Mechanical ventilation in obese patients according to the i-STAR Algorithm Intubate • Anticipate difficult airway management and difficult mask ventilation • Preoxygenate with Fi02100% and non-invasive positive pressure ventilation • Fluids and vasoactive drugs readily available for possible haemodynamic impairment Set - Up Initial Ventilation • Tidal volume: 4-6 mL'kg PBW in ARDS, 6-8 mL4(g in non-ARDS, volume controlled/guarantee modes • Low-moderate PEEP (ARDSnet low-PEEP table in ANDS, start with 5 cmH20 in non-ARDS) • Gradually lower Fi02 (to target normoxya in ARDS and non-ARDS) Titrate Ventilation Parameters • Respiratory rate: to keep pHa > 7.25 in non-ARDS and ARDS, tolerate mild hypercapnia in ARDS • PEEP: minimal to keep PaO2 55-80 mmHg or SatO2 88-92% in ARDS and non ARDS, no routine recruitment • FiO2: avoid hyperoxia, if desaturation prioritise FiO2 increase over PEEP increase Assess Harmfulness of Ventilation • Plateau pressure: target below 27 cmH20 + (IAP - 13)/2 in ARDS, 20 cmH2O + (IAP - 13)/2 in non-ARDS • Driving pressure (plateau-PEEP): target below 17 cmH2O in ARDS and 15 cm H2O in non-ARDS • Mechanical power: target below 17-20 J/m Rescue Strategies • Recruitment Maneuvers: only as rescue, stepwise increase in airway pressure • Prone positioning: also safe and feasible in obese ARDS • ECMO: consider in selected ARDS patients #iSTAR #Algorithm #Obesity #Mechanical #ventilation #obese #Management #CriticalCare
