I. Indications for Invasive Mechanical Ventilation

Invasive ventilation supports gas exchange and protects the airway when spontaneous breathing or airway defense is insufficient. Recognize four major indications to guide timely intubation and pharmacologic planning.

Hypoxemic respiratory failure

• PaO₂ < 60 mm Hg on room air or PaO₂/FiO₂ < 300
• Common causes: ARDS, severe pneumonia, cardiogenic pulmonary edema, sepsis
• Goals: optimize oxygenation, reduce work of breathing, prevent ventilator-induced lung injury

Hypercapnic respiratory failure

• PaCO₂ > 50 mm Hg with pH < 7.35
• Etiologies: COPD exacerbation, neuromuscular weakness, chest wall restriction
• Goals: restore alveolar ventilation, correct acid–base balance

Airway protection

• Impaired consciousness (GCS ≤ 8), high aspiration risk, airway edema
• Preemptive intubation to prevent aspiration or prevent airway loss

Procedural ventilation

• Short-term support for surgery, bronchoscopy, endoscopy in high-risk patients
• Requires short-acting sedatives/analgesics and rapid recovery profile

II. Mechanical Ventilation Modes and Pharmacologic Implications

Ventilator modes differ in how breaths are delivered and influence sedation depth, hemodynamics, and drug clearance. Tailor sedation and fluid management to the chosen mode.

II.a Volume-Controlled Ventilation (VCV)

• Preset tidal volume; airway pressures vary with compliance/resistance
• Ensures consistent minute ventilation; high pressures may cause barotrauma
• Often requires deeper sedation or neuromuscular blockade to prevent dyssynchrony

II.b Pressure-Controlled Ventilation (PCV)

• Preset inspiratory pressure; tidal volume varies with mechanics
• May improve comfort and lower barotrauma risk
• Monitor for hypoventilation if compliance worsens; adjust sedatives to avoid hypoventilation

II.c Assist-Control Ventilation (ACV)

• Mandatory rate + patient-triggered breaths at preset volume/pressure
• Risk of double-triggering if patient drive mismatches ventilator
• Sedation titration balances comfort against suppression of respiratory drive

II.d Pressure Support Ventilation (PSV) & SIMV

• PSV: patient-initiated breaths supported by fixed pressure; promotes weaning
• SIMV: combines mandatory breaths with spontaneous efforts
• Enable lighter sedation, early mobilization, reduced ICU-acquired weakness

III. Physiologic Consequences Affecting Drug Disposition

Positive-pressure ventilation triggers hemodynamic and fluid shifts that alter drug pharmacokinetics. Anticipate changes in distribution, metabolism, and elimination.

• Hemodynamic shifts:
  • ↑ intrathoracic pressure → ↓ venous return, ↓ cardiac output
  • ↓ hepatic and renal perfusion → reduced drug clearance, risk of accumulation
• Capillary leak & expanded volume of distribution:
  • Systemic inflammation increases permeability
  • Hydrophilic drugs (beta-lactams, aminoglycosides) require higher loading doses
• Fluid shifts & third spacing:
  • Aggressive resuscitation → interstitial fluid accumulation
  • Dilutes plasma concentrations; complicates dosing of water-soluble agents
• Organ perfusion changes:
  • Hypoperfusion impairs hepatic metabolism and renal excretion
  • Adjust doses of high-extraction drugs and renally cleared medications
• Acid–base & temperature derangements:
  • Respiratory acidosis alters drug ionization and protein binding
  • Hypothermia prolongs metabolic clearance and half-lives

IV. Pharmacologic Considerations in Mechanically Ventilated Patients

Sedation, analgesia, and adjunctive therapies must be individualized based on ventilator mode, hemodynamics, fluid status, and acid–base balance.

• Sedation & analgesia interplay:
  • Deeper sedation for fixed-volume modes or neuromuscular blockade
  • Lighter sedation for spontaneous modes to preserve respiratory drive
  • Choose agents with rapid onset/offset if frequent neurologic assessment is needed
• Hemodynamic effects on metabolism:
  • ↓ cardiac output prolongs half-life of high-extraction drugs (e.g., propofol)
  • Monitor blood pressure closely when titrating sedatives with vasodilatory properties
• Fluid status modifying distribution:
  • Volume overload dilutes hydrophilic drugs; monitor trough levels for antibiotics
  • Ultrafiltration or CRRT can rapidly decrease drug levels; adjust intervals
• Organ perfusion shifts requiring dose adjustments:
  • Use kidney-friendly sedation in AKI; reduce benzodiazepine infusion rates if clearance falls
  • In hepatic failure, prefer remifentanil over fentanyl for shorter context-sensitive half-time
• Acid–base derangements influencing receptor kinetics:
  • Acidosis increases free fraction of basic drugs, heightening effect/toxicity
  • Titrate neuromuscular blockers carefully in acidemic patients

V. Clinical Integration and Practice Pearls

Apply these principles through case examples to optimize ventilator synchrony and pharmacotherapy.

Case 1: ARDS on High PEEP + VCV

• High PEEP → ↓ venous return → hypotension
• Strategy: titrate propofol infusion slowly; consider norepinephrine to maintain MAP ≥ 65 mm Hg
• Monitor: sedation depth (RASS –2 to 0), hemodynamics, propofol triglycerides

Case 2: COPD Exacerbation on PSV

• Goal: preserve spontaneous effort and rapid weaning
• Strategy: low-dose dexmedetomidine for comfort without suppressing drive
• Monitor: respiratory rate, PaCO₂, sedation score (RASS 0 to –1)