Complications in the ventilated patient

The use of mechanical ventilation may subject patients to a variety of complications and adverse effects. Certain complications may be a direct result of mechanical ventilation, whereas others seen in association with this modality of therapy appear to be related to concurrent conditions and the severity of underlying disease. The incidence, evaluation, and management of major complications associated with mechanical ventilation are reviewed.     

Nutrition support in the acutely ventilated patient

Although the nutrition support literature is limited and therefore does not provide robust evidence to promote grade A or strong recommendations, there is a "signal" from all of these studies taken a a whole that critically ill patients may benefit from nutritional manipulation. The acutely ventilated patient that is likely to still be intubated by day three is a classic example of the critically ill patient who has the potential to achieve positive outcomes with nutritional support. Initiating nutrition support early improves the chances of benefit. However, nutrition cannot be provided in a vacuum. It is only one part of a multitude of treatments and therapies that must be optimally applied by a multidisciplinary team of professionals dedicated to the care of ICU patients. The exact makeup of the enteral (or parenteral) formula that is most likely to improve survival is unclear. More research is needed. Further study may demonstrate the possibility for nutritional manipulation to be one of the most important treatments physicians can offer to critically ill ventilated patients. Nutrition may have as much survival benefit as activated protein C, a drug costing over $7000 per course of therapy. No longer can it be said that nutrition makes no difference.     

Tracheostomy management in the chronically ventilated patient

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.     

Nutritional support in the mechanically ventilated patient

In summary, nutritional management of the intubated patient requires several decision steps. Nutritional support should be strongly considered if the patient has evidence of malnutrition by nutritional assessment or has a high likelihood of becoming malnourished by virtue of a severe, prolonged critical illness. Nutrition can be administered enterally if good gut function exists or parenterally in patients unable to tolerate enteral feeding. Nutritional goals in the intensive care unit include maintenance of body weight and lean body mass. Proper nutritional therapy includes assessment of adequate caloric requirements as well as appropriate protein, carbohydrate, and fat composition of the nutritional support. Monitoring the efficacy of nutritional therapy includes evaluating nitrogen balance. Complications of both enteral and parenteral therapy exist. Nutritional therapy is but one link in the chain of therapeutic endeavors given a critically ill patient but, as with all other treatment modalities, requires knowledge of basic fundamentals.     

Sedation and analgesia in the mechanically ventilated patient

Sedation and analgesia are important components of care for the mechanically ventilated patient in the intensive care unit (ICU). An understanding of commonly used medications is essential to formulate a sedation plan for individual patients. The specific physiological changes that a critically ill patient undergoes can have direct effects on the pharmacology of drugs, potentially leading to interpatient differences in response. Objective assessments of pain, sedation, and agitation have been validated for use in the ICU for assessment and titration of medications. An evidence-based strategy for administering these drugs can lead to improvements in short- and long-term outcomes for patients. In this article, we review advances in the field of ICU sedation to provide an up-to-date perspective on management of the mechanically ventilated ICU patient.     

Transport of the mechanically ventilated pediatric patient

Children deserve quality care when they are critically ill or injured. Specialized pediatric services may be limited outside major medical centers. Transport by specialized pediatric and neonatal transport teams may be required to deliver patients to tertiary pediatric medical centers. In addition, in the past decade a cost-effective, organized, systematic approach to health care management has assumed greater importance, leading to the concept of the so-called medical home. In this model, a child with a complex medical problem is cared for in the environment in which he or she will receive the best care, with emphasis on providing rehabilitative and long-term care near the child's home. It is likely, then, that the field of pediatric transport medicine will assume greater importance in the coming decade.     

Exhaled breath condensate collection in the mechanically ventilated patient

Collection of exhaled breath condensate (EBC) is a non-invasive means of sampling the airway-lining fluid of the lungs. EBC contains numerous measurable mediators, whose analysis could change the management of patients with certain pulmonary diseases. While initially popularized in investigations involving spontaneously breathing patients, an increasing number of studies have been performed using EBC in association with mechanical ventilation. Collection of EBC in mechanically ventilated patients follows basic principles of condensation, but is influenced by multiple factors. Effective collection requires selection of a collection device, adequate minute ventilation, low cooling temperatures, and sampling times of greater than 10?min. Condensate can be contaminated by saliva, which needs to be filtered. Dilution of samples occurs secondary to distilled water in vapors and humidification in the ventilator circuit. Dilution factors may need to be employed when investigating non-volatile biomarkers. Storage and analysis should occur promptly at -70?°C to -80?°C to prevent rapid degradation of samples. The purpose of this review is to examine and describe methodologies and problems of EBC collection in mechanically ventilated patients. A straightforward and safe framework has been established to investigate disease processes in this population, yet technical aspects of EBC collection still exist that prevent clinical practicality of this technology. These include a lack of standardization of procedure and analysis of biomarkers, and of normal reference ranges for mediators in healthy individuals. Once these procedural aspects have been addressed, EBC could serve as a non-invasive alternative to invasive evaluation of lungs in mechanically ventilated patients.     

Interhospital transport of the adult mechanically ventilated patient

Interhospital transport of the adult mechanically ventilated patient may be necessary for those who require specialized care. An experienced medical team can safely transport even the most critically ill patients if the care is optimized before departure. Patients with severe respiratory failure may have to remain on an ICU ventilator throughout the transport period, depending on the specific transport ventilator. Near-terminal ARDS can be treated with ECLS, and these patients also may be safely transported to a regional center.     

Intrahospital transport of the adult mechanically ventilated patient

As the diagnosis and treatment of critically ill patients continues to advance, the frequency of intrahospital transport of ventilator-dependent patients increases. Once the risks and benefits of transport are established, even the sickest ICU patient can be transported safely when adequate time is taken and preparations are made before beginning the transport. Patients should be stabilized as much as possible and monitored before, during, and after transport. Those responsible for the patient should be trained to provide a safe outcome. This necessitates that caregivers receive education in patient evaluation, potential risks, complications, interventions, equipment operation, and troubleshooting that may be necessary when caring for ventilated patients outside the ICU. All members of the transport team should communicate effectively and be aware of their roles in the transport process to minimize delays and mishaps during transport and at the final destination. Written policies that define the level of personnel, level of training, level of support, and equipment necessary can facilitate the transport process. When choosing a device to provide ventilation, the patient's clinical condition should be determine which method is used for transport.     

Paralyzation and sedation of the ventilated trauma patient

Sedation and analgesia will be required in the mechanically ventilated pediatric trauma patient. Adequate provision of both has a number of beneficial physiologic and psychologic effects. There are a number of categories of sedatives available for use. To provide optimal management and avoid adverse sequellae, an understanding of the pharmacology of these agents should guide their use in this group of patients, who are likely to have variable pharmacokinetic responses and therapeutic goals. Neuromuscular blockade is warranted in only a select population of mechanically ventilated ICU patients. Given newer ventilator technology and modes, it is certainly possible to achieve patient-ventilator synchrony with the use of sedation alone. Neuromuscular blockade is associated with a number of possible adverse effects, including prolonged weakness or paresis, and prohibits ongoing clinical assessment. When the use of this therapy is deemed necessary, it is again essential to understand the pharmacodynamics and pharmacokinetics of the available agents to avoid potential complications.     

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.     

Fatal re-expansion pulmonary oedema in a mechanically ventilated patient

Fatal course of re-expansion pulmonary oedema (REPO) is infrequent and very rarely documented in mechanically ventilated patients. We report a case of fatal REPO following tube thoracostomy for a right-sided pneumothorax in an elderly patient of chronic obstructive pulmonary disease (COPD) with respiratory failure on mechanical ventilation.     

Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient

Bronchopleural fistulas are associated with high morbidity and mortality and are particularly challenging in the ventilated patient. Familiarity with both basic and more technical medical management techniques may lessen morbidity and improve survival. Prompt recognition of BPFs and appropriate placement of a chest tube with an adequate suction device are crucial to prevent potential tension pneumothorax and to drain an infected pleural space. The chest tube may be used therapeutically to decrease BPF air leak and to promote fistula repair. Appropriate conventional ventilator manipulations aimed at decreasing fistula air leak and maintaining adequate oxygenation and ventilation may fail and necessitate a trial of HFV. Definitive therapy by the bronchoscopic application of a sealing agent to occlude the fistula site can be used, particularly in the poor surgical candidate.