What are the recommended ventilator modes and settings for patients requiring mechanical ventilation?

From the Guidelines

The recommended ventilator modes for patients requiring mechanical ventilation are volume-controlled ventilation (VCV) or pressure-controlled ventilation (PCV) with settings tailored to the patient's condition, prioritizing lung-protective strategies to minimize morbidity, mortality, and improve quality of life. For most adult patients, initial settings should include a tidal volume of 6-8 mL/kg of ideal body weight, respiratory rate of 12-20 breaths per minute, PEEP (positive end-expiratory pressure) of 5-10 cmH2O, and FiO2 (fraction of inspired oxygen) starting at 100% and titrated down to maintain SpO2 above 92% 1.

Key Considerations for Ventilator Settings

• Tidal volume: 6-8 mL/kg of ideal body weight for most patients, but 4-6 mL/kg for patients with ARDS to prevent ventilator-induced lung injury 1.
• Respiratory rate: 12-20 breaths per minute.
• PEEP: 5-10 cmH2O initially, with adjustments based on the patient's response and the need to maintain a plateau pressure below 30 cmH2O 1.
• FiO2: Starting at 100% and titrated down to maintain SpO2 above 92%.

Special Considerations for ARDS

• Lung-protective ventilation strategies are crucial, using lower tidal volumes and higher PEEP levels to prevent ventilator-induced lung injury 1.
• Prone positioning should be considered for patients with severe ARDS who do not show improvement with standard ventilator settings 1.
• Recruitment maneuvers and higher PEEP levels may be beneficial for some patients with ARDS, but their use should be individualized based on the patient's response 1.

Monitoring and Adjustment

• Continuous monitoring of arterial blood gases, plateau pressures, and the patient's clinical response is essential to adjust ventilator settings appropriately 1.
• Daily assessment of readiness for weaning should be performed, with spontaneous breathing trials conducted when appropriate 1.

Weaning from Mechanical Ventilation

• A two-step approach to weaning, including a daily screening test and a spontaneous breathing trial, is recommended for patients who are ready to be liberated from mechanical ventilation 1.
• Pressure support ventilation (PSV) may be used during weaning or for patients with some spontaneous breathing capacity 1.

From the Research

Ventilator Modes and Settings

The recommended ventilator modes and settings for patients requiring mechanical ventilation are crucial in improving outcomes. The following points highlight the key findings:

• Mechanical ventilation with low tidal volumes has been shown to improve outcomes for patients both with and without acute respiratory distress syndrome 2.
• Lung protective ventilation is defined as a tidal volume of less than or equal to 8 mL/kg of predicted body weight, with a positive end-expiratory pressure (PEEP) and limited plateau pressure 3, 4.
• The choice of ventilatory mode and settings should account for low tidal volume ventilation, limited plateau pressure, and PEEP 3.
• Pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) are not different ventilatory modes, but rather different control variables within a mode 5.
• PCV may offer lower work of breathing and improved comfort for patients with increased and variable respiratory demand, but offers no advantage over VCV in patients who are not breathing spontaneously 5.

Key Recommendations

• Use lung protective ventilation with a tidal volume of less than or equal to 8 mL/kg of predicted body weight 2, 4.
• Limit plateau pressure to 30 cm H2O or less 3, 4.
• Use PEEP to maintain adequate oxygenation 3, 6.
• Consider using PCV or VCV with a decelerating flow waveform to reduce the risk of ventilator-induced lung injury 5.
• Adjust ventilator settings based on the patient's actual breathing mechanics and anticipate the generation of intrinsic PEEP 3.

Ventilator Modes

• Pressure Support (PS) and Continuous Positive Airway Pressure (CPAP) are common ventilator modes used in patients with subarachnoid hemorrhage 6.
• The use of lung protective ventilation is associated with improved outcomes in patients with acute lung injury and the acute respiratory distress syndrome 4.
• The development of acute respiratory distress syndrome (ARDS) is associated with higher peak pressures and lower PEEP levels 6.