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Acute respiratory failure is a common reason for admission to the intensive care unit (ICU). Patients may arrive requiring support to oxygenate arterial blood (low partial pressure of arterial oxygen [PaO2]) or to achieve adequate ventilation (as reflected by high partial pressure of arterial carbon dioxide [PaCO2]). In this section, we cover the following approaches to management of respiratory failure:
A patient may need endotracheal intubation for many reasons. The broad categories include:
Mechanical ventilators and their modes have become increasingly complicated in recent years. The following are the basic modes used in most intubated patients:
The following algorithm can help you choose a ventilation strategy:
When the underlying cause for mechanical ventilation starts to improve, it’s time to think about weaning. Being on a ventilator can cause serious harm. The following are some evidence-based strategies that can reduce the duration of mechanical ventilation:
Weaning strategy: All mechanically ventilated patients should, when appropriate, have a daily spontaneous awakening trial (SAT; i.e., interruption of sedatives) with a paired spontaneous breathing trial (SBT). In the Awakening and Breathing Controlled trial, this SAT/SBT strategy resulted in more days breathing without assistance, shorter ICU length of stay, shorter hospital length of stay, and lower mortality than standard of care. However, there is no one size fits all strategy for liberating patients from the ventilator. Much variation exists for determining when a patient can be weaned and extubated, balancing a shorter duration on ventilation with a higher likelihood of needing reintubation.
The following is one possible algorithm to determine when to extubate. An SBT may involve placing a patient on continuous positive airway pressure (CPAP) at 5 cm H2O or ventilation through a T-piece (no CPAP). Some clinicians calculate a rapid shallow breathing index (RSBI; respiratory rate divided by tidal volume in liters) at the end of an SBT to help determine readiness; the lower the RSBI, the more likely a patient is to succeed. An RSBI <105 is a typical cut-off.
When a patient has imminent respiratory failure, but before he/she progresses to requiring endotracheal intubation, other methods of providing respiratory support can temporize or even prevent the need for conventional mechanical ventilation.
Procedures explained and demonstrated
The video “Emergency Intubation in Covid-19” is intended for health care personnel involved in performing emergency endotracheal intubation in patients with suspected or proven infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes the respiratory illness coronavirus disease 2019 (Covid-19).
Examination of the neck veins is routinely performed to evaluate right atrial pressure and to estimate intravascular volume in patients with dyspnea, edema, or hypovolemia. In patients with dyspnea or edema, it is essential to estimate the venous pressure and to perform the abdominojugular reflux test at the bedside, as described in...
A tracheostomy is a surgically created airway that is kept open with a breathing tube, or tracheostomy tube. The tube is inserted directly into the trachea through an incision in the neck. A tracheostomy can be created with an open surgical or a percutaneous dilation technique and can take place in the operating room or at the patient’s...
As is the case with medical procedures, family meetings require clinician training and a structured approach. The key functions of a family meeting are to build rapport with the family and to offer support, provide updates about the patient’s medical status, discuss...
This video demonstrates a procedure for putting on and removing one type of PPE that has been recommended by the CDC for use in U.S. hospitals to minimize the risk of exposure to infectious material during the care of patients with Covid-19.
The indications for pleural drainage are diagnostic and therapeutic. This video demonstrates ultrasound-guided placement of a small-bore, pigtail catheter for drainage of a pleural effusion.
Geurin C et al. for the PROSEVA Study Group. N Engl J Med 2013.
In the multicenter PROSEVA trial, 466 patients with moderate-to-severe ARDS (P/F ratio <150) were randomized within 36 hours of intubation and mechanical ventilation to the prone or supine position. Prone positioning reduced 28-day (16% vs. 33%, P<0.001) and 90-day mortality (24% vs. 41%, P<0.001). All centers had used prone positioning in daily practice for more than 5 years and complication rates were similar in the two groups.
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This video demonstrates the assessment of neuromuscular function after administration of neuromuscular blocking agents. Because these agents can be lethal, clinicians should be familiar with the use of nerve stimulators and monitors in the assessment of neuromuscular function.
The placement of a central venous line is an essential technique in the treatment of many hospitalized patients. This video will demonstrate the placement of a central venous catheter in the internal jugular vein with the use of one of several variations of the Seldinger technique.
Four Videos on Point-of-Care Ultrasonography
Brief case presentations with pictures