What is the approach to a patient on a ventilator (mechanical ventilation) with hypoxia (low oxygen levels)?

From the Guidelines

When approaching a patient on a ventilator with hypoxia, the most critical step is to immediately increase FiO2 to 100% and adjust ventilator settings as needed, including increasing PEEP by 2-3 cmH2O increments, to quickly improve oxygenation and prevent further complications, as recommended by recent guidelines and expert opinions 1.

To manage a patient on a ventilator with hypoxia, follow these steps:

• Check ventilator settings and adjust as needed:
  • Increase PEEP by 2-3 cmH2O increments (up to 15-20 cmH2O) to prevent alveolar collapse and improve oxygenation
  • Increase tidal volume to 6-8 mL/kg ideal body weight, but avoid excessive volumes that may cause lung injury
  • Adjust I:E ratio to 1:1 or consider inverse ratio ventilation to optimize gas exchange
• Perform rapid assessment:
  • Check for ventilator disconnection or malfunction
  • Ensure proper ETT position and patency
  • Auscultate chest for breath sounds and check for symmetry
  • Review recent chest X-ray or obtain a new one to evaluate lung expansion and potential complications
• Consider potential causes:
  • Atelectasis: Perform recruitment maneuvers to open atelectatic alveoli and improve oxygenation
  • Pneumothorax: Prepare for chest tube placement if suspected to prevent further complications
  • Pulmonary edema: Administer furosemide 40mg IV to reduce fluid overload and improve oxygenation
  • Mucus plugging: Perform airway suctioning to clear secretions and improve ventilation
  • ARDS: Consider prone positioning to improve oxygenation and reduce lung injury, as recommended by recent guidelines 1
• Obtain ABG to assess oxygenation and ventilation status, and adjust treatment accordingly
• If hypoxia persists, consider advanced interventions:
  • Inhaled nitric oxide (start at 5-20 ppm) may be considered, but its use is not routinely recommended due to lack of mortality benefit 1
  • ECMO evaluation if severe, refractory hypoxemia, as a last resort to support oxygenation and ventilation

The approach to managing a patient on a ventilator with hypoxia should prioritize quick identification and addressing of the cause of hypoxia, while optimizing ventilator support to prevent further complications and improve outcomes, as recommended by recent guidelines and expert opinions 1.

From the FDA Drug Label

INOmax® is indicated to improve oxygenation and reduce the need for extracorporeal membrane oxygenation in term and near-term (>34 weeks gestation) neonates with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension in conjunction with ventilatory support and other appropriate agents.

The approach to a patient on a ventilator with hypoxia is to improve oxygenation using inhaled nitric oxide (INH), such as INOmax, in conjunction with ventilatory support and other appropriate agents, as it has been shown to reduce the need for extracorporeal membrane oxygenation in term and near-term neonates with hypoxic respiratory failure associated with pulmonary hypertension 2.

• Key benefits of inhaled nitric oxide include:
  • Improved oxygenation
  • Reduced need for extracorporeal membrane oxygenation
• Target population: term and near-term (>34 weeks gestation) neonates with hypoxic respiratory failure associated with pulmonary hypertension.

From the Research

Approach to a Patient on a Ventilator with Hypoxia

The approach to a patient on a ventilator with hypoxia involves several strategies to improve oxygenation while minimizing the risk of ventilator-induced lung injury (VILI).

• The standard supportive treatment for acute respiratory distress syndrome (ARDS) patients with severe hypoxemia is mechanical ventilation, with possible adjuvant therapies considered 3.
• Tailoring mechanical ventilation to the individual patient is fundamental to reduce the risk of VILI, including applying a low tidal volume and selecting the optimal level of positive end-expiratory pressure (PEEP) based on the severity of the disease and lung recruitability 3, 4.
• Targeting oxygenation of 88-92% and tolerating a moderate level of hypercapnia are considered safe choices 3, 4, 5.
• Neuromuscular blocking agents (NMBAs) and prone positioning can be useful in improving oxygenation and reducing the risk of VILI, especially in severe cases 3.
• The use of extracorporeal membrane oxygenation (ECMO) may be considered in severe ARDS cases, although its use is still considered a rescue therapy due to a lack of randomized trials 3.
• Personalizing mechanical ventilation according to physiologic parameters, such as dead space, lung compliance, and ventilation patterns, can help stabilize alveoli and minimize VILI 6.
• Optimization of mechanical ventilator settings, including tidal volume, ventilation rate, inspiratory/expiratory ratio, PEEP, and inspired fraction of oxygen, can be achieved through computational models and global optimization algorithms to ensure adequate oxygenation and carbon dioxide clearance while minimizing the risk of VILI 7.