WHAT YOU NEED TO KNOW SERIES – REVIEWS
Modern mechanical ventilation strategies for the acute care
surgeon: What you need to know
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Pauline K. Park, MD, FACS, FCCM and Lena M. Napolitano, MD, FACS, FCCP, MCCM, Ann Arbor, Michigan
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PULMONARY COMPLICATIONS AND ACUTE
RESPIRATORY FAILURE
Trauma and acute care surgery often involves acute management
of life-threatening conditions. Emergency surgery carries increased
risk of infection, hemorrhage, and uncorrected physiologic de-
rangement and is associated with increased risks of postopera-
tive complications1 and mortality2,3 The development of compli-
cations following surgery is strongly associated with mortality.4–7
Postoperative pulmonary complications remain among the most
frequent and costly events following surgery and lead to similar
increases in morbidity, mortality, and length of stay as cardiac
complications.8 In particular, postoperative pulmonary compli-
cations in elderly patients may predict long-term mortality.9
The ability to rescue from postoperative complications consti-
tutes an important factor in determining eventual outcome.10
Respiratory and other disease states resulting in acute re-
spiratory failure (ARF; Table 1) account for a large number of
intensive care unit (ICU) admissions and are associated with
prolonged ICU length of stay and high mortality rates. Most pa-
tients with ARF will require mechanical ventilation. Evidence-based
mechanical ventilation management of ARF patients is associ-
ated with improved outcomes.
Acute respiratory failure is classified as either hypoxemic
or hypercapnic. Severe hypoxemic ARF raises the concern for
possible acute respiratory distress syndrome (ARDS).
• Oxygenation failure — hypoxemic respiratory failure (type I),
defined as arterial partial pressure of oxygen (PaO2) <60 mm
Hg on room air, is the most common form of respiratory failure
and a threat to organ function.
• Ventilation failure — hypercapnic respiratory failure (type II),
defined as arterial partial pressure of carbon dioxide of
>50 mm Hg on room air.
This review will focus on basics of mechanical ventilation
(Fig. 1) and consideration of conventional and targeted ventila-
tory support strategies (Fig. 2).
Submitted: October 16, 2023, Revised: February 6, 2024, Accepted: October 17, 2023,
Published online: January 10, 2024.
From the Division of Acute Care Surgery, Department of Surgery (P.K.P., L.M.N.), and
Weil Institute for Critical Care Research and Innovation (P.K.P., L.M.N.), Univer-
sity of Michigan, Ann Arbor, Michigan.
Supplemental digital content is available for this article. Direct URL citations appear in
the printed text, and links to the digital files are provided in the HTML text of this
article on the journal’s Web site (www.jtrauma.com).
Address for correspondence: Pauline K. Park, MD, FACS, FCCM, Division of Acute
Care Surgery, Department of Surgery, University of Michigan, 1C340B-UH, 1500
E Medical Center Dr, Ann Arbor, MI 48109-5033; email: parkpk@med.umich.edu.
DOI: 10.1097/TA.0000000000004194
J Trauma Acute Care Surg
Volume 96, Number 4
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ENDOTRACHEAL INTUBATION
When endotracheal intubation is required, the orotracheal
route is preferred. The optimal intubating conditions require rapid
sequence intubation (RSI) using a combination of short- and
rapid-acting sedatives with a neuromuscular blocking agent.
The 2023 national clinical practice guidelines for RSI in the crit-
ically ill adult patient provide evidence-based recommendations
for RSI12 (Table 2).
Video-laryngoscopy may be the optimal method for suc-
cessful intubation. Among critically ill adults requiring tracheal
intubation in an emergency department or ICU, the use of video
laryngoscopy resulted in a significantly higher incidence of suc-
cessful intubation on the first attempt compared with the use
of direct laryngoscopy (85.1% vs. 70.8%; absolute risk differ-
ence, 14.3 percentage points; 95% confidence interval, 9.9–18.7;
p < 0.001).13
MECHANICAL VENTILATION
Mechanical ventilation for ARF is life-saving but can
paradoxically lead to secondary lung injury, referred to as
ventilator-induced lung injury (VILI). Mechanisms contribut-
ing to the development of VILI include diffuse alveolar injury
resulting from overdistension (volutrauma), pressure-related injury
(barotrauma), injury caused by repeated cycles of recruitment/
derecruitment (atelectrauma), and injury related to the local
release of cytokines with systemic impact (biotrauma). 14
Evidence-based practice has evolved to minimize these events
by using lung protective ventilation with lower tidal volumes,
limitation of plateau pressures (PPlat), and attention to the lower
inflection point and work of breathing. In ARDS patients, ox-
ygenation and ventilation requirements can exceed the limits
of conventional mechanical ventilation, increasing the risk of
complications from VILI. Nevertheless, implementation of evidence-
based ventilation practices even in severe ARDS still remains
inconsistent.15–17
MECHANICAL VENTILATION FUNDAMENTALS
Goals of ventilatory support center on assuring adequate ox-
ygen delivery and alveolar ventilation, reducing work of breath-
ing and minimizing VILI.
The mechanical ventilator supports each breath in three
phases:
• Trigger event that initiates inspiration: machine (based on timer)
or patient (based on effort)
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Park et al.
TABLE 1. Common Etiologies of ARF and Need for
Mechanical Ventilation
• Apnea or respiratory arrest
• Hypoxemia
• Hypercarbia
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• Tachypnea (respiratory rate >30 breaths/min) or bradypnea
• Vital capacity <15 mL/kg, <1.0 L, or <30% predicted
• Minute ventilation >10 L/min
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• Exacerbation of chronic obstructive pulmonary disease
• Respiratory muscle fatigue
• Neuromuscular diseases
• Obtundation or coma, need for airway protection
• Severe hypoxemia, ARDS
• Target/limit variable that regulates gas delivery during in-
spiration: flow (for volume breaths) or inspiratory pressure
(for pressure breaths)
• Cycle goal that terminates inspiration: volume, time, and flow.
Respiratory parameters routinely displayed on the ven-
tilator monitor may include respiratory rate, fraction of in-
spired oxygen (FiO2), tidal volume, minute ventilation, peak
and mean airway pressures, and positive end-expiratory pres-
sure (PEEP).
Figure 1. Fundamentals of mechanical ventilation. Source: Marks, onepagericu.com.11
524
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J Trauma Acute Care Surg
Volume 96, Number 4
Two important parameters, AutoPEEP (intrinsic PEEP)
and PPlat, require measurement during pauses in the breath cycle
to allow equilibration of pressures between the alveoli and the
ventilator (Fig. 3).
• AutoPEEP (intrinsic PEEP) is residual pressure in the venti-
lator circuit at the end of expiration. It is not directly mea-
sured but is calculated by measuring the total PEEP in the
circuit and subtracting the delivered set PEEP. Total PEEP
is measured during an expiratory hold (pause during the
expiratory phase of the breath). Elevations in AutoPEEP
occur from gas trapping from insufficient exhalation or
bronchospasm and may occur when there is insufficient
expiratory time.
• Plateau pressure represents the alveolar pressure applied dur-
ing the majority of the breath cycle and is measured during an
inspiratory hold (pause during the inspiratory phase of the
breath). It is the variable monitored to reduce VILI from
barotrauma during lung protective ventilation and is main-
tained ≤30 cm H2O.
Most ventilators monitor and continuously display the peak
inspiratory pressure (the highest pressure recorded at peak inspi-
ration, which reflects both the PPlat and the additional pressure
applied to overcome flow resistance and elastic recoil of the
lungs and chest wall). Differences between the peak inspiratory
pressure and PPlat should alert the surgeon that a primary
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 J Trauma Acute Care Surg
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Figure 2. Conventional and targeted approaches to mechanical ventilatory support: a precision approach. VT, tidal volume; EELV,
end-expiratory lung volume; IC, inspiratory capacity; AI, artificial intelligence. Source: Pelosi et al. Crit Care. 2021;25:250.

TABLE 2. Complete Recommendations and Suggestions for Clinical Practice Guidelines for RSI in the Critically Ill Adult Patient
1. Positioning
2. Preoxygenation
3. Medication-assisted preoxygenation We suggest using medication-assisted preoxygenation to improve
4. Nasogastric tube decompression
5. Peri-intubation vasopressors
6. Induction agent use
7. Induction agent selection
8. Etomidate and corticosteroid use
9. NMBA use
10. NBMA selection
Source: Acquisto et al.12
HFNO, heated high flow nasal oxygen; NIPPV, noninvasive positive pressure ventilation; IV, intravenous; NMBA, neuromuscular blocking agent.
Recommendation or Suggestion Strength of Recommendation Quality of Evidence
We suggest use of the head and torso inclined (semi-Fowler) position Conditional Very low
during RSI
We suggest preoxygenation with HFNO when laryngoscopy is Conditional Low
expected to be challenging
We suggest preoxygenation with NIPPV in patients with severe
hypoxemia PaO2/FiO2 <150
Conditional Very low
preoxygenation in patients undergoing RSI who are not able to
tolerate a face mask, NIPPV, or HFNO because of agitation,
delirium, or combative behavior
We advise nasogastric tube decompression when the benefit outweighs Best practice statement Ungraded
the risk in patients who are undergoing RSI and are at high risk of
regurgitation of gastric contents
There is insufficient evidence to make a recommendation that there is a Insufficient evidence Not applicable
difference in the incidence of further hypotension or cardiac arrest
between the administration of peri-intubation vasopressors or IV
fluids for hypotensive critically ill patients undergoing RSI
We advise administering a sedative-hypnotic induction agent when an Best practice statement Ungraded
NMBA is used for intubation
We suggest that there is no difference between etomidate and other Conditional Moderate
induction agents administered for RSI with respect to mortality or
the incidence of hypotension or vasopressor use in the
peri-intubation period and through hospital discharge
We suggest against administering corticosteroids following RSI with Conditional Low
etomidate for the purpose of counteracting etomidate-induced
adrenal suppression
We recommend administering an NMBA when a sedative-hypnotic Strong Low
induction agent is used for intubation
We suggest administering either rocuronium or succinylcholine for Conditional Low
RSI when there are no known contraindications to succinylcholine

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Figure 3. Waveform evaluation of intrinsic PEEP (AutoPEEP). (A) Examination of the flow-time curve from the ventilator gives an
indication that there is intrinsic PEEP but does not give an indication of the magnitude. (B) A quantitative measurement of intrinsic PEEP
can be obtained in an apneic patient by using the expiratory pause hold control on the ventilator. This allows equilibration of pressures
between the alveoli and the ventilator allowing the total PEEP to be measured. The value for total PEEP can be read from the PEEP display.
Intrinsic PEEP = Total PEEP − Set PEEP. PEEPi, intrinsic PEEP; PEEPtot, total PEEP; PEEPe, set PEEP. Source: Fawley J, Napolitano N. The
Trauma Manual, Chapter 47, 2019.

resistance problem, such as endotracheal tube obstruction or mu- can improve patient comfort, add support to reduce work of breath-
cous plugging, may be contributing to respiratory compromise. ing, and are used as a means to facilitate ventilator weaning.

Continuous Mandatory Ventilation and

Assist Control
Continuous mandatory ventilation (CMV) delivers manda-
tory machine-delivered breaths at a set rate to achieve a preset
minute ventilation, using either a volume or pressure target.
In pure CMV modes, there is no patient participation in trig-
gering the ventilator. Continuous mandatory ventilation is most
commonly used in heavily sedated patients or those who are
receiving neuromuscular blockade. By interfering with normal
diaphragmatic contraction, CMV may lead to diaphragmatic
dysfunction and atrophy.
Assist control is the most commonly used type of CMV.
The ventilator will allow patient-triggered and preset machine
support. When the ventilator is triggered by the patient or by
the ventilator, a full preset breath is delivered. If the patient does
not trigger a breath within a set time interval, the ventilator will
deliver a controlled breath. Assist control is associated with low
work of breathing, as a set minute ventilation is delivered using
fully supported breaths.
Synchronized Intermittent Mandatory Ventilation
Synchronized intermittent mandatory ventilation delivers
mandatory breaths at a set rate and permits additional spontane-
ous, patient-triggered, variable breaths above the mandatory rate.
If the patient does not trigger spontaneous breaths, mandatory
breaths are delivered at the preset respiratory rate. This mode at-
tempts to minimize the barotrauma that may occur with manda-
tory nonsynchronized ventilation, by synchronizing gas flow with
the patient's inspiratory effort and avoiding delivery of a full pre-
set breath during patient inspiration (breath stacking) or is exhal-
ing forcefully. Pressure support (see hereinafter) may be added
to supplement the spontaneous breaths.
Spontaneous Ventilation
Fully spontaneous modes of ventilation provide no man-
datory breaths. The respiratory rate is triggered by the patient; if
the underlying respiratory drive is diminished, there is a risk of
hypoventilation. Apnea alarms or back-up mandatory minimum
ventilation is required to assure patient safety. Spontaneous modes
VOLUME AND PRESSURE BREATHS
Neither volume nor pressure-based breath types are supe-
rior to the other. The potential benefits and disadvantages should
be considered when choosing the initial mode of mechanical
ventilation. Familiarity with volume and pressure modes allows
the provider options to prioritize adjusting tidal volumes or ele-
vated airway pressures (Fig. 1).
Volume Control Breaths (Time Triggered, Flow
Limited, Volume Cycled)
In volume control breaths, tidal volume is set as the pri-
mary variable. Airway pressures vary with pulmonary compliance
(PPlat) and airway resistance (peak airway pressure). Initial tidal
volumes are typically set at 6 to 8 mL/kg predicted body weight.
In the setting where high PPlat are required to achieve the preset
volume, barotrauma may result.
Pressure Control Breaths (Time Triggered,
Pressure Limited, Time Cycled)
In pressure control breaths, the airway pressure is set as the
primary variable. Tidal volumes vary with thoracic compliance,
pulmonary resistance, and changes in mechanical ventilator set-
tings, such as the inspiratory time. Sudden decreases in pulmo-
nary compliance will result in rapid reduction of minute ventila-
tion from associated decreases in tidal volumes. Acute respiratory
acidosis can ensure. Conversely, decreases in compliance or resis-
tance can lead to increased tidal volumes, with overdistention and
volutrauma.
Pressure-Regulated Volume Control Breaths
(Patient and Time Triggered, Pressure Limited,
Time Cycled)
Pressure-regulated volume control combines a volume tar-
get with pressure breaths. Software-based algorithms use lung
compliance measured during prior ventilator cycles to estimate
the inspiratory pressure needed to achieve the target tidal volume
for the following breath. Thus, changes in compliance or patient
effort automatically signal the ventilator to change the degree of

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 J Trauma Acute Care Surg
Volume 96, Number 4 Park et al.

TABLE 3. Joint Society Practice Recommendations for VAP Prevention

Category Rationale Intervention Quality of Evidence
Essential practices Good evidence that the intervention decreases the Avoid intubation and prevent reintubation High
average duration of mechanical ventilation, • Use high-flow nasal oxygen or NIPPV as
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length of stay, mortality, and/or costs; benefits
likely outweigh risks
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appropriate whenever safe and feasible
Minimize sedation Moderate
• Avoid benzodiazepines in favor of other agents
• Use a protocol to minimize sedation
• Implement a ventilator liberation protocol

Maintain and improve physical conditioning Moderate

Elevate the head of the bed to 30–45 Low*
Provide oral care with tooth brushing but without Moderate
chlorhexidine
Provide early enteral vs. parenteral nutrition High
Change the ventilator circuit only if visibly soiled or High
malfunctioning (or per manufacturers' instructions)
Additional approaches Good evidence that the intervention improves Use selective oral or digestive decontamination in High*
outcomes in some populations but may confer countries and ICUs with low prevalence of
some risk in others antibiotic-resistant organisms
May lower VAP rates but insufficient data to Use endotracheal tubes with subglottic secretion Moderate
determine impact on duration of mechanical drainage ports for patients expected to require
ventilation, length of stay, or mortality >48–72 h of mechanical ventilation
Consider early tracheostomy Moderate
Consider postpyloric rather than gastric feeding for Moderate
patients with gastric intolerance or at high risk for
aspiration
Generally not recommended Inconsistently associated with lower VAP rates and no Oral care with chlorhexidine
impact or negative impact on duration of Probiotics
mechanical ventilation, length of stay, or mortality Ultrathin polyurethane endotracheal tube cuffs Moderate
Tapered endotracheal tube cuffs Moderate
Automated control of endotracheal tube cuff pressure Moderate
Frequent cuff-pressure monitoring Moderate
Silver-coated endotracheal tubes Moderate
Kinetic beds Moderate
Prone positioning Moderate
Chlorhexidine bathing Moderate
No impact on VAP rates, average duration of Stress-ulcer prophylaxis Moderate
mechanical ventilation, length of stay, or mortality* Monitoring residual gastric volumes Moderate
Early parenteral nutrition Moderate
No recommendation No impact on VAP rates or other patient outcomes, Closed endotracheal suctioning systems Moderate
unclear impact on costs
*May be indicated for reasons other than VAP prevention.
Source: Klompas et al.44
NIPPV, noninvasive positive pressure ventilation.

support. As the preset pressure limit is reached, no further vol-
ume is administered, and hypoventilation may occur in patients
with severely diminished compliance.
Pressure Support Ventilation (Patient Triggered,
Pressure Limited, Flow Cycled)
Pressure support ventilation (PSV) is a spontaneous breath
type, augmenting the patient's own respiratory efforts. Once trig-
gered, a set inspiratory pressure is delivered until inspiratory flow
drops below a predetermined threshold (e.g., 25% of peak flow).
Pressure support ventilation can be incorporated with other modes
or function a stand-alone mode to facilitate patient-ventilator
synchrony and support the work of breathing during ventilator
weaning.
Airway Pressure Release Ventilation/Bilevel and
Time-Controlled Adaptive Ventilation (Patient
and Time Triggered, Pressure Limited,
Time Cycled)
These modes refer to administering continuous positive
airway pressure alternating high and low PEEP levels and allowing
both controlled and spontaneous breaths. Airway pressure re-
lease ventilation (APRV) is often specifically used to refer to
pronounced inverse-ratio continuous positive airway pressure

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Park et al.
mode of mechanical ventilation with a longer inspiratory time
(time at high pressure [Thigh]) and a very short expiratory time
or “release” (time at low pressure [Tlow]) to promote rapid exha-
lation and supplement spontaneous minute ventilation. Typical
I:E ratios are set between 7:1 and 10: 1, with CPAP phase pres-
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sure (Phigh) generally set between 25 and 30 cm H2O and expi-
ratory phase pressure (Plow), usually 0 cm H2O. Similar to airway
pressure release ventilation, in bilevel or biphasic ventilation, man-
datory pressure breaths are prescribed, with spontaneous breathing
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permitted at both Phigh or Plow. Spontaneous breaths also may be
pressure supported. Compared with APRV, bilevel Tlow is generally
longer, which allows for more spontaneous breaths during Tlow.
Machine breath tidal volumes are determined by the dif-
ference between the Phigh and Plow PEEP. Spontaneous breathing
at the higher pressure is encouraged. This mode is well tolerated
in terms of hemodynamic stability and patient comfort while on
little or no sedation. APRV has been advocated for severe hyp-
oxic patients, as it attains high mean airway pressures and can
improve alveolar recruitment. However, the impact of poten-
tially large swings in transpulmonary pressure or large exhaled
volumes is not known, and randomized data supporting transla-
tion to improved patient outcomes are not extensive.
APRV using the time-controlled adaptive ventilation
(TCAV) protocol was developed to minimize dynamic alveolar
strain by adjusting the delivered breath according to the mechan-
ical characteristics of the lung.18–20 Time-controlled adaptive
ventilation may prevent VILI and ARDS by multiple mechanisms
(improved alveolar recruitment and homogeneity, reduction in al-
veolar microstrain, reduction in alveolar tidal volumes, and chest
wall recruitment). By setting Tlow to stop at 75% of the peak ex-
piratory flow rate, the Plow never reaches 0 cm H2O and maintains
PEEP throughout the cycle. Further changes to Tlow are made
based on the expiratory flow curve. As elastance increases, Tlow
is further decreased to prevent derecruitment and atelectrauma.
ADVANCED MODES OF MECHANICAL
VENTILATION IN THE ICU
Newer modes of mechanical ventilation listed hereinafter
are focused on improving the patient-ventilator interface, resulting
in decreased ventilator dyssynchrony and improved patient
comfort, allowing greater time in spontaneous breathing. These
advanced modes require that the patient have an intact ventilator
drive and spontaneous breathing and should not be used in pa-
tients with high cervical spinal cord injury or heavy sedation.
A recent systematic review and network meta-analysis of 28 ran-
domized trials (n = 3,189) confirmed that proportional assist
ventilation, compared with PSV, was associated with a threefold
higher rate of liberation from mechanical ventilation. Interestingly,
compared with proportional assist ventilation and PSV, neurally
adjusted ventilatory assist was associated with reduced mortality
in the ICU. No difference in mechanical ventilation duration or
ICU/hospital length of stay was noted.21 Automated closed-loop
mechanical ventilation systems (SmartCare/PS (Draeger Medical,
Lubeck, Germany); IntelliVent (Hamilton Medical, Bonaduz,
Switzerland)) assist with ventilator weaning and reduce respiratory
care workload.22 Cochrane systematic reviews including 21 trials
with 1,676 participants indicated that automated closed loop
528
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J Trauma Acute Care Surg
Volume 96, Number 4
systems reduced the mean duration of mechanical ventilation,
but no effect on mortality was identified.23
Proportional Assist Ventilation
Airway pressure is proportional to the instantaneous pa-
tient effort and is amplified according to respiratory mechanics
(pulmonary compliance and airway resistance) and desired level
of assistance (0–100%). Proportional assist ventilation plus
(PAV+) provides intermittent automated measurements of com-
pliance, resistance, and auto-PEEP used to adjust specific sup-
port for the patient.
Adaptive Support Ventilation
Adaptive support ventilation can deliver both controlled
and assisted pressure breaths based on automated measurements
of the patient's respiratory mechanics and ensures a minute ven-
tilation target set by the clinician.
Neurally Adjusted Ventilatory Assist
The level of ventilator assistance is proportional to the patient's
effort, but the signal arises from electromyogram of diaphragmatic
contraction measured by a specialized esophageal catheter. Neu-
rally adjusted ventilatory assist algorithms ensure that the respi-
ratory muscles are supported throughout inspiration to facilitate
patient-ventilator synchrony and reduce work of breathing.
SmartCare-PS/Intellivent-ASV
These closed loop systems provide automated PSV adap-
tation and automated weaning protocol to decrease PSV support
and initiate spontaneous breathing trials when a low level of
PSV is attained.
HOW WE DO IT: SETTING MECHANICAL
VENTILATION
Oxygenation Targets
Systemic oxygenation varies with both oxygen delivery
and degree of ventilation-perfusion matching. Hypoxia can be
improved by increasing the FiO2, increasing the mean alveolar
pressure by increasing the mean airway pressure (increasing
PEEP, I:E ratio or inspiratory time), reducing atelectasis, and re-
ducing intrapulmonary shunt.
Clinically, a natural bias is to assume that higher PaO2/FIO2
ratios in response to early treatment are inevitably associated
with a good prognosis, while they instead may be associated
with overly aggressive mechanical ventilation. In the ARDS
Network’s lower tidal volumes trial (ARMA), improved oxy-
genation (higher PaO2) alone was not a good surrogate endpoint
for survival; the higher tidal volume group achieved higher
mean PaO2 levels during the trial yet had higher mortality than
the lower tidal volume group.24 While many target oxygen satu-
rations of >96%, current data do not support advantages to “nor-
malization,” and in some conditions, hyperoxia may have a det-
rimental effect. To date, several clinical trials have failed to dem-
onstrate mortality advantages of lower or higher oxygen targets in
the ICU. As a result, many practitioners titrate oxygen saturation
to symptom relief, consider higher targets in the presence of po-
tential ischemia (myocardial, mesenteric), and target saturations
of 90% to 92% or higher without high values.
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 J Trauma Acute Care Surg
Volume 96, Number 4
Conversely, hypoxemia can be easily overlooked. A seem-
ingly acceptable arterial blood gas with a PaO2 of 90 mm Hg on
0.60 FiO2 actually represents a PaO2/FIO2 ratio of 150 and
would represent moderate-severe ARDS if other diagnostic
criteria were met. Acute care surgeons should also be aware that
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disparities in pulse oximetry measurement may critically under-
estimate the depth of hypoxia in darker-skinned individuals.25
Ventilation Targets
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Ventilation is largely dependent on alveolar ventilation
(respiratory rate  (tidal volume − dead space)), as rapid CO2
elimination occurs through the lungs. Hypercarbia or hyperven-
tilation can be improved by changing the overall minute ventila-
tion by increasing or decreasing tidal volume or respiratory rate.
Lung Protective Ventilation
Mechanical ventilation in the face of acute lung injury re-
quires a balance between hypoxemia, atelectatic hypercarbia, and
injurious mechanical ventilation. Tidal volumes and airway pres-
sures are titrated to navigate between derecruitment/atelectasis
and overdistension.
In ARDS patients, lung protective ventilation24 (tidal vol-
ume of 6 mL/kg predicted body weight [PBW], PPlat limited to
≤30 cm H2O) remains a strong recommendation in 2023 European
Society of Intensive Care Medicine (ESICM) ARDS guidelines26
and should form the baseline standard of care for mechanical
ventilation in ARDS. In ICU patients without ARDS, the PRe-
VENT (Protective Ventilation in patients without ARDS) trial27
randomized 961 patients and found that a strategy with low tidal
volumes (6 mL/kg PBW) compared with intermediate tidal vol-
umes (10 mL/kg PBW) using a volume-controlled ventilation
mode did not result in a significant difference in ventilator-free
days. Despite the data, there has been drift in guideline recom-
mendation and practice toward lower tidal volume in critical
care, to minimize any contribution to VILI.
To standardize for differences in body habitus, tidal volume
calculations are based on patient height and sex, which is used to
calculate PBW. As a rule of thumb, empiric setting of tidal volume
goals at 350 mL for women and 400 mL for men will approximate
4 to 8 mL/kg PBW for the majority of the population. Priority
should be given to given to tidal volume and PPlat, at the expense
of accepting lower PaO2 targets and, in some cases, reduced ven-
tilation (permissive hypercapnia) and respiratory acidosis.
Higher PEEP Strategy
Higher PEEP strategies have been advocated to support
oxygenation in combination with the low tidal volume strategy.
Higher levels of PEEP can recruit collapsed alveoli, reduce
ventilation-perfusion mismatch, improve arterial oxygenation,
and increase functional residual lung capacity. Unstable alveoli
that are prone to collapse can be “opened” by maintaining an el-
evated PEEP.
While extensively studied, any benefit seen in meta-analyses
is restricted to patients with moderate or severe ARDS.28 Higher
airway pressures may aggravate hemodynamics of low-preload
state and increase shunt and distension. Positive end-expiratory
pressure settings tested in randomized trials are higher than those
tested in common clinical practice, that is, PEEP 16 to 20 cm H2O
before increasing FIO2 to 0.60. The optimal PEEP level remains
© 2024 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
Park et al.
uncertain, as both underdistension and overdistension of the alveoli
can lead to VILI. Recommendations for the use of higher PEEP
strategy to improve alveolar recruitment and reduce atelectrauma
in ARDS have been downgraded to “no recommendation for
or against higher PEEP strategy” in the latest ESICM guideline.
Recruitment
Recruitment refers to the dynamic process of reopening unsta-
ble airless alveoli, thus increasing the overall alveolar units available
to participate in gas exchange. Strategies of intentional recruitment
using higher pressure mechanical ventilation have been studied.
Unfortunately, initial gains in oxygenation are not durable29
unless the subsequent ventilator strategy incorporates higher PEEP
to maintain inflation. The majority of recruitment occurs below a
threshold of 45 cm H2O30; if ventilation strategy includes limiting
PPlat to <30 cm H2O, limited gains may be seen for the risk of in-
creased barotrauma. Episodes of hypotension and desaturations
during maneuvers may reflect acute right heart dysfunction. Of
note, a randomized trial of PEEP titration, which included recruit-
ment maneuvers to 45 cm H2O, reported higher all-cause 28-day
mortality in the recruitment group.31 Finally, Bayesian network
analysis suggested that mortality was higher in patients with lung
recruitment maneuvers combined with higher PEEP.32
ESICM recommendations have been updated to recom-
mend against routine use of prolonged recruitment maneuvers
(airway pressure >35 cm H2O for at least 1 minute) and suggest
against brief (airway pressure >35 cm H2O for <1 minute) as a
strategy to decrease mortality.26 As such, recruitment maneuvers
are likely most useful in the initial management of recruitable
atelectatic lung, in obese patients, and for rescue from hypoxia
associated from acute derecruitment such as following ventilator
disconnection or bronchoscopy.
Driving Pressure, Mechanical Power
Driving pressure (ΔP) reflects the change in tidal volume
divided by respiratory compliance. During controlled mechani-
cal ventilation, ΔP can easily be approximated at the bedside
as PPlat − PEEP. While most lung protective strategies have fo-
cused on setting tidal volume and PPlat, the mortality benefit of
lung-protective ventilation with ARDS varies with elastance, sug-
gesting that ΔP may be a target.33 In observational mediation
analysis, the ΔP or ΔP has been observed to be the pressure var-
iable most associated with mortality.34 Additional large registry
study suggested that increasing ΔP was associated with in-
creased mortality, particularly with more severe hypoxia.35 A
single-center retrospective evaluation of ΔP in trauma patients
with ARDS thoracic injury and ISS of >15 suggested no associ-
ation between high ΔP and mortality; however, almost 90% of
patients were ventilated with ΔP < 14 mm H2O.36
Mechanical power, a summary variable that can be calcu-
lated at the bedside based on tidal volume, ΔP, flow, PEEP, and re-
spiratory rate, has been proposed as a more complete measure to
evaluate the dose of mechanical ventilation.37 Mechanical power
has been associated ventilation in ARDS, but a simpler model,
using only the ΔP and respiratory rate, was an equivalent predictor
of mortality, with the ΔP accounting for the majority of the effect.38
At present, there are no randomized clinical studies estab-
lishing benefit of ΔP as a therapeutic target in mechanical ventila-
tion. Clinical trials testing the efficacy of manipulating drive
529

Park et al.
pressure on outcomes are in progress; in the meantime, maintaining
a ΔP goal of ≤14 mm H2O has been suggested as reasonable.39–41
Transpulmonary Pressure Monitoring
Chest and abdominal wall compliance may alter optimal
PEEP setting. Transpulmonary pressure-based ventilation may al-
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low individualized titration of PEEP42 to minimize atelectrauma,
particularly in high body mass index patients. Theoretically, PEEP
titration to maintain an end-expiratory transpulmonary pressure
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greater than zero would allow adjustment of ventilator support to
match lung recruitability while minimizing atelectasis.
Transpulmonary pressures (Ptp) are estimated by taking
the measured airway pressure and subtracting the transpleural
pressure (estimated by esophageal balloon manometry) using
the following formula: Ptp ~ peak airway pressure − esophageal
pressure. While a single-center study showed strong signal for
mortality improvement,43 a follow-up multicenter trial showed
no advantage compared with the ARDSNet high PEEP table.42
Testing ventilator titration through a personalized, PtP-based ap-
proach is being evaluated in clinical trial (Precision Ventilation
vs. Standard Care for ARDS [PREVENT VILI; ClinicalTrials.
gov NCT06066502]).
SEDATION DURING MECHANICAL VENTILATION
Maintaining light levels of sedation in ARF ICU patients is
associated with improved clinical outcomes (shorter duration of me-
chanical ventilation and ICU length of stay). Analgesia-first sedation
should be used in mechanically ventilated adult ICU patients. The
Richmond Agitation-Sedation Scale and the Sedation-Agitation
Scale are the most valid and reliable sedation assessment tools
for measuring quality and depth of sedation in adult ICU pa-
tients. Recent guidelines suggest that using nonbenzodiazepine
sedatives (either propofol or dexmedetomidine) may be preferred
Figure 4. Summary of ventilatory targets after brain injury. CBF, cerebral blood flow; CPP, cerebral perfusion pressure; HOB, head of
bed; ICP intracranial pressure; JVO, jugular venous outflow; LTVV, low tidal volume ventilation; MAP, mean arterial pressure; PaCO2,
partial pressure of carbon dioxide; PbtO2, partial pressure of brain tissue oxygen. Source: Taran et al.45
530
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J Trauma Acute Care Surg
Volume 96, Number 4
over benzodiazepines (either midazolam or lorazepam) to improve
clinical outcomes in mechanically ventilated adult ICU patients.
PREVENTION OF VENTILATOR-ASSOCIATED
PNEUMONIA DURING MECHANICAL
VENTILATION
Ventilator-associated pneumonia (VAP) is pneumonia that
develops 48 hours or more after mechanical ventilation via en-
dotracheal tube or tracheostomy and is a common complication
of prolonged mechanical ventilation. In general, about 10% of
patients who require mechanical ventilation develop VAP.
All efforts to prevent VAP should be initiated immediately after
intubation and initiation of mechanical ventilation.44 The recent
2022 Practice Recommendations for VAP Prevention provide
information on essential practices for VAP prevention in all pa-
tients (Table 3).44 Other evidence-based strategies for preven-
tion can be considered in ICUs with a high prevalence of VAP,
including continuous aspiration using subglottic secretions en-
dotracheal tubes, and selective oral decontamination or digestive
tract decontamination.
ARF AND MECHANICAL VENTILATION IN
SPECIAL POPULATIONS
Acute and Traumatic Brain Injury Patients
The management of patients with acute and traumatic brain in-
jury (TBI) commonly requires mechanical ventilation. Optimal
lung protective mechanical ventilation may be challenging in
these patients because of the need to also manage optimal partial
pressure of carbon dioxide targets in addition to intracranial
pressure and cerebral blood flow targets. We currently have lim-
ited data regarding optimal approaches in this setting, but com-
mon principles are reviewed in Figure 4.45
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 J Trauma Acute Care Surg
Volume 96, Number 4 Park et al.

The VENTIBRAIN study (NCT04459884) is a multicenter
observational study on the optimal practice of mechanical venti-
lation and ventilator settings in brain-injured patients and as-
sociation with patient outcomes. The VENTIBRAIN study was
initiated in September 2021 and is scheduled to enroll 3,000 pa-
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associated with almost a 50% 28-day mortality reduction (31% vs.
16%, p = 0.012; hazard ratio, 0.32), which persisted at 3 months
(41% vs. 22%) and 6 months/1 year (41% vs. 22%).50 Additional
studies are required to confirm that personalized mechanical
ventilation in obese patients is associated with improved outcomes.

tients, with study completion date estimated in December 2023, Recommendations for optimal mechanical ventilation in obese
and will provide extensive information to hopefully improve patients are reviewed in Figure 5.45
mechanical ventilation outcomes in these patients for the future.
ARDS Patients
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Obese Patients Acute respiratory distress syndrome and severe hypoxemia

Obesity is a significant risk factor for higher complica-
tions and morbidity related to need for mechanical ventilation
in the ICU and is associated with increased duration of mechan-
ical ventilation and ICU length of stay.46 Obese patients are
more prone to increased lung atelectasis and commonly require
higher PEEP and recruitment maneuvers to avoid it during invasive
mechanical ventilation.47 Related to the large abdominal and chest
wall loads on the diaphragm, obese patients have increased atelec-
tasis and resultant hypoxemia and therefore require higher airway
and pleural pressures to maintain adequate oxygen saturation.48,49
In obese patients with ARDS, a single-institution retrospec-
tive study compared patients with ventilator settings determined
by the ARDSnet table for lower PEEP/higher FiO2 to patients
with ventilator settings individualized by a protocol established
by a lung rescue team, using lung recruitment maneuvers, esoph-
ageal manometry, and hemodynamic monitoring with electrical
impedance tomography. Personalized mechanical ventilation was
patients have high mortality rates and prolonged duration of me-
chanical ventilation and ICU length of stay. In large observational
series from Europe (LUNG-SAFE16), the United States (SAGE17),
and Canada,15 in patients with severe ARDS (PaO2/FiO2 ratio
<100 by the Berlin definition),51 crude mortality remained 37%
to 48.6%, depending on the severity of baseline hypoxemia and
associated comorbid conditions. Early identification ARDS and
early initiation of evidence-based strategies for optimal mechani-
cal ventilation and nonventilatory adjuncts (Fig. 6) are associated
with improved patient outcomes.
NONVENTILATOR ADJUNCTS IN ARDS AND
SEVERE HYPOXEMIA
Nonventilator adjuncts for severe respiratory failure can
be considered in stepwise fashion and consideration of the indi-
vidual patient's condition (Fig. 5). Recent ESICM guidelines for

Figure 5. Mechanical ventilation in obese patients. Main respiratory physiological modifications and suggestions for mechanical
ventilation in critically ill patients with obesity. The main respiratory physiological modifications (functional residual capacity decreased,
abdominal pressure often increased, pulmonary and chest wall compliance often decreased, cephalic ascension of diaphragm, oxygen
consumption, and work of breathing increased) lead to shunt via atelectasis and gas exchange impairment. Comorbidities are often
associated with obesity: obstructive apnea syndrome and obesity hypoventilation syndrome. Consequences on airway management,
potentially difficult, include the preparation of adequate material for difficult intubation as videolaryngoscopes, preoxygenation with
noninvasive ventilation in a semisitting position, considering adding apneic oxygenation (OPTINIV method, high flow nasal cannula
oxygen and noninvasive ventilation), rapid sequence induction, and recruitment maneuver following intubation after hemodynamic
stabilization. Ventilatory settings include low or limited tidal volume (6–8 mL/kg/PBW or less), moderate to high PEEP (7–20 cm H2O) if
hemodynamically well tolerated, recruitment maneuver (if hemodynamically well tolerated, in selected patients), monitoring of
esophageal pressure if possible, and use of prone positioning in a trained team in case of severe ARDS, without contraindicating ECMO.
After extubation, CPAP or NIV should be considered early, as implementation of positive pressure therapies at home after evaluation.
CPAP, continuous positive airway pressure; NIV, noninvasive ventilation; HFNC, high-flow nasal cannula oxygen. Source: De Jong et al.47

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Park et al.
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Figure 6. Mechanical ventilation in ARDS patients. NMB, neuromuscular blockade; APRV, airway pressure release ventilation;
VV-ECMO, venovenous extracorporeal membrane oxygenation; VT, tidal volume; RR, respiratory rate, Pes, esophageal pressure; EIT,
electrical impedance tomography.
ARDS care recently updated recommendations for high PEEP
strategy, recruitment maneuvers, and extracorporeal membrane
oxygenation (ECMO).26
Prone positioning increases oxygenation through improv-
ing ventilation-perfusion matching, chest wall compliance, and
recruiting dependent portions of the lung. Rapid improvements
in oxygenation are seen in 60% to 70% of patients. The tech-
nique was associated with reduced mortality in patients with
moderate to severe ARDS,52,53 but despite the evidence,
pre-COVID observational studies demonstrate low use of prone
positioning in the United States (4% in severe ARDS patients)
compared with European studies.17 Prone positioning can be
performed safely in surgical patients, and its use has been re-
ported with open abdomens54 and on ECMO.55 Multidisciplin-
ary teamwork, planning, and attention are needed to avoid inap-
propriate use, pressure injury, extubation, or dislodgement of
lines,56 but the technique can be performed simply and safely
without specialized equipment (Supplemental Digital Content,
Supplementary Video 1, http://links.lww.com/TA/D525).
Conservative fluid management strategies have been rec-
ommended in patients with ARDS and have been associated
with decreases in duration of mechanical ventilation and ICU
stay.57 Diuretic therapy may be considered in patients with
ARDS and a central venous pressure greater than 4,58 with the
addition of albumin supplementation considered for patients with
hypoalbuminemia.59 Frequent assessment of cardiac function and
adequate perfusion should be considered during active diuresis.
Routine use of continuous neuromuscular blockade is not
recommended26 but may be initiated to facilitate management of
ventilatory dysynchrony, excessive oxygen consumption, and
work of breathing.
532
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J Trauma Acute Care Surg
Volume 96, Number 4
Use of inhaled pulmonary vasodilators has not been asso-
ciated with mortality benefit in patients with respiratory failure
but can have applications in rescue from refractory hypoxia and
facilitation of safe transport to a higher level of care.60
Two randomized controlled clinical trials suggest benefit of
ECMO in severe ARDS, the CESAR (Conventional ventilatory
support vs. Extracorporeal membrane oxygenation for Severe
Adult Respiratory failure) trial61 and the EOLIA (ECMO to rescue
Lung Injury in severe ARDS) trial,62 as well as early clinical success
during the H1N1 and COVID pandemics. Venovenous ECMO
is increasingly offered as rescue therapy for patients with severe
ARDS.16,17,63 Current ESICM guidelines recommend “that patients
with severe ARDS not due to COVID-19 as defined by the EOLIA
trial eligibility criteria, should be treated with ECMO in an ECMO
center, which meets defined organizational standards, adhering to
a management strategy similar to that used in the EOLIA trial.”26
Experience with ECMO in trauma ARDS continues to ac-
crue. Extracorporeal Life Support Organization (ELSO) review
reported 279 patients with a trauma diagnosis between the year
1989 and 2016, with an overall survival of 70%.64 A retrospective
Trauma Quality Improvement Program (TQIP) review (2010–2019)
identified 1,045 trauma patients who received ECMO; however,
only 542 met the prespecified criteria for inclusion in study. Extra-
corporeal membrane oxygenation was initiated within the first
4 hours in 18.9% and in the first 24 hours in 44% of the cohort.
The overall survival was 62%, with age, transfusion, external AIS
score of >3, and initiation of ECMO within 4 hours as significant
variables.65 A recent single-center retrospective cohort study of
early VV-ECMO to stabilize patients to undergo procedural treatment
of injuries reported a 70% survival in 57 patients.66 Optimal ventila-
tion while on ECMO remains a topic of great interest. Benefits of
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 J Trauma Acute Care Surg
Volume 96, Number 4 Park et al.

TABLE 4. Clinical Practice Guideline for Liberation From Mechanical Ventilation

Certainty in the Evidence
Recommendation Strength of Recommendation (i.e., Quality of Evidence)
1. For acutely hospitalized patients ventilated >24 h, we suggest that the initial SBT be conducted Conditional Moderate certainty in the evidence
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with inspiratory pressure augmentation (5–8 cm H2O) rather than without (T-piece or CPAP)
2. For acutely hospitalized patients ventilated >24 h, we suggest protocols attempting to minimize Conditional Low certainty in the evidence
sedation
3. For patients at high risk for extubation failure who have been receiving mechanical ventilation Strong Moderate certainty in the evidence
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for >24 h and who have passed a spontaneous breathing trial, we recommend extubation to
preventive NIV
4. For acutely hospitalized patients who have been mechanically ventilated for >24 h, we suggest Conditional Low certainty in the evidence
protocolized rehabilitation directed toward early mobilization
5. We suggest managing acutely hospitalized patients who have been mechanically ventilated for Conditional Low certainty in the evidence
>24 h with a ventilator liberation protocol
6a. We suggest performing cuff leak test in mechanically ventilated adults who meet extubation Conditional Very low certainty in the evidence
criteria and deemed high risk for PES
6b. For adults who have failed a cuff leak test but are otherwise ready for extubation, we suggest Conditional Moderate certainty in the evidence
administering systemic steroids at least 4 h before extubation. A repeat cuff leak test is not
required.
Source: Ouellette et al.67
CPAP, continuous positive airway pressure; NIV, noninvasive ventilation; PES, postextubation stridor; SBT, spontaneous breathing trial.

continuing mechanical ventilation on ECMO versus extubation successful extubation at 24 hours, but no difference in reintubation
and complete liberation from the ventilator are unknown. rates and ventilator-free days at day 28 was found.

LIBERATION FROM MECHANICAL VENTILATION Consider Extubation

Protocolized Ventilator Weaning
When patients have recovered from ARF, ventilator weaning
is promptly initiated. The American Thoracic Society/American
College of Chest Physicians Clinical Practice Guideline for Liber-
ation from Mechanical Ventilation in critically ill adults provides
evidence-based recommendations (Table 4).67
The importance of early liberation was documented in the
WIND (Weaning according to a New Definition) study, which cate-
gorized weaning duration in 2,729 patients into 3 groups: <24 hours,
greater than 1 day and less than 1 week, and 1 week or more. Mor-
tality was 19% in the first group and increased to 37% after 10 days.
Every additional day without a ventilator weaning success was as-
sociated with significantly increased mortality risk.68
Protocolized standard ventilator weaning is associated with re-
duced duration of mechanical ventilation, weaning duration, and
ICU length of stay compared with nonprotocolized weaning.
Daily paired spontaneous awakening trial and spontaneous
breathing trial are associated with improved survival, increased
ventilator-free days, decreased ICU length of stay, and reduced
ventilator-associated events.69,70
A randomized trial (n = 1,151) confirmed that the use of
30 minutes of PSV (8 cm H2O) during an initial spontaneous
breathing trial compared with 2 hours of T-piece ventilation was
associated with significantly higher rates of successful extubation
(82.3% vs. 74.0%, p = 0.001) and reduced hospital mortality
(10.4% vs. 14.9%, p = 0.02) and 90-day mortality (13.2% vs.
17.3%, p = 0.04).71 Interestingly, in a multicenter open-label ran-
domized trial of patients (n = 969) at high risk of extubation fail-
ure (older than 65 years or chronic cardiac/respiratory disease)
comparing pressure support (8 cm H2O) or T-piece for 1 hour
duration,72 pressure support was associated with higher rate of
The most accurate measure to predict successful extubation
is the rapid shallow breathing index, calculated as respiratory rate
(frequency) divided by tidal volume (f/VT < 105 breaths/min/L).
Other issues to assess include adequate oxygenation and ventila-
tion on spontaneous breathing trial, hemodynamic stability, res-
olution or control of the cause of the respiratory failure, even or
negative fluid balance, normal acid/base and electrolyte balance,
minimal secretions and intrinsic cough, and adequate endotra-
cheal tube cuff-leak test to assess for airway edema. If airway
edema is identified, steroids should be initiated before consider-
ing extubation.73 Methylprednisolone (20 mg intravenous) was
started 12 hours before planned extubation and continued every
4 hours with last injection at endotracheal tube removal (total
80 mg), which is a total of four doses.
Long-term Outcomes
The overall morbidity and trajectory following hospitaliza-
tion for critical illness are likely substantial. Outcomes of surgical
patients requiring mechanical ventilation are not well-known,
and conclusion is hampered by a relative lack of long-term follow-up
data. A linked National Trauma Data Bank TBI Model systems
database study identified that the development of hospital ac-
quired pneumonia had a one-third higher risk of unfavorable
Glasgow Outcome scale-extended (GOS-E) over the first 5 years
after TBI when compared with patients who did not.74 Duration
of mechanical ventilation is likely associated with worse out-
comes; patients requiring long-term mechanical ventilation (de-
fined as >21 days) were found to have greater in-house and
postdischarge mortality health care utilization and health care
costs compared with patients who undergo shorter periods of me-
chanical ventilation.75 The impact may be persistent; in a cohort
of ARDS patients followed for 5 years, careful follow-up

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Park et al.
identified physical and psychological sequelae, as well as increased
cost and use of health care service.76,77 Further study of patient-
centered outcomes of trauma survivorship is meaningful and
should include not only residual pulmonary function but also
overall physical function, cognitive, and psychological outcomes.
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CONCLUSION
Acute care surgery patients are at increased risk for pul-
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monary complications including ARF, which require mechanical
ventilation support. Familiarity with fundamentals of mechanical
ventilation and evidence-based and adjunctive target setting is
necessary to ensure optimal patient outcomes.
AUTHORSHIP
P.K.P. and L.M.N. contributed in the content, writing, and editing of the
manuscript.
ACKNOWLEDGMENTS
We thank the dedicated multidisciplinary team of the University of
Michigan SICU and the expertise of Andrew Weirauch, BSRT, RRT-ACCS.
DISCLOSURE
Conflicts of Interest: Author Disclosure forms have been supplied and are pro-
vided as Supplemental Digital Content (http://links.lww.com/TA/D526).
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