RSPT 2335

1
RSPT 2335

• Mechanical Ventilation
• Module E
• Discontinuation

2
MODULE EAssignments

• READ
• Pilbeams Mechanical Ventilation
• Chapter 20 21 (pp. 402 427 428 452)
• Egan References
• Chapter 47 (pp. 1199 - 1227)

3
MODULE EAssignments

• Review
• ACCP, AARC, ACCCM - Evidence Based Clinical
  Practice Guideline Weaning and Discontinuing
  Ventilatory Support
• Homework
• Locate a copy of an actual ventilator weaning
  protocol at your work or clinical site.

4
Optional Videotapes DVDs

• AARC PR 2005 Weaning Prolonged Mechanical
  Ventilation Patients in LTACHs (DVD)
• AARC PR 2004 Withholding and Withdrawing Life
  Support in the ICU
• AARC PR 2003 Weaning the Long Term Ventilator
  Dependent Patient
• AARC PR 2002 Transitioning the Ventilator
  Patient From the Hospital to Home
• AARC PR 2002 Talking With Patients and
  Families About Death and Dying
• Passy-Muir Tracheostomy Ventilation Speaking
  Valves

5
MODULE EObjectives

• When you complete this module, you should be able
  to
• List the different ways to wean from mechanical
  ventilation and explain which are the most
  commonly used methods.
• Explain the 12 guidelines as stated in the ACCP,
  AARC, ACCCM - Evidence Based Guidelines.
• Describe how to assess discontinuation
  potential.

6
MODULE EObjectives

• When you complete this module, you should be able
  to
• Describe how to do a spontaneous breathing trial.
• Describe the signs of a patient in distress.
• Explain how to evaluate the objective and
  subjective signs of tolerance of a spontaneous
  breathing trial.

7
Objectives(continued)

• When you complete this module, you should be able
  to
• Explain the process to follow if a patient fails
  a SBT.
• Describe the assessment recommended prior to
  extubation.
• Explain the present viewpoint on the use of
  weaning parameters.

8
Objectives(continued)

• When you complete this module, you should be able
  to
• Explain the purpose of weaning protocols and how
  they work.
• Explain when tracheotomy should be considered.
• List the criteria for permanent ventilator
  dependence.

9
Objectives(continued)

• When you complete this module, you should be able
  to
• Describe how to use a Passy Muir valve on a
  ventilator dependent patient.
• Explain the criteria for terminal weaning.
• List the different types of Advanced Directives.

10
Objectives(continued)

• When you complete this module, you should be able
  to
• Explain the hierarchy for health care decision
  making and the role of the Durable Power of
  Attorney for health care.
• Explain the Criteria for Determination of Brain
  Death.
• Describe the apnea testing procedure and why it
  is done.

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MODULE EMajor Topics

1. Liberation from Ventilation Weaning Parameters
2. Evidence-Based Guidelines for Weaning and
   Discontinuing Ventilatory Support
3. End of Life Issues

12
Part 1

• Liberation Parameters

13
Balance Between Conservative and Aggressive
Weaning

• Complications of Premature Extubation

• Complications of Prolonged Ventilation

• Prolonged ICU Stay
• Upper Airway Injury
• Infection
• Mortality

• Infection
• Lung Injury
• Laryngeal Injury
• Cost

A Reasonable Re-Intubation Rate is 10 20.
14
There are many methods for withdrawing the
mechanical ventilator

• Titrated
• Bi-Level
• Bi-Level PS
• Pressure Support
• SIMV
• SIMV PS
• T-piece

• Automated
• ATC
• VS
• PAV
• VAPS or PAug
• Automode
• MMV
• ASV
• Smart Care

15
Method to Use

• Use method supported by evidence.
• Monitor assess patient frequently.
• Start weaning as soon as possible.
• Have a protocol with clear parameters
  procedures.

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Weaning Parameters

• Mechanics
• Spontaneous tidal volume and respiratory rate.
• Rapid Shallow Breathing Index
• Vital Capacity
• Maximal Inspiratory Pressure
• Work of Breathing
• Gas Exchange
• PaO2/FiO2, PaO2/PAO2, P(A-a)O2
• Minute Ventilation
• Deadspace

Weaning Parameters are not predictive! Meade, et
al, Chest 2001. 120 400S-424S
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To RSBI or Not?

• Control (n151) f/Vt was measured and used
  (threshold of 105 breaths/min/L)
• Weaning time significantly shorter in the group
  where f/Vt was not used (2.0 vs 3.0 dyas, p0.04)
• No difference in extubation failure, hospital
  mortality rate, tracheostomy, or unplanned
  extubation.
• Tanios, Critical Care Med 206. 342530

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Spontaneous Breath Trials

• T-piece, PSV (7 cm H2O), Tube Compensation
  equally acceptable for SBT (Estaban et al, Am J
  Resp Crit Care Med 1997. 156 459).
• Spontaneous breathing trial can be applied on
  ventilator (0/0 SBT)
• 30 minutes is adequate for spontaneous breathing
  trial (Esteban et al, Am J Respir Crit Care Med
  1999. 159512).
• CPAP with 5 cm H2O can produce false positive
  trial with COPD and CHF.
• THE BEST WEANING PARAMETER IS A SPONTANEOUS
  BREATHING TRIAL.

19
Weaning Parameters

• See Chart Provided
• Wide variation between sources
• Study Pilbeam column on chart (Table 20-1 p.
  412)
• Problems with weaning parameters
• They are not reproducible or reliable if they are
  therapist dependent.
• VC MIP
• Best parameters are patient driven.
• R.S.B.I.
• P0.1
• Spontaneous rate
• Spontaneous tidal volume
• Vital signs

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Occlusion Pressure Measurements

• P0.1s or P100
• Occlude airways for first 100 msec and measure
  pressure.
• Index of ventilatory drive.
• Fast-twitch vs. slow-twitch fibers of diaphragm.

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Pressure-Time Product

• Comparison of transdiaphragmatic pressure and
  maximal inspiratory pressure.
• What percentage of the maximal inspiratory
  pressure is being used for a normal breath.
• Use of specialized esophageal catheter with two
  balloons positioned above the diaphragm
  (Fig.10-25, p. 196).

22
Part 2

• Evidence-Based Guidelines for Weaning and
  Discontinuing Ventilatory Support

23
Reprinted in Respiratory Care 2002 47(1)69-90)
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Grades of Evidence

• A Scientific evidence provided by well-designed,
  well-conducted, controlled trials (randomized and
  nonrandomized) with statistically significant
  results that consistently support the guideline
  recommendation.
• B Scientific evidence provided by observational
  studies or by controlled trials with less
  consistent results to support the guideline
  recommendation.
• C Expert opinion supported the guideline
  recommendation, but scientific evidence either
  provided inconsistent results or was lacking.

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Guideline 1 (Grade B)

• In patients requiring mechanical ventilation for
  gt 24 hours, a search for all the causes that may
  be contributing to ventilator dependence should
  be undertaken.
• This is particularly true in the patient who has
  failed attempts at withdrawing the mechanical
  ventilator.
• Reversing all possible ventilatory and
  non-ventilatory issues should be an integral part
  of the ventilator discontinuation process.

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Reversing all possible ventilatory and
non-ventilatory issues

• Why was the patient placed on the ventilator in
  the first place?
• Why wont they come off the ventilator?
• Neurological Issues
• Respiratory system muscle (load interaction)
• Metabolic factors
• Gas exchange factors
• Cardiovascular factors
• Psychological factors

27
Guideline 2 (Grade B)

• Patients receiving mechanical ventilation for
  respiratory failure should undergo a formal
  assessment of discontinuation potential if the
  following criteria are satisfied

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Criteria

• Evidence of some reversal of the underlying cause
  of respiratory failure.
• Adequate oxygenation
• PaO2/FiO2 gt 150-200.
• Requiring positive end-expiratory pressure PEEP
  lt or 5-8 cm H2O
• FiO2 lt or 0.4 - 0.5
• pH gt or 7.25
• Hemodynamic stability as defined by
• the absence of active myocardial ischemia.
• the absence of clinically important hypotension.
• no vasopressor therapy or therapy with only
  low-dose vasopressors such as dopamine or
  dobutamine lt 5 micro g/kg/min.
• The capability to initiate an inspiratory effort.

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Assessment of Discontinuation Potential

• A acid/base normalized for patient
• B bronchospasm controlled
• C cardiac problems controlled (CHF, rhythm,
  BP)
• D drugs for sedation limited or eliminated
• E electrolytes fluids in balance
• H hemoglobin gt10 gms
• I infection reversed (MV temp WNL)
• N nutrition appropriate
• E endocrine function acceptable (thyroid
  pituitary)
• S sleep secretions under control

30
Guideline 3 (Grade A)

• Formal discontinuation assessments for patients
  receiving mechanical ventilation for respiratory
  failure should be done during spontaneous
  breathing rather than while the patient is still
  receiving substantial ventilatory support.
• An initial brief period of spontaneous breathing
  can be used to assess the capability of
  continuing onto a formal SBT.

31
Spontaneous breathing trial (SBT)

• Most patients on ventilators do not require
  formal weaning.
• The tolerance of a formal SBT for 30 120
  minutes should prompt consideration for permanent
  ventilator discontinuation.
• Studies have shown a 77 weaning success rate
  with this criteria.

32
Methods for performing a spontaneous breathing
trial (SBT)

• Low level Pressure Support (5-7 cm H2O) with or
  without PEEP.
• Automated Tube Compensation with or without PEEP.
• T-bar (no alarms, more equipment, high Raw).

33
Comparison of Weaning Methods

• Brochard, Am J Respir Crit Care Med 1994.
  150896.
• Patients screened for weaning readiness.
• T-piece trial for 2 hours 75 tolerated and
  extubated.
• Greatest success for PSV (worst for SIMV)

34
Automatic Tube Compensation Do We Need It?

• Does not compensate for changes in resistance
  that occur in vivo e.g. kinking or secretions.
• Estaban, Am J Respir Crit Care Med1997. 156459
• PSV or T-piece acceptable for SBTs.
• Straus, Am J Respir Crit Care Med 1998 15723
• Spontaneous breathing through ET tube mimics work
  of breathing after extubation.
• Haberthur, Acta Anaesthesiol Scan 2002. 46973
• No difference in patient tolerance of SBT between
  patients randomized to TC, PSV of 5 cm H2O or
  T-piece.

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Formal Discontinuation Assessment

• Respiratory pattern
• Adequacy of gas exchange
• Hemodynamic stability
• Subjective comfort

37
Formal Discontinuation Assessment

• Are respiratory muscles capable of sustaining
  spontaneous breathing?
• Ventilatory pattern
• f lt/ 30 35
• f not changed gt 50
• No increased work of breathing
• Use of accessory muscles
• Thoracoabdominal paradox

38
Assessment of Discontinuation Potential

• Are there conditions that can contribute to
  respiratory muscle fatigue?
• Hyperinflation
• Malnutrition
• Hypoxemia
• Acidosis
• Electrolyte imbalance
• Endocrine disorders
• Drugs (paralytics steroid combos)
• Neuromuscular problems

39
Objective Measures Indicating Tolerance

• Gas exchange
• SpO2 gt/ 85 90
• PaO2 50 60 mmHg
• pH gt/ 7.32
• PaCO2 increase no more than 10 mmHg.
• Hemodynamics
• HR lt 120 140
• HR change lt20
• No vasopressors required.

40
Subjective Measures Indicating Tolerance

• Mental state
• No somnolence, coma, agitation, anxiety.
• No onset or worsening discomfort or dyspnea.
• No diaphoresis.

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Guideline 4 (Grade C)

• The removal of the artificial airway from a
  patient who has successfully been discontinued
  from ventilatory support should be based on
  assessments of airway patency and the ability of
  the patient to protect the airway.

43
Reference Material

• AARC Clinical Practice Guideline
• Removal of the Endotracheal Tube 2007 Revision
  Update

44
Extubation

• REMEMBER Weaning from ventilatory support does
  not mean the patient is ready for extubation.
• Assessments of airway patency
• Review history
• Do cuff leak test
• Assessment of ability of the patient to protect
  the airway
• Amount of secretions
• Ability to cough gag
• Level of consciousness

45
Guideline 5 (Grade A)

• Patients receiving mechanical ventilation for
  respiratory failure who fail an SBT should have
  the cause for the failed SBT determined.
• Once reversible causes for failure are corrected,
  and if the patient still meets the criteria,
  subsequent SBTs should be performed every 24
  hours.

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Guideline 6 (Grade B)

• Patients receiving mechanical ventilation for
  respiratory failure who fail an SBT should
  receive a stable, non-fatiguing, comfortable form
  of ventilatory support.

50
Guideline 7 (Grade A)

• Anesthesia/sedation strategies and ventilator
  management aimed at early extubation should be
  used in post-surgical patients.

51
Guideline 8 (Grade A)

• Weaning/discontinuation protocols designed for
  non-physician health care professionals (HCPs)
  should be developed and implemented by ICUs.
• Protocols aimed at optimizing sedation should
  also be developed and implemented.

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53
1. Evaluate discontinuation potential
2. Discontinuation assessment
3. Evaluate extubation potential
54
Guideline 9 (Grade B)

• Tracheotomy should be considered after an initial
  period of stabilization on the ventilator when it
  becomes apparent that the patient will require
  prolonged ventilator assistance.
• Tracheotomy should then be performed when the
  patient appears likely to gain one or more of the
  benefits ascribed to the procedure.

55
Patients who may derive particular benefit from
early tracheotomy are the following

• Those requiring high levels of sedation to
  tolerate translaryngeal tubes.
• Those with marginal respiratory mechanics (often
  manifested as tachypnea) in whom a tracheostomy
  tube having lower resistance might reduce the
  risk of muscle overload.
• Those who may derive psychological benefit from
  the ability to eat orally, communicate by
  articulated speech, and experience enhanced
  mobility and
• Those in whom enhanced mobility may assist
  physical therapy efforts.

56
Guideline 10 (Grade B)

• Unless there is evidence for clearly irreversible
  disease (e.g., high spinal cord injury or
  advanced amyotrophic lateral sclerosis), a
  patient requiring prolonged mechanical
  ventilatory support for respiratory failure
  should not be considered permanently ventilator
  dependent until 3 months of weaning attempts
  have failed.

57
Permanently Ventilator Dependent

• Examples
• Irreversible diseases
• High spinal cord injury
• Advanced amyotropic lateral sclerosis (ALS)
• Polio postpolio sequelae
• Incurable diseases
• COPD
• Kyphoscoliosis
• Pulmonary Fibrosis

58
Guideline 11 (Grade C)

• Critical-care practitioners should familiarize
  themselves with facilities in their communities,
  or units in hospitals they staff, that specialize
  in managing patients who require prolonged
  dependence on mechanical ventilation.
• Such familiarization should include reviewing
  published peer-reviewed data from those units, if
  available.
• When medically stable for transfer, patients who
  have failed ventilator discontinuation attempts
  in the ICU should be transferred to those
  facilities that have demonstrated success and
  safety in accomplishing ventilator
  discontinuation.

59
Guideline 12 (Grade C)

• Weaning strategy in the permanent mechanical
  ventilator patient should be slow-paced and
  should include gradually lengthening
  self-breathing trials.

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Prolonged Mechanical Ventilator (PMV) patient

• Consider use of Passy-Muir Valve
• Use slow paced trials
• Gradually increase self-breathing trials
• Often used when partial support ventilation is
  providing ½ the support needed by the patient
• Awake, alert, stable patient able to manage
  secretions

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Part 3

• End of Life Issues

63
Advanced Directives

• Legal documents written, signed, witnessed and
  notarized
• Examples
• Living Will - Gives health care providers
  guidelines regarding the wishes of the patient in
  the event that the patient is no longer of sound
  mind and cannot make decisions regarding his
  care.
• Do Not Resuscitate order (DNR) Provides
  guidance when the heart stops or the patient
  stops breathing.
• Chemical Code Only
• Do Not Intubate
• Do Not Shock
• Withhold Nutrition Hydration (consult state
  law)

64
Durable Power of Attorney (DPA) for Health Care
Decisions

• Person designated to make health care decisions
  for the patient should the patient become
  incapacitated.
• If person not designated the law recognizes
  hierarchy of relationships
• Parents or legal guardian of minor
• Durable Power of Attorney
• Spouse
• Adult children (all must agree)
• Parents of patient
• Adult siblings (all must agree)

65
Sustaining vs. Comfort Care

• Terminally ill patients should be made as
  comfortable as possible (palliative care).
• Observe for agitation and grimacing.
• Use adequate doses of sedatives analgesics.
• Excessive dosing to hasten death in not allowed
  (causing apnea or cardiac arrest).
• Allow open family visitation if possible.
• Minimize monitoring alarms.
• Stop testing (labs, x-rays).

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End of Life Issues

• Criteria for Terminal Weaning
• Patients informed consent.
• Medical futility (in last 100 cases, treatments
  were useless).
• Reduction of pain and suffering.

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End of Life Issues

• Handouts
• Brain Death Criteria
• Apnea Testing Procedure

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End of Life Issues

• Criteria for Determination of Brain Death
• No hypothermia.
• No purposeful movement to stimulation.
• Absence of brain stem reflexes.
• Pupils fixed.
• No corneal reflex.
• No cough or gag.
• Absence of dolls eyes.
• No toxins or drug effects.
• Apnea Testing or Negative Brain Flow Study.

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Dolls Eye Sign

• An indicator of brain stem dysfunction, the
  absence of the doll's eye sign is detected by
  rapid, gentle turning of the patient's head from
  side to side.
• The eyes remain fixed in midposition, instead of
  the normal response of moving laterally toward
  the side opposite the direction the head is
  turned.

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Dolls Eye Sign

• The absence of doll's eye sign indicates injury
  to the midbrain or pons, involving cranial nerves
  III and VI.
• It typically accompanies coma caused by lesions
  of the cerebellum and brain stem.
• This sign usually can't be relied upon in a
  conscious patient because he can control eye
  movements voluntarily.
• Absent doll's eye sign is necessary for a
  diagnosis of brain death.

72
End of Life Issues

• An example of an Apnea Test for determination of
  brain death
• Patient placed on 100 O2.
• Rate decreased so PetCO2 gt40 mmHg.
• Patient removed from vent and put on 100 O2.
• After 2 minutes draw an ABG patient returned to
  ventilator.
• OBJECTIVE Demonstrate lack of spontaneous
  breathing in presence of PaCO2 gt60 mmHg and no
  hypoxemia.

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Protocols

• Homework Assignment
• Get a copy of the ventilator weaning protocol
  from the institution where you work or are doing
  your clinical rotation.

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LONG-TERM VENTILATION TRANSPORT
75
Objectives

• State the goals of mechanical ventilation in an
  alternate environment.
• Name the factors used to estimate the cost of
  home mechanical ventilation.
• Describe facilities used for long-term mechanical
  ventilation.
• Compare the criteria for discharging a child
  versus discharging an adult who is ventilator
  dependent.
• Describe other forms of ventilation for the
  long-term ventilator dependent patient.

76
Categories of Patients Requiring Long-Term
Ventilation

• Those recovering from an acute illness.
• Guillain-Barre
• Those recovering from a chronic illness.
• COPD
• Kyphoscoliosis
• Both have high mortality
• 2-year mortality of 57.
• 5-year mortality of 66-97.

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Factors Associated with Increase in VAIs

• Ventilator-Assisted Individuals
• Individuals requiring MV for at least 6 hours/day
  for 21 days or more. (ACCP)
• Improvements in technology have led to increased
  survival of critically ill patients.
• Increased emphasis on reducing costs by
  transferring patients out early.

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Factors Associated with Increase in VAIs

• NIV is a effective alternative to invasive
  ventilation.
• Simpler and more versatile equipment are now
  available.
• Increased availability of LTACs and other
  agencies that allow for ventilation in the home
  or other SNFs.
• Example Christopher Reeves

79
Goals of LTMV

• Enhancing the individuals living potential.
• Improving physical and physiological level of
  function.
• Reducing mortality.
• Reducing hospitalizations.
• Extending life.
• Providing cost-effective care.

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Sites for LTMV

• Acute-Care Sites
• ICU or specialized respiratory-care units.
• General Medical-Surgical floors.
• LTACs
• Intermediate-Care Sites
• Sub-Acute Units
• Long-term care hospitals
• Rehabilitation Hospitals
• Long-Term Care Sites
• SNFs
• Single-Family homes

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Patient Selection for LTMV

• Disease Process Clinical Stability
• Acute illness/ARF who arent responding to
  conventional liberation techniques.
• Chronic disorders who need support only during
  certain times of the day.
• Need for continuous support.
• CVA
• Diaphragmatic paralysis

Box 21-2 pg. 429
82
Patient Selection for LTMV

• Psychosocial Factors
• Prior to discharge.
• Family awareness and preparedness.
• Psychological evaluation.
• Other support systems.
• Respite Care

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Patient Selection for LTMV

• Financial Considerations
• High cost regardless of site.
• Multiple factors
• Diagnosis.
• Level of acuity.
• Need for rehabilitation services.
• Need for monitoring.
• Oxygen medications.

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Preparation for Discharge

• Assessment
• Education
• Training
• Plan of Care

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Preparation for Discharge

• Multi-disciplinary
• Primary Care Physician
• Pulmonologist
• Nurse
• RT
• Social Worker/Discharge Planner
• PT
• OT
• Speech Pathologist
• Dietician
• DME

86
Geographic Home Assessment

• Proximity to home care services.
• Modifications to Home.
• Mapping of electrical circuits. (Box 21-4, pg.
  433)

87
Training

• Family Education
• Detailed, written instructions.
• Equipment troubleshooting.
• Disinfection.
• Status change recognition.
• Return demonstration.

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Follow-Up

• Especially important in infants children
  because of changes due to growth and development.
• Adequate nutrition.
• Family/Social issues.

89
Alternatives to Invasive Mechanical Ventilation
in the Home

• Non-invasive Positive Pressure
• Negative-Pressure Ventilation
• Iron lung
• Chest Cuirass
• Body Suit
• Rocking Bed
• Pneumobelt
• Diaphragmatic Pacing

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Complications of Long-Term Mechanical Ventilation
Fig. 21-6 p. 440
91
Transport

• Necessity
• Monitoring
• Evaluation of Transport Team
• Transport Ventilator
• MRD
• Critical Care Ventilator
• Transport Ventilator
• LTV
• Dräger