Can ventilator patients receive acute care?

Ventilator Patients Can and Should Receive Acute Care

Ventilator patients not only can receive acute care, but often require it as part of comprehensive management of their condition. 1 Mechanical ventilation is a cornerstone of critical care medicine and is frequently used in acute care settings for patients with respiratory failure.

Evidence Supporting Acute Care for Ventilated Patients

Types of Ventilation in Acute Care

• Invasive mechanical ventilation: Used in intensive care settings for patients with severe respiratory failure 1
• Non-invasive ventilation (NIV): Particularly indicated in:
  • COPD with respiratory acidosis (pH 7.25-7.35)
  • Hypercapnic respiratory failure from chest wall deformity or neuromuscular diseases
  • Cardiogenic pulmonary edema unresponsive to CPAP
  • Weaning from tracheal intubation 1

Acute Care Interventions for Ventilated Patients

1. Respiratory Support Management:

   • Lung-protective ventilation strategies with lower tidal volumes (4-8 ml/kg predicted body weight) 2
   • Titration of PEEP based on severity of respiratory failure 2
   • Regular assessment of ventilator parameters and patient-ventilator synchrony 3

2. Medical Management:

   • Antibiotics for ventilated patients with signs of infection (especially with increased sputum purulence) 1
   • Supplemental oxygen titrated to improve hypoxemia (target saturation 88-92%) 1
   • Sedation management to maintain appropriate level of consciousness while avoiding over-sedation 4

3. Specialized Interventions:

   • Prone positioning for patients with severe ARDS 2
   • Neuromuscular blockade for refractory hypoxemia or ventilator dyssynchrony 1, 2
   • ECMO consideration for severe cases refractory to conventional therapy 2

4. Nutritional Support:

   • Early initiation of enteral nutrition for ventilated patients 5
   • Appropriate caloric and protein provision to prevent malnutrition 5

Weaning from Mechanical Ventilation

Weaning is a critical component of acute care for ventilated patients:

• Protocol-driven weaning by respiratory therapists can significantly decrease duration of mechanical ventilation and mortality 6
• Daily assessment for weaning readiness should be conducted 1
• Spontaneous breathing trials should be performed when appropriate 7
• NIV can be used as a bridge during the weaning process 1

Special Considerations

Prolonged Mechanical Ventilation

• For patients requiring prolonged ventilation, specialized weaning units may be beneficial 8
• Regular reassessment of ventilation goals and strategies is essential 1
• Early mobilization and physiotherapy improve outcomes 8

End-of-Life Considerations

• Ventilation therapy should be discontinued if the desired therapeutic goal cannot be realistically achieved or is not desired by the patient 1
• Communication should be transparent and empathic with patients and families 1
• Appropriate symptom management should be provided if ventilation is being withdrawn 1

Pitfalls to Avoid

1. Inappropriate Sedation Management:

   • Avoid abrupt discontinuation of sedation in ventilated patients, which can lead to anxiety, agitation, and resistance to mechanical ventilation 4
   • Titrate sedation to maintain minimal level needed for patient comfort and ventilator synchrony 4

2. Ventilator-Associated Complications:

   • Monitor for and prevent ventilator-associated pneumonia
   • Avoid excessive tidal volumes that can cause lung injury 2
   • Prevent patient-ventilator asynchrony which can lead to ineffective ventilation and increased work of breathing 3

3. Delayed Weaning:

   • Avoid unnecessary prolongation of mechanical ventilation 6
   • Implement daily assessment for weaning readiness 7

In conclusion, ventilator patients not only can receive acute care but often require comprehensive acute care management to address their complex needs, optimize outcomes, and facilitate successful liberation from mechanical ventilation when appropriate.