The main purposes of breathing are to get oxygen into the blood and to remove carbon dioxide from the blood. Some diseases prevent patients from maintaining safe levels of oxygen and carbon dioxide in the blood. This is known as respiratory (breathing) failure, which can be caused by many different conditions, including pneumonia, asthma, COPD, drug overdose, and neurologic disorders such as Myasthenia Gravis. Mechanical ventilation is a form of life support for patients with respiratory failure. Many patients with respiratory failure recover and resume independent breathing after a period of treatment for the underlying disease. The time required for recovery varies considerably depending on the nature of the disease or condition. However, occasional patients cannot recover to independent breathing. In these instances, we work towards comfort and stability with chronic mechanical ventilation support and then explore opportunities for continued care outside the intensive care environment.

We utilize several different approaches to mechanical ventilation, depending on each patient's needs.

With CMV, a plastic tube is inserted through the mouth into the trachea (windpipe) and connected to a machine that provides breaths of air with an oxygen-enriched mixture of gases. The size of the breath of air delivered with CMV is similar to the size of a normal breath.

This is a form of mechanical ventilation that utilizes very small breaths of air at very rapid breathing rates. It is designed to reduce excessive forces in the lungs that may occur when conventional mechanical ventilation is used in patients with severe pneumonia, acute respiratory distress syndrome, and other diseases in which the lungs are very inflamed. As with conventional ventilation, a tube is inserted through the mouth into the trachea (windpipe) and connected to the high frequency ventilator.

This is a form of mechanical ventilation for patients who require modest levels of support from a ventilator. This approach does not require a tube in the trachea (windpipe). Instead, ventilation assistance is provided through a tight-fitting facemask. This approach allows some patients to speak and eat normally.

This approach resembles conventional ventilation in that it requires a tube in the trachea (windpipe). It is used in occasional patients whose breathing on conventional ventilation is uncomfortable. It may also be useful for patients with very inflamed lungs, as in pneumonia and other causes of the acute respiratory distress syndrome.

Traditional nasal cannula oxygen systems deliver pure oxygen at flow rates are 1 to 6 liters per minute. Because this oxygen is dry and cool, it is uncomfortable to patients when more than 3-4 liters/minute are delivered. Moreover, because patients' inspiratory flow rates are considerably greater than traditional cannula flow rates, patients entrain an unknown amount of room air, resulting in an unknown fraction of inspired oxygen. HFNC flow rates can be as high as 60 liters/minute, and the FiO₂ can be adjusted from 40% to 100%. This allows more precise control over FiO₂. HFNC has additional beneficial effects: 1) it decreases dead space by flushing out exhaled gas in the mouth and pharynx, 2) it provides small amounts of end-expiratory pressure, which can reduce shunt, 3) it reduces work of breathing. We are using HFNC for an increasing number of indications, including patients at high risk of re-intubation, acute hypoxemic respiratory failure, and asthma.

In severe cases of respiratory (breathing) failure, it may not be possible to maintain adequate oxygen and carbon dioxide levels in the blood, even when the lungs are supported by mechanical ventilation. When the disease is severe but potentially reversible, we may use ECCMO or ECGE as a substitute for the lungs while we treat the disease and wait for recovery. During ECMO or ECGE, blood is pumped from a tube in a large vein into a machine (ECMO or ECGE machine) that adds oxygen to the blood and removes carbon dioxide. The blood is then returned to the patient through a tube placed in a vein or artery. This machine can replace most of the function of the lungs. Studies are ongoing to assess the benefit of this approach, which is not routinely available at smaller hospitals.

Occasional patients recover from respiratory failure, but they cannot breathe independently and comfortably because their lung disease has become too advanced. In some of these instances we explore the possibility of lung transplantation with physicians in the Johns Hopkins Lung Transplantation Program. Cystic fibrosis, COPD, and pulmonary fibrosis are the most common diseases that lead to lung transplantation.

Most patients in the Medical Intensive Care Unit cannot eat normally because they are too weak or receive treatments (such as mechanical ventilation) that interfere with normal eating. When patients are seriously ill for days and sometimes weeks, they become malnourished, which weakens the body's ability to recover from illness. For most of our patients, we provide nutritional support with a small tube inserted through the mouth or nose that continues down the esophagus (swallowing tube) into the stomach or small intestine. A liquid nutrition formula is pumped through this tube at a slow rate into the digestive system. In a few patients, the digestive tract is unable to absorb the liquid nutrition. In these instances we may provide nutrition intravenously. Nutritional support is customized to meet each patient's needs and is guided by a team of nutrition experts.

In most intensive care units, patients receive little or no physical activity. It is assumed that they must lie in bed to conserve energy. Some patients are very weak after recovery from a critical illness and have difficulty returning to work and regular activities. The Johns Hopkins Critical Care Physical Medicine & Rehabilitation program provides specialized treatment individually tailored to improve each patient’s recovery. Physical therapists, occupational therapists, and speech and swallowing specialists have expertise in treating patients in the intensive care unit and provide dedicated support. This multifaceted team uses safe and innovative treatments to improve recovery, including in-bed cycling, interactive video games, and a tilt table bed. Our patients enjoy participating in these activities which help them maintain strength and speeds their recovery.

Cognitive Behavior Therapy is another approach utilized by our Physical Medicine team. It is difficult for patients to experience a sense of control and calm in a stressful setting such as an intensive care unit. Anxiety is a common and distressing symptom for some ICU patients. Medications for anxiety often have unfavorable side effects. Our Critical Care Physical Medicine & Rehabilitation team includes a rehabilitation psychologist with expertise in treating anxiety symptoms in ICU patients using non-medication, cognitive-behavioral approaches. This treatment can help improve critically ill patients' psychological and physical rehabilitation throughout hospitalization and ensure a better recovery after they are discharged from the hospital. An article about our Critical Care Physical Medicine Program appeared in the New York Times.

Medical social workers assist with communications between families and the health care team. They provide information and assistance to patients and families for advanced directive planning. They may work with patients, family, physicians, nurses, and therapists to match a patient's needs after discharge to a rehabilitation center or skilled nursing facility.

Our Interventional Pulmonary team conducts procedures that require specialized training and experience. These include rigid and flexible bronchoscopy, foreign body removal, tracheal and bronchial stents, endobronchial ultrasound, and bronchoscopic laser, thermal, cryotherapy, and photodynamic therapy. Our pleural disease service performs thoracoscopy for diagnosis and management of pleural effusions, empyema, and pleural abscess, chest tube placement including PleurRx® and pigtail catheters.

Our Interventional Radiology team performs transvenous intrahepatic porto-systemic shunts (TIPS, for gastrointestinal bleeding from cirrhosis), catheter directed embolization for gastrointestinal and for pulmonary bleeding, vena cava filters for deep vein thrombosis and pulmonary embolism, percutaneous drainage of intra-abdominal and intra-thoracic abscesses and closed space infections, and percutaneous biopsies of suspected tumors or infected mass lesions.

Our Blood Bank provides patient-specific matched packed red blood cells, platelets, fresh-frozen plasma, and factor concentrates including Factors VII.