Ten rules for 

optimizing ventilatory settings

and targets in post-cardiac arrest patients

Oleh: Lusy Herawati Alwi

Pembimbing: dr. Fadhillah Maricar, SP.JP, FIHA

JOURNAL READING

20 FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
22 MAKASSAR
2022
 ABSTRACT

We will provide ten

tips and key insights
to apply a lung-
CARDIAC ARREST (CA)
protective ventilator Cardiac arrest (CA) is a major cause of
A lung-protective
strategy in post-CA morbidity and mortality frequently
ventilator strategy is
patients associated with neurological and systemic
currently the
involvement. Supportive therapeutic
standard of care
Keywords: Cardiac
among critically ill
strategies such as mechanical ventilation,
arrest, Mechanical hemodynamic settings, and temperature
patients since it
ventilation, Lung- management have been implemented in
demonstrated
protective ventilation, the last decade in post-CA patients, aiming
benefcial efects on
Mechanical power, Brain at protecting both the brain and the lungs
mortality, ventilator-
injury and preventing systemic complications.
free days, and other
clinical outcomes.
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 BACKGROUND

Several therapeutic and

Cardiac arrest supportive strategies
(CA) is a major cause have been implemented
of morbidity and over the last years to
mortality with a high optimize outcomes of post-
potential for CA patients, aiming at the
detrimental systemic improvement in
and cerebral neurological outcomes and
complications [1]. survival [2, 3].

Among others, supportive strategies include appropriate settings of

mechanical ventilation, aiming at optimizing gas exchange and limiting
ventilator-induced lung injury (VILI), while avoiding systemic
complications [3].
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 BACKGROUND

The literature in non-CA patients Recently, the concept of

agrees on the importance of the use mechanical power (MP),
of lung-protective ventilator the mechanical energy
strategies (i.e., targeting at low tidal delivered per time by the
volume=VT of 6–8 ml/Kg predicted ventilator on the respiratory
body weight (PBW), low plateau system or the lung, has also
pressure=PPLAT <20 cmH2O, driving been proposed as an
pressure=ΔP<13 cmH2O and low important component of
positive end-expiratory pressure mechanical ventilation
(PEEP)<7 cmH2O [5, 17–27] with settings.
some safety measures for patients
with/or at risk of brain injury [28].

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 BACKGROUND
Rule one: Tidal volume should be protective
All these studies suggest a
progressive reduction in VT
VT represents one of the key over years which can be
parameters of lung-protective interpreted as an expression of
ventilator strategies. increasingly application of
lung-protective ventilator
strategies in patients with CA.
Low tidal volume (VT) in patients without ARDS
(VT of 6–8 mL/kg PBW) resulted in no diferences
in ventilator-free days, intensive care unit (ICU),
and hospital length of stay, 28-day and 90-day
mortality in comparison with an intermediate VT
strategy [21].

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 BACKGROUND
Rule one: Tidal volume should be protective

We suggest that in post-CA patients the VT should be

set between 6 and 8 mL/kg PBW, in volume- or
pressure-controlled ventilation but keeping in mind the
interplay between VT and other parameters of MV (i.e.,
PPLAT, ΔP, PEEP, MP) as well as hemodynamics. Assisted
ventilation may be used according to clinical conditions
and the level of sedation of the patient.

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 BACKGROUND
Rule two: Plateau pressure should be personalized

The PREVENT trial in

PPLAT is another critically ill patients without
important parameter of ARDS reported lower PPLAT
lung-protective (PPLAT=18 cmH2O) in the
ventilation, since it group at lower VT as
depends on the compared to intermediate
relationship between VT (PPLAT=21 cmH2O),
volume and compliance without signifcant
of the respiratory system diferences in ventilator-free
in the absence of fow. days, length of stay,
complications, and
mortality between the two
groups [21].
We suggest that in
post-CA patients the
PPLAT should be kept
equal or lower than
20 cmH2O and
corrected for intra-
abdominal pressure
when clinically
indicated.

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 BACKGROUND
Rule three: Positive end‑expiratory pressure should be low but enough

PEEP represents a key In this context, zero or very

component of mechanical low PEEP levels should be
ventilation. Evidence agrees avoided in the post-CA population to
on that very low PEEP or zero guarantee optimal oxygenation while
PEEP can aggravate the risk of limiting atelectasis or dynamic
atelectasis hyperinfation, hemodynamic
and worsen lung derangement, impaired brain
damage [38]. physiology, and other systemic
complications [42, 43]

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 BACKGROUND
Rule three: Positive end‑expiratory pressure should be low but enough

We suggest that in post-CA

patients a PEEP of 5 cmH2O
should be initially used to reach a
SatO2 at least above 92% and
progressively increase in case of
oxygen desaturation or worsening
of respiratory mechanics.

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 BACKGROUND
Rule four: Pay attention to the driving pressure!
Driving pressure (ΔP)
represents the distending
pressure of the lungs, being the
result of PPLAT minus PEEP, and
representing the stress applied
to the respiratory system. Te VT
changes diferently afect the
variation of ΔP (ΔΔP) and PPLAT,
in relation to diferent static
compliance of the respiratory
system (Fig. 1).
The PRoVENT study in patients
without ARDS concluded that ΔP
was not independently
associated with in-hospital
mortality, although ΔP value was
available for 343 patients only
[23]. In the PRoVENT-iMiC,
median ΔP was similar in patients
with or without lung injury but
was higher in those with ARDS.
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 BACKGROUND
Rule four: Pay attention to the driving pressure!

We suggest in post-CA patients to maintain a ΔP<13 cmH2O

optimizing the VT for the respective compliance of the
respiratory system.

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 BACKGROUND
Rule four: Pay attention to the driving pressure!

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 BACKGROUND
Rule four: Pay attention to the driving pressure!

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 BACKGROUND
Rule five: Respiratory rate should be targeted to pHa and PaCO2

In normal conditions, when

either volume or pressure
increases, the respiratory rate
decreases via the Hering–
Breuer refex [44]. Te
Respiratory rate is regulation of PaCO2 and
one of the key variables oxygenation in post-CA
of mechanical population is challenging but
ventilation. Its deserves important attention
contribution as harm in order to avoid secondary
during MV has been brain damage [28].
often underestimated.

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 BACKGROUND
Rule five: Respiratory rate should be targeted to pHa and PaCO2

As discussed above, respiratory rate should be adapted to ΔP

and total mechanical power. We suggest that in post-CA
patients, the respiratory rate should be kept in a range
between 8 and 16 breaths/min.

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 BACKGROUND
Rule six: Mechanical power is an attractive target, but with caution

1 2 3

MP is the product of mechanical Previous studies on post-CA As per evidence to date, if

energy and respiratory rate
applied to the respiratory system
or the lungs. MP accounts for
several parameters of MV, and for
this reason in the current years is
gaining increased attention as a
possible determinant of patient
outcome [46].
patients did not assess MP as
a possible variable associated
with outcome. In 2022, Robba
et al. found that in post-CA
patients, MP was
independently associated with
both 6 months of mortality
and neurological outcome [28].
assessed at the bedside,
we suggest that in post-
CA patients MP should be
targeted as lower than 17
J/min, taking into account
ΔP and respiratory rate [28,
47]

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 BACKGROUND
Rule six: Mechanical power is an attractive target, but with caution

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 BACKGROUND
Rule seven: Oxygenation should be accurately targeted to normoxia

Oxygenation is a key Hypoxemia in post-CA syndrome

parameter to monitor in post-
CA patients since this
syndrome can activate diferent
mechanisms such as
reperfusion injury and
oxidative stress, which can
contribute to brain injury and
neuronal damage [48].
acts by altering the cerebral aerobic
metabolism, which, if not restored,
can lead to neuronal injury and cell
death. Once the oxygen is restored
after the return of spontaneous
circulation, a possible reperfusion
mechanism occurs, thus further
accelerating neuronal death [3]

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 BACKGROUND
Rule seven: Oxygenation should be accurately targeted to normoxia

Signifcant
While waiting for the
recommendations will results of ongoing
come from the Mega-ROX clinical trials, according
trial (ANZCTRN to the fndings to date, a
12620000391976) that cutof of PaO2 of 70–110
will compare a liberal mmHg seems
(SpO2 without upper reasonable in this
limits, but>90%) versus patient population.
conservative (SpO2 91–
94%) oxygen therapy in
critically ill patients [62]

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 BACKGROUND
Rule eight: Carbon dioxide should be within normal ranges: so far

The role of carbon dioxide levels Changes in PaCO2 as well as

is frequently underestimated in post- mechanical ventilation during
CA patients. Hypercapnia and and after CA can afect carbon
hypocapnia are detrimental to the dioxide and pH levels and trigger
brain physiology. An alteration of dangerous pathways around pH,
PaCO2 can widely afect the changes in cellular demand, and
intracellular pH and infuence catecholamine release [3], thus
metabolic energy and oxygen demand afecting the outcome.
also to the brain [3].

While waiting for the results of the TAME randomized clinical trial
(NCT03114033), the appropriate threshold to apply in post-CA patients
is yet to be defned. According to the literature, a value of PaCO2
ranging between 35 and 50 mmHg seems to be preferable [3].

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 BACKGROUND
Rule nine: Temperature can infuence ventilatory function
The role of temperature management in
post-CA patients is becoming increasingly clear,
but its efect on the setting of the ventilatory
parameter and gas exchange is still uncertain.
Hypothermia at a targeted temperature of 33
°C did not confer a beneft as compared with a
targeted temperature of 36 °C [65].
In patients who remain comatose post-CA,
the guidelines recommend continuous monitoring
of core temperature and prevention of fever
(defned as a temperature >37.7 °C) for at least 72
h. Evidence is insufcient to recommend for or
against temperature control at 32–36 °C or early
cooling after CA [68].
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 BACKGROUND
Rule ten: Hemodynamics should be maintained stable

Hemodynamics The administration of

represents another fuids to restore the end-
important piece for diastolic volume can be
optimization of MV. In considered in presence of
post-CA patients, MV, fuids PEEP if concomitant
and vasopressor impaired left ventricular
management, and contractility and cardiac
temperature control can output occur.
infuence hemodynamics
and outcome.

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 BACKGROUND
Rule ten: Hemodynamics should be maintained stable

In summary, patients with post-CA syndrome need

to be strictly monitored for possible detrimental
respiratory and cardiovascular interactions, thus
accounting for targeted temperature management
(around 36 °C) and personalized cardiovascular
targets.

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 FUTURE DIRECTIONS

The role of protective mechanical

ventilation in post-CA patients is becoming
even more clear. Figure 4 resumes the key rules for
optimizing the setting of the ventilator in post-CA
patients while accounting for lungs–heart and brain
interactions. The PRoVENT-iMiC study showed
that protective mechanical ventilation is easy to
achieve following simple rules also in low- and
middleincome countries where the resources are
scarcer than high-income counties [19].

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FUTURE DIRECTIONS

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CONCLUSIONS
The role of protective and
personalized mechanical ventilation
setting in patients without ARDS and after
CA is becoming more evident.
Optimization of mechanical ventilation is
cheap and may be adopted in high and
middle-low economic income countries
requiring only training and education.

However, the individual role of each

parameter of protective ventilation to
minimize lung injury and their association
with clinical major outcomes have not
been completely elucidated in post-CA
patients and deserve further research.

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9. dll
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thank
you