What are the key assessments and interventions in a respiratory intensive care unit (ICU)?

Key Assessments and Interventions in a Respiratory ICU

Airway Management and Monitoring

Waveform capnography must be used continuously for all intubated patients, as failure to use it contributes to >70% of ICU airway-related deaths. 1

• Document and verify endotracheal tube depth on the bedside chart each shift and whenever respiratory deterioration occurs 1
• Maintain cuff pressure at 20-30 cm H₂O using regular measurements; higher inspiratory pressures may require higher cuff pressures 1
• Assume any apparent cuff leak is partial extubation until proven otherwise and investigate immediately 1
• Provide humidification and regular tracheal suction to prevent tube blockage 1
• Perform prompt fiberoptic inspection if partial tracheal tube obstruction is suspected 1
• Watch for "airway red flags" including absence or change of capnograph waveform, increasing airway pressure, reducing tidal volume, or inability to pass a suction catheter 2

Ventilator Settings and Respiratory Mechanics

Target tidal volume of 6-8 mL/kg ideal body weight to minimize ventilator-associated lung injury in critically ill patients. 3

• Apply PEEP of at least 5 cmH₂O after intubation of hypoxemic patients, with individualized higher PEEP strategies based on patient response 3
• Target SpO₂ 88-94% to avoid hyperoxia and hypocapnia, with careful CO₂ monitoring 3
• Maintain inspiratory-to-expiratory ratio of 1:2 or 1:3 to prevent air trapping, especially critical in patients with obstructive lung disease 3
• Monitor end-tidal CO₂ (ETCO₂) continuously with capnography interpretation, respiratory mechanics, and patient-ventilator synchrony 3
• Use Assist Control Ventilation (ACV) in 47% of patients to provide mandatory backup rate preventing central apneas during sleep 3
• Use Pressure Support Ventilation (PSV) in 46% of patients to allow patient-triggered breaths with variable tidal volumes 3

Vital Signs and Physiological Monitoring

Monitor respiratory frequency continuously, as elevated fR predicts adverse outcomes and ICU readmission in critically ill patients. 1

• Assess breathing pattern including respiratory frequency and tidal volume, as abnormalities commonly reflect respiratory muscle dysfunction 1
• Monitor arterial blood gases or pulse oximetry on admission and regularly thereafter 1
• Measure basic blood chemistry including red and white blood cell count, differential cell count, creatinine, urea nitrogen, aminotransferases, sodium, and potassium 1
• Track C-reactive protein (CRP) as the clinical course is closely reflected by CRP course, though it cannot differentiate bacterial from nonbacterial pneumonia 1
• Monitor heart rate and blood pressure as part of routine vital function assessment 1

Respiratory Muscle Function Assessment

Assess respiratory muscle function using P I,max and P E,max measurements, as respiratory muscle performance is the major issue in deciding timing and pace of mechanical ventilation discontinuation. 1

• Evaluate diaphragmatic function using bedside ultrasound, particularly in patients being weaned from mechanical ventilation 4
• Monitor for signs of diaphragmatic dysfunction including ineffective patient triggering and weaning failure 4
• Measure transdiaphragmatic pressure when severe diaphragmatic dysfunction is suspected, requiring simultaneous recordings of esophageal and gastric pressures 4

Positioning and Physical Assessment

Maintain 35-degree head-up positioning to reduce airway swelling and improve laryngoscopic view. 1

• Avoid unnecessary positive fluid balances to minimize airway edema 1
• Nominate an experienced team member solely to safeguard the airway during high-risk procedures such as patient turns, physiotherapy, transfers, and insertion of devices near the airway 1
• Assess for physical deconditioning focusing on deficiencies at physiological and functional level rather than medical diagnosis 1
• Monitor vital functions appropriately to ensure physiotherapy interventions are both therapeutic and safe 1

Radiographic and Laboratory Studies

Obtain post-intubation chest X-ray to confirm appropriate tracheal tube insertion depth and identify complications. 1

• Perform chest radiograph for all patients hospitalized with suspected community-acquired pneumonia 1
• Monitor for pneumothorax following difficult laryngoscopy, as it is associated with inadvertent endobronchial intubation and traumatic intubation 1
• Observe for bleeding, swelling, and surgical emphysema if the airway has been traumatized or operated upon 1

Weaning and Extubation Preparation

Before initiating weaning, ensure the precipitant cause of respiratory failure is treated, pH is normalized, and chronic hypercapnia is corrected. 4

• Provide physiotherapy treatment before and after extubation to reduce weaning duration and risk of extubation failure 4
• Consider prophylactic non-invasive ventilation after extubation for patients at high risk of reintubation 4
• Assess sedation holds carefully as they are hazardous with high-risk airways and require risk assessment 1
• Use "mittens" and other forms of physical restraint to minimize risk of self-extubation 1

Early Mobilization and Rehabilitation

Initiate early mobilization after initial cardiorespiratory and neurological stabilization, as it reduces time to wean from mechanical ventilation and is the basis for functional recovery. 1

• Begin physical activity as safe and feasible intervention after stabilization, as no adverse effects on inflammatory status have been reported 1
• Reduce active muscle mass, duration of exercise, or number of repetitions to lower metabolic demands in hemodynamically unstable patients 1
• Avoid aggressive mobilization in patients with hemodynamic instability or those on high FiO₂ and high levels of ventilatory support 1

Critical Complications to Monitor

Administer intravenous corticosteroids for at least 12 hours in high-risk patients to reduce airway edema, post-extubation stridor, and reintubation rates. 1

• Monitor for pharyngeal or oesophageal injury following difficult airway management, which may lead to deep infection and life-threatening sepsis 1
• Assess for difficult facemask ventilation complications including gastric distension necessitating decompression for optimal mechanical ventilation 1
• Evaluate for upper airway infection and administer antibiotics if suspected 1

ICU Admission Criteria

Consider ICU or intermediate care unit admission for patients with acute respiratory failure, severe sepsis or septic shock, or radiographic extension of infiltrates. 1

• Use severe CAP criteria for ICU referral: systolic blood pressure <90 mmHg, severe respiratory failure (PaO₂/FiO₂ ratio <250), multilobar involvement, or requirement for mechanical ventilation or vasopressors 1