Oct 14, 2023

The Rules of Mechanical Ventilation

Keith Lamb

Over the last few years there have been many advances in technology that have been implemented in critical care, especially as it pertains to mechanical ventilation and the utilization of imaging to make clinical decisions.

The universal teaching of newer modes of ventilation and of theories like the equation of motion and mechanical power has become standard. Many programs have implemented these ideas in their curriculum, particularly in post graduate programs and critical care fellowships.

The above being said, these advances have little or no evidence that they impact clinical outcomes and are difficult for the average bedside clinician to understand and effectively utilize in real time while taking care of critically ill or injured patients. Many graduate from programs without understanding the basic tenets of mechanical ventilation and how to implement them at the bedside.

There are several approaches to the management of mechanical ventilation that do have data and evidence to support positive effect on outcomes and are reasonably easy to conceptualize and understand. I have reduced these concepts down to what I call the “Rules of Mechanical Ventilation”.  I list these rules here, and I have developed short videos that are available that discuss these rules along with many other topics that are being developed weekly. These videos are available on my YouTube Channel. I call these videos RT CIMS, or RT Complex Issues Made Simple. Please click this link to subscribe and follow my Respiratory Critical Care Channel. Click to Subscribe

Here are my “Rules of Mechanical Ventilation”.

  1. Initiate mechanical ventilation utilizing tidal volumes between 4-8ml/kg/pbw. Then dose the ventilator to the patient.
  2. Keep plateau pressure less than 30 cm H2O
  3. Keep driving pressure less than 15 cm H2O
  4. Customize PEEP to prevent atelectrauma, improve compliance, and to allow the use of the lowest FiO2 available.
  5. Make the ventilator fit the patient to prevent asynchrony. Do not make the patient fit the ventilator except in a small number of patients.
  6. Get rid of the ventilator as soon as possible.
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Keith Lamb

Keith Lamb, RRT, RRT-ACCS, FAARC, FCCM is a Respiratory Therapist and researcher with 25 years of experience. He has held positions as a staff respiratory therapist, clinical team leader, clinical specialist, research coordinator, ECMO coordinator, and ECMO director. He lectures locally, nationally, and internationally on topics related to respiratory critical care. He has authored/co-authored over 100 peer reviewed articles and book chapters, served as Principal Investigator on numerous research initiatives and has held elected positions within the American Association for Respiratory Care and the Society of Critical Care Medicine. He is a Fellow of both the American Association for Respiratory Care and the American College of Critical Care Medicine.

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