Mechanical ventilation of adults in the emergency department
- Peter Hou, MD
Peter Hou, MD
- Instructor in Medicine
- Harvard Medical School
- Amado Alejandro Baez, MD, MSc, MPH, FAAEM, FCCM
Amado Alejandro Baez, MD, MSc, MPH, FAAEM, FCCM
- Residency Director
- Jackson Memorial Hospital
- University of Miami Miller School of Medicine
Patients present to the emergency department (ED) with a wide range of conditions that may require tracheal intubation or positive pressure ventilation, including: pneumonia, asthma, chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, acute respiratory distress syndrome, stroke, trauma, drug overdose, severe sepsis, shock, and neuromuscular disorders such as myasthenia gravis or Guillain-Barré syndrome.
Once a definitive airway has been secured, ventilatory management ensues. Ventilatory strategies vary according to the clinical scenario, and to provide optimal care, emergency clinicians must understand the fundamental concepts of mechanical ventilation.
This topic review will discuss concepts needed to manage mechanical ventilation in the ED, including ventilator settings, modes of mechanical ventilation, complications of mechanical ventilation, management of ventilated patients in distress, general and disease-specific ventilation strategies, and weaning from ventilatory support [1-5]. Although useful guidelines are provided, clinicians will need to individualize mechanical ventilation strategies based upon the clinical scenario. Tracheal intubation and other aspects of airway management are discussed elsewhere. (See "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) in children".)
OBJECTIVES AND OVERVIEW OF MECHANICAL VENTILATION
Clinicians place patients on mechanical ventilation to accomplish any of a number of goals, including:
●To protect the airway
- Slutsky AS. Mechanical ventilation. American College of Chest Physicians' Consensus Conference. Chest 1993; 104:1833.
- Tobin MJ. Mechanical ventilation. N Engl J Med 1994; 330:1056.
- Tobin MJ. Advances in mechanical ventilation. N Engl J Med 2001; 344:1986.
- Gluck E, Sarrigianidis A, Dellinger RP. Mechanical ventilation. In: Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 2nd, Parrillo JE, Dellinger RP. (Eds), Mosby, St. Louis 2002. p.137.
- Fessler MB, Welsh CH. Mechanical ventilation: invasive and noninvasive. In: Current Diagnosis & Treatment in Pulmonary Medicine, Hanley ME, Welsh CH. (Eds), McGraw-Hill, New York 2006.
- Connors AF Jr, McCaffree DR, Gray BA. Effect of inspiratory flow rate on gas exchange during mechanical ventilation. Am Rev Respir Dis 1981; 124:537.
- Mosier JM, Hypes C, Joshi R, et al. Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department. Ann Emerg Med 2015; 66:529.
- Wright BJ. Lung-protective ventilation strategies and adjunctive treatments for the emergency medicine patient with acute respiratory failure. Emerg Med Clin North Am 2014; 32:871.
- Spiegel R, Mallemat H. Emergency Department Treatment of the Mechanically Ventilated Patient. Emerg Med Clin North Am 2016; 34:63.
- Poponick JM, Renston JP, Bennett RP, Emerman CL. Use of a ventilatory support system (BiPAP) for acute respiratory failure in the emergency department. Chest 1999; 116:166.
- Tobin MJ, Jubran A, Laghi F. Patient-ventilator interaction. Am J Respir Crit Care Med 2001; 163:1059.
- Gattinoni L, D'Andrea L, Pelosi P, et al. Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory distress syndrome. JAMA 1993; 269:2122.
- Mohr NM, Fuller BM. Low tidal volume ventilation should be the routine ventilation strategy of choice for all emergency department patients. Ann Emerg Med 2012; 60:215.
- Wright BJ, Slesinger TL. Low tidal volume should not routinely be used for emergency department patients requiring mechanical ventilation. Ann Emerg Med 2012; 60:216.
- Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank. J Trauma 2005; 59:1140.
- Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991; 75:731.
- Vincent JL, Berré J. Primer on medical management of severe brain injury. Crit Care Med 2005; 33:1392.
- Stocchetti N, Maas AI, Chieregato A, van der Plas AA. Hyperventilation in head injury: a review. Chest 2005; 127:1812.
- Postresuscitation management, in Pediatric Advanced Life Support Provider Manual. Chameides L, et al (Eds), American Heart Association, Dallas, Texas, 2011, p.171.
- Huang DT, Osborn TM, Gunnerson KJ, et al. Critical care medicine training and certification for emergency physicians. Crit Care Med 2005; 33:2104.
- Hospital-based Emergency Care: At the Breaking Point. Institute of Medicine report. Washington, DC, National Academy Press, June 14, 2006.
- Cook D, Meade M, Guyatt G, et al. Criteria for weaning from mechanical ventilation. Evid Rep Technol Assess (Summ) 2000; :1.
- MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120:375S.
- OBJECTIVES AND OVERVIEW OF MECHANICAL VENTILATION
- VENTILATOR SETTINGS
- MODES OF VENTILATION
- APPROACH TO VENTILATORY MANAGEMENT
- General principles
- Selecting a ventilatory strategy
- Implementing the chosen ventilatory strategy
- - Noninvasive positive pressure ventilation
- - General invasive positive pressure ventilation
- - Lung-protective positive pressure ventilation
- DISEASE-SPECIFIC VENTILATORY MANAGEMENT
- Pulmonary diseases
- - Asthma and COPD
- - Hypoxemic respiratory failure
- - Acute cardiogenic pulmonary edema
- - Acute respiratory distress syndrome
- Neuromuscular diseases
- - Guillain-barré syndrome
- - Myasthenia gravis
- Elevated intracranial pressure
- Other conditions
- - Pregnancy
- - Abdominal compartment syndrome
- APPROACH TO VENTILATED PATIENT IN DISTRESS
- SEDATION AND ANALGESIA FOR THE VENTILATED PATIENT
- WEANING AND DISCONTINUATION OF MECHANICAL VENTILATION
- SUMMARY AND RECOMMENDATIONS