Q: When are sedative, analgesic, or neuromuscular blocking agents indicated in critically ill patients with respiratory disease?

Asynchrony with the ventilator (“bucking the vent”) is a common indication for starting treatment with sedative, analgesic, and neuromuscular blocking agents. These agents depress respiratory effort to reduce patients’ discomfort and facilitate oxygenation, particularly when complex ventilatory modes are being used. However, many patients who require mechanical ventilation need short-term sedation and/or analgesia for reasons that are less obvious in noncommunicating patients than in patients who can communicate: to relieve anxiety produced by the intensive care unit (ICU) environment, underlying illness, or invasive diagnostic or therapeutic procedures (eg, presence of an endotracheal tube, tracheal suctioning). It is well known that inadequate control of pain or anxiety can stimulate various stress responses, resulting in tachycardia, increased myocardial oxygen consumption, reduced lung volumes, immuno-suppression,...

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