Cardiogenic Shock: Mechanical Ventilation – Part 6 Of Excerpts From The 2017 AHA Guidelines

This post is the sixth of a series I’ve made for my study notes on Cardiogenic Shock. This post contains links to and excerpts from the Mechanical Ventilation section of Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Circulation. 2017 Oct 17;136(16):e232-e268.

The above article has been cited by 38 PubMed Central articles.

For more information on the other aspects of management of cardiogenic shock, please see Cardiogenic Shock: Management Of CS – Part 5 Of Excerpts From The 2017 AHA Guidelines
Posted on November 22, 2019 by Tom Wade MD.

Here is the section on Mechanical Ventilation:

Mechanical Ventilation

The reported prevalence of MV is 78% to 88% in patients with CS, and it is often required for the management of acute hypoxemia, increased work of breathing, airway protection, and hemodynamic or electric instability.9,42,227 Very few studies have addressed the ideal MV mode for the CS population. In nonshock HF cohorts, noninvasive MV is often used to treat respiratory failure resulting from pulmonary edema.228 Although noninvasive MV can improve dyspnea and hypoxemia, along with their associated metabolic derangements, its influence on mortality is unclear.228 The majority of patients
with CS, however, will require invasive MV.*

There is insufficient evidence to recommend specific ventilation
modes, strategies (including lung protective ventilation),
or physiological end points in the CS population.

Suggestions for Clinical Practice

The decision to intubate patients with CS should be
based on standard critical care criteria; however, clinicians should be both aware of and prepared for the potential hemodynamic deterioration associated with induction therapies (eg, sedatives and analgesics), inappropriate ventilation settings, the transition from spontaneous breathing to positive-pressure ventilation, and vagal stimulation association with endotracheal tube placement.

In the absence of high-quality data in the CS population, we suggest that MV modes and settings be adjusted to prevent hypoxemia and hyperoxia, to minimize patient discomfort and ventilator dyssynchrony, and to optimize hemodynamics.

*So these unstable patients will very likely require endotracheal intubation. But beware!

First, here is Dr. Weingart’s Podcast 176 – Updated EMCrit Rapid Sequence Intubation Checklist
June 27, 2016

See and review Dr. Weingart’s posts on intubating the unstable patient and of the dangers of the HOP killers:

Here is the wee on the HOp Killers: Hemodynamic Kills, Oxygenation Kills, and pH Kills

Intubating the Hemodynamically Unstable Patient

Intubating the Patient at Risk for Critical Hypoxemia

Intubating the Patient with Metabolic Acidosis

Also see and review Dr. Weingart’s EMCrit 207 – A Case to Acid Test your Resus Logistics
September 5, 2017 which also deals with the unstable patient who requires intubation.

Here is a list of other resources that Dr. Weingart links to in EMCrit 207. All relate in one way or another to intubation of the physiologically unstable patient.