Key messages

• In the presence of severe hypoxemia search for the etiology and pathogenesis, and establish the dominant damage: consolidation in direct lung injury, compression atelectasis in indirect lung injury, and perfusion alterations in vascular disease.

• Immediately after intubation, open the lung by a recruitment maneuver. Consider that the transmural pressure for full opening is approximately 30 cmH 2O. Remember that in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) caused by an indirect insult the chest wall elastance is higher than normal; consequently the airway pressure to reach a transmural pressure of 30 cmH2O will be higher than in ALI/ARDS caused by a direct insult.

• Target the blood gases to the values that the patient is assumed to have had before the acute insult (consider age and previous respiratory diseases).

• Consider lung injury secondary to mechanical ventilation (fractional inspired oxygen (FiO 2), plateau pressure, tidal volume, intratidal collapse and decollapse), and remember that positive end-expiratory pressure (PEEP) seems to have a protective effect.

• Set the mechanical ventilation with PEEP adequate to keep open compression atelectasis and tidal volume adjusted according to the end-expiratory lung volume. Accept hypercapnia if plateau pressure (or transmural pressure) is excessively high. Always remember that a tidal volume that is too low may result in reabsorption atelectasis.

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