Review of Anesthesia Versus Intensive Care Unit Ventilators and Ventilatory Strategies: COVID-19 Patient Management Implications - AANA
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COVID-19 Resources
Review of Anesthesia Versus Intensive Care
Unit Ventilators and Ventilatory Strategies:
COVID-19 Patient Management Implications
Kaitlyn Jackson, DNAP
Brenda Wands, PhD, CRNA, CHSE
The coronavirus disease 2019 (COVID-19) respiratory tors are reviewed, as are the lung-protective ventilation
illness has increased the amount of people needing air- strategies, including positive end-expiratory pressure,
way rescue and the support of mechanical ventilators. used to manage patients with COVID-19–induced acute
In doing so, the pandemic has increased the demand respiratory distress syndrome. Adjuncts to mechanical
of healthcare professionals to manage these critically ventilation, recruitment maneuvers, prone position-
ill individuals. Certified Registered Nurse Anesthetists ing, and extracorporeal membrane oxygenation are
(CRNAs), who are trained experts in airway manage- also reviewed. More research is needed concerning
ment and mechanical ventilation with experience in the management of COVID-19–infected patients, and
intensive care units (ICUs), rise to this challenge. How- CRNAs must become familiar with their ICU units’ indi-
ever, many CRNAs may be unfamiliar with advance- vidual ventilator machine, but this brief review provides
ments in critical care ventilators. The purpose of this a good place to start for those returning to the ICU.
review is to provide a resource for CRNAs returning to
the ICU to manage patients requiring invasive mechani- Keywords: Acute respiratory distress syndrome, anes-
cal ventilation. The most common ventilator modes thesia ventilator, COVID-19, intensive care unit ventila-
found in anesthesia machine ventilators and ICU ventila- tor, ventilator modes.
T
he coronavirus disease 2019 (COVID-19) pan- tor (Avance CS2, GE Healthcare).4 Although many venti-
demic has caused an unprecedented impact lators also include noninvasive (nonintubated) ventilator
on healthcare systems and healthcare pro- modes, only invasive (intubated) ventilator modes are
fessionals worldwide.1 This new respiratory covered in this review.
illness has increased the number of people The complexity of ventilator modes and the differing
needing airway rescue and the support of mechanical names of modes associated with different manufactur-
ventilators, and has therefore increased the number of ers complicates succinct categorization.5 Therefore, it is
advanced healthcare providers needed to manage these imperative that readers familiarize themselves with the
critically ill patients. Certified Registered Nurse Anesthe- ventilator found in their individual practice setting by
tists (CRNAs) who are trained in airway and mechanical visiting the manufacturer’s website.
ventilation have experience in critical care. However,
many CRNAs may not have practiced in the ICU in a Basics of Ventilators
number of years and may be unfamiliar with advance- Despite the complexities and differences of ventilators
ments in critical care ventilators. Priorities of care are very among the different manufacturers and hospital settings,
different when managing ventilation of patients in the all ventilators have some basic characteristics, and there
operating room (OR) vs patients in the intensive care unit are simple ways to differentiate between the available
(ICU).2 A review of current ventilator modes and patient modes. Ventilators have evolved since the negative pres-
management is needed to provide optimal patient care in sure iron lung used during the polio epidemic of the
this new yet still familiar setting. 1950s.2 Ventilators are now positive pressure ventilators
This review describes common invasive ventilator and can be described and classified based on their mechan-
modes found in anesthesia machine ventilators compared ics (bellows, piston, turbine, and sophisticated micropro-
with ICU ventilator modes. Included are other methods cessors) or their manufacturer. Ventilator modes are dif-
used to improve ventilation and gas exchange in these ferentiated based on what triggers the breath (patient or
critically ill patients. Although others are mentioned, machine), and whether the ventilation is volume-targeted
the ventilator modes covered in this article are based or pressure-targeted.2 When a breath switches from inha-
primarily on an ICU ventilator (Servo-U, Maquet Medical lation to exhalation, this is called a cycle, and ventilator
Systems USA, Getinge Group)3 and an anesthesia ventila- modes are often classified as time-cycled, pressure-cycled,
62 AANA Journal February 2021 Vol. 89, No. 1 www.aana.com/aanajournalonline
Mode Basic description Considerations Adjustable settings
Volume control ventilation Machine-triggered, time-cycled Not ideal for inhomogeneous Fio2, RR, VT, I:E ratio,
(VCV)/controlled mandatory mode with a volume target2,7,8 lung units. PEEP2,7,8
ventilation (CMV) (base Will not support spontaneous
mode) breaths.2,7,9
Used frequently for patients with
ARDS to ensure low VT.
Pressure control ventilation Machine-triggered, time-cycled, VT achieved is variable between Fio2, inspiratory pressure, I:E
(PCV)/CMV-pressure control pressure-targeted mode9,10 breaths, because it is based on ratio, RR, PEEP2,6,8,10,11
the compliance of the patient’s
lungs and the resistance in the
airway.2,6,8,10,11
PCV-volume guarantee (VG)/ A preset pressure will be First breath is sensing breath Fio2, RR, VT, I:E ratio,
volume mode with autoflow delivered to achieve a volume used by the ventilator to inspiratory pressure, PEEP2,7
Pressure-regulated volume target. determine what pressure is
control (PRVC)4,12 Combines VCV and PCV needed to deliver subsequent
breaths.
Synchronized intermittent Patient is able to initiate his or In SIMV-PC and SIMV-PSV Depends on the specific
mandatory ventilation her own breaths outside those ventilatory modes, the patient’s version used; basic adjustable
(SIMV); can be combined set by the base mode; weaning spontaneous breath is sensed settings include Fio2,
with PCV, VCV, PRVC/ ventilatory mode and supported by a pressure minimum RR, VT, sensitivity
PCV-VG, or pressure support setting.2,7 trigger, PEEP, pressure
support2-4 support2,7
Pressure support ventilation Spontaneous breath is sensed Protect feature includes a Fio2, minimum RR, sensitivity,
(PSV)/PSV-Protect and supported with pressure backup mode that will be pressure support, PEEP2,9
support11; weaning ventilatory activated if the patient is
mode apneic or if RR drops below
the minimum setting for an
extended time.2
Sensitivity trigger in anesthesia
ventilators is flow vs negative
pressure in ICU ventilators.7
Table 1. Shared Modes of Ventilation
Abbreviations: ARDS, acute respiratory distress syndrome; Fio2, fraction of inspired oxygen; ICU, intensive care unit; I:E, inspiratory to
expiratory; PEEP, positive end-expiratory pressure; RR, respiratory rate; VT, tidal volume.
or volume-cycled.6 The 2 base modes found in ICU and demands were high. The combination of poor lung com-
anesthesia machine ventilators are pressure control venti- pliance and high minute ventilation demand associated
lation and volume control ventilation.2 with ARDS requires that the ventilator deliver effective
Table 1 describes the major ICU and anesthesia minute ventilation to avoid hypercapnia and respira-
machine ventilator configurations.2-4,6-12 Usually ICU tory acidosis. A volume control ventilation mode is com-
ventilators offer more ventilator modes than can be monly recommended for use with patients experiencing
found on anesthesia ventilators as well as a more complex ARDS because of the tight control on low tidal volumes,
functionality. See Table 2 for a list of common ventilator a major component of lung-protective ventilation (LPV).
modes found in ICU ventilators.1,2,7-9,13-15 However, with a volume control ventilation mode, the
The following discussion will highlight consider- practitioner must vigilantly monitor for excessive peak
ations for the anesthesia provider choosing a ventilator inspiratory pressure to ensure injury does not occur.
mode for a patient experiencing acute respiratory dis- Benefits of using pressure control ventilation as an LPV
tress syndrome (ARDS), including COVID-19–induced strategy includes a more homogenous gas distribution
ARDS presentation. However, the decision of choosing due to the constant pressure delivered during the breath
an effective mode of ventilation for any patient requiring cycle.2,6,8,10,11 A disadvantage of using a pressure-con-
mechanical ventilation in the ICU should be based on trolled ventilation mode for this patient population in-
patient-specific considerations. cludes the inability to guarantee a consistent and optimal
When one is choosing between a volume control low tidal volume. The tidal volume achieved is intimately
mode and a pressure control mode to ventilate a patient dependent on compliance of the lung.2,6,8,10,11 The con-
experiencing COVID-19–induced ARDS or other forms tinuous and potential high flow rate pattern associated
of ARDS in either the ICU or the OR, the following with pressure control ventilation could also lead to injury
should be considered. Earlier models of anesthesia venti- compared with the constant flow pattern of volume
lators suffered from poor performance when ventilation control ventilation.16 The practitioner must decide which
www.aana.com/aanajournalonline AANA Journal February 2021 Vol. 89, No. 1 63
Adjustable
Mode Basic description Considerations
settings
Mandatory minute Desired minute ventilation Patient is able to breathe spontaneously, and Fio2, RR, VT, PEEP,
ventilation/intermittent is set using an initial spontaneous breaths are supported by a preset pressure support2,7
mandatory ventilation mandatory RR and an pressure support. In IMV, the patient’s spontaneous
(IMV) ideal VT2,7 breath is not supported by a pressure support breath.2
Assist control Minimum RR and VT are Disadvantage: if the patient’s RR is too high for the Fio2, minimum
ventilation set; will ensure that the patient to be able to fully exhale the delivered VT, then RR and VT, PEEP,
desired VT is delivered breath stacking and volutrauma can occur.2 backup mode2
with every breath,
including the patient-
initiated breaths2,7
Volume support Ventilator will sense Supports the patient’s spontaneous breath and Fio2, minimum RR,
ventilation vs pressure the patient’s breath and ensures that a desired VT is achieved. sensitivity, target VT,
support ventilation effort and will adjust the PEEP2
pressure support level
to deliver the desired
volume2
Airway pressure release Time-cycled, pressure- Patient is able to breathe spontaneously throughout Fio2, Phigh, Plow,
ventilation/bilevel targeted mode.2,7 A type the ventilatory cycle.2,7,8 Used as a rescue mode Thigh, Tlow2,8
ventilation of inverse ratio ventilatory to manage patients with ARDS in the ICU.2,13
mode, it is intended that Contraindicated in patients with severe COPD and
the patient spend more lung disease.2
time in the inspiratory
cycle, or Thigh.8,9
Proportional assist Provider sets the 6.0-cm ET tube or equivalent minimum.9 Consistent Fio2, PEEP, type
ventilation/proportional percentage of work monitoring is recommended to ensure the ventilator and size of airway
pressure support performed by the is sensing the patient’s effort accurately.2 Considered tube, sensitivity
ventilator, and the one of the most comfortable modes of ventilation; trigger, patient’s
remaining percentage of promotes sleep.2,9 weight2,7,9
work is performed by the
patient7,9
Adaptive support Ventilator will determine Patient-initiated breaths supported by pressure Fio2, patient’s
ventilation and initiate an RR and support.2 height, gender, goal
VT that will produce the minute ventilation,
least amount of work PEEP2,9
for the patient while still
maintaining ventilation2,9;
weaning mode
Neurally adjusted Mode driven by the Designed to decrease asynchrony associated with Fio2, PEEP, NAVA
ventilator assist (NAVA) neural input signals of the ventilator modes that depend on flow for input and level2,7,9
diaphragm; sensed using are susceptible to miscalculations if a leak is present
an esophageal catheter2,9 or flow devices are malfunctioning.9 Does not limit
ET tube size.9 Should be avoided in patients in
which one does not want the respiratory centers
to drive ventilation, because hyperventilation can
occur.2,7,9,14,15
High-frequency Delivery of a rapid RR To increase the patient’s Pao2, the Fio2 and mean Fio2, inspiratory
oscillatory ventilation with small VT used airway pressure are adjusted, and intermittent time, frequency,
(HFOV) as a rescue mode of recruitment maneuvers should be performed.2 To amplitude, mean
ventilation for patients manipulate CO2 levels, the amplitude and frequency airway pressure7,9
with severe ARDS2,7,9 should be titrated.7,9,13 Frequency waves cause
expiration of CO2.7,9,13 The VT delivered are lower
than dead space volume, and patient may require
recruitment maneuvers.2,13 Pneumothorax is a
potential complication.2 The possibility of increased
aerosolization should be considered before placing a
COVID-19–positive patient on HFOV.1
Table 2. ICU Ventilator Modes
Abbreviations: CO2, carbon dioxide; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease 2019; ET,
endotracheal; Fio2, fraction of inspired oxygen; ICU, intensive care unit; PEEP, positive end-expiratory pressure; Phigh, pressure high;
Plow, pressure low, RR, respiratory rate; Thigh, time spent at high pressure; Tlow, time spent at low pressure; VT, tidal volume.
64 AANA Journal February 2021 Vol. 89, No. 1 www.aana.com/aanajournalonline
ventilator mode is safest for management of the patient Severity of Pao2/Fio2 (P/F)
on an individual basis.13 ARDS ratio, mm Hgb
Mild
Permissive hypoxemia to Pao2 goal of 55-80 mm Hg1,17 Permissive hypercapnia to a goal of a pH >7.21,17,23 Respiratory rate
dependent atelectasis results in regional compliance dif- corporeal membrane oxygenation (ECMO) is used for
ferences and may contribute to volutrauma in normal patients with ARDS who are refractory to LPV strate-
lung segments. If these changes are gravity dependent, it gies and other strategies, such as prone positioning.
is logical to assume that if the patient is turned from the Venous-venous (V-V) ECMO is the most common form
supine to prone position that these would dissipate and of ECMO used in patients with ARDS. Only the lungs
improve gas exchange.23 are bypassed in V-V ECMO, and it is considered a type of
Prone positioning decreases abdominal pressure on lung rest.8,19,41,42 Intact cardiac function is still needed for
lung units, improves ventilation and perfusion match- V-V ECMO.8,19,41,42 Due to the invasiveness of ECMO, it
ing, decreases the occurrence of ventilator-induced lung is often considered a last-resort rescue therapy, although
injury, and provides more homogenous ventilation of centers that specialize in ECMO may have a lower thresh-
alveoli.16,21,34-36 Prone positioning should be initiated old for its initiation.19
early in patients with COVID-19.1 The results of some Extracorporeal membrane oxygenation should be con-
studies show a benefit to prone positioning patients ex- sidered only in patients who have a reversible cause of
periencing ARDS before their condition progresses to the respiratory failure.8,19,41 When patients with COVID-19
point they need to be intubated.37,38 Patients should be demonstrate refractory and worsening respiratory failure
positioned prone for greater than 12 hours a day (many despite implementation of LPV evidence-based rescue
experts recommend up to 16 hours) and then should be therapies, such as prone positioning and use of neu-
turned supine for the remainder of the day.1,17,21,35,36 romuscular blockers, ECMO may improve outcomes.1
Patients can be turned prone manually or using a Indications that may be used to consider initiating ECMO
specialty bed. This intervention can be technically chal- in these patients include the following: Pao2/Fio2 ratio
lenging and requires a team skilled in turning patients below 100 mm Hg (some experts recommend 80 mm Hg) or a pH below 7.2, and plateau pres-
providers to infection with the severe acute respiratory sures above 30 cm H2O despite reduced tidal volumes to
syndrome coronavirus-2 (SARS-CoV-2), the virus that below 4 mL/kg.2,8,19,41-43 To be considered a candidate,
causes COVID-19. More research is needed to determine the patient must be able to be anticoagulated, which has
if the benefit of prone positioning is worth the potential been associated with complications of thrombocytopenia
exposure to healthcare providers. and life-threatening bleeding.19,44
Skin breakdown, including pressure ulcer formation, The 2018 ECMO to Rescue Lung Injury in Severe
is a common occurrence when a patient is in a prone ARDS (EOLIA) study evaluated the mortality risk as-
position. Bony prominences and the facial area should sociated with ECMO for patients with severe ARDS, and
have proper padding and be positioned carefully.36,40 The the results found no statistically significant reduction
provider should ensure that intravenous catheter lines in 60-day mortality in patients with ARDS randomly
and devices do not put pressure on the patient’s skin.37 assigned to receive ECMO vs conventional LPV.19,43
Other concerns include accidental extubation, bronchus Although the difference was not significant, this treat-
intubation, and line and/or chest tube removal, and prac- ment may be clinically meaningful to providers who
titioners should have a plan for turning the patient supine are using ECMO as a last resort in severely hypoxemic
quickly if the patient becomes unintentionally extubated patients.44 This study was limited by a 28% crossover
or experiences cardiac arrest. rate from conventional therapy to ECMO and early ter-
There is conflicting evidence regarding the effective- mination due to futility, resulting in a likely underpow-
ness of prone positioning in decreasing mortality. The ered study.43 Encouragingly, patients receiving ECMO
Proning Severe ARDS Patients (PROSEVA) study find- had fewer days requiring renal replacement therapy.43
ings revealed that prone positioning during mechani- Also, the fact that the EOLIA investigators considered it
cal ventilation leads to decreased mortality when used necessary to cross over 28% of patients from the control
early and for extended periods in patients with ARDS.35 group to the ECMO group is encouraging for the use of
Three limitations of the PROSEVA study are that it was ECMO as a rescue therapy in dire cases.43,44 Given the
performed in ICUs that had experience in prone po- limitations of the EOLIA trial, further studies are needed
sitioning patients with ARDS, the prone phase of care to elucidate the efficacy of ECMO in the management of
was for at least 16 hours per day, and the study was pre- severe ARDS, specifically those with COVID-19.44
COVID-19.35 Munshi et al,36 in 2017, performed a meta-
analysis and systematic review and found an association Conclusion
between prone positioning for at least 12 hours a day and Certified Registered Nurse Anesthetists returning to the
increased survivability, especially in patients defined as ICU will encounter evolutions in mechanical ventila-
having severe ARDS. tors that greatly differ from those seen in the traditional
• Extracorporeal Membrane Oxygenation. Extra- anesthesia machine ventilators. One major limitation of
www.aana.com/aanajournalonline AANA Journal February 2021 Vol. 89, No. 1 67
this review is the incomplete data and information on for the critical care pharmacist. J Pharm Pract. 2019;32(2):186-198.
doi:10.1177/0897190017734766
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Ann Am Thorac Soc. 2017;14(suppl 4):S280-S288. doi:10.1513/ AUTHORS
AnnalsATS.201704-343OT Kaitlyn Jackson, DNAP, was a student registered nurse anesthetist enrolled
37. Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves at Virginia Commonwealth University, Richmond, Virginia, at the time this
oxygenation in spontaneously breathing nonintubated patients with article was submitted. Email: jacksonke6@mymail.vcu.edu.
hypoxemic acute respiratory failure: A retrospective study. J Crit Care. Brenda A. Wands, PhD, MBA, CRNA, CHSE, is assistant professor and
2015;30(6):1390-1394. doi:10.1016/j.jcrc.2015.07.008 director of interprofessional education, Department of Nurse Anesthesia,
38. Ding L, Wand L, Wanhong M, He H. Efficacy and safety of early Virginia Commonwealth University. Email: bawands@vcu.edu.
prone positioning combined with HFNC or NIV in moderate to
severe ARDS: a multi-center prospective cohort study. Crit Care. DISCLOSURES
2020;24(28):1-8. doi:10.1186/s13054-020-2738-5 The authors have declared no financial relationships with any commercial
39. Parissopoulos S, Mpouzika MD, Timmins F. Optimal support tech- entity related to the content of this article. The authors did not discuss
niques when providing mechanical ventilation to patients with acute off-label use within the article. Disclosure statements are available for
respiratory distress syndrome. Nurs Crit Care. 2017;22(1):40-51. viewing upon request.
50 Years in the OR
By Ron Whitchurch
Ron Whitchurch wrote this wildly
entertaining book to offer a firsthand
look at what happens after patients are
anesthetized and what challenges the staff
face in keeping them healthy and safe.
50 Years in the OR will give readers an intimate sense
of what it’s like to be the only person in the OR
who knows the heartbeat-to-heartbeat status of a
surgical patient at any given moment. Available on
Amazon.com.
50yearsintheor.com
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