Updated February 2025

ICU Best Practices

Mechanical Ventilation: Lung‑Protective Settings and Evidence‑Based Weaning

Prioritize low tidal volume ventilation with constraints on plateau and driving pressures, judicious PEEP titration, and early, protocolized liberation. Evidence from landmark trials and contemporary syntheses supports strategies that reduce ventilator‑induced lung injury and improve clinical outcomes in ARDS. Apply structured daily readiness assessments, spontaneous breathing trials, and sedation minimization to accelerate safe weaning.

Clinical question

What lung‑protective ventilator settings and weaning protocols improve outcomes and minimize ventilator‑induced lung injury in adults with acute respiratory failure/ARDS?

ARDSVentilator-Induced Lung InjuryDriving PressurePEEPWeaningSBTICU Protocols

Key points

Lung‑Protective Core

Use low tidal volumes (~6 mL/kg PBW) with plateau ≤30 cm H2O and driving pressure minimization; these strategies reduce VILI and improve outcomes in ARDS ^[5], ^[7].

Pressure Targets that Matter

Driving pressure (ΔP = Pplat − PEEP) correlates with mortality; reducing ΔP within lung‑protective ventilation is associated with better survival signals ^[5].

Readiness and SBTs

Daily weaning readiness checks followed by spontaneous breathing trials (SBT) using low‑support methods shorten ventilation duration and complications when paired with sedation‑light strategies ^[6].

Personalization and Monitoring

When available, consider recruitability assessment to individualize PEEP; avoid injurious overdistension or derecruitment ^[7].

Early Application Beyond ICU

Initiating lung‑protective settings in the ED lowers pulmonary complications downstream, supporting early protocolization ^[6].

Evidence highlights

≈ 6 mL/kg PBW (4–8 range) ^[7]

Tidal Volume Target

Keep ≤ 30 cm H2O ^[7]

Plateau Pressure

Aim ≤ 14–15 cm H2O when feasible ^[5]

Driving Pressure

SpO2 88–95% with FiO2 minimization ^[6]

FiO2/SpO2

Initial Setup

Lung‑Protective Ventilation: Practical Implementation

Align settings to minimize mechanical stress and strain while meeting gas exchange goals. Emphasize low VT, pressure limits, and cautious PEEP titration.

Set Mode and Tidal Volume

Choose volume‑assist control (or pressure‑targeted equivalent ensuring consistent low VT). Target ~6 mL/kg PBW (allow 4–8); adjust based on compliance and PaCO2/pH, tolerating permissive hypercapnia if pH ≥7.20 ^[7].

Limit Pressures

Measure plateau pressure with an inspiratory hold; keep Pplat ≤30 cm H2O. Track driving pressure (ΔP) and aim to keep ΔP ≤14–15 cm H2O by lowering VT or optimizing PEEP when safe ^[5], ^[7].

PEEP and FiO2

Use ARDS‑style PEEP/FiO2 tables as a starting point; escalate PEEP judiciously to improve oxygenation while avoiding overdistension. Target SpO2 88–95% and minimize FiO2 as soon as feasible ^[6], ^[7].

Recruitment and Personalization

Avoid routine aggressive recruitment maneuvers. Consider recruitability‑guided approaches (e.g., R/I ratio, imaging/EIT) to tailor PEEP in selected patients; evidence favors selective rather than universal recruitment ^[7].

Synchrony and Sedation

Use light sedation and address patient–ventilator asynchrony with trigger/cycle adjustments or short courses of neuromuscular blockade if severe; minimize exposure to avoid delayed weaning ^[7].

Daily Care

Weaning Readiness and Spontaneous Breathing Trials

Protocolized assessments shorten ventilation and reduce complications when paired with sedation minimization and early oxygen weaning.

Readiness to Wean: Daily Screen

Hemodynamic stability (no escalating vasopressors)

Improving or stable gas exchange: SpO2 ≥88–90% on FiO2 ≤0.40–0.50 and PEEP ≤8 cm H2O

Adequate mental status and cough; manageable secretions

No active procedures or immediate need for deep sedation

Low ventilator demands: RR <35, VT adequate, acceptable pH

SBT Methods

T‑piece or minimal support (PS 0–5 cm H2O, PEEP 0–5) for 30–120 minutes

Pass if: RR <35, SpO2 ≥88–90%, HR and BP stable, no distress, pH acceptable

If fail: identify reversible causes (fluid overload, bronchospasm, excessive sedation), treat, retry in 24 hours

Sedation Strategy

Daily sedation interruption or light‑sedation targets

Analgesia‑first approach; avoid benzodiazepines when possible

Assess delirium and address reversible factors

Post‑SBT Extubation Readiness

Airway protection: strong cough, manageable secretions

Cuff‑leak test in high‑risk laryngeal edema

Plan for post‑extubation support (HFNC/NIV) in high‑risk patients

Safety and VILI Prevention

Avoid VT creep: re‑confirm PBW and set hard VT alarms

Reassess Pplat and ΔP after any setting change

Early FiO2 weaning to limit oxygen toxicity ^[6]

When to Re‑Evaluate Strategy

Pplat >30 or ΔP rising despite low VT

Worsening oxygenation despite higher PEEP

Marked asynchrony or dynamic hyperinflation

Evidence Signals

What the Literature Supports

Synthesis of high‑value findings to guide bedside decisions.

Low VT and Pressure Limits

The ARDS low‑VT strategy is foundational: ~6 mL/kg PBW, Pplat ≤30 cm H2O; consistently reduces VILI and improves survival signals in ARDS ^[7].

Driving Pressure Matters

Across trials of lung‑protective ventilation, lower ΔP is associated with improved survival; aim to minimize ΔP by adjusting VT/PEEP within safe limits ^[5].

Early, Protocolized Care

ED‑initiated lung‑protective bundles (low VT, appropriate PEEP, rapid FiO2 weaning) reduce pulmonary complications after ICU admission ^[6].

Personalized PEEP and Recruitment

Use recruitability assessment to avoid injurious overdistension; evidence favors selective recruitment over routine maneuvers ^[7].

Mechanical Power and VILI

High mechanical power components (VT, RR, pressures, flow) contribute to VILI; strategies that reduce power may mitigate injury, though implementation challenges remain ^[1], ^[2].

References

Source material

Primary literature that informs this article.