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Indications
Acute Respiratory Failure
- Hypoxemic (type I): refractory to O2, ARDS
- Hypercapnic (type II): COPD exacerbation, NM disease, drug OD
Airway Protection
- Altered mental status (GCS †8)
- Aspiration risk
- Inability to clear secretions
Hemodynamic
- Septic shock + â work of breathing
- Cardiogenic shock
- Massive PE
Neurologic
- Status epilepticus
- ICH with ICP elevation
- Coma
Procedural
- General anesthesia
- Airway interventions
Modes of Ventilation
Volume-Controlled Ventilation (VCV)
- Set tidal volume + RR + flow
- Pressure variable
- Most common ICU
- ARDS lung-protective standard
Pressure-Controlled Ventilation (PCV)
- Set inspiratory pressure + time
- Volume variable
- Useful when concerns about high pressure
- ARDS, severe asthma
Pressure Support Ventilation (PSV)
- Patient-triggered breaths supported by set pressure
- Spontaneous breathing required
- Weaning mode
Synchronized Intermittent Mandatory Ventilation (SIMV)
- Combination of mandatory + patient-triggered
- Less commonly used now
- Was popular for weaning
Airway Pressure Release Ventilation (APRV)
- Continuous CPAP-like with brief releases
- For severe hypoxia, refractory
- Selected indications
Continuous Positive Airway Pressure (CPAP) / Bilevel (BiPAP)
- Non-invasive
- CPAP: continuous pressure
- BiPAP: different IPAP + EPAP
- Indications: OSA, COPD exacerbation, OHS, cardiogenic pulmonary edema, post-extubation
Lung-Protective Ventilation (Foundation)
ARDSnet Strategy
- Tidal volume 6 mL/kg PBW (PBW = predicted body weight by height + sex formula)
- Plateau pressure < 30 cm H2O
- PEEP titrated (PEEP-FiO2 table, ART trial confirms)
- Driving pressure (Plateau - PEEP) < 15 cm H2O
- Permissive hypercapnia (pH > 7.20 OK)
PEEP Strategies
- Lower PEEP for mild ARDS, normal lungs
- Higher PEEP for moderate-severe ARDS
- Best PEEP = optimal lung recruitment with limited overinflation
Patient-Specific Adjustments
- Auto-PEEP measurement
- Adjustments based on plateau, compliance, oxygenation
- Driving pressure-guided
Sedation + Analgesia
Goals
- Patient comfort + dyssynchrony management
- Target light sedation when possible
- SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial) daily
- ABCDEF bundle (Awakening + Breathing + Choice + Delirium + Early mobility + Family)
Common Agents
- Propofol: short-acting, no accumulation
- Dexmedetomidine (Precedex): minimal respiratory depression, less delirium (MENDS-2)
- Midazolam: longer half-life, delirium risk (avoid if possible)
- Fentanyl: analgesia, short-acting (commonly used)
- Hydromorphone: alternative
- Ketamine: status asthmaticus, hemodynamic support
Delirium
- CAM-ICU assessment
- Common in ICU (40-80%)
- Prevention: minimize sedation, sleep hygiene, mobilization, family
- Treatment: address cause; antipsychotics if severe
Weaning
Spontaneous Breathing Trial (SBT)
- Daily assessment if ready
- Criteria: hemodynamically stable, alert, FiO2 †50%, PEEP †8, adequate cough
- T-piece or pressure support trial (30 min)
- Success criteria: comfortable, adequate ventilation, hemodynamic stability
SAT (Spontaneous Awakening Trial)
- Daily interruption of sedation
- Paired with SBT
- Earlier extubation
- Better outcomes
Failure Causes
- Persistent respiratory failure
- Cardiac dysfunction
- Diaphragm weakness (ICUAW)
- Anxiety
- Secretions
- Upper airway issues
Re-Intubation
- 10-20% post-extubation
- Higher mortality
- HFNC + NIV preferred over immediate re-intubation for select
Complications
Ventilator-Associated Pneumonia (VAP)
- Hospital-acquired pneumonia in mechanically ventilated > 48 hours
- Incidence: 1-3% per day
- Common pathogens: Pseudomonas, MRSA, Acinetobacter, ESBL Enterobacteriaceae
- Diagnosis: new infiltrate + leukocytosis + fever + purulent secretions + positive cultures
- Treatment: empiric broad-spectrum then narrow per cultures
- 7-day course typically for non-MDR
VILI (Ventilator-Induced Lung Injury)
- Volutrauma + barotrauma + atelectotrauma + biotrauma
- Prevention: lung-protective ventilation
Auto-PEEP
- Air trapping (asthma, COPD)
- Detection: expiratory hold maneuver
- Management: reduce RR, prolong expiration, treat bronchospasm
Ventilator Dyssynchrony
- Patient + ventilator mismatch
- Multiple types: ineffective, double trigger, reverse trigger, etc.
- Treatment: optimize mode, sedation, address cause
Tracheal Stenosis
- Post-prolonged intubation
- Symptomatic > 50% stenosis
- Treatment: dilation, stenting, surgery
ICU-Acquired Weakness (ICUAW)
- Critical illness polyneuropathy + myopathy
- Diaphragm weakness common
- Prolongs weaning
- Prevention: minimize sedation + early mobility
Other
- DVT, PE
- Pressure injuries
- Glucose dysregulation
- Stress ulcers
- Sinusitis
- Aspiration (microaspiration even with cuffs)
Non-Invasive Ventilation (NIV)
Indications
- COPD exacerbation with pH < 7.35 (Class I)
- Acute cardiogenic pulmonary edema (alternative to CPAP)
- Immunocompromised hypoxemic RF
- Post-operative respiratory failure
- Post-extubation prophylaxis for high-risk
- Palliative ventilation (DNI patients)
Contraindications
- Coma / severe altered mental status
- Hemodynamic instability
- Inability to protect airway
- Excessive secretions
- Facial trauma / surgery
- Severe upper GI bleeding
NIV Failure
- 20-50% in severe respiratory failure
- Worse outcomes if delayed intubation
- Need close monitoring
High-Flow Nasal Cannula (HFNC)
Mechanism
- Heated humidified high-flow O2 (up to 60 L/min)
- â Dead space
- Slight PEEP
- Improved comfort vs face mask
Indications
- Hypoxemic respiratory failure (FLORALI 2015)
- Post-extubation in high-risk
- Bronchoscopy / pre-procedural oxygenation
- Awake proning support (COVID era)
- Palliative care
Evidence
- FLORALI (2015): comparable to NIV for hypoxemic RF; reduced reintubation
- OPERA (2020): HFNC vs O2 mask + NIV for high-risk post-extubation â non-inferior
- COVID-19 era: extensive use, awake proning combo
Tracheostomy
Indications
- Prolonged mechanical ventilation (> 14 days expected)
- Failed extubation
- Upper airway obstruction
- Inability to clear secretions
Timing
- Earlier (within 7-10 days) vs later (after 2-3 weeks) â controversial
- TracMan (2013): no mortality benefit early
- TRACS vs delayed
- Individual decisions
Benefits
- Comfort
- Easier suctioning
- Reduced sedation needs
- Earlier mobilization
- Speaking valve
Complications
- Bleeding
- Pneumothorax
- Infection
- Tracheal stenosis (late)
- Decannulation
Chronic / Long-Term Ventilation
Indications
- ALS + advanced
- Spinal cord injury (high cervical)
- Severe neuromuscular disorders
- Chronic OHS
- Severe COPD with chronic hypercapnia
- Post-trach in specialized facility
Home Mechanical Ventilation
- Increasingly common
- Multidisciplinary
- Caregiver training
- Insurance + resource considerations
Diaphragm Pacing
- For bilateral diaphragm paralysis with intact phrenic nerves
- High cervical spinal cord injury
- Improves QOL, reduces ventilator dependence
- NeuRx Diaphragm Pacing System
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- ARDS ventilation: Vt 6 mL/kg PBW + plateau < 30 + driving pressure < 15
- Weaning: SAT + SBT daily; HFNC/NIV for post-extubation high-risk
- VAP: empiric broad-spectrum then narrow; 7-day typical
- NIV: COPD exacerbation pH < 7.35 (Class I); cardiogenic pulmonary edema
- HFNC: hypoxemic RF; awake proning; post-extubation
- Tracheostomy: prolonged MV > 14 days
- Diaphragm pacing: bilateral paralysis + intact phrenic
- ABCDEF bundle for ICU bundles