanical ventilation at the earliest
possible moment after they have begun to recover from their initial illness has become the focus of
attention in the modern era.
The application of the principles of evidence-based medicine to the problem of liberation from
mechanical ventilation, led to the publication of guidelines at the beginning of this century that
outlined clinical strategies for critical care physicians. 3 MacIntyre and colleagues promoted several
recommendations that physicians have adopted into daily practice. 3 Chief among these are the use
of spontaneous breathing trials (SBTs) as an assessment tool for readiness to be liberated from the
ventilator, and the use of discontinuation protocols. Today, these techniques are part of the daily
routine in the management of ventilated patients in intensive care units.
The American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have
recently collaborated to develop new evidence-based recommendations that inform practitioners
about the process of ventilator discontinuation. 4 The use of non-invasive ventilation following
extubation in patients at high risk for re-intubation is a strong recommendation. 5 Patients at high risk
may include those with chronic obstructive pulmonary disease, those with congestive heart failure,
and patients with a chronic respiratory acidosis. The guidelines also inform practitioners about the
methods for performing SBTs, recommending that inspiratory pressure augmentation be employed
during such trials. 5 Physicians and their colleagues are advised to use protocols to minimize sedation, to
institute protocols for rehabilitation to promote early mobilization, and to manage acutely hospitalized
patients ventilated for more than 24 hours with ventilator liberation protocols. 5,6 Cuff leak tests are
recommended for patients at high risk for post-extubation stridor; patients failing a cuff leak test
should be treated with systemic steroids for at least 4 hours before extubation. 6 Recommendations
were developed by an expert panel that performed literature searches, meta analyses, and approved
recommendations through a process of iterative Delphi voting.
Many advances have been made over the last 50 years in the application of mechanical ventilation
to the care of patients with respiratory failure. The work of many scientists, researchers, guideline
experts, with the support of societies like CHEST and the ATS, will ensure that practitioners can
provide innovative and state-of-the-art life-saving treatments to critically ill patients in the future.
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