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Table 3 Suggested ventilation strategies depending on the presence of ARDS and IAH

From: Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know

  Normal ARDS IAH IAH and respiratory failure
Tidal volume 6 to 8 mL/kg PBW may be beneficial Recommended 4–8 mL/kg PBW (Grade 1B) [123, 124] 6 to 8 mL/kg PBW may be beneficial 4–8 mL/kg PBW may be beneficial
Inspiratory plateau pressure < 20 cmH2O Recommended < 30 cmH2O to reduce risk of alveolar over-distension (Grade 1B) [123] Higher airway pressures may be acceptable and may arise due to reduced chest wall compliance. Corrected target plateau pressure = target plateau pressure − 7 + IAP (mmHg) * 0.7 Higher airway pressures may be acceptable and may arise due to reduced chest wall compliance. Corrected target plateau pressure = target plateau pressure − 7 + (mmHg) * 0.7
Driving pressure < 14 cmH2O < 14 cmH2O (Grade 2B) [84] < 14 cmH2O < 14 cmH2O
Inspiratory plateau trans-pulmonary pressure < 15 cmH2O is reasonable < 25 cmH2O is reasonable [29] < 25 cmH2O is reasonable < 25 cmH2O may be a reasonable target
PEEP 5 in cmH2O Higher PEEP levels in moderate to severe ARDS improves survival rate (Grade 2B) [123]. We suggest 5–10 cmH2O in mild to moderate ARDS and 10–15 in moderate to severe ARDS Higher PEEP levels may reduce atelectasis and atelectrauma. We suggest not to exceed 15 cmH2O Higher than usual PEEP levels may be required to improve oxygenation and respiratory mechanics. We suggest not to exceed 15 cmH2O
PEEP titration We suggest avoidance of excessive driving pressure Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. Oesophageal pressure guided is a reasonable alternative Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. We suggest PEEP in cmH2O = IAP in mmHg Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. Oesophageal pressure guided is a reasonable alternative
Recruitment manoeuvre (RM) RM not routinely recommended RM improves oxygenation, but outcome may be worsened with RM. Best RM method is unknown [65, 123] RM not routinely recommended Higher airway pressures might be required for RM to be effective
Prone Not recommended Recommended as it improves oxygenation and survival rate in patients with ARDS (Grade 1B) [108, 123] Not recommended May reduce IAP and improve oxygenation Important to assure free hanging abdomen and absent IAP increase [29]
NMBA Not recommended Short term NMBA may be beneficial [125] May reduce IAP [121] May reduce IAP and/or improve oxygenation
Adjunctive therapy   Nitric oxide Negative fluid balance Negative fluid balance
ECCO2R Ascites drainage Ascites drainage
ECMO Laparostoma [26, 121] Laparostoma
   Nitric oxide, ECCO2R, ECMO
  1. ARDS acute respiratory distress syndrome, ECCO2R extracorporeal CO2 removal, ECMO extracorporeal membrane oxygenation, IAH intra-abdominal hypertension, IAP intra-abdominal pressure, PBW predicted body weight, PEEP positive end-expiratory pressure, RM recruitment manoeuvre