Abstract
Background:
Mechanical ventilation is a critical intervention for patients with respiratory failure. Recent advancements and quality improvement initiatives in Saudi Arabia have contributed to refining mechanical ventilation practices. This guideline represents the first national evidence-based framework developed through a multidisciplinary approach.
Objectives:
This guideline provides evidence-based recommendations for the management of mechanically ventilated adults in intensive care units in Saudi Arabia, incorporating best practices to improve patient outcomes and standardize care across healthcare institutions.
Methods:
The guideline development followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT methodology, an internationally accepted approach for adopting, adapting, and developing guidelines. A multidisciplinary task force, comprising intensivists, pulmonologists, anaesthesiologists, respiratory therapists, and nursing specialists, conducted a systematic review of the literature and contextualized recommendations for local healthcare settings. The guideline addressed 14 prioritized questions.
Results:
The guideline included strong recommendations for using low tidal volume ventilation for patients with ARDS, utilizing higher levels of positive end-expiratory pressure, and employing head-of-bed elevation. The guideline provided conditional recommendations for using veno-venous extracorporeal membrane oxygenation, daily sedation interruption, protocolized spontaneous breathing trials, prone positioning, using an endotracheal tube with subglottic secretion drainage, using light sedation, and early tracheostomy. The guideline also included a conditional recommendation against using nitric oxide and a neutral recommendation regarding recruitment maneuvers and early mobility.
Conclusion:
This guideline serves as a foundational framework for optimizing mechanical ventilation practices in Saudi Arabia. Future research should focus on local implementation strategies, cost-effectiveness analysis, and the impact of guideline adherence on clinical outcomes.
Keywords: Acute respiratory distress syndrome, lung-protective ventilation, mechanical ventilation, Saudi Arabia, sedation, ventilator-associated pneumonia, weaning strategies
INTRODUCTION
Mechanical ventilation is a life-saving intervention that is widely provided in Intensive Care Units (ICUs).[1] Recent advancements in research have significantly enhanced the outcomes of patients undergoing mechanical ventilation. In Saudi Arabia, the focus has shifted from solely preventing ventilator-associated pneumonia (VAP) to a more comprehensive strategy aimed at preventing ventilator-associated events (VAEs). This approach combines the ABCDE bundle (Awakening and Breathing trial Coordination, Delirium management, and Early mobilization) with insights from the Wake Up and Breathe Collaborative trial.[2] Various initiatives have been implemented to enhance the care of mechanically ventilated patients, such as the international Comprehensive Unit-based Safety Program (CUSP 4 MVP) in 2015, which involved 17 intensive care units from 8 hospitals in Saudi Arabia. Additionally, the National Approach to Standardize and Improve Mechanical Ventilation (NASAM) project had recruited 78 ICUs in Saudi Arabia by March 2019, focusing on improving ventilatory care through practices like subglottic suctioning, head of bed elevation, spontaneous awakening trials, spontaneous breathing trials, early mobilization, and avoidance of neuromuscular blockers unless there is a clear indication.[1,3,4]
This guideline is the result of 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[5,6,7] and the Guidelines International Network).[8,9] The work was conducted under the aegis 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. In 2022, it transitioned to the Saudi Health Council’s National Center for Evidence-Based Medicine.[10]
Scope and purpose
This guideline 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 ICUs or similar settings, including intensivists, emergency physicians, anesthesiologists, pulmonologists, respiratory therapists, physiotherapists, and nursing staff in Saudi Arabia, as well as hospital policy makers, administrators, quality specialists, and infection control practitioners involved with or developing national health population programs for Saudi Arabia.
METHODS
The guideline development followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE)-ADOLOPMENT methodology, an internationally accepted approach for adoption, adaptation, and de novo guideline development.[5]
The guideline was developed by a multidisciplinary local group of 26 experts, led by a Clinical Lead [Online Supplement (20MB, pdf) ]. The experts were selected to represent different disciplines involved in the management of mechanical ventilation in Saudi Arabia, taking into consideration their clinical experience and research involvement. The panel included adult critical care consultants, pulmonologists, anesthesiologists, respiratory therapists, physiotherapists, and nursing specialists from Saudi Arabia. Members represented a range of Ministry of Health, University, Military, and National Guard institutions, geographical regions, and medical societies, with several participants trained in epidemiology and guideline methodology [Online Supplement (20MB, pdf) ]. Their work was supported by an international team of guideline methodology, evidence synthesis, and dissemination and implementation experts based at (or contracted by) Elsevier [Online Supplement (20MB, pdf) ].
Upon joining the project, members of both groups were asked to declare any relevant Conflicts of Interest from the previous four years. All Task Force members confirmed that they had no conflicts of interest to declare. All members of the Guideline Support Team (who had no voting rights for the scoping, recommendation, and finalization workshops) declared that they were salaried or freelance employees of Elsevier, contracted to support the setting up of the National Guidelines Program and the development of its first 12 guidelines.
Fourteen clinical questions were prioritized after group deliberations following a consensus-based approach (60% threshold), using 5 questions from “An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome”[11] and 9 questions via Task Force suggestions as the starting point for scoping [Online Supplement (20MB, pdf) ]. Up to 7 critical clinical outcomes for each question were determined during two subsequent outcome prioritization workshops.
In March 2022, literature searches were carried out to identify recent high-quality systematic reviews for the 14 prioritized clinical questions, followed by update searches in May-June 2022 for the selected systematic reviews[12,13,14,15,16,17,18,19,20,21,22,23,24,25] [Please refer to the Online Supplement (20MB, pdf) for further details]. The panel revisited all questions in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendations.
Search results were dual-screened to make inclusion/exclusion decisions based on title and abstract, and subsequently on full text, with discrepancies resolved through discussion. The included studies were assessed for risk of bias using the Cochrane risk of bias tool for randomized controlled trials (RoB 2) and the Newcastle–Ottawa tool for observational studies, and their results were extracted into a predefined template. The overall results were meta-analyzed if appropriate, and the quality of the new body of evidence was evaluated using the GRADE approach.[5,6]
In addition, literature searches were conducted in May 2022 to identify global systematic review evidence and regional primary studies on contextual factors (epidemiology, values and preferences, equity, acceptability, feasibility, implementation, and cost). Their results were summarized in a narrative manner.
The evidence syntheses for the benefits and harms of the included interventions, together with the contextual factor summaries, informed the creation of GRADE Evidence-to-Decision (EtD) frameworks for each question, and in turn, the formulation of associated guideline recommendations.[7] Pooled estimates were calculated using random-effects models in RevMan. Heterogeneity was assessed using the I2 statistic, and risk ratios with 95% confidence intervals were derived for dichotomous outcomes. Certainty of evidence was rated using GRADE, considering risk of bias, precision, consistency, and directness across studies. Full methodological details are provided in the Online Supplement (20MB, pdf) , which serves as a detailed extension of the main manuscript.
Following drafting and external peer review, the guideline was submitted to nominated members of the Saudi Health Council’s (SHC) Scientific Committee for review and sent out for public consultation before being officially approved by the SHC as a national guideline [Table 1].
Table 1.
Questions, recommendations, and comparison with source guideline
| Question | ADOLOP-ed Recommendation | Additional observations | Comparison with source guideline* |
|---|---|---|---|
| Should low-tidal-volume versus nonvolume-limited strategies be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation? | In adults with ARDS receiving invasive mechanical ventilation, the mechanical ventilation task force recommends using low-tidal volume ventilation (strong recommendation, favoring the intervention; moderate certainty in the evidence of effects) | The mechanical ventilation task force recommends using low-tidal volume ventilation at 4–8 mL/kg PBW and maintaining plateau airway pressure (Pplat) ≤30 cmH2O Implementing a low tidal volume intervention is one component of lung protection strategies aimed at achieving the target plateau pressure or driving pressure | Adopted recommendation |
| Should higher versus lower levels of PEEP be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation? | In adults with ARDS receiving invasive mechanical ventilation, the mechanical ventilation task force recommends using higher levels of PEEP (strong recommendation, favoring the intervention; moderate certainty in the evidence of effects) | The mechanical ventilation task force emphasizes that implementing higher levels of 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/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, those with barotrauma, and those who have high PCO2 or lung overdistention | Adapted recommendation (from moderate to strong recommendation in view of the strengthened evidence base through a 2021 systematic review[13]) |
| Should recruitment maneuvers versus standard care be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation? | 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) | 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 s), 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 | Adapted recommendation (from conditional recommendation for recruitment maneuvers to a recommendation either for or against recruitment maneuvers as standard care in view of the low certainty in the evidence of effects and strong emphasis on careful patient selection) |
| Should venovenous ECMO versus no ECMO be used in adults with severe acute respiratory distress syndrome? | 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) | The mechanical ventilation task force suggests using venovenous ECMO only for appropriately selected patients in accordance with established selection criteria (such as those reported in the EOLIA trial[26]) 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 are typically considered to handle a minimum of 8 cases annually, while centers of excellence manage a minimum of 20 cases annually and are staffed by experts in the field | Adapted recommendation (from “additional evidence necessary” to conditional recommendation for the intervention) |
| Should daily sedation interruption versus no daily sedation interruption be used in adults receiving invasive mechanical ventilation? | 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) | The mechanical ventilation task force suggests the implementation of daily sedation interruption as standard practice in all mechanically ventilated intensive care unit 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 | New recommendation |
| Should protocolized spontaneous breathing trial versus no spontaneous breathing trial be used in adults receiving invasive mechanical ventilation? | 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 | New recommendation |
| Should prone positioning versus no prone positioning be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation? | 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) | 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 | Adapted recommendation (from strong to conditional recommendation in view of the low certainty in the evidence of effects) |
| Should endotracheal tube with subglottic secretion drainage versus standard endotracheal tube be used in adults receiving invasive mechanical ventilation? | 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) | New recommendation | |
| Should inhaled nitric oxide versus no inhaled nitric oxide be used in adults receiving invasive mechanical ventilation? | 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) | 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, until other measures such as prone positioning or ECMO can be applied 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) | New recommendation |
| Should light versus deep sedation be used in adults receiving invasive mechanical ventilation? | 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) | 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 | New recommendation |
| Should continuous neuromuscular blockade versus no neuromuscular blockade (or neuromuscular blockade on demand) be used in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation? | 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) | 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 h or less if there is clinical improvement) Patients under neuromuscular blockade require close monitoring to prevent unnecessary high dosages and should be assessed for improvement after treatment initiation | New recommendation |
| Should head-of-bed elevation versus supine positioning be used for the prevention of ventilator-associated pneumonia in adults receiving mechanical ventilation? | 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) | New recommendation | |
| Should early tracheostomy (≤10 days after tracheal intubation) versus late tracheostomy (>10 days after tracheal intubation) be used in adults receiving mechanical ventilation? | 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) | The mechanical ventilation task force advises caution in patients with severe acute respiratory distress syndrome on a high ventilation setting (high PEEP) due to the risk of lung derecruitment and severe hypoxemia during the procedure | New recommendation |
| Should early mobilization versus usual be used in adults receiving mechanical ventilation? | 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) | The identified studies contain a wide range of definitions of early mobilization and standards of care, complicating the interpretation of the existing evidence The mechanical ventilation task force advises that each hospital should have a protocol for mobilization that matches stakeholder experience and resources and includes clear selection criteria to ensure safe application | New recommendation |
*Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with ARDS[11]. PBW – Predicted body weight; PEEP – Positive end-expiratory pressure; FiO2 – Fractional inspired oxygen; ECMO – Extracorporeal membrane oxygenation; ARDS – Acute Respiratory Distress Syndrome; PCO2 – Partial pressure of carbon dioxide
RECOMMENDATIONS AND EVIDENCE SUMMARIES
Question 1 - Low-tidal volume vs. non-volume-limited strategies
| Should low-tidal volume versus non-volume-limited strategies be used in adults with ARDS receiving invasive mechanical ventilation? |
| Recommendation |
| In adults with ARDS 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 of 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 aimed at achieving the target plateau pressure or driving pressure |
PBW – Predicted body weight; ARDS – Acute respiratory distress syndrome
Introduction
Ventilator-associated lung injury can be mitigated by lung-protective ventilation (LPV) among patients with acute respiratory distress syndrome (ARDS). New data are emerging regarding the importance of limiting the driving pressure. However, further studies are needed before a recommendation can be made.
Evidence summary
We identified six systematic reviews[12,26,27,28,29,30] that included in total ten randomized controlled trials[31,32,33,34,35,36,37,38,39,40] and one observational study[41] that compared low-tidal volume ventilation versus non-volume-limited strategies (that did not mandate low-tidal volume) in adults with acute respiratory distress syndrome (ARDS) receiving invasive mechanical ventilation, reported results for the prioritized outcomes, and were used for our meta-analysis. Our search conducted in May 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Low-tidal volume ventilation results in:
A large reduction in:
Short-term mortality at longest follow-up (RR, 0.83; 95% CI, 0.72 to 0.94; high certainty in the evidence of effects), corresponding to 71 fewer per 1000 events (from 118 fewer to 25 fewer).
A large increase in:
Ventilator-free days (MD, 2.54; 95% CI, 1.24 to 3.84; moderate certainty in the evidence of effects)
Hospital length of stay (MD, 6.3; 95% CI, -7.53 to 20.13; moderate certainty in the evidence of effects). For this question, the increase in hospital length of stay is a desirable effect, as it only occurs when patient survival improves.
An increase in:
Intensive care unit (ICU) length of stay (MD, 2.67; 95% CI, 2.12 to 3.22; high certainty in the evidence of effects). The increase in ICU LOS may be related to the improved survival with lower tidal volume.
The evidence is very uncertain about the effect of low-tidal volume ventilation in:
Short Form-36 Health Survey, physical functioning scores (MD, 8.3; 95% CI, -6.77 to 23.37; very low certainty in the evidence of effects)
Short Form-36 Health Survey, quality of life scores (MD, -1.4; 95% CI, -14.1 to 11.3; very low certainty in the evidence of effects).
None of the included studies reported data on vasopressor-free days.
The Mechanical Ventilation Task Force noted that possible adverse events from low-tidal volume ventilation that might arise include hypercapnia and atelectasis, and should be considered particularly in patients with traumatic brain injury.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as moderate based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious inconsistency.
Values, resource use, and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, the intervention was not associated with additional cost, did not affect equity, and was acceptable and feasible.
With regard to cost-effectiveness, we identified indirect evidence from a US economic modelling and analysis.[42] The study reported that, from a societal perspective, the implementation of LPV resulted in a 15% increase in quality-adjusted life years (QALYs) at a lifetime cost increase of $7,233 per patient. The incremental cost-effectiveness ratios for LPV were $22,566 per life saved at hospital discharge and $11,690 per QALY gained. The authors concluded that LPV was a highly cost-effective strategy.
Research needs
The Mechanical Ventilation Task Force highlighted the need for high-quality studies to:
Establish the best low tidal volume;
Compare volume-limited versus driving pressure-limited strategies;
Evaluate the effects of different low tidal volume strategies (driving pressure, positive end-expiratory pressure, plateau pressure);
Establish the balance of effects in patients with varied baseline characteristics;
Evaluate the use of this intervention in other clinical settings (e.g., the emergency department);
Gather data relating to long-term outcomes, such as patient recovery and survival;
Include patient-reported outcomes, such as functional outcomes, quality of life, and values and preferences; and
Evaluate the acceptability of the intervention by clinical staff and the feasibility of implementation.
Question 2 - Low versus high positive end-expiratory pressure
| Should higher versus lower levels of PEEP 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 PEEP (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 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/FiO2 titration tables or using 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, hemodynamically unstable, and those who have high PCO2 or lung overdistention. |
PEEP – Positive end-expiratory pressure; FiO2 – Fractional inspired oxygen; PCO2 – Partial pressure of carbon dioxide
Introduction
The use of positive end-expiratory pressure (PEEP) during mechanical ventilation reduces the risk of end-expiratory alveolar collapse and counteracts mechanical strain, thus minimizing atelectrauma and alveolar overdistension.[43]
Evidence summary
The source systematic review “High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome”[13] identified 10 randomized controlled trials[31,32,44,45,46,47,48,49,50,51] and conducted a meta-analysis comparing the effects of higher versus lower levels of positive end-expiratory pressure (PEEP) in adults with acute respiratory distress syndrome (ARDS) who were receiving invasive mechanical ventilation. Our search update conducted in June 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
The use of higher levels of PEEP:
May result in little to no difference in:
Ventilator-free days until day 28 (MD, 0.77 days; 95% CI, -0.91 to 2.45; low certainty in the evidence of effects)
Hospital length of stay (MD, 0.37 days; 95% CI, -2.63 to 3.38; low certainty in the evidence of effects).
Results in little to no difference in:
Intensive care unit length of stay (MD, -0.42 days; 95% CI, -1.52 to 0.67; moderate certainty in the evidence of effects)
Short-term mortality at the longest follow-up (RR, 0.91; 95% CI, 0.80 to 1.02; moderate certainty in the evidence of effects), corresponding to 39 fewer events per 1000 events (from 87 fewer to 9 more).
None of the included studies reported data on vasopressor-free days or functional outcomes such as activities of daily living.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as moderate based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, the intervention was not associated with additional cost, did not affect equity, and was acceptable and feasible. Because there was a trend towards reduced mortality and high PEEP is often considered a component of a lung-protective strategy, the panel made a strong recommendation in favor of the intervention.
Research needs
The Mechanical Ventilation Task Force identified the need for more high-quality studies on the effect of positive end-expiratory pressure (PEEP) on ventilator-free and vasopressor-free days, length of hospital stay, and functional outcomes in ventilated ARDS patients and sub-populations. More local research is needed on the acceptability and cost-effectiveness of higher levels of PEEP, and its impact on health equity.
Question 3 - Recruitment maneuvers versus standard care
| Should recruitment maneuvers versus standard care be used in adults with ARDS receiving invasive mechanical ventilation? |
| Recommendation |
| In adults with ARDS 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 s); 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 |
ARDS – Acute respiratory distress syndrome
Introduction
Recruitment maneuvers aim to open up collapsed airless alveoli by using transiently increased transpulmonary pressure.[52]
Evidence summary
The source systematic review “Recruitment maneuvers for adults with acute respiratory distress syndrome receiving mechanical ventilation”[14] identified 10 randomized controlled trials[31,44,45,46,53,54,55,56,57,58] and conducted a meta-analysis comparing the effects of recruitment maneuvers versus standard care in adults with acute respiratory distress syndrome (ARDS) receiving invasive mechanical ventilation. Our search update conducted in May 2022 identified six additional studies for inclusion,[47,48,59,60,61,62] also included in the ARDS Clinical Practice Guideline[63] [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and, according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
The effect of recruitment maneuvers:
Probably reduces:
In-hospital mortality (RR, 0.90; 95% CI, 0.78 to 1.3; moderate certainty in the evidence of effects), corresponding to 47 fewer events per 1000 events (from 104 fewer to 14 more).
May have little to no effect on:
Hospital length of stay (MD, -0.75; 95% CI, -2.42 to 0.92).
The evidence is very uncertain about the effect of recruitment maneuvers on:
Short-term mortality at 28 days (RR, 0.90; 95% CI, 0.78 to 1.05; very low certainty in the evidence of effects), corresponding to 40 fewer events per 1000 events (from 88 fewer to 20 more)
Rate of barotrauma (RR, 0.96; 95% CI, 0.62 to 1.49; very low certainty in the evidence of effects), corresponding to 3 fewer events per 1000 events (from 24 fewer to 31 more)
Ventilator-free days (MD, 0.92 days; 95% CI, -1.54 to 3.39; very low certainty in the evidence of effects)
Intensive care unit length of stay (MD, -1.01; 95% CI, -2.46 to 0.45; very low certainty in the evidence of effects).
None of the included studies reported data on vasopressor-free days.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious risk of bias, serious inconsistency, serious indirectness, and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, the intervention was not associated with additional cost, did not affect equity, and was acceptable and feasible.
Research needs
The Mechanical Ventilation Task Force emphasized the need for more high-quality studies to assess the clinical effects of short-duration recruitment maneuvers compared to standard care in adults with ARDS who are receiving invasive mechanical ventilation. More research is also needed to determine the ideal recruitment maneuvers protocolized in a standardized manner and establish their effect independently of other intervention strategies applied in parallel.
Question 4 – Venovenous extracorporeal membrane oxygenation
| Should venovenous ECMO versus no ECMO be used in adults with severe ARDS? |
| Recommendation |
| In adults with severe ARDS, 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 ECMO only for appropriately selected patients in accordance with established selection criteria (such as those reported in the EOLIA trial[64]) • Patients requiring ECMO should be referred early to either specialized teams or centers in case of failure of optimized conventional therapies (LPV, 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 |
ECMO – Extracorporeal membrane oxygenation; ARDS – Acute respiratory distress syndrome; LPV – Lung-protective ventilation
Introduction
Venovenous extracorporeal membrane oxygenation (ECMO) ensures full blood oxygenation and easy CO2 elimination.[15]
Evidence summary
The source systematic review “ECMO for severe ARDS: systematic review and individual patient data meta-analysis”[15] identified two randomized controlled trials[64,65] and conducted a meta-analysis to compare the effects of venovenous extracorporeal membrane oxygenation (ECMO) versus no ECMO in adults with severe acute respiratory distress syndrome (ARDS). Our search update conducted in May 2022 found no additional studies eligible for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and, according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
ECMO results in:
A large reduction in:
Short-term mortality at 90-day follow-up (RR, 0.75; 95% CI, 0.60 to 0.94; high certainty in the evidence of effects), corresponding to 120 fewer events per 1000 events (from 192 to 29 fewer).
A large increase in:
Ventilator-free days (MD, 8 days; 95% CI, 0.91 to 15.09; high certainty in the evidence of effects)
Neurological failure-free days measured at 60 days (MD, 7.38 days; 95% CI, 1.91 to 12.84; high certainty in the evidence of effects)
Intensive care unit length of stay (MD, 8.08 days; 95% CI, -0.57 to 16.73; moderate certainty in the evidence of effects)
Hospital length of stay (MD, 14.18 days; 95% CI, 8.23 to 20.13; high certainty in the evidence of effects).
ECMO probably results in little to no difference in:
ECMO cannulation-related mortality (RR, 1.61; 95% CI, 0.20 to 12.96; moderate certainty in the evidence of effects), corresponding to 3 more events per 1000 events (from 4 fewer to 56 more)
Massive blood transfusion (RR, 3.02; 95% CI, 0.32 to 28.68; low certainty in the evidence of effects), corresponding to 16 more events per 1000 events (from 5 fewer to 221 more).
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as moderate based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious inconsistency and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, the intervention was not associated with additional cost, did not affect equity, and was acceptable and feasible.
With regard to equity, we identified indirect evidence from a US retrospective cohort study using a nationwide readmissions database.[66] The study reported significant disparities in patient selection for ECMO, with female patients, patients with Medicaid (government-sponsored health insurance for low-income individuals), and patients living in the lowest-income neighborhoods less likely to be treated with ECMO compared with men, patients with private insurance, or those living in the highest-income neighborhoods. A second US study confirmed the association between Medicaid insurance and lower ECMO utilization compared with patients with private insurance.[67]
Research needs
The Mechanical Ventilation Task Force highlighted the need for more high-quality studies to establish the selection criteria for suitable candidates for ECMO and to determine the best treatment to administer after the initiation of ECMO. More local research is needed on the cost-effectiveness of ECMO as well as its acceptability to clinical staff, feasibility of implementation, and impact on health equity in the local context.
Question 5 – Daily sedation interruption
| Should daily sedation interruption (DSI) versus no DSI be used in adults receiving invasive mechanical ventilation? |
| Recommendation |
| In adults receiving invasive mechanical ventilation, the mechanical ventilation task force suggests using DSI (conditional recommendation, favors the intervention. Low certainty in the evidence of effects). |
| Additional observation |
| The mechanical ventilation task force suggests the implementation of DSI as standard practice for 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. |
ICU – Intensive care unit; DSI – Daily sedation interruption
Introduction
Sedation is frequently used during mechanical ventilation to enhance patient comfort and safety, as well as to facilitate synchronization.[16] However, excessive sedation has been associated with poor clinical outcomes (e.g., long duration of mechanical ventilation). Different sedation strategies are in use to optimize this procedure (e.g., protocolized sedation, daily sedation interruption).
Daily sedation interruption (DSI) has been proposed to reduce the risk of excessive sedation and sedative agent use, and it was a component of the National Approach to Standardize and Improve Mechanical Ventilation (NASAM) collaborative quality improvement project, which was implemented in 42 intensive care units in Saudi Arabia to enhance ventilatory care,[3] and was associated with reduced mortality. However, studies have shown conflicting results with this strategy.
Evidence summary
The source systematic review “Effects of daily sedation interruption in intensive care unit patients undergoing mechanical ventilation: A meta-analysis of randomized controlled trials”[16] identified 12 randomized controlled trials[68,69,70,71,72,73,74,75,76,77,78,79] and conducted a meta-analysis comparing the use of daily sedation interruption (DSI) versus no DSI in adults receiving invasive mechanical ventilation. Our search update conducted in May 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and, according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
The evidence suggests that DSI:
Probably reduces:
Short-term mortality measured at the longest follow-up (RR, 0.91; 95% CI, 0.81 to 1.01; moderate certainty in the evidence of effects), corresponding to 33 fewer events per 1000 events (from 70 fewer to 4 more).
Probably results in little to no difference in:
Unplanned device removal (RR, 1.23; 95% CI, 0.61 to 2.48; moderate certainty in the evidence of effects), corresponding to 32 more events per 1000 events (from 54 fewer to 205 more)
Reintubation rate (OR, 1.01; 95% CI, 0.71 to 1.42; moderate certainty in the evidence of effects), corresponding to 1 more event per 1000 events (from 32 fewer to 43 more).
Results in little to no difference in:
Ventilator-associated pneumonia (OR, 1.12; 95% CI, 0.35 to 3.57; low certainty in the evidence of effects), corresponding to 12 more events per 1000 events (from 68 fewer to 195 more)
Duration of mechanical ventilation (MD, 0.01 days; 95% CI, -2.2 to 2.23; low certainty in the evidence of effects)
Intensive care unit length of stay (MD, 0.55 days; 95% CI, -1.38 to 2.47; low certainty in the evidence of effects).
None of the included studies reported data on functional outcomes such as activities of daily living.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious inconsistency and very serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, and that DSI is feasible and acceptable.
With regard to cost, the Mechanical Ventilation Task Force agreed that DSI requires fewer medications (e.g., sedatives and analgesics) but demands more monitoring by trained staff, potentially influencing its overall costs. They emphasized that when considering cost-effectiveness, it is important to focus on factors such as the number of mechanical ventilation days and the length of stay in the intensive care unit.
The Mechanical Ventilation Task Force also noted that the implementation of DSI – aimed at reducing the duration of mechanical ventilation and intensive care unit stays – could alleviate the strain on the healthcare system, and thus increase health equity.
Research needs
The Mechanical Ventilation Task Force highlighted the need for more high-quality randomized controlled trials to evaluate the effect of daily discontinuation of sedation in adults receiving invasive mechanical ventilation on ventilator-associated pneumonia, duration of mechanical ventilation, length of ICU stay, and functional outcomes, and to develop standardized protocols for daily sedation interruption.
Question 6 – Protocolized spontaneous breathing trial
| Should protocolized spontaneous breathing trial (SBT) versus no SBT be used in adults receiving invasive mechanical ventilation? |
| Recommendation |
| In adults receiving invasive mechanical ventilation, the mechanical ventilation task force suggests using a protocolized SBT (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. |
SBT – Spontaneous breathing trial
Introduction
Reducing weaning time from invasive mechanical ventilation is desirable for minimizing potential complications from mechanical ventilation.[17] Standardized weaning protocols (such as those reported for the 17 studies included in the Cochrane review that underpins our meta-analysis[17] and the Saudi National Approach to Standardize and Improve Mechanical Ventilation [NASAM] project[3,4]) are purported to reduce time spent on mechanical ventilation but the evidence supporting their use in clinical practice is inconsistent. A multi-center, cross-sectional study conducted in Saudi Arabia in September-November 2021 found that weaning protocols were in place in 32/39 (82%) of surveyed ICUs, with decisions about the readiness to wean and weaning method mostly taken in a collaborative manner between respiratory therapists, nurses, and other physicians.[80] A multinational survey conducted in Asia between September 2016 and June 2017 found a lower protocol rate, with only 61.8% of respondents reporting that they worked in an ICU with a weaning protocol, and 78.2% saying that they frequently/always followed the protocol.[81]
Evidence summary
The source systematic review “Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients”[17] identified 13 randomized controlled trials[82,83,84,85,86,87,88,89,90,91,92,93,94] and conducted a meta-analysis comparing the effects of protocolized spontaneous breathing trial (SBT) versus no SBT in adults receiving invasive mechanical ventilation. Our search update conducted in May 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Protocolized spontaneous breathing trial:
Results in a large reduction in:
Intensive care unit length of stay (GMD, -9.5% days; 95% CI, -18.1% to 0%; high certainty in the evidence of effects).
Likely results in a large reduction in:
Total duration of mechanical ventilation (GMD, -27,4% hours; 95% CI, -40% to -12.2%; moderate certainty in the evidence of effects).
Probably results in little to no difference in:
Reintubation (RR, 0.72; 95% CI, 0.42 to 1.24; moderate certainty in the evidence of effects), corresponding to 33 fewer events per 1000 events (from 69 fewer to 29 more)
Self-extubation (RR, 0.46; 95% CI, 0.14 to 1.46; moderate certainty in the evidence of effects), corresponding to 24 fewer events per 1000 events (from 38 fewer to 20 more)
Tracheostomy (RR, 0.84; 95% CI, 0.52 to 1.35; moderate certainty in the evidence of effects), corresponding to 20 fewer events per 1000 events (from 59 fewer to 43 more)
Hospital length of stay (GMD, -1% days; -10.4 to 11.6%; moderate certainty in the evidence of effects).
Results in little to no difference in:
Short-term mortality at the longest follow-up (RR, 1.02; 95% CI, 0.88 to 1.18; low certainty in the evidence of effects), corresponding to 5 more events per 1000 events (from 28 fewer to 41 more).
None of the included studies reported data on functional outcomes or quality of life for this comparison.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious inconsistency and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no significant uncertainty or variability in patients’ values and preferences regarding the selected outcomes, the intervention was not associated with additional costs, was feasible, and was acceptable.
Regarding equity, the Mechanical Ventilation Task Force noted that a reduction in the length of mechanical ventilation use and ICU stay resulting from protocolized SBT would lower the burden on the healthcare system, allow care for other critically ill patients, improve quality of care, and likely contribute to increased health equity.
Research needs
The Mechanical Ventilation Task Force emphasized the need for high-quality studies to assess the impact of protocolized spontaneous breathing trials on short-term mortality and patient-centered outcomes, including quality of life and functional outcomes, as well as their safety in specific populations (e.g., neurological patients). More local research is needed on cost-effectiveness and the intervention’s impact on health equity.
Question 7 – Prone positioning
| Should prone positioning versus 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. |
Introduction
Acute respiratory distress syndrome, one of the main causes of hypoxemia requiring mechanical ventilation, continues to be associated with 30-40% mortality. Mechanical ventilation provided in the prone position may improve lung mechanics and gas exchange.
Evidence summary
The systematic review “Prone position for acute respiratory failure in adults”[18] identified nine randomized controlled trials[95,96,97,98,99,100,101,102,103] and conducted a meta-analysis comparing the effects of prone positioning versus no prone positioning in adults with acute respiratory distress syndrome who received invasive mechanical ventilation. Our search update conducted in May 2022 found one additional study for inclusion[104] [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and, according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Prone positioning:
May result in a large reduction in:
Short-term mortality (RR, 0.82; 95% CI, 0.67 to 1.02; low certainty in the evidence of effects), corresponding to 67 fewer events per 1000 events (from 124 fewer to 7 more).
Likely results in a large reduction in:
Duration of mechanical ventilation (MD, -1.34 days; 95% CI, -1.91 to -0.78; moderate certainty in the evidence of effects).
Probably results in a slight increase in:
PaO2/FiO2 quotient at 7 or 10 days (MD, 24.03 mmHg; 95% CI, 13.35 to 34.71; moderate certainty in the evidence of effects)
Pressure ulcers (RR, 1.25; 95% CI, 1.06 to 1.48; moderate certainty in the evidence of effects), corresponding to 85 more events per 1000 events (from 20 to 164 more)
Arrhythmias (RR, 0.64; 95% CI, 0.47 to 0.87; moderate certainty in the evidence of effects), corresponding to 89 fewer events per 1000 events (from 131 to 32 fewer).
May result in little to no difference in:
Intensive care unit length of stay (MD, 1.06 days; 95% CI, -1.13 to 3.26; low certainty in the evidence of effects).
Results in little to no difference in:
Tracheal tube displacement (RR, 1.06; 95% CI, 0.82 to 1.36; low certainty in the evidence of effects), corresponding to 6 more events per 1000 events (from 19 fewer to 37 more)
Tracheal tube obstruction (RR, 1.72; 95% CI, 1.35 to 2.18; moderate certainty in the evidence of effects), corresponding to 70 more events per 1000 events (from 34 to 115 more)
Pneumothorax (RR, 1.16; 95% CI, 0.65 to 2.08; low certainty in the evidence of effects), corresponding to 9 more events per 1000 events (from 20 fewer to 61 more).
None of the included studies reported data on functional outcomes or overall length of stay for this comparison.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious risk of bias, serious inconsistency, and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, and that prone positioning is feasible and acceptable.
The Mechanical Ventilation Task Force noted that the essential resources mainly consist of fixed costs, such as trained personnel familiar with the procedure and specialized beds for prone positioning. They concluded that, in view of the benefits of prone positioning on patient outcomes, cost-effectiveness probably favors the intervention.
The mechanical ventilation task force noted that acceptability may vary among patients’ relatives, primarily because the intervention is not widely used across different intensive care units.
Feasibility may also vary in smaller units based on the availability of trained personnel and resources.
Research needs
The Mechanical Ventilation Task Force highlighted the need for more high-quality studies on the effects of prone positioning in patients with ARDS on short-term mortality, length of hospital stay, patient-centered and informed outcomes (e.g., quality of life), and adverse events. More local research is needed on Saudi patients’ values and preferences, as well as the intervention’s acceptability, cost-effectiveness, and its impact on health equity.
Question 8 – Endotracheal tube with subglottic secretion drainage
| Should endotracheal tube with subglottic secretion drainage (SSD) versus 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 SSD (conditional recommendation, favors the intervention. Low certainty in the evidence of effects). |
SSD – Subglottic secretion drainage
Introduction
An estimated one-third of patients who require mechanical ventilation develop ventilator-associated pneumonia (VAP).[105] VAP is the most prevalent hospital-acquired infection in intensive care units (ICUs), and its mortality is 4.6-13%.[106] Due to its high incidence and mortality, VAP generates a high economic burden for healthcare systems that need to be minimized through cost-effective interventions.[107] Subglottic secretion drainage (SSD) is one of the approaches widely used for preventing ventilator-associated pneumonia (VAP).[108] According to a 2013 survey, 55% of U.S. hospitals use this technique regularly. US, Canadian, and European guidelines all recommend the use of endotracheal tubes with SSD.[109,110,111] SSD is also part of the recommended measures of the National Approach to Standardize and Improve Mechanical Ventilation (NASAM) collaborative quality improvement project, which involved 42 intensive care units in Saudi Arabia and aimed at enhancing ventilatory care.[3]
Evidence summary
The source systematic review “Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis”[19] identified 19 randomized controlled trials[112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130] and conducted a meta-analysis comparing the effects of using an endotracheal tube with subglottic secretion drainage (SSD) versus a standard endotracheal tube in adults receiving invasive mechanical ventilation. Our search update conducted in May 2022 found one additional study for inclusion[131] [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Endotracheal tube with SSD:
Probably reduces:
Ventilator-associated pneumonia (RR, 0.60; 95% CI, 0.53 to 0.68; moderate certainty in the evidence of effects), corresponding to 92 fewer events per 1000 events (from 108 to 74 fewer).
Probably results in little to no difference in:
Hospital length of stay (MD, -1.38 days; 95% CI, -2.64 to -0.11; moderate certainty in the evidence of effects).
May reduce:
Short-term mortality at the longest follow-up (RR, 0.92; 95% CI, 0.83 to 1.02; low certainty in the evidence of effects), corresponding to 21 fewer events per 1000 events (from 44 fewer to 5 more).
The evidence is very uncertain about the effect of using an endotracheal tube with SDD on:
Duration of mechanical ventilation (MD, -0.53 days; 95% CI, -1.37 to 0.31; very low certainty in the evidence of effects)
Intensive care unit length of stay (MD, -1.21 days; 95% CI, -2.54 to 0.12; very low certainty in the evidence of effects).
None of the included studies reported data on functional outcomes, such as activities of daily living, for this comparison.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the most important prioritized critical outcomes (short-term mortality and ventilator-associated pneumonia), owing to serious risk of bias and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes and that implementing the use of endotracheal tubes with SSD did not affect equity and was feasible and acceptable.
The Mechanical Ventilation Task Force noted that the resources required for using endotracheal tubes with SSD result in moderate costs, but cost-effectiveness probably favors the intervention.
Research needs
The Mechanical Ventilation Task Force highlighted the need for more high-quality studies on the effect of the endotracheal tube with SSD on short-term mortality, the duration of mechanical ventilation, hospital stay, and functional outcomes. More local research is needed to evaluate the intervention’s cost-effectiveness and its impact on health equity in Saudi Arabia.
Question 9 – Inhaled nitric oxide
| Should inhaled nitric oxide (INO) versus no INO be used in adults receiving invasive mechanical ventilation? |
| Recommendation |
| In adults receiving invasive mechanical ventilation, the mechanical ventilation force suggests not using INO (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 INO 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 INO need to be closely monitored for potential complications (including monitoring methemoglobin levels and renal function). |
INO – Inhaled nitric oxide
Introduction
Inhaled nitric oxide (INO) has a half-life of three to five seconds and is rapidly inactivated on contact with hemoglobin.[20] INO has been used to improve oxygenation, providing selective pulmonary vasodilation.
However, some studies have found sparse evidence on important clinical outcomes and a high risk of adverse effects (e.g., renal dysfunction), so its role remains controversial.
In view of its powerful effect as a rescue agent, it is important to evaluate its effectiveness and safety for this population.
Evidence summary
The source systematic review “Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults”[20] identified 10 randomized controlled trials[132,133,134,135,136,137,138,139,140,141] and conducted a meta-analysis comparing the effects of inhaled nitric oxide versus placebo or no intervention in adults receiving invasive mechanical ventilation. Our search update conducted in June 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Inhaled nitric oxide increases:
Renal impairment (RR, 1.59; 95% CI, 1.17 to 2.16; high certainty in the evidence of effects), corresponding to 68 more events per 1000 (from 20 more to 134 more).
Inhaled nitric oxide may result in little to no difference in:
Overall mortality (OR, 1.14; 95% CI, 0.88 to 1.48; low certainty in the evidence of effects), corresponding to 31 more events per 1000 (from 30 fewer to 96 more)
Ventilator-free days measured at 28 to 30 days (MD, -0.57 days; 95% CI, -1.82 to 0.69; low certainty in the evidence of effects)
Intensive care unit length of stay (MD, 5.29 days; -4.34 to 14.93; low certainty in the evidence of effects)
Hospital length of stay (MD, 0.1 days; -4.51 to 4.71; low certainty in the evidence of effects)
Activities of Daily Living Scale scores at six months (MD, -1; 95% CI, -5.09 to 3.09; low certainty in the evidence of effects).
None of the included studies reported data on vasopressor-free days for this comparison.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low, based on the lowest certainty in the evidence for the prioritized critical outcomes, due to a serious risk of bias and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use, cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the mechanical ventilation task force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, and that inhaled nitric oxide was generally acceptable.
However, the Mechanical Ventilation Task Force noted that the widespread use of inhaled nitric oxide could lead to equipment shortages in neonatal and pediatric critical care units, impacting health equity. They also highlighted that this intervention is costly and likely not cost-effective, so it may only be feasible to implement in a limited number of specialized centers or as a last resort.
Research needs
The mechanical ventilation task force emphasized the need for more high-quality studies on the short- and long-term clinical effects (e.g., survival) of inhaled nitric oxide in patients with ARDS and in specific patient subgroups, such as critically ill patients with acute lung injury. More local research is needed on the values and preferences of Saudi patients, as well as to establish the intervention’s cost-effectiveness, feasibility of implementation, and impact on health equity.
Question 10 – Light versus deep sedation
| Should light versus 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. |
Introduction
Sedation is often used in the care of mechanically ventilated patients and there is increasing recognition that the management of such non-ventilator aspects of care influences clinical outcomes.[21]
Sedation during the initial period of mechanical ventilation appears especially impactful.[142,143] Observational data indicate that deep sedation (Richmond Agitation-Sedation Scale [RASS] score of -4 or 5) within the first 48 hours following the initiation of mechanical ventilation occurs in over 70% of patients and is associated with increased mortality.[21] As such, there is a knowledge gap regarding the impact of early sedation depth on clinically relevant outcomes.
Evidence summary
The source systematic review “Practice patterns and outcomes associated with early sedation depth in mechanically ventilated patients”[21] identified three randomized controlled trials[142,143,144] and conducted a meta-analysis comparing the effects of light sedation versus deep sedation in adults receiving mechanical ventilation. Our search update conducted in June 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Light sedation:
Results in a large reduction in:
Duration of mechanical ventilation (days) (MD, -0.85; 95% CI, -1.58 to -0.11; high certainty in the evidence of effects).
Likely results in a large reduction in:
Hospital length of stay (days) (MD, -3.47; 95% CI, -5.58 to -1.36; high certainty in the evidence of effects).
Likely results in little to no difference in:
Mortality (RR, 1.03; 95% CI, 0.65 to 1.63; moderate certainty in the evidence of effects), corresponding to 7 more events per 1000 events (from 81 fewer to 145 more)
Tracheostomy incidence (RR, 0.51; 95% CI, 0.15 to 1.69; moderate certainty in the evidence of effects), corresponding to 30 fewer events per 1000 events (from 53 fewer to 43 more)
Intensive care unit length of stay (days) (MD, -0.16; 95% CI, -3.04 to 2.73; moderate certainty in the evidence of effects)
Accidental removal of device (extubation) (OR, 0.65; 95% CI, 0.10 to 4.00; moderate certainty in the evidence of effects), corresponding to 15 fewer events per 1000 events (from 40 fewer to 112 more).
May result in little to no difference in:
Incidence of delirium (RR, 0.97; 95% CI, 0.56 to 1.67; low certainty in the evidence of effects), corresponding to 11 fewer events per 1000 events (from 156 fewer to 238 more).
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low, based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to a serious risk of bias and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, and that light sedation is generally acceptable.
Indirect evidence from a non-randomized multicenter study involving 13 intensive care units conducted in Chile[145] showed that implementing an analgesia-based sedation protocol reduced deep sedation, was a safe and feasible approach in mechanically ventilated patients, and successfully decreased the need for sedative drugs.
The Mechanical Ventilation Task Force agreed that the reduction in mechanical ventilation days associated with light sedation resulted in moderate savings, and cost-effectiveness probably favored the intervention. They mentioned that light sedation reduced the amount of drugs required and improved the availability of the medication, reducing the burden on the healthcare system and increasing health equity. The Mechanical Ventilation Task Force recognized that reluctance to implement light sedation could pose a potential barrier, but based on the evidence, their experience, and knowledge, they concluded that light sedation would probably be feasible to implement in Saudi Arabia’s facilities and healthcare teams, provided there was sufficient staff coverage for patient monitoring.
Research needs
The Mechanical Ventilation Task Force highlighted the need for more high-quality studies on the optimal sedation target and sedation measurement for deep versus light sedation, and on patient-centered outcomes such as delirium. More local research is needed to establish the intervention’s cost-effectiveness, acceptability, and feasibility of implementation.
Question 11 – Continuous neuromuscular blockade
| Should continuous neuromuscular blockade versus 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 h or less if there is clinical improvement). • Patients under neuromuscular blockade require close monitoring to prevent unnecessary high dosages and should be assessed for improvement after treatment initiation. |
Introduction
In patients undergoing mechanical ventilation neuromuscular blocking agents may improve oxygenation, decrease ventilator-induced lung injury, trend toward lower mortality, and be appropriate for facilitating mechanical ventilation when sedation alone is inadequate, most notably in patients with severe gas-exchange impairments.[146]
However, this intervention may cause muscle weakness and other adverse events, so other than when there is a clear indication, its use should be avoided, as it was also outlined in the National Approach to Standardize and Improve Mechanical Ventilation [NASAM] collaborative quality improvement project among 42 intensive care units in Saudi Arabia to enhance ventilatory care.[3]
Therefore, it is important to clarify the effectiveness and safety of neuroblocking agents for this population.
Evidence summary
The source clinical practice guideline “Neuromuscular blockade in patients with ARDS: a rapid practice guideline”[22] identified five randomized controlled trials[146,147,148,149,150] and conducted a meta-analysis comparing the effects of continuous neuromuscular blockade versus no neuromuscular blockade (or neuromuscular blockade on demand) in adults with acute respiratory distress syndrome receiving invasive mechanical ventilation. Our search update conducted in June 2022 found no additional studies for inclusion [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Continuous neuromuscular blockade:
May result in a large reduction in:
Short-term intensive care unit mortality at the longest follow-up (OR, 0.46; 95% CI, 0.22 to 0.99; low certainty in the evidence of effects), corresponding to 192 fewer events per 1000 events (from 347 to 2 fewer).
May result in little to no difference in:
Short-term mortality at the longest follow-up (OR, 0.86; 95% CI, 0.70 to 1.05; low certainty in the evidence of effects), corresponding to 37 fewer events per 1000 events (from 85 fewer to 12 more)
Short-term hospital mortality at the longest follow-up (OR, 0.90; 95% CI, 0.73 to 1.12; moderate certainty in the evidence of effects), corresponding to 26 fewer events per 1000 events (from 74 fewer to 28 more)
Rate of barotrauma (OR, 0.53; 95% CI, 0.33 to 0.85; high certainty in the evidence of effects), corresponding to 32 fewer events per 1000 (from 47 to 10 fewer).
Intensive care unit acquired weakness (OR, 1.39, 95% CI, 0.97 to 1.99; moderate certainty in the evidence of effects), corresponding to 44 more events per 1000 (from 4 fewer to 103 more)
Medical Research Council (MRC) Scale for Muscle Strength scores at intensive care unit discharge (MD, 0; 95% CI, -2.77 to 2.77; low certainty in the evidence of effects).
Results in little to no difference in:
Overall ventilator-free days (MD, 0.52 days; 95% CI, -0.55 to 1.59; low certainty in the evidence of effects)
Ventilator-free days measured at 28 days (MD, 0.42 days; 95% CI, -0.66 to 1.49; low certainty in the evidence of effects)
Ventilator-free days measured at 60 days (MD, 9.2 days; 95% CI, -0.58 to 18.98; low certainty in the evidence of effects).
The evidence is very uncertain about the effect of continuous neuromuscular blockade on:
Hospital length of stay, considering days outside the intensive care unit, from 1 to 28 days (MD, -0.7; 95% CI, -10.71 to 9.31; very low certainty in the evidence of effects).
None of the included studies reported data on intensive care unit length of stay for this comparison.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious risk of bias, and very serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia.
The Mechanical Ventilation Task Force emphasized that factors such as deep sedation and the need for continuous monitoring influenced the resource requirements associated with neuromuscular blockade. Furthermore, while the equipment needed is moderately expensive, it is already available in many ICUs. It is worth mentioning that the choice of a particular drug may result in variations in resource requirements, potentially leading to higher overall costs. The Mechanical Ventilation Task Force concluded that the use of continuous neuromuscular blockade might result in reduced health equity; however, implementing continuous neuromuscular blockade was likely feasible in Saudi Arabia’s facilities and healthcare teams. However, the Mechanical Ventilation Task Force highlighted the need to maintain proper sedation levels and adequate monitoring by specialists to ensure its effectiveness, as well as specific storage requirements for the medication, which could be a barrier to its implementation.
Research needs
The Mechanical Ventilation Task Force emphasized the need for more high-quality studies comparing intermittent bolus versus continuous neuromuscular blockade, as well as evaluating the impact of continuous neuromuscular blockade on mortality, ventilator-free days, length of hospital stay, and long-term functional and cognitive outcomes. Further studies should be conducted to investigate the interactions between different ventilation strategies (e.g., high versus low positive end-expiratory pressure, prone versus supine ventilation) when using neuromuscular blocking agents. More local research is needed on the intervention’s cost-effectiveness, feasibility of implementation, and impact on health equity.
Question 12 – Head-of-bed elevation vs. supine positioning
| Should head-of-bed elevation versus supine positioning be used for the prevention of VAP 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 VAP (strong recommendation, favors the intervention; low certainty in the evidence of effects). |
VAP – Ventilator-associated pneumonia
Introduction
Ventilator-associated pneumonia (VAP) is associated with increased mortality, length of hospital stay, and healthcare costs in critically ill patients.[23] Guidelines recommend a semi-recumbent position (30º to 45º) for preventing VAP among patients receiving mechanical ventilation.[109,110,111] The intervention is also part of the National Approach to Standardize and Improve Mechanical Ventilation (NASAM) collaborative quality improvement project among 42 intensive care units in Saudi Arabia to enhance ventilatory care.[3] However, due to methodological limitations in existing systematic reviews, uncertainty remains regarding the benefits and harms of the semi-recumbent position for preventing VAP.
Evidence summary
The source systematic review “Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation”[23] identified 10 randomized controlled trials[151,152,153,154,155,156,157,158,159,160] and conducted a meta-analysis comparing the effects of head-of-bed elevation versus supine positioning in the prevention of ventilator-associated pneumonia (VAP) in adults requiring mechanical ventilation. Our search update conducted in June 2022 identified three additional studies eligible for inclusion,[161,162,163] also included in two relevant systematic reviews identified by the Task Force[164,165] [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Comparison 1: Semirecumbent position (30° to 60°) versus 0° to 10° supine position
Semirecumbent position (30° to 60°):
May result in a large reduction in:
Clinically suspected VAP (RR, 0.42; 95% CI, 0.29 to 0.62; low certainty in the evidence of effects), corresponding to 193 fewer per 1000 events (from 236 fewer to 126 fewer).
Probably results in little to no difference in:
Intensive care unit (ICU) mean length of stay (days) 17 days (range 1 to 108; n=117) versus 15 days (range 2 to 66; n=112) with supine positioning (moderate certainty in the evidence of effects)
Hospital mean length of stay (days) 29 days (range 3 to 108; n=117) versus 27 days (range 3 to 121; n=112) with supine positioning (moderate certainty in the evidence of effects).
The evidence is very uncertain about the effect of semirecumbent position (30° to 60°) in:
Microbiologically confirmed VAP (RR, 0.44; 95% CI, 0.11 to 1.77; very low certainty in the evidence of effects), corresponding to 177 fewer events per 1000 events (from 281 fewer to 243 more)
Short-term ICU mortality (RR, 0.87; 95% CI, 0.59 to 1.27; very low certainty in the evidence of effects), corresponding to 36 fewer events per 1000 events (from 113 fewer to 74 more)
Short-term hospital mortality (RR, 0.92; 95% CI, 0.64 to 1.33; very low certainty in the evidence of effects), corresponding to 20 fewer events per 1000 events (from 89 fewer to 82 more)
ICU length of stay (days) (MD, -1.64; 95% CI, -4.41 to 1.14; very low certainty in the evidence of effects)
Hospital length of stay (days) (MD, -9.47; 95% CI, -34.21 to 15.27; very low certainty in the evidence of effects)
Duration of ventilation (days) (MD, -3.35; 95% CI, -7.8 to 1.09; very low certainty in the evidence of effects)
Adverse events (pressure ulcers) (RR, 0.96; 95% CI, 0.65 to 1.41; very low certainty in the evidence of effects), corresponding to 7 fewer events per 1000 events (from 60 fewer to 70 more).
Comparison 2: Semirecumbent position (45°) versus 25° to 30°
The evidence is very uncertain about the effect of the semirecumbent position (30° to 60°) in:
Clinically suspected VAP (RR, 0.69; 95% CI, 0.43 to 1.12; very low certainty in the evidence of effects), corresponding to 45 fewer per 1000 events (from 83 fewer to 18 more)
Microbiologically confirmed VAP (RR, 0.61; 95% CI, 0.20 to 1.84; very low certainty in the evidence of effects), corresponding to 150 fewer events per 1000 events (from 308 fewer to 323 more)
Short-term ICU mortality (RR, 0.57; 95% CI, 0.15 to 2.13; very low certainty in the evidence of effects), corresponding to 132 fewer events per 1000 events (from 262 fewer to 348 more)
Short-term hospital mortality (RR, 1.00; 95% CI, 0.38 to 2.65; very low certainty in the evidence of effects), corresponding to 0 fewer events per 1000 events (from 81 fewer to 215 more)
ICU length of stay (days) (MD, 1.6; 95% CI, -0.88 to 4.08; very low certainty in the evidence of effects).
Semirecumbent position (45°) may slightly increase:
Adverse events (RR, 1.50; 95% CI, 0.87 to 2.57; low certainty in the evidence of effects), corresponding to 76 more events per 1000 events (from 20 fewer to 237 more).
None of the included studies reported data on hospital length of stay and duration of ventilation outcomes for these comparisons.
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious risk of bias, serious inconsistency, and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource use and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, and that head-of-bed elevation is feasible and acceptable.
A Delphi method study[166] identified head-of-bed elevation as one of the important interventions for implementing a VAP prevention bundle. The Mechanical Ventilation Task Force emphasized that all hospital beds are equipped with the capability to be elevated, hence the intervention is associated with minimal additional cost. As the balance of effects favors the intervention, it is probably also a cost-effective measure. The reduction in pneumonia leads to better resource allocation, which reduces the burden on the healthcare system and increases the availability of resources and access for other patients, resulting in improved equity. To ensure maximum impact, in cases where the bed’s specifications do not specify the degree of elevation, healthcare teams should ensure that the recommended 30° elevation is achieved.
Research needs
The Mechanical Ventilation Task Force emphasized the need for more high-quality studies on the optimal degree of head-of-bed elevation and its impact on preventing ventilator-associated pneumonia. Further local research is needed on the cost-effectiveness, acceptability to clinical staff, and the impact of the intervention on health equity.
Question 13 – Early versus late tracheostomy
| Should early tracheostomy (≤10 days after tracheal intubation) versus 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 PEEP) due to the risk of lung derecruitment and severe hypoxemia during the procedure. |
PEEP – Positive end-expiratory pressure
Introduction
Tracheostomy is a common surgical or percutaneous procedure, indicated in critically ill patients who require prolonged mechanical ventilation or those with failed extubation.[167,168] The potential benefits of tracheostomy include lower airway resistance, easier and safer tracheal suction, greater patient comfort, better communication, improved oral feeding, faster weaning from the ventilator, and lower rates of ventilator-associated pneumonia.[24] On the other hand, some of the disadvantages of tracheostomy include dislodgement or obstruction, wound infection, scarring, a false passage, hemorrhage, and subglottic and tracheal stenosis. The timing of tracheostomy is therefore of utmost clinical importance. There is no agreed-upon definition for early versus late tracheostomy, as different definitions have been used. Based on consensus, the Mechanical Ventilation Task Force used a cutoff of 10 days to distinguish between early and late tracheostomy.
Evidence summary
The source systematic review “Early versus late tracheostomy for critically ill patients”[24] identified eight randomized controlled trials[169,170,171,172,173,174,175,176] and conducted a meta-analysis comparing the effects of early tracheostomy (≤10 days after tracheal intubation) versus late tracheostomy (>10 days after tracheal intubation) in adults receiving mechanical ventilation. Our search update, conducted in June 2022, identified six additional studies for inclusion[177,178,179,180,181,182] [Online Supplement (20MB, pdf) ]. The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Early tracheostomy:
Likely reduces:
Mortality at longest follow-up (RR, 0.84; 95% CI, 0.74 to 0.94; moderate certainty in the evidence of effects), corresponding to 76 fewer events per 1000 events (from 124 fewer to 29 fewer).
Likely results in a large reduction in:
Duration of mechanical ventilation (MD, -10.72; 95% CI, -12.82 to -8.61; moderate certainty in the evidence of effects)
Length of intensive care unit (ICU) stay (MD, -10.78; 95% CI, -14.87 to -6.68; moderate certainty in the evidence of effects)
Hospital length of stay (MD, -17.43; 95% CI, -29.23 to -5.64; moderate certainty in the evidence of effects).
May result in a slight increase in:
Ventilator-associated pneumonia at any time point (OR, 1.22; 95% CI, 0.93 to 1.59; low certainty in the evidence of effects), corresponding to 33 more events per 1000 events (from 11 fewer to 83 more)
Laryngotracheal lesions at any time point (in the epiglottis, vocal cords, or larynx, subglottic ulceration, and inflammation, or stenosis) (OR, 1.50; 95% CI, 0.41 to 5.43; low certainty in the evidence of effects), corresponding to 51 more events per 1000 events (from 70 fewer to 312 more).
May result in little to no difference in:
Accidental tracheostomy dislodgment (RR, 0.32; 95% CI, 0.01 to 7.35; low certainty in the evidence of effects), corresponding to 36 fewer events per 1000 events (from 52 fewer to 334 more).
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious risk of bias, and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes, and that early tracheostomy was probably feasible.
The Mechanical Ventilation Task Force acknowledged that shorter hospital and ICU stays, along with reduced mechanical ventilation duration, can result in cost savings and that cost-effectiveness probably favors the intervention. Lower resource utilization may also reduce the burden on the healthcare system, thereby increasing equity.
The Mechanical Ventilation Task Force noted that although many stakeholders may find early tracheostomy within 10 days acceptable, some might prefer to delay the procedure. It is essential to acknowledge that the acceptability of the intervention can be influenced by factors such as previous negative experiences reported by patients and their families, as well as their concerns about potential short- and long-term effects on the patient’s speech. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that early tracheostomy would probably be acceptable to most key stakeholders in Saudi Arabia, such as patients, clinical providers, and decision-makers.
Research needs
The Mechanical Ventilation Task Force highlighted the need for more high-quality studies on long-term outcomes (e.g., mortality and quality of life) and the safety of early tracheostomy (≤10 days after tracheal intubation) in adults receiving mechanical ventilation. More local research is needed on the intervention’s cost-effectiveness, feasibility of implementation, and impact on health equity.
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 contain a wide range of definitions of early mobilization and standards of care, complicating the interpretation of the existing evidence. • The Mechanical Ventilation Task Force advises that each hospital should have a protocol for mobilization that matches stakeholder experience and resources and includes clear selection criteria to ensure safe application. |
Introduction
After surviving a critical illness, survivors often face a variety of problems that begin in the intensive care unit (ICU) and/or continue after discharge. Among these are muscle weakness, cognitive impairments, psychological difficulties, decreased physical function, such as in activities of daily living (ADLs), and decreased quality of life. Interventions such as mobilization, active exercise, or both may help mitigate the effects of critical illness sequelae.[25]
A 2019 systematic integrative review of definitions and activities related to early mobilization in patients receiving mechanical ventilation identified 76 studies and highlighted the absence of a standardized definition for this intervention.[183] Studies used different timings of commencement, with most regarding mobilization as early as possible, if started at any time during the course of mechanical ventilation or within 48-72 hours of starting mechanical ventilation. Some studies used definitions that included an explicit list of included activities, such as cycle ergometry exercises, sitting on the edge of the bed or out of bed in a chair, standing (e.g. using a tilt table), marching, and walking. Types of activities included axial loading exercises, movements against gravity, activities requiring energy expenditure, or active activities (defined as those involving muscle strength and the ability to control movements, using conscious muscle activation, and strengthening and mobility exercises, or assisted exercises). Finally, some definitions focused on the desired effects of early mobilization, such as preventing joint contractures and delirium, counteracting the effects of immobilization, achieving the highest functional level, or regaining the functional status before ICU admission.
A 2017 systematic review evaluating safety criteria for early mobilization in ICU patients receiving mechanical ventilation (search date: May 2015) found that most studies deemed hemodynamically unstable patients who require high doses of vasopressors as not suitable for starting early mobilization.[184] In contrast, the presence of a femoral catheter was reported to be no reason to restrict the intervention. The use of mobilization in patients on hemodialysis seems more controversial, although at least two studies found the practice to be safe and feasible in this patient group. Higher concordance was found across studies regarding respiratory criteria for initiating the mobilization protocol, with peripheral oxygen saturation (SpO2) of >88%, a fraction of inspired oxygen (FiO2) of ≤ 0.6, and a positive end-expiration pressure (PEEP) of ≤ 10 cmH2O reported as safe thresholds. In terms of neurological criteria, patients with elevated intracranial pressure and those in whom deep sedation is combined with neuromuscular blockers are not considered to be candidates for this procedure. Paralysis or paresis, cognitive dysfunction, abnormal brain perfusion, and the use of devices for continuous brain monitoring were reported as further reasons hindering early mobilization.
Early mobilization is part of the National Approach to Standardize and Improve Mechanical Ventilation (NASAM) collaborative quality improvement project among 42 intensive care units in Saudi Arabia to enhance ventilatory care.[3]
Evidence summary
The source systematic review “Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit”[25] identified four randomized controlled trials[185,186,187,188] and conducted a meta-analysis comparing the effects of early mobilization versus usual care in adults receiving mechanical ventilation. Our search update conducted in June 2022 found 14 additional studies for inclusion,[189,190,191,192,193,194,195,196,197,198,199,200,201,202] also included in two relevant systematic reviews identified by the Task Force.[203,204] We also report the findings of two systematic reviews addressing the safety criteria and adverse events of early mobilization flagged by a peer reviewer[184,205] [Online Supplement (20MB, pdf) ], The panel revisited this PICO in September 2025, and according to the panel’s knowledge, there are no major new studies that would clearly result in changes to the recommendation.
Benefits and harms [Online Supplement (20MB, pdf) ]
Early mobilization:
Results in a large increase in:
Functional Status Score for the Intensive Care Unit (MD, 4.5; 95% CI, 1.41 to 7.59; high certainty in the evidence of effects).
Early mobilization likely results in a large increase in:
Functional Performance Inventory scores (MD, 0.2; 95% CI, -0.01 to 0.41; moderate certainty in the evidence of effects).
May result in a large increase in:
Return to work (RR, 3.25; 95% CI, 0.76 to 13.86; low certainty in the evidence of effects), corresponding to 196 more events per 1000 events (from 21 fewer to 1118 more)
36-Item Short Form Survey scores (MD, 3.92; 95% CI, -1.15 to 9; low certainty in the evidence of effects).
Probably increases:
Medical Research Council Scale for Muscle Strength scores (MD, 4.6; 95% CI, -2.69 to 11.89; moderate certainty in the evidence of effects)
Katz Index of Independence in Activities of Daily Living scores (MD, 1.1; 95% CI, -2.12 to 4.32; moderate certainty in the evidence of effects).
Probably increases slightly:
Short Physical Performance Battery scores (MD, 0.4; 95% CI, -0.32 to 1.12; moderate certainty in the evidence of effects)
Physical Function in Intensive Care Unit (ICU) Test scores (MD, 0.2; 95% CI, -0.97 to 1.37; moderate certainty in the evidence of effects).
Results in a large reduction in:
Continuous Scale-Physical Functional Performance-10 scores (MD, -4.5; 95% CI, -5.91 to -3.09; high certainty in the evidence of effects).
Reduces slightly:
Handgrip strength (MD, -0.9; 95% CI, -1.29 to -0.5; high certainty in the evidence of effects).
Likely reduces:
Lawton Instrumental Activities of Daily Living Scale scores (MD, -0.5; 95% CI, -1.39 to 0.39; moderate certainty in the evidence of effects).
May reduce slightly:
ICU length of stay (MD, -0.79; 95% CI, -1.97 to 0.4; low certainty in the evidence of effects)
Ventilator-free days (MD, -0.8; 95% CI, -2.85 to 1.24; low certainty in the evidence of effects)
ICU-acquired muscle weakness (RR, 0.85; 95% CI, 0.63 to 1.16; moderate certainty in the evidence of effects), corresponding to 41 fewer per 1000 events (from 101 fewer to 44 more).
Likely results in little to no difference in:
Six-Minute Walk Test (meters) (MD, 5.13; 95% CI, -45.55 to 55.81; moderate certainty in the evidence of effects)
Six-Minute Walk Test (minutes) (MD, -0.7; 95% CI, -1.49 to 0.09; moderate certainty in the evidence of effects)
Barthel Index (MD, -0.7; 95% CI, -1.49 to 0.09; moderate certainty in the evidence of effects)
Adverse events (RR, 1.37; 95% CI, 0.81 to 2.31; moderate certainty in the evidence of effects), corresponding to 18 more events per 1000 events (from 9 fewer to 62 more). A 2017 systematic review evaluating adverse events of early mobilization in ICU patients receiving mechanical ventilation (search date May 2015) found that rates were low (in most studies < 3%) and usually associated with respiratory or cardiovascular complications such as desaturation, tachypnea, heart rate changes, and postural hypotension—as a reflection of the limited individual reserve of patients—and with loss of devices connected to patients (e.g. tubes or catheters).[184] A second systematic review, published in 2017 (search date: June 2016), confirmed these findings, reporting a cumulative incidence of potential safety events of 2.6%,[205] which is considerably lower than, for example, the 37% reported for morning care in a mixed ICU population.[206] In particular, the absolute number of removed devices—potentially resulting in serious harm or death—was reported to be very low. The authors concluded that early mobilization of critically ill patients appears to be safe, even when implemented as part of routine clinical practice
EuroQol-5D (MD, 0; 95% CI, -0.04 to 0.04; moderate certainty in the evidence of effects)
Delirium (RR, 1.05; 95% CI, 0.85 to 1.30; moderate certainty in the evidence of effects), corresponding to 18 more events per 1000 events (from 53 fewer to 106 more)
Short-term mortality (RR, 1.03; 95% CI, 0.89 to 1.20; moderate certainty in the evidence of effects), corresponding to 7 more events per 1000 events (from 25 fewer to 46 more).
May result in little to no difference in:
36-Item Short Form Survey (version 2) scores (MD, 0.08; 95% CI, -4.59 to 4.75; low certainty in the evidence of effects).
Certainty in the evidence of effects
We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the prioritized critical outcomes, owing to serious Inconsistency, and serious imprecision.
Values, resource use and cost-effectiveness, equity, acceptability, and feasibility
We did not find primary evidence addressing values, resource requirements and cost-effectiveness, equity, acceptability, and feasibility in Saudi Arabia. Based on their experience and knowledge, the Mechanical Ventilation Task Force concluded that there was probably no important uncertainty or variability in patients’ values and preferences towards the selected outcomes.
The Mechanical Ventilation Task Force emphasized that the costs associated with early mobilization include staff training, essential equipment, and the time required to implement the intervention. The Mechanical Ventilation Task Force concluded that, overall, the resources needed to implement this intervention resulted in moderate costs; the cost-effectiveness and impact on equity were unknown, but early mobilization was generally feasible and acceptable.
Research needs
The Mechanical Ventilation Task Force highlighted the need for high-quality studies to evaluate the effect of early mobilization on ICU length of stay and ventilator-free days, and on outcomes focused on and reported by patients (such as physical function, health-related quality of life or well-being, and values and preferences). More local research is needed on the intervention’s cost-effectiveness, feasibility of implementation, its impact on health equity, and other factors that may affect early mobility practice, such as medicolegal concerns, reimbursement systems, safety culture, the presence of performance indicators, competency and training, resistance, and prevailing cultural norms.
SUMMARY
This guideline represents the first comprehensive, evidence-based Saudi consensus on adult mechanical ventilation, developed through multidisciplinary national collaboration and the GRADE framework. Its strengths include systematic evidence synthesis, structured recommendation grading, and contextual adaptation to Saudi ICU practice. Limitations include reliance on existing published evidence for certain PICOs and a limited number of recommendations in domains such as ECMO, sedation, and tracheostomy. Despite these limitations, the guideline provides a rigorous and transparent framework for standardizing mechanical ventilation practices and serves as a foundation for future research, implementation, and quality-improvement initiatives across Saudi critical care units.
Peer review
This Guideline was peer-reviewed by two independent and anonymous reviewers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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