In this chapter we discuss recommendations on the identification of patients with acute respiratory distress syndrome (ARDS), indications for mechanical ventilation, and strategies for lung-protective ventilation in resource-limited settings. Where blood gas analyzers are unavailable, it can be replaced by the plethysmographic oxygen saturation/fractional inspirational oxygen concentration (SpO2/FiO2) gradient. Bedside lung ultrasound is a valuable diagnostic tool assessing pulmonary edema and other pathologies. A number of recommendations for safe and lung-protective mechanical ventilation in patients with sepsis and respiratory failure are provided. However, many of these have not been trialed specifically in resource-limited settings. These recommendations include an elevated head-of-bed position and a minimum level of positive end-expiratory pressure (PEEP) of 5 cm H2O only to be in patients with moderate or severe ARDS. In addition, low FiO2 and low oxygenation goals are suggested, using PEEP/FiO2 tables. Recruitment maneuvers are indicated in refractory hypoxia, but require experienced staff. Low tidal volumes (5–7 ml/kg predicted body weight, avoiding >10 ml/kg) are recommended and if at all possible in combination with end-tidal carbon dioxide (CO2) monitoring for recognition of dislodgement of the endotracheal tube and under- or overventilation. “Volume-controlled” modes could be safer than “pressure-controlled” modes, and we recommend to check regularly whether a patient tolerates a “support” mode; we also suggest to perform spontaneous breathing trials to timely identify patients who are ready for extubation, but also to plan extubating patients when sufficient staff is around to guarantee safe re-intubation.
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