General rules for setting mechanical ventilation

We believe that the following rules should be adopted in the treatment of ALI/ARDS.

1. Collect an accurate history to establish the etiology and pathogenesis. This provides initial information about the underlying pathology.

2. Condition the lung immediately after intubation (recruitment), as described previously.

3. Assess the dominant underlying pathology in patients who are already anesthetized and paralyzed for intubation;

a. measure the respiratory mechanics (possibly including the 'pleural' pressure, by means of an esophageal balloon);

b. obtain radiographs or Ct scans at different airway pressures;

c. perform imaging procedures for the detection of embolism/thrombosis if suspected.

4. Institute the type of mechanical ventilation with the most favorable cost-benefit ratio, aiming to 'open the lung and keep it open'.

a. After conditioning keep the lung open by adequate PEEP, remembering that the PEEP requirement in ALI/ARDS from indirect insult may be higher than that in ALI/ARDS from direct insult or vascular alterations. PEEP is mandatory to maintain recruitment when compression atelectasis is present. In consolidation and vascular alteration, PEEP may improve oxygenation by regional diversion of ventilation-perfusion. The inflection point on the P-V curve may help in setting PEEP. A PEEP trial is always recommended.

b. Try to maintain the plateau pressure below 35 cmH2O, remembering that the transmural pressures for a given Paw are lower in ALI/ARDS from indirect insult. In this case plateau pressures above 35 cmH2O should not be dangerous.

c. After setting the pressures (plateau and PEEP), adjust FiO2 to maintain PaO2 around 80 mmHg (10.7 kPa). Accept hypercapnia and decrease tidal volume if the pressure set is too high. However, it should be remembered that an excessively low tidal volume may cause a slow deterioration of oxygenation through the development of reabsorption atelectasis.

5. Interventions other than mechanical ventilation should be considered, such as the prone position which is probably the most effective maneuver for regional recruitment and has been tested in a randomized trial.

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