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CoverArticle

CE Continuing Education

Mechanical Ventilation
of Patients With Acute
Respiratory Distress
Syndrome and Patients
Requiring Weaning
The Evidence
Guiding Practice
Suzanne M. Burns, RN, MSN, RRT, ACNP, CCRN

M echanical ventilation is
one of the most commonly used tech-
nologies in critical care. Despite the
this article, I discuss the science
related to mechanical ventilation in
patients with acute respiratory dis-
* This article has been designated for CE credit.
A closed-book, multiple-choice examination fol-
lows this article, which tests your knowledge of
prevalence of ventilators, care plan- tress syndrome (ARDS) and in the following objectives:
ning is heavily influenced by anecdote patients who require weaning. 1. Identify lung-protective strategies in acute
respiratory distress syndrome (ARDS)
and clinical preference. A vast array 2. Describe the benefits of low-tidal-volume
ventilation in ARDS
of ventilator modes and mode options The Acute Stage of Ventilation: 3. Discuss evidence-based guidelines of
exist, and claims of what works and Supplying Ventilation to the mechanical ventilation in ARDS
what does not abound. Critical care Lungs in Patients With ARDS Author
nurses knowledge and understand- The acute stage of ventilation is
Suzanne M. Burns is a professor of
ing of mechanical ventilation are cen- described as that stage at which the nursing and an advanced practice nurse
tral to ensuring patients safe passage patients require a high level of venti- in the medical intensive care unit at the
from the acute stage of ventilation to latory support and their hemody- University of Virginia in Charlottesville.
weaning. Of key importance is the namic status is often unstable.1-5 A To purchase reprints, contact The InnoVision Group,
use of evidence that may improve variety of volume and pressure modes 101 Columbia, Aliso Viejo, CA 92656. Phone, (800)
809-2273 or (949) 362-2050 (ext 532); fax, (949)
patients outcomes. To that end, in of ventilation are used in an effort to 362-2049; e-mail, reprints@aacn.org.

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improve oxygenation, ventilation, to maintain peak airway pressures less monly selected tidal volumes were
and acid-base status. The results of than 30 cm H2O. Hospital mortality not in the range of 6 mL/kg but were
recent research in patients with ARDS for the patients was significantly rather in a higher range, findings
are dramatically affecting how we lower than the mean mortality pre- that somewhat dispelled the validity
use mechanical ventilation in such dicted on the basis of on Acute of the concerns.
patients and how clinical end points Physiology and Chronic Health Eval- Regardless, questions persist
of mechanical ventilation are selected. uation II scores. After this study, the about the effect of tidal volumes from
The concept of lung-protective ARDS Network16 reported on the 7 to 11 mL/kg and about the use of
strategies, which include low-tidal- results of a randomized controlled pressure modes to control plateau
volume ventilation, positive end- trial designed to compare clinical pressures in patients with ARDS.19,20
expiratory pressure (PEEP), and outcomes of patients with ARDS Because pressure modes of ventila-
prone positioning of patients, has who were assigned to low-volume tion have characteristics that make
emerged along with a renewed inter- (6 mL/kg) versus traditional-volume them attractive for use in patients
est in the potential efficacy of high- (12 mL/kg) ventilation. The study with noncompliant lungs, many
frequency oscillation. A discussion was stopped after a preliminary wonder if pressure-targeted ventila-
focused on the evidence related to analysis of 861 patients indicated tion might be a comparable substi-
the use of such therapies follows. that mortality in the low-tidal-volume tute for volume-targeted ventilation
group was significantly lower than in patients with ARDS. Some of the
Are Volume or Pressure Modes that in the control group (31.0% vs characteristics of pressure-targeted
Better for Patients With ARDS? 39.8%, P = .007). Of interest, the ventilation are discussed next.
Investigators6-11 have shown that plateau pressures when the tidal vol- The decelerating flow pattern
animals with induced ARDS, treated ume of 6 mL/kg was used were in associated with pressure modes is
with mechanical ventilation with the range of 26 to 30 cm H2O.16 This thought to provide better gas distribu-
traditional (ie, large) ventilator pressure was far lower than the tion than volume ventilation does.21-23
volumes experience more lung injury plateau pressure (<35 cm H2O) that In addition, plateau pressure can be
than do similar animals treated with had been suggested as potentially reliably limited by using pressure
mechanical ventilation with lower lung protective in the animal studies. modes. Although some might assume
ventilator volumes.6,7 In these animals, But, the ARDS Networks study16 that using pressure ventilation in
plateau pressures of 35 cm H2O or has been criticized. For example, some patients with stiff lungs (in order to
greater for 72 hours resulted in alve- have noted that volumes between 6 ensure a low plateau pressure) might
olar fractures and increased alveolar and 12 mL/kg (ie, 7, 8, 9, 10, and result in outcomes similar to those
flooding.8-11 The term volutrauma was 11 mL/kg) were not tested, yet those found in the ARDS Networks trial,
coined to describe injuries due to the volumes may be more reflective of much remains to be determined. For
large traditional volumes, although common practice patterns. Others example, volumes delivered with
questions remained about whether contended that the control group pressure ventilation are affected by
the tidal volumes or the resultant dis- assignment of 12 mL/kg was exces- compliance (lung and chest wall)
tending (plateau) pressures were actu- sively high and that the principle of and resistance. Using a plateau pres-
ally responsible for the lung injury. scientific equipoise (ie, that genuine sure to ensure lung protection may
Because the potential for volutrauma uncertainty exists about what treat- not ensure volumes comparable to
in humans was recognized, recom- ment is best) may have been vio- the tidal volume of 6 mL/kg used in
mendations for the use of smaller lated. Rubenfeld et al17 and Weinert the ARDS Networks study.
tidal volumes began to emerge12,13 et al18 subsequently examined prac- The superiority of selected new
and studies in humans followed.14-16 tice patterns in the selection of tidal pressure modes, such as pressure-
In a study by Hickling et al,14 a volume at academic institutions release ventilation, for use in ARDS
total of 53 patients with ARDS were where clinicians were aware of the also has not been established. Ran-
treated with mechanical ventilation at results of the ARDS Networks study. domized controlled trials comparing
low volumes (7 mL/kg) in an attempt Their results17,18 indicated that com- the modes with low-volume targeted

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ventilation will be necessary before technically difficult, and this method are necessary to reopen the lungs.
the new pressure modes can be widely is unlikely to be widely used in clini- Knowledge of how the lungs in
endorsed. cal practice. Although the results of patients with ARDS inflate during
To date, the study by the ARDS Amato et al24 suggest that PEEP levels mechanical ventilation is essential to
Network,16 in which tidal volumes of of 14 to 16 cm H2O are required to our understanding of recruitment.
6 mL/kg were used, is the only study open the lung in patients with ARDS, Computed tomography scans of
that has demonstrated a change in definitive methods for determining patients with ARDS have improved
mortality. Until the effects of other the appropriate level of required PEEP our understanding of the alveolar
modes of mechanical ventilation on are unknown. filling patterns associated with
the outcomes of patients with ARDS In the ARDS Network study,16 an ARDS.26,27 Once thought to be
are clarified, the use of low-volume algorithmic approach was used to homogeneous, the pattern of alveo-
targeted ventilation rather than assign levels of PEEP. Unfortunately, lar filling in ARDS is actually hetero-
pressure-targeted ventilation is the auto-PEEP (occult PEEP due to inad- geneous. Some areas of the lung are
suggested ventilatory strategy for equate expiratory time) also occurred open and others are closed. In the
protecting the lungs of these patients. in many of the patients (eg, those with areas of aerated lung, the entire
brunt of a tidal volume breath is
Until the effects of other modes of experienced by the compliant (and
open) lung tissue. Unfortunately,
mechanical ventilation on the outcomes this small area of the lung (also
of patients with ARDS are clarified, the called baby lung) is at increased
risk of injury from overdistention
use of low-volume targeted ventilation and the shear forces of repetitive
rather than pressure-targeted ventilation opening and closing with tidal
breathing. The stress on the lungs
is the suggested ventilatory strategy for from the tidal breath may be an
protecting the lungs of these patients. important mechanism associated
with volutrauma.
What About PEEP Levels? high respiratory rates and high The closed lung parenchyma of
In a randomized controlled trial minute volumes), making accurate patients with ARDS cannot be
of patients with ARDS, Amato et al24 assessment of the total level of PEEP recruited without applying a critical
studied outcomes associated with difficult. Some have suggested that opening pressure (ie, a pressure high
different levels of PEEP. The optimal the auto-PEEP may have recruited enough to open closed alveoli). Fur-
level was determined by measuring the lung, perhaps contributing to ther, once opened, the lung tissue is
lung compliance at increasing levels the beneficial outcomes described at risk of closing again (derecruitment)
of PEEP. A level just above the lower by the investigators.25 if optimal levels of PEEP or other
inflection point (that level that How best to apply PEEP to recruit strategies are not applied. Thus the
resulted in an increase in compliance the lung and prevent derecruitment concepts of lung recruitment and
with a given level of PEEP) was is not yet clear. Regardless, an under- derecruitment are integrally related.
selected as the lung recruitment PEEP standing of these concepts is helpful The use of PEEP levels from 14 to
for the intervention group. Findings for focusing clinical interventions. 16 cm H2O, as described by Amato
of the study suggested that levels of et al,24 is suggested as one way to open
PEEP of about 14 to 16 cm H2O (ie, Recruiting the Lungs the lungs. Another method is to pro-
higher than levels generally selected) and Keeping Them Open vide periodic episodes of super-high
were necessary to prevent derecruit- (Preventing Derecruitment) levels of PEEP. Referred to as 40/40
ment (lung closure). In patients with ARDS, noncom- or 60/60 maneuvers (eg, 40 cm H2O
Unfortunately, measurement of pliant lungs tend to collapse, and once of PEEP for 40 seconds), these tech-
the inflection point at the bedside is collapsed, high inflation pressures niques have been used in a number

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of studies, but they are associated elucidated. To date, definitive meth- often require paralytic agents to
with a risk of barotrauma.24,27-29 ods of applying PEEP to ensure lung ensure compliance with high-fre-
protection and to prevent derecruit- quency oscillation.
Once the Lungs Are Opened, ment have not been clearly identified. Prone positioning is useful in
How Are They Kept Open? Regardless, arbitrary selection of a recruiting lung tissue. Studies in
Unfortunately, it is unclear how PEEP level is unlikely to accomplish animal models and patients with
to select a level of PEEP to stabilize the goal. ARDS in the prone position have
ventilation once a recruitment maneu- revealed a number of responsible
ver is completed.30-32 Although moni- Other Ways to Recruit the Lungs: mechanisms.35-45 Blood flow and gas
toring the effects of the selected What About High-Frequency distribution in the lungs are affected
settings on oxygenation and ventila- Oscillation and Prone by gravity. When patients are supine,
tion is a generally accepted way of Positioning of Patients? the alveoli in the dependent parts of
deciding if the settings are preventing Unlike traditional ventilatory the lungs (ie, the back) fill with fluid
derecruitment over time, oxygenation modes, high-frequency oscillation and collapse. When patients are
may not be the best indicator. Oxy- does not require bulk movement of turned to the prone position, the
genation, traditionally used to assess volume in and out of the lungs; rather, effect of gravity is reversed and lung
the adequacy of PEEP, is unreliable a bias flow of gases is provided and tissue is recruited.35 In addition,
because the increase in oxygenation an oscillator disperses the gases pleural pressures are more uniform
may be the result of either recruit- throughout the lung at very high in the dorsal than in the ventral
ment or redistribution of blood flow frequencies in what has been called position, so lung recruitment is
to aerated areas of the lung (thus augmented dispersion. The lungs enhanced.36-41 The third mechanism
decreasing the shunt and improving are recruited and a mean airway is a mechanical one. With prone
oxygenation). Identification of a pressure sufficient to cause a chest positioning, the heart rests against
PEEP level that recruits lung and vibration (or wiggle) is maintained.34 the sternum (rather than against the
prevents repetitive opening injury Although some think that this mode lungs) and the abdomen moves
associated with tidal breathing is of ventilation may recruit the lungs away from the lungs.38,42-44 As much
thus an elusive clinical goal. and prevent tidal stress (damage due as a third of the posterior part of the
Investigators have used com- to tidal volume and repetitive open- lungs may be recruited when
puted tomography to compare lung ing of the stiff alveoli), to date only a patients are prone.42 Last, the ante-
recruitment when different ventilatory single randomized controlled trial rior part of the chest, normally the
maneuvers are used.27,33 Although has been completed. The Multicen- most mobile part of the chest, is
this method is accurate, it is imprac- ter Oscillatory Ventilation for Acute slightly restricted when patients are
tical for use in most clinical settings Respiratory Distress Syndrome prone. Consequently, when the
and widespread use of it is unlikely. Trial34 was designed to test the safety lungs are ventilated in a patient who
Theoretically, another way to assess and efficacy of a specific ventilator is prone, the air is redistributed
recruitment is to increase the level for high-frequency oscillation. The more evenly throughout the chest,
of PEEP and monitor the difference results indicated a positive but non- including the dependent regions.45
between the plateau pressure and significant trend in 30-day mortality The effect of prone positioning
the PEEP level. If the addition of in patients receiving mechanical of patients on outcomes in ARDS is
PEEP results in recruitment of lung, ventilation with high-frequency as yet unclear. Although our under-
the plateau pressure should not oscillation. Unfortunately, the tidal standing of how prone positioning
change; however, if PEEP is adding volumes in the control group were improves lung recruitment is fairly
to alveolar overdistention, the plateau not maintained in the protective good, to date the only randomized
pressure will increase. range, a situation that makes it diffi- controlled trial of prone positioning
Although we have learned much cult to interpret the results. An addi- in patients with ARDS did not show
about the effectiveness of PEEP in tional concern is that patients a change in mortality.46 Patients in
treating ARDS, much remains to be generally require heavy sedation and the study were maintained in a

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prone position for at least 6 hours a pH (approximately 7.25).7,14,15,49-53 of entry criteria that established the
day for 10 days. The study was done Bicarbonate infusions may be used if subjects readiness to be weaned. If
before the results of the ARDS study necessary in patients whose pH is patients met the readiness criteria,
on ventilation with low lung vol- lower and thought to be potentially they were assigned to a 2-hour spon-
umes were published,27 however, so harmful.14-16,49 Although it is generally taneous breathing trial during which
volumes were not controlled. Of tolerated well in most patients, per- they were monitored for signs of
interest, in the sickest cohort of missive hypercarbia is not appropri- intolerance to the trial. If signs of
patients in the study, patients with a ate for all patients. Examples include intolerance emerged, the weaning
ratio of PaO2 to fraction of inspired patients with elevated intracranial trial was classified as a failure and
oxygen of less than 88 (a ratio <200 pressures and patients with some the patient was randomly assigned
is defined as ARDS), those assigned cardiac conditions.51-53 to a weaning protocol. In the study
to the prone position had a better by Esteban et al,55 patients who suc-
10-day survival rate than did those The Weaning Stage of cessfully sustained the 2-hour trial
who remained supine. Mechanical Ventilation were extubated; the reintubation
Perhaps the most important fact The weaning stage of mechanical rate was 20%.
associated with positioning patients ventilation is described as that time The protocol methods to which
prone is that it is a relatively safe when the patients physiological sta- patients were randomly assigned
intervention compared with other tus is stable and progressive libera- included pressure-support ventila-
techniques (albeit a time- and effort- tion from mechanical ventilation is tion, intermittent mandatory venti-
intensive one) that recruits lung and possible.1-5 Various mechanical venti- lation, and spontaneous breathing
assists with drainage of secretions.47,48 latory modes and methods are used trials. Although Brochard et al54
Although studies are needed to defin- to ensure an expeditious process. found that pressure-support ventila-
itively determine the importance of Recent research on weaning has elu- tion resulted in faster weaning and
prone positioning in the management cidated the importance of approaches Esteban et al55 found that spontaneous
of ARDS, the use of this position in which protocols and comprehen- breathing trials once per day were
may be less risky than use of some sive multidisciplinary processes of superior, both groups of investigators
of the other recruitment maneuvers care delivery are used. used similar protocols for assessing
described.

What Ventilation, Oxygenation,


Recent research on weaning has
and Acid-Base Thresholds elucidated the importance of approaches
Should Be Used With Protective
Ventilatory Strategies?
in which protocols and comprehensive
Use of low-volume ventilation multidisciplinary processes of care
may result in significant hypercar-
bia.7,14,15,49-53 In the past, ventilator set-
delivery are used.
tings were adjusted to attain eucarbia
and a normal pH. Because the goal Mechanical Ventilation in the weaning readiness, advancing wean-
is to protect the lung, such an end Weaning Stage: What Works? ing trials, and defining success (tol-
point may not be possible. Instead, To date, no mode of weaning has erance) or failure (intolerance). The
the goal should be to ensure that been shown to be superior to the results of those 2 studies54,55 stimu-
volutrauma does not occur. Because others, yet how the various methods lated interest in testing the efficacy
low-volume ventilation results in of weaning are used does seem to and safety of weaning protocols.
decreased alveolar ventilation, hyper- make a difference in clinical outcomes. In studies by Ely et al56 and
carbia is expected. Called permissive In randomized controlled trials by Kollef et al,57 patients were randomly
hypercarbia, the goal for acid-base Brochard et al54 and Esteban et al,55 assigned either to a weaning protocol
status is to maintain a reasonable patients were selected on the basis managed by a nurse and respiratory

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therapist or to a traditional weaning of compliance with the protocol was weaning assessment tool (Burns Wean
plan designed by a physician. Com- that the protocol was not managed Assessment Program). Results of the
pared with weaning according to the by any specific person (as it had been intervention were compared with out-
physicians plan, weaning via the pro- during the original study).60 comes prospectively collected before
tocol resulted in significantly shorter Other methods of improving implementation of the approach.
durations of mechanical ventilation weaning outcomes for patients treated The findings included significant
in both studies and a significantly with mechanical ventilation include reductions in duration of mechanical
shorter stay in the intensive care unit systematic comprehensive initiatives ventilation, lengths of stay in the ICU
(ICU) in the study by Kollef et al.57 in which multiple evidence-based and hospital, and mortality in the
The usefulness of protocols in interventions are applied together in managed group. The beneficial out-
decreasing variation in processes of a single approach.61-68 The interven- comes were attributed to the man-
care is not restricted to weaning trials. tions include clinical pathways, meth- agement and monitoring of the
The use of sedatives in patients receiv- ods for evaluating progress, specific process by the advanced practice
ing mechanical ventilation has been elements of care (eg, deep vein pro- nurses and the systematic multidis-
associated with prolonged duration phylaxis, nutrition, mobility) and ciplinary evidence-based approach
of mechanical ventilation and pro- protocols for weaning trials. Two to care of the patients.
longed stays in the ICU and hospital.57 prospective system initiatives indicate
In randomized controlled trials, the the effectiveness of the more compre- Conclusions and Summary
algorithmic management of sedation58 hensive approaches. To achieve the best outcomes, we
and use of a protocol to wean patients Smyrnios et al67 designed a large- must have an in-depth understand-
off infusions of sedatives59 resulted scale multidisciplinary approach to ing of the evidence related to appro-
in significantly shorter duration of care of patients receiving mechanical priate use of mechanical ventilation
mechanical ventilation and shorter ventilation in a medical ICU, a surgi- in patients with ARDS and in
stays in the ICU and in the hospital. cal ICU, and a coronary care unit. The patients who require weaning. We
The use of protocols is linked to initiative consisted of using a weaning have learned much from studies con-
improved outcomes. However, the algorithm and a nurse clinician to ducted in such patients, yet many
results of a study by Ely et al60 suggest ensure compliance with the processes questions about how best to apply
that protocols must be applied care- of care. Duration of mechanical ven- the therapy remain unanswered.
fully. Ely et al sought to implement a tilation, length of stay in the ICU, Low-volume lung ventilation is asso-
protocol for weaning in surgical units and length of stay in the hospital all ciated with decreased mortality as
that involved spontaneous breathing improved significantly when the care applied in the ARDS Networks
trials. The protocol had been previ- initiative was used. Financial gains study.16 Until additional studies of
ously tested in a study of patients in also occurred; however, mortality other modes (pressure modes and
a medical ICU and coronary care was not affected. high-frequency oscillation) indicate
unit.56 Components of the protocol In another study,68 all adult comparable outcomes, use of low-
included a weaning readiness screen- patients in 5 critical care units (med- volume ventilation in patients with
ing, a spontaneous breathing trial, ical ICU, coronary care unit, thoracic- ARDS should be encouraged. Unfor-
and end points for stopping the trial. cardiovascular ICU, surgical-trauma tunately, questions still abound
Educational sessions were used to ICU, and neurological ICU) who related to how we might best recruit
update clinicians about the study, required mechanical ventilation for the lungs and keep them open (eg,
and respiratory care practitioners more than 3 consecutive days were optimal levels of PEEP, prone posi-
implemented the protocol. The spon- managed and monitored by 4 tioning).
taneous breathing trials were imple- advanced practice nurses for 1 year. In the area of weaning, evidence
mented only 10% of the time initially, The process consisted of an evidence- indicates that it is not the mode used
but implementation increased to 30% based clinical pathway, protocols but rather the method, specifically
with additional educational sessions. for weaning trials and sedation the use of protocols, that results in
One of the major reasons for the lack management, and a standardized improved clinical outcomes. Further,

CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 21


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1993 at Northbrook, Illinois, USA: part 1. injury and acute respiratory distress syn- tion is reduced in patients with cardiomegaly
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CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 23


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CE Test Test ID C054: Mechanical Ventilation in Patients With Acute Respiratory Distress Syndrome and Patients Requiring Weaning:
The Evidence Guiding our Practice
Learning objectives: 1. Identify lung-protective strategies in acute respiratory distress syndrome (ARDS) 2. Describe the benefits of low-tidal-volume
ventilation in ARDS 3. Discuss evidence-based guidelines of mechanical ventilation in ARDS
1. Which of the following is not a lung-protective strategy in the 7. Low-tidal-volume ventilation may result in which of the following?
management of acute respiratory distress syndrome (ARDS)? a. Hypocarbia
a. Low-tidal-volume ventilation b. Eucarbia
b. Positive end-expiratory pressure (PEEP) c. Hyperventilation
c. Lateral positioning of patients d. Hypercarbia
d. High-frequency oscillation
8. The goal for acid-base status in ARDS is to
2. Which of the following tidal volumes contributed maintain a pH at which of the following levels?
to a lower mortality rate in the ARDS Networks study? a. 7.15
a. 4 mL/kg b. 7.25
b. 6 mL/kg c. 7.35
c. 8 mL/kg d. 7.45
d. 10 mL/kg
9. Permissive hypercarbia should be avoided in which of the following?
3. Which of the following PEEP levels may be a. Increased intracranial pressure
benef icial in preventing alveolar closure in ARDS? b. Decreased intracranial pressure
a. 10 to 12 cm H2O c. Acute lung injury
b. 12 to 14 cm H2O d. ARDS
c. 14 to 16 cm H2O
d. 16 to 18 cm H2O 10. Which of the following is not a component of a weaning protocol?
a. Assessing weaning readiness
4. Which of the following mechanisms of prone b. Advancing spontaneous weaning trial
positioning is benef icial in recruiting lung in ARDS? c. Tolerance criteria
a. Low pleural pressure d. Failure criteria
b. Elevation of the diaphragm
c. Low tidal volume
11. The use of a weaning protocol has been
d. Reversed gravity
associated with which of the following?
a. Decreased morbidity
5. Which of the following PaO2 to fraction of
b. Decreased use of paralytics
inspired oxygen ratios is indicative of ARDS?
c. Decreased use of sedation
a. Less than 200
d. Decreased ventilator days
b. Less than 250
c. Less than 300
d. Less than 350

6. Which of the following is a goal of low-tidal-volume ventilation?


a. Increased oxygenation
b. Eucarbia
c. Decreased volutrauma
d. Normal pH

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. a 2. a 3. a 4. a 5. a 6. a 7. a 8. a 9. a 10. a 11. a
b b b b b b b b b b b
c c c c c c c c c c c
d d d d d d d d d d d
Test ID: C054 Form expires: August 1, 2007. Contact hours: 2.0 Fee: $12 Passing score: 8 correct (73%) Category: A Test writer: John P. Harper, RN, MSN, BC
Program evaluation Name Member #
Yes No
Objective 1 was met Address
Objective 2 was met City State ZIP
Objective 3 was met
Content was relevant to my Country Phone
Mail this entire page to: nursing practice
My expectations were met E-mail
AACN This method of CE is effective RN Lic. 1/St RN Lic. 2/St
101 Columbia for this content
The level of difficulty of this test was: Payment by: Visa M/C AMEX Discover Check
Aliso Viejo, CA 92656 easy medium difficult
To complete this program, Card # Expiration Date
(800) 899-2226 it took me hours/minutes. Signature

24 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

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Mechanical Ventilation of Patients With Acute Respiratory Distress Syndrome and
Patients Requiring Weaning: The Evidence Guiding Practice
Suzanne M. Burns
Crit Care Nurse 2005;25 14-23
Copyright 2005 by the American Association of Critical-Care Nurses
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