1. Respiratory Supportive Measures

Noninvasive and mechanical ventilation can be used as time-limited trials to relieve refractory hypoxemia or hypercapnia, unload respiratory muscles, and reduce dyspnea. Careful patient selection, initiation, monitoring, and weaning improve tolerance and outcomes.

A. Noninvasive Ventilation (NIV)

Indications:

• Acute hypercapnic respiratory failure (e.g., COPD exacerbations)
• Cardiogenic pulmonary edema
• Select cases of hypoxemic respiratory failure unresponsive to standard oxygen

Contraindications:

• Facial trauma or recent surgery preventing mask fit
• Decreased consciousness or inability to protect the airway
• Excessive secretions or vomiting
• Uncooperative or severely agitated patient

Initiation and Monitoring:

• Choose an oronasal vs. nasal mask based on patient comfort and air leak.
• Set initial inspiratory positive airway pressure (IPAP) to 10–12 cm H₂O and expiratory positive airway pressure (EPAP) to 4–6 cm H₂O. Titrate FiO₂ to maintain SpO₂ of 88–92%.
• Monitor respiratory rate, SpO₂, heart rate, tidal volumes, air leak, and patient–ventilator synchrony.
• Assess skin and mucosal integrity, rotating the interface every 12–24 hours to prevent pressure injury.

B. Mechanical Ventilation

Indications:

• Failure of NIV or contraindications to NIV
• Refractory hypoxemia (e.g., PaO₂/FiO₂ ratio <150)
• Need for airway protection or management of severe hemodynamic instability

Ventilation Strategy:

• Employ lung-protective settings: tidal volumes of 4–8 mL/kg of ideal body weight and plateau pressure <30 cm H₂O.
• Titrate PEEP based on ARDSnet tables or individualized methods to optimize oxygenation.
• Titrate FiO₂ to achieve a PaO₂ of 55–80 mm Hg or an SpO₂ of 88–95%.
• Consider prone positioning for patients with a PaO₂/FiO₂ ratio <100 despite other optimizations.

2. ICU-Related Prophylaxis

Critically ill patients are at high risk for venous thromboembolism (VTE), stress ulcers, and nosocomial infections. Protocolized prophylaxis and early mobilization are key to reducing morbidity.

A. VTE Prophylaxis

Pharmacologic prophylaxis is standard unless contraindicated. Mechanical devices are used when bleeding risk is high. Early mobilization is a crucial adjunct.

B. Stress Ulcer Prophylaxis

Indicated for high-risk patients, typically those on mechanical ventilation for >48 hours or with coagulopathy (INR >1.5 or platelets <50 ×10⁹/L). Common agents include proton pump inhibitors (e.g., pantoprazole 40 mg IV daily) or H₂-receptor antagonists. The benefit must be weighed against the potential increased risk of ventilator-associated pneumonia (VAP) due to acid suppression.

C. Infection Control

The ABCDE bundle is a cornerstone of VAP prevention and overall ICU care:

• A: Awakening and Breathing Coordination
• B: Spontaneous Breathing Trials
• C: Choice of Analgesia and Sedation
• D: Delirium Assessment and Management
• E: Early Mobilization and Exercise

Additional essential measures include elevating the head of the bed to 30–45°, routine oral care with chlorhexidine, strict hand hygiene, and adherence to central line insertion and maintenance bundles.

3. Management of Iatrogenic Complications

Opioids, corticosteroids, and sedatives are cornerstones of dyspnea management but carry significant risks. Structured monitoring and reversal protocols are essential to mitigate harm.

A. Opioid-Induced Respiratory Depression

For dyspnea relief, low-dose morphine (e.g., 2 mg IV every 2 hours as needed) can be effective. Monitor respiratory rate, SpO₂, and sedation level (e.g., RASS) closely. For reversal, use a naloxone protocol that avoids complete reversal of analgesia: 0.04 mg IV bolus, repeated every 2 minutes until respiratory rate is ≥10 breaths/min and SpO₂ is ≥92%.

B. Steroid-Induced Hyperglycemia

When using corticosteroids like dexamethasone (4–8 mg PO/IV every 12 hours) for airway inflammation, monitor blood glucose every 6 hours. Initiate an insulin protocol (sliding-scale or basal–bolus) if glucose levels consistently exceed 180 mg/dL. Align rapid-acting insulin administration with the predicted glucose peak, which typically occurs 4–6 hours after the steroid dose.

C. Sedation-Related Delirium

Avoid routine benzodiazepine use. Dexmedetomidine infusion (0.2–0.7 µg/kg/h) is a preferred agent for agitation, especially with ventilator dyssynchrony. Implement nonpharmacologic strategies first: daily delirium screening (CAM-ICU), promoting sleep hygiene, frequent reorientation, providing sensory aids (glasses, hearing aids), and championing early mobilization.

4. Multidisciplinary Goals-of-Care Discussions

Shared decision-making integrates clinical evidence, prognosis, and patient values to guide the use of invasive or burdensome therapies. Early integration of palliative care improves the alignment of care with patient goals.

A. Framework for Shared Decision Making

A structured approach helps ensure all relevant factors are considered. Key triggers for a formal goals-of-care discussion include ICU admission, consideration of intubation, failure of maximal medical therapy, or a significant change in prognosis. It is vital to document goals of care, advance directives, and designated proxy decision-makers.

B. Advance Directives and Family Communication

Upon ICU admission, it is crucial to review any existing advance directives and confirm proxy designations. Schedule regular family meetings, using clear, empathetic language to provide updates on prognosis and treatment options. Aligning interventions with patient-stated goals helps reduce moral distress for families and non-beneficial treatments for patients.