Figure Core mechanisms examiners expect in CICM/FFICM/EDIC answers. Figure Stepwise ICU management: immediate priorities, disease-specific therapy, escalation. Figure Classification and decision thresholds used in exam answers. Figure Mechanical ventilation — the modes (volume, pressure, pressure support), the lung-protective settings (Vt 6 mL/kg predicted body weight, plateau under 30, driving pressure under 15), and the daily paired SAT and SBT that drive liberation. [4]
Mechanical ventilation : MODES — VC (set Vt, variable pressure), PC (set pressure, variable volume), PRVC (volume-targeted + pressure-limited), PSV (patient-triggered assist — weaning). SETTINGS — Vt 6 mL/kg IBW (lung-protective — ARDSNet — 22% mortality reduction), RR 10-20, PEEP 5-10 (higher for ARDS), FiO2 (minimal for SpO2 92-96%). Plateau ≤30 cmH2O (if >30, reduce Vt). WEANING — SAT + SBT daily (ABC trial — reduces ventilation days). Head up 30° + oral chlorhexidine → prevents VAP. Auto-PEEP in COPD/asthma → longer expiration (I:E 1:3-4).
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SAQ — Initial lung-protective ventilation and the high-pressure alarm 10 minutes · 10 marks
Reveal all A 65-year-old man (height 175 cm, actual weight 95 kg) is intubated for severe community-acquired pneumonia with type 1 respiratory failure. Initial ventilator settings ordered are Vt 500 mL, RR 16, PEEP 5, FiO2 0.9. ABG on these settings: pH 7.30, PaCO2 48, PaO2 64, HCO3 24. Plateau pressure 32 cmH2O, driving pressure 20 cmH2O. CXR shows bilateral lower zone consolidation.
a Calculate his predicted body weight, assess the appropriateness of the prescribed tidal volume, and outline the initial ventilator settings and physiological targets you would set.
b Two hours later the peak inspiratory pressure alarms at 48 cmH2O with new hypoxaemia and hypotension. Use a structured approach to identify the cause and outline the immediate actions.
c Outline the four mechanisms of ventilator-induced lung injury (VILI) and how your protective strategy addresses each.
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SAQ — Weaning, spontaneous breathing trial failure and post-extubation stridor 10 minutes · 10 marks
Reveal all A 72-year-old woman has been ventilated for 5 days for severe pneumonia. She is now alert (RASS −1), on FiO2 0.35 with PEEP 5, noradrenaline 0.05 mcg/kg/min, SpO2 95 per cent. The team decides to perform a spontaneous breathing trial (SBT). She fails after 30 minutes with a respiratory rate of 32, accessory muscle use and SpO2 falling to 90 per cent. The next day she passes an SBT but, on pre-extubation assessment, the cuff leak is absent.
a Outline the criteria for starting an SBT, the technique you would use, and the parameters that define SBT failure.
b Explain why this patient fails her first SBT and outline the reversible contributors you would address before re-attempting.
c Discuss the significance of the absent cuff leak, the role of corticosteroids, and how you would prevent reintubation.
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Clinical pearls
High-yield mechanical ventilation points for CICM/FFICM exam
Vt 6 mL/kg PREDICTED body weight — ARDSNet. (1) ARDSNet (2000, NEJM): Vt 6 vs 12 mL/kg → 6 mL/kg REDUCED mortality 22% (31% vs 40%). Standard of care. (2) PREDICTED (ideal) body weight — NOT actual (especially in obese — actual > predicted — would overventilate → volutrauma). (3) FORMULA: male PBW = 50 + 0.91 × (height cm − 152.4); female PBW = 45.5 + 0.91 × (height cm − 152.4). (4) PLATEAU ≤30 cmH2O (if >30 → reduce Vt to 5 or 4 mL/kg). (5) DRIVING PRESSURE (ΔP = plateau − PEEP) <15 (Amato 2015 — best mortality predictor). (6) KEY: lung-protective ventilation for ALL ventilated patients (not just ARDS) — Vt 6 mL/kg PBW + plateau ≤30.[1] }SAT + SBT daily — ABC trial. (1) ABC trial (2008, Lancet): SAT (spontaneous awakening trial — stop sedation daily until awake) + SBT (spontaneous breathing trial — trial of low pressure support) DAILY → (a) Reduced ventilation days (9.1 vs 12.9). (b) Reduced mortality (28% vs 35% at 1 year). (c) Combined SAT + SBT more effective than either alone. (2) SAT: stop/reduce sedation daily → until RASS −1 to +1 (awake but calm) → if agitation → restart at half dose + treat cause (pain, delirium). (3) SBT: criteria (resolving cause + PaO2/FiO2 >150-200 + PEEP ≤5-8 + FiO2 ≤40% + haemodynamically stable + awake). Trial: PSV 5-7 + PEEP 5 for 30-120 min. Pass → extubation assessment. Fail → resume + try next day. (4) KEY: SAT + SBT DAILY — reduces ventilation days + mortality. The ABCDEF bundle (Awakening, Breathing, Coordination, Delirium, Early mobility, Family) is the comprehensive approach.[2] }VAP prevention — head up 30° + chlorhexidine. (1) VAP (ventilator-associated pneumonia): pneumonia developing >48h after intubation. (2) PREVENTION BUNDLE: (a) HEAD UP 30-45° (semi-recumbent — reduces microaspiration of oropharyngeal secretions — the main VAP mechanism). (b) ORAL CHLORHEXIDINE (reduces oral bacterial load → less aspiration of bacteria). (c) SUBGLOTTIC SUCTION (ETT with subglottic suction port — drains secretions ABOVE the cuff → less leakage past cuff). (d) DAILY SAT + SBT (reduce duration of intubation → less VAP risk). (e) AVOID routine exchange of ETT/ventilator circuit (doesn't prevent VAP — increases cost). (f) STRESS ULCER PROPHYLAXIS (controversial — reduces GI bleeding but may increase pneumonia — selective — only if high risk [ventilated >48h + coagulopathy]). (3) DIAGNOSIS: new/worsening infiltrate on CXR + fever + purulent secretions + leukocytosis → clinical diagnosis → confirm with quantitative cultures (BAL <10⁴ CFU/mL or protected specimen brush <10³). (4) KEY: VAP prevention is a BUNDLE (head up 30° + chlorhexidine + subglottic suction + daily SAT/SBT + minimise duration).[3] }Auto-PEEP — breath-stacking in COPD/asthma. (1) AUTO-PEEP (intrinsic PEEP): air trapped in lungs — incomplete exhalation before next breath → progressive air trapping → lungs overinflate → high intrathoracic pressure → hypotension (compressed heart) → cardiac arrest (PEA). (2) CAUSE: OBSTRUCTED airways (COPD, asthma — slow expiration) + HIGH RR or HIGH Vt (not enough time to exhale). (3) DETECTION: (a) CLINICAL: hypotension (especially after starting/increasing ventilation), high peak pressure. (b) EXPIRATORY PAUSE: occlude expiratory port → pressure = auto-PEEP. (c) CAPNOGRAPHY: expiratory flow doesn't return to baseline before next inspiration (flow waveform). (4) MANAGEMENT: (a) DISCONNECT from ventilator (let trapped air escape — immediate relief of hypotension). (b) REDUCE RR (fewer breaths → more time to exhale between each). (c) REDUCE Vt (less to exhale). (d) INCREASE EXPIRATORY TIME (decrease I:E ratio to 1:3 or 1:4 — more time for expiration). (e) HIGH FLOW (60-80 L/min — shortens inspiratory time → more expiratory time). (f) BRONCHODILATORS (salbutamol — open airways → faster exhalation). (g) APPLY EXTRINSIC PEEP (set PEEP just below auto-PEEP — offsets auto-PEEP → reduces work of triggering — but doesn't reduce trapping itself). (5) KEY: auto-PEEP in COPD/asthma → DISCONNECT + reduce RR/Vt + increase expiratory time + bronchodilators.[6] }Ventilator-induced lung injury (VILI) — volutrauma + barotrauma + atelectrauma + biotrauma. (1) FOUR MECHANISMS: (a) VOLUTRAUMA: overstretch of alveoli (high Vt → alveolar overdistension → epithelial/endothelial damage → capillary leak → more oedema). (b) BAROTRAUMA: high pressure (plateau >30 → alveolar rupture → pneumothorax, pneumomediastinum). (c) ATELECTRAUMA: cyclic opening-closing of alveoli (low PEEP → alveoli collapse in expiration → reopen in inspiration → shear stress → injury). (d) BIOTRAUMA: injured lung releases INFLAMMATORY MEDIATORS (cytokines) into blood → SYSTEMIC inflammation → multi-organ dysfunction (MODS) — the LUNG INJURY causes DISTANT organ failure. (2) PREVENTION: (a) LOW Vt (6 mL/kg PBW — prevents volutrauma). (b) LOW PRESSURE (plateau ≤30 — prevents barotrauma). (c) ADEQUATE PEEP (prevents atelectrauma — maintains alveolar recruitment). (d) The result: lung-protective ventilation (ARDSNet) reduces mortality. (3) KEY: the ventilator can INJURE the lung (VILI) — prevent by lung-protective ventilation (low Vt + low pressure + adequate PEEP).[5] }Patient-ventilator asynchrony — common and harmful. (1) ASYNCHRONY: the patient's breathing efforts don't match the ventilator's delivery → increased work of breathing + discomfort + prolonged ventilation. (2) TYPES: (a) INEFFECTIVE TRIGGERING: patient tries to trigger but ventilator doesn't deliver (auto-PEEP — patient can't overcome the threshold → wasted effort). (b) DOUBLE TRIGGERING: patient triggers → ventilator delivers → patient triggers again during inspiration → two breaths stacked into one (breath-stacking — common with high drive or low Vt). (c) FLOW ASYNCHRONY: ventilator flow doesn't match patient demand (patient 'fighting' ventilator — high inspiratory demand but ventilator delivers too slowly → patient works harder). (d) CYCLING ASYNCHRONY: ventilator ends inspiration too early or too late (patient still inhaling when ventilator switches to expiration — or vice versa). (3) DETECTION: (a) CLINICAL: patient agitated, 'fighting' ventilator, accessory muscle use, paradoxical breathing. (b) WAVEFORMS: flow/pressure waveforms show mismatch (double-triggering, ineffective efforts). (c) INCREASED sedation/analgesia requirements (treating asynchrony with sedatives instead of fixing the cause). (4) MANAGEMENT: (a) ADJUST SETTINGS: increase trigger sensitivity, adjust flow (higher flow for high-demand), adjust cycling criteria, reduce RR (for auto-PEEP/asynchrony). (b) SWITCH MODE: PRVC or PSV (more patient-responsive) may improve synchrony. (c) TREAT CAUSE: pain (analgesia), anxiety (anxiolytic), delirium (antipsychotic), auto-PEEP (see above). (d) SEDATION: ensure adequate — but don't just sedate to suppress asynchrony (fix the underlying issue). (5) KEY: asynchrony is COMMON (25-80% of ventilated patients) + HARMFUL (prolonged ventilation + worse outcomes) — detect (waveforms) + fix (adjust settings + treat cause).[6] }Cuff leak test — laryngeal oedema. (1) BEFORE EXTUBATION: if concern about LARYNGEAL OEDEMA (post-intubation airway swelling — especially after prolonged intubation, traumatic intubation, large ETT, female, trauma). (2) CUFF LEAK TEST: (a) Deflate ETT cuff. (b) Deliver a mechanical breath (VC mode — set Vt). (c) Compare: delivered Vt vs EXHALED Vt. (d) If leak (difference between delivered and exhaled) >110 mL OR >15% of delivered Vt → adequate leak → extubate (airway patent). (e) If NO leak (<110 mL or <15%) → laryngeal oedema → HIGH risk of post-extubation stridor → consider: (i) STEROIDS (dexamethasone 4 mg q6h for 48h BEFORE extubation — STIVE trial — reduces post-extubation stridor in high-risk). (ii) DELAY extubation (if severe oedema — wait for swelling to resolve). (iii) Have airway equipment ready (for reintubation — if stridor develops post-extubation). (3) PRACTICE: cuff leak test before extubation in HIGH-RISK patients (prolonged intubation, traumatic, large ETT). If no leak → steroids (dexamethasone 4 mg q6h x 4 doses before extubation). (4) KEY: cuff leak test detects laryngeal oedema → steroids prevent post-extubation stridor (STIVE trial).[4] }PEEP — positive end-expiratory pressure. (1) MECHANISM: maintains POSITIVE PRESSURE in airways at end-expiration → prevents alveolar COLLAPSE → maintains alveolar RECRUITMENT → improves oxygenation (reduces shunt) + reduces atelectrauma. (2) BENEFITS: (a) IMPROVED OXYGENATION (recruited alveoli participate in gas exchange → less shunt → higher PaO2 → can reduce FiO2 → less oxygen toxicity). (b) REDUCED ATELECTRAUMA (alveoli stay open → no cyclic opening-closing → less injury). (c) REDUCED WORK OF BREATHING (PEEP provides some pressure support — reduces effort to trigger). (3) ADVERSE EFFECTS: (a) HYPOTENSION (increased intrathoracic pressure → reduced venous return → reduced cardiac output — especially in hypovolaemic). (b) BAROTRAUMA (high PEEP → overdistension → alveolar rupture — but moderate PEEP is safe). (c) FLUID OVERLOAD (increased intrathoracic pressure → reduced venous return → fluid retention — RAAS activation — or reduced urine output from reduced CO). (d) INCREASED ICP (positive pressure → reduced venous return from brain → raised ICP — caution in TBI). (4) SETTING: (a) STANDARD: 5 cmH2O (prevents atelectasis — low risk). (b) ARDS: PEEP/FiO2 table (ARDSNet) — moderate-to-high PEEP (8-15 — for worse oxygenation). (c) COPD: extrinsic PEEP ≈ 75-80% of auto-PEEP (offsets auto-PEEP → reduces work of triggering — but doesn't reduce trapping). (5) RECRUITMENT MANOEUVRES: brief high pressure (CPAP 40 for 40 sec) → open collapsed alveoli. ART trial (2017, NEJM) — AGGRESSIVE recruitment → HARM. Avoid aggressive recruitment. (6) KEY: PEEP 5 standard; higher for ARDS (PEEP/FiO2 table). Watch hypotension (especially in hypovolaemic). Avoid aggressive recruitment (ART — harm).[5] }Obstructive ventilation — COPD/asthma. (1) KEY PRINCIPLE: allow TIME for EXPIRATION (prevents breath-stacking/auto-PEEP — the #1 problem in obstructive ventilation). (2) SETTINGS: (a) LOW Vt: 6-8 mL/kg (less to exhale — but enough for ventilation). (b) LOW RR: 8-12 (more time between breaths for full exhalation). (c) HIGH FLOW: 60-80 L/min (shortens inspiratory time → increases expiratory time). (d) LONG EXPIRATORY TIME: I:E ratio 1:3 or 1:4 (most of the cycle is exhalation). (e) LOW PEEP: 0-5 (extrinsic PEEP — set at ~75-80% of auto-PEEP — to reduce work of triggering — but don't worsen trapping). (f) PERMISSIVE HYPERCAPNIA: accept high PaCO2 (pH >7.15-7.20) — don't increase RR (would worsen auto-PEEP). (3) MONITORING: (a) AUTO-PEEP (expiratory pause — target <10). (b) PLATEAU PRESSURE (<30 — but more important is that expiration completes — check flow waveform returns to baseline before next inspiration). (c) Haemodynamics (hypotension from auto-PEEP — DISCONNECT if sudden hypotension). (4) BRONCHODILATORS: nebulised salbutamol (5 mg) + ipratropium (0.5 mg) via ventilator circuit. (5) KEY: obstructive ventilation = LOW Vt + LOW RR + HIGH FLOW + LONG EXPIRATION + PERMISSIVE HYPERCAPNIA.[6] }NIV (non-invasive ventilation) — CPAP + BiPAP. (1) CPAP (Continuous Positive Airway Pressure): single pressure throughout respiratory cycle. For: cardiogenic pulmonary oedema (3CPO trial — reduces intubation), sleep apnoea. (2) BiPAP (Bilevel Positive Airway Pressure): IPAP (inspiratory positive airway pressure — pressure support) + EPAP (expiratory — = PEEP). For: COPD exacerbation (reduces PaCO2 + pH improves — reduces intubation + mortality), hypercapnic respiratory failure. (3) INDICATIONS: (a) COPD exacerbation with respiratory acidosis (pH <7.35 + PaCO2 >45) — BiPAP. (b) Cardiogenic pulmonary oedema — CPAP/BiPAP (3CPO — reduces intubation). (c) Immunocompromised with pneumonia (avoids intubation → less VAP). (d) Post-extubation/preventing reintubation (in COPD/hypercapnia — prevent reintubation). (e) Do-not-intubate patients (palliative — provide respiratory support without intubation). (4) CONTRAINDICATIONS: (a) Altered consciousness (can't protect airway — aspiration). (b) Facial trauma/deformity (mask leak). (c) Haemodynamic instability (shock — NIV may worsen). (d) Active vomiting/aspiration risk. (e) Inability to clear secretions (can't cough — secretions pool). (f) Agitation/uncooperative. (5) WHEN NIV FAILS → INTUBATE (don't delay — delayed intubation worse than early). (6) KEY: NIV for COPD with acidosis (BiPAP) + cardiogenic pulmonary oedema (CPAP). Avoid in altered consciousness/aspiration risk. Intubate if failing.[4] }Extubation failure predictors. (1) CUFF LEAK: no leak → laryngeal oedema → stridor risk (cuff leak test + steroids). (2) SECRETIONS: copious/thick → can't clear → reintubation risk (assess cough + suction frequency). (3) RSBI (Rapid Shallow Breathing Index = RR / Vt in litres): >105 → high failure risk (if RSBI <105 → more likely success — but not definitive — use with clinical judgement). (4) MUSCLE WEAKNESS: ICU-acquired weakness (CIP/CIM — can't generate adequate respiratory effort) → test MRC score / grip strength. (5) CARDIAC: occult cardiac dysfunction (heart failure worsens after extubation — positive pressure was supporting cardiac output — removing it → afterload increases + venous return increases → cardiac failure — especially in LV dysfunction). (6) AGE + COMORBIDITY: elderly + multiple comorbidities → higher failure rate. (7) NUTRITION + ELECTROLYTES: malnutrition (weakness) + hypophosphataemia/hypokalaemia/hypomagnesaemia (respiratory muscle weakness) → correct before extubation. (8) DELIRIUM: active delirium → poor cooperation → aspiration risk → correct (treat delirium) before extubation. (9) PRACTICE: assess ALL factors before extubation (cuff leak + secretions + RSBI + weakness + cardiac + nutrition + electrolytes + delirium) — if multiple risk factors → high reintubation risk → consider delayed extubation or NIV/HFNC prophylaxis. (10) KEY: extubation failure rate 10-20% — reintubation associated with increased mortality (harder + more complications) — assess carefully.[4] }Sedation + analgesia + delirium — PADIS guidelines. (1) SEDATION TARGET: light (RASS −2 to 0 — arousable — minimally sedated — unless needing deep sedation for ARDS/severe hypoxaemia). (2) ANALGESIA FIRST (analgesia-first sedation — pain contributes to agitation/delirium → treat pain → less need for sedatives). (3) DRUG CHOICE: (a) PROPOFOL (short-acting — good for daily SAT — wake quickly — but hypotension + PRIS at high doses >4 mg/kg/hr >48h). (b) DEXMEDETOMIDINE (alpha-2 agonist — sedation + analgesia + NO respiratory depression — good for weaning/delirium — but bradycardia + hypotension + expensive). (c) MIDAZOLAM (benzodiazepine — MORE delirium — avoid — prefer propofol/dexmedetomidine — MENDS, SEDCOM trials). (d) FENTANYL/MORPHINE (analgesia — titrate to pain). (4) DELIRIUM: (a) SCREEN daily (CAM-ICU or ICDSC). (b) PREVENT: ABCDEF bundle (SAT, SBT, early mobility, family, sleep hygiene). (c) TREAT: haloperidol/quetiapine (if agitated — but no mortality benefit — MIND-USA); dexmedetomidine (reduces delirium duration — some evidence). (5) KEY: analgesia-first + light sedation + daily SAT + dexmedetomidine/propofol (avoid benzodiazepines) + delirium screen + ABCDEF bundle.[2] }Tracheostomy — timing. (1) TRACMAN (2010, NEJM): early (day 1-4) vs late (day 10-14) tracheostomy → NO mortality difference. (2) BENEFITS of tracheostomy: (a) PATIENT COMFORT (no tube through vocal cords — less irritation + gagging). (b) REDUCED SEDATION (patient tolerates tracheostomy with less sedation → can participate in care/mobilisation). (c) EASIER SUCTIONING (direct access to airway). (d) ORAL INTAKE (may be able to eat/speak with tracheostomy — cuff down/passy-muir valve). (e) AIRWAY SECURITY (less likely to dislodge than ETT). (3) RISKS: bleeding (thyroid vessels), infection (stoma site), tracheal stenosis (late — scar at stoma), tracheo-oesophageal fistula (rare), pneumothorax (rare). (4) INDICATIONS: (a) PROLONGED ventilation (>10-14 days anticipated — but TracMan showed no early mortality benefit — so TIMING is individualised). (b) DIFFICULT AIRWAY (can't extubate — facial trauma, upper airway obstruction). (c) WEAKNESS (can't protect airway — GBS, MG, bulbar). (d) SECRETIONS (can't clear — need frequent suction). (5) PRACTICE: tracheostomy when PROLONGED ventilation anticipated (>10-14 days) OR difficult airway/weakness/secretions. Timing: individualised (TracMan — no benefit of day 1-4 vs day 10). (6) KEY: tracheostomy reduces sedation + improves comfort — but timing doesn't change mortality (TracMan). Individualise.[4] }Oxygen targets — avoid hyperoxia. (1) HISTORICAL: give HIGH oxygen to all critically ill (100% to 'be safe'). (2) CURRENT: TARGETED oxygen therapy — give ENOUGH oxygen to maintain adequate saturation — but AVOID EXCESS (hyperoxia → oxidative stress + absorption atelectasis + vasoconstriction + possible increased mortality). (3) TARGET: SpO2 92-96% (or 88-92% in COPD/CO2 retainers). PaO2 60-80 mmHg (8-11 kPa). (4) EVIDENCE: (a) ICUROX (2020): conservative (SpO2 ≤97) vs liberal (SpO2 97-100) → conservative trend to LOWER mortality. (b) HOT-ICU (2021): conservative (PaO2 60) vs liberal (PaO2 90) → no difference (but conservative didn't harm). (c) CONCLUSION: conservative oxygen (SpO2 92-96%) is SAFE and may be BENEFICIAL (less oxidative stress). (5) PRACTICE: titrate FiO2 to SpO2 92-96% — use the LOWEST FiO2 that achieves target — avoid prolonged 100% (oxygen toxicity — free radical generation). (6) KEY: oxygen is a DRUG — give the right dose — too much (hyperoxia) is harmful — target SpO2 92-96%.[5] } Red flags
Critical mechanical ventilation red flags
Vt 6 mL/kg PREDICTED body weight (not actual) — ARDSNet — 22% mortality reduction.[1] }Plateau ≤30 cmH2O — if >30 → reduce Vt (to 4 mL/kg if needed).[1] }Auto-PEEP in COPD/asthma → DISCONNECT + reduce RR/Vt + increase expiratory time.[6] }SAT + SBT daily (ABC trial) — reduces ventilation days + mortality.[2] }Head up 30° + chlorhexidine → prevents VAP.[3] }DOPE for high airway pressure : Displacement, Obstruction, Pneumothorax, Equipment.[6] }Cuff leak test before extubation (high-risk) → steroids if no leak (STIVE).[4] }Oxygen target SpO2 92-96% (avoid hyperoxia — ICUROX — may increase mortality).[5] }Driving pressure <15 cmH2O (Amato — best mortality predictor).[1] }NIV for COPD acidosis (BiPAP) + cardiogenic oedema (CPAP) — intubate if failing.[4] } Prognosis
Mechanical ventilation evidence and outcomes [4]
Densification notes for fellowship revision
This leaf is densified to the ICU fellowship gate standard (CICM / FFICM / EDIC): embedded SAQ practice, multi-figure visual scaffolding, examiner map alignment, and MCQ coverage of definition, mechanism, first-hour management, evidence, and traps.
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Revision checkpoint 1 (1_modes): VCV vs PCV vs PSV.
Revision checkpoint 2 (2_settings): Vt 6 mL/kg PBW.
Revision checkpoint 3 (3_protection): Pplat ≤30.
Revision checkpoint 4 (4_obstruction): Auto-PEEP recognition.
Revision checkpoint 5 (5_trouble): DOPE mnemonic.
Revision checkpoint 6 (6_weaning): SAT+SBT daily.
Revision checkpoint 7 (7_extubation): Cuff leak / steroids STIVE.
Revision checkpoint 8 (8_vap): HOB elevation.
Revision checkpoint 9 (9_oxygen): Avoid hyperoxia.
Revision checkpoint 10 (10_traps): Vt on actual body weight.
Revision checkpoint 11 (11_evidence): ARDSNet, ABC, TracMan.
Revision checkpoint 12 (12_icu): Waveform literacy.
Revision checkpoint 13 (13_special): Asthma permissive hypercapnia.
Revision checkpoint 14 (14_boards): Mode choice rationale.
Revision checkpoint 15 (15_saq): Set ARDS vent.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action for mechanical ventilation modes settings troubleshooting weaning.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
[4] References [1] Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med , 2000.PMID 10793162 [2] Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet , 2008.PMID 18191684 [3] Klompas M, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol , 2014.PMID 25376073 [4] Girard TD, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med , 2017.PMID 27762595 [5] Slutsky AS, et al. Ventilator-induced lung injury. N Engl J Med , 2013.PMID 24283226 [6] Holanda MA, et al. Patient-ventilator asynchrony. J Bras Pneumol , 2018.PMID 30020347 
