Pulmonary care of the critically ill

In managing the patient requiring ventilatory support, the clinician must exercise vigilance to avoid unnecessary complications. The most obvious of these include barotrauma (pneumothorax, subcutaneous emphysema), hypovolemic hypotension, pneumonia, hypoventilation, and atelectasis. However, the clinician also must be concerned with more subtle, but nonetheless significant factors, such as oxygen toxicity and volutrauma, that may aggravate underlying lung injury. Additionally, the development of unrecognized dynamic hyperinflation, or auto-PEEP, may compromise the clinician's ability to allow adequate exhalation in the patient receiving mechanical ventilatory support. For these reasons, communication between the physician and the respiratory therapy and nursing personnel who provide care for the mechanically ventilated patient is essential. Attention to the patient's plateau airway pressure, inspired oxygen concentration, and flow mechanics is as necessary to the care of the patient as vital signs, physical examination, and chest roentgenograms.