Mechanical ventilation: advanced modes and waveforms

^{[1] [8] [14]}

Meet the patient

A 62-year-old man with community-acquired pneumonia is ventilated on volume control for moderate ARDS (PaO₂/FiO₂ 110 — moderate by the Berlin bands; Vt 6 mL/kg PBW, plateau 27, within the lung-protective ceiling of 30 cmH₂O). His SpO₂ dips every time the physiotherapist suctions, the flow scalar shows a concave hollow on every pressure-support breath, and the bedside nurse reports he is "fighting the ventilator" — one of the roughly one in four ventilated patients with a high rate of patient-ventilator asynchrony.^[11][13][14]

The registrar reaches for the advanced-mode menu. Stop. The question is not which advanced mode — it is what is the mismatch on the waveform, and is the lung being protected first. Two answers have to come before the mode choice: lung-protective settings are running (Vt 6 mL/kg of predicted body weight with plateau pressure kept at or below 30 cmH₂O, per the ARDS Network trial, and driving pressure minimised — the ventilation variable most strongly associated with survival), and the asynchrony pattern is named. Only then does picking a mode make sense.^[11][12]

The two facts that decide the next hour are the two facts that decide every advanced mode decision: is the lung protected? (the ventilator settings, the plateau, the driving pressure) and is the patient synchronous? (the waveforms). Hold those, and the menu collapses from a wall of acronyms into a few targeted choices.^[1][28]

^{[8] [19] [20] [23] [3] [4] [21]}

References28ShowHide

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