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Indications for Intubation and Mechanical Ventilation
- 1. Indications for Intubation and Mechanical Ventilation
- 2. Indications for Intubation & Mechanical Ventilation • Hypoxic Respiratory Failure • Hypercarbic Respiratory Failure • Airway Protection • Non-Sustainable Work of Breathing
- 3. Hypoxemia • PaO2 < 60mmHg • SpO2 < 94% There are several causes of Hypoxemia: • Decreased FiO2 • Alveolar Hypoventilation • Dead Space (e.g. pulmonary emboli) • Shunt (e.g. pneumonia or ARDS) Oxygen (O2 )
- 4. Hypercarbia • PaCO2 > 45mmHg Hypercarbia is common with: • COPD/Emphysema • Hypoventilation • Medications • Altered mental status (e.g. head injury, stroke) • Severe metabolic derangement (e.g. hypoglycemia or myxedema coma) Carbon Dioxide (CO2 )
- 5. Airway Protection • Altered mental status, hypoventilation, and inability to clear secretions • Examples: stroke, head injury, sedation, medications, anesthesia
- 6. Non-sustainable work of breathing • Patient is struggling to oxygenate, ventilate, balance acidosis, or overcome airway obstruction • High minute ventilation • High BPM • Inability to speak in full sentences • Accessory muscle use
Editor's Notes
- Before discussing airway management and modes of mechanical ventilation it is important to review the indications for intubation and mv support.
- The indications for intubation and mechanical ventilation can be divided into 4 broad categories: hypoxemic respiratory failure, hypercarbic respiratory failure airway protection, and a non-sustainable work of breathing
- Hypoxemia is defined as a partial pressure of arterial oxygen less than 60 millimeters of mercury OR SpO2 less than 94%. Although an SpO2 < 94% defines hypoxemia, oxygen therapies and mechanical ventilation may not be indicated until more severe hypoxemia occurs or respiratory failure becomes evident. Causes of hypoxemia include decreased inhaled oxygen, alveolar hypoventilation, and V - Q mismatch. V – Q mismatch includes dead space and shunt. Hypoxemia is common in several pathologic clinical states including, pneumonia, ARDS, and pulmonary emboli.
- Hypercarbia is defined as a partial pressure of arterial carbon dioxide greater than 45 millimeters of mercury. Hypercarbia is common in COPD, emphysema and hypoventilation. Common causes of hypoventilation include medications, altered mental status, head injury, and severe metabolic derangements, such as hypoglycemia or myxedema coma.
- Patients often need to be intubated and mechanically ventilated for airway protection. Patients with altered mental status may have associated hypoventilation and inability to clear secretions. Further, obtunded patients in the supine position have muscle relaxation of the tongue and soft tissues of the posterior oro-pharynx, which fall backwards, obstructing air flow. Examples where airway protection may be needed include stroke, head injury, sedation, medications, and anesthesia.
- Patients with a non-sustainable work of breathing may need to be intubated and mechanically ventilated. Patients struggling to oxygenate, ventilate, balance a metabolic acidosis, or overcome airway obstruction, should be considered for mechanical ventilation. Struggling patients demonstrate any or all of the following characteristics: high minute ventilation with an increased number of breaths per minute, an inability to speak in full sentences, and obvious accessory muscle use. Pathologic examples include status asthmaticus and severe metabolic acidosis.