Alveolar hypoventilation with hypercapnea and hypoxemia

                  Respiratory and neuromuscular disease, including coma and OD

      •   Inadequate pulmonary gas exchange

                  Acute respiratory distress

                  Clinical deterioration, especially shock

                  RR 35 breaths /min

                  Increased work of breathing respiratory muscle fatigue

                  Abnormal ABGs

Therapeutic

      •   CO intoxication

      •   CNS disease with high intracranial pressure

Inability to protect airways from aspiration

      •   LOC – Glasgow Coma Scale 8

      •   Vocal cord dysfunction

Clinical manifestations of respiratory distress

      •   Nasal flaring

      •   Accessory muscle

      •   recruitment

      •   Tracheal tug

      •   Intercostal recession

      •   Tachypnea

      •   Tachycardia

      •   Hypertension or

      •   hypotension

      •   Diaphoresis

      •   Changes in mental status

Laboratory evidence of impaired gas exchange

      •   PaCO₂ > 50 mmHg with academia (pH 7.25)

      •   PaCO₂ of 5–10 mmHg from baseline in patients with COPD and a change in clinical status

      •   PaO₂ < 55 mmHg on a FiO₂ = 60%

Goals

      •   Improve oxygenation

      •   Increase CO₂ excretion

      •   Reduce work of breathing

Discussion

Not all the patients with the above indications need ventilator support. There is no threshold of PaO₂ or PaCO₂ for which mechanical ventilation is mandatory. The indications are flexible and lack boundaries. Physician judgment is imperative. Because mechanical ventilation only provides assistance for breathing and does not cure disease, it is not indicated if the underlying problem is not correctable.

Study question

Summarize the treatment of the most recent patient you cared for who required mechanical ventilation. What was the indication for mechanical ventilation? Did this decision depend on quantitative information from blood gases or clinical information from bedside assessment?

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