Ventilation Strategies for Critically Ill Patients

General Principles of Mechanical Ventilation

The European Society of Intensive Care Medicine recommends using standard full-featured ventilators rather than basic flow generators for optimal control and monitoring in critically ill patients 2
Implementing lung-protective ventilation strategies to prevent ventilator-induced lung injury is recommended by the American Thoracic Society 2, 1
Monitoring pressure-time and flow-time scalars to optimize ventilator synchrony is suggested by the Society of Critical Care Medicine 2
Regularly measuring peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP is recommended by the American Association for Respiratory Care 2

The American College of Chest Physicians recommends setting tidal volume at 4-8 mL/kg predicted body weight 1, 2
Maintaining plateau pressure <30 cmH2O is recommended by the European Society of Intensive Care Medicine 1, 2
For patients with moderate to severe ARDS, using a higher PEEP strategy (>10 cmH2O) is suggested by the American Thoracic Society 1, 2
For patients with mild ARDS or non-ARDS respiratory failure, using a lower PEEP strategy (5-10 cmH2O) is recommended by the Hepatology society 3, 2

Maintaining SpO2 between 92-97% when PEEP <10 cmH2O is recommended by the European Society of Intensive Care Medicine 1, 2
Targeting SpO2 between 88-92% when PEEP ≥10 cmH2O is suggested by the American Thoracic Society 1, 2
Maintaining PaO2 >55 mmHg is recommended by the American Association for Respiratory Care 2
Targeting PaCO2 between 35-45 mmHg for healthy lungs, but permissive hypercapnia is acceptable in ARDS, is recommended by the Society of Critical Care Medicine 2
Keeping pH >7.20 is suggested by the European Society of Intensive Care Medicine 1, 2

Volume-controlled ventilation with low tidal volumes is strongly recommended as the primary mode by the American College of Chest Physicians 1
Pressure-controlled ventilation may be used as an alternative if plateau pressure can be maintained <30 cmH2O, as suggested by the American Thoracic Society 2

Implementing prone positioning for 12-16 hours for moderate to severe ARDS is recommended by the European Society of Intensive Care Medicine 1, 2
Considering recruitment maneuvers in patients with persistent hypoxemia, but avoiding staircase (incremental PEEP) recruitment maneuvers, is suggested by the American Thoracic Society 1
Considering a trial of inhaled pulmonary vasodilators for severe refractory hypoxemia despite optimizing ventilation and other rescue strategies is recommended by the European Society of Intensive Care Medicine 1
Considering venovenous ECMO if available or referring to an ECMO center for severe refractory hypoxemia is suggested by the American Thoracic Society 1

Using intermittent boluses of neuromuscular blocking agents as needed rather than continuous infusion is recommended by the European Society of Intensive Care Medicine 1
Considering continuous neuromuscular blockade infusion (up to 48 hours) only for persistent ventilator dyssynchrony, need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures is suggested by the American Thoracic Society 1

Using low tidal volume strategy (6 mL/kg PBW) and low plateau pressure (<30 cmH2O) for patients with liver disease/ACLF is recommended by the Hepatology society 3
Using low PEEP strategy (<10 cmH2O) for mild acute lung injury (PaO2/FiO2 200-300 mmHg) to minimize risk of impairing venous return is suggested by the Hepatology society 3
Using higher PEEP may be required with careful hemodynamic monitoring for moderate-severe acute lung injury (PaO2/FiO2 <200 mmHg) is recommended by the Hepatology society 3

Measuring PCO2 in arterial or capillary blood samples is recommended by the European Society of Intensive Care Medicine 4
Considering transcutaneous CO2 monitoring is suggested by the American Thoracic Society 4
Measuring end-tidal CO2 in all ventilated patients is recommended by the American Association for Respiratory Care 4
Measuring SpO2 continuously is suggested by the European Society of Intensive Care Medicine 4
Performing daily extubation readiness testing is recommended by the Society of Critical Care Medicine 4, 2