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Understanding Mechanical Ventilation: A Practic...

Mechanical ventilation is necessary to sustain life in acute settings; hence, its management is essential for clinicians and other healthcare providers to understand and apply it safely. This knowledge must be built on a solid understanding of the basic principles of human physiology and airway mechanics. This article will focus on the management of the intubated patient in the first few hours of care on mechanical ventilation. It will review the basics of invasive mechanical ventilation, the common modes of ventilation, initial settings, and supportive care for intubated patients will be discussed in this review. Noninvasive ventilation (NIV) will be addressed separately.[1]

Understanding Mechanical Ventilation: A Practic...


It stands to reason then, that learning about ventilator waveform interpretation will involve first understanding the technical aspects of patient-ventilator interaction including ventilator design and the associated terminology. Next, one would have to learn how waveforms reflect the underlying patient-ventilator interaction and be able to classify them as normal or abnormal. And to make use of the interpretation for determining proper ventilator management, one would have to know how to assess the goal of ventilation for a given patient. That knowledge would then be paired with a knowledge of ventilator mode taxonomy so that the mechanisms of action and indications for many different modes can be discerned. Finally, one would have to know how to select the most appropriate mode to meet the therapeutic goal. Mastering these skills is imperative to appropriately manage mechanical ventilation.

The optimal quantity and timing of nutrition support for critically ill patients has long been debated. In the past, nutrition guidelines supported early aggressive feeding to meet estimated energy expenditure (EE), aimed at the prevention of malnutrition and muscle loss. However, clinical studies have failed to prove an unequivocal benefit of early high-dose nutrition support, and several prospective randomized clinical trials showed significant harm, including increased hyperglycemia, hepatic steatosis, and mortality [1,2,3,4,5]. In contrast, undernourishment is also common in ICU and post-ICU patients due to both prescription inadequacy and failure to reach the nutrition target [6,7,8,9,10,11,12]. A negative energy balance in critically ill patients is associated with increased morbidity, including increased length of hospital stay, infections, organ failure, prolonged mechanical ventilation, and even mortality [2, 13]. Although there is a clear understanding that over- and underfeeding are associated with worse outcome, optimization of nutrition support is impeded by a lack of insight into the variable nutritional needs of critically ill patients during ICU stay and convalescence, both on a group and individual level [1, 8, 14]. The available evidence indicates numerous factors that may lead to significant daily variations in EE in and between critically ill patients [1, 15, 16]. Therefore, individualized real-time nutrition therapy is the next step toward optimal patientcare [1, 15, 17,18,19,20,21]. Indirect calorimetry (IC) is considered the gold standard to measure caloric needs in critically ill patients at bedside, and its use has been strongly recommended by the recent European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines [1, 16, 18, 22].

Gain a deeper understanding of commercial-scale building HVAC&R concepts. This course will stress the core principles, and how mechanical systems are selected and installed in today's building projects. Participants with some understanding, but not expertise, in building mechanical systems will benefit the most. 041b061a72


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