What non-traditional medications (non-conventional meds) can be used for a patient on a ventilator (mechanical ventilation)?

Non-Traditional Medications for Ventilated Patients

For patients on mechanical ventilation, non-traditional medications that can be considered include neuromuscular blocking agents, kinetic bed therapy, anticholinergics for sialorrhea, and doxapram as adjuncts to conventional management. These interventions can significantly impact morbidity, mortality, and quality of life outcomes when used appropriately.

Neuromuscular Blocking Agents (NMBAs)

• Recommended for: Early severe ARDS patients 1
• Benefits: May decrease mortality (RR 0.74; 95% CI 0.56-0.98) compared to no NMBAs, with greatest benefit when compared to deep sedation strategies 1
• Administration options:
  • Either bolus dosing or continuous infusion
  • Cisatracurium most frequently used in clinical trials
  • Consider cessation after 48 hours or earlier for rapidly improving patients
• Cautions: May increase ICU-acquired weakness (RR 1.16; 95% CI 0.98-1.37) 1

Positioning Strategies

• Semi-recumbent positioning:

  • Recommended at 45 degrees from horizontal 1
  • Decreases incidence of ventilator-associated pneumonia
  • Low-cost and feasible intervention

• Kinetic bed therapy:

  • Associated with decreased VAP incidence based on multiple trials 1
  • Consider implementation despite cost concerns

• Prone positioning:

  • May decrease VAP incidence 1
  • Particularly useful in severe ARDS

Pharmacologic Interventions for Specific Conditions

For Dyspnea Management

• First-line: Opioids (high recommendation) 1

  • Titrate to control respiratory distress

• Second-line: Benzodiazepines or propofol if dyspnea persists despite adequate opioid doses 1

  • Particularly useful when anxiety contributes to dyspnea

For Sialorrhea (Excessive Secretions)

• First-line: Trial of anticholinergic medication 1

  • Start with inexpensive oral anticholinergic
  • Consider longer-acting anticholinergic patch as alternative

• Second-line: Botulinum toxin therapy to salivary glands if inadequate response to anticholinergics 1

For Respiratory Stimulation

• Doxapram:
  • May be used while preparing for NIV or when NIV is unavailable/not tolerated 1
  • Can be combined with NIV in patients prone to CO2 retention or who remain drowsy on NIV

End-of-Life Considerations for Ventilated Patients

For terminal ventilator withdrawal:

• Discontinue neuromuscular blockers and allow effects to wear off
• Provide anticipatory titrated doses of opioids and benzodiazepines 1
• Consider discontinuing antibiotics and IV fluids that may cause respiratory congestion 1
• Choose between terminal extubation or terminal weaning based on patient/family preferences and clinical circumstances 1
• For death rattle (noisy breathing), consider anticholinergic agents 1

Important Clinical Considerations

1. Sedation management:

   • Titrate sedation with daily interruptions to minimize duration of mechanical ventilation 1
   • Use validated assessment tools to guide sedation

2. Ventilation parameters:

   • Avoid routine hyperventilation with hypocapnia as it may worsen global brain ischemia 1
   • Target normocapnia (PaCO2 40-45 mmHg or PETCO2 35-40 mmHg) 1

3. For VAP prevention/treatment:

   • Consider empirical treatment with combination antibiotics when risk factors for multidrug-resistant pathogens exist 2
   • Include coverage for MRSA and two antibiotics with antipseudomonal activity from different classes 2

Pitfalls to Avoid

1. Prolonged use of neuromuscular blockers without adequate sedation
2. Failure to monitor for ICU-acquired weakness with prolonged NMBA use
3. Inappropriate hyperventilation causing cerebral vasoconstriction
4. Neglecting to address dyspnea with appropriate medications
5. Inadequate initial antibiotic therapy for VAP, which is associated with higher mortality 2

When implementing these non-traditional approaches, always consider the patient's specific condition, contraindications, and the balance between potential benefits and harms to optimize outcomes.