Optimal Ventilator Strategies in Acute Respiratory Distress Syndrome

Michael C. Sklar, MD; Bhakti K. Patel, MD; Jeremy R. Beitler, MD, MPH; Thomas Piraino, RRT; Ewan C. Goligher, MD, PhD


Semin Respir Crit Care Med. 2019;40(1):81-93. 

In This Article


This review suggests that much progress remains to be made in optimizing mechanical ventilation. The astute clinician will carefully consider the patient's clinical features, physiological status, and response to ventilatory support to determine how to optimally ventilate the patient. The overarching goals of optimal ventilator management are to provide appropriate gas exchange while aiming to minimize dynamic stress and strain on the injured lung. This can be accomplished by minimizing tidal volume to the extent clinically permitted, increasing PEEP if improved mechanics and gas exchange suggest benefit, and implementing evidence-based strategies including neuromuscular blockade (discussed in the article by Syed et al on pp. 101–113) and prone positioning (discussed in the article by Gattinoni et al on pp. 94–100). The judicious use of NIV in appropriately selected candidates with mild/moderate ARDS may also be appropriate. HFOV and APRV may be considered as options for rescue therapy in deteriorating patients, although extracorporeal therapies (discussed in the article by Fan et al on pp. 114–128) may take on more importance in this context.