ANAESTHESIA

Able to maintain normocapnia without a very high minute ventilation

(e.g. less than 10 litters per minute).

Third, he should have adequate cardiovascular reserve to tolerate

unassisted breathing. Myocardial ischemia and reduced left ventricular function
impair a patient’s ability to breathe without assistance. Cardiogenic pulmonary
edema benefits from the reduction in preload and afterload brought on by
positive pressure breathing, and extubation can aggravate this.18 A spontaneous
breathing trial using a T-piece instead of CPAP or PSV may be helpful to
determine if a patient with left ventricular dysfunction is ready for extubation.

Mental status is often a consideration when considering readiness for

extubation. Patients who are stuporous or comatose have difficulty maintaining
adequate airway tone and may have diminished protective reflexes, so
aspiration and pneumonia are potential risks. In addition, patients with brain
illness or injury can have disorders of central respiratory drive. Nevertheless,
one study demonstrated that brain-injured patients who had no other reason to
stay intubated other than mental status-that is, they didn’t have high oxygen
requirements, weren’t being suctioned frequently, and didn’t have periods of
apnea-actually did better with early extubation.

Weaning Parameters

Several clinical indices are commonly used to assess readiness for

extubation. These can be obtained at the bedside, without much need for
specialized equipment.

MIP: maximal inspiratory pressure; also known as the negative inspiratory

force (NIF). Healthy young men can generate a MIP of -120 cm H:0; women

Page no.. 1
can generate a MIP of -90. For intubated patients, a MIP of less than 30 is
usually considered adequate.

FVC: forced vital capacity. Normal subjects have an FVC of 70-80 ml/kg. In
intubated patients, an FVC of 10-15 ml/kg is considered sufficient for
unassisted breathing.

Minute Ventilation: a minute ventilation of more than 10 liters per minute to

keep a normal PaCO2 is generally too much work for a patient to perform
without assistance from the ventilator.

Weaning parameters have several drawbacks, however. The MIP and FVC
depend on adequate patient cooperation and effort, and they are static
measurements at one point in time. The minute ventilation is a dynamic
measurement over a period of time, but it may be affected by patient discomfort
or agitation. None of these parameters have sufficient positive or negative-
predictive value by themselves, although they can be useful adjuncts to clinical
decision-making. For the most part, weaning parameters have been replaced by
the concept of the spontaneous breathing trial.

Spontaneous Breathing Trial

A spontaneous breathing trial (SBT) is performed by observing a patient’s

respiratory efforts r a period of time, usually 30-120 minutes, with w or no
ventilator support. One of the first major trials to show the utility of the SBT
required putting the patient on a T-piece-oxygen tubing attached to e end of the
endotracheal tube, which looks like the eter T. The T-piece trial has the
advantage of sting the patient’s breathing without any ventilator apport. It can
be labor-intensive, though, and it’s difficult to measure the tidal volume without
a special device attached to the tube.

Other trials have shown that either CPAP sione, 20 or CPAP with the addition
of low-level pressure support (5-8 cm H2O)21.22 are as effective as T-piece

Page no.. 2
SBT. Using CPAP or PSV has the advantage of letting you see the rate and tidal
volume and not nquiring disconnection from the ventilator.

At the conclusion of the SBT, assess the patient’s readiness for extubation.
Much of this is by a simple clinical examination-the person who is tachypneic,
tachycardic, and diaphoretic is not ready; the person who is breathing slowly
and deeply and seems comfortable probably is. In order to assist you. There’s an
index called the Rapid Shallow Breathing Index, or RSBI. This is the ratio
between the patient’s respiratory rate and the tidal volume (in liters). It’s easier
to breathe fast than deep, so a patient without A lot of respiratory muscle
strength will take fast, hallow breaths. Slow, deep breaths are better. As an
example, a patient with a respiratory rate of 10 and a tidal volume of 500 mL
has an RSBI of 20 (10/0.5). Another patient with a respiratory rate of 50 and a
tidal volume of 100 mL has an RSBI of 500 (50/0.1).

Both have the same minute ventilation (10 L/min), but the latter patient is
clearly not ready for extubation.

An RSBI of 105 is predictive of successful Extubation. Since I do SBTs on the

vent with PSV, 1 use a slightly stricter threshold of 80 to account for the
assistance provided. You have to use some common sense and clinical judgment
as well-someone with an RSBI of 75 who has a paradoxical breathing pattern
and is gasping will probably not do too well off the vent. Another person with
an RSBI of 110 who otherwise looks calm and seems comfortable may in fact
do well, and it could be worth giving her a chance.

An SBT should be done on every patient who meets the criteria. In order to be
effective, the SBT assessment should be an automatic thing for all ventilated
patients unless there’s a specific reason not to (like an open chest, or high
intracranial pressure, or a difficult airway). Ideally, the respiratory therapist will
conduct the SBT at the same time that the nurse does the daily sedation

Page no.. 3
vacation-this will improve your odds at getting patients extubated quickly.
Remember that the ventilator is not therapeutic, and that the patient will come
off the vent when he’s ready. The purpose of the SBT is to recognize when he’s
ready and to not make him spend. Any more time on the vent than is necessary.

Daily SBTs have two advantages-first, they are simple to do. A daily
assessment and spontaneous breathing trial takes up a short amount of time and
gives you a reliable way to know who can be extubated and who cannot.
Second, they are the most effective way of liberating patients from mechanical
ventilation. Daily SBTs have proven superior to SIMV and PSV “weaning” in
terms of time on the ventilator and length of stay in the ICU.

There are two types of days for patients with respiratory failure-vent days and
get-off-the-vent days. A daily spontaneous breathing trial lets you know which
kind of a day it is. If the patient passes, extubate! If not, put him back on assist-
control ventilation. There’s no benefit from “working him out” are by finding
the level of support just above that where be fatigues. Let him rest and try again
tomorrow. This method is simple. It’s easy to make a part of your daily practice
in the ICU. And, it works.

Daily SBT Protocol

Assessment Criteria

FiO2: <50%

PEEP ≤8

Able to follow directions

Not requiring frequent suctioning

Hemodynamically stable Not a known difficult airway

Not on unconventional ventilation (APRV

Page no.. 4
HFOV) No physician order for "No Daily SBT

If all of the assessment criteria are met, begin the Spontaneous Breathing
Trial

1. CPAP 5 cm, PS 7 cm for 30-60 minutes

2. At the end of the SBT, calculate the RSBI

3. If the RSBI is < 80, extubate the patient

4. If the RSBI is > 80, back to assist-control

5. If there is concern over the patient's readiness

for extubation, call the physician

Abort the SBT for any of the following

Desaturation below 88%

Increase in heart rate by 20 beats/min

Significant change in blood pressure Diaphoresis

Accessory muscle use or paradoxical breathing

Pattern

Too high (0.85 or higher), it can lead to excessive work of breathing after all,
the lungs are the organs that have to clear all of the CO produced by
metaboliem A metabolic cart study can be used to determine the RQ. If it
exceeda 0.86, I switch to a lower carbohydrate tube feeding formula.

The metabolic cart study can also calculate the resting energy expenditure
(1616) in kcal/day. There are many formulas for predicting how many calories
over the Rich a patient needs. I try to keep it simple and provide about 500 kcal

Page no.. 5
above the REE, and I try to provide all of the patient’s caloric needs with
carbohydrates and fat (in a 60/40 ratio, to keep the HQ down). That way protein
can be used to build muscle instead of being burned for energy.

Most of the nitrogen by products of protein metabolism are excreted in the

urine. About 2 K N are lost in the stool, and another 2 g are lost through the
skin. A 24-hour urine urea nitrogen (UUN) collection tells you how much is lost
in the urine. Adding these up, we know the patient’s daily nitrogen excretion.
Since protein is 10% elemental nitrogen, multiplying the total daily nitrogen
excretion by 6.25 gives the amount of protein, in grams, necessary to break
even. In order to provide enough protein for skeletal muscle anabolism, I try to
give about 10-20 grams of protein above this. For example, if a patient has a 24-
hour UUN of 10 g N, his daily excretion in 14 g (10 from the urine, 2 from the
stool, 2 from the skin). Multiplying 14 by 6.26 gives us 87.5 g protein needed to
break even. Therefore, I would make sure he’s taking in about 100 grams of
protein a day.

Chapter 16

Prolonged Respiratory Failure

About 20% of ventilated patients will not be able to liberate quickly once their
illness or injury resolves, This may be due to pre existing illnesses, poor cardiac
function, chronic lung disease. Malnutrition, deconditioning, or critical illness
polyneuromyopathy. A good definition of prolonged respiratory failure, or
difficult weaning, is when the patient is still intubated after at least three
spontaneous breathing trials and more than seven days after resolution of the
acute illness or injury.

Timing of tracheostomy

Timing of tracheostomy placement is Controversial and varies widely between

institutions and practitioners. While many critical care physicians would agree a

Page no.. 6
tracheostomy should be performed after two weeks of respiratory failure, there
are a substantial number who believe that this is too long to wait. The literature
is divided on the topic-some studies have shown a benefit,” while a recent.

multicenter randomized trial showed no advantage to rly tracheostomy. In this

trial, a significant number of patients randomized to tracheostomy at 14 a were
extubated prior to the operation, suggesting that waiting is not necessarily a bad
thing.

Benefits of earlier tracheostomy include patient Fort, increased mobility, less

need for sedation, and a shorter time in the ICU. Drawbacks of tracheostomy
include the need for an invasive procedure, the risk of tracheal stenosis, and the
psychological burden it places on the patient (since any people associate a
tracheostomy with chronic illnesses like cancer). There is a psychological shift
among caregivers as well, in my experience for some patients, once a
tracheostomy is placed that person becomes a “trach patient.” Physicians and
nurses seem to be more likely to send a “trach patient” to a nursing home, and
there can be a reluctance to decannulate (ie. Remove) the tracheostomy tube,
even after the patient is liberated from the ventilator.

Like everything else, this decision needs to be individualized for the patient. If
prolonged ventilation is anticipated due to neurologic illness or injury or
because of airway obstruction, then tracheostomy should occur rather quickly.
On the other hand, if the disease process is one where you expect recovery
within one to two weeks (chest or abdominal trauma, pneumonia, status
asthmaticus, CHF exacerbation), then I would wait.

Removing the Tracheostomy

Once the patient is free of the vent, it’s time to begin thinking about
decannulation. This, obviously. Depends on many factors and there is no
specific rule

Page no.. 7
Regarding when a tracheostomy tube can be removed. Some general
requirements for decannulation are

1. The patient should be able to get out of bed and get around (even with
a wheelchair).
2. He should be able to speak and breathe comfortably with the
tracheostomy tube occluded (e.g. with a Passy-Muir Speaking Valve).
3. There should be no need for frequent suctioning or other pulmonary
toilet measures.
4. There should be no anticipated need for positive pressure ventilation.

Contributors to Prolonged Respiratory Failure

Many of the reasons why patients are ventilated are self-evident and should be
treated. The following list mentions some that may not be as obvious. Dynamic
hyperinflation, delirium, diaphragmatic paralysis, hypothyroidism and
neuromuscular disease are all good examples of relatively common occult
conditions leading to prolonged respiratory failure.

Pulmonary: dynamic hyperinflation, diaphragmatic paralysis, pulmonary

fibrosis

Cardiac: impaired left ventricular systolic function, pulmonary hypertension,

pericardial effusion, constrictive pericarditis

Neurologic: brainstem lesions, cervical spine injury or disease, neuromuscular

disease

Endocrine: hypothyroidism, hypoadrenaliem. Low testosterone (in men)

Malnutrition

Critical Illness Neuromyopathy

Deconditioning

Page no.. 8
Delirium

Nutritional Support

Adequate caloric and protein intake via the enteral route is a tenet of critical
care medicine. For most patients in the ICU, nutritional needs can be estimated-
25-30 kcal/kg from carbohydrates and fat, with 1-1.5 g/kg protein. For people
with prolonged respiratory failure, I do a more detailed evaluation of their
nutritional regimen every one to two weeks.

A balanced diet yields a respiratory quotient (RQ) of 0.8. The RQ represents the
body’s CO2 production divided by its 02 consumption. Different food sources
have a different RQ-a diet consisting solely of fat would have an RQ of 0.7,
while a carbohydrate-only diet has an RQ of 1.0. If the RQ is

BIOMEDICAL WASTE MANAGEMENT

Facilitator:

Dr. NAVPREET

Assistant Professor, Department of Community Medicine Govt. Medical

College & Hospital, Chandigarh.

Specific Learning Objectives

 At the end of session, the learner shall be able to know about:

INTRODUCTION
 Since beginning, the hospitals are known for the treatment of sick persons
but we are unaware about the adverse effects of the garbage and filth
generated by them on human body and environment. Now it is a well
established fact that hospital waste is a potential health hazard to the
health care workers, public and flora and fauna of the
area.

Page no.. 9
 The act was passed by the Ministry of Environment and Forests in 1986
& notified the Bio Medical Waste (Management and Handling) Rules in
July 1998. In accordance with these rules, it is the duty of every
‘occupier” i.e. a person who has the control over the institution or its
premises, to take all steps to ensure that waste generated is handled
without any adverse effect to human health and Environment.

DEFINITIONS

 Hospital waste refers to all waste, biological or non- biological that is

discarded and not intended for further use.
 Bio-medical waste means any waste, which is generated during the
diagnosis, treatment or immunization of human beings or animals or in
research activities pertaining thereto or in the production or testing of
biologicals, and including categories mentioned in Schedule I.
 Infectious waste: The wastes which contain pathogens in sufficient
concentration or quantity that could cause diseases. It is hazardous e.g.
culture and stocks of infectious agents from laboratories, waste from
surgery, waste originating from infectious patients.

SOURCES OF BIO MEDICAL WASTE

 Hospitals
 Nursing homes
 Clinics
 Medical laboratories
 Blood banks
 Mortuaries
 Medical research & training centers
 Biotechnology institution/production units
 Animal houses etc.

Page no.. 10
  Such a waste can also be generated at home if health care is being
provided there to a patient (e.g. injection, dressing material etc.)

TRANSPORTATION AND STORAGE

 The waste may be temporarily stored at the central storage area of the
hospital and from there it may be sent in bulk to the site of final disposal
once or twice a day depending upon the quantum of waste. During
transportation following points should be taken care of:
 Ensure that waste bags/containers are properly sealed and labeled.
 Bags should not be filled completely, so that bags can be picked up by the
neck again for further handling. Hand should not be put under the bag. At
a time only one bag should be lifted.
 Manual handling of waste bags should be minimized to reduce the risk of
needle prick injury and infection.
 BMW should be kept only in a specified storage area. After removal of
the bag, clean the container including the lid with an appropriate
disinfectant.
 Waste bags and containers should be removed daily from wards / OPDS
or even more frequently if needed (as in Operation Theatres, ICUs, labour
rooms). Waste bags should be transported in a covered wheeled
containers or large bins in covered trolleys.
 No untreated bio-medical waste shall be kept stored beyond a period
of 48 hours

TRANSPORT TO FINAL DISPOSAL SITE

 Transportation from health care establishment to the site of final disposal

in a closed motor vehicle (truck, tractor-trolley etc.) is desirable as it
prevents spillage of waste on the way.

Page no.. 11
  Vehicles used for transport of BMW must have the “Bio-Hazard”
symbol and these vehicles should not be used for any other purpose.

CYTOTOXIC HAZARD SYMBOL

Note: Label shall be non-washable & prominently visible.

DISPOSAL OF BIOMEDICAL WASTE

 Deep burial:
- Category 1 and2 only
- In cities having less than 5 lakh population & rural area.

Autoclave and microwave treatment

- Standards for the autoclaving and microwaving are also mentioned

in the Biomedical waste (Management and Handling) Rules 1998.
- All equipment installed/shared should meet these Specifications.
- Category 3, 4, 6 and 7 can be treated by these techniques.

Shredding

- The plastic (I.V. bottles, I.V. sets, syringes, catheters etc.), sharps
(needles, blades, glass etc) should be shredded but only after
chemical treatment/microwaving/autoclaving.
- Needle destroyers can be used for disposal of needles directly
without chemical treatment.

Land disposal:

- Open dumps
- Secured/Sanitary landfill: advantages.
- The incinerator ash, discarded medicines, cytotoxic substances and
solid chemical waste should be treated by this option.

Page no.. 12
 Incineration
• A high temperature dry oxidation process, organic and
combustible incombustible matter. Waste which reduces to
inorganic
• Usually used for the waste that can not be reused, recycled or
disposed of in landfill site.
• The incinerator should be installed and made operational as per
specification under the BMW rules 1998.
• Certificate may be taken from CPCB/State Pollution Control
Board.

• Category 1, 2, 3, 5, and 6 can be incinerated.

• Characteristics of waste suitable for incineration are:

Low heating volume

➤ above 2000 Kcal/Kg for single chamber incinerators and

Above 3500 Kcal/Kg for pyrolytic double chamber incinerators.

> Content of combustible matter above 60%.

Content of non combustible matter below 50%.

Content of non combustible fines below 20%.

Moisture content below 30%.

Waste types not to be incinerated are

- Pressurized gas containers.

- Large amount of reactive chemical wastes.
- Silver salts and photographic or radiographic wastes.
Page no.. 13
 - Halogenated plastics such as PVC.
- Waste with high mercury or cadmium content such as broken
thermometers, used batteries.
- Sealed ampoules or ampoules containing heavy Metals.
1. Double chamber pyrolytic incinerators
2. Single-chamber furnaces
3. Rotary kilns

Safety measures

All the generators of biomedical waste should adopt universal precautions and
appropriate safety measures while handling the bio-medical waste.

It should be ensured that:

Drivers, collectors and other handlers are aware of the nature and risk of the
waste.

Written instructions provided regarding the procedures to be adopted in the

event of spillage/accidents.

Protective gears provided and instructions regarding their uses are given.

workers are protected by vaccination against tetanus and hepatitis B.

Training

• Every hospital must have well planned awareness and training programme for
all category of personnel.

• Training should be conducted in appropriate language/medium and in an

acceptable manner.

• All the medical professionals must be made aware of Bio-medical Waste

(Management and Handling) Rules 1998.

Management and Administration

Page no.. 14
• Each hospital should constitute a hospital waste management committee

- chaired by the head of the Institute and having wide representation

from all major departments.

•This committee should be responsible for making Hospital specific action plan.

- For hospital waste management and its supervision, monitoring and

implementation.

•The annual reports, accident reports, as required under BMW rules should be
submitted to the concerned authorities as per BMW rules format.

Measures for waste minimization

• As far as possible, purchase of reusable items made of glass and metal should
be encouraged.

•Select non PVC plastic items.

•Adopt procedures and policies for proper management of waste generated, the
mainstay of which is segregation to reduce the quantity of waste to be treated.

• Establish effective and sound recycling policy for plastic recycling and get in
touch with authorized manufactures.

Page no.. 15
 CASUALTY
MINOR SURGERIES
✓ Accident Case
✓ Poison Case
✓ Cutting Case
✓ Snake Bite
✓ Dog Bite
✓ Bees Bite
✓ Dressing

Casualty, accident and emergency, or emergency medicine, the evolution

At Sakr. J Wardrope

Hospitals have always had to make arrangements for those who arrive at their
doors seeking help. Over the years the numbers and complexity of problems
presenting in this way have increased at an exponential rate. This increase in
demand has been managed in different ways in different countries but in North
America, Australia, some parts of Europe and the de United Kingdom a new
medical specialty has evolved, that of accident and emergency (A&E) medicine
(UK) or emergency med cine. This article will examine the evolution of the
specialty in the United Kingdom and also look at the possible future changes in
the scope of the specialty.
The A&E department is the “shop window” of acute hospitals. It is the part of
the hospital most closely in contact with the public as it offers the most informal
access.
It plays the most important part in caring for the acutely ill and injured patients.
Also it is surrounded by so much drama, tragedy, and b media interest.

Page no.. 16
The department and specialty are a rich subject for programmes, debates and
criticism; if Shakespeare had been a doctor he would surely have worked in the
A&E department.
What are the origins of our specialty, what has made it successful and what
lessons of the Past should we not forget when planning our Future?
Casualty
The original term (casualty) meant a seriously injured patient. It was
predominantly a military word, a general term for the accidents of serv- ice:
after a battle the dead, the wounded, and the sick lumped together as
“casualties”. The term “casual” has its origin from the work- house “casual”
who was not one of the unem- ployable permanents, but the irregular and
unexpected caller who needed temporary help.”
The casualty ward also occurred in Shake- speare, and Dickens writing in 1837
to describe the hospital ward in which accidents were treated.’ The Lancet also
described the casual ward as a ward that provided special assistance for those
taken sick upon the road. It also provided shelter and accommodation for
labouring man in search for work.5-9 The early casualty departments were to
treat casual attendees as well as real casualties.
In 1869, the outpatients department in St Bartholomew’s was divided into two
categories. The “Casualty”, which comprised those who were supposed to
require temporary treatment for simple diseases or injuries. And the
“Outpatient” who, after receiving a regular letter of admission, was entitled to
the advice of the assistant surgeons and physicians for a period of two months.
The casualty patients were attended to in a new building. It consisted of a large
well ventilated room, capable of seating 600 persons. The surgical casualties
were seen by the house surgeon and the dressers of the inpatients, while the
medical casualties were seen by the apothecaries of the hospital who were paid
officials. Later the situation changed so medical casualties were seen by the
house physicians in the few years before the investigation.
In the Royal Free and Great Northern Hospitals the casualty cases were attended
to by the house surgeon.”
The need for specialised care-early trauma services
The care of the injured, especially those injured in battle has been one of the
important stimuli to improving trauma care. The Knights of St John were said to

Page no.. 17
have been taught by the Greek doctors during the Crusades, later they further
developed the first aid principles and ambulance services.
Napoleon’s chief surgeon, Baron Dominique Jean Larrey (1766-1842) is
credited with the concepts of; collecting and treating all the injured in an area
close to the front line by quickly evacuating them by fast light horse drawn
vehicles, the “Ambulances volantes”. He also wrote his great work on military
surgery Memoires de chirurgie militaire et cam-pagnes in 1812.-
In civilian practice the concentration of workers involved with the creation of
the great works of the Industrial Revolution led to large number of injuries and
health problems. The pioneering work of Robert Jones as surgeon to the
Manchester Ship Canal where with 20 000 workers the accidents rate was high,
was inspiring. He organised a series of first aid stations, backed up by a
hospital. A resident doc- tor and nurses staffed each hospital. All these hospitals
were connected by railway.”
At the outbreak of the first world war in 1914 Robert Jones became attached to
the Western Command as a major. He was appalled by the lack of the provision
for the treatment of those who suffered gunshot wounds. In 1916 he persuaded
the war minister to reserve 400 military beds in Alder Hey Hospital This was
followed by the conversion of Hammersmith Infirmary into a military
orthopaedic hospital. This kind of hospital started to spread all over Britain and
by 1918 the army orthopaedic service had 30 000- beds.” One of the most
important developments in the care of the injured was the foundation of the
British Orthopaedic Association in 1918 by Robert Jones and Robert Osgood.
This has created a strong cooperation between orthopaedic surgeons across the
Atlantic,
The interest in trauma started to flourish and the need for a specialist service for
fracture patients became a necessity. One of the early examples of specialisation
in this field was the establishement of separate fracture clinics in Manchester by
Harry Platt in 1913-14.” Also, the American College of Surgeons first
considered trauma care in 1922,”
In 1935 the British Medical Association Report on Fractures pointed out the
deficiencies in dealing with fracture patients. There was lack of organisation
and continuity of care. Patients were admitted under the nominal. Charge of a
surgeon who took little interest in such cases. These cases were delegated

Page no.. 18
usually to the house surgeons. There was also no proper rehabilitation after
discharge.
The recommendations were that a “casualty officer” should examine patients
with ambulatory fractures and provide initial management. A “chief assistant”
then would see patients the next day in the daily clinic. Inpatients fractures
admitted through casualty or outpatients would be seen by the house surgeons if
uncomplicated. Complicated and compound fractures were to be dealt with as
emergencies. They were to be treated in operating theatre by the surgeon or
chief assistant. After discharge they were be followed up in the outpatient
department.
Later in 1943 The British Orthopaedic Association in its Memorandum on
Accident Services emphasised that accident services of The future should
embrace the treatment of Fractures as well as soft tissue injuries, infections, and
all other injuries of the locomotor System. They also believed that accident
Services must be developed by surgeons who Have been trained and qualified to
deal with Trauma.”
One of the prominent landmarks in dealing with trauma was the development of
Birmingham Accident Hospital in 1941. The hospital was established to deal
with the rapidly increasing road traffic and industrial accidents. The pioneer of
the project was Professor William Gissane. The hospital looked after all sorts of
injury including victims of air raids during the war. The hospital provided
continuous cover with a full time consultant surgeon. 24 hour radiography, and
blood transfusion, and a mobile operating theatre (surgical unit) that was based
at the hospital.” Within one year of its foundation the Birmingham Acc dent
Hospital attracted the interest of the Medical Research Council under the
direction of Sir Ashley Miles. There was an ambitious research project studying
wound infection and the first controlled trial of penicillin in local infection was
undertaken.”
The idea of a separate accident hospital was extremely innovative but the
isolation of the unit from other acute specialties led to problems. Professor
Gissane planned to associate the hospital more closely with special units. These
plans were shelved because of a lack of Funds,
The National Health Service in July 1918 inherited a large number of casualty
departments, most of them in substandard accommodation. The staffing was
poor, with absent sup port from seniors who were in nominal charge only

Page no.. 19
absentee landlords” as called by Mau- rice Ellis As most of the departments
were not planned or staffed adequately, the situation became serious and the
level of care was below the expected standard. In 1959 the British Orthopaedic
Association Memorandum on Accident Services recommended that regional
hospital boards, in association with teaching hospital boards, set up at least one
comprehensive accident service within its area. It was I hoped that such units
would integrate to form a nationwide accident service. They were in favour of
having accident units that were part of a general hospital. Orthopaedic surgeons
should be in charge, as the locomotor system accounted for three quarters of all
injuries.
This was the probably the beginning of the structure of the modern UK service
of the “DGH A&E
The Nuffield Provincial Report (1960) showed that the casualty services in the
studied f areas were still badly housed in unplanned daccommodation. The
staffing was inadequate with juniors receiving very little support from seniors.
The main duties of the consultant in charge were to plan the rota and to do pre-
planned clinics. The majority of the departments received low rating in all
aspects apart from the quality of the casualty sisters.
Concerns had increased over the level of care f provided for the seriously ill and
injured patients. These concerns and the desire to improve the service initiated
the subcommittee report prepared by Sir Harry Platt, the first meeting was held
on 20 April 1960. They met 19 times until the production of their package of
recommendations.
The birth of A&E-The Platt Report”
Sir Harry Platt, the chairman of the Accident and Emergency Services Sub-
Committee of the Standing Medical Advisory Committee. Produced the famous
report in 1962 (fig 1).
Clarkson expressed similar opinions in 1960. Writing in the Guy’s Hospital
Gazette. He said that casualty departments should act as a receiving room for
the “acute sick” as well as for accident cases, also segregation of cases
The Platt Report
 The name “casualty service should be altered to “accident and emergency
service”

Page no.. 20
  Every major accident and emergency unit should have three consultant
surgeons (orthopaedic) devoting substantial part of their time to the unit,
and be supported by Adequate number of intermediate and junior medical
staff.
 The department should receive all undiagnosed medical emergencies as
Accident victims.
 Injured patients should be taken to the department that is staffed and
equipped to Deal efficiently with the type and severity of their injuries,
not to the nearest one.
 The departments should be purpose built.
 Separate provision must be made for treatment of minor non-traumatic
conditions However this should not interfere with care of seriously ill.
This could be provided in Hospitals with non-designated departments.
 The care of accident patients should be in general hospitals where all
specialities are available.
 Minor cases could be reduced by the provision of GP services.
 Rotation of the medical staff between A/E and general surgical work is
valuable particularly at registrar level.
 There should be adequate nursing staff, radiographers, secretarial,
receptionists and other supporting services.
 The number of the departments should be reduced. Each unit should not
normally serve a population of less than 150 000.
Should occur inside the department not at the hospital gate. Such “medical”
cases had been part of the workload of many “casualty” departments.”
With all the positive changes recommended in the Platt report unfortunately
there was no provision for creating senior career posts for the newly named
department. A few depart- ments, such as Leeds General Infirmary, had
appointed senior doctors to run the A&E department (Morris Ellis 1949) and
in others experienced doctors became the leaders of departments although
many did not have
The Clark Report
1 The committee strongly supported the inclusion of accident work within the
Early post registration rotation, for Senior House Officers they recommended a
series of six month periods in different specialties, one of which might be
accident work. For Surgical registrars they recommend that they spend six
months of their rotation in Accident and emergency.
Page no.. 21
2 Senior registrars from surgical or medical specialties should be allowed to
Obtain experience in accident work, should they desire to do so.
3 Every student must spend officially prescribed time in an accident unit.
4 The report also recommends in detail the design of accident units; also Special
supporting services availability such as laboratory and rehabilitation facilities.
Consultant status. These doctors saw that running an A&E department required
different skills from orthopaedic surgery and this was one of the main driving
forces for the formation of the Casualty Surgeons Association in 1967. It was
supported by the acceptance of the Department of Public Health that casualty
departments needed to be supervised by consultants dedicated to the specialty
and providing shop floor leadership and supervision. The main aim of the
Association was to form a professional body to further the standard of A&E
care. Mr M Ellis was then elected as president in the first annual general
meeting held in the Walsall General Hospital On the 23 of March 1968.
Concerns about difficulties in staffing departments increased. Some felt that the
creation of dedicated consultant posts in busy departments would improve the
service and Encourage appointments at assistant grade.
Others felt that the creation of career grades should be at all levels and the
consultant in charge trained in both general and orthopaedic surgery. Also
improving work conditions was essential as bad conditions led to poor quality
Work and a difficulty in recruiting doctors.
Many hospitals tried to overcome the staffing problem by appointing senior
hospital medical officers, but the job was regarded as a “dead end”. And
upgrading of this post was not considered. The shortage of juniors in the
casualty department was almost national. Only famous hospitals were not
affected. Even at that time litigation was perceived as a major problem that
made A&E work difficult and unattractive.
However, many were still resistant to any changes in the pattern of department
staffing. Believing that “casualty work” was not a Specialty.”
Nationally there was no fixed strategy for staffing. Some hospitals employed
full time or casualty officers, while in others casualties used to be seen by
resident house staff as part of their routine duties.”

Page no.. 22
In response to these difficulties the accident services review committee
(Chairman Sir H 5f Osmond Clark 1970),” after a series of investigations,
reported that staffing was still inadequate. Although orthopaedic consultants
were in nominal charge they were busy with their specialty and found it difficult
to devote enough time to shop floor commitment. There was also difficulty in
appointing experienced middle grade doctors, and registrars had to be called
away from other work to cover the department.
Most departments were still in old accommodation, there was little room for
expansion, and the facilities were appalling (fig 2).
The emergence of A&E medicine as a Specialty
In 1971 the Joint Consultants Committee set up a subcommittee to investigate
“the prob- lem” under the chairmanship of Sir John Bruce.” The key
recommendation of this report was the experimental appointment of 32
consultants in “Accident and Emergency” to work full time in major
departments. Later in 1974 The Department of Health reported “In No instance
has an appointment failed to Achieve some positive benefit. In a number of
Instances there have been significant improvements in the organisation of the
accident and Emergency services in its wider connotation”.
There were earlier calls for appointing seniors at consultant level in 1966, the
Lancet reported that the appointment of the dedicated consultants was approved.
It was the Joint Consultant Committee and the Health De- partments views that
some A&B departments should be the responsibility of a consultant who gave
all his time to this work, they also. Made it possible for senior casualty officers
to Apply.
The number of consultant appointments started to increase, and by 1976 there
were 105 consultants in post, most of them had been working in a variety of
non-consultant posts, having chosen A&E as a career.”
Some enthusiastic committed doctors began to design their own training
schemes and a few undertook research leading to an MD, a considerable
achievement at the birth of a spe- cialty. By the mid 1970s it was evident that
there was an urgent need to formalise training of consultants and the Specialist
Advisory Committee in A&E medicine was established and a training
programme designed. The first senior registrar appointment was in 1977. The
number of consultants and trainees continued to increase and by 1997 there
were almost 400 consultants and over 269 SpRs in post.”

Page no.. 23
Emergency medicine around the world
Clinicians all over the world desire to provide the highest quality of emergency
care to combat the increasing death rate from injuries as a result of rapid
urbanisation and industrialisation. Examining the emergency care in the
developed countries we find that it is practised mainly in two models.
THE ANGLO-AMERICAN MODEL This is practised in UK,” USA, Ireland,
Australia,” New Zealand, Canada, Japan, Taiwan, South Korea, and Israel.” “
The care of emergency patients is provided by specially trained hospital based
doctors who deliver a wide range of services for all patients presenting to a
separate emergency department. Emergency medicine in these countries is a
recognised independent specialty with professional associations. There is a
structured training programme for trainees, and recognised qualifications..
THE FRANCO-GERMAN MODEL” “
This is practised mainly in Germany, France, and other European countries
including Russia.”
In Germany emergency medicine is not a recognised specialty, and there is a
strong resistance to its creation. Most doctors practising emergency medicine
are from specialties such as anaesthesia, surgery, and medicine. The situation is
similar in France where the specialty does not exist and most practising
physicians comes from other specialties In Switzerland emergency medicine is
not an autonomous specialty and there is no representing official medical
association The Russian and the eastern European systems are more similar to
the Franco-German model. In this model the initial resuscitation is delivered by
anaesthetist; this is followed by direct triage to a specialty Recently, emergency
medicine in Italy, which was regarded organisationally as a branch of general
medicine, has changed." In 1996 a training programme starred in emergency
medicine with a shift from the Franco- German system to the Anglo-American
one
EMERGENCY MEDICINE IN THE DEVELO COUNTRIES
Many countries have realised the need for emergency medicine while others
have different priorities and no one model fits all health systems, In Hong
Kong" the first consultant appointment in emergency medicine was in 1981
with the creation of The Society for Emergency Medicine in 1985, In
Singapore" emergency medicine has been a specialty since 1984 with a

Page no.. 24
structured training programme started in 1989. In South Korea" emergency
medicine has been a recognised specialty since 1006 with a training programme
and board certification, In China" the need for emergency medicine as a
specialty was realised with growing industrialisation. The specialty is beginning
to be recognised and a five year training residency programme has started. In
Nicaragua" emergency medicine training started in 1993, a residency
programme designed on the American model followed by a written and oral
examination with a diploma of specialty awarded to who pass,
In India, Thailand, South Africa," Namibia, Madagascar, Lebanon, Jordan the
situation is different. In India and emergency medicine is not a specialty. The
service is provided in "Casualty Centres" staffed by physicians who have no
postgraduate qualifications and the post is temporary in most circumstances.
Ambulances are privately owned and operate on a fee for service base. In
Thailand the departments are poorly staffed, particularly after working hours
and in rural areas (young staff and old equipments). In South Africa emergency
medicine is not a specialty, doctors working in the emergency departments are
called "Casualty Officers" most of them have never had specialty training A
new specialty diploma has been introduced but most of those who hold the
diploma work in private hospitals,
In Namibia, Madagascar, Lebanon and Jordan the post in the emergency
department is temporary, on call staff physicians are summoned if patients
present after clinics.
The future
At the start of the millennium the challenges facing A&E departments continue
to grow and so the specialty must grow to meet these demands. It is important to
remember the reasons for the foundation of the specialty, a need to have
properly trained consultants organising, supervising and training these involved
in the delivery of care to patients attending the A&B department. This work
needs to have the priority; work that cannot be carried out without presence in
the department and on the "shop floor However, the casemix of A&E is
changing. Patients with serious medical conditions outnumber those with
serious injury by 8 to 1. Even with minor injury we see a change in casemis
with marry elderly people attending with minor falls many of which are
attributable to other medical problems"

Page no.. 25
Patients are more likely to come with other health problems that will influence
management. The expectations of the public and increasingly of the profession
are that we can always "get it right" first time.
What will be the changes to our specialty in the next 10-15 years? Demands
will continue to increase. There will be more patients, with more serious illness
and higher expectations. There will continue to be pressure on hospital beds.
More elderly people will be living alone on the margins of safety in the
community with the A&E department as a key source of help
It would be foolish to try and tackle all these needs from within the specialty.
Different models of diverting demand have been suggested, such as NHS
Direct. At present there is little if any evidence that schemes such as NHS
Direct will reduce A&B workload. We should continue to work with primary
care, social work and other community services to try to ensure that the correct
response to emergency health and social needs are adequately met. In some
areas the concept of local primary care emergency centres and minor injury
units will probably gain strength and popularity. They may be more expensive
than A&E care but they fulfil most of the emergency health needs for
populations of 50-100 000. These centres, if properly set up, can probably deal
with 30-40% of the patients arriving in our depart- ments. If this more minor
workload is removed then the A&E department will be left with a marked
increase in the complexity of the work it does. The patient mix will be heavily
biased to acute general medicine and the "difficult" musculoskeletal problems
that are too complex for the minor injuries unit or general practice. However, in
many areas with lower populations the A&E department will continue to
provide all these services
The increasing specialisation of other hospital specialists is leaving a gap in
health care. We have seen that general surgeons feel that they no longer have
the skills to observe minor head injury. A&E specialists probably have the skills
to care for such patients. There is an emerging vacuum in acute care and it is for
our specialty to choose paths to develop
The initial assessment and early treatment in resuscitation, trauma, medical and
paediatric emergency will remain the "core" role of the A&E practitioner. If
there is an increasing need to take over more of the care of patients for longer
periods of their illness then we must start to plan now to develop the skills and
experience to deal with them. This process is already well underway with more
trainees entering the specialty with a general A&E training or general medical
Page no.. 26
training often with anaesthetic/TTU bias. We should start to identify some
specific gaps in training and perhaps to restructure training programmes to
ensure the necessary skills are obtained.
Equally important we need to start to realise that consultants and staff grades
already in post need to acquire some new skills. The process of continuing
professional development should identify gaps in training and skills. The crunch
will come when time has to be found to allow senior staff sabbaticals and
"secondments". It is naive to think that the average senior will be able to find
the time for such extra training in an already over commit- ted schedules.
However, if "consultant appraisal" and "continuing professional development"
are to have real impact then it is clear that time and money must be found to
allow the acquisition and retention of new skills.
Having identified the skills, what working patterns will be required? The
present consult- ant led service, a 24 hour consultant led service or a service
where all care is provided by permanent staff (including nurse practitioners)?
This is a key question for our specialty. There is little good evidence on the best
model Any change from the present model is going to be more expensive.
Experience from systems that have full 24 hour A&E specialist provision
suggests that retention of staff is an increasing problem and that it may be
difficult to maintain such patterns with increasing years. There is simply not
enough evidence on outcomes, costs and human resource issues to make
"evidence based policy" on this issue.
There is so much work that we know that we can do better than the current
system and many have an almost evangelical zeal to improve the care of the
critically ill patient. However, we must not forget that increases in the services
to one part of our workload should 1 not decrease the level of service to other
patients in our departments Expansion of responsibility needs more manpower,
to neglect this very obvious statement risks the overwork of those currently
providing the service. Many departments are at present struggling to cope with
current workloads. Many are experiencing increased waiting times especially
for minor injuries. More resources are the key to any development and given
our key position in emergency care we are in a very good position to make a
strong case of need.
Throughout this paper the specialty has been referred to as A&E medicine.
Increasingly 5 emergency medicine is being used as a title for consultants and to
describe departments There is much debate on whether we should formally
Page no.. 27
change. We do see and treat both accidents and emergencies. The public has a
growing respect for the specialty and the recent high profile "A&E
modernisation" initiative has further cemented the title as "A&E". Yet it s
probably only a matter of time until the groundswell of opinion from within the
specialty forces a change. We practise the most acute parts of "medicine" in its
widest context including medicine, surgery, anaesthesia, paediatrics, psychiatry.
Our specialty, where it exists in the rest of the world is called emergency
medicine. It is clear that if in the future we might want to change the name of
our specialty then we should delay debate no longer.
Whatever the future brings we should remember the reason for our success as a
specialty, the ability to provide a presence, when needed, at the front door of the
hospital for all the many and different emergency health needs that patients
bring to our departments. Over the past 25 years we have been developing the
systems, the flexibility and breadth of training to cope with these demands. Any
development should not detract from these core aims or we might find ourselves
specialising to such an extent that we are no longer available "on the shop floor"
for the next difficult case and we will have lost the main reason for the success
of our specialty.

Page no.. 28
 The Ventilator

Introduction
So, here you are in the Intensive Care Unit at 3:30 in the morning. The
Emergency Department has just admitted a patient to your service-a young man
with a rather sudden onset of fever, rigors, and respiratory distress. He had to be
intubated in the ED and the ventilator seems to be alarming with a nerve-
racking frequency. His chest X-ray looks horrible, with diffuse infiltrates and
consolidations. The ICU respiratory therapist looks at you and asks the question
you have been dreading since the patient arrived-“Doctor, what vent settings do
you want?”
This is a familiar story for those of us who spend a lot of time in the ICU, and
an experience that just about every resident has at least once during his or her
training. Mechanical ventilation can be intimidating-it has its own terminology,
not all of which makes sense; it’s a life-sustaining technology. And
misapplication can have serious consequences; and practitioners of mechanical
ventilation tend to talk in esoteric ways about what the ventilator is doing. This
can confuse even the smartest resident or medical student.
To make things worse, there aren’t a lot of practical resources for busy
physicians who just need some quick guidance on how to adjust the ventilator.
Don’t get me wrong-there are plenty of great textbooks on mechanical
ventilation. And, if you have the time, they are well worth reading. The
operative word, however, is “time.” Reading a hundred pages on the pros and
cons of pressure control ventilation may be a good use of an afternoon in the
library but it’s holly impractical while taking care of patients in a busy ICU.
What’s necessary is a how-to guide, and that’s why I’ve written this book. Since
there’s only e author, this book will be biased. Not too much, I hope, but I’m
not delusional enough to think that my approach is completely objective and
based in fact. Lake everyone else in medicine, personal anecdote and experience
has shaped my practice.
The first part of this user’s manual is designed help you make good decisions
quickly. It is broken down into clinical problems with a proposed approach for

Page no.. 29
each. This is something that you can use on the fly. It closes out with the Eleven
Commandments of Mechanical Ventilation.
The second part of the book is intended to teach you about mechanical
ventilation. The chapters are short, and each can be read easily within 15-20
minutes. Here, you’ll learn to speak the language and understand the rationale
for why things work and why intensivists do what they do.
At this point, it’s necessary for me to point out that while this book is chock-full
of great advice, none of it is specific to the care of any individual patient. Have
any of your faculty ever told you that the patients don’t read the textbook?
They’re right. Every patient needs an individualized approach. Believe it or not,
my lawyer didn’t make me write this. It’s just common sense.
Philosophy of Mechanical Ventilation
The art of medicine consists of amusing the patient while Nature takes its
course.
-Voltaire
Mechanical ventilation is a wonderful tool. The birth of modern-day critical
care occurred in Copenhagen in 1952, when Bjorn Ibsen realized that positive
pressure ventilation could save lives during a polio epidemic when the iron
lungs (a negative pressure ventilator) were failing. The most common reason for
admission to a medical intensive care unit is the need for mechanical ventilation
support. The combination of endotracheal intubation and positive pressure
ventilation has likely saved hundreds of thousands, if not millions, of lives.
Likewise, artificial ventilation has prolonged the lives of thousands of people
afflicted with spinal cord injuries and devastating neuromuscular diseases.
Ventilators attached to wheelchairs permit patients with these conditions to
engage in life, to pursue their interests, and to generally live lives that would not
have been possible a half-century ago. Truly, this invention has had a positive
effect on many, many people.
As is the case with any technology, however, there is the potential for misuse. It
is essential that anyone working in an intensive care unit remember the Third
Commandment that the ventilator is a means of support, and not a cure for any
condition. In other words, it is folly to believe that the application of mechanical
ventilation can reverse chronic lung disease, malignancy, congestive heart
failure, or any of the myriad diseases and injuries that result in respiratory
failure. The ventilator exists to maintain the respiratory and metabolic functions
of the lungs until the patient recovers from his or her illness. It cannot make the

Page no.. 30
patient better by itself. This is actually a point lost on many physicians, who
believe that small tweaks and adjustments to the ventilator will accelerate the
patient’s recovery from acute respiratory failure.
If it is important for physicians to understand the natural history and trajectory
of a patient’s disease, it is equally important that the physician present this
information to the patient and his family in concise, understandable, and even
blunt terms. A life spent connected to a ventilator may be acceptable to a patient
with amyotrophic lateralizing sclerosis, who may require mechanical ventilation
but can otherwise speak, interact, and engage in what he considers an acceptable
quality of life. It is a different matter entirely for a patient suffering from a
massive intracerebral hemorrhage who is comatose, and is expected to remain
comatose for, if not the rest of his life, a great deal of it. While the patient or his
family nay consider this to be a worthwhile existence, it behooves the physician
to inform them of the stark realities of preserved life on a ventilator (including
the medical, social, and financial ramifications) before they pursue this
treatment option.
So, what is a dedicated, caring physician, nurse, or respiratory therapist to do?
Unsubstantiated optimism can be harmful, but so can overly Pessimistic
nihilism. Most patients with respiratory failure who recover from the inciting
illness or injury will recover; true ventilator dependence, meaning a need for
mechanical ventilation more than a year afterward, is rare. Here's what we can
do:
1. Protect the lung from iatrogenic injury. Use an evidence and physiology-
based approach to ventilator settings.
2. Promptly and aggressively treat the inciting illness or injury.
3. No disease is effectively treated with starvation. Proper nutritional support is
very important.
4. People aren't meant to lie in bed all day. Unless the patient is comatose, in
shock, or has profound respiratory failure, it's time to start getting him out of
bed and into a chair. Walking, even. I'll add that this, of course, requires a
strong dose of common sense. Mobilizing a patient with an open sternum might
not be a good idea. But, it's surprising how many patients lie flat on their backs
for their entire ICU stay. Not healthy.
5. When the patient seems to be recovering, start assessing his readiness for
extubation every day. 6. Be patient. It might take longer than you think.

Page no.. 31
7. Once it's evident that the patient will require prolonged mechanical
ventilation, get on with the tracheostomy. There's no need to wait an arbitrary
number of days.
8. Pay attention to the little things like DVT prophylaxis, skin care, and
preventing delirium
9. Be patient. And.....
10. Remember that your patient is a fellow human being with wants, needs,
cares, and concerns that may be strikingly similar to your own. He deserves to
be spoken to, even if he can't speak back. He deserves respect, even though he
may not be able to return that respect. He deserves the basics of human kindness
and touch. Remember that he has placed his life in your hands. Your job is not
an easy one, and not one that most people can do. The recognition that you have
positively affected the life of another person in a way that few can is the
greatest reward of this great profession.
Chapter 1
Initial Settings
*Note on measurements-unless otherwise specified, all airway pressures are
measured in cm H2O. All tidal volumes are expressed as mL/kg of predicted
body weight (PBW).
Modes of Ventilation
There are several different modes of ventilation, and each ventilator
manufacturer has its own (usually trademarked) name for them (PRVC, VC+,
CMV with Auto flow, ASV, PAV, Volume Support, and the list goes on and
on). This can be intimidating at first-who’s to know what to pick? Fortunately,
like medications, all of these have a generic name as well. That’s all you really
need to know, because all of the modes on the different ventilators available for
sale will be essentially the same (just with a different trade name).
Each mode of ventilation has its strengths and weaknesses. No mode is perfect,
and no mode is useless. It’s best to pick the mode that best suits the patient’s
needs at the time. Each of these modes is discussed in more detail in the
following chapters, but here’s a brief overview.
Assist-Control Ventilation
Astist-Control Ventilation is the mode of choice in most circumstances. It
allows the ventilator to essentially take over the work of breathing and is
preferred when a patient has acute cardiac or respiratory failure. It provides full
Page no.. 32
respiratory support. If the patient wants to breathe over the set rate, he can;
when he triggers the ventilator, he gets the full breath with minimal effort.
Upside: Takes over the work of breathing: clinician can choose to set a tidal
volume (volume control) or an inspiratory pressure (pressure control).
Downside: A tachypneic patient will get the full tidal volume on every breath,
so without adequate sedation this could lead to significant respiratory alkalosis
or air trapping. This can be a problem in patients with COPD or asthma.
SIMV with Pressure Support
SIMV also can provide full ventilator support and is a very popular mode. Like
Assist Control, the clinician can choose a tidal volume or an inspiratory
pressure. The major difference between SIMV and Assist Control is what
happens when the patient initiates a breath-in A/C, he gets the full tidal volume;
in SIMV, he gets whatever he can pull (usually with the help of pressure
support).
Upside: Can take over the work of breathing but allows the patient more
spontaneous breathing than in assist-control. Can be useful for weaning support
gradually.
Downside: If the machine rate is not set high enough, an unstable patient can
get fatigued due to excessive work of breathing. If the pressure support is not
set high enough, spontaneous breaths may be fast and shallow, which also leads
to fatigue.
Pressure Support Ventilation
PSV doesn’t have a set rate-instead, it allows the patient to breathe on his own
and “boosts” each breath with a pressure that the clinician selects. It’s used in
conjunction with CPAP to improve alveolar recruitment. PSV is used in patients
who are either intubated for reasons other than cardiac or respiratory failure
(altered mental status, jeopardized airway) or for weaning. It can also be used
when the patient has a severe metabolic acidosis-if he has a pH of, say, 6.88 and
a HCO3 of 4, his respiratory drive will be markedly elevated and a mode like
assist- control may not be able to meet his metabolic demands.
Upside: Allows the patient to set his own rate and pattern of breathing, which is
more comfortable; spontaneous breathing has salutary effects on hemodynamic
and VQ matching.

Page no.. 33
Downside: There’s no backup rate, so if the patient goes apnoeic nothing will
happen until the alarms sound. Unstable patients will fatigue rapidly if the work
of breathing is imposed on them, even with high levels of pressure support.
Unconventional Modes
Airway pressure release ventilation (APRV) and high frequency oscillatory
ventilation (HFOV) are used to treat severe hypoxemia. They are seldom the
first-line option for acute respiratory failure and will be discussed later in the
book. For now, just focus on the odes already listed (A/C, SIMV, PSV).
Ventilator Settings Based on Pathophysiology
Restrictive Lung Disease
Examples: ARDS, aspiration pneumonitis, pneumonia, pulmonary fibrosis,
pulmonary edema, Alveolar hemorrhage, chest trauma
Restrictive lung diseases are associated with a reduction in respiratory system
compliance. The lungs want to collapse. In other words, it’s hard to get air in
and easy to get air out. The ventilation strategy is to recruit vulnerable alveoli,
prevent cyclical alveolar closure, provide adequate oxygenation, and to
minimize volutrauma from overdistension.
The initial mode should be one that takes over the work of breathing for the
patient. Assist-control, using either volume-controlled or Pressure-controlled
ventilation, is the mode of choice.
For volume-controlled ventilation:
1. Tidal volume of 6 mL/kg PBW
2. Rate of 14-18 breaths per minute, with adecelerating flow pattern
3. FiO2 100% at first; reduce to 60% if SpO2 ≥ 88%
4. PEEP of 5-10 cm H2O, depending on the degree Of hypoxemia.
Remember The more Opacification in the lungs on the chest X-ray. The
more PEEP will be needed to reduce intrapulmonary shunting.
5. If hypoxemia persists, increase the PEEP until The SpO2 is 88% or
better. Don’t exceed 20.
6. After adjusting the PEEP, check the plateau pressure. If the PPLAT is
more than 30 cm H2O, decrease the tidal volume until the PPLAT is less
than 30. Don’t go below 4 mL/kg PBW.
For pressure-controlled ventilation:

Page no.. 34
 1. PEEP of 5-10 cm H2O, depending on the degree of hypoxemia
2. FiO2 100%; reduce to 60% if SpO2 ≥ 88% 3. Driving pressure (or
inspiratory pressure) of 15 cm H2O
4. Rate of 14-18 breaths per minute
5. Inspiratory time adjusted to keep the I:E ratio 1:1.5 or higher. The I-
time is usually 1.0-1.5 Seconds. A rate of 20 and an I-time of 1.0
Seconds has an I:E ratio of 1:2 (one second Inspiration, two seconds
expiration). A rate of
15 with an
I-time of 1.5 seconds has an I:E ratio of 1:1.67 (1.5 seconds inspiration,
2.5 seconds expiration). This is displayed on the ventilator screen.
6.If hypoxemia persists, increase the PEEP until the SpO2 is 88% or
better. Don’t exceed 20 cm H₂O.
7. Look at the exhaled tidal volume. If it exceeds6 mL/kg. lower the
driving pressure until the tidal volume is in the 4-6 mL/kg range.

After initiating ventilation, check an arterial blood gas. 15-20 minutes is enough
time for gas exchange to equilibrate.
Make changes in the respiratory rate to change the PaCO2 (a higher rate lowers
the PaCO2, and vice verse). Leave the tidal volume in the 4-6 mL/kg range,
keeping the PPLAT (volume-control) or PINSP (pressure control) at 30 cm H:0
or less. Remember that lung protection is more important than normal
ventilation-a pH of 7.15 or better is acceptable and s not worth injuring the
lungs with over distension it the form of high tidal volumes) to get a normal pH
or PaCO2.
Lower the FiO2, keeping the PaO2 between 55 and 70 Hg and the SpO2
between 88% and 94%. There's thing to gain from keeping the PaO2 above this
range, with few exceptions. Patients with traumatic rain injury sometimes
require a higher PaO2, usually in conjunction with brain tissue oxygen
monitoring. Victims of carbon monoxide poisoning also benefit from breathing
100% oxygen.
Obstructive Airways Disease
Example: COPD, Asthma
Obstructive lung disease is associated with increase in respiratory system
compliance and an ruction to expiratory airflow. It's easy to get air but hard to
get it out.

Page no.. 35
The ventilation strategy is to rest the respiratory muscles, provide adequate
oxygenation, and reduce hyperinflation.
Assist-control ventilation is usually the mode of choice, and volume-control is
preferable to pressure- control. SIMV with PS can also be used, however, as
long as the rate and PS are set high enough to prevent tachypnea and fatigue.
High airway resistance and high peak inspiratory pressures characterize
exacerbations of COPD and asthma, even though the PPLAT may be
significantly lower. Using pressure- control in this situation leads to very low
tidal volumes. Volume-control guarantees that the desired tidal volume will be
delivered.
1.Tidal volume of 8 mL/kg PBW. Lower tidal volumes can lead to air trapping
and worsening hyperinflation.
2. Rate of 10-14 breaths per minute
3.Inspiratory time adjusted to keep an I:E ratio of 1:3 or higher. In obstructive
airways disease, air gets in easily but has a hard time getting out due to narrow,
inflamed bronchioles and bronchi. Give the air some time to escape.
4.With asthma, applied PEEP will worsen Hyperinflation. With COPD, PEEP
can be used To splint open airways that are prone to Collapse. This is because
COPD is characterized by dynamic airway obstruction, while the obstruction is
fixed in an asthma exacerbation. A good starting point for both is a PEEP of 0,
or ZEEP-zero applied end-expiratory pressure.
5. FiO2 of 100% to start; lower this to 60% as long As the SpO2 remains 88%
or better.
Sometimes, patients with COPD or asthma will main tachypneic despite
adequate sedation. In st-control, every patient-triggered breath delivers full tidal
volume, and this can lead to air trapping or severe respiratory alkalosis. If this is
the case, witching the mode to SIMV may help.
Severe Metabolic Acidosis
Examples: Salicylate poisoning, septic shock, toxic exposures, acute renal
failure, diabetic ketoacidosis
The normal response of the respiratory system in the setting of metabolic
acidosis is to hyperventilate. CO₂ volatile acid and the lungs can rapidly
eliminate this acid from the body in an attempt to bring the pH closer to normal.
In a patient with a HCO3 of 4 mEq/L., fe example, the PaCO2 will be 14-15

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mm Hg if there’s appropriate respiratory compensation. This requires a very
high minute ventilation to accomplish.
It is very difficult to set the ventilator to provide a high minute ventilation, even
if you set the rate to be 30-35 and the tidal volume to be 800-1000 mL. Patients
with severe metabolic acidosis will often breathe in when the vent is trying to
breathe out, and Tice versa-this leads to significant patient-ventilator
dyssynchrony and alarming of the machine. More consequentially, the volume
and pressure alarms that are normally helpful will actually work against the
patient by limiting the minute ventilation that can Occur.
Consider the aforementioned example-a patient who has a pH of 6.88 and a
HCO3 of 4 needs a PaCO2 of 14- 15. If he’s intubated and sedated, and the vent
settings are put in the “usual” range, his PaCO2 may rise to 25-30. In the setting
of severe acidemia, this increase in CO2 will cause his pH to fall to 6.6 or so,
which will most likely lead to a cardiac arrest.
The best way to deal with this situation is to let the patient’s naturally high
respiratory drive work in his favor.
1. Use the bare minimum of sedation to intubate and avoid neuromuscular
blockers entirely.
2. Set the vent mode to be Pressure Support Ventilation.
3. CPAP (a.k.a. PEEP) 5-10 cm H2O, depending On the degree of
hypoxemia
4. Pressure Support (PS) of 10-15 cm H2O. Adjust if needed to allow the
patient to breathe comfortably; most of the time, 10 cm is enough PS.
5. Allow the patient to have a minute ventilation of 18-25 L/min. Don’t be
alarmed to see him pull spontaneous volumes of 1000-2000 mL. The high
minute ventilation will keep the pH up while the cause of the metabolic
acidosis is being treated.
Key Ventilator Concepts for Other Clinical Situations

 The left ventricle likes PEEP-increasing the intrathoracic pressure

lowers preload and afterload, which is beneficial in acute cardiac
failure due to left ventricular dysfunction (either systolic or
diastolic).

 The right ventricle, on the other hand, doesn’t care for PEEP very
much. Increased intrathoracic pressure can increase pulmonary
vascular pressures and stress the thin-walled RV. In situations

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 where RV failure is present (massive pulmonary embolism,
worsening pulmonary hypertension), use more FiO2 and less PEEP
(ideally 10 cm or less) to maintain oxygenation.

 When there is acute brain injury, be it from stroke, hemorrhage,

trauma, or something else, the priority with mechanical ventilation
is the maintenance of adequate oxygenation. Aim for an SpO2 of
94-98% and a PaO2 of 80-100 mm Hg. PEEP may increase the
intracranial pressure, but it seems to be significant only when the
PEEP is 15 cm or higher. Hypoxemia, on the other hand, definitely
increases intracranial pressure. Therefore, use what it takes to
oxygenation. Maintain adequate cerebral

 Hyperventilation (PaCO2 < 32) lowers intracranial pressure, but it

works by causing cerebral vasoconstriction. In other words, it
works by making the brain ischemic. This may be helpful if a
patient is about to herniate and you need 5 minutes to get the
mannitol in, or 10 minutes to get to the OR. Prolonged
hyperventilation, on the other hand, worsens brain ischemia and
has no lasting effect on intracranial hypertension. Aim for a normal
(35-40) PaCO2.

Chapter 2
Quick Adjustments
These are ways to adjust the ventilator based on the arterial blood gas.
Obviously, the patient’s condition should dictate what’s done. The adjustments
are in order of preference.
PaO2 Too Low
Assist-Control, SIMV: increase PEEP, increase FiO2
APRV: increase PHIGH, increase THIGH, increase FiO2
HFOV: increase mean airway pressure, increase FiO2
PaCO2 Too High
Volume Assist-Control Or SIMV: increase rate, Increase tidal volume
Pressure Assist-Control or SIMV: increase rate, increase driving pressure.

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APRV: increase the gradient between PHIGH and PLOW, decrease THIGH,
increase TLOW
HFOV: decrease the frequency, increase amplitude, increase T1%, allow a 5 cm
cuff leak
PaCO2 Too Low
Volume Assist-Control or SIMV: decrease rate, lower tidal volume
Pressure Assist-Control or SIMV: decrease rate, lower driving pressure
APRV: increase THIGH, lower PHIGH, decrease TLOW
HFOV: increase the frequency, lower the amplitude, Decrease TI%
Chapter 3
Troubleshooting
These are problems that you’ll be called about. As always, the first thing you
should do is examine the patient. Remember your ABCs and use this guide to
help you figure out what’s wrong.
Problem: High Peak Airway (PAW) Pressures
Your first step should be to perform an inspiratory pause and measure the
plateau pressure (PPLAT). The plateau pressure represents the alveolar
pressure, while the peak pressure is a combination of the alveolar pressure and
airway resistance.
High PAW, Low PPLAT-this means the problem is high airway resistance.
 Kinked endotracheal tube-unkink the tube
 Mucus plugging-pass a suction catheter
 Bronchospasm-inhaled bronchodilators
 Too narrow of an endotracheal tube-change
The tube, or accept higher PAW
High PAW, High PPLAT-this means the problem is in the lungs.
 Main stem intubation-pull the endotracheal tube back into the trachea
 Atelectasis of a lobe or lung-chest percussion or bronchoscopy to open up
the airway .
 Pulmonary edema diuretics or inotropes
 ARDS-use a lower tidal volume, higher PEEP Strategy
 Pneumothorax-chest tube

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Problem: Dynamic Hyperinflation (Auto-PEEP)
This is usually due to inadequate time for exhalation. High airway resistance
(bronchospasm, COPD, mucus plugging) makes it worse. On exam, the
patient’s abdominal muscles will contract forcefully during exhalation. Neck
veins may be distended, and you may hear loud wheezing. The ventilator’s
expiratory flow waveform will not return to the baseline of zero flow.
 Lower the ventilator rate, usually between 10- 14 breaths per minute
 Shorten the inspiratory time to keep the I:E ratio in the 1:3-1:5 range
 Keep the tidal volume in the 6-8 ml/kg rang higher tidal volume will
often slow the patient’s spontaneous respirations
 Increase the inspiratory flow to 60-80 liters per Minute if the patient
seems to be “air hungry
 Adequate sedation with narcotics will help Blunt a tachypneic response
 Treat bronchospasm with inhaled bronchodilators and systemic steroids
Problem: Sudden drop in Sp0:
New or worsening hypoxemia is always cause for arm. The first step is to
exclude mechanical mblems or tube displacement.
 Disconnect the patient from the ventilator and bag him
 Make sure the tube is in place (use either color- change or waveform
capnometry if there’s any doubt about the tube) and that breath sounds
are present and equal
 Obtain an arterial blood gas
 Chest X-ray-this will show you worsening infiltrates, pneumothorax,
pulmonary edema, atelectasis, or new effusions
 Always consider pulmonary embolism cause for new hypoxemia in an
ICU patient and have a low threshold for diagnostic studies
 Absent breath sounds on one side-pull the
endotracheal tube back a few centimeters .
 Absent breath sounds on one side, even with the tube pneumothorax, in
the right place-think or mucus plugging with complete atelectasis of the
lung
 Tension pneumothorax should be suspected if breath sounds are absent on
one side and if the patient is hypotensive. Distended neck veins and
tracheal shift away from the affected side are supportive but not always
seen. The treatment is immediate needle decompression and placement of
a chest tube.
Problem: Fighting the Ventilator

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 Before sedating or paralyzing a patient for "fighting the ventilator," you
should always check TSS-Tube, Sounds, Sats. Make sure that the
endotracheal tube is in place and not obstructed, that breath sounds are
present and equal, and that the patient is not hypoxemic. Other things you
should look for are:
 Dynamic hyperinflation (see above for how to treat this)
 Untreated pain, especially in trauma and surgical patients
 Make sure the vent is providing an adequate rate and tidal volume
 Switch to assist-control ventilation, if the patient is getting fatigued
 Search for other causes of distress-cardiac ischemia, fever,
abdominal neurologic deterioration, etc.
Problem: Change in ETCO2
First, , look at the waveform. If there is no waveform, moans one of three
things:
 The endotracheal or tracheostomy tube is not in the trachea
 The tube is completely occluded
 The ETCO2 sensor is faulty
Obviously, the first two are serious emergencies and should be dealt with
immediately. The third is diagnosed only after ruling out the first two.
The waveform is present, then look at the ETco2 value. With a significant
change in the ECO, an arterial blood gas should be obtained as well to see what
the PaCO2 is.
Rising E-CO2 and PaCO2-this indicates either increased CO2 production or
alveolar hypoventilation.
 Fever
 Malignant hyperthermia
 Thyrotoxicosis
 Suppressed respiratory drive without a sufficient ventilator backup rate
Falling E-CO₂ with unchanged or rising PaCO-the widening gradient between
the two suggests an increase in dead space ventilation.
 Pulmonary embolism
 Falling cardiac output (cardiogenic or Hypovolemic shock)
 Dynamic hyperinflation with autoPEEP Falling ETCO2 and falling
PaCO2 indicates an increase in alveolar ventilation.
 Pain
 Agitation
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  Fever
 Sepsis
Chapter 4

The Eleven Commandments of Mechanical Ventilation

Thou shalt mind thy patient’s COMPLIANCE, and measure it daily.
 Compliance is the change in volume divided by the change in pressure.
Dynamic compliance is the exhaled tidal volume divided by the dynamic
change in pressure (peak minus PEEP). Static compliance is the exhaled
tidal volume divided by the static pressure differential (plateau minus
PEEP). If there’s a big difference between the two, increased airway
resistance is usually to blame.
 Normal respiratory system compliance is about 100 mL/cm H2O; normal
for a ventilated patient is 70-80.
 Falling compliance can mean fluid overload, developing pneumonia or
ARDS, pneumothorax, or many other bad things.
 Improving compliance usually means the patient is getting better, at least
from a pulmonary mechanics point of view.
 ‘Tis nobler to INTUBATE and
VENTILATE than to needlessly allow a patient to suffer the slings and
arrows of critical illness.
 Intubating a critically ill patient is never a sign Of weakness; rather, it is a
sign of decisiveness.
 A few of the indications for intubation are refractory hypoxemia,
hypercapnia, jeopardized airway, shock, and great metabolic
disturbances.
III. Thy mechanical ventilator is merely a means of SUPPORT, and offers no
curative properties in itself.
 . It’s a mistake to think that the ventilator itself
Can help the patient. It merely allows the
Patient to survive until he recovers.
 A ventilator has only three therapeutic benefits:
1) Guaranteed delivery of high levels of
Oxygen
2) Positive pressure to reduce intrapulmonary shunt (from atelectasis,
ARDS, pneumonia, pulmonary edema, etc.)
3) Providing the work of breathing until the patient is able to do it
himself.

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IV. Thou shalt be familiar with the ABUNDANCE of MODES, as no one is
perfect for every situation and no one is completely useless.
 While you may have your preferred mode, remember that you can
ventilate most any patient with any given mode as long as you set the
ventilator properly.
 Some patients will seem to prefer one mode over another. I don’t know
why this happens. But it does. Deal with it and don’t be afraid to find out
what vent settings suit the patient best.
V. Thou shalt mind the TIDAL VOLUME closely and without fail, lest
the lungs suffer from excessive distension.
 Of all the studies done on mechanical ventilation in acute lung injury and
ARDS, the only thing that seems to affect survival is the use of excessive
tidal volumes.
 Your resting tidal volume is 4-6 mL/kg of your predicted body weight.
Your patient’s should be as well.
 The patient’s actual body weight should not be used for this calculation.
Carry a table, memorize the formula, or download an app to figure out the
PBW. You will need the patient’s height and gender (both usually easy to
obtain).
 Be wary of physicians who confidently tell you that the plateau pressure
is more important, or that 7, or 8, or 9 mL/kg is better than 6-while they
may be right, they possess no evidence to support their claims.

Thou shalt OPEN thy patient’s lungs and KEEP THEM OPEN.
 Positive end-expiratory pressure is used to recruit collapsed alveoli and to
prevent them From closing during exhalation.
 This helps to restore at least some functional residual capacity and reduce
intrapulmonary shunt.
 A general rule is that if you can see white stuff
In the lungs on the chest X-ray, increasing the
PEEP is better than using high levels of oxygen
For correcting hypoxemia.
VII. For the PERFECT ABG is a mythical creature and should not be pursued
lest the patient suffer grave harm in the form of barotrauma and volutrauma.
 It’s more important to protect the patient from harm than to blindly
pursue a “normal” blood gas, especially if it means using
excessively high tidal volumes or ventilator pressures.

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  All decisions regarding ventilator settings should be made with the
whole patient in mind. Permissive hypercapnia is perfectly
acceptable in status asthmaticus but not in the patient with cerebral
edema.
 In most cases, a PaO2 of 55 is adequate.
VIII. Thou shalt not allow thy shocked patient to FATIGUE, but instead provide
the ventilator support necessary for him to recover.
 In the setting of shock, hemorrhage, or severe sepsis, work
of breathing can account for 40- 50% of a patient's basal
energy expenditure. Mechanical ventilation should be used
to take over this work until the underlying cause has been
treated adequately.
 Assist-control ventilation is one of the best. ways to do this
and is the preferred mode most of the time in these
situations.
 There are many theories about exercising the diaphragm and
allowing the patient to "work out" on SIMV or CPAP/PSV,
but no one has proven that it helps (and it may in fact be
harmful).
 Assist-control, with a daily spontaneous breathing trial if
indicated, is a simple formula that is also very effective at
minimizing the time a patient stays on the ventilator.
IX. Thou shalt seek out DYNAMIC HYPERINFLATION wherever it may be
found, and treat it, for ‘tis an insidious beast!
 Hyperinflation is also known as auto PEEP or breath
stacking. It occurs when the patient can’t get all of the
air out before the next breath starts.
 If unchecked, dynamic hyperinflation can lead to
discomfort, hypercapnia, hypotension, and even PEA
arrest. Suspect it in all patients on the vent who have
obstructive lung disease and look for it even in
patients who don’t. If the PaCO2 keeps going up as
the rate is increased, hyperinflation is the likely
culprit.
 Treat this condition by slowing the ventilator rate,
extending the time for exhalation, and treating
bronchospasm. A small measure of applied PEEP may
help prevent airway collapse during exhalation.

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X.Verily, a SPONTANEOUS
BREATHING TRIAL should be performed readily and daily on all patients
whose conditions permit.
 No one is good enough to reliably predict which patients can be extubated
on a given day.
 A spontaneous breathing trial (SBT) should be done whenever the reason
for intubation (severe Hypoxemia, coma, shock, bronchospasm) has
resolved. The SBT can be in the form of a T-piece or low-level pressure
support ventilation.
 Don’t be afraid to act on the results of the trial. If the patient looks ready,
extubate him. The occasional reintubation is not a sign of failure. In fact,
if you never reintubate a patient, you’re probably waiting too long to
extubate the others.
XI. Thy Respiratory Therapist is the ordained KEEPER OF THE VENT and
should be treated with utmost esteem.
 Do not make any changes to the ventilator settings without the RT
present. If you want to experiment with different settings to see what
happens, call the RT first.
 While you may know what you’re doing, you probably don’t know how
to reset all the alarms, sensors, etc. That have to be adjusted when
significant changes are made. It’s also the RT’s responsibility, and if you
make changes without notifying him/her it makes a difficult job even
harder.
Chapter 5
Acute Respiratory Failure
Acute respiratory failure is one of the most common reasons for admission to
the intensive care unit. The majority of cases will require some sort of positive
pressure ventilation, either from a mask (CPAP, BiPAP) or an endotracheal
tube. Obviously, this is important. There’s a reason why A and B come first in
the ABC’s of resuscitation-without adequate gas exchange (oxygenation being
the most important), the patient can die within minutes. Many times, the
physician has to treat acute respiratory failure before he can figure out the whys
and hows of what happened. That’s OK! Once the patient is stabilized,
however, the detective work begins.

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Acute respiratory failure, according to the textbook by Parrillo and Dellinger, is
“the inability of the respiratory system to meet the oxygenation, ventilation, or
metabolic requirements of the patient.”
Let’s break this definition down:
 The respiratory system”: More than the lungs. Obviously, the lungs are
the major players, but disorders of the upper airway, chest wall.
Cardiovascular system, and neurologic system can cause significant
respiratory dysfunction.
 Oxygenation Requirements”: Type I respiratory failure is defined as a
PaO2 less than 60 mm Hg. The first priority in treating patients with
acute respiratory failure is to correct hypoxemia!
 Ventilation requirements”: Type II respiratory failure is a PaCO2 greater
than 50 mm Hg, with a pH less than 7.30. The pH is important in
distinguishing acute from chronic respiratory failure.
 Metabolic requirements”: This is often forgotten, but the lungs have a key
role in maintaining metabolic homeostasis. CO₂ clearance by the
respiratory system is adjusted to balance out metabolic derangements.
Likewise, oxygen intake and delivery to the tissues begins in the lungs.
 “Of the patient”: Probably the most important part of the definition. A
particular patient may have “normal” blood gas numbers but still require
respiratory support. Conversely, another patient may have terrible
numbers but not require any kind of acute intervention. Like everything
else in medicine, start with the history and physical exam. In the future,
patients can be plugged into a machine that will immediately analyze all
of their medical problems and print out a list for the physician. I saw that
on Star Trek. Until then, we still have to do an H&P.
Common Diagnostic Testing
Arterial Blood Gas: to determine whether or not respiratory failure is present,
assess the metabolic status of the patient, and to determine (in part) the cause of
respiratory failure. Co- oximetry can help diagnose carbon monoxide poisoning
and methemoglobinemia.
Chest X-ray: to diagnose cardiac failure, pneumonia, pneumothorax, pleural
effusion, and a whole lot of other diseases. Also, helpful if it’s normal-a clear
X-ray and hypoxemia should make you consider a pulmonary embolism.
CT Chest: for a better look at the thoracic structures; if done with angiographic
technique, it can diagnose pulmonary embolism and aortic dissection.

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Bronchoscopy: to diagnose inhalational injury, foreign body, upper airway
obstruction, pneumonia, and alveolar hemorrhage.
Hypoxemic Respiratory Failure
Hypoxemia poses the most immediate threat to the patient. Vital organs like the
brain, heart, etc. Depend on a continuous delivery of oxygen to use for energy
.Production. That’s why just about all

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