Sunday, July 7, 2013

Why is this patient on mechanical ventilation TODAY?

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It is very frustrating when I meet with the ICU staff Respiratory Therapist and ask why is this patient on the ventilator today and I get the following response “they had surgery”, “they coded”, “they had ventilatory failure”, “they have ARDS”, etc. Yet, these events happened hours, days, or even weeks ago, and they are not in the acute stages of their illness anymore.  There is a huge difference between initial indications for mechanical ventilation (MV) versus current goals for MV.

Sure, we maintain consistent goals throughout the entire span someone is on MV in regards to providing patient safety, promoting lung protection, and promoting patient comfort. However, daily goals are very different.

An example; a patient may have been intubated & placed on MV due to hypoxic respiratory failure, secondary to ARDS. The goals for this initial day maybe:

1.       Reverse hypoxemia.
2.       Permit sedation (if having difficulty maintaining safe tidal volumes). Note- patients are sedated all the time without MV, I mean deep sedation.
3.       Decrease systemic oxygen consumption (if ARDS is secondary to sepsis).

However, say this patient is not in the acute phase anymore, their chest x-ray has cleared up, their P/F ratio is > 200, and their set PEEP has been decreased. The goals for today maybe:

1.       Initial spontaneous breathing trials (SBT).
2.       Decrease the FiO2.
3.       Reverse respiratory distress (after failed SBT).
4.       Reverse ventilatory muscle fatigue (after failed SBT).

As you can see the goals/indications are very different and if you continue to treat your patient as if they were in the acute phase of their illness you may prolong liberation.

I would encourage you to ask “why is this patient on the ventilator today?” versus “what is the reason they were placed on MV?”