Internal Medicine

0521779407-22 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:23

Ventilator Management in the ICU 1521

■Peak and plateau airway pressures, to allow adjustment of respiratory

rate, tidal volume, and ventilator mode

■Other thoracic imaging – ultrasound or CT scan to evaluate suspected

pleural effusion

■With pulmonary infiltrates, consider fiberoptic bronchoscopy

differential diagnosis

n/a

management

What to Do First

■Establish airway, usually by endotracheal intubation

General Measures

■Ventilate with FIO 2 =1.0 (100% oxygen)

■Evaluate cause of acute respiratory failure by performing focused

cardio-pulmonary examination

■Use etiology to guide choice of ventilator mode and settings

specific therapy

Indications

■Acute hypercapneic respiratory failure, with rising PCO 2 , respiratory

distress, and / or somnolence (e.g., chronic obstructive pulmonary

disease exacerbation)

■Acute hypoxemic respiratory failure, refractory to high levels of sup-

plemental oxygen by face mask (e.g., pneumonia)

■Respiratory distress – physical signs suggesting distress or “tiring

out”

■Depressed level of consciousness, inability to protect airway (e.g.,

stroke, subarachnoid hemorrhage, drug overdose)

Treatment Options

■Assist control (AC) ventilation, synchronized intermittent manda-

tory ventilation (SIMV), and pressure control ventilation (PCV)

■Ventilator mode should be guided by etiology of respiratory failure

■Tidal volume based on “predicted” body weight, not actual body

weight

■For male patients, predicted body weight is 50+0.91 (centimeters of

height-152.4); for female patients, 45.5+0.91 (centimeters of height-

152.4).