Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department

Abstract

Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. Noninvasive ventilation is recommended for patients with acute exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Less evidence supports its use in asthma and other causes of acute respiratory failure. Use of noninvasive ventilation in the prehospital setting is relatively new, and some evidence suggests benefit. Monitoring priorities for noninvasive ventilation include response to treatment, respiratory and hemodynamic stability, noninvasive ventilation tolerance, detection of noninvasive ventilation failure, and identification of air leaks around the interface. Application of injurious ventilation increases patient morbidity and mortality. Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive and invasively ventilated patients are discussed, with a particular emphasis on initiation and ongoing monitoring priorities focused on maintaining patient safety and improving patient outcomes.

Research Progress on the Mechanism of Right Heart-Related Pulmonary Edema

“…The principles of treatment for pulmonary edema are correction of the primary cause of pulmonary edema, and respiratory support to improve patient oxygenation [ 62 ]. Non-invasive positive pressure ventilation is the first line of treatment to improve cardiogenic pulmonary edema and correct hypoxemia; in patients, who are already mechanically ventilated, a lung-protective ventilation strategy needs to be implemented to avoid further damage to alveolar epithelial cells and vascular endothelial cells from mechanical ventilation [ 63 ]. Due to the drastic individual differences, there is no unifying medication.…”

Noninvasive Ventilation: Education and Training. A Narrative Analysis and an International Consensus Document

“…Overall, a certain skill mix of a multidisciplinary NIV team is needed to initiate and deliver safe and effective NIV treatment to patients with acute respiratory failure. Data from the literature indicates that, with the exception of the respiratory therapists, the level of knowledge and skills needed to deliver safe and effective NIV remains deficient among many healthcare professionals who are entrusted with managing patients with acute respiratory failure in different healthcare facilities [28][29][30][31][32][33][34][35][36].…”

Vibrating Mesh Nebulisers – Can Greater Drug Delivery to the Airways and Lungs Improve Respiratory Outcomes?

“…MV is used for the most seriously ill and critical patients, but more recently there has been a general trend towards less invasive means of ventilatory support for many such patients. [54][55][56] Aerosol therapy is frequently introduced into mechanical breathing circuits and is used by over 95% of intensivists, mostly for bronchodilator, antibiotic and steroid administration, 51,[57][58][59] and less frequently for anticoagulants, diuretics, mucoactive agents, prostacyclins and surfactants. 46 One recent in vitro study compared the performance of four different nebulisers; the SideStream ® Disposable JN (Philips Healthcare Limited, Guildford, Surrey, UK), the Multisonic ® InfraControl UN (Flores medical GmbH, Probstzella, Germany), the Aerogen ® Pro VMN and the Aerogen ® Solo VMN (Aerogen, Dangan, Galway, Ireland) to deliver salbutamol in a model MV system.…”