Invasive mechanical ventilation

Patients with SARS-related respiratory failure who continue to deteriorate while on NIV, or in whom NIV is contraindicated, should be promptly intubated and mechanically ventilated. The actual endotracheal intubation procedure bears a high infective risk and healthcare workers must strictly adhere to all infection control measures. To minimize the risk, the procedure is best performed by highly skilled personnel (Lapinsky & Hawryluck 2003) using rapid sequence induction. Other approaches like a “modified awake” intubation technique and elective intubation upon recognizing signs of imminent need for airway management have been recommended (Cooper et al 2003).

Most centers (Lew et al 2003; Gomersall & Joynt 2003) used ventilation method and settings with reference to the strategies for acute respiratory distress syndrome (ARDS) (The ARDS network 2000). Both pressure and volume control ventilation can be employed. The tidal volume should be kept low at 5-6 ml per Kg of the predicted body weight, and plateau pressures be kept less than 30 cm H2O. Positive end-expiratory pressure (PEEP) should also be titrated to as low as possible to maintain the oxygenation, since a high rate (34%) of barotraumas have been reported (Fowler et al 2003). Mechanically ventilated patients should be adequately sedated and a short-term neuromuscular blockade may be required for permissive hypercapnia.