Ventilatory strategies for acute respiratory failure

Abstract

W hile our basic understanding of the pathophysiology of acute respiratory failure (ARF) is steadily improving, optimal management of surgical patients with ARF remains controversial.’ For many of the commonly used modalities, there is insufficient data to conclusively state that one is better than the other. Thus, local expert opinion prevails and typically surgeons are excluded from establishing institutional policies which undermines their autonomy in the management of complex ICU patients. Consequently, when reorganizing our Surgical Intensive Care Unit at Denver General Hospital in 1986, we developed practice guidelines (Figure 1) that defined our standard approach as well as the sequence of alternatives (some unconventional). Additionally, we created a clinical specialist position to insure guideline implementation as well as ongoing assessment and revision. This chapter will focus on the intubated surgical patient who requires mechanical ventilation and will specifically address (1) methods to improve oxygenation, (2) methods to assure ventilation, and (3) other nonventilator alternatives that we have found useful in our patient population.