Mechanical Ventilation Strategies in Critical Care Medicine

Mechanical ventilation remains a cornerstone of support for patients with acute respiratory failure, particularly those with acute respiratory distress syndrome (ARDS), severe pneumonia and perioperative complications. Contemporary strategies emphasise minimising ventilator-induced lung injury by limiting tidal volumes to four to eight millilitres per kilogram of predicted body weight, constraining plateau pressures below 30 cm H₂O and applying positive end-expiratory pressure (PEEP) tailored to lung recruitability. Recruitment manoeuvres and prone positioning can further enhance oxygenation by redistributing ventilation and reducing regional stress and strain. Advances in bedside monitoring—incorporating measurements of airway driving pressure and imaging techniques such as electrical impedance tomography—have enabled more personalised ventilator settings. Together with protocols for neuromuscular blockade, sedation minimisation and judicious use of extracorporeal support, these approaches seek to balance the need for adequate gas exchange with protection of the pulmonary parenchyma and cardiovascular function. Recent events such as the COVID-19 pandemic have underscored the global significance of optimised ventilation protocols, prompting rapid evaluation of novel methods for PEEP titration, dynamic assessment of recruitable lung and strategies to reduce inflammatory biotrauma. Ongoing research continues to refine our understanding of mechanical power, lung heterogeneity and the interplay between chest wall mechanics and transpulmonary pressures, with the aim of improving outcomes across diverse healthcare settings.

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Mechanical Ventilation Strategies in Critical Care Medicine publication trend

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Technical terms

Acute respiratory distress syndrome (ARDS): A form of respiratory failure marked by diffuse alveolar damage, hypoxaemia and reduced lung compliance.

Tidal volume: The volume of gas delivered to the lungs with each ventilator breath, usually expressed in mL per kg of predicted body weight.

Positive end-expiratory pressure (PEEP): The pressure maintained in the airways at end-expiration to prevent alveolar collapse and improve oxygenation.

Plateau pressure: The static pressure measured at end-inspiration during a pause, reflecting alveolar distending pressure.

Driving pressure: The difference between plateau pressure and PEEP; an indicator of cyclic lung stress per breath.

Ventilator-induced lung injury (VILI): Tissue damage resulting from overdistension, repetitive collapse and reopening of lung units under mechanical ventilation.

Lung recruitability: The proportion of collapsed alveolar units that can be reopened by increasing airway pressure.

Electrical impedance tomography (EIT): A non-invasive imaging technique that maps regional ventilation by measuring changes in electrical impedance across the thorax in real time.

References

1. Lung Recruitment Assessed by Electrical Impedance Tomography (RECRUIT): A Multicenter Study of COVID-19 Acute Respiratory Distress Syndrome. American Journal of Respiratory and Critical Care Medicine (2023).
2. Formal guidelines: management of acute respiratory distress syndrome. Annals of Intensive Care (2019).
3. Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials. Critical Care (2016).
4. Airway driving pressure and lung stress in ARDS patients. Critical Care (2016).
5. The future of mechanical ventilation: lessons from the present and the past. Critical Care (2017).