What are common pitfalls in mechanical ventilator management?

From the Guidelines

Common pitfalls in mechanical ventilator management include patient-ventilator asynchrony, inadequate adjustment of ventilator settings, and failure to minimize ventilator-induced lung injury (VILI).

Key Considerations

• Patient-ventilator asynchrony can be minimized through informed adjustment of ventilator settings, such as using proportional and NAVA ventilation 1.
• Inadequate adjustment of ventilator settings, such as tidal volume and positive end-expiratory pressure (PEEP), can lead to VILI and worsen patient outcomes 1.
• Failure to use lung-protective strategies, such as low tidal volume ventilation and prone positioning, can increase the risk of VILI and mortality in patients with acute respiratory distress syndrome (ARDS) 1.

Ventilator Settings

• Tidal volume should be limited to 4-6 mL/kg ideal body weight for adults and neonates, and 5-8 mL/kg for children 1.
• Respiratory rate should be adjusted to 10 breaths/min for adults, 20-30 breaths/min for infants and children, and 30 breaths/min for neonates 1.
• PEEP should be adjusted to balance lung volumes and venous return, and to prevent auto-triggering of the ventilator 1.

Clinical Recommendations

• Regular assessment and adjustment of ventilator settings are crucial to prevent patient-ventilator asynchrony and minimize VILI 1.
• Use of recruitment maneuvers, high PEEP, and prone positioning may be beneficial in some patients with ARDS, but should be individualized based on patient response and clinical condition 1.

From the Research

Common Pitfalls in Mechanical Ventilator Management

• Inappropriate ventilation settings can result in injury to the lungs or respiratory muscles and worsen morbidity and mortality 2
• Ventilator-induced lung injury (VILI) can occur due to unphysiological increases of transpulmonary pressure and pleural pressure during positive or negative pressure ventilation 3
• High tidal volumes and high transpulmonary pressures can cause VILI, and respiratory rate and inspiratory flow may also play a role in its genesis 3
• Failure to personalize mechanical ventilation based on individual physiological characteristics and responses to therapy can lead to poor outcomes 2
• Inadequate assessment and management of dyspnea and patient-ventilator dyssynchrony can result in adverse events 4
• Ventilator management decisions can have hidden consequences, such as alterations in venous return, blood pressure, and cardiac output, which can lead to additional interventions with their own risk/benefit profile 5

Key Considerations

• The need for a more complete and individually personalized understanding of ARDS lung mechanics and its interaction with the ventilator 3
• The importance of considering the functional lung size, lung inhomogeneity, and lung recruitability when selecting ventilator settings 3
• The potential for mechanical ventilation to be toxic and the need to withdraw it when clinically appropriate 6
• The importance of communication among healthcare team members regarding ventilator management decisions and their potential consequences 5