Biomedical engineer’s guide to the clinical aspects of intensive care mechanical ventilation

Abstract

BackgroundMechanical ventilation is an essential therapy to support critically ill respiratory failure patients. Current standards of care consist of generalised approaches, such as the use of positive end expiratory pressure to inspired oxygen fraction (PEEP–FiO2) tables, which fail to account for the inter- and intra-patient variability between and within patients. The benefits of higher or lower tidal volume, PEEP, and other settings are highly debated and no consensus has been reached. Moreover, clinicians implicitly account for patient-specific factors such as disease condition and progression as they manually titrate ventilator settings. Hence, care is highly variable and potentially often non-optimal. These conditions create a situation that could benefit greatly from an engineered approach. The overall goal is a review of ventilation that is accessible to both clinicians and engineers, to bridge the divide between the two fields and enable collaboration to improve patient care and outcomes. This review does not take the form of a typical systematic review. Instead, it defines the standard terminology and introduces key clinical and biomedical measurements before introducing the key clinical studies and their influence in clinical practice which in turn flows into the needs and requirements around how biomedical engineering research can play a role in improving care. Given the significant clinical research to date and its impact on this complex area of care, this review thus provides a tutorial introduction around the review of the state of the art relevant to a biomedical engineering perspective.DiscussionThis review presents the significant clinical aspects and variables of ventilation management, the potential risks associated with suboptimal ventilation management, and a review of the major recent attempts to improve ventilation in the context of these variables. The unique aspect of this review is a focus on these key elements relevant to engineering new approaches. In particular, the need for ventilation strategies which consider, and directly account for, the significant differences in patient condition, disease etiology, and progression within patients is demonstrated with the subsequent requirement for optimal ventilation strategies to titrate for patient- and time-specific conditions.ConclusionEngineered, protective lung strategies that can directly account for and manage inter- and intra-patient variability thus offer great potential to improve both individual care, as well as cohort clinical outcomes.

Risk-Based Care: Let's Think Outside the Box

“…The trade-off between these types of risk can be found in many core ICU therapies. Mechanical ventilation has the tradeoff between the sudden impact of barotrauma or volutrauma vs. the "slow" damage of increased inspired oxygen settings when setting PEEP or tidal volume (33). Thus, quantifying the risk, via new metrics or personalized models, would allow the proper assessment of patient response and thus whether (or not) to provide more aggressive ventilation settings, which if done incorrectly increase the risk of cost, length of stay, and mortality.…”

GlasVent—The Rapidly Deployable Emergency Ventilator

“…The two possible modes ( Figure a,b) for delivering mechanical ventilation are noninvasive and invasive, determined by the intubation of the patient or not. [ 9 ] The ventilation modes can be further subdivided into control or support modes, depending on the patient's breathing efforts and sedation, and finally, pressure or volume‐controlled modes. Noninvasive ventilation is delivered via face mask, whereas, invasive ventilation involves insertion of a laryngeal mask, endotracheal tube, or tracheostomy, as shown in Figure 3a,b.…”

Network Data Acquisition and Monitoring System for Intensive Care Mechanical Ventilation Treatment

“…However, these approaches are generalized and do not consider patient-specific disease state and their response to treatment. As a result, patients ventilated with excessive airway pressure or tidal volume can develop ventilator induced lung injury (VILI), increasing morbidity and mortality [4], [9]. Thus, accurate, predictive, and patientspecific MV strategies could significantly advance MV care, and minimize both VILI and mortality [10], [11].…”

“…Currently, no effective standardized method exists for clinicians to determine the optimal patient-specific MV settings, leading to uncertainty, variability, and increased risk [4], [12]. Model-based methods are a growing means of personalising care [13]- [16].…”