When is it necessary to consider mechanical ventilation to rest a patient's lungs?

From the Guidelines

When debating a patient to give their lungs a rest, mechanical ventilation should be instituted if oxygen supply, even with high flow nasal oxygen, or continuous positive airway pressure became ineffective in correcting tachypnea and dyspnea, with a focus on lung-protective strategies when invasive ventilation is needed. This approach is supported by the 2019 WSES guidelines for the management of severe acute pancreatitis 1. The decision to intubate and provide mechanical ventilation should be based on signs of respiratory failure or distress that cannot be managed with non-invasive methods, such as persistent hypoxemia, hypercapnia with respiratory acidosis, increased work of breathing, or altered mental status affecting airway protection.

Key considerations for mechanical ventilation include:

• Using lung-protective strategies when invasive ventilation is needed, as recommended by the guidelines 1
• Instituting mechanical ventilation if non-invasive methods are ineffective in correcting tachypnea and dyspnea
• Considering the potential for pain, intra-abdominal hypertension, and pleural effusion to contribute to respiratory symptoms, despite adequate arterial oxygenation
• Being aware of the risk of pulmonary edema after fluid resuscitation due to increased systemic permeability

In terms of specific ventilation strategies, the guidelines recommend using lung-protective strategies when invasive ventilation is needed, which may include:

• Tidal volume 6-8 mL/kg ideal body weight
• Respiratory rate 12-20 breaths/minute
• PEEP 5-10 cmH2O
• FiO2 adjusted to maintain SpO2 >92% It is essential to regularly assess the patient's readiness for extubation once they show improvement in respiratory parameters and the underlying condition.

From the Research

Debating a Patient to Give Their Lungs a Rest

• The concept of giving a patient's lungs a rest is often associated with managing chronic lung diseases, such as Chronic Obstructive Pulmonary Disease (COPD) or Interstitial Lung Disease (ILD) 2.
• Studies have shown that providing supplemental oxygen to hospitalized adults can be beneficial, but it's crucial to follow evidence-based practices to avoid harm 3.
• In patients with COPD, combination therapy with bronchodilators, such as albuterol and ipratropium bromide, can be more effective than single-agent therapy in improving lung function and symptoms 4, 5, 6.
• The use of long-term oxygen therapy in patients with severe chronic resting hypoxemia has been strongly recommended, while ambulatory oxygen use in patients with severe exertional hypoxemia has been conditionally recommended 2.
• Education on oxygen equipment and safety is essential for patients and their caregivers to ensure proper use and minimize risks 2.

Management of COPD

• Combination therapy with fluticasone propionate/salmeterol has been shown to be more effective than ipratropium bromide/albuterol in improving lung function, symptoms, and quality of life in patients with COPD 5.
• A combination of ipratropium and albuterol has been found to be more effective than either agent alone in improving lung function and symptoms in patients with COPD 6.
• The use of inhaled corticosteroids and long-acting beta2-adrenoceptor agonists, such as fluticasone propionate/salmeterol, has been found to be beneficial in patients with COPD 5.

Oxygen Therapy

• Oxygen therapy has evolved over the years, and clinicians should follow evidence-based practices to provide maximum benefit and avoid harm 3.
• The American Thoracic Society has provided guidelines for the use of home oxygen therapy in adults with COPD or ILD, highlighting the need for individualized assessment and monitoring 2.
• Humidification of supplemental oxygen may be considered when flows exceed 4 L/min to prevent dryness and discomfort in the airways 3.