The authors would like to thank Anna Ciullo, M.D. for her assistance with curriculum development and execution. There was no outside funding for this report.

All methods described here were found to be exempt from review by the Summa Institutional Review Board.
1. Day 1 &#8211; Pre-Testing Evaluation
<ol>
	<li>Print critical action checklists, pretest confidence surveys, pretest cognitive multiple-choice exams.</li>
	<li>Place three human-patient simulators in ICU beds with the following designations: acute respiratory distress syndrome (ARDS), complete lung atelectasis secondary to mucus plugging, and pneumothorax. Set simulators in separate rooms or far enough apart that learners will not be able to easily hear the other simultaneously executed sessions. Place simulators in a dedicated learning space.</li>
	<li>Intubate the human-patient simulators. Do not place the endotracheal tube in the trachea of the simulator, but rather through a hole in the simulator&#39;s inner cheek that leads to the back of the simulator&#39;s neck.
	<ol>
		<li>Connect the corrugated airway tubing from the lung simulator to the endotracheal tube that is now hidden behind the simulator&#39;s neck. Once connected, the lung simulator is now functional. Use a pillow to conceal this connection.</li>
	</ol>
	</li>
	<li>Turn on the lung simulator. Choose selected pathologic state from the menu in the patient library folder. Initiate the selected pathology on the lung simulator.
	<ol>
		<li>Connect the mechanical ventilator to the endotracheal tube coming out of the simulator&#39;s mouth. If the ventilator is connected to the endotracheal tube prior to initiating the lung pathology software program, the ventilator will not function properly.</li>
		<li>Connect human-patient simulators to breathing simulators. Connect the intubated human-patient simulators to mechanical ventilators.</li>
	</ol>
	</li>
	<li>Place a simulated patient monitor by each human-patient simulator. Select the vital sign software within the lung simulator program. Choose appropriate initial vital signs for onset of simulated patient presentation. Enable the vital signs monitor.</li>
	<li>Upload pre-selected patient&#39;s vital signs, portable chest X-ray images, electrocardiograms, and arterial blood gas measurements for each patient case to each respective patient monitor (e.g., autoPEEP images are uploaded to the human-patient simulator designated as the autoPEEP patient).</li>
	<li>Set out critical actions checklists at each station for each learner wherever faculty members will be observing the case. This may be behind a one-way glass or on a bedside table, but at enough distance away that the learners will not be able to read the checklists. Assign one faculty member to each station.</li>
	<li>Have each learner pick a four-digit identifying code to use for confidence surveys, cognitive exams, and critical action checklists. The codes may be used to review collected data in an anonymous fashion. Learners may choose any four-digit code that they will consistently remember throughout the curriculum.</li>
	<li>In a separate room, administer 5-minute pretest confidence survey to learners. Upon its completion, administer 25-minute pretest cognitive multiple-choice exams to learners.</li>
	<li>Have learners report to a station, with one learner present at each station. Remaining students may wait in a separate room. Have learners provide their four-digit identifying code to faculty for their critical action checklist.</li>
	<li>Have faculty read the case stem to learner. Allow learners a maximum of ten minutes per station to work through a scenario. Do not administer feedback during case. At the conclusion of the scenario, dismiss learners to return back to their separate room.</li>
	<li>Have faculty fill out critical action checklists for each learner upon completion of each case. Rotate learners through all stations individually until all learners have completed all stations. Distribute supplemental readings to learners via paper or email.</li>
</ol>
2. Day 2 &#8211; Curriculum and Educational Intervention
<ol>
	<li>Set up five stations with human-patient simulators, breathing simulators, ventilators, and monitors as described above.</li>
	<li>Assign each station one of the following topics: ARDS, atelectasis secondary to mucus plugging, pneumothorax, altered mental status secondary to drug overdose, and dynamic hyperinflation. Arrange learners in groups of two or three people. Assign one faculty member to each station.</li>
	<li>Allow each team 10 min to work through a case scenario. Give faculty 35 min to provide feedback and bedside instruction. Rotate learners through the remaining four stations.</li>
</ol>
3. Day 3 &#8211; Post-testing Evaluation
<ol>
	<li>Print critical action checklists, posttest confidence surveys, post-test cognitive multiple-choice exams. Set up three stations with human-patient simulators, breathing simulators, ventilators, and monitors as described above. Assign each station one of the following topics: ARDS, atelectasis secondary to mucus plugging, pneumothorax.</li>
	<li>Upload vital signs, portable chest X-ray images, electrocardiograms, and arterial blood gas measurements for each patient case to each respective patient monitor (e.g., autoPEEP images are uploaded to the human-patient simulator designated as the autoPEEP patient).</li>
	<li>Set out critical actions checklists at each station for each learner. Assign one faculty member to each station. Administer 5-minute post-test confidence survey and 25-minute posttest cognitive multiple-choice exam.</li>
	<li>Have learners report to a station, with one learner present at each station. Remaining students may wait in a separate room. Have learners provide their four-digit identifying code to faculty for their critical action checklist.</li>
	<li>Have faculty read the case stem to learner. Allow learners a maximum of ten minutes per station to work through a scenario. Do not administer feedback during case. At the conclusion of the scenario, dismiss learners to return back to their separate room.</li>
	<li>Have faculty fill out critical action checklists for each learner upon completion of each case. Rotate learners through all stations individually until all learners have completed all stations. Administer 10-minute post-curriculum survey to all learners.</li>
</ol>

<ol>
	<li>Slutsky, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=History+of+mechanical+ventilation.+From+vesalius+to+ventilator-induced+lung+injury.">History of mechanical ventilation. From vesalius to ventilator-induced lung injury.</a> Am J Respir Crit Care Med. 191 (10), 1106-1115 (2015).</li><li>Ahmed, N., Devitt, K. S., Keshet, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Systematic+Review+of+the+Effects+of+Resident+Duty+Hour+Restrictions+in+Surgery.">A Systematic Review of the Effects of Resident Duty Hour Restrictions in Surgery.</a> Ann Surg. 259 (6), 1041-1053 (2014).</li><li>Ziv, A., Wolpe, P. R., Small, S. D., Glick, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-Based+Medical+Education:+An+Ethical+Imperative.">Simulation-Based Medical Education: An Ethical Imperative.</a> Acad Med. 78 (8), 783-788 (2003).</li><li>Duwat, A., Hubert, V., Deransy, R., Dupont, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Difficult+airway+management:+assessment+of+knowledge+and+experience+in+anaesthesiology+residents.">Difficult airway management: assessment of knowledge and experience in anaesthesiology residents.</a> Ann Fr Anesth Reanim. 32 (40), 231-234 (2013).</li><li>Lee, M. O., Brown, L. L., Bender, J., Machan, J. T., Overly, F. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+medical+simulation-based+educational+intervention+for+emergency+medicine+residents+in+neonatal+resuscitation.">A medical simulation-based educational intervention for emergency medicine residents in neonatal resuscitation.</a> Acad Emerg Med. 19 (5), 577-585 (2012).</li><li>Barsuk, J. H., Cohen, E. R., Caprio, T., McGaghie, W. C., Simuni, T., Wayne, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+education+with+mastery+learning+improves+residents'+lumbar+puncture+skills.">Simulation-based education with mastery learning improves residents' lumbar puncture skills.</a> Neurology. 79 (2), 132-137 (2012).</li><li>Barsuk, J. H., Cohen, E. R., Vozenilek, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+education+with+mastery+learning+improves+paracentesis+skills.">Simulation-based education with mastery learning improves paracentesis skills.</a> J Grad Med Educ. 4 (1), 23-27 (2012).</li><li>Sohmer, B., Hudson, C., Hudson, J., Posner, G. D., Naik, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+echocardiography+simulation+is+an+effective+tool+in+teaching+psychomotor+skills+to+novice+echocardiographers.">Transesophageal echocardiography simulation is an effective tool in teaching psychomotor skills to novice echocardiographers.</a> Can J Anaesth. 61 (3), 235-241 (2014).</li><li>Sigounas, V. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+simulation-based+training+model+on+vascular+anastomotic+skills+for+surgical+residents.">Evaluation of simulation-based training model on vascular anastomotic skills for surgical residents.</a> Simul Healthc. 7 (6), 334-338 (2012).</li><li>Dawe, S. R., Windsor, J. A., Broeders, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+of+surgical+skills+transfer+after+simulation-based+training:+laparoscopic+cholecystectomy+and+endoscopy.">A systematic review of surgical skills transfer after simulation-based training: laparoscopic cholecystectomy and endoscopy.</a> Ann Surg. 259 (2), 236-248 (2014).</li><li>Spadaro, S., Karbing, D. S., Fogagnolo, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation+Training+for+Residents+Focused+on+Mechanical+Ventilation.">Simulation Training for Residents Focused on Mechanical Ventilation.</a> Simul Healthc. , (2017).</li><li>Yee, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mechanical+Ventilation+Boot+Camp:+A+Simulation-Based+Pilot+Study.">Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study.</a> Crit Care Res Pract. 2016, (2016).</li><li>Ryoo, E. N., Ha, E. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Importance+of+Debriefing+in+Simulation-Based+Learning:+Comparison+Between+Debriefing+and+No+Debriefing.">The Importance of Debriefing in Simulation-Based Learning: Comparison Between Debriefing and No Debriefing.</a> Comput Inform Nurs. 33 (12), 538-545 (2015).</li><li>Shinnick, M. A., Woo, M., Horwich, T. B., Steadman, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Debriefing:+The+Most+Important+Component+in+Simulation?.">Debriefing: The Most Important Component in Simulation?.</a> Clin Simul Nurs. 7 (3), e105-e111 (2011).</li></ol>

The authors have nothing to disclose.

The boot camp consists of three separate sessions. During the first day, learners complete a pre-testing confidence survey and medical knowledge test before undergoing a five-minute scenario. Faculty evaluate the learners using pre-determined critical actions. Leaners are then given asynchronous reading to complete before day 2. The second day is composed of the intervention stage, where groups of 2-3 learners work through five different scenarios. Faculty are at the bedside to provide immediate and personalized feedback. The third day is the post-testing evaluation, where learners complete a post-testing confidence survey and medical knowledge test. They then undergo a five-minute scenario, rated against critical actions.
In the authors&#39; opinion, the most critical point of the curriculum is the bedside teaching by critical care content experts. As reviewed in the literature, the debriefing process is the most important step in simulation and is essential for knowledge gains.13,14
The curriculum evolved throughout its execution. Residents were invited to provide feedback at the end of the curriculum. Many residents expressed a desire to review articles that provided foundational knowledge of an overview of mechanical ventilation and pulmonary physiology. Faculty also became more streamlined in their teaching presentations as the curriculum developed.
Limitations are largely related to finances and time. Renting or purchasing simulation equipment may be expensive, particularly if a simulation center does not regularly use this sophisticated simulation equipment. Training simulation staff to become readily proficient on the use of the breathing simulators required a significant amount of time. Intensivists had to schedule time off well in advance to be available for teaching. We suggest that interested educators dedicate ample time to ensure they have sufficient funding and time to execute this curriculum.
There is a paucity of literature describing simulation as a method to teach novice learners the principles of ventilator management. Learners are able to manage low-frequency events on mannequins versus learning on critically-ill patients. This curriculum provides a means for novice medical providers to visualize the consequences of their management decisions in real-time. The breathing simulators used in conjunction with the mechanical ventilators allow for learners to practice on real clinical equipment for hands-on experience that may be intimidating to use in the clinical setting. Additionally, the curriculum allows for bedside personalized teaching by critical care faculty.

This boot camp was developed to teach residents how to manage a mechanically-ventilated patient, as well as troubleshoot ventilator alarms. Management of this patient population may be intimidating to the novice practitioner who may have limited experience with critically ill patients. Teaching critical care principles at the bedside is made more difficult by national work-hour restrictions1,2, and medicolegal concerns3 in the United States. Simulation is an effective modality to develop and refine critical care skills4,5, as well as invasive procedures6,7,8,9,10. Through simulation, learners may experience what the consequences of their medical decision-making is without putting patients at risk. This curriculum allows for a variety of different learning modalities, including bedside teaching from an intensivist, hands-on practice with a ventilator, and supplemental asynchronous reading.
Previous studies have shown increased knowledge with mannequin-based education of mechanical ventilation11,12. Spadaro et al.11 compared computer-based training with mannequin-based training for anesthesiology residents undergoing simulation-based teaching of mechanical ventilation. Residents who underwent mannequin-based training had higher key action and global rating scores. As noted in our previous study12, first-year residents demonstrated improved knowledge, confidence, and competency after the conclusion of this boot camp curriculum.
As written, this three-day curriculum allows for educators to initially assess their learners&#39; baseline knowledge on day one, as well as evaluate changes in competency, knowledge, and confidence upon curriculum completion on day three. Days one and three are dedicated towards assessment, while the second day is focused on bedside teaching by content experts. Pathological conditions (acute respiratory distress syndrome [ARDS], atelectasis secondary to mucus plugging, and pneumothorax) were used for the initial assessment and final testing days, while an altered mental status station was added during the teaching day to review ventilator basics. Dynamic hyperinflation was also added to the teaching day as to reinforce ventilator diagnostics and management, including its consideration in patients with a high plateau pressure. Educators may substitute the pathologies as they feel appropriate for their teaching needs.
In preparation, simulation faculty held an initial rehearsal day to ensure all participating educators were aware of their roles and to ensure equipment was working appropriately. While we used simulation faculty for assessment and critical care physicians for teaching, educators may adjust the roles of faculty as resources dictate. Execution of this boot camp requires preparatory logistics planning. First-year residents should be scheduled protected time to ensure they can complete all three days of the curriculum. Intensivists will need to schedule time off in advance to attend bedside teaching sessions. Simulation equipment such as breathing simulators, mechanical ventilators, and human-patient simulators may have to be purchased, rented, or borrowed.

<table><tbody><tr><td>Puritan Bennett 840 Ventilator</td><td>Medtronic</td><td>4-840120EMC-01</td><td>http://www.medtronic.com/covidien/en-us/products/acute-care-ventilation/puritan-bennett-pb840-ventilator.html</td></tr><tr><td>ASL 5000 Breathing Simulator</td><td>IngMar</td><td>31 00 117</td><td>https://www.ingmarmed.com/</td></tr><tr><td>Smart Stat Basic</td><td>Simulaids</td><td>101-8002</td><td>https://www.simulaids.com/product/101-8002</td></tr></tbody></table>

mechanical ventilation boot camp curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased morbidity and mortality. A three-day simulation-based boot camp serves to provide one-on-one instruction with a critical care provider. These intensivists may dispense personalized immediate feedback as learners engage in hands-on practice with a real mechanical ventilator. Multiple different pathologies can be reviewed that may not be encountered in the clinical setting. Learners can visualize immediate consequences of their actions and may troubleshoot and ask questions, all while in a safe learning environment. We describe the use of human-patient simulators connected to breathing simulators and mechanical ventilators. Potential curriculum executors should be aware of the cost of the equipment and the time needed to dedicate to boot camp execution; however, this intensive interactive training has been shown to increase provider competency, knowledge, and confidence in ventilator management. This curriculum outline provides guidance on how to execute a simulation-based boot camp to train providers on the management of mechanically ventilated patients.

As noted in Yee et al, first-year residents who underwent this boot camp demonstrated significantly improved confidence, knowledge, and performance12. Cognitive knowledge, assessed by the pre- and post-intervention multiple choice tests, increased from a mean score of 40.3% to 67.1%, with a mean change in score of +26.8% (Figure 1).
Critical actions were evaluated by faculty on days 1 and 3. The ARDS case had an initial mean of 1.5 critical actions met on day 1 (out of a total of 5), which increased to 4.1 on day 3. The atelectasis secondary to mucus plugging case had an initial mean of 1.24 on day 1 (out of a total of 5) and a postintervention score of 4.47 on day 3 (Figure 2).
Learners felt more confident after the boot camp intervention. Their initial confidence on day 1 was rated as a mean score of 1.56 out of 5, which increased to a mean score of 3.64 on day 3 (Figure 3).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57303/57303fig1.jpg" /> 
Figure 1: Knowledge Assessment Pre- and Post-Intervention 
This figure has been reformatted with permission from Yee J. et al. Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study. Crit Care Res Pract. 2016, (2016). doi:10.1155/2016/4670672. <a href="https://cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57303/57303fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57303/57303fig2.jpg" /> 
Figure 2: Critical Actions Performance Assessment Pre-and Post-Intervention 
This figure has been reformatted with permission from Yee J. et al. Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study. Crit Care Res Pract. 2016, (2016). doi:10.1155/2016/4670672. <a href="https://cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57303/57303fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57303/57303fig3.jpg" /> 
Figure 3: Confidence Assessment Pre- and Post-Intervention 
This figure has been reformatted with permission from Yee J. et al. Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study. Crit Care Res Pract. 2016, (2016). doi:10.1155/2016/4670672. <a href="https://cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/57303/57303fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Mechanical Ventilation Boot Camp Curriculum at JoVE.com

Mechanical Ventilation Boot Camp Curriculum

This curriculum outlines how to execute a simulation-based boot camp to teach providers how to manage mechanically ventilated patients.

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased ...

mechanical-ventilation-boot-camp-curriculum

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Fundamentals of Respiratory Care: Techniques and Management

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10.1K Views.  The Ohio State University. This curriculum outlines how to execute a simulation-based boot camp to teach providers how to manage mechanically ventilated patients.

Video: Mechanical Ventilation Boot Camp Curriculum

Evaluation of Respiratory System Mechanics in Mice using the Forced Oscillation Technique

The forced oscillation technique (FOT) is a powerful, integrative and translational tool permitting the experimental assessment of lung function in mice in a comprehensive, detailed, precise and reproducible manner. It provides measurements of respiratory system mechanics through the analysis of pressure and volume signals acquired in reaction to predefined, small amplitude, oscillatory airflow waveforms, which are typically applied at the subject's airway opening. The present protocol details the steps required to adequately execute forced oscillation measurements in mice using a computer-controlled piston ventilator (flexiVent; SCIREQ Inc, Montreal, Qc, Canada). The description is divided into four parts: preparatory steps, mechanical ventilation, lung function measurements, and data analysis. It also includes details of how to assess airway responsiveness to inhaled methacholine in anesthetized mice, a common application of this technique which also extends to other outcomes and various lung pathologies. Measurements obtained in na&iuml;ve mice as well as from an oxidative-stress driven model of airway damage are presented to illustrate how this tool can contribute to a better characterization and understanding of studied physiological changes or disease models as well as to applications in new research areas.

The present protocol provides a detailed step-by-step description of the procedures required to execute measurements of respiratory system mechanics as well as the assessment of airway responsiveness to inhaled methacholine in mice using the forced oscillation technique (flexiVent; SCIREQ Inc, Montreal, Qc, Canada).

The  forced oscillation technique (FOT) is a powerful, integrative and translational  tool permitting the experimental assessment of lung function in mice ...

Biology

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

The blindfolded code training exercise, which blindfolds the team leader in a code resuscitation simulation, is an advanced teaching technique to improve closed-loop communication, organizational skills, and critical thinking.&#160;

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to ...

Use of an Integrated Low-Flow Anesthetic Vaporizer, Ventilator, and Physiological Monitoring System for Rodents

Low-flow digital vaporizers commonly utilize a syringe pump to directly administer volatile anesthetics into a stream of carrier gas. Per animal welfare recommendations, animals are warmed and monitored during procedures requiring anesthesia. Common anesthesia and physiological monitoring equipment include gas tanks, anesthetic vaporizers and stands, warming controllers and pads, mechanical ventilators, and pulse oximeters. A computer is also necessary for data collection and to run equipment software. In smaller spaces or when performing field work, it can be challenging to configure all this equipment in limited space.
The goal of this protocol is to demonstrate best practices for use of a low-flow digital vaporizer using both compressed oxygen and room air, along with an integrated mechanical ventilator, pulse oximeter, and far infrared warming as an all-inclusive anesthesia and physiological monitoring suite ideal for rodents.

Here, we present a protocol to safely and effectively administer anesthetic gas to mice using a digital, low flow anesthesia system with integrated ventilator and physiological monitoring modules.

Low-flow digital vaporizers commonly utilize a syringe pump to directly administer volatile anesthetics into a stream of carrier gas. Per animal welfare ...

Normothermic Negative Pressure Ventilation Ex Situ Lung Perfusion: Evaluation of Lung Function and Metabolism

Lung transplantation (LTx) remains the standard of care for end-stage lung disease. A shortage of suitable donor organs and concerns over donor organ quality exacerbated by excessive geographic transportation distance and stringent donor organ acceptance criteria pose limitations to current LTx efforts. Ex situ lung perfusion (ESLP) is an innovative technology that has shown promise in attenuating these limitations. The physiologic ventilation and perfusion of the lungs outside of the inflammatory milieu of the donor body affords ESLP several advantages over traditional cold static preservation (CSP). There is evidence that negative pressure ventilation (NPV) ESLP is superior to positive pressure ventilation (PPV) ESLP, with PPV inducing more significant ventilator-induced lung injury, pro-inflammatory cytokine production, pulmonary edema, and bullae formation. The NPV advantage is perhaps due to the homogenous distribution of intrathoracic pressure across the entire lung surface. The clinical safety and feasibility of a custom NPV-ESLP device have been demonstrated in a recent clinical trial involving extender criteria donor (ECD) human lungs. Herein, the use of this custom device is described in a juvenile porcine model of normothermic NPV-ESLP over a 12 h duration, paying particular attention to management techniques. Pre-surgical preparation, including ESLP software initialization, priming, and de-airing of the ESLP circuit, and the addition of anti-thrombotic, anti-microbial, and anti-inflammatory agents, is specified. The intraoperative techniques of central line insertion, lung biopsy, exsanguination, blood collection, cardiectomy, and pneumonectomy are described. Furthermore, particular focus is paid to anesthetic considerations, with anesthesia induction, maintenance, and dynamic modifications outlined. The protocol also specifies the custom device's initialization, maintenance, and termination of perfusion and ventilation. Dynamic organ management techniques, including alterations in ventilation and metabolic parameters to optimize organ function, are thoroughly described. Finally, the physiological and metabolic assessment of lung function is characterized and depicted in the representative results.

Normothermic Negative Pressure Ventilation Ex Situ Lung Perfusion: Evaluation of Lung Function and Metabolism

This paper describes a porcine model of negative pressure ventilation ex situ lung perfusion, including procurement, attachment, and management on the custom-made platform. Focus is made on anesthetic and surgical techniques, as well as troubleshooting.

Lung transplantation (LTx) remains the standard of care for end-stage lung disease. A shortage of suitable donor organs and concerns over donor organ ...

Employing the Forced Oscillation Technique for the Assessment of Respiratory Mechanics in Adults

There is increasing interest in the use of the forced oscillation technique (FOT) or oscillometry to characterize respiratory mechanics in healthy and diseased individuals. FOT, a complementary method to traditional pulmonary function testing, utilizes a range of oscillatory frequencies superimposed on tidal breathing to measure the functional relationship between airway pressure and flow. This passive assessment provides an estimate of respiratory system resistance (Rrs) and reactance (Xrs) that reflect airway caliber and energy storage and dissipation, respectively. Despite the recent increase in popularity and updated Technical Standards, clinical adoption has been slow which relates, in part, to the lack of standardization regarding the acquisition and reporting of FOT data. The goal of this article is to address the lack of standardization across laboratories by providing a comprehensive written protocol for FOT and an accompanying video. To illustrate that this protocol can be utilized irrespective of a particular device, three separate FOT devices have been employed in the case examples and video demonstration. This effort is intended to standardize the use and interpretation of FOT, provide practical suggestions, as well as highlight future questions that need to be addressed.

As the use of forced oscillation technique (FOT) is increasingly utilized to characterize respiratory mechanics, there is a need to standardize methods with respect to nascent technical guidelines and various manufacturer's recommendations. A detailed protocol is provided including FOT assessment and interpretation for two cases to facilitate the standardization of methods.

There is increasing interest in the use of the forced oscillation technique (FOT) or oscillometry to characterize respiratory mechanics in healthy and ...

Ex Vivo Porcine Experimental Model for Studying and Teaching Lung Mechanics

Mechanical ventilation is widely used and requires specific knowledge for understanding and management. Health professionals in this field may feel insecure and lack knowledge because of inadequate training and teaching methods. Therefore, the objective of this article is to outline the steps involved in generating an ex vivo porcine lung model to be used in the future, to study and teach lung mechanics. To generate the model, five porcine lungs were carefully removed from the thorax following the guidelines of the Animal Research Ethics Committee with adequate care and were connected to the mechanical ventilator through a tracheal cannula. These lungs were then subjected to the alveolar recruitment maneuver. Respiratory mechanics parameters were recorded, and video cameras were used to obtain videos of the lungs during this process. This process was repeated for five consecutive days. When not used, the lungs were kept refrigerated. The model showed different lung mechanics after the alveolar recruitment maneuver every day; not being influenced by the days, only by the maneuver. Therefore, we conclude that the ex vivo lung model can provide a better understanding of lung mechanics and its effects, and even of the alveolar recruitment maneuver through visual feedback during all stages of the process.

Ex Vivo Porcine Experimental Model for Studying and Teaching Lung Mechanics

We present an ex vivo pig lung model for the demonstration of pulmonary mechanics and alveolar recruitment maneuvers for teaching purposes. The lungs can be used for more than one day (up to five days) with minimal changes in pulmonary mechanics variables.

Mechanical ventilation is widely used and requires specific knowledge for understanding and management. Health professionals in this field may feel ...

Basic Life Support Part II:  Airway/Breathing and Continued Cardiopulmonary Resuscitation

Source: <a href="https://www-jove-com.bdigitaluss.remotexs.co/author/Julianna_Jung">Julianna Jung</a>, MD, FACEP, Associate Professor of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
High-quality cardiopulmonary resuscitation (CPR) and defibrillation are the most important interventions for patients with cardiac arrest, and should be the first steps that rescuers perform. This is reflected in the American Heart Association's new "CAB" mnemonic. While rescuers were once taught the "ABCs" of cardiac arrest, they now learn "CAB" - circulation first, followed by airway and breathing. Only once CPR is underway (and defibrillation has been performed, if a defibrillator is available) do we consider providing respiratory support. This video will describe the correct technique for providing respiratory support to a patient in cardiac arrest, and how to continue basic life support over the period of time until help arrives.
This video assumes that all the steps described in "Basic Life Support Part I: Cardiopulmonary Resuscitation and Defibrillation" have already been completed. This video does NOT depict the initial steps taken when arriving at the scene of a cardiac arrest.

Basic Life Support II: Airway/Breathing &amp; Cardiopulmonary Resuscitation

Source: Julianna Jung, MD, FACEP, Associate Professor of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
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Mechanical Ventilation I: Indication and Settings

Mechanical ventilation is a life-saving technique for managing acute respiratory failure and other respiratory complications. The process involves using a machine known as a ventilator to supply oxygen to the lungs and assist in removing carbon dioxide. It serves as a bridge to long-term mechanical ventilation or a temporary measure until ventilatory support is discontinued. The ventilator can maintain this function for a prolonged period, providing critical support for patients until they can breathe independently.
Indications
Mechanical ventilation may be necessary for a variety of reasons. These include managing acute respiratory failure, controlling the patient&#39;s breathing during surgery or treatment, providing adequate oxygenation when the patient&#39;s own ventilatory efforts are insufficient, and allowing the respiratory muscles to rest. Several factors, including thoracic or abdominal surgery, drug overdose, neuromuscular disorders, inhalation injury, Chronic Obstructive Pulmonary Disease (COPD), multiple trauma, circulatory shock, multisystem failure, and coma, can result in respiratory failure and the need for mechanical ventilation. It allows patients on a ventilator to breathe spontaneously, alleviating the exhausting effort it would otherwise require.
Settings of Mechanical Ventilator
The settings of a mechanical ventilator are adjusted based on the patient&#39;s condition, level of consciousness, respiratory muscle strength, chest x-ray, and arterial blood gases (ABGs). These settings include:
<ol style="list-style-type: circle;">
	<li>Respiratory rate: It refers to the number of breaths the ventilator delivers per minute.</li>
	<li>Tidal volume (VT): It is the volume of gas delivered to the patient during each ventilator breath.</li>
	<li>O2 concentration (FIO2): This fraction of inspired O2 delivered to the patient can be set between 30% and 100%.</li>
	<li>Positive-end-expiratory pressure (PEEP): Positive pressure is applied at the end of the expiration of ventilator breaths.</li>
	<li>Pressure support: This is used to augment a patient&#39;s inspiratory pressure during spontaneous breathing.</li>
	<li>I/E ratio: This is the duration of inspiration (I) to the duration of expiration (E).</li>
	<li>Inspiratory flow rate and time: This is the speed with which the VT is delivered.</li>
	<li>Sensitivity: This determines the patient&#39;s effort to initiate a breath from the ventilator.</li>
	<li>Peak inspiratory pressure (PIP): This is the maximal pressure the ventilator can generate to deliver the VT.</li>
</ol>
Manipulating these settings can help correct hypoxemia and hypercarbia. As the patient&#39;s condition improves, the settings can be adjusted to allow them to take more control over their work of breathing.
Types of Mechanical Ventilation
Mechanical ventilators can be classified into two general categories: Negative pressure ventilators and positive-pressure ventilators.
Negative-pressure ventilators, also known as &#34;iron lungs,&#34; are older modes of ventilatory support that are rarely used today.
Positive-pressure ventilators inflate the lungs by exerting positive pressure on the airway, pushing air in, similar to a bellows mechanism, and forcing the alveoli to expand during inspiration. Expiration occurs passively. These ventilators are widely used in hospital settings and include:
<ol style="list-style-type: circle;">
	<li>Volume-Cycled Ventilators</li>
	<li>Pressure-Cycled Ventilators</li>
	<li>High-Frequency Oscillatory Support Ventilators</li>
	<li>Noninvasive Positive-Pressure Ventilation (NIPPV)</li>
	<li>Continuous positive airway pressure (CPAP)</li>
	<li>Bilevel positive airway pressure (BiPAP)</li>
</ol>
Each ventilator has distinctive features and is employed based on the patient&#39;s needs. The selection of the ventilator type is a critical decision made by healthcare professionals, made by considering the patient&#39;s current health status and the potential benefits and risks associated with each ventilator type.

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Mechanical Ventilation II: Invasive Ventilation

Ventilators are essential medical equipment used to aid patients with respiratory difficulties. Their primary function is to assist or replace spontaneous breathing by providing mechanical ventilation. There are two general classes of mechanical ventilators: negative-pressure and positive-pressure ventilators.
Negative-Pressure Ventilators
Negative-pressure ventilators create a vacuum around the chest or body to draw air into the lungs, simulating breathing. This method does not require an artificial invasive airway; as a result, it is categorized as a form of non-invasive ventilation (NIV).
The &#34;iron lung,&#34; developed in the 1950s during the polio epidemic, was the first form of negative pressure ventilation. It intermittently reduces intrathoracic pressure, causing air to rush into the upper airway, followed by passive expiration when the machine cycles off. Portable negative-pressure ventilators are available for home use, primarily for patients with chronic neuromuscular diseases and central nervous system problems.
Positive-Pressure Ventilators
Positive-pressure ventilators differ from negative-pressure ventilators in their mechanism of lung inflation. Instead of exerting negative pressure to draw air into the lungs, positive-pressure ventilators apply positive pressure to the airway, expanding the alveoli and facilitating inspiration. Expiration occurs passively. These ventilators require ET intubation or tracheostomy and are widely used in hospitals and homes.
Volume-Cycled Ventilators
Volume-cycled ventilators deliver a preset volume of air with each inspiration. The ventilator cycles off after this volume is delivered, allowing passive exhalation. Volume-cycled ventilators ensure consistent breaths but may cause barotrauma due to the potentially excessive pressures needed to deliver breaths.
Pressure-Cycled Ventilators
Pressure-cycled ventilators deliver airflow until a preset pressure is reached, and then they cycle off for passive expiration. The air volume can vary with changes in the patient&#39;s airway resistance or compliance, possibly leading to inconsistent tidal volumes and compromised ventilation.
High-Frequency Oscillatory Support Ventilators
These ventilators deliver high respiratory rates, low tidal volumes, and high airway pressures. They are used to open alveoli in situations characterized by closed small airways, such as atelectasis and ARDS, and are believed to protect the lungs from pressure injury.

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Mechanical Ventilation III: Noninvasive Ventilation

Noninvasive positive-pressure ventilation (NIPPV), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP) are essential methods in respiratory care. These ventilation techniques offer unique benefits for patients with various respiratory conditions, providing adequate support without requiring intubation. Let&#39;s explore how each method is crucial in improving patient outcomes and enhancing respiratory therapy.
Noninvasive Positive-Pressure Ventilation (NIPPV)
NIPPV is a method of positive pressure ventilation that does not require intubation. It involves using facemasks or nasal devices to maintain prescribed pressure, reducing the risk of nosocomial infections. This method is suitable for patients with acute or chronic respiratory failure, acute pulmonary edema, COPD, chronic heart failure, or sleep-related breathing disorders.
Continuous Positive Airway Pressure (CPAP)
CPAP maintains a constant positive pressure in the airways throughout the breathing cycle, helping to keep alveoli open and prevent respiratory failure. This method is especially beneficial in treating obstructive sleep apnea, ensuring the airways remain open during sleep.
Bilevel Positive Airway Pressure (BiPAP)
BiPAP offers independent control of inspiratory and expiratory pressures while providing pressure support ventilation. It delivers two levels of positive airway pressure via a nasal or oral mask, nasal pillow, or mouthpiece with a tight seal and a portable ventilator. BiPAP is often used for patients who require ventilatory assistance at night.
Each type has advantages and disadvantages, and the choice depends on the patient&#39;s clinical condition, comfort, and the healthcare provider&#39;s expertise.

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