What is positive-pressure ventilation and how did its use develop for mechanical ventilation?

Answer

Concepts that the military developed during World War II to deliver oxygen and gas volume to fighter pilots operating at high altitude were incorporated into the design of the modern positive-pressure ventilator. With the development of safe endotracheal tubes with high-volume, low-pressure cuffs, positive-pressure ventilation replaced the iron lung.

Intensive use of positive-pressure mechanical ventilation gained momentum during the polio epidemic in Scandinavia and the United States in the early 1950s. In Copenhagen, the patient with polio and respiratory paralysis who was supported by manually forcing 50% oxygen through a tracheostomy had a reduced mortality rate. However, this heroic intervention required the continuous activity of 1400 medical students recruited from the universities. The overwhelming manpower needed, coupled with a decrease in mortality rate from 80% to 25%, led to the adaptation of the positive-pressure machines used in the operating room for use in the ICU.

Positive-pressure ventilation means that airway pressure is applied at the patient's airway through an endotracheal or tracheostomy tube. The positive nature of the pressure causes the gas to flow into the lungs until the ventilator breath is terminated. As the airway pressure drops to zero, elastic recoil of the chest accomplishes passive exhalation by pushing the tidal volume out.

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Media Gallery

An example of the Drinker and Shaw negative-pressure ventilator (iron lung).
The pressure, volume, and flow to time waveforms for assist-control ventilation.
The pressure, volume, and flow to time waveforms for controlled ventilation.
The components of mechanical ventilation inflation pressures. Paw is airway pressure, PIP is peak airway pressure, Pplat is plateau pressure.
The effects of decreased respiratory system compliance (A) and increased airway resistance (B) on the pressure-time waveform.
Determination of the lower inflection point to estimate the best (optimal) positive end-expiratory pressure (PEEP) from the pressure-volume hysteresis curve.
The effect of positive end-expiratory pressure (PEEP) on the pressure-time inflation curve.
The pressure, volume, and flow to time waveforms for synchronized intermittent mandatory ventilation (SIMV).
The pressure, volume, and flow to time waveforms for synchronized intermittent mandatory ventilation (SIMV) with pressure-support ventilation.
The flow to time waveform demonstrating auto–positive end-expiratory pressure (auto-PEEP).
The pressure, volume, and flow to time waveforms for pressure-regulated volume-controlled ventilation.
The pressure, volume, and flow to time waveforms for proportional-assist ventilation.
The pressure, volume, and flow to time waveforms for airway pressure–release ventilation.

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Author

Christopher D Jackson, MD Faculty, Department of Internal Medicine, University of Tennessee Health Science Center College of Medicine-Memphis; Staff Physician, Christ Community Health Services; Staff Physician, Baptist Memorial Hospital

Christopher D Jackson, MD is a member of the following medical societies: American College of Physicians, Memphis Medical Society, National Medical Association, Southern Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Muthiah P Muthiah, MD, FCCP, D-ABSM Associate Professor of Medicine, Division of Pulmonary and Critical Care and Sleep Medicine, Vice Chair for Internal Medicine (VA Academic Affairs), University of Tennessee Health Science Center College of Medicine; Director of Medical Intensive Care Unit (MICU), Memphis Veterans Affairs Medical Center

Muthiah P Muthiah, MD, FCCP, D-ABSM is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Thomas M Roy, MD Chief, Division of Pulmonary Disease and Critical Care Medicine, Quillen Mountain Home Veterans Affairs Medical Center; Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Fellowship Program Director, James H Quillen College of Medicine, East Tennessee State University

Thomas M Roy, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Southern Medical Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Gregg T Anders, DO Medical Director, Great Plains Regional Medical Command , Brooke Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio

Disclosure: Nothing to disclose.

Oleh Wasyl Hnatiuk, MD Program Director, National Capital Consortium, Pulmonary and Critical Care, Walter Reed Army Medical Center; Associate Professor, Department of Medicine, Uniformed Services University of Health Sciences

Oleh Wasyl Hnatiuk, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Semaan Georges Kosseifi, MD Fellow in Pulmonary/Critical Care Medicine, East Tennessee State University

Disclosure: Nothing to disclose.

What is positive-pressure ventilation and how did its use develop for mechanical ventilation?

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