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Mechanical ventilation of adults in the emergency department

Aut hors: Peter Hou, MD, Amado Alejandro Baez, MD, MSc, MPH, FAAEM, FCCM
Sect ion Editor: Ron M Walls, MD, FRCPC, FAAEM
Deput y Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.

Lit erat ure review current t hrough: Aug 2019. | T his topic last updat ed: Feb 07, 2019.

INTRODUCTION

Pat ient s present t o t he emergency depart ment (ED) wit h a wide range of condit ions t hat may require
t racheal int ubat ion or posit ive pressure vent ilat ion, including: pneumonia, ast hma, chronic obst ruct ive
pulmonary disease (COPD), cardiogenic pulmonary edema, acut e respirat ory dist ress syndrome,
st roke, t rauma, drug overdose, severe sepsis, shock, and neuromuscular disorders such as myast henia
gravis or Guillain-Barré syndrome.

Once a definit ive airway has been secured, vent ilat ory management ensues. Vent ilat ory st rat egies
vary according t o t he clinical scenario, and t o provide opt imal care, emergency clinicians must
underst and t he fundament al concept s of mechanical vent ilat ion.

This t opic review will discuss concept s needed t o manage mechanical vent ilat ion in t he ED, including
vent ilat or set t ings, modes of mechanical vent ilat ion, complicat ions of mechanical vent ilat ion,
management of vent ilat ed pat ient s in dist ress, general and disease-specific vent ilat ion st rat egies,
and weaning from vent ilat ory support [1-5]. Alt hough useful guidelines are provided, clinicians will need
t o individualize mechanical vent ilat ion st rat egies based upon t he clinical scenario. Tracheal int ubat ion
and ot her aspect s of airway management are discussed elsewhere. (See "Rapid sequence int ubat ion
for adult s out side t he operat ing room" and "Rapid sequence int ubat ion (RSI) out side t he operat ing
room in children: Approach".)

OBJECTIVES AND OVERVIEW OF MECHANICAL VENTILATION

Clinicians place pat ient s on mechanical vent ilat ion t o accomplish any of a number of goals, including:
 ● To prot ect t he airway
● To improve pulmonary gas exchange (ie, reverse hypoxemia or acut e respirat ory acidosis)
● To relieve respirat ory dist ress (ie, decrease oxygen consumpt ion or respirat ory muscle fat igue)
● To assist wit h airway and lung healing
● To permit appropriat e sedat ion and neuromuscular blockade

The vent ilat or simulat es four st ages of breat hing:

1. The vent ilat or or t he pat ient t riggers t he init iat ion of inspirat ion.

2. The vent ilat or provides a breat h, det ermined by preset variables (eg, pressure, volume, and flow
rat e).

3. The vent ilat or halt s inspirat ion when a preset paramet er, such as t idal volume, inspirat ory t ime, or
airway pressure, is reached.

4. The vent ilat or swit ches t o expirat ion and t he breat h is complet ed. Expirat ion occurs when t he
expirat ory valve opens, and generally involves a passive mechanism generat ed by t he recoil of t he
chest wall, lungs, and diaphragm.

VENTILATOR SETTINGS

To provide t he benefit s of mechanical vent ilat ion, emergency clinicians must be familiar wit h t he
vent ilat or apparat us in use at t heir hospit al and underst and t he various set t ings t hat can be modified.
In t his sect ion, basic vent ilat or set t ings of import ance t o t he emergency clinician are described. More
det ailed discussions of mechanical vent ilat ion set t ings are found separat ely. (See "Overview of
mechanical vent ilat ion" and "Modes of mechanical vent ilat ion".)

Vent ilat or set t ings are adjust ed t o provide adequat e minut e vent ilat ion t o meet met abolic demand,
while minimizing t he risk of iat rogenic complicat ions. Minut e vent ilat ion (MV) equals t idal volume
mult iplied by respirat ory rat e (MV = TV x RR). Normal MV ranges from 5 t o 10 L/min. The basal
vent ilat ory rat e is select ed by t he clinician. Tidal volume is generally based on ideal body weight and
varies according t o t he vent ilat ion mode chosen. (See 'Modes of vent ilat ion' below.)

● Breat h t ypes – Mechanical vent ilat ors can deliver different kinds of breat hs. A mandat ory breat h
is st art ed, cont rolled, and ended by t he vent ilat or, which does all t he work. An assist ed breat h is
init iat ed by t he pat ient , but cont rolled and ended by t he vent ilat or. A spont aneous breat h is
init iat ed, cont rolled, and ended by t he pat ient ; t he volume of t he breat h delivered by t he
vent ilat or is det ermined by t he pat ient ’s effort and physiologic reserve. (See "Overview of
mechanical vent ilat ion".)
● Triggers – An assist ed breat h can be t riggered by eit her pressure or flow. The former requires a
demand valve, which senses a negat ive airway pressure deflect ion when t he pat ient init iat es a
breat h. A t rigger sensit ivit y t hreshold of -1 t o -3 cmH2O is common. When t he t hreshold is
reached, t he vent ilat or delivers a breat h. (See "Overview of mechanical vent ilat ion".)

The flow t rigger uses a circuit of gas t hat flows cont inuously past t he pat ient . A preset change in
flow rat e, creat ed when t he pat ient init iat es a breat h, t riggers t he vent ilat or t o deliver a breat h. A
basal flow rat e of 10 L/min is common, and a t rigger sensit ivit y t hreshold of 2 L/min is frequent ly
used.

Regardless of t he t rigger mechanism, t he t hreshold must be appropriat e. If it is t oo low, t he

vent ilat or will "aut o-cycle" (ie, deliver a cont inual series of breat hs), result ing in respirat ory
alkalosis; if t oo high, t he pat ient will be "locked out " from vent ilat or-support ed breat hs, while
expending considerable energy. In bot h condit ions, t he mechanically-vent ed pat ient will appear t o
be in respirat ory dist ress, and t he work of breat hing will increase.

● Respirat ory rat e – The clinician det ermines t he minimum number of breat hs per minut e (ie,
respirat ory rat e) given t o t he pat ient by t he vent ilat or. The rat e can be adjust ed according t o t he
disease process. (See 'Disease-specific vent ilat ory management ' below and "Overview of
mechanical vent ilat ion".)

● Inspirat ory t o expirat ory (I:E) rat io – Inspirat ory t ime is equal t o t idal volume divided by flow rat e (I
t ime = TV/FR). Decreasing t he t idal volume or increasing t he flow rat e decreases t he inspirat ory
t ime, and decreases t he inspirat ory t o expirat ory (I:E) rat io. The normal I:E rat io is 1:2 or 1:3.

Clinicians oft en reduce t he I:E rat io t o 1:4 or 1:5 in t he presence of obst ruct ive airway disease,
which requires great er t ime for expirat ion. An inverse I:E rat io may be necessary in st at es of low
lung compliance, such as acut e respirat ory dist ress syndrome (ARDS). Inverse rat io vent ilat ion
may improve oxygenat ion in ARDS wit hout elevat ing peak alveolar and inspirat ory plat eau
pressures t hat can lead t o furt her lung injury. (See "Modes of mechanical vent ilat ion", sect ion on
'Inverse rat io vent ilat ion'.)

● Flow – Flow rat es and waves represent addit ional inspirat ion variables. Flow rat es of 60 L/min are
st andard. Higher flow rat es (up t o 100 L/min) may be required in cert ain condit ions, such as
obst ruct ive airway disease (OAD) [6]. In OAD, higher flow rat es deliver t he desired t idal volume
more rapidly, allowing for increased expirat ory t ime. (See "Modes of mechanical vent ilat ion",
sect ion on 'Volume-limit ed vent ilat ion'.)

● Cycling – Vent ilat or "cycling" refers t o t he mechanism by which a breat h changes from inspirat ion
t o expirat ion. Common met hods for cycling a vent ilat or are volume, flow, and t ime. Volume-cycled
 breat hs t ransit ion from inspirat ion t o expirat ion aft er a preset volume of gas is delivered. This is
t he most common form. Flow-cycled inspirat ory breat hs t ransit ion aft er a preset airway pressure
is reached, and flow decreases t o a part icular rat e. Time-cycled inspirat ory breat hs t ransit ion
aft er a predet ermined inspirat ory t ime.

Inspirat ory hold can also be included in t he cycling mechanism. This funct ion keeps air in t he lungs
at end-inspirat ion for longer int ervals in order t o maximize gas exchange.

● Posit ive end-expirat ory pressure – Applied or ext rinsic posit ive end-expirat ory pressure (PEEPe)
can be provided by t he vent ilat or t o prevent premat ure airway closure and alveolar collapse at
end expirat ion. PEEPe allows for improved oxygenat ion by increasing funct ional residual capacit y
(FRC), which is t he volume at which pressure from elast ic recoil equals PEEPe. By improving
oxygenat ion, PEEPe can help clinicians reduce t he fract ion of inspired oxygen (FiO2) being
provided t o t he pat ient . PEEPe is oft en init ially set wit h a minimum of 5 cmH2O, a level t hought
t o be equivalent t o physiologic PEEPe. (See "Posit ive end-expirat ory pressure (PEEP)".)

● Fract ion of inspired oxygen (FiO2) – FiO2 is t ypically set at 1.0 (ie, 100 percent ) when mechanical
vent ilat ion is init iat ed. As soon as possible, clinicians should reduce t he FiO2 t o nont oxic levels
(generally 0.6 or less), provided t hat an oxygen sat urat ion (SpO2) of 90 percent or great er can be
maint ained (PaO2 above 60mmHg). (See "Oxygen t oxicit y".)

MODES OF VENTILATION

The emergency clinician should be familiar wit h t he following modes of mechanical vent ilat ion:

● Assist -cont rol vent ilat ion (ACV)

● Synchronized int ermit t ent mandat ory vent ilat ion (SIMV)
● Pressure support vent ilat ion (PSV)
● Noninvasive posit ive pressure vent ilat ion (NPPV)

ACV and SIMV are used most frequent ly in t he emergency depart ment . Eit her ACV or SIMV can be
cycled based on t he volume of gas delivered or t he airway pressure reached. A brief descript ion of
t he modes of vent ilat ion of great est relevance t o emergency pract ice is provided here. There is no
evidence t hat eit her mode of vent ilat ion is superior t o t he ot her in t erms of pat ient out comes. More
det ailed discussions of t he modes and advanced alt ernat ive modes of mechanical vent ilat ion are
found separat ely. (See "Modes of mechanical vent ilat ion" and "High-frequency vent ilat ion in adult s".)

● Assist -cont rol vent ilat ion (ACV) – Wit h ACV, every breat h is fully support ed by t he vent ilat or,
regardless of whet her t he breat h is init iat ed by t he pat ient or t he machine. The clinician
det ermines a base vent ilat ory rat e, but t he pat ient is able t o breat he fast er t han t his preset rat e.
 ACV provides t he pat ient wit h increased vent ilat ory support and reduces t he work of breat hing.
Pot ent ial dangers include diminished cardiac out put and inappropriat e hypervent ilat ion. (See
"Physiologic and pat hophysiologic consequences of mechanical vent ilat ion".)

ACV may be volume or pressure-cycled. In volume-cycled (ie, volume-t arget ed) ACV, t he clinician
det ermines t he t idal volume, inspirat ory flow rat e, flow waveform, sensit ivit y t o t he pat ient 's
respirat ory effort (ie, t rigger), and basal vent ilat ory rat e. When t he pat ient breat hes fast er t han
t he preset basal vent ilat ory rat e, aut o-PEEP causing excessive peak inspirat ory pressure (PIP)
and subsequent lung injury may result , unless limit ed by a pressure alarm and "pop-off" valve.

In pressure-cycled (ie, pressure-t arget ed) ACV, t he clinician det ermines t he vent ilat or's sensit ivit y
t o t he pat ient 's respirat ory effort (ie, t rigger), and t he basal vent ilat ory rat e. Unlike volume-
cont rolled ACV, however, t he clinician det ermines pressure levels and inspirat ory t ime. Tidal
volume is not set by t he vent ilat or and is dependent upon airway pressures and t he compliance
of t he lung and chest wall. While t his mode allows t he clinician t o minimize PIP (and associat ed
pressure-induced lung injury), specific t idal volume is not guarant eed, and will vary based upon t he
pat ient ’s airway resist ance and lung compliance.

● Synchronized int ermit t ent mandat ory vent ilat ion (SIMV) – In SIMV mode, t he pat ient is allowed
int ermit t ent spont aneous breat hs bet ween t he mandat ed, preset number of vent ilat or-
support ed breat hs. Spont aneous breat hs above t he preset vent ilat ory rat e are not support ed by
t he vent ilat or. Eit her t he pat ient or t he vent ilat or can t rigger t he vent ilat or-support ed breat hs.

SIMV creat es less int erference wit h normal cardiovascular funct ion by decreasing aut o-PEEP,
lowering mean airway pressures, and preserving respirat ory muscle funct ion. However, it does
increase t he pat ient 's work of breat hing compared wit h ACV. SIMV also creat es t he risk of
dyssynchrony bet ween pat ient effort and vent ilat or-support ed breat hs. (See "Physiologic and
pat hophysiologic consequences of mechanical vent ilat ion".)

Wit h volume-cycled (ie, volume-t arget ed) SIMV, t he t idal volume, inspirat ory flow rat e, flow
waveform, sensit ivit y, and basal vent ilat ory rat e are det ermined by t he vent ilat or. Wit h pressure-
cycled (ie, pressure-t arget ed) SIMV, airway pressures, inspirat ory t ime, sensit ivit y, and basal
vent ilat ory rat e are det ermined by t he vent ilat or.

SIMV is almost always combined wit h pressure support vent ilat ion (PSV) in order t o reduce t he
amount of work during int ermit t ent spont aneous breat hs. Generally, t he set respirat ory rat e
should allow 80 percent of breat hs t o be provided by t he vent ilat or in order t o minimize t he work
of breat hing.
 ● Pressure support vent ilat ion (PSV) – Wit h PSV, each breat h must be pat ient -t riggered, so t he
pat ient must possess int act respirat ory drive. PSV is pressure-cycled and designed t o reduce t he
pat ient 's work of breat hing by part ially support ing spont aneous breat hs. A minimal amount of
pressure support is necessary t o compensat e for t he inherent resist ance of t he endot racheal
t ube (ETT) and vent ilat or circuit ; t he smaller t he ETT diamet er, t he higher t he pressure support
required. Most modern vent ilat ors aut omat ically compensat e for t his increased resist ance, even
when t he PSV is set at zero. PSV is used primarily during st able vent ilat ory support periods and
for weaning pat ient s from vent ilat ory support . It is cont raindicat ed in paralyzed and heavily
sedat ed pat ient s who cannot init iat e a spont aneous breat h.

● Noninvasive posit ive pressure vent ilat ion (NPPV) – NPPV includes cont inuous posit ive airway
pressure (CPAP) and bi-level posit ive airway pressure (BLPAP), which is CPAP plus PSV. NPPV is
delivered t hrough a nasal or facial mask or a helmet , rat her t han an endot racheal or t racheot omy
t ube. CPAP is t he noninvasive equivalent of cont inuous posit ive end-expirat ory pressure (PEEP);
BLPAP is t he noninvasive equivalent of vent ilat or-support ed breat hing. Cont raindicat ions t o
NPPV include t he need for a definit ive airway, high aspirat ion risk, and inabilit y t o t olerat e mask
vent ilat ion (t able 1). In select pat ient s wit h acut e respirat ory dist ress, NPPV has reduced t he
need for convent ional mechanical vent ilat ion. (See "Noninvasive vent ilat ion in acut e respirat ory
failure in adult s".)

COMPLICATIONS

Mechanical vent ilat ion is associat ed wit h a number of pat hophysiologic derangement s which can lead
t o injury. Among t hese are:

● Diminished cardiac out put and hypot ension

● Pulmonary barot rauma (eg, pneumot horax)
● Vent ilat or-associat ed lung injury
● Aut o-PEEP (ie, int rinsic PEEP)
● Elevat ed int racranial pressure

These complicat ions are discussed in det ail elsewhere, but are briefly described below. (See
"Physiologic and pat hophysiologic consequences of mechanical vent ilat ion".)

Hypot ension and vent ilat or-associat ed lung injury (VALI), including barot rauma, are among t he more
import ant problems t hat occur aft er t he inst it ut ion of mechanical vent ilat ion. Hypot ension most
oft en result s from a combinat ion of sedat ion, decreased venous ret urn from elevat ed int rat horacic
pressure, and diminished int ravascular volume. These complicat ions are oft en observed immediat ely
aft er endot racheal int ubat ion; hence, close monit oring during t he post -int ubat ion period is imperat ive.
Barot rauma result s from elevat ed pulmonary pressures. Clinicians can reduce t he risk of barot rauma
by minimizing plat eau airway pressures. Reduced airway pressures, as well as reduced t idal volumes,
also help minimize t he risk of VALI. Clinicians need t o be aware t hat some abnormalit ies, such as an
elevat ed PaCO2, need not be correct ed immediat ely t o achieve physiologic norms or t he pat ient ’s
baseline, and t hat at t empt s t o do so may increase t he risk of VALI.

Pneumonia is a well-described complicat ion of mechanical vent ilat ion. ED clinicians can reduce t he
risk of vent ilat or-associat ed pneumonia (VAP) simply by elevat ing t he head of t he pat ient 's bed by at
least 30 degrees, eit her by inclining t he head of t he bed upwards (ie, reverse Trendelenburg) or by
placing t he pat ient in a semirecumbent posit ion (ie, not laying flat ). Ot her st rat egies for reducing t he
risk of VAP are discussed elsewhere. (See "Risk fact ors and prevent ion of hospit al-acquired and
vent ilat or-associat ed pneumonia in adult s".)

APPROACH TO VENTILATORY MANAGEMENT

General principles — There is no single opt imal mode of mechanical vent ilat ion [7-9]. Diseases and
pat ient condit ion vary over t ime, so clinicians should regularly reassess t he set t ings and mode of
vent ilat ion. Nevert heless, cert ain guiding principles should be applied in most inst ances:

● Minimize plat eau pressures and t idal volumes, allowing hypercapnia if necessary (except in brain-
injured pat ient s), t o reduce t he risk of lung injury.

● Opt imize ext rinsic posit ive end-expirat ory pressure (PEEPe) t o prevent alveolar collapse and
improve oxygenat ion.

● Reduce inspired oxygen t o nont oxic levels (≤60 percent ) as quickly as possible.

● Minimize risk of vent ilat or-associat ed pneumonia (VAP) by maint aining t he head in an elevat ed
posit ion whenever possible. (See "Risk fact ors and prevent ion of hospit al-acquired and vent ilat or-
associat ed pneumonia in adult s", sect ion on 'Prevent ion'.)

Selecting a ventilatory strategy — Emergency clinicians can select among t hree fundament al

st rat egies for mechanical vent ilat ion: noninvasive posit ive pressure vent ilat ion (NPPV), general
invasive posit ive pressure vent ilat ion (IPPV), and lung-prot ect ive invasive posit ive pressure vent ilat ion
(L-IPPV). Below we describe t he basic principles, indicat ions, cont raindicat ions, and set t ings for each.
Modificat ions t o t hese basic approaches may be needed in specific disease st at es and t hese are
described in t he sect ion on disease-specific management , as well as in separat e UpToDat e t opic
reviews. (See 'Disease-specific vent ilat ory management ' below.)
Noninvasive posit ive pressure vent ilat ion (NPPV) has proven most effect ive in pat ient s wit h acut e
exacerbat ions of chronic obst ruct ive pulmonary disease (COPD) and acut e cardiogenic pulmonary
edema (CPE). It may also be helpful in t he management of immunocompromised pat ient s and select
pat ient s wit h early ARDS. (See "Noninvasive vent ilat ion in acut e respirat ory failure in adult s".)

Cont raindicat ions t o NPPV include t he need for a definit ive airway, high aspirat ion risk, and inabilit y t o
t olerat e mask vent ilat ion (t able 1). Alt hough NPPV support s t he pat ient 's vent ilat ion, it does not
secure t he airway. The clinician using NPPV must be prepared t o perform t racheal int ubat ion if
necessary, and accept able t o t he pat ient or healt h care proxy. Pat ient s should be monit ored closely
and formally reassessed wit hin 30 minut es of applicat ion t o ensure improvement or st abilizat ion of
respirat ory compromise [10].

General invasive posit ive pressure vent ilat ion (IPPV) is t he basic approach used in t he majorit y of
pat ient s who require invasive vent ilat ion. Such pat ient s may include t hose wit h COPD, CPE,
int oxicat ion, t rauma, and neuromuscular disease.

Lung-prot ect ive invasive posit ive pressure vent ilat ion (L-IPPV) is t he st rat egy used t o prevent
vent ilat or-associat ed lung injury (VALI), including barot rauma [11-13]. This is accomplished by using
low-t idal volumes and by minimizing airway pressures, even if hypercapnia and mild acidosis result (so-
called permissive hypercapnea). Oxygenat ion is maint ained at low normal levels by using ext rinsic
posit ive end-expirat ory pressure (PEEPe) and adjust ing flow rat es and t he inspirat ory t o expirat ory
(I:E) rat io t o minimize injurious levels of FiO2. Pat ient s who benefit from t his approach include t hose
wit h ARDS, pneumonia, t horacic t rauma (eg, pulmonary cont usion), and severe sepsis. Since
hypercapnia and acidosis can compromise cerebral perfusion, L-IPPV should generally be avoided in
pat ient s wit h cerebral injury, st roke, or elevat ed int racranial pressure from ot her causes. If such
pat ient s are at high risk for ARDS, L-IPPV may be used IF hypercapnia and acidosis can be avoided.
(See "Vent ilat or management st rat egies for adult s wit h acut e respirat ory dist ress syndrome" and
"Permissive hypercapnia during mechanical vent ilat ion in adult s".)

Below we discuss some basic principles and t he init ial vent ilat or set t ings for each st rat egy.

Implementing the chosen ventilatory strategy

Noninvasive positive pressure ventilation — NPPV is defined and it s mechanics described above.

(See 'Modes of vent ilat ion' above.)

The following set t ings are appropriat e when init iat ing bi-level posit ive airway pressure (BLPAP), t he
preferred form of NPPV:

● Inspirat ory posit ive airway pressure (IPAP) 8 t o 12 cm H2O

● Expirat ory posit ive airway pressure (EPAP) 0 t o 5 cm H2O
A gradient of at least 5 cm H20 bet ween IPAP and EPAP should be maint ained. NPPV is generally
st art ed at an IPAP/EPAP of 10/5 cm H2O. Bot h values can be increased gradually over approximat ely
10 minut es t o provide great er vent ilat ory support . IPAP can be increased up t o 20 cm H2O, and EPAP
up t o 10 t o 12 cm H2O. Cont inuous pulse oximet ry and end-t idal CO2 monit oring can help t o
det ermine NPPV's effect iveness in improving oxygenat ion and vent ilat ion. Clinicians should reassess
t he pat ient wit hin 30 minut es t o det ermine if t reat ment is successful.

General invasive positive pressure ventilation — Most pat ient s wit hout parenchymal pulmonary
disease or risk fact ors for respirat ory dist ress syndrome (ARDS) who require int ubat ion are managed
using IPPV. Basic IPPV set t ings are used in pat ient s wit hout severe pulmonary disease or ot her
complicat ions (eg, st roke) obviat ing t he use of lung-prot ect ive vent ilat ory st rat egies. These set t ings
consist of t he following:

● Assist cont rol mode

● Tidal volume 8 mL/kg (use ideal body weight )
● Respirat ory rat e 12 t o 20 breat hs/minut e
● Inspirat ory flow rat e 60 lit ers/minut e
● FiO2 100 percent (t it rat e t o 60 percent or below as quickly as possible based on pulse oximet ry)
● PEEPe 5 t o 10 cm H2O

The clinician must assess t he pat ient 's response t o t hese set t ings frequent ly and adjust t hem as
necessary.

The pat ient 's baseline lung compliance, airway resist ance, and int rinsic posit ive end-expirat ory
pressure (PEEPi) should be measured and recorded immediat ely following t he init iat ion of invasive
mechanical vent ilat ion, while t he pat ient is paralyzed or heavily sedat ed.

Clinicians should frequent ly reassess pat ient comfort and pat ient -vent ilat or synchrony [14]. Adequat e
pat ient sedat ion and analgesia should be provided. (See 'Sedat ion and analgesia for t he vent ilat ed
pat ient ' below.)

Lung-protective positive pressure ventilation — Most pat ient s wit h or at risk for acut e lung
injury/acut e respirat ory dist ress syndrome (ALI/ARDS) requiring int ubat ion are managed using L-IPPV.
Reasonable init ial set t ings for t his st rat egy include:

● Assist cont rol mode

● Tidal volume 6 t o 8 mL/kg (use ideal body weight )
● Respirat ory rat e 14 t o 16 breat hes/minut e (can t it rat e up t o 35 in order t o keep pH above 7.25)
● Inspirat ory flow rat e 60 t o 90 lit ers/minut e
● FiO2 100 percent (t it rat e t o 60 percent or below as quickly as possible)
 ● PEEPe of 5 t o 10 cm H2O
● Keep plat eau pressures at 30 cm H2O or less

L-IPPV can result in hypercapnea, which may be minimized by increasing t he vent ilat ory rat e t o a point
just below t hat at which PEEPi (ie, breat h st acking) develops [15]. Vent ilat ors can measure PEEPi,
which should be monit ored. Avoid acut e hypercapnea, which can exacerbat e neurologic dysfunct ion, in
pat ient s wit h acut e brain injury. Cont rol of acidemia using sodium bicarbonat e is cont roversial.
Implement at ion of L-IPPV may require high levels of sedat ion wit h appropriat e monit oring. (See
"Permissive hypercapnia during mechanical vent ilat ion in adult s".)

Clinicians should be aware t hat cont roversy exist s about t he rout ine use of a low t idal volume
vent ilat ion st rat egy in emergency respirat ory support [16,17]. The primary reason for advocat ing a low
t idal volume st rat egy is t hat many emergency depart ment pat ient s who require invasive mechanical
vent ilat ion are already at risk for developing ARDS and t he use of low t idal volumes helps t o prevent a
second pulmonary insult in t he form of vent ilat or-associat ed lung injury. Nevert heless, in bot h t he
general and lung-prot ect ive approach t o IPPV, a t idal volume of 8 mL/kg is a reasonable init ial set t ing.

DISEASE-SPECIFIC VENTILATORY MANAGEMENT

Pulmonary diseases

Asthma and COPD — Pat ient s wit h ast hma and chronic obst ruct ive pulmonary disease (COPD)
can present t o t he emergency depart ment (ED) wit h impending respirat ory failure. The major reason
for inst it ut ing mechanical vent ilat ion in t hese pat ient s is clinical manifest at ion of respirat ory dist ress,
relat ed t o det eriorat ing gas exchange. Treat ment of t hese pat ient s is discussed in det ail separat ely.
(See "Acut e exacerbat ions of ast hma in adult s: Home and office management " and "Management of
exacerbat ions of chronic obst ruct ive pulmonary disease".)

For pat ient s wit h severe ast hma or COPD requiring mechanical vent ilat ion, we recommend t he
following approach:

● Use larger-sized endot racheal t ube (eg, ≥8 mm) (pat ient at t ribut es suggest ing difficult int ubat ion
may preclude use of large t ubes)
● Keep minut e vent ilat ion (MV) below 115 mL/kg
● Keep t idal volume (VT) below 8 mL/kg
● Maint ain respirat ory rat e at 10 t o 14 breat hs per minut e
● Maint ain inspirat ory flow rat e at 80 t o 100 lit ers/minut e
● Allow increased expirat ory t ime wit h decreased I:E rat io (1:3 or 1:4 up t o 1:5)
● Maint ain plat eau pressures below 30 cm H2O if possible
 ● Allow hypercapnea for pat ient s wit h high peak pressures

In-dept h discussions of t his st rat egy and relat ed issues are found separat ely. (See "Invasive
mechanical vent ilat ion in adult s wit h acut e exacerbat ions of ast hma" and "Approach t o t he difficult
airway in adult s out side t he operat ing room".)

As reflect ed in t he set t ings above, we recommend a st rat egy of permissive hypercapnea for
int ubat ed ast hmat ics wit h high peak airway pressures. In addit ion, we recommend minimizing int rinsic
posit ive end-expirat ory pressure (PEEPi). Paralysis may be necessary t o prevent pat ient -vent ilat or
dyssynchrony, minimize PEEPi, and avoid dynamic hyperinflat ion, alt hough t he use of neuromuscular
blocking agent s should be avoided if possible.

Mechanical vent ilat ion in pat ient s wit h ast hma and COPD can result in high airway pressures,
barot rauma, and added morbidit y and mort alit y, all secondary t o increased lung volumes and narrowed
airways. When int ubat ing t hese pat ient s, clinicians should use larger-sized endot racheal t ubes (eg, ≥8
mm) if possible in order t o minimize added airway resist ance.

Noninvasive posit ive pressure vent ilat ion (NPPV) benefit s many pat ient s wit h COPD exacerbat ions
and may be helpful for some ast hmat ics, alt hough t his is cont roversial. Cont raindicat ions t o NPPV
include t he need for a definit ive airway, high aspirat ion risk, and inabilit y t o t olerat e mask vent ilat ion
(t able 1). (See 'Select ing a vent ilat ory st rat egy' above and "Noninvasive vent ilat ion in acut e respirat ory
failure in adult s".)

Hypoxemic respiratory failure — Acut e hypoxemic respirat ory failure (AHRF) is defined as severe
art erial hypoxemia refract ory t o supplement al oxygen. Vent ilat ion-perfusion (V/Q) mismat ch and
shunt are t he t wo primary mechanisms for such hypoxemia. Condit ions such as pulmonary edema,
pulmonary embolus, severe pneumonia, and acut e respirat ory dist ress syndrome (ARDS) are oft en
responsible. Noninvasive posit ive pressure vent ilat ion (NPPV) can be a useful st rat egy in select ed
pat ient s, part icularly t hose wit h acut e COPD exacerbat ions, acut e cardiogenic pulmonary edema, or
malignancy. (See 'Select ing a vent ilat ory st rat egy' above and "Noninvasive vent ilat ion in acut e
respirat ory failure in adult s" and "Evaluat ion of t he adult wit h dyspnea in t he emergency depart ment ".)

In severe cases t racheal int ubat ion wit h mechanical vent ilat ion may be required. In general, we
suggest a lung-prot ect ive vent ilat ory st rat egy for t hese pat ient s. (See 'Lung-prot ect ive posit ive
pressure vent ilat ion' above.)

Vent ilat or set t ings must be adjust ed according t o t he underlying disease. (See 'Acut e cardiogenic
pulmonary edema' below and 'Acut e respirat ory dist ress syndrome' below.)

Acute cardiogenic pulmonary edema — ED management of t he pat ient wit h acut e cardiogenic
pulmonary edema (CPE) may require t racheal int ubat ion and mechanical vent ilat ion t o relieve
respirat ory dist ress, improve pulmonary gas exchange, and reduce bot h preload and aft erload.
Clinicians should implement invasive mechanical vent ilat ion if respirat ory failure appears likely or if
sympt oms fail t o respond t o st andard t herapy, including oxygen, vasodilat ors, diuret ics, and NPPV.
(See "Treat ment of acut e decompensat ed heart failure: General considerat ions" and "Physiologic and
pat hophysiologic consequences of mechanical vent ilat ion".)

Clinicians can init iat e mechanical vent ilat ion in t hese pat ient s using t he general IPPV st rat egy, but if
significant edema creat es elevat ed airway pressures t hey should change t o a lung prot ect ive
st rat egy. (See 'General invasive posit ive pressure vent ilat ion' above and 'Lung-prot ect ive posit ive
pressure vent ilat ion' above.)

Ext rinsic posit ive end-expirat ory pressure (PEEPe) can be increased as t olerat ed t o improve
oxygenat ion and furt her reduce preload. Excessive PEEPe can result in hypot ension in pat ient s
dependent upon preload t o maint ain cardiac out put (eg, pat ient s wit h right vent ricular dysfunct ion).

Many pat ient s wit h acut e CPE benefit from NPPV t reat ment . NPPV improves cardiac performance
and decreases pulmonary edema. However, some pat ient s are not amenable t o t reat ment wit h NPPV
(t able 1). (See "Noninvasive vent ilat ion in acut e respirat ory failure in adult s".)

Acute respiratory distress syndrome — Acut e respirat ory dist ress syndrome (ARDS) is defined
as a syndrome of acut e and persist ent lung inflammat ion wit h increased vascular permeabilit y. ARDS is
charact erized by four feat ures:

● Timing – Develops wit hin one week of a known clinical insult or new or worsening respirat ory
sympt oms.

● Radiographic appearance – Bilat eral opacit ies not fully explained by effusions, lobar/lung
collapse, or nodules.

● Pulmonary edema – Respirat ory failure not fully explained by cardiac failure or fluid overload;
Need object ive assessment (eg, echocardiography) t o exclude hydrost at ic edema if no risk
fact or present .

● Compromised oxygenat ion – Mild: 200 mmHg <PaO2/FiO2 ≤300 mmHg wit h PEEP or CPAP ≥5
cmH2O; Moderat e: 100 mmHg <PaO2/FiO2 ≤300 mmHg wit h PEEP ≥5 cmH2O; Severe:
PaO2/FiO2 ≤100 mmHg wit h PEEP ≥5 cmH2O.

A lung-prot ect ive vent ilat ion st rat egy, using low t idal volumes, is t he best approach when performing
mechanical vent ilat ion in pat ient s wit h ARDS. Airway pressures must be reassessed frequent ly. In
pat ient s wit h severe ARDS, early administ rat ion of a neuromuscular blocking agent may be beneficial
and alt ernat ive st rat egies t o improve oxygenat ion may be needed (eg, Airway pressure release
vent ilat ion [APRV], Ext racorporeal membrane oxygenat ion [ECMO]). ARDS is discussed in det ail
separat ely. (see 'Lung-prot ect ive posit ive pressure vent ilat ion' above and "Acut e respirat ory dist ress
syndrome: Clinical feat ures, diagnosis, and complicat ions in adult s" and "Acut e respirat ory dist ress
syndrome: Support ive care and oxygenat ion in adult s" and "Vent ilat or management st rat egies for
adult s wit h acut e respirat ory dist ress syndrome" and "Modes of mechanical vent ilat ion", sect ion on
'Airway pressure release vent ilat ion' and "Ext racorporeal membrane oxygenat ion (ECMO) in adult s")

Neuromuscular diseases — Pat ient s wit h neuromuscular disease requiring t racheal int ubat ion can be
managed using a general IPPV st rat egy, provided t hat no comorbid pulmonary condit ions exist . (See
'General invasive posit ive pressure vent ilat ion' above and "Respirat ory muscle weakness due t o
neuromuscular disease: Clinical manifest at ions and evaluat ion" and "Respirat ory muscle weakness due
t o neuromuscular disease: Management ".)

Guillain-Barré syndrome — The respirat ory st at us of pat ient s wit h Guillain-Barré syndrome (GBS)
can det eriorat e quickly and unpredict ably. Many pat ient s require mechanical vent ilat ion. Respirat ory
feat ures associat ed wit h progression t o respirat ory failure in pat ient s wit h severe GBS include:

● Vit al capacit y less t han 20 mL/kg

● Maximal inspirat ory pressure less t han 30 cmH2O
● Maximal expirat ory pressure less t han 40 cmH2O, or a reduct ion of more t han 30 percent in vit al
capacit y

Clinical feat ures associat ed wit h respirat ory failure include:

● Time of onset t o admission less t han seven days

● Inabilit y t o cough
● Inabilit y t o st and
● Inabilit y t o lift t he elbows
● Inabilit y t o lift t he head

Bulbar dysfunct ion, aut onomic dysfunct ion, and bilat eral facial palsy are also associat ed wit h t he need
for mechanical vent ilat ion. (See "Guillain-Barré syndrome in adult s: Treat ment and prognosis", sect ion
on 'Respirat ory failure' and "Guillain-Barré syndrome in adult s: Clinical feat ures and diagnosis".)

Myasthenia gravis — Pat ient s wit h myast henic crisis oft en develop oropharyngeal and respirat ory
muscle weakness and become unable t o prot ect t heir airway. Two measures have been found t o
predict respirat ory failure in t hese pat ient s: decline in funct ional vit al capacit y t o less t han 15 mL/kg
of body weight and an inspirat ory force of -25 cmH20 or less. Clinicians should not e t hat muscle
weakness may prevent t hese pat ient s from manifest ing accessory muscle use. (See "Myast henic
crisis", sect ion on 'Assessment of respirat ory funct ion'.)
Trauma — Clinicians should exercise caut ion when init iat ing mechanical vent ilat ion in t he t rauma
pat ient and should consider t he implicat ions of pot ent ial hypovolemia, poor lung compliance,
abdominal dist ent ion, and increased int racranial pressure (ICP).

In t he severely injured pat ient wit h a t raumat ic brain injury, in which cerebral aut oregulat ion may be
disrupt ed, hypot ension, hypoxemia, and hypercarbia must be avoided. Respect ively, t hese goals are
achieved wit h aggressive volume resuscit at ion and blood t ransfusion, oxygen supplement at ion and
appropriat e levels of PEEP t o maint ain t he SpO2 above 93 percent , and appropriat e minut e vent ilat ion
t o achieve normocarbia while minimizing high airway pressures. A general IPPV st rat egy is a reasonable
approach when init iat ing mechanical vent ilat ion in t hese pat ient s; a lung-prot ect ive st rat egy may
compromise cerebral perfusion and should be avoided. Cont inuous end-t idal CO2 monit oring should be
used if available. Frequent reevaluat ion is mandat ory t o ensure adequat e mean art erial pressure (and
adequat e cerebral perfusion pressure), oxygenat ion, and normocarbia. (See "Init ial management of
t rauma in adult s" and "Management of acut e severe t raumat ic brain injury" and 'General invasive
posit ive pressure vent ilat ion' above and 'Elevat ed int racranial pressure' below.)

In pat ient s wit h hemorrhagic shock, PEEPe can exacerbat e hypot ension. Most pat ient s can t olerat e a
PEEPe of 5 cmH2O, but higher levels increase int rat horacic pressure and can reduce cardiac preload,
and t herefore should be avoided. Likewise, elevat ed plat eau pressures can reduce cardiac out put and
should be avoided in t hese pat ient s. (See "Init ial evaluat ion of shock in t he adult t rauma pat ient and
management of NON-hemorrhagic shock".)

Pat ient s wit h significant t horacic t rauma (eg, pulmonary cont usion) may be difficult t o oxygenat e and
can have poor pulmonary compliance, increasing t he risk of barot rauma. For t hese pat ient s, a higher
PEEPe may be required t o maint ain adequat e oxygenat ion. In addit ion, a lung-prot ect ive vent ilat ory
st rat egy t hat minimizes airway pressures and incorporat es permissive hypercapnea may be required t o
minimize reduct ions in cardiac out put , provided t here is no concomit ant t raumat ic brain injury [18]. (See
'Lung-prot ect ive posit ive pressure vent ilat ion' above.)

Elevated intracranial pressure — The goal of management in t he pat ient wit h t raumat ic brain injury
(TBI), st roke, or ot her causes of elevat ed int racranial pressure (ICP) is t o opt imize cerebral perfusion
pressure and oxygen delivery. Lung prot ect ive vent ilat ion st rat egies (ie, L-IPPV) should be avoided in
pat ient s wit h elevat ed ICP because hypercapnia and acidosis can compromise cerebral perfusion.
However, if such pat ient s are at high risk for ARDS, L-IPPV may be used IF hypercapnia and acidosis
can be avoided. A PaCO2 bet ween 35 and 40 mmHg is recommended. (See "Evaluat ion and
management of elevat ed int racranial pressure in adult s".)

Prophylact ic hypervent ilat ion t herapy (PaCO2 ≤35 mmHg) aft er TBI may cause harm and should be
avoided [19-21]. Hypervent ilat ion can compromise cerebral perfusion immediat ely following injury,
when cerebral blood flow may already be reduced. Hypervent ilat ion may be used for a brief period if
t here is acut e neurologic det eriorat ion (eg, herniat ion) t hat is unresponsive t o st andard t herapies, such
as sedat ion, osmot ic diuresis (eg, mannit ol), paralysis, and cerebrospinal fluid drainage. Hypervent ilat ion
t herapy should not ext end beyond a brief period (eg, one t o t wo hours) needed t o allow ot her
t herapies t o work or t o permit t ransfer t o t he operat ing room.

Other conditions

Pregnancy — Pregnant pat ient s normally exhibit a respirat ory alkalosis, wit h a baseline art erial pH
of 7.40 t o 7.47 and an art erial PaCO2 of approximat ely 32 mmHg. Consequent ly, t his PaCO2 should be
considered t he t arget during mechanical vent ilat ion in pregnant pat ient s. Animal st udies suggest t hat
higher vent ilat ion rat es producing an art erial part ial pressure of carbon dioxide significant ly below t his
level may reduce ut erine blood flow and t hus should be avoided.

The st rat egy of permissive hypercapnia, which may be necessary when vent ilat ion is difficult , does not
appear t o affect t he fet us adversely (at least t o a carbon dioxide level of 60 mmHg). In t hird-
t rimest er pregnant pat ient s wit hout hypovolemia, higher levels of PEEPe may be needed t o prevent
at elect asis caused by t he gravid ut erus. (See "Crit ical illness during pregnancy and t he peripart um
period", sect ion on 'Mechanical vent ilat ion' and "Mat ernal adapt at ions t o pregnancy: Physiologic
respirat ory changes and dyspnea", sect ion on 'Respirat ory changes'.)

Abdominal compartment syndrome — Emergency clinicians need t o be cognizant of t he

physiologic feat ures of abdominal compart ment syndrome (ACS), as early diagnosis can improve
out come. In ACS, rising int raabdominal pressure is t ransmit t ed t o t he t horax via an elevat ed diaphragm,
result ing in ext rinsic compression of t he pulmonary parenchyma, increased int rapulmonary shunt
fract ion, and increased alveolar dead space, causing hypoxemia and hypercarbia. (See "Abdominal
compart ment syndrome in adult s".)

In mechanically vent ilat ed pat ient s wit h ACS, peak inspirat ory, mean airway, and plat eau pressures are
increased, while chest wall compliance and spont aneous t idal volume are markedly reduced, creat ing a
risk for barot rauma. In t his scenario, a vent ilat ory st rat egy ut ilizing permissive hypercapnea may be
useful t o reduce airway pressures. Neuromuscular blocking agent s may be needed when st andard
t reat ment s are ineffect ive. Obt ain immediat e surgical consult at ion when ACS is suspect ed.

APPROACH TO VENTILATED PATIENT IN DISTRESS

Emergency clinicians should not reflexively t reat t he "bucking," dist ressed pat ient , presumed t o be
"fight ing" t he vent ilat or, wit h neuromuscular blocking agent s and sedat ive medicat ions. To do so is t o
risk missing pot ent ially life-t hreat ening problems, such as a t ension pneumot horax. Approach t he
dist ressed mechanically vent ilat ed pat ient in a syst emat ic fashion, as out lined in t he at t ached
algorit hm (algorit hm 1). Crit ical aspect s of t his approach are described below. This problem is
discussed in great er det ail separat ely. (See "Assessment of respirat ory dist ress in t he mechanically
vent ilat ed pat ient ".)

When a pat ient develops severe respirat ory dist ress or hemodynamic inst abilit y while receiving
mechanical vent ilat ion, t he clinician should immediat ely disconnect t he pat ient from t he vent ilat or and
provide bag vent ilat ion wit h 100 percent oxygen. This maneuver removes a large number of pot ent ial
problems and enables t he clinician t o concent rat e on t he pat ient , rat her t han t he vent ilat or.

The emergency clinician can t hen approach t he pat ient like any ot her int ubat ed pat ient in respirat ory
dist ress, beginning wit h assessment of t he airway, breat hing, and circulat ion. Look for immediat e
t hreat s t o life, such as a dislodged or obst ruct ed endot racheal t ube, a t ension pneumot horax,
disrupt ion of t he oxygen supply, or dysrhyt hmia. Perform a focused hist ory and physical examinat ion
including vit al signs. The nurse and respirat ory t herapist may provide import ant hist ory. Assess t rends
in vent ilat or paramet ers, such as a rising plat eau pressure. If t he cause of dist ress is not immediat ely
apparent and easily rect ified, obt ain an immediat e port able chest x-ray and elect rocardiogram.

A useful mnemonic for t he causes of unexpect ed, acut e decompensat ion of mechanically vent ilat ed
pat ient s is DOPE [22]:

● Dislodgement of t he endot racheal t ube (ETT)

● Obst ruct ion of t he ETT
● Pneumot horax
● Equipment failure

Once t hese causes have been ruled out , t he clinician can evaluat e t he pat ient 's respirat ory mechanics
and t he adequacy of sedat ion and vent ilat ory support , and t reat t he underlying cause of pat ient -
vent ilat or dyssynchrony.

Oft en, respirat ory dist ress can be managed by observing t he pat ient 's breat hing pat t ern and by
adjust ing cont rolled variables (eg, t idal volume, respirat ory rat e, inspirat ory flow rat e, t rigger
sensit ivit y) t o mat ch pat ient demand. As an example, when a pat ient is "aut o-t riggering" (ie, t riggering
frequent breat hs) or "locked-out " (ie, failing t o t rigger breat hs), t he t rigger sensit ivit y t hreshold should
be made higher or lower, respect ively.

Assessment of airway pressures can provide insight int o t he cause of respirat ory difficult y in pat ient s
whose problems resolve once t hey are disconnect ed from t he vent ilat or or whose problems are less
severe and who remain hemodynamically st able. By measuring peak and plat eau airway pressures, t he
clinician can localize problems t o t he airway or alveoli and det ermine a different ial diagnosis, as shown
in t he following diagram (algorit hm 2).

The combinat ion of elevat ed peak and plat eau pressures reflect s low compliance from underlying
disease, such as pneumot horax, severe pulmonary edema, pulmonary effusion, hyperinflat ion, or
elevat ed int raabdominal pressure from ascit es or compart ment syndrome. The combinat ion of
elevat ed peak pressures wit h normal plat eau pressures suggest s an obst ruct ion t o air flow wit hin t he
vent ilat or circuit (eg, clogged endot racheal t ube) or t he proximal airways (eg, copious secret ions,
bronchospasm). Int rinsic peak end-expirat ory pressure (PEEPi) should also be measured t o det ermine
if dynamic hyperinflat ion is present . Such pat ient s are difficult t o vent ilat e wit h a bag. Allowing a
prolonged expirat ion and adjust ing set t ings t o prevent PEEPi should resolve t his problem.

SEDATION AND ANALGESIA FOR THE VENTILATED PATIENT

Once organic causes of dist ress are addressed, clinicians must ensure t hat t he int ubat ed pat ient
receives adequat e sedat ion and analgesia. A few import ant principles are ment ioned below. The t opic
is discussed in det ail separat ely. (See "Sedat ive-analgesic medicat ions in crit ically ill adult s: Select ion,
init iat ion, maint enance, and wit hdrawal" and "Pain cont rol in t he crit ically ill adult pat ient ".)

The Societ y of Crit ical Care Medicine's algorit hm for sedat ion and analgesia of mechanically
vent ilat ed pat ient s provides a reasonable approach. We have modified t he original version for use in
t he emergency depart ment (ED) (algorit hm 3).

In t he ED, it is oft en bet t er t o use short -act ing medicat ions when managing acut ely unst able pat ient s
whose diagnoses may be unclear. Propofol is an excellent short -act ing sedat ive, and allows t he
clinician t o perform frequent neurological examinat ions in pat ient s wit h brain-injury. However, propofol
can cause hypot ension, and blood pressure support wit h a vasopressor (eg, phenylephrine) may be
needed. The use of propofol and ot her sedat ive (and analgesic) agent s for longer t erm sedat ion of
t he crit ically ill is discussed separat ely. (See "Sedat ive-analgesic medicat ions in crit ically ill adult s:
Propert ies, dosage regimens, and adverse effect s".)

The addit ion of analgesics is usually necessary for pat ient comfort , and reduces t he amount of
sedat ive required. Fent anyl, a short -act ing analgesic, is oft en used. Morphine and hydromorphone are
also effect ive. Mechanically vent ilat ed pat ient s expect ed t o have a prolonged ED st ay are t reat ed
wit h infusions of sedat ives and analgesics t it rat ed t o achieve t arget ed goals based upon pain and
sedat ion/agit at ion scales.

WEANING AND DISCONTINUATION OF MECHANICAL VENTILATION

As t he need for crit ical care services and emergency depart ment lengt hs of st ay increase,
emergency clinicians will increasingly be called upon t o provide long-t erm crit ical care management ,
including weaning and discont inuat ion of mechanical vent ilat ion [23,24].

Weaning is t he process whereby mechanical vent ilat ory support is gradually wit hdrawn and t he pat ient
resumes spont aneous breat hing. Weaning can be separat ed int o t wo part s: weaning t o part ial
vent ilat or support , and weaning t o discont inuat ion of support and removal of t he endot racheal t ube.
Aspect s of weaning of part icular import t o t he emergency clinician are described below. Weaning
from mechanical vent ilat ion is discussed in det ail elsewhere. (See "Weaning from mechanical
vent ilat ion: Readiness t est ing" and "Met hods of weaning from mechanical vent ilat ion" and
"Management of t he difficult -t o-wean adult pat ient in t he int ensive care unit ".)

Before beginning a weaning t rial, clinicians should det ermine whet her t he pat ient is ready using t he
following crit eria as a general guide [25,26]:

● Evidence for some reversal of t he underlying cause of respirat ory failure

● Adequat e oxygenat ion (PaO2 >60 mmHg on FiO2 <0.4; PEEPe <10 cmH2O; PaO2/FiO2 >150 t o
300)
● St able cardiovascular st at us (HR <140; st able BP; no, or minimal, use of vasopressors)
● No significant respirat ory acidosis (pH ≥7.25)
● Adequat e hemoglobin (generally Hgb >7 g/dL in pat ient s wit hout ischemic cardiac disease, or Hgb
>10 in pat ient s wit h ischemic cardiac disease)
● Adequat e ment at ion (arousable; can follow commands reliably; no cont inuous sedat ive infusions)
● St able met abolic st at us (accept able elect rolyt e levels)

Clinicians should adapt t hese crit eria t o clinical circumst ances; some pat ient s will not sat isfy all
crit eria yet be successfully weaned off mechanical vent ilat ion. Over t he years, a wide variet y of
physiologic indices have been proposed t o assist in t he discont inuat ion of vent ilat ory support . Such
indices have varying st rengt hs and weaknesses, and different applicat ions. Variables such as
respirat ory rat e, PaO2/FiO2 (P/F) rat io, and t he rapid shallow breat hing index (RSBI) are used.

RSBI is a commonly used assessment t ool t o det ermine readiness t o wean and discont inue
mechanical vent ilat ion in t he ICU. The RSBI measurement consist s of a one-minut e t rial of unassist ed
breat hing wit h an ext rinsic posit ive end-expirat ory pressure (PEEPe) of 0 cmH20 and pressure support
of 0 cmH2O. At t he end of one minut e, t he average respirat ory rat e is divided by t he average t idal
volume (VT) t o obt ain t he RSBI (ie, RSBI = RR/VT). A number less t han or equal t o 105 has been found
t o be most predict ive of successful ext ubat ion. (See "Weaning from mechanical vent ilat ion:
Readiness t est ing".)
Aft er an init ial assessment of weaning, including calculat ion of a RSBI, we perform a spont aneous
breat hing t rial (SBT) t o det ermine if t he pat ient is prepared for discont inuat ion of mechanical
vent ilat ion. There are t hree ways t o perform an SBT: put t ing t he pat ient on minimal pressure support
and PEEPe, assessing respirat ory paramet ers (so-called "performing mechanics"); using cont inuous
posit ive airway pressure (CPAP) alone; or using a T-piece t rial, which requires t he pat ient t o breat he
t hrough t he endot racheal t ube for a preset period of t ime wit h oxygen but wit hout vent ilat ory
support . Inst it ut ional approaches vary, but any of t he met hods described is accept able. (See
"Met hods of weaning from mechanical vent ilat ion".)

The crit eria used t o assess pat ient t olerance during an SBT are t he respirat ory pat t ern, adequacy of
gas exchange, hemodynamic st abilit y, and pat ient comfort . Generally, if t he pat ient t olerat es an SBT
last ing 30 minut es, t he mechanical vent ilat or should be discont inued and t he endot racheal t ube
removed. A longer SBT (up t o 120 minut es) may be necessary if t he pat ient 's condit ion is more
uncert ain.

Ot herwise healt hy pat ient s int ubat ed for a t ransient problem (eg, acut e drug int oxicat ion) can oft en
be ext ubat ed rapidly following a brief period of observat ion. Once t he problem has resolved and t he
pat ient is awake, breat hing spont aneously, and manifest ing no signs of respirat ory or hemodynamic
inst abilit y, t he endot racheal t ube can be removed.

SUMMARY AND RECOMMENDATIONS

● Mechanical vent ilat ion is performed in t he emergency depart ment (ED) t o accomplish any of a
number of goals, including t he following:

• To prot ect t he airway

• To improve pulmonary gas exchange (ie, reverse hypoxemia or acut e respirat ory acidosis)
• To relieve respirat ory dist ress (ie, decrease oxygen consumpt ion or respirat ory muscle
fat igue)
• To permit appropriat e sedat ion and neuromuscular blockade

● To perform mechanical vent ilat ion properly, emergency clinicians must be familiar wit h vent ilat or
set t ings, modes of vent ilat ion, and pot ent ial complicat ions. Pot ent ial complicat ions include
diminished cardiac out put , vent ilat or associat ed lung injury, and pneumonia. Vent ilat or
management and addit ional complicat ions are described in t he t ext . (See 'Vent ilat or set t ings'
above and 'Modes of vent ilat ion' above and 'Complicat ions' above.)

● There is no single opt imal mode of mechanical vent ilat ion; diseases and pat ient condit ion vary
over t ime and vent ilat or set t ings must be adjust ed accordingly. Nevert heless, cert ain guiding
 principles should be applied in most inst ances, including:

• Minimize plat eau pressures and t idal volumes, allowing hypercapnia if necessary (except in
brain-injured pat ient s), t o reduce t he risk of lung injury.

• Opt imize ext rinsic posit ive end-expirat ory pressure (PEEPe) t o prevent alveolar collapse and
improve oxygenat ion.

• Reduce inspired oxygen t o nont oxic levels (≤60 percent ) as quickly as possible.

● Emergency clinicians can select among t hree fundament al st rat egies for mechanical vent ilat ion:
noninvasive posit ive pressure vent ilat ion (NPPV), general invasive posit ive pressure vent ilat ion
(IPPV), and lung-prot ect ive invasive posit ive pressure vent ilat ion (L-IPPV). NPPV has proven
most effect ive in pat ient s wit h acut e exacerbat ions of chronic obst ruct ive pulmonary disease
and acut e cardiogenic pulmonary edema. L-IPPV is t he st rat egy used t o prevent vent ilat or-
associat ed lung injury, including barot rauma. Each approach, including init ial vent ilat or set t ings, is
described in t he t ext . (See 'Approach t o vent ilat ory management ' above.)

● To improve pat ient out comes, modificat ions t o mechanical vent ilat ion must be made based upon
t he disease process. Approaches t o vent ilat or management for import ant condit ions t hat
confront t he emergency clinician are provided in t he t ext . (See 'Disease-specific vent ilat ory
management ' above.)

● Emergency clinicians should not reflexively t reat t he "bucking," dist ressed pat ient , presumed t o
be "fight ing" t he vent ilat or, wit h neuromuscular blocking agent s and sedat ive medicat ions. To do
so is t o risk missing pot ent ially life-t hreat ening problems, such as a t ension pneumot horax.
Approach t he dist ressed mechanically vent ilat ed pat ient in a syst emat ic fashion, as out lined in
t he at t ached algorit hm (algorit hm 1). (See 'Approach t o vent ilat ed pat ient in dist ress' above.)

● Once organic causes of dist ress are addressed, clinicians must ensure t hat t he int ubat ed pat ient
receives adequat e sedat ion and analgesia. The Societ y of Crit ical Care Medicine's algorit hm for
sedat ion and analgesia of mechanically vent ilat ed pat ient s provides a reasonable approach. We
have modified t he original version for use in t he ED(algorit hm 3). (See 'Sedat ion and analgesia for
t he vent ilat ed pat ient ' above.)

Use of UpToDat e is subject t o t he Subscript ion and License Agreement .

REFERENCES
 1. Slut sky AS. Mechanical vent ilat ion. American College of Chest Physicians' Consensus
Conference. Chest 1993; 104:1833.

2. Tobin MJ. Mechanical vent ilat ion. N Engl J Med 1994; 330:1056.

3. Tobin MJ. Advances in mechanical vent ilat ion. N Engl J Med 2001; 344:1986.

4. Gluck E, Sarrigianidis A, Dellinger RP. Mechanical vent ilat ion. In: Crit ical Care Medicine: Principles
of Diagnosis and Management in t he Adult , 2nd, Parrillo JE, Dellinger RP (Eds), Mosby, St . Louis 2
002. p.137.

5. Fessler MB, Welsh CH. Mechanical vent ilat ion: invasive and noninvasive. In: Current Diagnosis & Tr
eat ment in Pulmonary Medicine, Hanley ME, Welsh CH (Eds), McGraw-Hill, New York 2006.

6. Connors AF Jr, McCaffree DR, Gray BA. Effect of inspirat ory flow rat e on gas exchange during
mechanical vent ilat ion. Am Rev Respir Dis 1981; 124:537.

7. Mosier JM, Hypes C, Joshi R, et al. Vent ilat or St rat egies and Rescue Therapies for Management
of Acut e Respirat ory Failure in t he Emergency Depart ment . Ann Emerg Med 2015; 66:529.

8. Wright BJ. Lung-prot ect ive vent ilat ion st rat egies and adjunct ive t reat ment s for t he emergency
medicine pat ient wit h acut e respirat ory failure. Emerg Med Clin Nort h Am 2014; 32:871.

9. Spiegel R, Mallemat H. Emergency Depart ment Treat ment of t he Mechanically Vent ilat ed
Pat ient . Emerg Med Clin Nort h Am 2016; 34:63.

10. Poponick JM, Renst on JP, Bennet t RP, Emerman CL. Use of a vent ilat ory support syst em
(BiPAP) for acut e respirat ory failure in t he emergency depart ment . Chest 1999; 116:166.

11. Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Prot ect ive Vent ilat ion Init iat ed in t he Emergency
Depart ment (LOV-ED): A Quasi-Experiment al, Before-Aft er Trial. Ann Emerg Med 2017; 70:406.

12. Fuller BM, Ferguson I, Mohr NM, et al. Lung-prot ect ive vent ilat ion init iat ed in t he emergency
depart ment (LOV-ED): a st udy prot ocol for a quasi-experiment al, before-aft er t rial aimed at
reducing pulmonary complicat ions. BMJ Open 2016; 6:e010991.

13. Wilcox SR, Richards JB, Fisher DF, et al. Init ial mechanical vent ilat or set t ings and lung prot ect ive
vent ilat ion in t he ED. Am J Emerg Med 2016; 34:1446.

14. Tobin MJ, Jubran A, Laghi F. Pat ient -vent ilat or int eract ion. Am J Respir Crit Care Med 2001;
163:1059.
 15. Gat t inoni L, D'Andrea L, Pelosi P, et al. Regional effect s and mechanism of posit ive end-
expirat ory pressure in early adult respirat ory dist ress syndrome. JAMA 1993; 269:2122.

16. Mohr NM, Fuller BM. Low t idal volume vent ilat ion should be t he rout ine vent ilat ion st rat egy of
choice for all emergency depart ment pat ient s. Ann Emerg Med 2012; 60:215.

17. Wright BJ, Slesinger TL. Low t idal volume should not rout inely be used for emergency
depart ment pat ient s requiring mechanical vent ilat ion. Ann Emerg Med 2012; 60:216.

18. Shafi S, Gent ilello L. Pre-hospit al endot racheal int ubat ion and posit ive pressure vent ilat ion is
associat ed wit h hypot ension and decreased survival in hypovolemic t rauma pat ient s: an analysis
of t he Nat ional Trauma Dat a Bank. J Trauma 2005; 59:1140.

19. Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effect s of prolonged hypervent ilat ion in
pat ient s wit h severe head injury: a randomized clinical t rial. J Neurosurg 1991; 75:731.

20. Vincent JL, Berré J. Primer on medical management of severe brain injury. Crit Care Med 2005;
33:1392.

21. St occhet t i N, Maas AI, Chieregat o A, van der Plas AA. Hypervent ilat ion in head injury: a review.
Chest 2005; 127:1812.

22. Post resuscit at ion management . In: Pediat ric Advanced Life Support Provider Manual, Chameide
s L, Samson RA, Schexnayder SM, Hazinski MF (Eds), American Heart Associat ion, Dallas 2011. p.
171.

23. Huang DT, Osborn TM, Gunnerson KJ, et al. Crit ical care medicine t raining and cert ificat ion for
emergency physicians. Crit Care Med 2005; 33:2104.

24. Hospit al-based Emergency Care: At t he Breaking Point . Inst it ut e of Medicine report . Washingt o
n, DC, Nat ional Academy Press, June 14, 2006.

25. Cook D, Meade M, Guyat t G, et al. Crit eria for weaning from mechanical vent ilat ion. Evid Rep
Technol Assess (Summ) 2000; :1.

26. MacInt yre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and
discont inuing vent ilat ory support : a collect ive t ask force facilit at ed by t he American College of
Chest Physicians; t he American Associat ion for Respirat ory Care; and t he American College of
Crit ical Care Medicine. Chest 2001; 120:375S.

Topic 277 Version 18.0

GRAPHICS
Contraindications to noninvasive positive pressure ventilation

Ca rdia c or respira tory a rrest

Nonrespira tory orga n fa ilure tha t is a cutely life-threa tening

Severe encephalopathy (eg, GCS < 10)
Severe upper gas trointes tinal bleeding
Hemodynamic ins tability or uns table cardiac arrhythmia

Fa cia l or neurologica l surgery, tra um a , or deform ity

Upper a irway obstruction

Ina bility to coopera te/protect a irway

Ina bility to clea r secretions

High risk for a spira tion

GCS: Glasgow Coma Score.

Adapted with permission from: International Consensus Conferences in Intensive Care Medicine: Noninvasive positive pressure ventilation in
acute respiratory failure. Am J Respir Crit Care Med 2001; 163:283. Copyright © 2001 American Thoracic Society.

Gra phic 60442 Version 3.0

Emergency department approach to the ventilated patient in respiratory distress

ETT: endotra chea l tube; PEEP: pea k end-expira tory pressure; ECG: electroca rdiogra m ; ABG: a rteria l blood ga s; ARDS: a cute
respira tory distress syndrom e.

Gra phic 77096 Version 4.0

Assessment of airway pressures during mechanical ventilation

ETT: Endotra chea l tube; PE: Pulm ona ry em bolism ; PIP: Pea k inspira tory pressure; Ppla t:
Pla tea u pressure; RMSB: Right m a in-stem bronchus

Reproduced with permission from: Fessler, MB, Welsh, CH. Mechanical Ventilation: Invasive and
Noninvasive. In: Current Diagnosis and Treatment in Pulmonary Medicine, McPhee, SJ, Papadakis,
MA, Tierney, LM (Eds), McGrawHill 2003. Copyright © 2003 McGraw-Hill Companies, Inc.

Gra phic 50510 Version 3.0

Emergency department sedation of ventilated adults

This algorithm is a general guideline for the use of analgesics and sedatives. Refer to the text for clinical and
pharmacologic issues that dictate optimal drug selection, recommended assessment scales, and precautions
for patient monitoring. Doses are approximate for a 70-kg adult.

IVP: intravenous push.

* Num eric ra ting sca le or other pa in sca le.
• Riker Seda tion-Agita tion Sca le or other seda tion sca le.
Δ Confusion Assessm ent Method for the ICU.

Adapted from: Jacobi, J, Fraser, GL, Coursin, DB, et al. Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult. Crit Care Med 2002; 30:119. Official Journal of the Society of Critical Care Medicine,
Copyright © 2002 Society of Critical Care Medicine.

Gra phic 76559 Version 2.0

Contributor Disclosures
Peter Hou, MD Nothing to disclose Amado Alejandro Baez, MD, MSc, MPH, FAAEM, FCCM Nothing to
disclose Ron M Walls, MD, FRCPC, FAAEM Other Financial Interest: Airway Management Education Center
[Healthcare provider education and resources (Cook Melker Universal Cricothyrotomy kit, the Difficult Airway
course)]. Jonathan Grayzel, MD, FAAEM Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
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