Ventilator Configuration and Management

Initial Configuration

• The British Journal of Anaesthesia recommends initial ventilator settings with a tidal volume of 6-8 ml/kg of predicted body weight and a positive end-expiratory pressure (PEEP) of 5 cm H2O, with subsequent individualization of PEEP according to patient needs 1
• The American Academy of Sleep Medicine suggests that the evidence on optimal configuration of the inspiration:expiration ratio is limited, but generally recommends a range of 1:2 to 1:1.5 2
• The British Journal of Anaesthesia recommends setting the FiO2 to 0.4 after intubation and then using the lowest possible concentration to achieve a SpO2 ≥94% 1

Adjustments for Specific Pathologies

• For patients with obstructive disease, the British Journal of Anaesthesia recommends using tidal volumes of 6-8 ml/kg, a respiratory frequency of 10-15 breaths per minute, and an inspiration:expiration ratio of 1:2 to 1:4 to allow sufficient time for expiration 3, 2
• For patients with neuromuscular disease and thoracic wall deformity, the Thorax journal recommends tidal volumes of 6 ml/kg, a respiratory frequency of 15-25 breaths per minute, and an inspiration:expiration ratio of approximately 1:1 3, 4

Monitoring and Adjustments

• The British Journal of Anaesthesia recommends monitoring dynamic compliance, driving pressure (Pplat-PEEP), and plateau pressure in all mechanically ventilated patients, and individualizing PEEP to avoid increases in driving pressure while maintaining a low tidal volume 5, 1

Special Considerations

• For patients in the prone position, the Intensive Care Medicine journal recommends protective lung ventilation with limited tidal volume, and notes that PEEP and prone positioning have an additive effect on improving oxygenation 6
• For patients intubated before cardiac arrest, the Circulation journal recommends increasing FiO2 to 1.0, using pressure-controlled or volume-controlled ventilation, and limiting pressure or tidal volume to generate adequate chest rise (4-6 ml/kg of ideal body weight) 7

Prevention of Complications

• The British Journal of Anaesthesia notes that the formation of clinically significant atelectasis can be an important risk factor for the development of postoperative pulmonary complications, and recommends maneuvers to recruit alveoli and improve lung mechanics 1, 8
• The British Journal of Anaesthesia recommends avoiding zero PEEP (ZEEP) and notes that there is no evidence to recommend a specific mode of controlled mechanical ventilation 1