Mechanical ventilation

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In architecture and climate control, mechanical or forced ventilation is the use of powered equipment, e.g. fans and blowers, to move air — see ventilation (architecture).
Mechanical ventilation
ICD-993.90 96.7
MeSHD012121
OPS-301 code8-71

In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows. Traditionally divided into negative-pressure ventilation, where air is essentially sucked into the lungs, or positive pressure ventilation, where air (or another gas mix) is pushed into the trachea. There are two main divisions of mechanical ventilation: invasive ventilation and non-invasive ventilation.[1] There are two main modes of mechanical ventilation within the two divisions: positive pressure ventilation and negative pressure ventilation.

History

The Roman physician Galen may have been the first to describe mechanical ventilation: "If you take a dead animal and blow air through its larynx [through a reed], you will fill its bronchi and watch its lungs attain the greatest distention."[2] Vesalius too describes ventilation by inserting a reed or cane into the trachea of animals.[3] In 1908 George Poe demonstrated his mechanical respirator by asphyxiating dogs and seemingly bringing them back to life.[4]

Complications

Mechanical ventilation is often a life-saving intervention, but carries many potential complications including pneumothorax, airway injury, alveolar damage, and ventilator-associated pneumonia.[5]

In many healthcare systems prolonged ventilation as part of intensive care is a limited resource (in that there are only so many patients that can receive care at any given moment). It is used to support a single failing organ system (the lungs) and cannot reverse any underlying disease process (such as terminal cancer). For this reason there can be (occasionally difficult) decisions to be made about whether it is suitable to commence someone on mechanical ventilation. Equally many ethical issues surround the decision to discontinue mechanical ventilation.[6]

Application and duration

It can be used as a short term measure, for example during an operation or critical illness (often in the setting of an intensive care unit). It may be used at home or in a nursing or rehabilitation institution if patients have chronic illnesses that require long-term ventilatory assistance. Owing[clarification needed] to the anatomy of the human pharynx, larynx, and esophagus and the circumstances for which ventilation is required then additional measures are often required to secure the airway during positive pressure ventilation to allow unimpeded passage of air into the trachea and avoid air passing into the esophagus and stomach. Commonly this is by insertion of a tube into the trachea which provides a clear route for the air. This can be either an endotracheal tube, inserted through the natural openings of mouth or nose or a tracheostomy inserted through an artificial opening in the neck. In other circumstances simple airway maneuvres, an oropharyngeal airway or laryngeal mask airway may be employed. If the patient is able to protect their own airway and non-invasive ventilation or negative-pressure ventilation is used then a airway adjunct may not be needed.

Negative pressure machines

An iron lung
Main article: Iron Lung

The iron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was one of the first negative-pressure machines used for long-term ventilation. It was refined and used in the 20th century largely as a result of the polio epidemic that struck the world in the 1940s. The machine is effectively a large elongated tank, which encases the patient up to the neck. The neck is sealed with a rubber gasket so that the patient's face (and airway) are exposed to the room air.

While the exchange of oxygen and carbon dioxide between the bloodstream and the pulmonary airspace works by diffusion and requires no external work, air must be moved into and out of the lungs to make it available to the gas exchange process. In spontaneous breathing, a negative pressure is created in the pleural cavity by the muscles of respiration, and the resulting gradient between the atmospheric pressure and the pressure inside the thorax generates a flow of air.

In the iron lung by means of a pump, the air is withdrawn mechanically to produce a vacuum inside the tank, thus creating negative pressure. This negative pressure leads to expansion of the chest, which causes a decrease in intrapulmonary pressure, and increases flow of ambient air into the lungs. As the vacuum is released, the pressure inside the tank equalizes to that of the ambient pressure, and the elastic coil of the chest and lungs leads to passive exhalation. However, when the vacuum is created, the abdomen also expands along with the lung, cutting off venous flow back to the heart, leading to pooling of venous blood in the lower extremities. There are large portholes for nurse or home assistant access. The patients can talk and eat normally, and can see the world through a well-placed series of mirrors. Some could remain in these iron lungs for years at a time quite successfully.

Today, negative pressure mechanical ventilators are still in use, notably with the polio wing hospitals in England such as St Thomas' Hospital in London and the John Radcliffe in Oxford. The prominent device used is a smaller device known as the cuirass. The cuirass is a shell-like unit, creating negative pressure only to the chest using a combination of a fitting shell and a soft bladder. Its main use is in patients with neuromuscular disorders who have some residual muscular function. However, it was prone to falling off and caused severe chafing and skin damage and was not used as a long term device. In recent years this device has re-surfaced as a modern polycarbonate shell with multiple seals and a high pressure oscillation pump in order to carry out biphasic cuirass ventilation.

Positive pressure machines

Neonatal mechanical ventilator

The design of the modern positive-pressure ventilators were mainly based on technical developments by the military during World War II to supply oxygen to fighter pilots in high altitude. Such ventilators replaced the iron lungs as safe endotracheal tubes with high volume/low pressure cuffs were developed. The popularity of positive-pressure ventilators rose during the polio epidemic in the 1950s in Scandinavia and the United States and was the beginning of modern ventilation therapy. Positive pressure through manual supply of 50% oxygen through a tracheostomy tube led to a reduced mortality rate among patients with polio and respiratory paralysis. However, because of the sheer amount of man-power required for such manual intervention, mechanical positive-pressure ventilators became increasingly popular.

Positive-pressure ventilators work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube. The positive pressure allows air to flow into the airway until the ventilator breath is terminated. Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and lungs push the tidal volume — the breath—out through passive exhalation.

Indications for use

Mechanical ventilation is indicated when the patient's spontaneous ventilation is inadequate to maintain life. It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs. Because mechanical ventilation only serves to provide assistance for breathing and does not cure a disease, the patient's underlying condition should be correctable and should resolve over time. In addition, other factors must be taken into consideration because mechanical ventilation is not without its complications (see below)

Common medical indications for use include:

Associated risk

Barotrauma — Pulmonary barotrauma is a well-known complication of positive pressure mechanical ventilation.[7] This includes pneumothorax, subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum.[7]

Ventilator-associated lung injury — Ventilator-associated lung injury (VALI) refers to acute lung injury that occurs during mechanical ventilation. It is clinically indistinguishable from acute lung injury or acute respiratory distress syndrome (ALI/ARDS).[8]

Diaphragm — Controlled mechanical ventilation may lead to a rapid type of disuse atrophy involving the diaphragmatic muscle fibers, which can develop within the first day of mechanical ventilation.[9] This cause of atrophy in the diaphragm is also a cause of atrophy in all respiratory related muscles during controlled mechanical ventilation.[10]

Motility of mucocilia in the airways — Positive pressure ventilation appears to impair mucociliary motility in the airways. Bronchial mucus transport was frequently impaired and associated with retention of secretions and pneumonia.[11]

Types of ventilators

SMART BAG MO Bag-Valve-Mask Resuscitator

Ventilators come in many different styles and method of giving a breath to sustain life. There are manual ventilators such as Bag valve masks and anesthesia bags require the user to hold the ventilator to the face or to an artificial airway and maintain breaths with their hands. Mechanical ventilators are ventilators not requiring operator effort and are typically computer controlled or pneumatic controlled.

Mechanical ventilators

Mechanical ventilators typically require power by a battery or a wall outlet (DC or AC) though some ventilators work on a pneumatic system not requiring power.

  • Transport ventilators — These ventilators are small, more rugged, and can be powered pneumatically or via AC or DC power sources.
  • Intensive-care ventilators — These ventilators are larger and usually run on AC power (though virtually all contain a battery to facilitate intra-facility transport and as a back-up in the event of a power failure). This style of ventilator often provides greater control of a wide variety of ventilation parameters (such as inspiratory rise time). Many ICU ventilators also incorporate graphics to provide visual feedback of each breath.
  • Neonatal ventilators — Designed with the preterm neonate in mind, these are a specialized subset of ICU ventilators which are designed to deliver the smaller, more precise volumes and pressures required to ventilate these patients.
  • Positive airway pressure ventilators (PAP) — These ventilators are specifically designed for non-invasive ventilation. This includes ventilators for use at home for treatment of chronic conditions such as sleep apnea or COPD.

Breath delivery

Trigger

The trigger is what causes a breath to be delivered by a mechanical ventilator. Breaths may be triggered by a patient taking their own breath, a ventilator operator pressing a manual breath button, or by the ventilator based on the set breath rate and mode of ventilation.

Cycle

The cycle is what causes the breath to transition from the inspiratory phase to the exhalation phase. Breaths may be cycled by a mechanical ventilator when a set time has been reached, or when a preset flow or percentage of the maximum flow delivered during a breath is reached depending on the breath type and the settings. Breaths can also be cycled when an alarm condition such as a high pressure limit has been reached, which is a primary strategy in pressure regulated volume control.

Limit

Limit is how the breath is controlled. Breaths may be limited to a set maximum circuit pressure or a set maximum flow.

Breath exhalation

Exhalation in mechanical ventilation is almost always completely passive. The ventilator's expiratory valve is opened, and expiratory flow is allowed until the baseline pressure (PEEP) is reached. Expiratory flow is determined by patient factors such as compliance and resistance.

Modes of mechanical ventilation

Main article: Modes of mechanical ventilation

Mechanical ventilation utilizes several separate systems for ventilation referred to as the "mode". Modes come in many different delivery concepts but all modes generally fall into one of the few main flagship categories such as volume controlled continuous mandatory ventilation, volume controlled intermittent mandatory ventilation, pressure controlled continuous mandatory ventilation, pressure controlled intermittent mandatory ventilation, continuous spontaneous ventilation and the high frequency ventilation systems.

Volume controlled continuous mandatory ventilation

Controlled mechanical ventilation (CMV) — In this mode the ventilator provides a mechanical breath on a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable for children and adults who are conscious and is usually only used in an unconscious patient. It may also be used in infants who often quickly adapt their breathing pattern to the ventilator timing. Since CMV is no longer contained in its original form the term volume controlled continuous mandatory ventilation has consumed it into its definition and overall has combined any CMV mode for mechanical ventilation into the more accepted term in nomenclature for mechanical ventilation.

Volume controlled continuous mandatory ventilation — In this mode the ventilator provides a mechanical breath with either a pre-set tidal volume or peak pressure every time the patient initiates a breath. Traditional assist-control used only a pre-set tidal volume—when a preset peak pressure is used this is also sometimes termed intermittent positive pressure ventilation (IPPV). However, the initiation timing is the same—both provide a ventilator breath with every patient effort. In most ventilators a back-up minimum breath rate can be set in the event that the patient becomes apnoeic. Although a maximum rate is not usually set, an alarm can be set if the ventilator cycles too frequently. This can alert that the patient is tachypneic or that the ventilator may be auto-cycling (a problem that results when the ventilator interprets fluctuations in the circuit due to the last breath termination as a new breath initiation attempt).

Volume controlled intermittent mandatory ventilation

Volume controlled intermittent mandatory ventilation (VC-IMV). Formerly known as synchronized intermittent mandatory ventilation (SIMV). In this mode the ventilator provides a pre-set mechanical breath (volume limited) every specified number of seconds (determined by dividing the respiratory rate into 60 seconds — thus a respiratory rate of 12 results in a 5 second cycle time). Within that cycle time the ventilator waits for the patient to initiate a breath using either a pressure or flow sensor. When the ventilator senses the first patient breathing attempt within the cycle, it delivers the preset ventilator breath. If the patient fails to initiate a breath, the ventilator delivers a mechanical breath at the end of the breath cycle. Additional spontaneous breaths after the first one within the breath cycle do not trigger another SIMV breath. However, SIMV may be combined with pressure support (see below). SIMV is frequently employed as a method of decreasing ventilatory support (weaning) by turning down the rate, which requires the patient to take additional breaths beyond the SIMV triggered breath.

Pressure controlled continuous mandatory ventilation

Pressure controlled continuous mandatory ventilation (PC-CMV) — mechanical ventilation with preset inspiratory pressure (PIP) and inspiratory time (Ti). Every breath is machine initiated and mandatory.its right way

Pressure controlled intermittent mandatory ventilation

Pressure controlled intermittent mandatory ventilation (formerly known as SIMV) — In this mode the ventilator provides a pre-set pressure limited mechanical breath every specified number of seconds SIMV is frequently employed as a method of decreasing ventilatory support (weaning) by turning down the rate, which requires the patient to take additional breaths beyond the SIMV triggered breath. PC-IMV is fundamentally the same as VC-IMV with an emphasis on pressure support and control instead of volume. An example of PC-IMV is in the mode pressure regulated volume control.

High frequency ventilation

High frequency ventilation refers to ventilation that occurs at rates significantly above that found in natural breathing. High frequency ventilation is further defined as any ventilation with a respiratory rate (Vf) greater than 150 respirations per minute. Within the category of high-frequency ventilation, the two principal types are high-frequency ventilation (passive) (i.e. high-frequency jet ventilation) and high-frequency ventilation (active) (i.e. high-frequency oscillatory ventilation).

Continuous spontaneous ventilation

Pressure Support Ventilation

Pressure support ventilation (PSV). When a patient attempts to breathe spontaneously through an endotracheal tube, the narrowed diameter of the airway results in higher resistance to airflow, and thus a higher work of breathing. PSV was developed as a method to decrease the work of breathing in-between ventilator mandated breaths by providing an elevated pressure triggered by spontaneous breathing that "supports" ventilation during inspiration. Thus, for example, SIMV might be combined with PSV so that additional breaths beyond the SIMV programmed breaths are supported. However, while the SIMV mandated breaths have a preset volume or peak pressure, the PSV breaths are designed to cut short when the inspiratory flow reaches a percentage of the peak inspiratory flow (e.g. 10–25%). New generation of ventilators provides user-adjustable inspiration cycling off threshold, and some even are equipped with automatic inspiration cycling off threshold function. This helps the patient ventilator synchrony.[12] The peak pressure set for the PSV breaths is usually a lower pressure than that set for the full ventilator mandated breath. PSV can be also be used as an independent mode.

Continuous positive airway pressure

Continuous positive airway pressure (CPAP). A continuous level of elevated pressure is provided through the patient circuit to maintain adequate oxygenation, decrease the work of breathing, and decrease the work of the heart (such as in left-sided heart failure CHF). Note that no cycling of ventilator pressures occurs and the patient must initiate all breaths. In addition, no additional pressure above the CPAP pressure is provided during those breaths. CPAP may be used invasively through an endotracheal tube or tracheostomy or non-invasively with a face mask or nasal prongs. Non-invasive ventilation has become more common for treatment of acute respiratory failure.[1]

Choosing amongst ventilator modes

Assist-control mode minimizes patient effort by providing full mechanical support with every breath. This is often the initial mode chosen for adults because it provides the greatest degree of support. In patients with less severe respiratory failure, other modes such as SIMV may be appropriate. Assist-control mode should not be used in those patients with a potential for respiratory alkalosis, in which the patient has an increased respiratory drive. Such hyperventilation and hypocapnia (decreased systemic carbon dioxide due to hyperventilation) usually occurs in patients with end-stage liver disease, hyperventilatory sepsis, and head trauma. Respiratory alkalosis will be evident from the initial arterial blood gas obtained, and the mode of ventilation can then be changed if so desired.

Positive End Expiratory Pressure may or may not be employed to prevent atelectasis in adult patients. It is almost always used for pediatric and neonatal patients due to their increased tendency for atelectasis.

High frequency oscillation is used most frequently in neonates, but is also used as an always alternative mode in adults with severe ARDS.

Pressure regulated volume control is another option.

Modification of settings

In adults when 100% FiO
2 is used initially, it is easy to calculate the next FiO
2 to be used and easy to estimate the shunt fraction. The estimated shunt fraction refers to the amount of oxygen not being absorbed into the circulation. In normal physiology, gas exchange (oxygen/carbon dioxide) occurs at the level of the alveoli in the lungs. The existence of a shunt refers to any process that hinders this gas exchange, leading to wasted oxygen inspired and the flow of un-oxygenated blood back to the left heart (which ultimately supplies the rest of the body with unoxygenated blood).

When using 100% FiO
2, the degree of shunting is estimated by subtracting the measured PaO
2 (from an arterial blood gas) from 700 mmHg. For each difference of 100 mmHg, the shunt is 5%. A shunt of more than 25% should prompt a search for the cause of this hypoxemia, such as mainstem intubation or pneumothorax, and should be treated accordingly. If such complications are not present, other causes must be sought after, and PEEP should be used to treat this intrapulmonary shunt. Other such causes of a shunt include:

Weaning from mechanical ventilation

Withdrawal from mechanical ventilation—also known as weaning—should not be delayed unnecessarily, nor should it be done prematurely. Patients should have their ventilation considered for withdrawal if they are able to support their own ventilation and oxygenation, and this should be assessed continuously. There are several objective parameters to look for when considering withdrawal, but there is no specific criteria that generalizes to all patients.

Trials of spontaneous breathing have been shown to accurately predict the success of spontaneous breathing.[13]

Respiratory monitoring

Respiratory mechanics monitor

One of the main reasons why a patient is admitted to an ICU is for delivery of mechanical ventilation. Monitoring a patient in mechanical ventilation has many clinical applications: Enhance understanding of pathophysiology, aid with diagnosis, guide patient management, avoid complications and assessment of trends.[14]

Most of modern ventilators have basic monitoring tools. There are also monitors that work independently of the ventilator, which allow to measure patients after the ventilator has been removed, such as a T tube test.

Artificial airways as a connection to the ventilator

Main article: Artificial airway

There are various procedures and mechanical devices that provide protection against airway collapse, air leakage, and aspiration:

  • Face mask — In resuscitation and for minor procedures under anaesthesia, a face mask is often sufficient to achieve a seal against air leakage. Airway patency of the unconscious patient is maintained either by manipulation of the jaw or by the use of nasopharyngeal or oropharyngeal airway. These are designed to provide a passage of air to the pharynx through the nose or mouth, respectively. Poorly fitted masks often cause nasal bridge ulcers, a problem for some patients. Face masks are also used for non-invasive ventilation in conscious patients. A full face mask does not, however, provide protection against aspiration.
  • Laryngeal mask airway — The laryngeal mask airway (LMA) causes less pain and coughing than a tracheal tube. However, unlike tracheal tubes it does not seal against aspiration, making careful individualised evaluation and patient selection mandatory.
  • Tracheal intubation is often performed for mechanical ventilation of hours to weeks duration. A tube is inserted through the nose (nasotracheal intubation) or mouth (orotracheal intubation) and advanced into the trachea. In most cases tubes with inflatable cuffs are used for protection against leakage and aspiration. Intubation with a cuffed tube is thought to provide the best protection against aspiration. Tracheal tubes inevitably cause pain and coughing. Therefore, unless a patient is unconscious or anaesthetized for other reasons, sedative drugs are usually given to provide tolerance of the tube. Other disadvantages of tracheal intubation include damage to the mucosal lining of the nasopharynx or oropharynx and subglottic stenosis.
  • Esophageal obturator airway — sometimes used by emergency medical technicians and basic EMS providers not trained to intubate. It is a tube which is inserted into the esophagus, past the epiglottis. Once it is inserted, a bladder at the tip of the airway is inflated, to block ("obturate") the esophagus, and oxygen is delivered through a series of holes in the side of the tube which is then forced into the lungs.
  • Cricothyrotomy — Patients who require emergency airway management, in whom tracheal intubation has been unsuccessful, may require an airway inserted through a surgical opening in the cricothyroid membrane. This is similar to a tracheostomy but a cricothyrotomy is reserved for emergency access.[15]
  • Tracheostomy — When patients require mechanical ventilation for several weeks, a tracheostomy may provide the most suitable access to the trachea. A tracheostomy is a surgically created passage into the trachea. Tracheostomy tubes are well tolerated and often do not necessitate any use of sedative drugs. Tracheostomy tubes may be inserted early during treatment in patients with pre-existing severe respiratory disease, or in any patient who is expected to be difficult to wean from mechanical ventilation, i.e., patients who have little muscular reserve.
  • Mouthpiece — Less common interface, does not provide protection against aspiration. There are lipseal mouthpieces with flanges to help hold them in place if patient is unable.

References

  1. ^ a b Cabrini L, Landoni G, Zangrillo A (2011). "Noninvasive ventilation failure: the answer is blowing in the leaks". Respir Care. 56 (11): 1857–8. doi:10.4187/respcare.01565. PMID 22035827.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  2. ^ Colice, Gene L (2006). "Historical Perspective on the Development of Mechanical Ventilation". In Martin J Tobin (ed.). Principles & Practice of Mechanical Ventilation (2 ed.). New York: McGraw-Hill. ISBN 978-0-07-144767-6.
  3. ^ Chamberlain D (2003). "Never quite there: a tale of resuscitation medicine". Clin Med. 3 (6): 573–7. PMID 14703040.
  4. ^ "Smother Small Dog To See it Revived. Successful Demonstration of an Artificial Respiration Machine Cheered in Brooklyn. Women in the Audience, But Most of Those Present Were Physicians. The Dog, Gathered in from the Street, Wagged Its Tail". New York Times. May 29, 1908, Friday. Retrieved 2007-12-25. An audience, composed of about thirty men and three or four women, most of the men being physicians, attended a demonstration of Prof. George Poe's machine for producing artificial respiration in the library of the Kings County Medical Society, at 1,313 Bedford Avenue, Brooklyn, last night, under the auspices of the First Legion of the Red Cross Society. {{cite news}}: Check date values in: |date= (help)
  5. ^ Hess DR (2011). "Approaches to conventional mechanical ventilation of the patient with acute respiratory distress syndrome". Respir Care. 56 (10): 1555–72. doi:10.4187/respcare.01387. PMID 22008397.
  6. ^ O'Connor HH (2011). "Prolonged mechanical ventilation: are you a lumper or a splitter?". Respir Care. 56 (11): 1859–60. doi:10.4187/respcare.01600. PMID 22035828.
  7. ^ a b Parker JC, Hernandez LA, Peevy KJ (1993). "Mechanisms of ventilator-induced lung injury". Crit Care Med. 21 (1): 131–43. PMID 8420720.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ "International consensus conferences in intensive care medicine: Ventilator-associated Lung Injury in ARDS. This official conference report was cosponsored by the American Thoracic Society, The European Society of Intensive Care Medicine, and The Societé de Réanimation de Langue Française, and was approved by the ATS Board of Directors, July 1999". Am. J. Respir. Crit. Care Med. 160 (6): 2118–24. 1999. PMID 10588637. {{cite journal}}: Unknown parameter |month= ignored (help)
  9. ^ Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P; et al. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans". N Engl J Med. 358 (13): 1327–35. doi:10.1056/NEJMoa070447. PMID 18367735. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  10. ^ De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M; et al. (2002). "Paresis acquired in the intensive care unit: a prospective multicenter study". JAMA. 288 (22): 2859–67. PMID 12472328. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  11. ^ Konrad F, Schreiber T, Brecht-Kraus D, Georgieff M (1994). "Mucociliary transport in ICU patients". Chest. 105 (1): 237–41. PMID 8275739.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Du HL, Yamada Y (2005). "Expiratory asynchrony". Respir Care Clin N Am. 11 (2): 265–80. doi:10.1016/j.rcc.2005.02.001. PMID 15936693. {{cite journal}}: Unknown parameter |month= ignored (help)
  13. ^ Yang KL, Tobin MJ (1991). "A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation". N. Engl. J. Med. 324 (21): 1445–50. doi:10.1056/NEJM199105233242101. PMID 2023603. {{cite journal}}: Unknown parameter |month= ignored (help)
  14. ^ Tobin MJ (2006). Principles and Practice of Mechanical Ventilation (2nd ed.). McGraw Hill.
  15. ^ Carley SD, Gwinnutt C, Butler J, Sammy I, Driscoll P (2002). "Rapid sequence induction in the emergency department: a strategy for failure". Emerg Med J. 19 (2): 109–13. doi:10.1136/emj.19.2.109. PMC 1725832. PMID 11904254. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

External links

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