Mechanical Ventilation

  • Peter Rock
  • Vadivelu Sivaraman


Positive pressure mechanical ventilation was first introduced during the polio epidemic about 50 years ago and represents the most common form of life support in a modern intensive care unit (ICU).1 Management of the ventilated patient requires an understanding of how ventilators and the human respiratory system interact and what types of ventilators are available. In this chapter, we discuss the basics of mechanical ventilation, the most common modes of ventilation, the choice of ventilatory modalities in specific disease states, and the complications of mechanical ventilation.


Mechanical Ventilation Continuous Positive Airway Pressure Tidal Volume Airway Pressure Acute Respiratory Distress Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Esteban A, Anzueto A, Alía I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med. 2000;161(5):1450–1458.PubMedCrossRefGoogle Scholar
  2. 2.
    Aslanian P, El Atrous S, Isabey D, et al. Effects of flow triggering on breathing effort during partial ventilatory support. Am J Respir Crit Care Med. 1998;157(1):135–143.PubMedCrossRefGoogle Scholar
  3. 3.
    Younes M, Brochard L, Grasso S, et al. A method for monitoring and improving patient: ventilator interaction. Intensive Care Med. 2007;33(8):1337–1346.PubMedCrossRefGoogle Scholar
  4. 4.
    Marik PE, Krikorian J. Pressure-controlled ventilation in ARDS: a practical approach. Chest. 1997;112(4):1102–1106.PubMedCrossRefGoogle Scholar
  5. 5.
    Prella M, Feihl F, Domenighetti G. Effects of short-term pressure-controlled ventilation on gas exchange, airway pressures, and gas distribution in patients with acute lung injury/ARDS: comparison with volume-controlled ventilation. Chest. 2002;122(4):1382–1388.PubMedCrossRefGoogle Scholar
  6. 6.
    Jounieaux V, Duran A, Levi-Valensi P. Synchronized intermittent mandatory ventilation with and without pressure support ventilation in weaning patients with COPD from mechanical ventilation. Chest. 1994;105(4):1204–1210.PubMedCrossRefGoogle Scholar
  7. 7.
    Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033–1056.PubMedCrossRefGoogle Scholar
  8. 8.
    Downs JB, Stock MC. Airway pressure release ventilation: a new concept in ventilatory support. Crit Care Med. 1987;15(5):459–461.PubMedCrossRefGoogle Scholar
  9. 9.
    Habashi NM. Other approaches to open-lung ventilation: airway pressure release ventilation. Crit Care Med. 2005;33(3 Suppl):S228–S240.PubMedCrossRefGoogle Scholar
  10. 10.
    Wrigge H, Zinserling J, Neumann P, et al. Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: a randomized controlled computed tomography trial. Crit Care. 2005;9(6):R780–R789.PubMedCrossRefGoogle Scholar
  11. 11.
    Putensen C, Mutz NJ, Putensen-Himmer G, et al. Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;159(4 Pt 1):1241–1248.PubMedCrossRefGoogle Scholar
  12. 12.
    Putensen C, Zech S, Wrigge H, et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med. 2001;164(1):43–49.PubMedCrossRefGoogle Scholar
  13. 13.
    Habashi N, Andrews P. Ventilator strategies for posttraumatic acute respiratory distress syndrome: airway pressure release ventilation and the role of spontaneous breathing in critically ill patients. Curr Opin Crit Care. 2004;10(6):549–557.PubMedCrossRefGoogle Scholar
  14. 14.
    Ferguson ND, Stewart TE. The use of high-frequency oscillatory ventilation in adults with acute lung injury. Respir Care Clin N Am. 2001;7(4):647–661.PubMedCrossRefGoogle Scholar
  15. 15.
    van Kaam AH, de Jaegere A, Haitsma JJ, et al. Positive pressure ventilation with the open lung concept optimizes gas exchange and reduces ventilator-induced lung injury in newborn piglets. Pediatr Res. 2003;53(2):245–253.PubMedCrossRefGoogle Scholar
  16. 16.
    Kao KC, Tsai YH, Wu YK, et al. High frequency oscillatory ventilation for surgical patients with acute respiratory distress syndrome. J Trauma. 2006;61(4):837–843.PubMedCrossRefGoogle Scholar
  17. 17.
    Rimensberger PC, Cox PN, Frndova H, et al. The open lung during small tidal volume ventilation: concepts of recruitment and “optimal” positive end-expiratory pressure. Crit Care Med. 1999;27(9):1946–1952.PubMedCrossRefGoogle Scholar
  18. 18.
    Layon J, Banner MJ, Jaeger MJ, et al. Continuous positive airway pressure and expiratory positive airway pressure increase functional residual capacity equivalently. Chest. 1986;89(4):517–521.PubMedCrossRefGoogle Scholar
  19. 19.
    Tzoufi M, Mentzelopoulos SD, Roussos C, et al. The effects of nebulized salbutamol, external positive end-expiratory pressure, and their combination on respiratory mechanics, hemodynamics, and gas exchange in mechanically ventilated chronic obstructive pulmonary disease patients. Anesth Analg. 2005;101(3):843–850.PubMedCrossRefGoogle Scholar
  20. 20.
    Luecke T, Pelosi P. Clinical review: positive end-expiratory pressure and cardiac output. Crit Care. 2005;9(6):607–621.PubMedCrossRefGoogle Scholar
  21. 21.
    International consensus conferences in intensive care medicine: ventilator-associated Lung Injury in ARDS. This official conference report was cosponsored by the American Thoracic Society, The European Society of Intensive Care Medicine, and The Societe de Reanimation de Langue Francaise, and was approved by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med 1999;160(6):2118–2124.Google Scholar
  22. 22.
    Plötz FB, Slutsky AS, van Vught AJ, et al. Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses. Intensive Care Med. 2004;30(10):1865–1872.PubMedCrossRefGoogle Scholar
  23. 23.
    Dernaika TA, McCaffree DR. Open lung ventilation: waiting for outcome studies? Crit Care Med. 2007;35(3):961–963.PubMedCrossRefGoogle Scholar
  24. 24.
    Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):637–645.PubMedCrossRefGoogle Scholar
  25. 25.
    Jaber S, Delay JM, Chanques G, et al. Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation. Chest. 2005;128(4):2688–2695.PubMedCrossRefGoogle Scholar
  26. 26.
    Liesching T, Kwok H, Hill NS. Acute applications of noninvasive positive pressure ventilation. Chest. 2003;124(2):699–713.PubMedCrossRefGoogle Scholar
  27. 27.
    Corbetta L, Ballerin L, Putinati S, et al. Efficacy of noninvasive positive pressure ventilation by facial and nasal mask in hypercapnic acute respiratory failure: experience in a respiratory ward under usual care. Monaldi Arch Chest Dis. 1997;52(5):421–428.PubMedGoogle Scholar
  28. 28.
    International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure. Am J Respir Crit Care Med 2001;163(1):283–291.Google Scholar
  29. 29.
    Carlucci A, Richard JC, Wysocki M, et al. Noninvasive versus conventional mechanical ventilation. An epidemiologic survey. Am J Respir Crit Care Med. 2001;163(4):874–880.PubMedCrossRefGoogle Scholar
  30. 30.
    Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168(1):70–76.PubMedCrossRefGoogle Scholar
  31. 31.
    Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173(2):164–170.PubMedCrossRefGoogle Scholar
  32. 32.
    Martin TJ, Hovis JD, Costantino JP, et al. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Am J Respir Crit Care Med. 2000;161(3 Pt 1):807–813.PubMedCrossRefGoogle Scholar
  33. 33.
    Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163(2):540–577.PubMedCrossRefGoogle Scholar
  34. 34.
    Navalesi P. Weaning and noninvasive ventilation: the odd couple. Am J Respir Crit Care Med. 2003;168(1):5–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Squadrone V, Coha M, Cerutti E, et al. Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA. 2005;293(5):589–595.PubMedCrossRefGoogle Scholar
  36. 36.
    Masip J. Non-invasive ventilation. Heart Fail Rev. 2007;12(2):119–124.PubMedCrossRefGoogle Scholar
  37. 37.
    Ward NS, Dushay KM. Clinical concise review: mechanical ventilation of patients with chronic obstructive pulmonary disease. Crit Care Med. 2008;36(5):1614–1619.PubMedCrossRefGoogle Scholar
  38. 38.
    Keenan SP, Sinuff T, Cook DJ, et al. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med. 2003;138(11):861–870.PubMedCrossRefGoogle Scholar
  39. 39.
    Nava S, Carbone G, DiBattista N, et al. Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. Am J Respir Crit Care Med. 2003;168(12):1432–1437.PubMedCrossRefGoogle Scholar
  40. 40.
    Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;128(9):721–728.PubMedCrossRefGoogle Scholar
  41. 41.
    Artigas A, Bernard GR, Carlet J, et al. The American-European Consensus Conference on ARDS, part 2: ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;157(4 Pt 1):1332–1347.PubMedCrossRefGoogle Scholar
  42. 42.
    Brochard L, Roudot-Thoraval F, Roupie E, et al. Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS. Am J Respir Crit Care Med. 1998;158(6):1831–1838.PubMedCrossRefGoogle Scholar
  43. 43.
    Dreyfuss D, Ricard JD, Saumon G. On the physiologic and clinical relevance of lung-borne cytokines during ventilator-induced lung injury. Am J Respir Crit Care Med. 2003;167(11):1467–1471.PubMedCrossRefGoogle Scholar
  44. 44.
    Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med. 1998;157(1):294–323.PubMedCrossRefGoogle Scholar
  45. 45.
    Dreyfuss D, Soler P, Saumon G. Mechanical ventilation-induced pulmonary edema. Interaction with previous lung alterations. Am J Respir Crit Care Med. 1995;151(5):1568–1575.PubMedCrossRefGoogle Scholar
  46. 46.
    Martin-Lefevre L, Ricard JD, Roupie E, et al. Significance of the changes in the respiratory system pressure-volume curve during acute lung injury in rats. Am J Respir Crit Care Med. 2001;164(4):627–632.PubMedCrossRefGoogle Scholar
  47. 47.
    Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342(18):1301–1308.Google Scholar
  48. 48.
    The Acute Respiratory Distress Syndrome Network. Higher versus lower PEEP in patients with ARDS. N Engl J Med 2004;351:327–336.Google Scholar
  49. 49.
    Meade MO, Cook DJ, Arabi Y, et al. A multinational randomized controlled trial of a lung open ventilation strategy in ALI/ARDS – preliminary results. Am J Respir Crit Care Med. 2007;175:A507.CrossRefGoogle Scholar
  50. 50.
    Mercat A, Richard JC, Brochard L, et al. Comparison of two strategies for setting PEEP in ALI/ARDS (ExPress study). Am J Respir Crit Care Med. 2007;175:A507.CrossRefGoogle Scholar
  51. 51.
    Phua J, Kong K, Lee KH, et al. Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs other conditions: effectiveness and predictors of failure. Intensive Care Med. 2005;31(4):533–539.PubMedCrossRefGoogle Scholar
  52. 52.
    Ram FS, Lightowler JV, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2003;(1):CD004104.Google Scholar
  53. 53.
    Corbridge TC, Hall JB. The assessment and management of adults with status asthmaticus. Am J Respir Crit Care Med. 1995;151(5):1296–1316.PubMedCrossRefGoogle Scholar
  54. 54.
    Darioli R, Perret C. Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984;129(3):385–387.PubMedGoogle Scholar
  55. 55.
    Chao DC, Scheinhorn DJ. Barotrauma vs volutrauma. Chest. 1996;109(4):1127–1128.PubMedCrossRefGoogle Scholar
  56. 56.
    Ely EW Jr, Bowton DL, Reed JC, et al. Portable chest radiographs identify mechanical ventilator-associated hyperinflation. Chest. 1994;106(2):545–551.PubMedCrossRefGoogle Scholar
  57. 57.
    Gammon RB, Shin MS, Buchalter SE. Pulmonary barotrauma in mechanical ventilation. Patterns and risk factors. Chest. 1992;102(2):568–572.PubMedCrossRefGoogle Scholar
  58. 58.
    Johnson MM, Ely EW, Chiles C, et al. Radiographic assessment of hyperinflation: correlation with objective chest radiographic measurements and mechanical ventilator parameters. Chest. 1998;113(6):1698–1704.PubMedCrossRefGoogle Scholar
  59. 59.
    Kollef MH, Turner JF. Intrinsic PEEP and unilateral lung hyperinflation Pathophysiology and clinical significance. Chest. 1992;102(4):1220–1224.PubMedCrossRefGoogle Scholar
  60. 60.
    Loring SH, Malhotra A. Inspiratory efforts during mechanical ventilation: is there risk of barotrauma? Chest. 2007;131(3):646–648.PubMedCrossRefGoogle Scholar
  61. 61.
    Werner HA. Status asthmaticus in children: a review. Chest. 2001;119(6):1913–1929.PubMedCrossRefGoogle Scholar
  62. 62.
    Anzueto A, Frutos-Vivar F, Esteban A, et al. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med. 2004;30(4):612–619.PubMedCrossRefGoogle Scholar
  63. 63.
    Brunet F, Jeanbourquin D, Monchi M, et al. Should mechanical ventilation be optimized to blood gases, lung mechanics, or thoracic CT scan? Am J Respir Crit Care Med. 1995;152(2):524–530.PubMedCrossRefGoogle Scholar
  64. 64.
    Ricard JD, Dreyfuss D, Saumon G. Production of inflammatory cytokines in ventilator-induced lung injury: a reappraisal. Am J Respir Crit Care Med. 2001;163(5):1176–1180.PubMedCrossRefGoogle Scholar
  65. 65.
    Dreyfuss D, Basset G, Soler P, et al. Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis. 1985;132(4):880–884.PubMedGoogle Scholar
  66. 66.
    Dreyfuss D, Soler P, Basset G, et al. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis. 1988;137(5):1159–1164.PubMedCrossRefGoogle Scholar
  67. 67.
    Dreyfuss D, Saumon G. Role of tidal volume, FRC, and end-inspiratory volume in the development of pulmonary edema following mechanical ventilation. Am Rev Respir Dis. 1993;148(5):1194–1203.PubMedCrossRefGoogle Scholar
  68. 68.
    Ranieri VM, Suter PM, Tortorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1999;282(1):54–61.PubMedCrossRefGoogle Scholar
  69. 69.
    Parsons PE, Eisner MD, Thompson BT, et al. Lower tidal volume ventilation and plasma cytokine markers of inflammation in patients with acute lung injury. Crit Care Med. 2005;33(1):1–6. discussion 230–232.PubMedCrossRefGoogle Scholar
  70. 70.
    Carney DE, Bredenberg CE, Schiller HJ, et al. The mechanism of lung volume change during mechanical ventilation. Am J Respir Crit Care Med. 1999;160(5):1697–1702.CrossRefGoogle Scholar
  71. 71.
    Taskar V, John J, Evander E, et al. Surfactant dysfunction makes lungs vulnerable to repetitive collapse and reexpansion. Am J Respir Crit Care Med. 1997;155(1):313–320.PubMedCrossRefGoogle Scholar
  72. 72.
    Gajic O, Lee J, Doerr CH, et al. Ventilator-induced cell wounding and repair in the intact lung. Am J Respir Crit Care Med. 2003;167(8):1057–1063.PubMedCrossRefGoogle Scholar
  73. 73.
    Hubmayr RD. Perspective on lung injury and recruitment: a skeptical look at the opening and collapse story. Am J Respir Crit Care Med. 2002;165(12):1647–1653.PubMedCrossRefGoogle Scholar
  74. 74.
    Matthay MA, Zimmerman GA, Esmon C, et al. Future research directions in acute lung injury: summary of a National Heart, Lung, and Blood Institute working group. Am J Respir Crit Care Med. 2003;167(7):1027–1035.PubMedCrossRefGoogle Scholar
  75. 75.
    Vlahakis NE, Hubmayr RD. Cellular stress failure in ventilator-injured lungs. Am J Respir Crit Care Med. 2005;171(12):1328–1342.PubMedCrossRefGoogle Scholar
  76. 76.
    Gattinoni L, Pesenti A, Avalli L, et al. Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis. 1987;136(3):730–736.PubMedCrossRefGoogle Scholar
  77. 77.
    Imai Y, Parodo J, Kajikawa O, et al. Injurious mechanical ventilation and end-organ epithelial cell apoptosis and organ dysfunction in an experimental model of acute respiratory distress syndrome. JAMA. 2003;289(16):2104–2112.PubMedCrossRefGoogle Scholar
  78. 78.
    Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care – associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1–36.PubMedGoogle Scholar
  79. 79.
    Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115–2121.PubMedCrossRefGoogle Scholar
  80. 80.
    Cook DJ, Walter SD, Cook RJ, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med. 1998;129(6):433–440.PubMedCrossRefGoogle Scholar
  81. 81.
    Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med. 1995;332:345–350.PubMedCrossRefGoogle Scholar
  82. 82.
    Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med. 1994;150:896–903.PubMedCrossRefGoogle Scholar
  83. 83.
    Esteban A, Alia I, Ibañez J, et al. Modes of mechanism ventilation and weaning. A national survey of Spanish hospitals. Chest. 1994;106:1188–1193.PubMedCrossRefGoogle Scholar
  84. 84.
    Alía I, Esteban A. Weaning from mechanical ventilation. Crit Care. 2000;4(2):72–80.PubMedCrossRefGoogle Scholar
  85. 85.
    MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007;132(3):1049–1056.PubMedCrossRefGoogle Scholar
  86. 86.
    MacIntyre NR, Cook DJ, Ely EW, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl):375S–395S.PubMedCrossRefGoogle Scholar
  87. 87.
    Putensen C. Principles of mechanical ventilation. In: Kuhlen R, Moreno R, Ranieri M, Rhodes A, editors. 25 Years of progress and innovation in intensive care medicine. Berlin: Medizinisch Wissenschaftliche Verlagsgessellschaft; 2007. p. 101–108.Google Scholar
  88. 88.
    Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991;324:1445–1450.PubMedCrossRefGoogle Scholar
  89. 89.
    Ferrer M. Non-invasive ventilation in the weaning process. Minerva Anestesiol. 2008;74(6):311–314.PubMedGoogle Scholar
  90. 90.
    Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25(4):567–574.PubMedCrossRefGoogle Scholar
  91. 91.
    Lellouche F, Mancebo J, Jolliet P, et al. A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation. Am J Respir Crit Care Med. 2006;174(8):894–900.PubMedCrossRefGoogle Scholar
  92. 92.
    Krishnan JA, Moore D, Robeson C, et al. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med. 2004;169(6):673–678.PubMedCrossRefGoogle Scholar
  93. 93.
    Flaatten H. The role of tracheostomy in ventilatory care. In: Kuhlen R, Moreno R, Ranieri M, Rhodes A, editors. Controversies in intensive care medicine. Berlin: Medizinisch Wissenschaftliche Verlagsgessellschaft; 2008. p. 101–108, 47–53.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Peter Rock
    • 1
  • Vadivelu Sivaraman
    • 1
  1. 1.Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreUSA

Personalised recommendations