A 47-year-old man with COVID-19 pneumonia complicated by severe acute respiratory distress syndrome (ARDS) suddenly desaturates. Point-of-care ultrasound and chest x-ray are consistent with pneumothorax. After placement of a pigtail catheter, hypoxemia persists and a large continuous air leak is present. What are the next steps in management of a suspected bronchopleural fistula? 

Less than 5 percent of patients hospitalized for acute asthma exacerbation will require mechanical ventilatory support. However, ventilator management in status asthmaticus is unique and the impact of increased airway resistance on ventilation strategies must be understood to avoid life-threatening complications like severe acidosis, barotrauma and hypotension. 

Lung protective ventilation limiting tidal volume and plateau pressure improves survival in ARDS. The application of positive end-expiratory pressure (PEEP) further stabilizes the lung by preventing alveolar collapse during expiration, thereby reducing cyclic atelectasis. However, the optimal approach to PEEP titration to minimize ventilator-induced lung injury (VILI) has not been delineated. The EPVent-1 trial demonstrated that esophageal pressure-guided PEEP titration was feasible and safe with a trend toward increased survival and improved oxygenation in mild to moderate ARDS. However, interest in esophageal manometry in ARDS was deflated by the more recent EPVent-2 trial demonstrating no improvement in a composite outcome incorporating mortality and ventilator-free days in patients with moderate to severe ARDS. A new randomized control trial published last week by Wang et al. examined the role of esophageal manometry-guided PEEP titration in a novel subset of severe ARDS patients treated with VV ECMO. 

Like all medical therapies, we have learned that treatment with oxygen comes at a cost. The medical literature is replete with the detriments of hyperoxia in the management of myocardial infarction, acute stroke, cardiac arrest and septic shock. What is the optimal oxygenation target for critically ill patients requiring mechanical ventilation? Three landmark trials can guide us: Oxygen-ICU, ICU-ROX and LOCO₂. The end to the oxygenation fairytale remains to be told, but perhaps Goldilocks is “just right.”  

Over the last three decades since the introduction of the term ventilator-induced lung injury (VILI), we have recognized that positive pressure mechanical ventilation can injure the lungs. It is widely recognized that the cornerstone of lung protective ventilation requires control of tidal volume and transpulmonary pressure. On the other hand, there has been considerably less focus on the impact of respiratory rate and flow on VILI. Mechanical power unites the causes of ventilator-induced lung injury in a single variable that incorporates both the elastic and resistive load of the positive pressure breath.⁶ In other words, mechanical power quantifies the energy delivered to the lung during each positive pressure breath by assessing the relative contribution of pressure, volume, flow and respiratory rate.

Patient-ventilator asynchrony is underrecognized yet associated with increased mortality, ICU length of stay and duration of mechanical ventilation in critical illness. How do you diagnose and treat it? Hint: the answer is rarely deep sedation or paralysis!

An 82-year-old woman is mechanically ventilated for acute respiratory failure following acute intracerebral hemorrhage. Her FiO2 has been 30% with an arterial blood gas showing adequate ventilation and oxygenation for the last 24 hours (7.43/37/89/25). Suddenly, the ventilator alarms for low exhaled tidal volume. On bedside evaluation, her SpO2 is 84%, respiratory rate 20 breaths per minute, HR 124 beats per minute and blood pressure 105/65 mm Hg. Her ventilator graphics before and after the alarm are depicted below. What mode of mechanical ventilation is she receiving and what triggered the alarm? 

A 44-year-old man with a history of cardiac arrest complicated by hypoxic-ischemic encephalopathy presents to the ED in respiratory distress. He underwent tracheostomy 2 weeks ago for acute respiratory failure and was subsequently weaned to trach collar. He developed acute onset of respiratory distress at rehab this morning and now presents to the ED with acute hypoxic respiratory failure. On exam, he is hypertensive (169/88), tachycardic (HR 178), tachypneic with respirations assisted with bag-valve mask (BVM) ventilation and hypoxemic (SpO2 87%). What is your approach to the management of tracheostomy emergencies?

You are called to the bedside of a mechanically ventilated patient for an alarm that is being triggered on the ventilator. In red and blinking you see “Airway pressure high.” What’s your next move?

Analyzing ventilator waveforms in a patient with acute respiratory failure is as essential as monitoring the telemetry of a patient with suspected cardiac dysrhythmia. What life-threatening complication is demonstrated in the ventilator graphics?