What are the guidelines for using a mechanical ventilator (MV)?

From the Guidelines

Ventilators should be used with a target tidal volume of 6 mL/kg predicted body weight and an upper limit goal for plateau pressures of 30 cm H2O in adult patients with acute respiratory distress syndrome (ARDS). This recommendation is based on the most recent and highest quality study available, which suggests that mechanical ventilation using lower tidal volumes and lower inspiratory pressures can improve patient outcomes 1.

Key Considerations for Ventilator Use

• Initial ventilator settings should be individualized based on the patient's condition, with typical starting parameters including tidal volume of 6-8 mL/kg of ideal body weight, respiratory rate of 12-20 breaths per minute, FiO2 starting at 100% and titrating down to maintain SpO2 >92%, and PEEP typically starting at 5 cmH2O.
• Regular monitoring is essential, including vital signs, oxygen saturation, ventilator parameters, and patient comfort.
• Sedation is often necessary, commonly using medications like propofol (starting at 5-50 mcg/kg/min), midazolam (1-2 mg IV followed by 1-4 mg/hr), or dexmedetomidine (0.2-0.7 mcg/kg/hr) to ensure patient-ventilator synchrony.
• Alarm settings must be appropriately configured to detect disconnection, high pressure, or other complications.
• Daily assessment for readiness to wean from ventilation should be performed, including spontaneous breathing trials when appropriate.

Additional Recommendations

• Prone positioning should be used for more than 12 hours a day in patients with severe ARDS 1.
• Higher positive end-expiratory pressure (PEEP) should be used without lung recruitment maneuvers (LRMs) in patients with moderate to severe ARDS 1.
• Recruitment maneuvers should not be used routinely in patients with moderate to severe ARDS 1.
• Corticosteroids may be considered in patients with ARDS, although the evidence is not yet conclusive 1.

Infection Control Measures

• Regular circuit changes every 5-7 days and sterile suctioning techniques can help prevent ventilator-associated pneumonia.
• Proper infection control measures are crucial to prevent complications and improve patient outcomes.

From the Research

Guidelines for Using a Ventilator

• The lung-protective mechanical ventilation strategy is recommended as an initial approach to mechanical ventilation in both perioperative and critical care settings 2.
• Principles of lung-protective ventilation include:
  • Prevention of volutrauma (tidal volume 4 to 8 ml/kg predicted body weight with plateau pressure < 30 cmH2O)
  • Prevention of atelectasis (positive end-expiratory pressure ≥ 5 cmH2O, as needed recruitment maneuvers)
  • Adequate ventilation (respiratory rate 20 to 35 breaths per minute)
  • Prevention of hyperoxia (titrate inspired oxygen concentration to peripheral oxygen saturation (SpO2) levels of 88 to 95%)
• Mechanical ventilation with low tidal volumes has been shown to improve outcomes for patients both with and without acute respiratory distress syndrome 3.
• A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome 4.
• The optimal level of positive end-expiratory pressure (PEEP) remains controversial, and high PEEP can improve lung compliance and enhance oxygenation, but its effects on other organs, such as the heart, brain, and kidneys, need to be considered 5.
• Tidal volume selection is crucial in acute respiratory distress syndrome, and an approach based on the use of low tidal volumes scaled to the predicted body weight is suggested 6.