CLINICAL OVERVIEW

IMV Initiation for Adults in the ED

This clinical overview provides emergency physicians with a practical, evidence-based guide to initiating invasive mechanical ventilation (IMV) for adults in the emergency department (ED). It outlines common indications for IMV, including airway protection and hypoxic or hypercapnic respiratory failure, and highlights the importance of early, individualized ventilator management to prevent complications such as ventilator-induced lung injury (VILI), ventilator-associated pneumonia (VAP), and cardiovascular instability.

Key components of initial management include confirming endotracheal tube placement, selecting an appropriate ventilator mode (typically volume-limited assist control), and using lung-protective ventilation strategies—low tidal volumes, appropriate PEEP levels, and permissive hypercapnia when clinically acceptable. Special considerations are discussed for patients with ARDS, obstructive lung disease, and acute brain injury, each requiring tailored ventilator settings to balance oxygenation, ventilation, and hemodynamic goals.

The overview emphasizes supportive care strategies, such as light sedation, restrictive fluid management, prone positioning for ARDS, and evidence-based use of corticosteroids. It provides clear guidance on monitoring oxygenation, ventilation, and ventilator waveforms, and offers a stepwise approach for troubleshooting clinical deterioration. By adopting early interventions and personalized ventilator settings in the ED, clinicians can improve patient outcomes and continuity of care as patients transition to the ICU.