Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Updated Evidence- Based Recommendations for Choosing Modes and Setting Parameters of Mechanical Ventilation.

Summary

This 2025 GRADE-based guideline refines invasive ventilation for acute respiratory failure, shifting from early neuromuscular blockade toward early assisted strategies in moderate-to-severe ARDS, and introducing cautious, case-by-case recommendations for adaptive modes (e.g., ASV/INTELLiVENT-ASV, NAVA). It reinforces lung-protective ventilation (VT ~6 mL/kg PBW, plateau ≤30 cmH2O, driving pressure ≤14 cmH2O), individualized higher PEEP in moderate/severe ARDS, oxygen targets (SaO2/SpO2 92–96% or PaO2 70–90 mmHg), and continuous monitoring with capnography.

Key Findings

• Early neuromuscular blockade is no longer favored in moderate-to-severe ARDS; early assisted strategies are suggested when feasible.
• Adaptive ventilation modes (ASV/INTELLiVENT-ASV) and NAVA may be considered case-by-case; PAV/PAV+ is not recommended.
• Lung-protective ventilation targets: VT ≈6 mL/kg PBW (4–8 range), plateau pressure ≤30 cmH2O, driving pressure ≤14 cmH2O.
• PEEP should be higher in moderate/severe ARDS and individualized using bedside physiology.
• Oxygen targets (SaO2/SpO2 92–96% or PaO2 70–90 mmHg) and continuous monitoring including capnography are endorsed.

Clinical Implications

Adopt early assisted ventilation when appropriate in moderate-to-severe ARDS, maintain lung-protective settings with individualized PEEP, target SaO2/SpO2 92–96% (or PaO2 70–90 mmHg), and consider adaptive modes selectively while avoiding PAV/PAV+.

Limitations

• Heterogeneity and low/very low certainty for several recommendations, especially adaptive modes
• Guideline context tailored to DACH region; generalizability may vary

Future Directions

Prospective trials comparing early assisted vs. controlled strategies, rigorous evaluation of adaptive modes, and tools to individualize PEEP and oxygen targets.