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critical.mechanical-ventilation.core.v1

Mechanical Ventilation Management

critical_careacuteadult
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Identify indication for mechanical ventilation — respiratory failure (Type I/II), airway protection (GCS <=8), shock, post-operative (ATS/ESICM/SCCM 2024)

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Intubation indication confirmed and ventilator mode selected

Patient inputs (13)

PaO2, PaCO2, pH, HCO3 for ventilator parameter titration and P/F ratio calculation (ARDSNet Brower NEJM 2000)

Continuous oxygenation monitoring and S/F ratio surrogate (ATS/ESICM/SCCM 2024)

Respiratory rate for RSBI calculation and dyssynchrony detection (ATS/ACCP SBT 2017)

Fraction of inspired oxygen for P/F ratio denominator (ARDSNet Brower NEJM 2000)

PaO2/FiO2 ratio — severity grading and prone/ECMO triggers (ARDSNet Brower NEJM 2000; PROSEVA Guerin NEJM 2013)

Plateau pressure — must remain <30 cmH2O to prevent VILI (ARDSNet Brower NEJM 2000)

Driving pressure = Pplat - PEEP — target <15 cmH2O; strongest predictor of ARDS mortality (Amato NEJM 2015)

Positive end-expiratory pressure — lung recruitment vs hemodynamic compromise balance (ARDSNet Brower NEJM 2000)

Tidal volume — target 6 mL/kg PBW for lung-protective ventilation (ARDSNet Brower NEJM 2000)

Ventilator mode (AC-VC, AC-PC, PSV, SIMV) — drives management strategy (ATS/ESICM/SCCM 2024)

Predicted body weight (Devine formula) for VT 6 mL/kg PBW setting (ARDSNet Brower NEJM 2000)

Sex-specific PBW formula (ARDSNet Brower NEJM 2000)

Static compliance = VT / (Pplat - PEEP) — tracks lung recruitability and disease trajectory (ATS/ESICM/SCCM 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningrefractory_hypoxemia_pf_under_100
    Refractory hypoxemia P/F <100 despite optimized lung-protective ventilation, prone positioning, and adequate PEEP (ATS/ESICM/SCCM 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpneumothorax_ventilated
    Tension pneumothorax in ventilated patient — sudden hypoxia, hypotension, elevated peak pressures, absent breath sounds (ATS/ESICM/SCCM 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereventilator_associated_pneumonia
    New or worsening infiltrate + fever/leukocytosis + purulent secretions in patient ventilated >=48h (ATS/IDSA VAP 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereextubation_failure
    Reintubation within 48h of planned extubation — indicates weaning failure or upper airway obstruction (ATS/ACCP SBT 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereplateau_pressure_over_30
    Plateau pressure >30 cmH2O despite VT 6 mL/kg PBW and adequate sedation (ARDSNet Brower NEJM 2000)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateventilator_dyssynchrony
    Persistent patient-ventilator dyssynchrony despite sedation optimization — double triggering, breath stacking, flow starvation (ATS/ESICM/SCCM 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Ventilator mode selection and lung-protective strategy (ATS/ESICM/SCCM 2024; ARDSNet Brower NEJM 2000)
axis: ventilator_mode_and_lung_protectionstep ac_vc_lung_protective - Assist-Control Volume Control (AC-VC) — standard lung-protective baseline
Selected step "Assist-Control Volume Control (AC-VC) — standard lung-protective baseline" — Default initial mode for most intubated patients; guaranteed VT delivery (ATS/ESICM/SCCM 2024)
  • AC_VC_lung_protective_settings
    first line
    mechanical_ventilation
    VT 6 mL/kg PBW (range 4-8), RR 14-22 (titrate to pH >=7.20), PEEP per ARDSNet low/high table, FiO2 titrate to SpO2 88-95%, Pplat <30 cmH2O, dP <15 cmH2O • invasive_ventilator • continuous
    ARDSNet ARMA (Brower NEJM 2000) — VT 6 mL/kg PBW reduced mortality 9% vs 12 mL/kg; permissive hypercapnia accepted

icu playbook — drug actions (8)

  1. 1. lung-protective ventilation AC-VC
    VT 6 mL/kg PBW, Pplat <30, dP <15, PEEP per ARDSNet table, FiO2 to SpO2 88-95% • invasive_ventilator • continuous
    trigger: All intubated patients
    ARDSNet ARMA (Brower NEJM 2000) — lung-protective standard of care
  2. 2. fentanyl
    25-100 mcg/h IV • IV • continuous
    trigger: All mechanically ventilated patients
    Analgesia-first strategy (SCCM PADIS 2018)
  3. 3. propofol
    5-50 mcg/kg/min IV • IV • continuous with daily SAT
    trigger: Agitation despite analgesia
    Light sedation target RASS -1 to 0 (SCCM PADIS 2018)
  4. 4. dexmedetomidine
    0.2-1.4 mcg/kg/h IV • IV • continuous
    trigger: Delirium risk or weaning phase
    Lower delirium incidence (SCCM PADIS 2018)
  5. 5. cisatracurium
    0.2 mg/kg IV bolus then 1-3 mcg/kg/min x <=48h • IV • continuous
    trigger: Severe dyssynchrony or refractory hypoxemia on prone
    Selective use only (ACURASYS Papazian NEJM 2010; ROSE PETAL NEJM 2019)
  6. 6. prone positioning
    >=16 h/day • positioning • daily x >=5 sessions
    trigger: P/F <150 sustained >=12h
    PROSEVA (Guerin NEJM 2013) — 16% absolute mortality reduction
  7. 7. pantoprazole + enoxaparin
    Pantoprazole 40 mg IV daily; enoxaparin 40 mg SC daily • IV/SC • daily
    trigger: Mechanical ventilation >=48h
    Stress ulcer + VTE prophylaxis (SSC 2021; SUP-ICU Krag NEJM 2018)
  8. 8. enteral nutrition
    Trophic then advance to goal 25-30 kcal/kg/day • enteral • within 24-48h of intubation
    trigger: Hemodynamically stable on ventilator
    Early enteral nutrition reduces infection (ASPEN/SCCM 2016)

Auto-drafted A&P note

icu

Subjective

- Possible entry pathways: Type I (hypoxemic) respiratory failure — PaO2 <60 mmHg on room air or P/F <300 (ATS/ESICM/SCCM 2024); Type II (hypercapnic) respiratory failure — PaCO2 >50 mmHg with pH <7.35 (ATS/ESICM/SCCM 2024); Airway protection required — GCS <=8 or inability to protect airway (ATS/ACCP SBT 2017).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Mechanical Ventilation Management** (critical.mechanical-ventilation.core.v1).
Phenotype framing: 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)
Scope: Identify indication for mechanical ventilation — respiratory failure (Type I/II), airway protection (GCS <=8), shock, post-operative (ATS/ESICM/SCCM 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Ventilator mode selection and lung-protective strategy (ATS/ESICM/SCCM 2024; ARDSNet Brower NEJM 2000)** — step "Assist-Control Volume Control (AC-VC) — standard lung-protective baseline".
1. AC_VC_lung_protective_settings VT 6 mL/kg PBW (range 4-8), RR 14-22 (titrate to pH >=7.20), PEEP per ARDSNet low/high table, FiO2 titrate to SpO2 88-95%, Pplat <30 cmH2O, dP <15 cmH2O invasive_ventilator continuous (mechanical_ventilation, first line) — ARDSNet ARMA (Brower NEJM 2000) — VT 6 mL/kg PBW reduced mortality 9% vs 12 mL/kg; permissive hypercapnia accepted

Setting playbook (icu) — Deliver lung-protective ventilation, optimize mode selection, manage sedation/analgesia per PADIS, execute daily SAT/SBT weaning protocol, prevent VAP and complications, achieve timely extubation
2. lung-protective ventilation AC-VC VT 6 mL/kg PBW, Pplat <30, dP <15, PEEP per ARDSNet table, FiO2 to SpO2 88-95% invasive_ventilator continuous — All intubated patients (ARDSNet ARMA (Brower NEJM 2000) — lung-protective standard of care)
3. fentanyl 25-100 mcg/h IV IV continuous — All mechanically ventilated patients (Analgesia-first strategy (SCCM PADIS 2018))
4. propofol 5-50 mcg/kg/min IV IV continuous with daily SAT — Agitation despite analgesia (Light sedation target RASS -1 to 0 (SCCM PADIS 2018))
5. dexmedetomidine 0.2-1.4 mcg/kg/h IV IV continuous — Delirium risk or weaning phase (Lower delirium incidence (SCCM PADIS 2018))
6. cisatracurium 0.2 mg/kg IV bolus then 1-3 mcg/kg/min x <=48h IV continuous — Severe dyssynchrony or refractory hypoxemia on prone (Selective use only (ACURASYS Papazian NEJM 2010; ROSE PETAL NEJM 2019))
7. prone positioning >=16 h/day positioning daily x >=5 sessions — P/F <150 sustained >=12h (PROSEVA (Guerin NEJM 2013) — 16% absolute mortality reduction)
8. pantoprazole + enoxaparin Pantoprazole 40 mg IV daily; enoxaparin 40 mg SC daily IV/SC daily — Mechanical ventilation >=48h (Stress ulcer + VTE prophylaxis (SSC 2021; SUP-ICU Krag NEJM 2018))
9. enteral nutrition Trophic then advance to goal 25-30 kcal/kg/day enteral within 24-48h of intubation — Hemodynamically stable on ventilator (Early enteral nutrition reduces infection (ASPEN/SCCM 2016))

Non-pharmacologic actions:
- HOB elevation 30-45 degrees for VAP prevention (CDC/NHSN VAP bundle 2023)
- Oral care with chlorhexidine q6h for VAP prevention (CDC/NHSN VAP bundle 2023)
- Daily SAT + SBT protocol — paired awakening and breathing trial (ATS/ACCP SBT 2017; SCCM PADIS 2018)
- Subglottic secretion drainage if available (ATS/ESICM/SCCM 2024)
- Early mobilization and physical therapy (SCCM PADIS 2018)
- Glucose control 140-180 mg/dL — NICE-SUGAR protocol (Finfer NEJM 2009)
- DVT prophylaxis with SCDs if anticoagulation contraindicated (SSC 2021)

AVOID / contraindication checks:
-  avoid high PEEP in undrained pneumothorax — risk of tension (ATS/ESICM/SCCM 2024)
-  avoid excessive VT (>8 mL/kg PBW) — VILI risk (ARDSNet Brower NEJM 2000)
-  avoid rapid PEEP reduction in ARDS — derecruitment risk (ATS/ESICM/SCCM 2024)
-  auto PEEP check mandatory in obstructive physiology (COPD/asthma) before increasing set PEEP (ATS/ESICM/SCCM 2024)

Monitoring

Regimen monitoring:
- plateau pressure q1h and after any setting change (ARDSNet Brower NEJM 2000)
- driving pressure q1h — strongest mortality predictor (Amato NEJM 2015)
- P/F ratio q4h or after FiO2/PEEP change (ATS/ESICM/SCCM 2024)
- ABG q4h or after ventilator change (ATS/ESICM/SCCM 2024)
- auto-PEEP check q shift in obstructive disease (ATS/ESICM/SCCM 2024)
- RSBI daily during weaning phase (ATS/ACCP SBT 2017)

Setting (icu) monitoring:
- Plateau + driving pressure q1h (ARDSNet Brower NEJM 2000; Amato NEJM 2015)
- ABG q4h or after change (ATS/ESICM/SCCM 2024)
- RASS q1h (SCCM PADIS 2018)
- CAM-ICU q shift (SCCM PADIS 2018)
- CXR daily (ATS/ESICM/SCCM 2024)
- Cuff pressure q8h (ATS/ESICM/SCCM 2024)
- Ventilator circuit condensate management (CDC/NHSN VAP bundle 2023)

Follow-up plan: 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)
- Close-out criterion: Extubation successful or tracheostomy plan in place and post-ICU bundle initiated

Monitoring phase: 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)

Disposition

Current setting: icu — Deliver lung-protective ventilation, optimize mode selection, manage sedation/analgesia per PADIS, execute daily SAT/SBT weaning protocol, prevent VAP and complications, achieve timely extubation

Disposition criteria:
- Step-down: extubated, SpO2 >92% on <=4L NC, hemodynamically stable, RASS 0, CAM-ICU negative, tolerating diet (ATS/ACCP SBT 2017; SCCM PADIS 2018)

Escalation triggers (move to higher acuity):
- Refractory hypoxemia P/F <100 despite optimized settings + prone → ECMO referral (EOLIA Combes NEJM 2018)
- Tension pneumothorax → emergent needle decompression then chest tube (ATS/ESICM/SCCM 2024)
- Ventilator-associated pneumonia → broadened antimicrobials per local antibiogram (ATS/IDSA VAP 2016)
- Extubation failure (reintubation within 48h) → reassess weaning readiness, consider tracheostomy (ATS/ACCP SBT 2017)
- Severe auto-PEEP with hemodynamic compromise → disconnect briefly, reduce RR, increase I:E ratio (ATS/ESICM/SCCM 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Refractory hypoxemia P/F <100 despite optimized lung-protective ventilation, prone positioning, and adequate PEEP (ATS/ESICM/SCCM 2024)
- [LIFE_THREATENING] Tension pneumothorax in ventilated patient — sudden hypoxia, hypotension, elevated peak pressures, absent breath sounds (ATS/ESICM/SCCM 2024)
- [SEVERE] New or worsening infiltrate + fever/leukocytosis + purulent secretions in patient ventilated >=48h (ATS/IDSA VAP 2016)

Citations

- ATS/ESICM/SCCM 2024 Mechanical Ventilation Guideline + ARDSNet ARMA (Brower NEJM 2000) + ATS/ACCP SBT Guidelines 2017 + SCCM PADIS Guidelines 2018 [PMID:10793162](https://pubmed.ncbi.nlm.nih.gov/10793162/)
- Cited evidence (PMID 23688302) [PMID:23688302](https://pubmed.ncbi.nlm.nih.gov/23688302/)
- Cited evidence (PMID 20843245) [PMID:20843245](https://pubmed.ncbi.nlm.nih.gov/20843245/)
- Cited evidence (PMID 31112383) [PMID:31112383](https://pubmed.ncbi.nlm.nih.gov/31112383/)
- Cited evidence (PMID 30113379) [PMID:30113379](https://pubmed.ncbi.nlm.nih.gov/30113379/)

Last reconciled with current guidelines: 2026-05-13.
References
  • ATS/ESICM/SCCM 2024 Mechanical Ventilation Guideline + ARDSNet ARMA (Brower NEJM 2000) + ATS/ACCP SBT Guidelines 2017 + SCCM PADIS Guidelines 2018 — PMID:10793162
  • Cited evidence (PMID 23688302) — PMID:23688302
  • Cited evidence (PMID 20843245) — PMID:20843245
  • Cited evidence (PMID 31112383) — PMID:31112383
  • Cited evidence (PMID 30113379) — PMID:30113379