Mechanical Ventilation from Pathophysiology to Clinical Evidence

✍ Scribed by Giacomo Bellani (editor)

• Publisher: Springer
• Year: 2022
• Tongue: English
• Leaves: 422
• Category: Library

✦ Synopsis

This book aims to give a comprehensive overview of the current challenges and solution posed to the health care professionals who need to use mechanical ventilation to treat their patients.

Mechanical ventilation is a cornerstone of the treatment of critically ill patients, as also dramatically underlined by the recent COVID-19 pandemic. The topic is not simple to approach, since it requires integration of multiple data which, in turn, result from complex interplays between patient’s condition and ventilatory settings. While technological development empowered advanced monitoring and decision support, these also increase the burden of data on the practitioners.

Furthermore, considering that sometimes mechanical ventilation is seen under two, apparently opposite, approaches, “physiology vs. protocols”, the book aims to reconcile these two aspects. And this has been done by each author following the above trajectory in their chapters.

The exposure of the topic begins from the “pathophysiology” (i.e. the “physiology of the disease”) so that the reader can better understand the concept and rationale of any given approach. At the same time, any rationale or hypothesis (for as much as supported by physiology) must hold at the proof of clinical research and evidence, which is summarized in each chapter.
In summary, the purposes is that the readers understand not only which is the best clinical practice to adopt but also why and which mechanisms this is based upon and how to approach a novel issue they might encounter. The book – addressed to physicians, nurses and respiratory therapist – features chapters on “novel” or “hot” topics like, obviously, COVID-19, ECMO, but also MV in low resource setting.

✦ Table of Contents

Foreword
Preface
Contents
Part I: Techniques
1: Basic Physiology of Respiratory System: Gas Exchange and Respiratory Mechanics
1.1 Gas Exchange
1.2 Respiratory Mechanics
References
2: A Short History of Mechanical Ventilation
2.1 Respiration, Circulation, and Their Interaction
2.2 Oxygen, Combustion, Metabolism, Homeostasis
2.3 The Dawn of Mechanical Ventilation
2.4 Lessons Learned
References
3: Airway Management in the Critically Ill
3.1 Introduction
3.2 Indications for Tracheal Intubation in ICU
3.3 Planning and Preparation for Tracheal Intubation
3.3.1 Clinical History and General Examination
3.3.2 Airway Assessment
3.3.3 Airway Cart and Checklists
3.3.4 Team Preparation
3.4 The Tracheal Intubation Procedure
3.4.1 Patient Positioning
3.4.2 Preoxygenation and Apnoeic Oxygenation
3.4.3 Induction of Anaesthesia
3.4.3.1 Propofol
3.4.3.2 Etomidate
3.4.3.3 Ketamine
3.4.4 Controversies in Rapid Sequence Intubation
3.4.4.1 Use of Neuromuscular Blockade or Spontaneous Ventilation
3.4.4.2 Use of Cricoid Pressure
3.4.4.3 Mask Ventilation During RSI
3.4.5 Haemodynamic Support During Tracheal Intubation
3.4.6 Device Selection for Tracheal Intubation
3.4.6.1 Use of a Videolaryngoscope
3.4.6.2 Use of a Bougie
3.4.6.3 Use of a Stylet
3.4.7 Confirmation of Tracheal Tube Position
3.5 Rescue Oxygenation
3.6 Care and Maintenance of the Tracheal Tube
3.7 Human Factors in Airway Management
3.8 Future Research
3.9 Conclusion
References
4: Controlled Mechanical Ventilation: Modes and Monitoring
4.1 Pressure-Controlled Ventilation
4.2 Volume-Controlled Ventilation
4.3 Pressure-Regulated Volume-Guaranteed Ventilation
4.4 Physiological Features of Fully Controlled Modes
4.4.1 Lung Protection
4.4.2 Alveolar Ventilation
4.5 Modes Particularities During Inspiratory Effort
4.6 Monitoring During Controlled Ventilation
4.6.1 Static Measurements of Inspiratory Resistance and Respiratory Compliance
4.6.2 Low-Flow Pressure-Volume (P−V) Curves
4.6.3 Stress Index
4.7 Conclusion
References
5: Assisted Ventilation: Pressure Support and Bilevel Ventilation Modes
5.1 Introduction
5.2 Pressure Support Ventilation
5.2.1 Epidemiology, Potential Advantages and Disadvantages
5.2.2 Principles of Operation and Physiological Consequences of PSV
5.2.2.1 Trigger Sensitivity, Inspiratory Rise Time, Pressure Support Level, and Cycling-Off Criteria
5.2.2.2 Determinants of Ventilation and Impact on Breathing Pattern
5.2.3 Potentially Injurious Patient–Ventilator Interactions During Pressure Support Ventilation
5.2.3.1 Over-Assistance with Ineffective Efforts and Apnea Events
5.2.3.2 Under-Assistance Leading to Flow Starvation and Double Triggering
5.2.4 How to Set the Level of Support to Prevent Over and Under-Assistance
5.3 Bilevel Ventilation Modes
5.3.1 Bilevel Vs. Other Pressure-Controlled Modes
5.3.2 Physiologic Effects of Differences in Inspiratory Synchronization
5.3.3 Setting Bilevel Ventilation During Assisted Mechanical Ventilation
5.3.4 Clinical Evidence of Bilevel Vs. Conventional Modes During Assisted Mechanical Ventilation
5.4 Conclusion
References
6: Monitoring the Patient During Assisted Ventilation
6.1 Inspiratory Effort
6.1.1 Esophageal Pressure Derived Measurements
6.1.2 Tidal Volume and Respiratory Rate
6.1.3 p0.1
6.1.4 Occlusion Pressure
6.1.5 Pressure Muscle Index
6.1.6 Diaphragm Electrical Activity
6.2 Total Pressure Distending the Respiratory System
6.3 Asynchronies
6.4 Distribution of Ventilation and Pendelluft
6.5 Evaluation of Respiratory Muscles Activity by Ultrasound
6.6 Conclusion
References
7: Neurally Adjusted Ventilatory Assist
7.1 Working Principles
7.1.1 EAdi Signal
7.1.2 NAVA Mode
7.1.2.1 Trigger Under NAVA
7.1.2.2 The Level of Assist
7.2 How to Set Ventilatory Assistance During NAVA
7.2.1 Airway Pressure Targets
7.2.2 Tidal Volume Response to NAVAlevel Titration
7.2.3 EAdi Response to NAVAlevel Titration
7.2.4 Neuro-Ventilatory Efficiency (NVE)
7.2.5 EAdi Derived Indices with NAVA
7.3 How to Set PEEP Under NAVA
7.4 How to Wean NAVA
7.5 Clinical Effects of NAVA
7.5.1 Effect on VT
7.5.2 Effects on Asynchrony
7.5.3 NAVA During Non-Invasive Ventilation or Tracheostomy
7.6 Limitation of NAVA
7.7 Conclusion
References
8: Proportional Assist Ventilation
8.1 Introduction
8.2 Operation Principles
8.3 Advantages of PAV+
8.3.1 Protection from Over- or Under-Assistance
8.3.2 Breathing Pattern and Patient–Ventilator Interaction
8.3.3 Clinical Outcomes
8.4 Limitations in PAV/PAV+ Use
8.5 Titration of Assistance in PAV+
8.6 Conclusion
References
9: Non-Invasive Ventilation: Indications and Caveats
9.1 Introduction
9.2 NIV Interfaces
9.3 Mode of Ventilation
9.4 Physiological Effects of NIV
9.5 Indications for NIV
9.5.1 Hydrostatic Pulmonary Edema
9.5.2 Hypercapnic Respiratory Failure: Acute Exacerbation of COPD
9.5.3 De-Novo Acute Hypoxemic Respiratory Failure
9.5.3.1 Facemask NIV
9.5.3.2 Helmet NIV
9.5.4 Immunocompromised Patients
9.5.5 Pre-Oxygenation
9.5.6 After Invasive Mechanical Ventilation
9.5.6.1 Early Liberation
9.5.6.2 Pre-Emptive Strategy
9.5.6.3 Post-Extubation Acute Respiratory Failure Rescue
9.5.7 Insufficient Data
9.6 The Importance of Monitoring of Patient with NIV
9.6.1 Monitoring the Patient with NIV
9.6.1.1 Predicting NIV Failure in the Setting of De-Novo AHRF
9.6.1.2 Predicting NIV Failure in the Setting of Hypercapnic ARF
9.7 Conclusions
References
10: High Flow Nasal Oxygen: From Physiology to Clinical Practice
10.1 Introduction
10.2 Dead Space, Air Entrainment, and Washout
10.2.1 The Way Forward
10.3 Generation of PEEP (or Not)
10.3.1 The Way Forward
10.4 Work of Breathing (WOB)
10.4.1 Work of Breathing in Normal Adults and in Hypoxemic Respiratory Failure
10.4.2 Work of Breathing in Patients with Decompensated Chronic Obstructive Pulmonary Disease (COPD)
10.4.3 The Way Forward
10.5 Some Words of Caution
10.6 Conclusion
References
11: Nursing of Mechanically Ventilated and ECMO Patient
11.1 Mechanical Ventilation
11.2 Prone Position
11.3 ECMO
11.4 Conclusions
References
12: Closed-Loop Ventilation Modes
12.1 Introduction
12.2 Mandatory Minute Ventilation
12.3 Smartcare/PS
12.3.1 Principle of Operation
12.3.2 Monitoring
12.3.3 Evidence
12.4 Adaptive Support Ventilation
12.4.1 Principle of Operation
12.4.2 Settings and Monitoring
12.4.3 Weaning
12.4.4 Evidence
12.5 INTELLiVENT-ASV
12.5.1 Principle of Operation
12.5.2 Settings and Monitoring
12.5.3 Weaning
12.5.4 Evidence
12.6 Conclusion
References
13: Airway Pressure Release Ventilation
13.1 Introduction
13.2 Physiology
13.3 Indications
13.4 Settings
13.4.1 PHigh
13.4.2 THigh
13.4.3 PLow
13.4.4 TLow
13.5 Spontaneous Breathing
13.6 Weaning
13.7 Conclusion
References
Part II: Clinical Scenarios
14: Acute Hypoxaemic Respiratory Failure and Acute Respiratory Distress Syndrome
14.1 AHRF and ARDS: A Definition Problem
14.2 Epidemiology: Knowns and Unknowns
14.3 Pathophysiology: Insights and Gaps
14.4 Support of Gas Exchange
14.5 Invasive Mechanical Ventilation: From ‘Protective’ to ‘Personalized’
14.6 Adjuncts to Ventilation
14.7 Specific Therapies for ARDS and AHRF
14.8 Outcomes
14.9 AHRF: Changing the Paradigm
14.10 Conclusions
References
15: Ventilator-Induced Lung Injury and Lung Protective Ventilation
15.1 Mechanosensitivity of the Respiratory System
15.2 Pathophysiology of Ventilator-Induced Lung Injury
15.3 Bedside Assessment of VILI
15.4 Designing Lung Protective Strategies
15.5 Clinical Evidence on Protective Ventilation
15.6 Conclusion
References
16: Mechanical Ventilation in the Healthy Lung: OR and ICU
16.1 Introduction
16.2 Tidal Volume
16.3 Tidal Volume in the Operating Room
16.3.1 Benefit of a Lower VT
16.3.2 Challenges of a Lower VT
16.3.3 Temporal Changes in the Size of VT
16.3.4 Current Recommendations
16.4 Tidal Volume the Intensive Care Unit
16.4.1 Benefit of a Lower VT
16.4.2 Challenges of a Lower VT
16.4.3 Temporal Changes in the Size of VT
16.4.4 Current Recommendations
16.5 Positive End-Expiratory Pressure
16.6 PEEP in the Operating Room
16.6.1 Benefit of Higher PEEP
16.6.2 Challenges of Higher PEEP
16.6.3 Temporal Changes in PEEP
16.6.4 Current Recommendations
16.7 PEEP in the Intensive Care Unit
16.7.1 Benefit of Higher PEEP
16.7.2 Challenges of Higher PEEP
16.7.3 Temporal Changes in PEEP
16.7.4 Current Recommendations
16.8 Conclusions
References
17: PEEP Setting in ARDS
17.1 Introduction
17.2 Pathophysiology: Beneficial Effects of PEEP
17.3 Pathophysiology: Harmful Effects of PEEP
17.4 Recommendations of PEEP Setting in ARDS
17.5 Strategies Aimed at Titrating PEEP at Bedside
17.5.1 NIH PEEP/FiO2 Combination Tables
17.5.2 Respiratory Mechanics: Compliance and Driving Pressure of the Respiratory System (Cpl,rs)
17.5.3 Pressure–Volume (PV) Curve and Lung Volume Measurements
17.5.4 Stress Index (SI)
17.5.5 Transpulmonary Pressure
17.5.6 Lung Imaging
17.5.7 PEEP: The Role of ARDS Phenotypes
17.6 Conclusion
References
18: Mechanical Ventilation in Brain Injured Patients
18.1 Introduction
18.2 Indications for Invasive Mechanical Ventilation in Brain Injured Patients
18.3 Ventilatory Strategies and Targets
18.3.1 Ventilator Settings
18.3.2 Oxygenation and Carbon Dioxide Targets
18.4 Rescue Interventions for Refractory Respiratory Failure
18.5 Weaning and Tracheostomy
18.6 Ventilation in Neuromuscular Disease
18.7 Conclusions
References
19: Invasive and Non-invasive Ventilation in Patient with Cardiac Failure
19.1 Introduction
19.2 Pathophysiology of Respiratory Failure During Acute Cardiac Failure
19.2.1 Acute Cardiogenic Pulmonary Edema
19.2.2 Cardiogenic Shock
19.3 Rationale for Positive Airway Pressure in Patients with Cardiac Failure
19.3.1 Right Ventricle
19.3.2 Left Ventricle
19.4 Non-invasive Positive Pressure Ventilation for Cardiogenic Pulmonary Edema: Clinical Evidence
19.5 Non-invasive and Invasive Positive Pressure Ventilation for Cardiogenic Shock
19.6 Ventilation in the Post Cardiac Arrest Period
References
20: COPD and Severe Asthma
20.1 Pathophysiology
20.2 Respiratory Support Strategies in General
20.3 Controlled Invasive Ventilation of the Obstructive Patient: Goals, Monitoring of Dynamic Airtrapping and Settings Strategies
20.4 Assisted Invasive Ventilation of the Obstructive Patient and Weaning Strategy
References
21: Ventilation in the Obese Patient
21.1 Introduction
21.2 Input Ventilatory Parameters to Be Adjusted During Mechanical Ventilation in Obese Patients
21.2.1 Tidal Volume
21.2.2 Positive End-Expiratory Pressure
21.2.3 Recruitment Maneuvers
21.3 Output Ventilatory Parameters to Be Monitored During Mechanical Ventilation in Obese Patients
21.3.1 Driving Pressure
21.3.2 Plateau Pressure
21.3.3 Energy and Mechanical Power
21.4 Conclusion
References
22: Weaning the Simple and Complex Patients
22.1 Introduction
22.2 Weaning Definitions and Steps
22.2.1 What Is Weaning, When Does Is Start? (and When Does It End???)
22.2.2 Are There Simple and Complex Patients?
22.2.3 During the Acute Phase
22.2.4 After the Illness Acute Phase
22.3 The Separation Attempt Process
22.3.1 Challenges and Pitfalls
22.3.2 Which Spontaneous Breathing Trial?
22.3.3 Pathophysiology of Spontaneous Breathing Trial Failure
22.4 Preventing Extubation Failure
22.4.1 Complications Following Extubation: Epidemiology and Definitions
22.4.2 Risk Factors of Extubation Failure
22.4.3 Strategies Aiming at Preventing Extubation Failure
22.4.4 Summary of the Evidence Regarding the Efficacy of Strategies Aiming at Preventing Extubation Failure in the ICU
22.4.5 Treatment of Post-Extubation Respiratory Failure
22.5 Conclusion
References
23: Non-invasive Oxygenation Strategies for COVID-19 Related Respiratory Failure
23.1 Introduction
23.2 Non-invasive Oxygen Strategies: Devices, Physiology and Non-COVID-19 Evidence
23.2.1 Devices and Physiology
23.2.1.1 High-flow Nasal Oxygen Cannula
23.2.1.2 Non-invasive Ventilation
23.2.1.3 Evidence of Non-invasive Oxygen Strategies for De Novo Acute Respiratory Failure
23.3 Considerations for Non-invasive Oxygenation Strategies in the COVID-19 Pandemic
23.3.1 Caring for Critically-Ill Patients Outside of the Intensive Care Unit
23.3.2 The Risk of Aerosolization
23.3.3 Interhospital Transport
23.3.4 Evidence for Non-invasive Oxygenation Supports in COVID-19
23.3.5 Patient Positioning
23.4 Conclusion
References
24: Invasive Ventilation in COVID-19
24.1 Introduction
24.2 Endotracheal Intubation and Timing
24.3 Mechanical Ventilation Setting
24.4 Rescue Therapies
24.5 Tracheostomy
24.6 Conclusions
References
25: Mechanical Ventilation in Different Surgical Settings
25.1 Introduction
25.1.1 Postoperative Pulmonary Complications
25.1.2 Protective Mechanical Ventilation: Basic Concepts
25.1.3 Personalized PEEP: The Open Lung Approach (OLA)
25.2 Laparoscopic Surgery
25.2.1 Current Evidence
25.3 Obese Patients
25.3.1 Current Evidence
25.4 Thoracic Surgery
25.4.1 Current Evidence
25.5 Cardiac Surgery
25.5.1 Current Evidence
25.6 Neurosurgery
25.6.1 Current Evidence
25.7 Conclusions
References
26: Following Up the Patients at Long Term
26.1 Introduction
26.1.1 A Logistic and Cultural Framework to Assist ICU Survivors
26.2 The Follow-Up Clinic and the PICS Framework
26.2.1 Physical Impairment
26.2.2 Cognitive Impairment
26.2.3 Mental Health Impairment
26.3 Conclusions
References
27: Mechanical Ventilation in Limited Resource Settings
27.1 Introduction
27.2 Facilities for Mechanical Ventilation in Limited Resource Settings
27.3 Indications of Mechanical Ventilation in Resource Variable Settings
27.4 Modes of Mechanical Ventilation in Limited Resource Settings
27.5 Complications of Mechanical Ventilation in Limited Resource Settings
27.6 The Practice of Tracheostomy in Patients with Prolonged Mechanical Ventilation
27.7 Conclusion
References
28: Mechanical Ventilation During Patient’s Transferral
28.1 Overview
28.2 How Transport Changes Physiology
28.3 Setting the Ventilator for Transport
28.4 Pulmonary and Airway Complications
28.5 Cardiovascular Complications
28.6 Equipment Malfunction, Considerations, and Human Error
28.7 Importance of Checklists
28.8 Conclusion
References
Part III: Adjuncts to Mechanical Ventilation
29: Prone Position
29.1 Rationale
29.1.1 Effects on Oxygenation
29.1.2 VILI Prevention
29.1.3 Hemodynamics Effects
29.2 Timing of Proning Application
29.2.1 PaO2/FIO2 Threshold to Initiate Proning in ARDS
29.2.2 When to Start Proning
29.2.3 When to Stop Proning
29.2.4 Duration of Proning Sessions
29.3 Practical Issues
29.3.1 Patient Installation
29.3.2 Support of Abdomen
29.3.3 Sedation and Neuromuscular Blockade During Prone Position
29.3.4 Setting the Ventilator in Prone Position
29.3.5 Contraindications
29.4 Clinical Evidence
29.4.1 Effects of Survival in Intubated Patients with Classic ARDS
29.4.2 Findings in the COVID-19
29.5 Conclusions
References
30: Veno-Venous ECMO and ECCO2R
30.1 Pathophysiology of Severe Respiratory Failure: Pulmonary Shunt and Alveolar Dead Space
30.2 Why Extracorporeal Gas Exchange?
30.3 “Full” V-V ECMO Versus Low-Flow ECCO2R
30.4 Evidence for Extracorporeal Gas Exchange in ARDS Patients
30.5 Outcome of ARDS Patients Treated with V-V ECMO
30.6 Should the Number of ECMO Centers Be Increased?
30.7 Conclusions
References
31: Mechanical Ventilation Setting During ECMO
31.1 Introduction
31.1.1 Mechanical Ventilation Strategy in ARDS
31.1.2 Mechanical Ventilation Strategy in Severe ARDS Receiving ECMO
31.1.3 Effects of ECMO on Gas Exchange and Interactions with Native Lung Function
31.1.4 Interaction Between the Native and the Artificial Lung
31.1.5 Mechanical Ventilation on ECMO: General Principles
31.1.6 Mechanical Ventilation Setting on ECMO
31.1.6.1 Tidal Volume
31.1.6.2 Respiratory Rate
31.1.6.3 PEEP
31.1.7 Additional Considerations
31.1.7.1 Prone Position
31.1.7.2 Respiratory Effort
31.2 Conclusion
References
Part IV: Monitoring of Mechanical Ventilation
32: Ultrasound Assessment of the Respiratory System
32.1 Introduction
32.2 The Lungs
32.2.1 Introduction
32.2.1.1 Pleura
32.2.1.2 A-Lines
32.2.1.3 B-Lines
32.2.1.4 Consolidation
32.2.1.5 Pleural Effusion
32.2.2 Application in Clinical Practice
32.2.2.1 Diagnosis of Acute Respiratory Failure
32.2.2.2 Monitoring Lung Aeration
32.2.2.3 Lung Ultrasound-Guided Mechanical Ventilation
32.2.2.4 Detection and Draining Pleural Effusion
32.3 Diaphragm
32.3.1 Introduction
32.3.1.1 Excursion
32.3.1.2 Thickness and Thickening
32.3.2 Application in Clinical Practice
32.3.2.1 Diaphragm Protective Ventilation
32.3.2.2 Patient Ventilator Asynchrony
32.3.2.3 Weaning
32.3.2.4 Predicting Extubation Outcome
32.4 Accessory Respiratory Muscles
32.5 Limitations
32.6 Conclusion
References
33: Electrical Impedance Tomography
33.1 Introduction
33.2 EIT Basics
33.3 Patient Examination Using EIT
33.4 Assessment of Regional Lung Ventilation and Aeration Changes by EIT
33.5 Assessment of Regional Lung Perfusion by EIT
33.6 Summary
References
34: Esophageal Pressure Monitoring
34.1 Technique
34.2 Measurements of Pes-derived Variables
34.2.1 Transpulmonary Pressures
34.2.2 Indices of Inspiratory Effort and Dynamic Hyperinflation
34.3 Monitoring Esophageal Pressure to Guide Mechanical Ventilation
34.3.1 Monitoring PL,end-exp for PEEP Titration to Prevent Alveolar Collapse
34.3.2 Monitoring PL,end-insp and ΔPL for Tidal Volume/Inspiratory Pressure Titration to Prevent Overdistention
34.3.3 Monitoring Spontaneous Effort to Prevent Over- and Under-Assist and Optimize Patient-Ventilator Interaction
34.4 Conclusion
References
35: Lung Volumes and Volumetric Capnography
35.1 Introduction
35.2 Lung Volumes
35.2.1 Why Is Measuring Absolute Lung Volume Clinically Relevant?
35.2.2 How Are Absolute Lung Volumes Measured?
35.2.3 How Are the Changes in Lung Volume Measured?
35.2.4 How Is Recruitment Measured Using Computed Tomography?
35.2.5 How Is Recruitment Measured Using Pressure–Volume Curves?
35.2.6 How Is the Recruitment-to-Inflation Ratio Measured?
35.3 Volumetric Capnography
35.3.1 What Is Dead Space?
35.3.2 How Is Dead Space Calculated?
35.3.3 What Is Capnography?
35.3.4 What Is a Capnometer?
35.3.5 How Is Dead Space Measured Using Volumetric Capnography?
35.3.6 What Are the Clinical Implications?
References
36: Radiological Monitoring
36.1 Introduction
36.2 What Could We Expect from Chest X Ray in ICU?
36.2.1 Assessing Lung Oedema
36.2.2 Positioning of Monitor and/or Therapeutics Devices
36.2.3 Pleural Effusions
36.2.4 Pneumonia
36.3 When is CT Scan Indicated in Ventilated Patients?
36.4 Conclusions
References
Part V: Educational Material
37: Teaching Mechanical Ventilation: Online Resources and Simulation
37.1 Introduction
37.2 Online Resources and Applications
37.2.1 Standardized Education for Ventilatory Assistance (SEVA)
37.2.2 iVentilate App
37.2.3 The Toronto Centre of Excellence in Mechanical Ventilation (CoEMV Blog)
37.3 Mechanical Ventilation Simulation
37.3.1 Software Simulation Options
37.3.1.1 Simulation Interface for Ventilation Analysis (SIVA)
37.3.1.2 VentSim
37.3.1.3 XLung
37.3.2 Hardware Simulation Options
37.3.2.1 Test Lungs and Breathing Simulators
37.3.3 Setting Up a Successful Simulation Teaching Event
37.4 Summary
38: Vignettes: Controlled Mechanical Ventilation
38.1 Introduction
38.2 Clinical Vignettes
References
39: Vignettes: Assisted Mechanical Ventilation
39.1 Introduction
References