Saudi Guideline for Mechanical Ventilation in Adults – Executive Summary

Abstract

The Saudi Guideline for Mechanical Ventilation in Adults presents evidence-based recommendations for the care of adults requiring invasive mechanical ventilation. Fourteen priority clinical questions address ventilatory strategies for acute respiratory distress syndrome (ARDS), adjunctive and rescue therapies, sedation and weaning practices, airway management, and supportive ICU care. Strong recommendations support low–tidal-volume ventilation and higher positive end-expiratory pressure in ARDS, as well as head-of-bed elevation to prevent ventilator-associated pneumonia. Conditional recommendations include prone positioning, venovenous extracorporeal membrane oxygenation in selected severe ARDS patients, daily sedation interruption, protocolized spontaneous breathing trials, and early tracheostomy. For several interventions, evidence remains insufficient to support definitive recommendations. This guideline aims to standardize practice and improve outcomes across Saudi intensive care units.

INTRODUCTION

This Saudi Guideline for Mechanical Ventilation in Adults is designed to assist and support all healthcare professionals and their teams in providing care for adults with respiratory failure requiring mechanical ventilation in the intensive care units or similar settings.[1]

This executive summary lists the guideline recommendations on mechanical ventilation in adults resulting from the first national, multidisciplinary effort in Saudi Arabia to utilize an evidence-based guideline development methodology for mechanical ventilation (following the best practices developed by the GRADE Working Group). The work was conducted under the auspices of the National Guidelines Program in Saudi Arabia, launched in 2021 by the Saudi Arabian Ministry of Health and its Health Holding Company to support the healthcare transformation pillar of Vision 2030. It transitioned in 2022 to the Saudi Health Council’s National Center for Evidence-Based Medicine.[2] A full detailed description of the guideline, which also includes contextual issues such as feasibility and cost, is published simultaneously; a summary of the Guideline is provided in Table 1.[1] A review of the guideline by the National Center for Evidence-Based Medicine of the Saudi Health Council will occur no later than 5 years post-publication or earlier if needed, as outlined in the main document.[1]

Table 1.

Summary of the Saudi guideline for mechanical ventilation in adults

Question	Recommendation	Strength of recommendation and certainty in the evidence
Tidal volume in acute respiratory distress syndrome	In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, we recommend using low-tidal volume ventilation	Strong recommendation. Moderate certainty in the evidence of effects
Positive end-expiratory pressure in acute respiratory distress syndrome	In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, we recommend using higher levels of positive end-expiratory pressure	Strong recommendation. Moderate certainty in the evidence of effects
Recruitment maneuvers in acute respiratory distress syndrome	In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, we do not make a recommendation for or against recruitment maneuvers as standard care	Conditional recommendation. Low certainty in the evidence of effects
ECMO in acute respiratory distress syndrome	In adults with severe acute respiratory distress syndrome, we suggest using venovenous extracorporeal membrane oxygenation	Conditional recommendation. Moderate certainty in the evidence of effects
Daily sedation interruption	In adults receiving invasive mechanical ventilation, we suggest using daily sedation interruption	Conditional recommendation. Low certainty in the evidence of effects
Protocolized spontaneous breathing trial	In adults receiving invasive mechanical ventilation, we suggest using a protocolized spontaneous breathing trial	Conditional recommendation. Low certainty in the evidence of effects
Prone positioning in acute respiratory distress syndrome	In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, we suggest using prone positioning	Conditional recommendation. Low certainty in the evidence of effects
Endotracheal tube with subglottic secretion drainage	In adults receiving invasive mechanical ventilation, we suggest using endotracheal tube with subglottic secretion drainage	Conditional recommendation. Low certainty in the evidence of effects
Inhaled nitric oxide	In adults receiving invasive mechanical ventilation, we suggest not using inhaled nitric oxide	Conditional recommendation. Low certainty in the evidence of effects
Light versus deep sedation	In adults receiving invasive mechanical ventilation, we suggest using light sedation	Conditional recommendation. Low certainty in the evidence of effects
Continuous neuromuscular blockade in acute respiratory distress syndrome	In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, we do not make a recommendation for or against the routine use of continuous neuromuscular blockade	Conditional recommendation. Very low certainty in the evidence of effects
Head-of-bed elevation	In adults receiving mechanical ventilation, we recommend using head-of-bed elevation over supine positioning for the prevention of ventilator-associated pneumonia	Strong recommendation. Low certainty in the evidence of effects
Early tracheostomy versus late tracheostomy	In adults receiving mechanical ventilation, we suggest using early tracheostomy (≤10 days after tracheal intubation)	Conditional recommendation. Low certainty in the evidence of effects)
Early mobilization	In adults receiving mechanical ventilation, we do not make a recommendation for or against using early mobilization	Conditional recommendation. Very low certainty in the evidence of effects

ECMO – Extracorporeal membrane oxygenation

RECOMMENDATIONS

Question 1 - Low-tidal volume versus nonvolume-limited strategies

Should low-tidal-volume vs. non-volume-limited strategy be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation?

Recommendation

In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, the Mechanical Ventilation Force recommends using low-tidal volume ventilation (Strong recommendation, favors the intervention. Moderate certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force recommends using low-tidal volume ventilation at 4-8 ml/kg predicted body weight [PBW] and maintaining plateau airway pressure [Pplat] below or at 30 cmH₂O

• Implementing a low tidal volume intervention is one component of lung protection strategies to achieve target plateau pressure or driving pressure.

Question 2 - Low versus high positive end-expiratory pressure

Should higher vs. lower levels of Positive End-Expiratory Pressure be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation?

Recommendation

In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force recommends using higher levels of Positive End-Expiratory Pressure (Strong recommendation, favors the intervention. Moderate certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force emphasizes that implementing higher levels of Positive End-Expiratory Pressure (PEEP) should be considered within the context of lung protection strategies that limit target plateau pressure or driving pressure

• High PEEP can be implemented using high PEEP/Fractional inspired oxygen (FiO₂) titration tables or PEEP titration based principally on respiratory mechanics

• Caution is advised in patients who might not tolerate high PEEP, for example, those with right ventricular failure, who are hemodynamically unstable, and those who have high partial pressure of carbon dioxide (PCO₂) or lung overdistention.

Question 3 - Recruitment maneuvers versus standard care

Should recruitment maneuvers vs. standard care be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation?

Recommendation

In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force does not make a recommendation for or against recruitment maneuvers as standard care (Conditional recommendation, for either the intervention or the comparison. Low certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force suggests using recruitment maneuvers only for appropriately selected patients. Useful criteria for patient selection may include short recruitment maneuvers (40 cmH₂O × 40 seconds), hemodynamic stability, lung recruitability, and absence of contraindications such as elevated intracranial pressure

• Recruitment maneuvers with more prolonged duration and higher pressures should be avoided.

Question 4 - Venovenous extracorporeal membrane oxygenation

Should venovenous extracorporeal membrane oxygenation (ECMO) vs. no ECMO be used in adults with severe acute respiratory distress syndrome?

Recommendation

In adults with severe acute respiratory distress syndrome, the Mechanical Ventilation Task Force suggests using venovenous extracorporeal membrane oxygenation (Conditional recommendation, favors the intervention. Moderate certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force suggests using venovenous extracorporeal membrane oxygenation (ECMO) only for appropriately selected patients in accordance with established selection criteria (such as those reported in the EOLIA trial)[3]

• Patients requiring ECMO should be referred early to either specialized teams or centers in case of failure of optimized conventional therapies (lung-protective ventilation, sedation, paralysis, prone positioning). In Saudi Arabia, ECMO centers typically handle a minimum of 8 cases annually, while centers of excellence generally manage a minimum of 20 cases annually and are staffed by experts in the field.

Question 5 - Daily sedation interruption

Should daily sedation interruption vs. no daily sedation interruption be used in adults receiving invasive mechanical ventilation?

Recommendation

In adults receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force suggests using daily sedation interruption (Conditional recommendation, favors the intervention. Low certainty in the evidence of effects).

Additional observation

• The Mechanical Ventilation Task Force suggests the implementation of daily sedation interruption as standard practice in all mechanically ventilated ICU patients, except in cases where contraindications exist. Contraindications include the need for deep sedation for severe acute respiratory distress syndrome with high ventilatory settings, prone positioning, severe traumatic brain injury, elevated intracranial pressure, open abdomen, and uncontrolled status asthmaticus or status epilepticus.

Question 6 - Protocolized spontaneous breathing trial

Should protocolized spontaneous breathing trial vs. no spontaneous breathing trial be used in adults receiving invasive mechanical ventilation?

Recommendation

In adults receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force suggests using a protocolized spontaneous breathing trial (Conditional recommendation, favors the intervention. Low certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force suggests applying the intervention in accordance with a protocol that ensures the proper selection of patients who are ready for a spontaneous breathing trial

• Furthermore, the Task Force suggests incorporating the intervention in a bundle that encompasses daily sedation interruption protocols.

Question 7 - Prone positioning

Should prone positioning vs. no prone positioning be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation?

Recommendation

In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force suggests using prone positioning (Conditional recommendation, favors the intervention. Low certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force suggests applying proning for prolonged sessions (16 consecutive hours or more)

• Proning should only be used in the absence of contraindications, for example, patients with open surgical abdomen, facial trauma, cervical instability and severe hemodynamic instability.

Question 8 - Endotracheal tube with subglottic secretion drainage

Should endotracheal tube with subglottic secretion drainage vs. standard endotracheal tube be used in adults receiving invasive mechanical ventilation?

Recommendation

In adults receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force suggests using endotracheal tube with subglottic secretion drainage (Conditional recommendation, favors the intervention. Low certainty in the evidence of effects).

Question 9 - Inhaled nitric oxide

Should inhaled nitric oxide vs. no inhaled nitric oxide be used in adults receiving invasive mechanical ventilation?

Recommendation

In adults receiving invasive mechanical ventilation, the Mechanical Ventilation Force suggests not using inhaled nitric oxide (Conditional recommendation, favors the comparison. Low certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force suggests considering the temporary use of inhaled nitric oxide as a rescue therapy for patients on invasive mechanical ventilation who experience refractory hypoxemia

• It may also be considered for conditions such as right ventricular failure and pulmonary hypertension

• Patients receiving inhaled nitric oxide need to be closely monitored for potential complications (including monitoring methemoglobin levels and renal function).

Question 10 - Light versus deep sedation

Should light vs. deep sedation be used in adults receiving invasive mechanical ventilation?

Recommendation

In adults receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force suggests using light sedation (Conditional recommendation, favors the intervention. Low certainty in the evidence of effects).

Additional observation

• The Mechanical Ventilation Task Force agreed that deep sedation might be indicated in selected patients with specific conditions such as severe acute respiratory distress syndrome, neuromuscular blockade, severe traumatic brain injury, increased intracranial pressure, and severe asthma.

Question 11 - Continuous neuromuscular blockade

Should continuous neuromuscular blockade vs. no neuromuscular blockade (or neuromuscular blockade on demand) be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation?

Recommendation

In adults with acute respiratory distress syndrome receiving invasive mechanical ventilation, the Mechanical Ventilation Task Force does not make a recommendation for or against the routine use of continuous neuromuscular blockade (Conditional recommendation, for either the intervention or the comparison. Very low certainty in the evidence of effects).

Additional observations

• The Mechanical Ventilation Task Force indicates that continuous neuromuscular blockade can be considered for specific patients, such as those who meet the criteria reported in clinical trials, early in the course of moderate to severe acute respiratory distress syndrome, and for the shortest possible period of time (48 hours or less if there is clinical improvement).

• Patients under neuromuscular blockade require close monitoring to prevent unnecessarily high dosages and should be assessed for improvement after treatment initiation.

Question 12 - Head-of-bed elevation versus supine positioning

Should head-of-bed elevation vs. supine positioning be used for the prevention of ventilator-associated pneumonia in adults receiving mechanical ventilation?

Recommendation

In adults receiving mechanical ventilation, the Mechanical Ventilation Task Force recommends using head-of-bed elevation over supine positioning for the prevention of ventilator-associated pneumonia (Strong recommendation, favors the intervention; low certainty in the evidence of effects).

Question 13 - Early versus late tracheostomy

Should early tracheostomy (≤10 days after tracheal intubation) vs. late tracheostomy (>10 days after tracheal intubation) be used in adults receiving mechanical ventilation?

Recommendation

In adults receiving mechanical ventilation, the Mechanical Ventilation Task Force suggests using early tracheostomy (≤10 days after tracheal intubation) (Conditional recommendation, favors the intervention. Low certainty in the evidence of effects).

Additional observation

• The Mechanical Ventilation Task Force advises caution in patients with severe acute respiratory distress syndrome on a high ventilation setting (high Positive End-Expiratory Pressure [PEEP]) due to the risk of lung derecruitment and severe hypoxemia during the procedure.

Question 14 - Early mobilization versus usual care

Should early mobilization vs. usual care be used in adults receiving mechanical ventilation?

Recommendation

In adults receiving mechanical ventilation, the Mechanical Ventilation Task Force does not make a recommendation for or against using early mobilization (Conditional recommendation, for either the intervention or the comparison. Very low certainty in the evidence of effects).

Additional observations

• The identified studies encompass a wide range of definitions of early mobilization and standards of care, which complicates the interpretation of the existing evidence.

• The Mechanical Ventilation Task Force advises that each hospital should have a protocol for mobilization that aligns with stakeholder experience and resources and includes clear selection criteria to ensure safe application.

• The reader is referred to the detailed description of the recommendations including feasibility and other implementation related aspects in the main manuscript.[1]

Peer review

This article was peer-reviewed by two independent and anonymous reviewers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.