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{{Mechanical ventilation}}
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== Overview ==
Mechanical ventilation can be used in patients who have labored breathing and are unable to maintain adequate gaseous excange leading to hypoxemia and/or hypercapnia. Common clinical indications of mechanical ventilation include moderate to severe dyspnea, respiratory rate (RR) > 24-30/min, signs of increased breathing, accessory muscle use for breathing and abdominal paradox. It may also be used in patients who have inadequate arterial partial pressure of oxygen or critically low PaO2 (PaO2 < 70 mm Hg), hypercapnia PaCO2 > 45 mm Hg and PaO2/FiO2 < 200. Patients suffering from acute exacerbation of COPD, asthma/asthmatic attack, neuromuscular disease that prevents chest movement to allow gas exchange, central nervous system depression (CNS depression due to drugs, cardiac arrest, trauma), chest injury, chest malformation, acute and chronic respiratory failure, heart failure and ventilation-perfusion mismatch may also be candidates for mechanical ventilation.
 
== Indications for Use ==
== Indications for Use ==
Mechanical ventilation is indicated when the patient's spontaneous [[Breath|ventilation]] is inadequate to maintain life. It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs. Because mechanical ventilation only serves to provide assistance for breathing and does not cure a disease, the patient's underlying condition should be correctable and should resolve over time. In addition, other factors must be taken into consideration because mechanical ventilation is not without its complications.
The indications of the mechanical ventilation is as follows:<ref name="pmid9113518">{{cite journal |vauthors=Tung A |title=Indications for mechanical ventilation |journal=Int Anesthesiol Clin |volume=35 |issue=1 |pages=1–17 |year=1997 |pmid=9113518 |doi= |url=}}</ref><ref name="pmid26902369">{{cite journal |vauthors=Kreppein U, Litterst P, Westhoff M |title=[Hypercapnic respiratory failure. Pathophysiology, indications for mechanical ventilation and management] |language=German |journal=Med Klin Intensivmed Notfmed |volume=111 |issue=3 |pages=196–201 |year=2016 |pmid=26902369 |doi=10.1007/s00063-016-0143-2 |url=}}</ref><ref name="pmid22331041">{{cite journal |vauthors=Strøm T, Rian O, Toft P |title=[Fewer indications for sedation in mechanical ventilation therapy] |language=Danish |journal=Ugeskr. Laeg. |volume=174 |issue=7 |pages=406–9 |date=February 2012 |pmid=22331041 |doi= |url=}}</ref><ref name="pmid27560387">{{cite journal |vauthors=Simonds AK |title=Home Mechanical Ventilation: An Overview |journal=Ann Am Thorac Soc |volume=13 |issue=11 |pages=2035–2044 |date=November 2016 |pmid=27560387 |doi=10.1513/AnnalsATS.201606-454FR |url=}}</ref><ref name="pmid22186215">{{cite journal |vauthors=Boldrini R, Fasano L, Nava S |title=Noninvasive mechanical ventilation |journal=Curr Opin Crit Care |volume=18 |issue=1 |pages=48–53 |date=February 2012 |pmid=22186215 |doi=10.1097/MCC.0b013e32834ebd71 |url=}}</ref><ref name="pmid6812417">{{cite journal |vauthors=Cohen CA, Zagelbaum G, Gross D, Roussos C, Macklem PT |title=Clinical manifestations of inspiratory muscle fatigue |journal=Am. J. Med. |volume=73 |issue=3 |pages=308–16 |date=September 1982 |pmid=6812417 |doi= |url=}}</ref><ref name="pmid8252973">{{cite journal |vauthors=Slutsky AS |title=Mechanical ventilation. American College of Chest Physicians' Consensus Conference |journal=Chest |volume=104 |issue=6 |pages=1833–59 |date=December 1993 |pmid=8252973 |doi= |url=}}</ref>


Common medical indications for use include:
*The three most common indications for mechanical ventilation:
* Acute lung injury (including [[acute respiratory distress syndrome|ARDS]], trauma)
** '''''Inadequate oxygenation'''''
* [[Apnea]] with respiratory arrest, including cases from [[intoxication]]
** '''''Inadequate ventilation'''''
** '''''Inability to protect the airway'''''
Other indications for mechanical ventilation include the following:
* Bradypnea
* Tachypnea (>30 breaths/minute)
* Apnea with respiratory arrest including cases from [[intoxication]]
* Acute respiratory distress syndrome
* Vital capacity less than 15 ml/kg
* Minute ventilation greater than 10 Lts/min
* Reduced respiratory drive
* Abnormalities of the chest wall
* Respiratory muscle fatigue
* Intrapulmonary shunt
* V/Q mismatch (ventilation-perfusion)
* Decreased Functional Residual Capacity
* Arterial partial pressure of oxygen (PaO<sub>2</sub>) with a supplemental fraction of inspired oxygen (FIO<sub>2</sub>) of less than 55 mm Hg
* Alveolar-arterial gradient of oxygen tension (A-a DO<sub>2</sub>) with 100% oxygenation of greater than 450 mm Hg
* Coma
* Hypotension due to sepsis, shock, CHF
* Acute partial pressure of carbon dioxide (PaCO<sub>2</sub>) greater than 50 mm Hg with an arterial pH less than 7.25
* [[Chronic obstructive pulmonary disease]] ([[COPD]])
* [[Chronic obstructive pulmonary disease]] ([[COPD]])
* Acute [[respiratory acidosis]] with partial pressure of carbon dioxide (pCO<sub>2</sub>) > 50 mmHg and pH < 7.25, which may be due to paralysis of the [[Thoracic diaphragm|diaphragm]] due to [[Guillain-Barré syndrome]], [[Myasthenia Gravis]], [[spinal cord injury]], or the effect of [[anaesthesia|anaesthetic]] and [[muscle relaxant]] drugs
* Acute [[respiratory acidosis]] with  
** Partial pressure of carbon dioxide (pCO<sub>2</sub>) > 50 mmHg  
** pH < 7.25, which may be due to paralysis of the [[Thoracic diaphragm|diaphragm]] due to  
*** [[Guillain-Barré syndrome]]  
*** [[Myasthenia Gravis]]  
*** [[spinal cord injury]]  
*** The effect of [[anaesthesia|anaesthetic]] and [[muscle relaxant|muscle relaxants]]
* Increased work of breathing as evidenced by significant [[tachypnea]], retractions, and other physical signs of respiratory distress
* Increased work of breathing as evidenced by significant [[tachypnea]], retractions, and other physical signs of respiratory distress
* [[Hypoxemia]] with arterial partial pressure of oxygen (PaO<sub>2</sub>) with supplemental fraction of inspired oxygen (FiO<sub>2</sub>) < 55 mm Hg
* [[Hypoxemia]] with arterial partial pressure of oxygen (PaO<sub>2</sub>) with supplemental fraction of inspired oxygen (FiO<sub>2</sub>) < 55 mm Hg
* [[Hypotension]] including [[sepsis]], [[Shock (medical)|shock]], [[congestive heart failure]]
* Neuromuscular disease
 
Indications for mechanical ventilation have evolved substantially since widespread use of ventilatory support began in the early 1960s. While the metabolic and blood-gas alterations that mandate institution of ventilatory support have remained unaltered, new noninvasive modes of ventilation have widened the therapeutic options available to patients in acute respiratory failure. An understanding of the effect of mechanical ventilation on other organ systems has clarified the role of mechanical ventilation in the treatment of conditions other than respiratory failure such as stroke or head injury. Studies in patients recovering from major surgery have better defined the benefits and risks of postoperative mechanical ventilation. Finally, a better understanding of disease processes has led to more prognostic information that can help physicians, patients, and families decide on limits to compassionate care. The proper use of mechanical ventilation in disease states that do not involve respiratory failure as their primary manifestation is also important in light of the risks of respiratory support. In patients with CNS injury, the role of hyperventilation is limited to acute control of dangerous elevations of intracranial pressure. Although hypocarbia has been proposed to improve regional cerebral blood flow, studies have not demonstrated an improvement in outcome, suggesting that the risks of intubation, tracheal stimulation, sedation, and inability to examine the mental status outweigh any benefit. Some evidence suggests a detrimental effect from prolonged hyperventilation. The use of mechanical ventilation in postoperative care is another area that requires scrutiny. Numerous studies have shown that with coordination of care between surgeons, anesthesiologists, and nurses, many patients can be extubated significantly sooner than in the past. As techniques for administering anesthesia, performing surgery, and managing pain and mild respiratory insufficiency improve, knowledge in this area will continue to develop. Finally, the relation between mechanical ventilation, quality of life, and patient autonomy has come to play a greater role as the population ages. In many situations, respiratory failure represents the end stage of an irreversible disease. Whereas respiratory failure secondary to pulmonary contusion in young patients does not indicate a poor outcome, progressive respiratory failure in cystic fibrosis or following bone marrow transplantation usually represents a preterminal event. Understanding the epidemiology of respiratory failure in different disease categories is important to physicians, patients, and families in making informed decisions about their care. Mechanical ventilation represents a vital, fundamental form of life support. As the diseases, tools, and treatments change in anesthesia and critical care, careful definition of the role of mechanical ventilation in specific diseases, the route by which it is delivered, and the ability of such a form of life support to affect outcome will continue to be necessary.
 
PMID: 9113518


==References==
==References==

Latest revision as of 13:39, 4 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]Syed Hassan A. Kazmi BSc, MD [3]

Overview

Mechanical ventilation can be used in patients who have labored breathing and are unable to maintain adequate gaseous excange leading to hypoxemia and/or hypercapnia. Common clinical indications of mechanical ventilation include moderate to severe dyspnea, respiratory rate (RR) > 24-30/min, signs of increased breathing, accessory muscle use for breathing and abdominal paradox. It may also be used in patients who have inadequate arterial partial pressure of oxygen or critically low PaO2 (PaO2 < 70 mm Hg), hypercapnia PaCO2 > 45 mm Hg and PaO2/FiO2 < 200. Patients suffering from acute exacerbation of COPD, asthma/asthmatic attack, neuromuscular disease that prevents chest movement to allow gas exchange, central nervous system depression (CNS depression due to drugs, cardiac arrest, trauma), chest injury, chest malformation, acute and chronic respiratory failure, heart failure and ventilation-perfusion mismatch may also be candidates for mechanical ventilation.

Indications for Use

The indications of the mechanical ventilation is as follows:[1][2][3][4][5][6][7]

  • The three most common indications for mechanical ventilation:
    • Inadequate oxygenation
    • Inadequate ventilation
    • Inability to protect the airway

Other indications for mechanical ventilation include the following:

  • Bradypnea
  • Tachypnea (>30 breaths/minute)
  • Apnea with respiratory arrest including cases from intoxication
  • Acute respiratory distress syndrome
  • Vital capacity less than 15 ml/kg
  • Minute ventilation greater than 10 Lts/min
  • Reduced respiratory drive
  • Abnormalities of the chest wall
  • Respiratory muscle fatigue
  • Intrapulmonary shunt
  • V/Q mismatch (ventilation-perfusion)
  • Decreased Functional Residual Capacity
  • Arterial partial pressure of oxygen (PaO2) with a supplemental fraction of inspired oxygen (FIO2) of less than 55 mm Hg
  • Alveolar-arterial gradient of oxygen tension (A-a DO2) with 100% oxygenation of greater than 450 mm Hg
  • Coma
  • Hypotension due to sepsis, shock, CHF
  • Acute partial pressure of carbon dioxide (PaCO2) greater than 50 mm Hg with an arterial pH less than 7.25
  • Chronic obstructive pulmonary disease (COPD)
  • Acute respiratory acidosis with
  • Increased work of breathing as evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress
  • Hypoxemia with arterial partial pressure of oxygen (PaO2) with supplemental fraction of inspired oxygen (FiO2) < 55 mm Hg
  • Neuromuscular disease

References

  1. ↑ Tung A (1997). "Indications for mechanical ventilation". Int Anesthesiol Clin. 35 (1): 1–17. PMID 9113518.
  2. ↑ Kreppein U, Litterst P, Westhoff M (2016). "[Hypercapnic respiratory failure. Pathophysiology, indications for mechanical ventilation and management]". Med Klin Intensivmed Notfmed (in German). 111 (3): 196–201. doi:10.1007/s00063-016-0143-2. PMID 26902369.
  3. ↑ Strøm T, Rian O, Toft P (February 2012). "[Fewer indications for sedation in mechanical ventilation therapy]". Ugeskr. Laeg. (in Danish). 174 (7): 406–9. PMID 22331041.
  4. ↑ Simonds AK (November 2016). "Home Mechanical Ventilation: An Overview". Ann Am Thorac Soc. 13 (11): 2035–2044. doi:10.1513/AnnalsATS.201606-454FR. PMID 27560387.
  5. ↑ Boldrini R, Fasano L, Nava S (February 2012). "Noninvasive mechanical ventilation". Curr Opin Crit Care. 18 (1): 48–53. doi:10.1097/MCC.0b013e32834ebd71. PMID 22186215.
  6. ↑ Cohen CA, Zagelbaum G, Gross D, Roussos C, Macklem PT (September 1982). "Clinical manifestations of inspiratory muscle fatigue". Am. J. Med. 73 (3): 308–16. PMID 6812417.
  7. ↑ Slutsky AS (December 1993). "Mechanical ventilation. American College of Chest Physicians' Consensus Conference". Chest. 104 (6): 1833–59. PMID 8252973.

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