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Initiation of Mechanical Ventilation 219

TABLE 8-5 Indications for Prophylactic Ventilatory Support

Indication Examples

Reduce risk of pulmonary complications Prolonged shock
Head injury
Smoke inhalation

Reduce hypoxia of major body organs Hypoxic brain
Hypoxia of heart muscles

Reduce cardiopulmonary stress Prolonged shock
Coronary artery bypass
surgery
Other thoracic or
abdominal surgeries
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for mechanical ventilation are relative in nature and deal with the condition and
prognosis of the patient.
There are three considerations in which mechanical ventilation should be ter-
minated or should not be started (Campbell et al., 1992). They are based on (1)
patient’s informed request, (2) medical futility, and (3) reduction or termination
medical futility: A condition in
which medical interventions are of patient pain and suffering.
useless based on past experience. A patient’s informed request carries with it many legal, ethical, medical, and eco-
nomical concerns. The health care facilities and professionals should be prepared to
work with the patient and his family on this type of request. A protocol should be
established to serve as a guide before a hasty decision is needed concerning whether
ventilatory support should be started or discontinued.
Schneiderman et al. (1990) suggested that medical intervention may be futile if
the physicians have concluded that intervention was useless in the last 100 similar
cases. It is reasonable to infer that if medical intervention will not be effective in all
probability, life support measures including mechanical ventilation should not be
started. In this case, the physician must establish an open, honest discussion with
the patient and the concerned parties about the potential outcomes for withholding
ventilatory support.
Another relative contraindication for mechanical ventilation is to reduce or termi-
nate patient pain and suffering. In probable terminal cases such as metastatic cancer
and multiorgan failure, the benefit of mechanical ventilation must be weighed
against the degree of pain and expected length of suffering that a patient may be
subjected to. Physical restraints, painful and uncomfortable medical procedures,
and psychological trauma are just a few problems that may not be completely allevi-
ated by sedatives and analgesics (Campbell et al., 1992). Of course, medical futility
would be a concurrent concern in dealing with this question.
Withdrawing ventilatory support from a patient poses a greater challenge than with-
holding mechanical ventilation. But this difficult decision should be based on the fact
that mechanical ventilation is a supportive measure, rather than a curative procedure.

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