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Ventilator Management Strategies for Critical Care FREE TO VIEW

Lee K. Brown
Chest. 2003;124(5):2039-2040. doi:10.1378/chest.124.5.2039-a
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By Nicholas S. Hill and Mitchell M. Levy, eds. New York: Marcel Dekker, 2001; 832 pp; $225.00

Mechanical ventilation is a subject that commands respect from clinicians, who recognize its complexities, while inducing complacence and boredom in those who consider it to be a minor exercise in plumbing. I find that proper ventilator management at its best requires a skill set that encompasses respiratory and cardiovascular physiology and pathophysiology, fluid mechanics and mechanical engineering, electricity and electronics, pattern recognition, computer literacy, and, yes, plumbing. For those willing to explore the breadth of this complicated subject, there is no shortage of texts in the medical marketplace willing (but not always able) to provide the necessary expertise.

Into the fray jumps Ventilator Management Strategies for Critical Care, another volume in the extensive Lung Biology in Health and Disease series under the longstanding executive editorship of Claude Lenfant. This particular text is edited by Nicholas S. Hill and Mitchell M. Levy, both well-known and highly regarded academic intensivists from Brown University in Providence, RI, who in turn recruited an outstanding group of authors including Neil MacIntyre, Marin Kollef, Martin Tobin, G. Umberto Meduri, Edward Haponik, John Luce, and Alan Fein.

Hill and Levy have organized the text into six main sections. Part one covers demographics and epidemiology, and begins with an excellent chapter on the epidemiology of acute respiratory failure. Interesting to me were the changing indications for invasive mechanical ventilation over the years, with utilization in patients with COPD dropping as the use of nasal or oronasal bilevel positive airway pressure gained prominence (justified by data on outcomes). Of course, the relative constancy of short-term mortality in ARDS patients provided a sobering note. I enjoyed Neil MacIntyre’s overview of the development of the modern ventilator and would have liked even more detail. The chapter giving a specific non-North American perspective on ventilator utilization and outcomes was interesting, but should probably have been incorporated into the first chapter, since it repeats some of the information contained therein, and research into ventilator utilization and outcomes is truly an international collaboration anyway. This first part then concludes with an excellent, and very pertinent, discussion of the economics of mechanical ventilation.

Part two is meant to review the “nuts and bolts” of ventilator management, but could benefit from a change in the order of subjects covered. It starts with Marin Kollef’s excellent review of ventilator management by protocol and a useful discussion of noninvasive ventilation before actually discussing ventilator technology. The latter chapter is entitled “New Modes of Ventilation,” but really covers much of the technology and terminology for ventilatory modes that have been used for years. This would probably have been a better “lead-off” chapter, followed by the discussion of protocol-driven care, and with genuinely new modes of ventilation folded into the chapter on closed-loop ventilation authored by Brian Kimble and Mitchell Levy. Such a chapter also would benefit from the coverage of high-frequency ventilation (not covered until later in the book) and independent lung ventilation. The concluding chapters in this section cover agitation and its comorbidities and airway management. I was disappointed in the former chapter, which contains material of great importance but seemed poorly organized and repetitive. I was particularly struck by the absence of any discussion of paralytic agents. In contrast, the last chapter, on airway management, was useful and lucid (and includes some material on paralytic agents), lacking only a discussion of double-lumen endotracheal tubes and tubes incorporating a proximal lumen for the continuous aspiration of upper airway secretions.

Part three covers the use of mechanical ventilation in particular disorders, including asthma, COPD, ARDS, and noninvasive ventilation in the non-COPD patient. These sections provide some of the detail missing from earlier chapters and are generally quite useful. The chapter on noninvasive ventilation suffers somewhat from the excessive and confusing use of abbreviations, and from an all-too-brief discussion of ventilatory failure in patients with obstructive sleep apnea that fails to distinguish among that entity, the “overlap” syndrome, and obesity-hypoventilation (ie, “Pickwickian”) syndrome.

The focus of part four shifts to the liberation of patients from mechanical ventilation, beginning with an outstanding review by Budinger and Tobin. The following chapter (“Optimizing Weaning Efficiency”) builds on the knowledge developed in the first chapter with practical strategies that may be incorporated into one’s day-to-day practice. The last chapter nicely covers the use of noninvasive ventilation as a component of a weaning strategy.

Part five is an important section, covering the complications of mechanical ventilation. The chapter by Alan Fein and colleagues on ventilator-associated pneumonia is well-written and thorough, and the discussion of heart-lung interactions with mechanical ventilation by Michael Pinsky covers this important topic nicely, although a few typographical errors intrude (“rennin” should be “renin,” and “inertness” should be “inertance”). The sixth and concluding section incorporates a chapter on extubation failure that somewhat overlaps the information in previous chapters on weaning, and John Luce’s thoughtful and practical discussion of withholding and withdrawing mechanical ventilation.

Ventilator Management Strategies for Critical Care serves to collect critical reviews of a variety of important aspects of this subject into one volume and represents a useful addition to the pantheon of books already available. The text suffers somewhat from a bit of disorganization and repetition, and some of the chapters could have used a heavier hand in the editing. On balance, it will surely be of interest to pulmonary and critical care fellows, and to more advanced practitioners and scholars in the field of ventilatory support.




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