Table 2.

Proposed strategy for managing a patient in ICU on ventilator to facilitate weaning

Complications of mechanical ventilation	Steps to prevent them
Sedation and immobilization: Deep vein thrombosis and pulmonary embolism Pressure sore: Pain and infections Delirium	Early mobilization DVT prophylaxis Pressure sore prevention Minimize use of Benzodiazepines
Need for prolonged IV access and its complications	Implement CLABSI bundle Remove invasive lines at earliest possible
Disuse atrophy of diaphragm and respiratory muscles Critical Illness polyneuropathy Critical Illness myopathy	Shift to spontaneous mode of ventilation as soon as possible Minimize exposure to Neuromuscular blockade, corticosteroid, aminoglycosides, polymyxins and neuro-myotoxic molecules
Ventilator associated Pneumonia	Implement VAP prevention bundles
Barotrauma (Pneumothorax- Hypotension)	Do not allow Ppeak >40 cm H2O Limit Pplat below 30 cm H2O Limit driving pressure <15 cm H2O Set and review Ppeak and Vt alarms on Ventilator
Atelectotrauma Hypoxia, hyperoxia Reduced lung compliance	Minimize time spent with FiO2 = 1.0 (100% oxygen) Use minimum FIO2 to keep SpO2-90–94%
Volu-trauma Trans alveolar translocation of bugs, pneumothorax, mediastinal emphysema	Ventilate with tidal volume 6–8 mL/kg (avoid above 10 mL/kg) Down titrate pressure support to limit higher tidal volumes causing pVILI
Bio-trauma Cytokine surge leading to AKI, hypotension, Multi-organ dysfunction syndrome	Open lung strategy, Lung protective ventilation Limit driving pressure (ΔP) <15 cm H2O
Airway injury and peri-intubation or peri-extubation deteriorations Laryngeal edema, tracheal edema, ulcers, clots airway obstruction, stridor, dysphonia	Use of structured airway assessment to diagnose difficult airway pre-emptively Use rapid or delayed sequence intubation protocol Use extubation and post-extubation management protocol