What is the management of a person on a mechanical ventilator (MV)?

From the Guidelines

The management of a person on a mechanical ventilator should prioritize lung-protective ventilation strategies, with initial settings individualized based on the patient's condition, and adjustments made to prevent complications and promote weaning. The most recent and highest quality study 1 provides guidance on ventilator settings for patients with suspected or confirmed COVID-19, recommending the use of a HEPA filter to maintain a closed circuit and reduce aerosolization. Key considerations include:

• Adjusting ventilator settings to allow asynchronous ventilation, with suggestions such as increasing FiO2 to 1.0, using pressure or volume control ventilation, and limiting pressure or tidal volume to generate adequate chest rise
• Adjusting trigger settings to prevent auto-triggering with chest compressions and possible hyperventilation and air trapping
• Assessing the need to adjust the positive end-expiratory pressure (PEEP) level to balance lung volumes and venous return
• Ensuring endotracheal tube/tracheostomy and ventilator circuit continuity to prevent unplanned airway dislodgement or tubing disconnections Other studies 1 provide additional guidance on ventilator management, including the use of low tidal volume ventilation, recruitment maneuvers, and prone positioning in patients with acute respiratory distress syndrome (ARDS). However, the most recent study 1 takes precedence in guiding clinical practice, and its recommendations should be prioritized in the management of patients on mechanical ventilators. Regular assessment of ventilator parameters, arterial blood gases, chest X-rays, and daily spontaneous breathing trials are crucial for monitoring progress and determining readiness for extubation. This approach optimizes oxygenation and ventilation while minimizing complications such as ventilator-induced lung injury, pneumonia, and prolonged ventilator dependence. Prevention of complications includes elevating the head of bed to 30-45 degrees, deep vein thrombosis prophylaxis, stress ulcer prophylaxis, and implementing a ventilator bundle. Sedation and pain management are also essential for patient comfort and ventilator synchrony. By prioritizing lung-protective ventilation strategies and individualizing care based on patient needs, clinicians can improve outcomes and reduce morbidity and mortality in patients on mechanical ventilators.

From the FDA Drug Label

For intubated, mechanically ventilated adult patients, Intensive Care Unit (ICU) sedation should be initiated slowly with a continuous infusion in order to titrate to desired clinical effect and minimize hypotension. When indicated, initiation of sedation should begin at 5 mcg/kg/min (0.3 mg/kg/h). The infusion rate should be increased by increments of 5 mcg/kg/min to 10 mcg/kg/min (0. 3 mg/kg/h to 0.6 mg/kg/h) until the desired level of sedation is achieved. A minimum period of 5 minutes between adjustments should be allowed for onset of peak drug effect. Most adult patients require maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0. 3 mg/kg/h to 3 mg/kg/h) or higher. Administration should not exceed 4 mg/kg/hour unless the benefits outweigh the risks

The management of a person on a mechanical ventilator (MV) involves slow initiation of sedation with a continuous infusion of propofol, starting at 5 mcg/kg/min, and titrating to the desired clinical effect while minimizing hypotension.

• The infusion rate should be increased by increments of 5 mcg/kg/min to 10 mcg/kg/min until the desired level of sedation is achieved.
• A minimum period of 5 minutes between adjustments should be allowed for onset of peak drug effect.
• Maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min or higher may be required, but administration should not exceed 4 mg/kg/hour unless the benefits outweigh the risks 2.
• It is also important to monitor patients continuously for early signs of hypotension, apnea, airway obstruction, and/or oxygen desaturation, and to have facilities for maintenance of a patent airway, providing artificial ventilation, administering supplemental oxygen, and instituting cardiovascular resuscitation immediately available 2.

From the Research

Management of a Person on a Mechanical Ventilator (MV)

The management of a person on a mechanical ventilator (MV) involves several strategies to prevent complications and improve patient outcomes. Some of the key aspects of MV management include:

• Ventilator-associated pneumonia (VAP) prevention: This can be achieved through the use of VAP prevention bundles, which include measures such as head of bed elevation, oral care, and subglottic secretion removal 3.
• Sedation and weaning protocols: Sedation protocols can help minimize the risk of VAP, while weaning protocols can help reduce the duration of mechanical ventilation 3, 4.
• Mechanical ventilation protocols: These protocols may include the use of non-invasive positive pressure ventilation, low tidal volume ventilation, and conservative fluid management 4.
• Patient assessment and monitoring: Frequent patient assessment and monitoring are crucial to determine the need for continued ventilatory support and to identify potential complications early 5.
• Ventilatory support strategies: Strategies such as maximizing patient comfort, unloading the respiratory muscles, and providing gradual reduction of support can help improve patient outcomes 5.
• Prevention of microaspiration: Measures such as avoiding microaspiration, using positive end-expiratory pressure (PEEP), and continuous monitoring and adjustment of cuff pressure can help prevent VAP 6.
• Optimizing sedation: Sedation management is critical in mechanically ventilated patients, and strategies such as optimizing sedation administration and using pharmacologic properties of commonly used medications can help improve patient outcomes 7.

Key Interventions

Some of the key interventions that have been shown to be effective in managing patients on mechanical ventilators include:

• Non-invasive positive pressure ventilation for able patients 3
• Sedation and weaning protocols 3, 4
• Mechanical ventilation protocols, including head of bed elevation and oral care 3
• Removal of subglottic secretions 3
• Minimizing sedation and using paired daily spontaneous awakening and breathing trials 4
• Early exercise and mobility 4
• Conservative fluid management and blood transfusion thresholds 4
• Avoiding microaspiration and using PEEP 6
• Continuous monitoring and adjustment of cuff pressure 6
• Optimizing sedation administration and using pharmacologic properties of commonly used medications 7