Daily ventilatior care

 

Daily Ventilator Care in the ICU: A Comprehensive Review

Dr Neeraj Manikath, Claude.ai

Introduction

Mechanical ventilation is a cornerstone of critical care management, providing life-sustaining support for patients with respiratory failure. The daily care of mechanically ventilated patients involves a multifaceted approach that encompasses respiratory assessment, ventilator management, prevention of complications, and optimization of patient outcomes. This review outlines evidence-based practices for the daily care of ventilated patients in the intensive care unit (ICU).

1. Initial Daily Assessment

Clinical Evaluation

• Comprehensive physical examination with focus on respiratory system
• Vital signs assessment, including respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation
• Evaluation of patient-ventilator synchrony
• Assessment of patient comfort and sedation level[1]

Ventilator Parameters Review

• Ventilation mode and settings (tidal volume, respiratory rate, PEEP, FiO2)
• Pressure measurements (peak inspiratory pressure, plateau pressure, driving pressure)
• Flow and volume curves
• Auto-PEEP assessment[2,3]

Laboratory and Imaging

• Arterial blood gas analysis
• Daily chest radiograph evaluation
• Point-of-care ultrasound when indicated
• Complete blood count and metabolic panel[4]

2. Lung-Protective Ventilation Strategies

Low Tidal Volume Ventilation

• Target 6-8 mL/kg predicted body weight
• Limit plateau pressure to ≤30 cmH2O
• Monitor driving pressure (plateau pressure minus PEEP) aiming for <15 cmH2O[5,6]

PEEP Optimization

• Individualize PEEP based on respiratory mechanics, oxygenation, and hemodynamics
• Consider PEEP/FiO2 tables or respiratory mechanics-based approaches
• Higher PEEP strategies for moderate-severe ARDS (P/F ratio <200)[7,8]

Recruitment Maneuvers

• Consider in patients with refractory hypoxemia
• Use with caution and monitor hemodynamics
• Not recommended as routine practice[9]

3. Daily Ventilator Bundle Implementation

Sedation Management

• Daily sedation interruption ("sedation vacation")
• Target light sedation when appropriate
• Use validated sedation assessment tools (e.g., RASS, SAS)
• Balance comfort with wakefulness to facilitate weaning[10,11]

Spontaneous Breathing Trials (SBT)

• Daily assessment of readiness for SBT
• Criteria: FiO2 ≤0.4, PEEP ≤8 cmH2O, hemodynamic stability
• SBT methods: pressure support, T-piece, CPAP
• Duration typically 30-120 minutes[12,13]

Head-of-Bed Elevation

• Maintain head of bed at 30-45° unless contraindicated
• Reduces risk of ventilator-associated pneumonia (VAP)
• Monitor for pressure injuries with prolonged elevation[14]

4. Prevention of Ventilator-Associated Complications

Ventilator-Associated Pneumonia Prevention

• Oral care with chlorhexidine
• Subglottic secretion drainage with specialized endotracheal tubes
• Hand hygiene and aseptic technique during airway manipulation
• Avoid unnecessary circuit disconnections[15,16]

Ventilator-Induced Lung Injury Prevention

• Maintain appropriate tidal volumes (6-8 mL/kg PBW)
• Monitor plateau pressures and driving pressure
• Consider prone positioning for moderate-severe ARDS
• Avoid excessive FiO2 (target SpO2 88-95% in most cases)[17,18]

Endotracheal Tube Care

• Secure ETT and document position (cm mark at teeth/lips)
• Reposition ETT periodically to prevent pressure injuries
• Maintain cuff pressure between 20-30 cmH2O
• Use continuous cuff pressure monitoring when available[19]

5. Secretion Management

Suctioning Practices

• Use closed suction systems when possible
• Pre-oxygenate before suctioning
• Limit suction time to <15 seconds
• Base suctioning frequency on individual assessment rather than routine schedule[20,21]

Humidification

• Ensure adequate gas humidification
• Heat and moisture exchangers (HMEs) or heated humidifiers
• Change HMEs per institutional protocol or when visibly soiled
• Monitor for circuit condensation with heated humidifiers[22]

6. Positioning and Mobility

Prone Positioning

• Consider for patients with P/F ratio <150 despite optimized ventilation
• Implement for 12-16 hours daily
• Requires trained team and protocol
• Monitor for complications (pressure injuries, tube displacement)[23,24]

Early Mobilization

• Implement progressive mobility protocol
• Begin with passive range of motion when appropriate
• Advance to sitting position, dangling, and ambulation as feasible
• Coordinate with physical and occupational therapy[25,26]

7. Nutritional Support

Enteral Nutrition

• Initiate early enteral nutrition (within 24-48 hours if possible)
• Use gastric residual volume protocols as per institutional policy
• Consider post-pyloric feeding in patients at high risk for aspiration
• Monitor for tolerance and adequate caloric intake[27,28]

Protein Requirements

• Target 1.2-2.0 g/kg/day protein intake
• Higher protein needs in patients with burns, trauma, or prolonged critical illness
• Consider indirect calorimetry when available for energy expenditure assessment[29]

8. Tracheostomy Considerations

Timing

• Consider after 7-10 days if prolonged ventilation anticipated
• Early tracheostomy may benefit specific patient populations
• Decision should be individualized based on patient factors[30,31]

Care of Tracheostomy

• Stoma care according to institutional protocol
• Secure tracheostomy tube appropriately
• Regular inner cannula cleaning for non-disposable inner cannulas
• Cuff management similar to endotracheal tubes[32]

9. Psychological Support and Communication

Delirium Prevention and Management

• Daily delirium screening (CAM-ICU, ICDSC)
• Implement ABCDEF bundle
• Minimize deliriogenic medications
• Provide appropriate environmental modifications (day/night cycle)[33,34]

Communication Strategies

• Establish communication methods for non-verbal patients
• Use communication boards, writing tools, or electronic devices
• Involve speech therapy when appropriate
• Ensure hearing aids and glasses are available if needed[35]

10. Special Considerations

Asynchrony Management

• Identify type of asynchrony (trigger, flow, cycle, etc.)
• Adjust ventilator settings to improve synchrony
• Consider neuromuscular blockade if severe asynchrony persists despite optimization
• Re-evaluate need for sedation[36,37]

ECMO Patients

• Modified ventilator strategies (ultra-protective ventilation)
• Lower respiratory rate, PEEP, and driving pressure
• Different goals for blood gases while on ECMO
• Special considerations for mobilization[38]

11. Daily Multidisciplinary Rounds

Key Discussion Points

• Ventilation status and weaning readiness
• Sedation strategy
• Preventive measures compliance
• Goals of care and communication with family
• Barriers to progress and potential solutions[39,40]

Documentation

• Daily progress notes documenting ventilator settings
• Response to interventions
• Plan for continued ventilatory support or weaning
• Communication with family regarding goals and progress[41]

Conclusion

Daily care of mechanically ventilated patients requires a comprehensive, multidisciplinary approach that combines evidence-based ventilator management with careful attention to preventing complications. This approach should be tailored to individual patient needs while adhering to best practices for lung-protective ventilation, weaning readiness assessment, and complication prevention. Regular reassessment and adaptation of the care plan are essential for optimizing outcomes in this vulnerable patient population.

References

1. Pham T, Brochard LJ, Slutsky AS. Mechanical ventilation: state of the art. Mayo Clin Proc. 2017;92(9):1382-1400.
2. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.
3. Telias I, Brochard L. Driving pressure: importance for the management of mechanical ventilation. Intensive Care Med. 2020;46(4):728-733.
4. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-755.
5. Fan E, Del Sorbo L, Goligher EC, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263.
6. Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788-800.
7. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873.
8. Goligher EC, Costa ELV, Yarnell CJ, et al. Effect of lowering Vt on mortality in acute respiratory distress syndrome varies with respiratory system elastance. Am J Respir Crit Care Med. 2021;203(11):1378-1385.
9. Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69.
10. Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-1477.
11. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-e873.
12. Girard TD, Alhazzani W, Kress JP, et al. An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017;195(1):120-133.
13. Ouellette DR, Patel S, Girard TD, et al. Liberation from mechanical ventilation in critically ill adults: an official American College of Chest Physicians/American Thoracic Society clinical practice guideline. Chest. 2017;151(1):166-180.
14. Wang L, Li X, Yang Z, et al. Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation. Cochrane Database Syst Rev. 2016;(1):CD009946.
15. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(6):687-713.
16. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care. 2009;18(5):428-437.
17. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168.
18. Munshi L, Del Sorbo L, Adhikari NKJ, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280-S288.
19. Branson RD, Gomaa D, Rodriquez D Jr. Management of the artificial airway. Respir Care. 2014;59(6):974-989.
20. American Association for Respiratory Care. AARC clinical practice guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758-764.
21. Maggiore SM, Lellouche F, Pignataro C, et al. Decreasing the adverse effects of endotracheal suctioning during mechanical ventilation by changing practice. Respir Care. 2013;58(10):1588-1597.
22. Restrepo RD, Walsh BK. Humidification during invasive and noninvasive mechanical ventilation: 2012. Respir Care. 2012;57(5):782-788.
23. Guérin C, Albert RK, Beitler J, et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med. 2020;46(12):2385-2396.
24. Piehl MA, Brown RS. Use of extreme position changes in acute respiratory failure. Crit Care Med. 1976;4(1):13-14.
25. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-1882.
26. Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017;43(2):171-183.
27. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
28. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79.
29. Weijs PJM, Looijaard WGPM, Beishuizen A, Girbes ARJ, Oudemans-van Straaten HM. Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients. Crit Care. 2014;18(6):701.
30. Andriolo BN, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2015;(1):CD007271.
31. Hosokawa K, Nishimura M, Egi M, Vincent JL. Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. Crit Care. 2015;19(1):424.
32. Morris LL, Whitmer A, McIntosh E. Tracheostomy care and complications in the intensive care unit. Crit Care Nurse. 2013;33(5):18-30.
33. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.
34. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med. 2019;47(1):3-14.
35. Happ MB, Garrett K, Thomas DD, et al. Nurse-patient communication interactions in the intensive care unit. Am J Crit Care. 2011;20(2):e28-e40.
36. Blanch L, Villagra A, Sales B, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 2015;41(4):633-641.
37. Pham T, Telias I, Piraino T, Yoshida T, Brochard LJ. Asynchrony consequences and management. Crit Care Clin. 2018;34(3):325-341.
38. Schmidt M, Pham T, Arcadipane A, et al. Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: an international multicenter prospective cohort. Am J Respir Crit Care Med. 2019;200(8):1002-1012.
39. Costa DK, White MR, Ginier E, et al. Identifying barriers to delivering the awakening and breathing coordination, delirium, and early exercise/mobility bundle to minimize adverse outcomes for mechanically ventilated patients: a systematic review. Chest. 2017;152(2):304-311.
40. Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170(4):369-376.
41. Sosnowski K, Lin F, Mitchell ML, White H. Early rehabilitation in the intensive care unit: an integrative literature review. Aust Crit Care. 2015;28(4):216-225.