Clinical Commander

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critical.mechanical-ventilation.core.v1

Mechanical Ventilation Management

critical_careacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Ventilator mode ladder (AC-VC / AC-PC / PSV) with lung-protective targets (VT 6 mL/kg PBW, Pplat <30, dP <15) per ARDSNet Brower NEJM 2000 and Amato NEJM 2015. Sedation/analgesia/paralysis axis follows SCCM PADIS 2018 — analgesia-first (fentanyl) → propofol → dexmedetomidine → selective cisatracurium per ACURASYS Papazian NEJM 2010 / ROSE PETAL NEJM 2019. ICU prophylaxis bundle includes stress ulcer (SUP-ICU Krag NEJM 2018), VTE (SSC 2021), and early enteral nutrition (ASPEN/SCCM 2016). Weaning protocol centered on daily SAT/SBT (ATS/ACCP SBT 2017) with RSBI and extubation criteria. Severity triggers cover refractory hypoxemia → ECMO referral (EOLIA Combes NEJM 2018), dyssynchrony, pneumothorax, VAP (ATS/IDSA VAP 2016), extubation failure, and elevated Pplat. Sibling differentiation from pulm.ards.core.v1 (shared lung-protective but ARDS adds prone/NMB/dex/ECMO), cardio.hf.core.v1 (cardiogenic vs non-cardiogenic), and pulm.copd.core.v1 (obstructive vs restrictive physiology). PRODUCTION (2026-06-03): manifest reuses the closest existing sibling (pulm.ards) until a dedicated seed manifest is authored; design brief authored at packages/mechanical-ventilation/_design-brief.md; all RxCUIs RxNav-validated; vent_initial + calc.rsbi (+ calc.pf_ratio) resolve in clinical-tools-registry.

Entry points (5)

  • symptom
    Type I (hypoxemic) respiratory failure — PaO2 <60 mmHg on room air or P/F <300 (ATS/ESICM/SCCM 2024)
    type_I_respiratory_failure
  • symptom
    Type II (hypercapnic) respiratory failure — PaCO2 >50 mmHg with pH <7.35 (ATS/ESICM/SCCM 2024)
    type_II_respiratory_failure
  • vital_abnormality
    Airway protection required — GCS <=8 or inability to protect airway (ATS/ACCP SBT 2017)
    airway_protection_gcs_le8
  • problem_list
    Hemodynamic shock with respiratory compromise requiring intubation (SSC 2021)
    shock_requiring_ventilation
  • problem_list
    Post-operative mechanical ventilation — planned or unplanned prolonged intubation (ATS/ESICM/SCCM 2024)
    post_operative_ventilation

Required inputs (13)

  • abgrequired
    lab • used at CONTEXT
    PaO2, PaCO2, pH, HCO3 for ventilator parameter titration and P/F ratio calculation (ARDSNet Brower NEJM 2000)
  • spo2required
    vital • used at CONTEXT
    Continuous oxygenation monitoring and S/F ratio surrogate (ATS/ESICM/SCCM 2024)
  • rrrequired
    vital • used at CONTEXT
    Respiratory rate for RSBI calculation and dyssynchrony detection (ATS/ACCP SBT 2017)
  • fio2required
    vital • used at CONTEXT
    Fraction of inspired oxygen for P/F ratio denominator (ARDSNet Brower NEJM 2000)
  • peeprequired
    vital • used at TREATMENT
    Positive end-expiratory pressure — lung recruitment vs hemodynamic compromise balance (ARDSNet Brower NEJM 2000)
  • vtrequired
    vital • used at TREATMENT
    Tidal volume — target 6 mL/kg PBW for lung-protective ventilation (ARDSNet Brower NEJM 2000)
  • plateau_pressurerequired
    vital • used at MONITORING
    Plateau pressure — must remain <30 cmH2O to prevent VILI (ARDSNet Brower NEJM 2000)
  • driving_pressurerequired
    vital • used at MONITORING
    Driving pressure = Pplat - PEEP — target <15 cmH2O; strongest predictor of ARDS mortality (Amato NEJM 2015)
  • compliance
    vital • used at MONITORING
    Static compliance = VT / (Pplat - PEEP) — tracks lung recruitability and disease trajectory (ATS/ESICM/SCCM 2024)
  • pf_ratiorequired
    lab • used at DIFFERENTIAL
    PaO2/FiO2 ratio — severity grading and prone/ECMO triggers (ARDSNet Brower NEJM 2000; PROSEVA Guerin NEJM 2013)
  • moderequired
    vital • used at TREATMENT
    Ventilator mode (AC-VC, AC-PC, PSV, SIMV) — drives management strategy (ATS/ESICM/SCCM 2024)
  • heightrequired
    demographic • used at TREATMENT
    Predicted body weight (Devine formula) for VT 6 mL/kg PBW setting (ARDSNet Brower NEJM 2000)
  • sexrequired
    demographic • used at TREATMENT
    Sex-specific PBW formula (ARDSNet Brower NEJM 2000)

12-phase flow (12)

  1. 1FRAME
    Identify indication for mechanical ventilation — respiratory failure (Type I/II), airway protection (GCS <=8), shock, post-operative (ATS/ESICM/SCCM 2024)
    advance: Intubation indication confirmed and ventilator mode selected
  2. 2ENTRY
    Trigger from acute hypoxemia, hypercapnia, altered mental status, or hemodynamic instability requiring ventilatory support (ATS/ESICM/SCCM 2024)
    inputs: spo2, abg
    advance: Decision to intubate made or already intubated
  3. 3CONTEXT
    Capture patient demographics (height, sex for PBW), comorbidities (COPD, obesity, neuromuscular disease), pre-intubation status, and hemodynamic baseline (ATS/ESICM/SCCM 2024; ARDSNet Brower NEJM 2000)
    inputs: height, sex, rr, spo2, fio2
    advance: PBW calculated and initial ventilator settings selected
  4. 4RED_FLAGS
    Refractory hypoxemia (P/F <100), tension pneumothorax, auto-PEEP with hemodynamic collapse, massive air leak, unplanned extubation (ATS/ESICM/SCCM 2024)
    inputs: spo2, fio2, plateau_pressure
    advance: No emergent life-threatening ventilator complication or addressed
  5. 5INITIAL_WORKUP
    ABG, CXR post-intubation (ETT position, lung pathology), baseline labs (BMP, CBC, lactate), initial ventilator mechanics (Pplat, dP, compliance) (ATS/ESICM/SCCM 2024)
    inputs: abg, plateau_pressure, compliance
    actions: vent_initial
    advance: Post-intubation CXR reviewed and initial vent settings confirmed
  6. 6BRANCHING_WORKUP
    Determine underlying etiology — ARDS vs cardiogenic pulmonary edema (echo, BNP) vs COPD exacerbation (VBG, flow-volume) vs neuromuscular (NIF, VC) vs post-op atelectasis (ATS/ESICM/SCCM 2024)
    inputs: pf_ratio
    advance: Ventilation indication subtype established
  7. 7DIFFERENTIAL
    Mode selection: AC-VC (volume-targeted, flow-limited) vs AC-PC (pressure-targeted, decelerating flow) vs PSV (spontaneous, weaning mode); lung-protective vs permissive hypercapnia vs obstructive physiology settings (ATS/ESICM/SCCM 2024; ARDSNet Brower NEJM 2000)
    inputs: mode, vt, peep
    advance: Optimal mode and initial parameters set based on underlying pathology
  8. 8RISK_STRATIFICATION
    Calculate P/F ratio, driving pressure, static compliance, RSBI (for weaning readiness), APACHE II for mortality risk, ventilator-free days projection (ARDSNet Brower NEJM 2000; ATS/ACCP SBT 2017)
    inputs: pf_ratio, driving_pressure
    advance: Severity classified and weaning timeline estimated
  9. 9TREATMENT
    Lung-protective ventilation: VT 6 mL/kg PBW (range 4-8), Pplat <30, dP <15, PEEP per ARDSNet table (ARDSNet Brower NEJM 2000); ARDS protocol: prone >=16 h/day if P/F <150 (PROSEVA Guerin NEJM 2013); selective NMB for dyssynchrony (ACURASYS Papazian NEJM 2010; ROSE PETAL NEJM 2019); sedation: propofol/dex/fentanyl per PADIS (SCCM PADIS 2018); weaning: daily SAT/SBT protocol (ATS/ACCP SBT 2017)
    inputs: height, vt, peep, fio2, mode
    advance: Lung-protective targets met and ICU bundle initiated
  10. 10DISPOSITION
    ICU level of care for all mechanically ventilated patients; ECMO center transfer if refractory (EOLIA Combes NEJM 2018); step-down once extubated and stable (ATS/ESICM/SCCM 2024)
    advance: Appropriate level of care confirmed
  11. 11MONITORING
    Serial ABG q4h or after setting change, plateau + driving pressure q1h, P/F ratio q4h, daily SAT/SBT (SCCM PADIS 2018; ATS/ACCP SBT 2017), CXR daily, RASS q1h, CAM-ICU q shift, auto-PEEP check (ATS/ESICM/SCCM 2024)
    inputs: abg, plateau_pressure, driving_pressure, spo2
    advance: Daily targets documented and trends reviewed
  12. 12FOLLOWUP
    Post-extubation monitoring (stridor, reintubation risk), tracheostomy evaluation if ventilation >14 days, post-ICU syndrome screen (cognitive, physical, mental health), pulmonary rehab referral (ATS/ACCP SBT 2017; SCCM post-ICU 2020)
    advance: Extubation successful or tracheostomy plan in place and post-ICU bundle initiated