Invasive Mechanical Ventilation in Severe Respiratory Distress

Indications for Invasive Ventilation

• The American Thoracic Society recommends immediate invasive mechanical ventilation for patients with severe hypoxemia and altered mental status, as seen in this patient with pneumonia, due to the high risk of non-invasive ventilation failure 1, 2, 3
• Patients with altered mental status are at high risk for non-invasive ventilation failure and should be intubated promptly, as recommended by the British Medical Journal 4, 1, 2, 3

Contraindications to Non-Invasive Ventilation

• Altered mental status is an absolute contraindication to non-invasive ventilation, as it indicates an inability to protect the airway and cooperate with non-invasive ventilation 1, 2, 3
• Severe hypoxemia, defined as an SpO2 of 85-88% despite supplemental oxygen, is a relative contraindication to non-invasive ventilation and may require invasive mechanical ventilation 1, 2, 3

Ventilator Management

• The American College of Chest Physicians recommends a lung-protective ventilation strategy with a tidal volume of 4-6 mL/kg predicted body weight and a plateau pressure <30 cmH2O 1, 2, 3, 5
• Positive end-expiratory pressure (PEEP) should be set at least 5 cmH2O, with higher levels used in severe acute respiratory distress syndrome (ARDS) 1, 2, 3, 5

Additional Considerations

• Prone positioning for >12 hours daily may be beneficial for patients with severe ARDS, as recommended by the Society of Critical Care Medicine 1, 2, 3, 5
• Deep sedation and analgesia with muscle relaxation may be necessary in the first 48 hours for patients with moderate-severe ARDS, as recommended by the American Thoracic Society 1, 2, 3