[Ventilation strategies in intensive care medicine]

Mechanical ventilation is a life-saving intervention in intensive care, ensuring adequate gas exchange and reducing respiratory workload. However, inappropriate ventilation strategies can cause ventilator-induced lung injury (VILI) through mechanisms such as volutrauma, barotrauma, atelectrauma, and biotrauma, which may lead to systemic inflammation and multiorgan failure. This review summarizes evidence-based approaches for managing acute respiratory failure, focusing on both non-invasive and invasive ventilation strategies.Non-invasive techniques (HFNO, CPAP, NIV) are established for COPD exacerbations and cardiogenic pulmonary edema and may be considered in mild to moderate hypoxemia, provided close monitoring. In severe hypoxemia, early intubation and lung-protective ventilation are essential. Invasive ventilation should prioritize low tidal volumes (4-8 ml/kg PBW), limited plateau pressure (< 30 cmH₂O), and adequate PEEP to prevent alveolar collapse while avoiding overdistension. Driving pressure (Δp) has emerged as a key prognostic parameter, with values ≥ 15 cmH₂O linked to increased mortality.Advanced modes such as pressure- and volume-controlled ventilation, partially or fully synchronized assist modes, and adaptive or proportional support (e. g., ASV, NAVA, PAV+) aim to improve patient-ventilator synchrony, though outcome benefits remain unproven. Monitoring respiratory drive and inspiratory effort is crucial to prevent excessive strain during spontaneous breathing. Adjunctive measures for refractory hypoxemia include prone positioning, which significantly reduces mortality in moderate to severe ARDS, and rescue therapies such as inhaled nitric oxide or extracorporeal membrane oxygenation (ECMO) in specialized centers. Optimal oxygenation targets (PaO₂ 60-100 mmHg, SaO₂ 92-96%) should avoid both hypoxemia and hyperoxemia.Understanding physiological principles and individualized ventilation strategies is fundamental to minimizing complications and improving outcomes in critically ill patients with respiratory failure.