Mechanical Ventilation Modes

Mechanical Ventilation
IM 2013 (AVM)

Indications for Mechanical Ventilation
• Airway Compromise/ Respiratory Failure
 Hypoxemic Respiratory Failure (Type I)
• PaO2 < 60 mmHg in an otherwise healthy individual
• SaO2 < 90 %
 Hypercapnic Respiratory Failure (Type 2)
• PaCO2 > 50 mmHg in an otherwise healthy individual
• AKA “Ventilatory Failure”
• Caused by increased WOB, ↓ventilatory drive, or muscle fatigue
• Airway Protection/ Prophylactic Ventilatory Support
 Clinical conditions in which there is a high risk of future respiratory failure
• Examples: Brain injury, heart muscle injury, major surgery, prolonged shock, smoke
injury
• Ventilatory support is instituted to:
– Decrease the Work of Breathing (WOB)
– Minimize O2 consumption and hypoxemia
– Reduce cardiopulmonary stress
– Control airway with sedation

Criteria
• Clinical Assessment (most important)
 Clinical deterioration
 Tachypnea: RR >35; Bradypnea, Apnea
 Co-morbid conditions
• ABG’s
 Hypoxia: pO2<60mm Hg
 Hypercarbia: pCO2 > 50mm Hg
* ABGs and Physiological parameters cannot distinguish between acute
and chronic respiratory Failure
* What may be “normal” in a COPD patient (RR > 30/min, PCO2 > 60
mm Hg) may be indications for intubation in a young, otherwise
healthy adult

V/Q Matching. Zone 1 demonstrates dead-space ventilation
(ventilation without perfusion). Zone 2 demonstrates normal
perfusion. Zone 3 demonstrates shunting (perfusion without
ventilation).

Principles (1): Ventilation
• The goal of ventilation is to facilitate CO2 release and maintain
normal PaCO2
• Minute ventilation (VE)
• Total amount of gas exhaled/min.
• VE = (RR) x (TV)
• VE comprised of 2 factors
• VA = alveolar ventilation
• VD = dead space ventilation
• VD/VT = 0.33
• VE regulated by brain stem, responding to pH and PaCO2
• Ventilation in context of ICU
• Increased CO2 production
• fever, sepsis, injury, overfeeding
• Increased VD
• atelectasis, lung injury, ARDS, pulmonary embolism
• Adjustments: RR and TV

Principles (2): Oxygenation
• The primary goal of oxygenation is to maximize O2
delivery to blood (PaO2)
• Alveolar-arterial O2 gradient (PAO2 – PaO2)
• Equilibrium between oxygen in blood and oxygen in alveoli
• A-a gradient measures efficiency of oxygenation
• PaO2 partially depends on ventilation but more on V/Q matching
• Oxygenation in context of ICU
• V/Q mismatching
• Patient position (supine)
• Airway pressure, pulmonary parenchymal disease, small-airway
disease
• Adjustments: FiO2 and PEEP

Terminologies
• A/C: Assist-Control
• SIMV: Synchronized Intermittent Mandatory
Ventilation
• Bi-level/Biphasic: Non-inversed Pressure
Ventilation with Pressure Support (consists of 2
levels of pressure)
• PRVC: Pressure Regulated Volume Control
• PEEP: Positive End Expiratory Pressure
• CPAP: Continuous Positive Airway Pressure
• PSV: Pressure Support Ventilation
• NIPPV: Non-Invasive Positive Pressure Ventilation

Pressure Ventilation vs. Volume Ventilation
• Pressure-cycled modes deliver a fixed pressure at variable
volume (neonates)
• Volume-cycled modes deliver a fixed volume at variable
pressure (adults)
• Pressure-cycled modes
• Pressure Support Ventilation (PSV)
• Pressure Control Ventilation (PCV)
• CPAP
• BiPAP
• Volume-cycled modes
• Control
• Assist
• Assist/Control
• Intermittent Mandatory Ventilation (IMV)
• Synchronous Intermittent Mandatory Ventilation (SIMV)

Pressures in Positive Pressure Ventilation
• Baseline Pressure
• Peak Pressure
• Plateau Pressure
• Pressure at End of Exhalation

– Pressures are read from a zero baseline value
– At baseline pressure (end of exhalation), the volume
of air remaining in the lungs is the FRC.

– Continuous Positive Airway Pressure (CPAP)

– Positive End-Expiratory Pressure (PEEP)
• Prevents patients from exhaling to zero (atmospheric
pressure)
• Increases volume of gas left in the lungs at end of normal
exhalation – increases FRC

• Peak Pressure (PIP)
– The highest pressure recorded at the end of inspiration (PPeak, PIP)
– It is the sum of two pressures
• Pressure required to force the gas through the resistance of the
airways and to fill alveoli

• Plateau Pressure
– At the end of inspiration, before exhalation starts, the
volume of air in the lungs is the VT plus the FRC. The
pressure measured at this point with no flow of air is
plateau pressure
– Measured after a breath has been delivered and before
exhalation
• Ventilator operator has to perform an “inflation hold”
– Like breath holding at the end of inspiration
– Reflects the effect of elastic recoil on the gas volume
inside the alveoli and any pressure exerted by the volume
in the ventilator circuit that is acted upon by the recoil of
the plastic circuit

• Pressure at End of Expiration
– Pressure falls back to baseline during expiration
– Auto-PEEP
• Air trapped in the lungs during mechanical ventilation when not
enough time is allowed for exhalation
• When PEEPi occurs, the lung volume at end expiration is greater
then the FRC
• Need to monitor pressure at end of exhalation

• Pressure at End of Expiration
– Auto-PEEP

• Auto-PEEP
– Why does hyperinflation occur?
• Airflow limitation because of dynamic collapse
• No time to expire all the lung volume (high RR or Vt)
• Expiratory muscle activity
• Lesions that increase expiratory resistance
• Measured in a relaxed pt with an end-expiratory hold
maneuver on a mechanical ventilator immediately before the
onset of the next breath
• Adverse effects:
– Predisposes to barotrauma
– Predisposes hemodynamic compromises
– Diminishes the efficiency of the force generated by respiratory muscles
– Augments the work of breathing
– Augments the effort to trigger the ventilator

Modes of Ventilation
• Mode
– Description of a breath type and the timing of breath
delivery
• Basically there are three breath delivery techniques used
with invasive positive pressure ventilation
– CMV – Controlled ventilation
– IMV – Intermittent ventilation
– Spontaneous modes

• CMV
– All breaths are mandatory and can be volume or
pressure targeted
• Controlled Ventilation – when mandatory breaths are time
triggered
• Assist/Control Ventilation – when mandatory breaths are
either time triggered or patient triggered

• CMV
– when mandatory breaths are time triggered
• ventilator determines the start time (time triggered) and/or the
volume or pressure target
• Adequate alarms must be set to safeguard the patient
– E.g., disconnection
• Sensitivity should be set so that when the patient begins to
respond, they can receive gas flow from the patient

• CMV
– Appropriate when a patient can make no effort to
breathe or when ventilation must be completely
controlled
• Drugs
• Cerebral malfunctions
• Spinal cord injury
• Phrenic nerve injury
• Motor nerve paralysis

• CMV
– In other types of patients, controlled ventilation is
difficult to use unless the patient is sedated or
paralyzed with medications
• Seizure activity
• Tetanic contractions
• Inverses I:E ratio ventilation
• Patient is fighting (bucking) the ventilator
• Crushed chest injury – stabilizes the chest
• Complete rest for the patient

• Assist/Control Ventilation
– A time or patient triggered CMV mode in which the operator
sets a minimum rate, sensitivity level, type of breath (volume
or pressure)
– The patient can trigger breaths at a faster rate than the set
minimum, but only the set volume or pressure is delivered with
each breath

– Indications
• Patients requiring full ventilatory support
• Patients with stable respiratory drive
• The INITIAL mode usually set upon advent of mechanical
ventilation

– Advantages
• Decreases the work of breathing (WOB)
• Allows patients to regulate respiratory rate
• Helps maintain a normal PaCO2
• Useful in patients with neuromuscular weakness or CNS disturbances
– Complications
• Tachypnea may result in significant hypocapnia and respiratory
alkalosis
• Improper setting of sensitivity to trigger the ventilator may result in
“fighting the ventilator” when the sensitivity is set too low
• Increased sensitivity may result in hyperventilation; sensitivity is
generally set so that an inspiratory effort of 2 cm H20 / 2 Liters will
trigger the ventilation
• Since there is almost no work involved by the respiratory muscles,
muscle tone is not well-maintained (data have shown that muscle
atrophy starts within 6 hours of AC mode)

Selection of Settings for A/C Mode
• Tidal Volume (VT) :
– 8-10 ml/kg of ideal body weight
– 6 ml/kg for ALI/ARDS
• Rate (number of tidal breaths delivered/minute):
– backup rate is usually set 2 to 4 below the spontaneous rate and then the effect on
the patient of decreasing rate is noted
– This can be adjusted depending on the desired PaCO2 or pH ( increased rate =
decreased PaCO2 and increased pH)
• Oxygen Concentration (Fi02):
– the initial FiO2 should be 100% unless it is evident that a lower FIO2 will provide
adequate oxygenation
• Inspiratory Flow Rate:
– This is the rate air is delivered to the patient to achieve the Tidal Volume set.
– The initial flow rate is typically set at 40 to 60 L/minute.
– This rate typically needs to be higher in patients with asthma and COPD
– An inspiratory flow rate setting LOWER than the patient demand will increase the work
of breathing and is a common cause of patient-ventilator discordance

• Inspiratory Flow Pattern:
– This is how flow is distributed throughout the respiratory
cycle
– The wave forms usually available are:
1. SINE WAVE - the maximum flow is at mid inspiration and
resembles a normal spontaneous tidal breathing
2. SQUARE WAVE - this provides a maximum peak flow
throughout the inspiratory period
3. DECELERATING WAVE – the flow is maximal at the start and
diminishes as inspiration ends
• PEEP:
– “Physiologic PEEP” of about 5 cm H20 should be added
regardless of FiO2 to prevent the alveolar injury due to the
shearing effect of opening and closing of the alveoli

• Sensitivity:
– Ranges anywhere from –5 to –0.5 cm H20 (pressure
sensitivity) or 1- to 5 liters (flow sensitivity)
– The more sensitive (e.g. 0.5 cm or 1 L) , the easier
for patient to trigger the ventilator which may lead to
hyperventilation
– The less sensitive (e.g. 5 cm or 5 L), the harder for
the patient to trigger the ventilator which can lead to
increase of work of breathing and thus can cause
patient-ventilator desynchrony
– The usual triggering pressure to start with is –2.0 cm
or 2 L

• CMV
– Volume Controlled –
CMV
• Time or patient
triggered, volume
targeted, volume
cycled ventilation
• Graphic (VC-CMV)
– Time-triggered,
constant flow,
volume-targeted
ventilation

• CMV
– Volume Controlled –
CMV
• Time or patient
triggered, volume
targeted, volume
cycled ventilation
• Graphic (VC-CMV)
– Time-triggered,
descending-flow,
volume-targeted
ventilation

• CMV
– Pressure Controlled – CMV
• PC – CMV (AKA – Pressure control ventilation - PCV)
• Time or patient triggered, pressure targeted (limited), time
cycled ventilation
• The operator sets the length of inspiration (Ti), the
pressure level, and the backup rate of ventilation
• VT is based on the compliance and resistance of the
patient’s lungs, patient effort, and the set pressure

• CMV
– Pressure Controlled
– CMV
• Note inspiratory
pause

• CMV
– Pressure Controlled
– CMV
• Note shorter Ti

• CMV
• Airway pressure is limited, which may help guard against
barotrauma or volume-associated lung injury
– Maximum inspiratory pressure set at 30 – 35 cm H2O
– Especially helpful in patients with ALI and ARDS
• Allows application of extended inspiratory time, which may
benefit patients with severe oxygenation problems
• Usually reserved for patient who have poor results with a
conventional ventilation strategy of volume ventilation

• CMV
• Occasionally, Ti is set longer than TE during PC-CMV; known
as Pressure Control Inverse Ratio Ventilation
– Longer Ti provides better oxygenation to some patients by
increasing mean airway pressure
– Requires sedation, and in some cases paralysis

• Intermittent Mandatory Ventilation – IMV
– Periodic volume or pressure targeted breaths occur at set
interval (time triggering)
– Between mandatory breaths, the patient breathes
spontaneously at any desired baseline pressure without
receiving a mandatory breath
• Patient can breathe either from a continuous flow or gas or from a
demand valve

• Intermittent Mandatory Ventilation – IMV
– Indications
• Facilitate transition from full ventilatory support to partial
support
– Advantages
• Maintains respiratory muscle strength by avoiding muscle
atrophy
• Decreases mean airway pressure
• Facilitates ventilator discontinuation – “weaning”
– Complications
• When used for weaning, may be done too quickly and cause
muscle fatigue
• Mechanical rate and spontaneous rate may asynchronous
causing “stacking”
– May cause barotrauma or volutrauma

• Synchronized IMV
– Operates in the same way as IMV except that mandatory
breaths are normally patient triggered rather than time
triggered (operator set the volume or pressure target)
– As in IMV, the patient can breathe spontaneously through the
ventilator circuit between mandatory breaths

– At a predetermined interval (respiratory rate), which is set by
the operator, the ventilator waits for the patient’s next
inspiratory effort
– When the ventilator senses the effort, the ventilator assists the
patient by synchronously delivering a mandatory breath
– If the patient fails to initiate ventilation within a predetermined
interval, the ventilator provides a mandatory breath at the end
of the time period

– Indications
• Facilitate transition from full ventilatory support to partial support
– Advantages
• Maintains respiratory muscle strength by avoiding muscle atrophy
• Decreases mean airway pressure
• Facilitates ventilator discontinuation – “weaning”
– Complications/Disadvantages
• When used for weaning, may be done too quickly and cause muscle
fatigue
• With increased WOB resulting in increased oxygen consumption which
is deleterious in patients with myocardial insufficiency/hemodynamic
instability
• NOT useful in patients with depressed respiratory drive or impaired
neurologic status

Selection of Settings for SIMV Mode
• Rate :
– The initial rate set should be close to the
patient’s rate and then the rate decreased
noting the effect on patient acceptance.
• Tidal Volume (VT), FIO2, Inspiratory flow
rate, Inspiratory flow pattern (Wave form),
+/- PEEP are the same as that of A/C.

• Spontaneous Modes
– Three basic means of providing support for continuous
spontaneous breathing during mechanical ventilation
• Spontaneous breathing
• CPAP
• PSV – Pressure Support Ventilation

• Spontaneous Breathing
– Patients can breathe spontaneously through a
ventilator circuit;
– sometimes called T-Piece Method because it mimics
having the patient ET tube connected to a Briggs
adapter (T-piece)
– Advantage
• Ventilator can monitor the patient’s breathing and activate
an alarm if something undesirable occurs
– Disadvantage
• May increase patient’s WOB with older ventilators

– CPAP
• Ventilators can provide CPAP for spontaneously breathing patients
– Helpful for improving oxygenation in patients with refractory hypoxemia and a
low FRC
– CPAP setting is adjusted to provide the best oxygenation with the lowest positive
pressure and the lowest FiO2
• Advantages
– Ventilator can monitor the patient’s breathing and activate an alarm if
something undesirable occurs
– Serves to keep alveoli from collapsing, resulting in better oxygenation and
less WOB.
• Pre-set pressure is present in the circuit and lungs
throughout both the inspiratory and expiratory phases of
the breath.
• Commonly used as a mode to evaluate the patients
readiness for extubation.

• PEEP (Positive End Expiratory Pressure)
– “According to its purest definition, the term PEEP is defined as positive pressure
at the end of exhalation during either spontaneous breathing or mechanical
ventilation. However, use of the term commonly implies that the patient is also
receiving mandatory breaths from a ventilator.” (Pilbeam)
– PEEP becomes the baseline variable during mechanical
ventilation
– Helps prevent early airway closure and alveolar collapse and
the end of expiration by increasing (and normalizing) the
functional residual capacity (FRC) of the lungs
– Facilitates better oxygenation
– NOTE: PEEP is intended to improve oxygenation, not to provide ventilation,
which is the movement of air into the lungs followed by exhalation

• Pressure Support Ventilation – PSV
– Patient triggered, pressure targeted, flow cycled
mode of ventilation
– Requires a patient with a consistent spontaneous
respiratory pattern
– The ventilator provides a constant pressure during
inspiration once it senses that the patient has made
an inspiratory effort

• PSV
– Indications
• Spontaneously breathing patients who require additional
ventilatory support to help overcome
• WOB, CL, Raw
• Respiratory muscle weakness
• Weaning (either by itself or in combination with SIMV)

• PSV
– Advantages
• Full to partial ventilatory support
• Augments the patients spontaneous VT
• Decreases the patient’s spontaneous respiratory rate
• Decreases patient WOB by overcoming the resistance of the
artificial airway, vent circuit and demand valves
• Allows patient control of TI, VI, f and VT
• Set peak pressure
• Prevents respiratory muscle atrophy
• Facilitates weaning
• Improves patient comfort and reduces need for sedation
• May be applied in any mode that allows spontaneous
breathing, e.g., VC-SIMV, PC-SIMV

• PSV
– Disadvantages
• Requires consistent spontaneous ventilation
• Patients in stand-alone mode should have back-up
ventilation
• VT variable and dependant on lung characteristics and
synchrony
• Low exhaled VE
• Fatigue and tachypnea if PS level is set too low

– Flow Cycling During PSV
• Flow cycling occurs when the ventilator
detects a decreasing flow, which
represents the end of inspiration
• This point is a percentage of peak flow
measured during inspiration
– PB 7200 – 5 L/min
– Bear 1000 – 25% of peak flow
– Servo 300 – 5% of peak flow
• No single flow-cycle percent is right for
all patients

– Flow Cycling During PSV
• Effect of changes in
termination flow
• A: Low percentage (17%)
• B: High percentage (57%)
• Newer ventilators have an
adjustable flow cycle
criterion, which can range
from 1% - 80%, depending
on the ventilator

– PSV during SIMV
• Spontaneous breaths during SIMV can be supported
with PSV (reduces the WOB)
PCV – SIMV with PSV

– PSV during SIMV
• Spontaneous breaths during SIMV can be supported
with PSV
VC – SIMV with PSV

• PSV
– NOTE: During pressure support ventilation (PSV), inspiration ends if the
inspiratory time (TI) exceeds a certain value.
• This most often occurs with a leak in the circuit. For
example, a deflated cuff causes a large leak. The flow
through the circuit might never drop to the flow cycle
criterion required by the ventilator.
• Therefore, inspiratory flow, if not stopped would continue
indefinitely.
• For this reason, all ventilators that provide pressure support
also have a maximum inspiratory time.

• PSV
– Setting the Level of Pressure Support
• Goal: To provide ventilatory support
– Spontaneous tidal volume is 10 – 12 mL/Kg of ideal body
weight
– Maintain spontaneous respiratory rate <25/min
• Goal: To overcome system resistance (ET Tube, circuit,
etc.) in the spontaneous or IMV/SIMV mode
– Set pressure at (PIP – Pplateau) achieved in a volume breath or
at 5 – 10 cm H2O

– PSV - The results of your work
35 cm H2O
10 cm H2O

Selection of Settings for PSV
• Inspiratory Pressure:
– start with a pressure which gives a desired tidal volume (5 to 7 ml/kg) and the
respiratory muscles have been unloaded
– One can start with lower pressures (e.g. 15 to 20 cm H20) and titrate up until the
desired tidal volume is reached.
– One good clue that the desired inspiratory pressure is reached is the note of a
decreased frequency in respiratory rate
• FIO2:
– set at the inspired oxygen which can give an O2 saturation of 92% or higher
• PEEP:
– this can be added on to improve oxygenation or prevent shearing injury to the alveoli
• TIDAL VOLUME will be dependent on:
– Patient’s resistance and compliance
– The preset Inspiratory Pressure
– The preset Inspiratory Time (which can be adjusted by setting an
Inspiration:Expiration (I:E) time

PSV vs. PCV
PSV
• Patient determines RR, VE, inspiratory
time – a purely spontaneous mode
• Parameters
• Triggered by pt’s own breath
• Limited by pressure
• Affects inspiration only
• Uses
• Complement volume-cycled modes (i.e.,
SIMV)
• Does not augment TV but overcomes
resistance created by ventilator
tubing
• PSV alone
• Used alone for recovering intubated
pts who are not quite ready for
extubation
• Augments inflation volumes during
spontaneous breaths
• BiPAP (CPAP plus PS)
PCV
• No Patient participation
• Parameters
• Triggered by time
• Limited by pressure
• Affects inspiration only
• Disadvantages
• Requires frequent adjustments
to maintain adequate VE
• Pt with noncompliant
lungs may require
alterations in inspiratory
times to achieve adequate
TV

• Bilevel Positive Airway Pressure (BiPAP)
– An offshoot of PEEP/CPAP therapy
– Most often used in NPPV
– AKA
• Bilevel CPAP
• Bilevel PEEP
• Bilevel Pressure Support
• Bilevel Pressure Assist
• Bilevel Positive Pressure
• Bilevel Airway Pressure

– Commonly patient triggered but can be time triggered,
pressure targeted, flow or time cycled
– The operator sets two pressure levels
• IPAP (Inspiratory Positive Airway Pressure)
– IPAP is always set higher than EPAP
– Augments VT and improves ventilation
• EPAP (Expiratory Positive Airway Pressure)
– Prevents early airway closure and alveolar collapse at the end of
expiration by increasing (and normalizing) the functional residual
capacity (FRC) of the lungs
– Facilitates better oxygenation

– The operator sets two pressure levels
• IPAP
• EPAP
NOTE: The pressure difference between IPAP and EPAP is pressure support

Vent settings to improve <oxygenation>
•FIO2
• Simplest maneuver to quickly increase PaO2
• Long-term toxicity at >60%
• Free radical damage
•Inadequate oxygenation despite 100% FiO2
usually due to pulmonary shunting
• Collapse – Atelectasis
• Pus-filled alveoli – Pneumonia
• Water/Protein – ARDS
• Water – CHF
• Blood - Hemorrhage
PEEP and FiO2 are adjusted in tandem

Vent settings to improve <oxygenation>
•PEEP
• Increases FRC
• Prevents progressive atelectasis and
intrapulmonary shunting
• Prevents repetitive opening/closing (injury)
• Recruits collapsed alveoli and improves
V/Q matching
• Resolves intrapulmonary shunting
• Improves compliance
• Enables maintenance of adequate PaO2
at a safe FiO2 level
• Disadvantages
• Increases intrathoracic pressure (may
require pulmonary a. catheter)
• May lead to ARDS
• Rupture: PTX, pulmonary edema
PEEP and FiO2 are adjusted in tandem
Oxygen delivery (DO2), not PaO2, should be
used to assess optimal PEEP.

Vent settings to improve <ventilation>
•Respiratory rate
• Max RR at 35 breaths/min
• Efficiency of ventilation decreases with
increasing RR
• Decreased time for alveolar emptying
•TV
• Goal of 10 ml/kg
• Risk of volutrauma
•Other means to decrease PaCO2
• Reduce muscular activity/seizures
• Minimizing exogenous carb load
• Controlling hypermetabolic states
•Permissive hypercapnea
• Preferable to dangerously high RR and TV,
as long as pH > 7.15
RR and TV are adjusted to maintain VE and PaCO2
•I:E ratio (IRV)
• Increasing inspiration time will
increase TV, but may lead to auto-
PEEP
•PIP
• Elevated PIP suggests need for
switch from volume-cycled to
pressure-cycled mode
• Maintained at <45cm H2O to
minimize barotrauma
•Plateau pressures
• Pressure measured at the end of
inspiratory phase
• Maintained at <30-35cm H2O to
minimize barotrauma

Alternative Modes
• I:E inverse ratio ventilation (IRV)
• ARDS and severe hypoxemia
• Prolonged inspiratory time (3:1) leads to better
gas distribution with lower PIP
• Elevated pressure improves alveolar
recruitment
• No statistical advantage over PEEP, and does
not prevent repetitive collapse and reinflation
• Prone positioning
• Addresses dependent atelectasis
• Improved recruitment and FRC, relief of
diaphragmatic pressure from abdominal
viscera, improved drainage of secretions
• Logistically difficult
• No mortality benefit demonstrated
• ECHMO
• Airway Pressure Release (APR)
• High-Frequency Oscillatory
Ventilation (HFOV)
• High-frequency, low amplitude
ventilation superimposed over elevated
Paw
• Avoids repetitive alveolar open and
closing that occur with low airway
pressures
• Avoids overdistension that occurs at high
airway pressures
• Well tolerated, consistent improvements
in oxygenation, but unclear mortality
benefits
• Disadvantages
• Potential hemodynamic compromise
• Pneumothorax
• Neuromuscular blocking agents

References
• Mechanical Ventilation for Nursing by M Dearing and C
Shelley (ppt)
• Mechanical Ventilation Handout by DM Lieberman and
AS Ho (ppt)
• Mechanical Ventilation by Marc Charles Parent (ppt)
• Principles of Mechanical Ventilation RET 2284 by Stultz
(ppt)
• Sena, MJ et al. Mechanical Ventilation. ACS Surgery:
Principles and Practice 2005; pg. 1-16.
• Marino, PL. The ICU Book. 2nd edition. 1998.
• Byrd, RP. Mechanical ventilation. Emedicine, 6/6/06.

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