Brazilian recommendations of mechanical ventilation 2013. Part 2

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associacao de Medicina Intensiva Brasileira -AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia -SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in Sao Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.ResumoO suporte ventilatorio artificial invasivo e nao invasivo ao paciente grave tem evoluido e inumeras evidencias tem surgido, podendo ter impacto na melhora da sobrevida e da qualidade do atendimento oferecido nas unidades de terapia intensiva no Brasil. Isto posto, a Associacao de Medicina Intensiva Brasileira (AMIB) e a Sociedade Brasileira de Pneumologia e Tisiologia (SBPT) -representadas por seu Comite de Ventilacao Mecanica e sua Comissao de Terapia Intensiva, respectivamente, decidiram revisar a literatura e preparar recomendacoes sobre ventilacao mecanica, objetivando oferecer aos associados um documento orientador das melhores praticas da ventilacao mecanica na beira do leito, com base nas evidencias existentes, sobre os 29 subtemas selecionados como mais relevantes no assunto. O projeto envolveu etapas que visaram distribuir os subtemas relevantes ao assunto entre experts indicados por ambas as sociedades, que tivessem publicacoes recentes no assunto e/ ou atividades relevantes em ensino e pesquisa no Brasil, na area de ventilacao mecanica. Esses profissionais, divididos por subtemas em duplas, responsabilizaram-se por fazer uma extensa revisao da literatura mundial. Reuniram-se todos no Forum de Ventilacao Mecanica, na sede da AMIB, na cidade de Sao Paulo (SP), em 3 e 4 de agosto de 2013, para finalizacao conjunta do texto de cada subtema e apresentacao, apreciacao, discussao e aprovacao em plenaria pelos 58 participantes, permitindo a elaboracao de um documento final. Descritores: Recomendacoes; Ventilacao Mecanica; Insuficiencia Respiratoria. Completion of the drafting of the document: Special Article Brazilian recommendations of mechanical ventilation 2013. Part 2 J Bras Pneumol. 2014;40(5):458-486 459 http://dx.

# Introduction
Invasive or non-invasive mechanical ventilation (MV) must be performed in an adequate and safe principles, evidence collected in laboratory experiments, and randomized clinical or observational studies involving actual patients that were available in the literature, current MV recommendations indicate that ventilatory support should be performed at a tidal volume (Vt) of 6 mL/kg predicted body weight, with a delta between plateau pressure and positive end-expiratory pressure (PEEP) not greater than 15 cmH 2 O, and end-expiratory pressure levels sufficient to avoid airway and alveolar collapse and ensure adequate gas exchange. Other recommendations include positioning the patient to guarantee adequate and harmless ventilation (such as prone positioning in cases of severe acute respiratory distress syndrome -ARDS) and the use of advanced support techniques (such as extracorporeal carbon dioxide (CO 2 ) removal) in cases of refractory ARDS. The development of increasingly more sophisticated ventilators allow for fine adjustment of sensitivity and include several trigger mechanisms, different inspiratory flow speeds, acceleration, mechanisms for ending inspiratory time, and monitoring options, which enable adjustment of the patient-ventilator synchrony and MV as a function of the patient's disease. In this regard, the possibility of providing differential ventilatory support for restrictive and obstructive conditions stands out.
For that reason, joint analysis of the available evidence on ventilatory support by Brazilian experts who deal with mechanical ventilation like anesthesiologists, intensivists, pulmonologists, physical therapists, nurses, nutritionists and speech therapists was necessary. Such evidence, taken together with experience gathered by the various specialties, may provide guidance to health care professionals in Brazilian intensive care units (ICU) on how to provide safe and effective respiratory support for patients with respiratory failure, based on the best evidence available, in order to avoid the occurrence of ventilator-associated lung injury.
Therefore, the aim of the present study was to review the available literature on 29 subtopics related to ventilatory support for individuals with respiratory failure, and following presentation, discussion, and approval at a plenary session including all 58 participating specialists, to present the results in the form of recommendations and suggestions.

# Methods
Literature available from Medline and the Cochrane Central Register of Controlled Trials (CENTRAL) was reviewed by specialists with a higher education (intensivists, anesthetists, pulmonary specialists, physical therapists, and nurses) who were distributed in pairs for review of each of the 29 selected subtopics related to non-invasive and invasive ventilatory support for patients with respiratory failure.
After reviewing the articles available in the literature, each pair answered the questions formulated by the organizing commission (composed by Carmen Silvia Valente Barbas, President of the Committee of Respiratory Failure and Mechanical Ventilation of AMIB, Alexandre Marini Isola, National Coordinator of the Course of MV in ICU -VENUTI, and Augusto Manoel de Carvalho Farias, Coordinator of the Department of Intensive Care of the SBPT) according to criteria previously suggested by other authors. [bib_ref] What is "quality of evidence" and why is it important to clinicians?, Guyatt [/bib_ref] [bib_ref] Going from evidence to recommendations, Guyatt [/bib_ref] Thus, the term recommendation was used when the level of evidence was high, i.e., derived from randomized studies conducted with more than 100 participants, meta-analyses, all-or-nothing effect, or patient safety. The term suggestion was used when the available evidence was weak, i.e., based on observational or case-control studies, case series, or on the experience of specialists to provide guidance for efficient and safe ventilatory support in Brazil. We therefore hoped that these evidence-based recommendations would help to avoid potential deleterious effects associated with inadequate ventilatory support in our patients.
The 58 participating specialists were requested to answer the proposed questions during an eight-hour session conducted at the Brazilian Intensive Care Medicine Association (Associacao de Medicina Intensiva Brasileira -AMIB) on August 3, 2013. The answers were formulated based on the evidence available in the literature and on the experience of the specialists and were then presented at a plenary session that included all 58 participating specialists, which was held on August 4, 2013 at AMIB headquarters. During that session, the answers were discussed, modified when needed, voted on, and approved in accordance with the suggestions and observations of the specialists who attended the meeting.
The reports made by all the pairs of specialists were gathered by the project organizing commission, which revised, formatted and drafted the final document, following the authors' revisions. The document was then printed in the form of a bedside manual of recommendations to be distributed to ICUs all across Brazil, and it was also sent for publication in the Brazilian Journal of Intensive Care (Revista Brasileira de Terapia Intensiva -RBTI) and the Brazilian Journal of Pulmonology (Jornal Brasileiro de Pneumologia).

## Mechanical ventilation in chest trauma
Noninvasive mechanical ventilation Recommendation -Noninvasive ventilation (NIV) is contraindicated in patients with upper airway injury, in the presence of hemodynamic instability, and in severe craniocerebral trauma. [bib_ref] Randomized controlled trial comparing ventilatory with nonventilatory management, Bolliger [/bib_ref] [bib_ref] Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma:..., Duggal [/bib_ref] [bib_ref] Noninvasive ventilation in chest trauma: systematic review and meta-analysis, Chiumello [/bib_ref] [bib_ref] A comparative study of continuous positive airway pressure (CPAP) and intermittent positive..., Gunduz [/bib_ref] [bib_ref] Anaesthetic and critical care management of thoracic injuries, Round [/bib_ref] Recommendation -In patients with isolated chest trauma, early application of NIV can improve gas exchange, prevent orotracheal intubation (OTI), and reduce complications and ICU length of stay. [bib_ref] Randomized controlled trial comparing ventilatory with nonventilatory management, Bolliger [/bib_ref] [bib_ref] Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma:..., Duggal [/bib_ref] [bib_ref] Noninvasive ventilation in chest trauma: systematic review and meta-analysis, Chiumello [/bib_ref] [bib_ref] A comparative study of continuous positive airway pressure (CPAP) and intermittent positive..., Gunduz [/bib_ref] [bib_ref] Anaesthetic and critical care management of thoracic injuries, Round [/bib_ref] Recommendation -The use of NIV should be monitored at the bedside by a healthcare professional within 30 minutes to 2 hours. For NIV to be considered successful, the following criteria should be met: reduction of the respiratory rate (f), increase in the tidal volume (Vt), improvement of the level of consciousness, reduction or cessation of the use of accessory muscles, increase in the partial pressure of oxygen (PaO 2 ) and/or the peripheral oxygen saturation (SpO 2 ), and reduction of the partial pressure of carbon dioxide (PaCO 2 ) without significant abdominal distension. In unsuccessful cases, OTI and invasive MV should be performed immediately. [bib_ref] Effect of epidural analgesia in patients with traumatic rib fractures: a systematic..., Carrier [/bib_ref] Recommendation -Patients with severe chest trauma, respiratory failure, and specific contraindications to NIV should be promptly intubated and ventilated.

## Invasive mechanical ventilation
Recommendation -Initially, use an assistcontrol mode of ventilation, i.e., volume-cycled ventilation (VCV) or pressure-control ventilation (PCV), in chest trauma with severe respiratory failure.
Recommendation -Regardless of the mode selected (VCV or PCV), patients with chest trauma should be initially ventilated with a Vt of 6 mL/ kg predicted body weight, an f of 16-20 breaths/ 461 http://dx.doi.org/10.1590/S1806-37132014000500003 studies assessing conventional MV strategies versus protective strategies in patients undergoing surgery considered using a low Vt and a high PEEP in the protective strategies. In general, the use of a high PEEP results in better oxygenation and a lower incidence of PPC. [bib_ref] Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis, Hemmes [/bib_ref] [bib_ref] Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial, Unzueta [/bib_ref] Alveolar recruitment maneuvers Suggestion -Use alveolar recruitment maneuvers (RM) during the intraoperative period to reverse alveolar collapse and improve oxygenation. The use of RM, in association with maintenance of high PEEP levels, reduces the amount of collapsed lung and improves patient oxygenation during surgery. [bib_ref] Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis, Hemmes [/bib_ref] [bib_ref] Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial, Unzueta [/bib_ref] Among the RM most often cited in the literature is maximum recruitment strategy (MRS), which seeks to maintain a high plateau pressure (Pplat) in the airway (approximately 40-45 cmH 2 O) for 60 seconds (as described in Part 1 of the present Recommendations).

## Fraction of inspired oxygen
Suggestion -The lowest FiO 2 level that can maintain SpO 2 at approximately 96-98% should be used. The combination of an FiO 2 of approximately 30-40% and high PEEP levels can maintain adequate oxygenation and reduce lung atelectasis. The role of high levels of oxygen in preventing surgical wound infection remains controversial. [bib_ref] Oxygen and anesthesia: what lung do we deliver to the post-operative ward?, Hedenstierna [/bib_ref] Respiratory rate
Recommendation -Use f to maintain PaCO 2 at 38-43 mmHg (end-tidal CO 2 [CO 2 at end-expiration] of approximately 35-40 mmHg). The trend to use a low Vt during surgery requires the adoption of a high f. [bib_ref] Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis, Hemmes [/bib_ref] [bib_ref] Jaber S; IMPROVE Study Group. A trial of intraoperative low-tidal-volume ventilation in..., Futier [/bib_ref] Discontinuation of mechanical ventilation Recommendation -Discontinue MV in the postoperative period as early and as quickly as possible, as soon as the patient is hemodynamically stable, is under adequate analgesia, has no electrolyte disturbances, and has regained a sufficient level of consciousness to ensure maintenance of ventilatory drive and airway protection. Extubation can be performed in the operating room, in the post-anesthesia care unit, or in the ICU. [bib_ref] How can we prevent postoperative pulmonary complications?, De Abreu [/bib_ref] Pre-oxygenation during induction of anesthesia Recommendation -Pre-oxygenation with an FiO 2 of approximately 100% for all patients aims at increasing reserve and reducing the risk of hypoxemia. [bib_ref] Oxygen and anesthesia: what lung do we deliver to the post-operative ward?, Hedenstierna [/bib_ref] Use of noninvasive ventilation during induction of anesthesia Suggestion -Use NIV during induction of anesthesia for elective surgery in patients with decreased abdominal compliance and in those in whom it is necessary to use an FiO 2 of 100% for pre-oxygenation. The use of NIV can prevent the development of atelectasis in patients with decreased abdominal compliance and in those undergoing pre-oxygenation with an FiO 2 of 100%. [bib_ref] Oxygen and anesthesia: what lung do we deliver to the post-operative ward?, Hedenstierna [/bib_ref] Use of positive end-expiratory pressure and alveolar recruitment maneuvers during induction of anesthesia Suggestion -Use recruitment maneuvers and a PEEP of approximately 5-8 cmH 2 O after induction of anesthesia in patients with decreased abdominal compliance or in those who develop hypoxemia. [bib_ref] Oxygen and anesthesia: what lung do we deliver to the post-operative ward?, Hedenstierna [/bib_ref] Specific care during the intraoperative period

## Mode of ventilation
Suggestion -Use PCV to improve pulmonary mechanics in patients undergoing video-assisted laparoscopic surgery. Observe appropriate expired Vt values. [bib_ref] Pressure-controlled versus volume-controlled one-lung ventilation for MIDCAB, Heimberg [/bib_ref] [bib_ref] A comparison between volumecontrolled ventilation and pressure-controlled ventilation in providing better oxygenation..., Gupta [/bib_ref] In the remaining scenarios, there is no benefit of a mode of ventilation over another, provided that respiratory mechanics are respected.

## Tidal volume
Recommendation -The use of MV with a Vt of 6 mL/kg predicted body weight should be considered in all patients. Various studies in various scenarios (abdominal, thoracic, and cardiac surgery) have demonstrated the benefit of using low Vt during surgery. [bib_ref] Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis, Hemmes [/bib_ref] [bib_ref] Association between use of lung-protective ventilation with lower tidal volumes and clinical..., Neto [/bib_ref] [bib_ref] Jaber S; IMPROVE Study Group. A trial of intraoperative low-tidal-volume ventilation in..., Futier [/bib_ref] Mechanical ventilation in patients with central nervous system involvement Gas exchange -oxygen Recommendation -Avoid hypoxemia in patients with acute neurological injury, because it leads to increased morbidity and mortality. [bib_ref] Hypoxemia and arterial hypotension at the accident scene in head injury, Stochetti [/bib_ref] [bib_ref] The role of secondary brain injury in determining outcome from severe head..., Chesnut [/bib_ref] Suggestion -Avoid hyperoxia in cases of anoxic-ischemic encephalopathy. [bib_ref] Study of Oxygen in Critical Care (SOCC) Group. Arterial hyperoxia and in-hospital..., Bellomo [/bib_ref] Gas exchange -carbon dioxide Recommendation -Do not use prophylactic or prolonged hyperventilation, and maintain PaCO 2 between 35 and 40 mmHg during the acute phase of injury. [bib_ref] Hypocapnia and the injured brain: more harm than benefit, Curley [/bib_ref] [bib_ref] Adverse effects of prolonged hyperventilation in patients with severe head injury: a..., Muizelaar [/bib_ref] [bib_ref] Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local..., Marion [/bib_ref] Recommendation -Acute hyperventilation is indicated as rescue therapy in cases of cerebral herniation. [bib_ref] Hypocapnia and the injured brain: more harm than benefit, Curley [/bib_ref] [bib_ref] Adverse effects of prolonged hyperventilation in patients with severe head injury: a..., Muizelaar [/bib_ref] [bib_ref] Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local..., Marion [/bib_ref] Noninvasive ventilation after extubation Suggestion -The use of NIV should be considered in patients undergoing cardiac, thoracic, bariatric, or upper abdominal surgery, because it is associated with better oxygenation and a lower incidence of atelectasis. It should be performed with low pressure levels in upper abdominal and esophageal surgery. NIV should not delay reintubation.
Recommendation -NIV should not be used following the onset of an acute respiratory failure episode after extubation. [bib_ref] Postoperative noninvasive ventilation, Neligan [/bib_ref] 

## Mechanical ventilation in obese patients
Comment -Patients with a body mass index (BMI)  30 kg/m 2 are considered obese. This condition is characterized by a series of physiological changes, such as decreased lung compliance, which is caused by the direct mechanical effect of fat distribution and an abnormal position of the diaphragm, because of increased intra-abdominal pressure (IAP), reduced functional residual capacity (FRC), and reduced total lung capacity (TLC), and by the increased work of breathing, because of increased airway resistance (Raw) and increased chest wall resistance, as well as a need for high minute volumes, leading to an increase in PaCO 2 . [bib_ref] The effects of body mass index on lung volumes, Jones [/bib_ref] [bib_ref] The effects of body mass on lung volumes, respiratory mechanics, and gas..., Pelosi [/bib_ref] Recommendation -Consider every obese patient as potentially difficult airway. In obese patients with a Malampatti score  3 and a Cormack score of 3-4, as well as increased neck circumference, consider difficult airway and prepare the necessary infrastructure to manage this condition.Suggestion -Use the reverse Trendelenburg position during ventilation. [bib_ref] The effects of the reverse trendelenburg position on respiratory mechanics and blood..., Perilli [/bib_ref] The goal is to improve PaO 2 , static respiratory system compliance (Crs), and cardiac output, as well as reducing the development of atelectasis.
Suggestion -Avoid the supine position, because of reduced FRC, cardiac output, and increased work of breathing. If it is possible to use it, the beach chair position is suggested. [bib_ref] Effects of the beach chair position, positive end-expiratory pressure, and pneumoperitoneum on..., Valenza [/bib_ref] Suggestion -Use NIV in cases of hypercapnic respiratory failure, taking the necessary precautions. Care should be exercised in the use of NIV in patients with a BMI  45kg/m 2 , because there is a higher risk of failure in this group. 463 http://dx.doi.org/10.1590/S1806-37132014000500003 lation strategies such as recruitment maneuvers, prone positioning, arteriovenous extracorporeal membrane CO 2 removal (AV-ECCO 2 R), and extracorporeal membrane oxygenation (ECMO), assessing risk versus benefit on a case-by-case basis. [bib_ref] Lung recruitment maneuver in patients with cerebral injury: effects on intracranial pressure..., Bein [/bib_ref] [bib_ref] Prone position in subarachnoid haemorrhage patients with acute respiratory distress syndrome: effects..., Reinprecht [/bib_ref] [bib_ref] Extracorporeal membrane oxygenation resuscitation for traumatic brain injury after decompressive craniotomy, Yen [/bib_ref] 

## Head of the bed between 30o and 45o
Recommendation -Maintain the head of the bed between 30o and 45o because this improves cerebral venous return and reduces the effect of PEEP on ICP.Mechanical ventilation in patients with neuromuscular diseases Comment -In respiratory failure from neuromuscular disease, ventilatory support depends on the location of the injuries (from spinal cord injuries to direct muscle involvement) (Chart 1).

## Acute polyradiculoneuritis (guillain-barre syndrome)
Comment -One third of patients with acute polyradiculoneuritis (Guillain-Barre syndrome) require MV during the course of the disease. Generalized weakness, rapid progression, and bulbar involvement are associated with the need for MV in such patients. [bib_ref] Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders...., Vianello [/bib_ref] [bib_ref] Neuromuscular disease causing acute respiratory failure, Mehta [/bib_ref] [bib_ref] Anticipating mechanical ventilation in Guillain-Barre syndrome, Lawn [/bib_ref] [bib_ref] Post-intubation pulmonary function test in Guillain-Barre syndrome, Lawn [/bib_ref] Suggestion -Patients with acute polyradiculoneuritis should be periodically assessed by measuring maximum inspiratory pressure (PImax) from residual volume, maximum expiratory pressure (PEmax) from TLC, and vital capacity (VC). Patients with PImax < 30 cmH 2 O, PEmax < 40 cmH 2 O, and VC < 20 mL/kg or a reduction of more than 30% in VC should be electively intubated to prevent emergency OTI. [bib_ref] Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders...., Vianello [/bib_ref] [bib_ref] Neuromuscular disease causing acute respiratory failure, Mehta [/bib_ref] [bib_ref] Anticipating mechanical ventilation in Guillain-Barre syndrome, Lawn [/bib_ref] [bib_ref] Post-intubation pulmonary function test in Guillain-Barre syndrome, Lawn [/bib_ref] Recommendation -NIV should be used with care because of the instability of acute polyradiculoneuritis. Therefore, OTI and invasive MV should not be delayed when there is deterioration of lung function. [bib_ref] Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders...., Vianello [/bib_ref] [bib_ref] Neuromuscular disease causing acute respiratory failure, Mehta [/bib_ref] [bib_ref] Anticipating mechanical ventilation in Guillain-Barre syndrome, Lawn [/bib_ref] [bib_ref] Post-intubation pulmonary function test in Guillain-Barre syndrome, Lawn [/bib_ref] Suggestion -The decision to tracheostomize patients with Guillain-Barre syndrome may be postponed for 2 weeks. If, after 2 weeks, lung function test results do no improve significantly, tracheostomy should be considered. If lung function test results are improving, tracheostomy may be postponed until weaning is achieved. [bib_ref] Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders...., Vianello [/bib_ref] [bib_ref] Neuromuscular disease causing acute respiratory failure, Mehta [/bib_ref] [bib_ref] Anticipating mechanical ventilation in Guillain-Barre syndrome, Lawn [/bib_ref] [bib_ref] Post-intubation pulmonary function test in Guillain-Barre syndrome, Lawn [/bib_ref] Recommendation -Monitor CO 2 by capnography. When this tool is unavailable, assess PaCO 2 levels through blood gas sampling, more frequently during the acute phase.
Suggestion -In patients with acute ischemic stroke, avoid PaCO 2 < 35 mmHg because of risk of ischemia in the penumbra region.

## Acute respiratory distress syndrome
Recommendation -Use a protective ventilation strategy for the treatment of ARDS in patients with neurological injury, accompanied by intracranial pressure (ICP) and cerebral perfusion pressure monitoring. [bib_ref] Effect of a protective-ventilation strategy on mortality in the acute respiratory distress..., Amato [/bib_ref] More details are provided in the related section of the present Recommendations.
Suggestion -In cases of severe ARDS, the use of a high PEEP should be individualized and ICP should be monitored, because increased ICP can occur when there is a concomitant decrease in lung and brain compliance. [bib_ref] Effects of PEEP on the intracranial system of patients with head injury..., Caricato [/bib_ref] [bib_ref] Effects of varying levels of positive end-expiratory pressure on intracranial pressure and..., Mcguire [/bib_ref] 

## Modes of ventilation
Suggestion -Use the VCV mode for patients with severe neurological injury during the acute phase, [bib_ref] Ventila Study Group. Management and outcome of mechanically ventilated neurologic patients, Pelosi [/bib_ref] to avoid oscillations in Vt.
Recommendation -Patients with severe neurological injury, with intracranial hypertension (ICH) during the acute phase, should not be maintained on a spontaneous mode of ventilation.

## Airway approach
Recommendation -Intubate patients with a Glasgow Coma Scale score  8 and in whom the cough reflex is absent. [bib_ref] The use of Glasgow Coma Scale in poisoning, Chan [/bib_ref] Suggestion -Use rapid sequence intubation in patients with ICH or with suspected ICH, minimizing the risk of secondary brain injury due to increased intracranial pressure. This technique uses a combination of sedatives that have minimal cardiodepressant effects, such as ketamine (1-2 mg/kg i.v.) or etomidate (0.3 mg/kg i.v.), particularly in patients with hypotension or at risk of hypotension, and short-acting neuromuscular blocking agents (succinylcholine, 1.5 mg/kg i.v.) so that, within 45 to 60 seconds, the goal of paralysis and sedation is achieved. support. Most patients develop cardiomyopathy. Forced VC (FVC) < 1L and the onset of nocturnal hypoventilation are signs of poor prognosis, and NIV can be used to improve survival and quality of life outcomes. [bib_ref] Management guidelines for motor neurone disease patients on non-invasive ventilation at home, Eng [/bib_ref] [bib_ref] Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease, Radunovic [/bib_ref] Suggestion -Use NIV in cases of nocturnal hypoventilation and/or decreased VC (< 1L).
Suggestion -Invasive ventilation via elective tracheostomy is indicated for patients who do not tolerate NIV or who have been intubated for an acute event. [bib_ref] Management guidelines for motor neurone disease patients on non-invasive ventilation at home, Eng [/bib_ref] [bib_ref] Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease, Radunovic [/bib_ref] Amyotrophic lateral sclerosis Comment -Amyotrophic lateral sclerosis (ALS) is a degenerative motor neuron disease, during the course of which respiratory failure due to muscle failure may occur. Chronic aspiration due to bulbar muscle dysfunction and ineffective cough are additional complications. Most patients die from respiratory complications that vary in course. [bib_ref] Insuficiencia respiratoria cronica nas doencas neuromusculares: diagnostico e tratamento, Pascoal [/bib_ref] Recommendation -Use NIV in patients with ALS, except in the subgroup of patients with severe bulbar dysfunction.
Recommendation -Invasive MV via tracheostomy is indicated in patients with impaired airway protection and severe bulbar dysfunction, and it should only be instituted after its complications, as well as its social and logistical implications, are discussed in detail with the patients and their families.
Recommendation -Indications for ventilatory support include VC < 50% of predicted, PImax < 30 cmH 2 O or < 60% of predicted, peak expiratory flow (PEF) < 270 L/min, PCO 2 > 45 mmHg, and nocturnal hypoventilation. [bib_ref] Insuficiencia respiratoria cronica nas doencas neuromusculares: diagnostico e tratamento, Pascoal [/bib_ref] Suggestion -The parameters for invasive and NIV are as follows. An oral or nasal mask can be used provided that it is properly fitted. BiPAP should be used. Invasive MV via tracheostomy is usually carried out in the ventilation mode that is most suitable for the type of demand, if there is associated lung disease. Patients should be monitored for episodes of atelectasis, accumulation of secretions, and pneumonias. [bib_ref] Randomised controlled trial of non-invasive ventilation (NIV) for nocturnal hypoventilation in neuromuscular..., Wards [/bib_ref] Mechanical ventilation in patients with cardiovascular disease Comment -The goal of MV in patients with cardiovascular disease is to adjust oxygenation and ventilation and to ensure cardiac output.

## Myasthenia gravis
Comment -Acute respiratory failure results from a myasthenic crisis precipitated by neuromuscular junction failure, usually accompanied by bulbar weakness. Myasthenicspecific treatment with immunoglobulin or plasmapheresis should be initiated early. [bib_ref] Ventilatory care in myasthenia gravis crisis: assessing the baseline adverse event rate, Varelas [/bib_ref] [bib_ref] Chronic respiratory care for neuromuscular diseases in adults, Ambrosino [/bib_ref] [bib_ref] BiPAP in acute respiratory failure due to myasthenic crisis may prevent intubation, Rabinstein [/bib_ref] Suggestion -Consider using NIV (bilevel positive airway pressure [BiPAP]) in patients with myasthenic crisis in an attempt to prevent OTI, with PCO 2 > 50mmHg being a predictor of BiPAP failure; the use of NIV can be considered in persistent or recurrent weakness following extubation. [bib_ref] Ventilatory care in myasthenia gravis crisis: assessing the baseline adverse event rate, Varelas [/bib_ref] [bib_ref] Chronic respiratory care for neuromuscular diseases in adults, Ambrosino [/bib_ref] [bib_ref] BiPAP in acute respiratory failure due to myasthenic crisis may prevent intubation, Rabinstein [/bib_ref] Suggestion -Periodically assess patients with myasthenic crisis by measuring PImax, PEmax, and VC. Patients with VC < 20 mL/kg, PImax < 30 cmH 2 O, and PEmax > 40 cmH 2 O can undergo a trial treatment with NIV (BiPAP) and, if there is failure, they should be electively intubated to prevent emergency OTI. [bib_ref] Ventilatory care in myasthenia gravis crisis: assessing the baseline adverse event rate, Varelas [/bib_ref] [bib_ref] Chronic respiratory care for neuromuscular diseases in adults, Ambrosino [/bib_ref] [bib_ref] BiPAP in acute respiratory failure due to myasthenic crisis may prevent intubation, Rabinstein [/bib_ref] Suggestion -Conduct an intensive respiratory program, including sighs, use of PEEP, frequent aspiration of the bronchial tree, respiratory therapy, body position change, and administration of antibiotic therapy (in cases of documented infection), in patients placed on MV for a myasthenic crisis. [bib_ref] Ventilatory care in myasthenia gravis crisis: assessing the baseline adverse event rate, Varelas [/bib_ref] [bib_ref] Chronic respiratory care for neuromuscular diseases in adults, Ambrosino [/bib_ref] [bib_ref] BiPAP in acute respiratory failure due to myasthenic crisis may prevent intubation, Rabinstein [/bib_ref] Duchenne muscular dystrophy Comment -Duchenne muscular dystrophy (DMD) is a recessive X-linked disease that affects 1:3,000 male births. It is characterized by progressive loss of muscle strength, with VC decreasing progressively until the onset of respiratory failure, usually between 18 and 20 years of age, with a consequent need for ventilatory Recommendation -No mode of ventilation is recommended over another in patients with cardiovascular disease. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Suggestion -In patients on inotropic support, this support may be continued until after extubation. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Mechanical ventilation in patients with cardiovascular disease undergoing surgery

## Tidal volume
Recommendation -The use of a Vt of 6 mL/ kg predicted body weight, in the volume-control mode or peak/plateau inspiratory pressure, is sufficient to maintain this same volume in PCV. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Positive end-expiratory pressure Recommendation -Apply PEEP during general anesthesia, because it is associated with improved oxygenation and prevention of atelectasis. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Alveolar recruitment maneuvers Suggestion -RM can be used intraoperatively to prevent alveolar collapse.

## Fraction of inspired oxygen
Recommendation -At induction of anesthesia, use an FiO 2 of 100% to ensure adequate oxygenation for intubation. Fractions of oxygen needed to maintain SpO 2 > 94% are recommended. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] 

## Discontinuation of mechanical ventilation
Recommendation -Discontinuation of MV should be gradual, and pressure support ventilation (PSV) can be used. NIV is an important resource, which should be used immediately after extubation. [bib_ref] Noninvasive mechanical ventilation, Boldrini [/bib_ref] [bib_ref] Noninvasive mechanical ventilation in chronic obstructive pulmonary disease and in acute cardiogenic..., Cervera [/bib_ref] [bib_ref] Non-invasive ventilation in acute cardiogenic pulmonary oedema, Agarwal [/bib_ref] [bib_ref] The use of non-invasive ventilation in the treatment of acute cardiogenic pulmonary..., Ursella [/bib_ref] [bib_ref] Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with..., Peter [/bib_ref] [bib_ref] Noninvasive ventilation in acute cardiogenic pulmonary edema, Gray [/bib_ref] [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Postoperative analgesia Recommendation -Achieving adequate postoperative analgesia is associated with optimization of postoperative pulmonary function.

## Mechanical ventilation in interstitial lung diseases
Comment -Interstitial lung diseases (ILDs) are a heterogeneous group of diseases that Recommendation -Achieve an SpO 2  94% by using the lowest possible FiO 2 .
Recommendation -Noninvasive MV with either continuous positive airway pressure (CPAP) or BiPAP is safe, and both modes have similar effects and are effective in preventing OTI. They should be applied as a form of ventilatory support during acute pulmonary edema. [bib_ref] Noninvasive mechanical ventilation, Boldrini [/bib_ref] [bib_ref] Noninvasive mechanical ventilation in chronic obstructive pulmonary disease and in acute cardiogenic..., Cervera [/bib_ref] [bib_ref] Non-invasive ventilation in acute cardiogenic pulmonary oedema, Agarwal [/bib_ref] [bib_ref] The use of non-invasive ventilation in the treatment of acute cardiogenic pulmonary..., Ursella [/bib_ref] [bib_ref] Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with..., Peter [/bib_ref] [bib_ref] Noninvasive ventilation in acute cardiogenic pulmonary edema, Gray [/bib_ref] Recommendation -Apply the protective strategy to MV patients with cardiovascular disease. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Recommendation -Applying recruitment maneuvers is safe in patients with cardiovascular disease provided that there is proper monitoring and appropriate care. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Suggestion -Monitoring of cardiac output and measurement of extravascular lung water are suggested in MV patients with cardiovascular disease and ARDS, with the aim of volume adjustment and hemodynamic optimization.Suggestion -Monitoring of cardiac output, in patients with cardiovascular disease, can be performed with a pulmonary artery catheter (PAC) or noninvasively, by means of pulse contour analysis. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Suggestion -Transthoracic echocardiography can be performed in MV patients with cardiovascular disease who are hemodynamically unstable. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Suggestion -Perform transthoracic echocardiography in patients who exhibit hemodynamic instability after undergoing RM, in order to assess them for volume status and right ventricular (RV) dysfunction. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Recommendation -Discontinuation of MV in patients with cardiovascular disease follows the recommendations for patients with no cardiovascular disease. The use of NIV should be prioritized to facilitate the process of discontinuation of MV, and NIV should be applied immediately after extubation. [bib_ref] Noninvasive mechanical ventilation, Boldrini [/bib_ref] [bib_ref] Noninvasive mechanical ventilation in chronic obstructive pulmonary disease and in acute cardiogenic..., Cervera [/bib_ref] [bib_ref] Non-invasive ventilation in acute cardiogenic pulmonary oedema, Agarwal [/bib_ref] [bib_ref] The use of non-invasive ventilation in the treatment of acute cardiogenic pulmonary..., Ursella [/bib_ref] [bib_ref] Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with..., Peter [/bib_ref] [bib_ref] Noninvasive ventilation in acute cardiogenic pulmonary edema, Gray [/bib_ref] [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Suggestion -Increased brain natriuretic peptide (BNP) levels during weaning from ventilation in patients with cardiovascular disease show accuracy in predicting weaning failure. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] [bib_ref] Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial, Dessap [/bib_ref] Recommendation -A positive fluid balance should be avoided in MV patients with cardiovascular disease who are hemodynamically stable. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] Recommendation -Inhaled nitric oxide is an effective strategy in MV patients with cardiovascular disease, RV dysfunction, and pulmonary hypertension. [bib_ref] State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic..., Wiesen [/bib_ref] ously expressed the desire not to be intubated. Either CPAP or bilevel NIV can be used and should be applied early.
Recommendation -The use of NIV should be monitored at the bedside by a healthcare professional within thirty minutes to two hours. For NIV to be considered successful, the following criteria should be met: reduction of f, increase in Vt, improvement of the level of consciousness, reduction or cessation of the use of accessory muscles, increase in PaO 2 and/or SpO 2 , and reduction of PaCO 2 without significant abdominal distension. In unsuccessful cases, OTI and invasive MV should be performed immediately. Success is expected in 50% of this population. [bib_ref] Acute exacerbation of interstitial pneumonia other than idiopathic pulmonary fibrosis, Park [/bib_ref] Noninvasive mechanical ventilation Comment -Since the histological finding in AEs is diffuse alveolar damage (DAD), similar to that observed in patients with ARDS, and given the lack of prospective studies, some authors have suggested that strategies used for ARDS could be extrapolated to patients with AEs of ILD. Therefore, some experts advocate the use of protective ventilation, with a low Vt, set at approximately 6 mL/kg ideal body weight, and a Pplat  30 cmH 2 O. [bib_ref] Acute exacerbation of interstitial pneumonia other than idiopathic pulmonary fibrosis, Park [/bib_ref] [bib_ref] Noninvasive ventilation in acute exacerbation of idiopathic pulmonary fibrosis, Yokoyama [/bib_ref] [bib_ref] Potential benefits of early continuous positive pressure ventilation in patients with rapidly..., Yokoyama [/bib_ref] [bib_ref] Outcome of patients admitted to the intensive care unit for acute exacerbation..., Al-Hameed [/bib_ref] [bib_ref] Outcome of patients with idiopathic pulmonary fibrosis (IPF) ventilated in intensive care..., Mallick [/bib_ref] The use of a high PEEP in patients with ILD has not been investigated in any study. Two retrospective studies found an association between PEEP and the outcome of patients with ILD who underwent MV: Suh et al. reported low mortality in a group of patients with acute interstitial pneumonia who received an early intervention strategy, which involved a series of measures, including MV with a low Vt and a moderate PEEP, with a median of 11 cmH 2 O. [bib_ref] Early intervention can improve clinical outcome of acute interstitial pneumonia, Suh [/bib_ref] In contrast, in a more heterogeneous group of patients with ILD who underwent MV, Fernandez-Perez et al. observed that a PEEP > 10 cmH 2 O on the first day of MV was associated with high mortality, but they themselves comment that a high PEEP may be a marker of greater respiratory failure severity. [bib_ref] Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease, Fernandez-Perez [/bib_ref] Suggestion -Patients with ILD who require MV should be ventilated with a low Vt, set at approximately 6 mL/kg ideal body weight, and a Pplat < 30 cmH 2 O; a high f (> 30 breaths/ min) and a short inspiratory time can be used to prevent hypercapnia. Use a PEEP between 5 and 10 cmH 2 O.
Suggestion -The use of a high PEEP can be attempted with caution and should be indi-predominantly affect the lung interstitium, with varying degrees of inflammation and fibrosis, [bib_ref] Diretrizes de Doencas Pulmonares Intersticiais da Sociedade Brasileira de Pneumologia e Tisiologia, Baldi [/bib_ref] and that can progress with varying degrees of hypoxemia and gradual reduction in lung volumes. Patients with ILD may require MV because of a number of factors, including the anesthesia process in surgical procedures, such as open lung biopsy and other elective or emergency operations, respiratory infections leading to respiratory failure, and acute exacerbations (AEs -noninfectious) of the underlying interstitial disease. [bib_ref] Mechanical ventilation in patients with end-stage idiopathic pulmonary fibrosis, Mollica [/bib_ref] [bib_ref] Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease, Fernandez-Perez [/bib_ref] Indications for mechanical ventilation Comment -Respiratory failure in patients with ILD should be divided into two groups: progression of the underlying disease and AEs. AEs are characterized by acute, unexplained worsening of clinical symptoms of ILD, especially dyspnea and cough, usually in the last 30 days, accompanied by radiological worsening, often in the form of ground-glass changes superimposed on previous changes. AEs were initially described in patients with idiopathic pulmonary fibrosis (IPF), but they can occur in other forms of ILD. [bib_ref] Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease, Fernandez-Perez [/bib_ref] [bib_ref] Idiopathic Pulmonary Fibrosis Clinical Research Network Investigators. Acute exacerbations of idiopathic pulmonary..., Collard [/bib_ref] [bib_ref] Acute exacerbation of idiopathic pulmonary fibrosis, Hyzy [/bib_ref] [bib_ref] Early intervention can improve clinical outcome of acute interstitial pneumonia, Suh [/bib_ref] The onset of AEs seems to occur at some point in the course of IPF in 5 to 10% of patients, and mortality in those requiring MV is nearly 100%.
Recommendation -Before diagnosing an AE, it is necessary to exclude infections, pulmonary thromboembolism, cardiac dysfunction, druginduced pulmonary toxicity, etc. [bib_ref] Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease, Fernandez-Perez [/bib_ref] [bib_ref] Idiopathic Pulmonary Fibrosis Clinical Research Network Investigators. Acute exacerbations of idiopathic pulmonary..., Collard [/bib_ref] [bib_ref] Acute exacerbation of idiopathic pulmonary fibrosis, Hyzy [/bib_ref] [bib_ref] Early intervention can improve clinical outcome of acute interstitial pneumonia, Suh [/bib_ref] [bib_ref] Acute exacerbation of interstitial pneumonia other than idiopathic pulmonary fibrosis, Park [/bib_ref] Acute complication Suggestion -In AEs of ILD, the patient's previous status should be assessed. Invasive MV is indicated if the cause of acute respiratory failure is diagnosed as not being due to progression of the underlying disease.

## Progression of the underlying disease
Recommendation -ICU admission and invasive MV should be avoided, and any decision in this regard should be discussed with the patients or their families.

## Noninvasive mechanical ventilation
Suggestion -NIV can be used as initial ventilatory support in patients with ILD who develop acute respiratory failure or as palliative ventilatory support in patients who have previ-467 http://dx.doi.org/10.1590/S1806-37132014000500003 They should only be calculated in situation in which the decision is difficult and must NOT be used as the sole tool in the decision-making process regarding the SBT. [bib_ref] A prospective study of indexes predicting the outcome of trials of weaning..., Yang [/bib_ref] [bib_ref] A new integrative weaning index of discontinuation from mechanical ventilation, Nemer [/bib_ref] [bib_ref] Applying a new weaning index in ICU older patients, Azeredo [/bib_ref] Autonomous breathing trial (spontaneous breathing trial) Recommendation -In the SBT, patients should be placed on T-tube or ventilated with PSV of 5-7 cmH 2 O for 30-120 minutes. During the SBT, patients should be monitored for signs of failure. [bib_ref] Comparison of three methods of gradual withdrawal from ventilatory support during weaning..., Brochard [/bib_ref] [bib_ref] A comparison of four methods of weaning patients from mechanical ventilation. Spanish..., Esteban [/bib_ref] [bib_ref] Decision to extubate, Epstein [/bib_ref] [bib_ref] Clinical management of weaning from mechanical ventilation, Esteban [/bib_ref] [bib_ref] Effect on the duration of mechanical ventilation of identifying patients capable of..., Ely [/bib_ref] [bib_ref] A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation, Kollef [/bib_ref] [bib_ref] Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory..., Marelich [/bib_ref] [bib_ref] Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of..., Navalesi [/bib_ref] Successful SBTs are defined as those in which patients maintain an adequate breathing pattern, as well as adequate gas exchange, hemodynamic stability, and comfort (Chart 4). [bib_ref] Comparison of three methods of gradual withdrawal from ventilatory support during weaning..., Brochard [/bib_ref] [bib_ref] A comparison of four methods of weaning patients from mechanical ventilation. Spanish..., Esteban [/bib_ref] [bib_ref] Decision to extubate, Epstein [/bib_ref] [bib_ref] Clinical management of weaning from mechanical ventilation, Esteban [/bib_ref] [bib_ref] Effect on the duration of mechanical ventilation of identifying patients capable of..., Ely [/bib_ref] [bib_ref] A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation, Kollef [/bib_ref] [bib_ref] Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory..., Marelich [/bib_ref] [bib_ref] Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of..., Navalesi [/bib_ref] [bib_ref] Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation...., Esteban [/bib_ref] [bib_ref] Protocol-directed weaning from mechanical ventilation: clinical outcome in patients randomized for a..., Perren [/bib_ref] Recommendation -After a successful SBT, determine whether the airways are patent and whether the patient is able to protect them.

## How to determine the timing of extubation

## Assessment of airway protection
Recommendation -Determine whether the patient has the required level of consciousness (a Glasgow coma scale score > 8), an effective cough (a positive white card test result and a peak flow > 60 lpm), and a small amount of secretions (with no need for suctioning every 1 or 2 hours). [bib_ref] Neurologic status, cough, secretions and extubation outcomes, Salam [/bib_ref] Assessment of airway patency Suggestion -Test airway patency in patients at higher risk for laryngeal stridor and airway obstruction (prolonged ventilation and trauma); to that end, a qualitative or quantitative approach can be used. Perform thorough suctioning of the mouth and larynx before deflating the tube cuff for the test, in order to prevent unwanted material from entering the lower airways iatrogenically (Chart 5). [bib_ref] Cuff-leak test for predicting postextubation airway complications: a systematic review, Zhou [/bib_ref] Use of corticosteroids Recommendation -In patients at high risk for laryngeal stridor and laryngeal edema, as identified by the cuff leak test, the preventive use of corticosteroids may be beneficial. The prescribed doses range from 20 to 40 mg of i.v. methylprednisolone every 4 to vidualized for each patient. Rescue therapies for refractory hypoxemia, such as prone positioning, RM, and nitric oxide, can be used in referral centers with expertise in these therapies.

## Discontinuation of mechanical ventilation
Identifying patients who are ready to wean Recommendation -Discontinue patients from invasive MV as soon as it is clinically possible. [bib_ref] Comparison of three methods of gradual withdrawal from ventilatory support during weaning..., Brochard [/bib_ref] [bib_ref] A comparison of four methods of weaning patients from mechanical ventilation. Spanish..., Esteban [/bib_ref] Recommendation -The definitions of terms related to discontinuation of MV must be made clear in ICU guidelines. The concept of "successful weaning" refers to a patient successfully completing the spontaneous breathing trial (SBT) while still connected to the ventilator. "Successful extubation" refers to a patient having the endolaryngeal tube removed (extubation) after passing the SBT and not being reintubated in the following 48 hours. In tracheostomized patients, successful extubation means tolerating being disconnected from the ventilator after passing the SBT and not needing to be reconnected to the ventilator in the following 48 hours. [bib_ref] Decision to extubate, Epstein [/bib_ref] [bib_ref] Clinical management of weaning from mechanical ventilation, Esteban [/bib_ref] Recommendation -Assess and identify patients daily (active surveillance by means of internal guidelines established by a multidisciplinary team) with a view to the possibility of discontinuing ventilation, in order to reduce duration of MV and decrease costs. [bib_ref] Effect on the duration of mechanical ventilation of identifying patients capable of..., Ely [/bib_ref] [bib_ref] A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation, Kollef [/bib_ref] [bib_ref] Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory..., Marelich [/bib_ref] [bib_ref] Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of..., Navalesi [/bib_ref] Sedation Recommendation -Sedation should be interrupted daily to assess the patient's ability to maintain spontaneous ventilation [bib_ref] Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation, Kress [/bib_ref] (see the "Sedation and Analgesia" section in Part 1 of the present Recommendations).

## Criteria required for assessment of readiness to wean
Recommendation -Perform active surveillance, including the topics in Chart 2. [bib_ref] Effect on the duration of mechanical ventilation of identifying patients capable of..., Ely [/bib_ref] [bib_ref] A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation, Kollef [/bib_ref] [bib_ref] Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory..., Marelich [/bib_ref] [bib_ref] Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of..., Navalesi [/bib_ref] [bib_ref] Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation, Kress [/bib_ref] [bib_ref] Desmame e interrupcao da ventilacao mecanica, Goldwasser [/bib_ref] Predictive indices Recommendation -The most accurate weaning-predictive indices are the rapid shallow breathing index (RSBI), i.e., f divided by Vt (f/Vt), and the integrative weaning index (IWI) (Chart 3). disease (COPD), even in those who fail the SBT, provided that their clinical status is adequate. The patient should be managed in centers with experience in the use of NIV [fig_ref] Figure 1 -: Use of noninvasive ventilation for discontinuation of mechanical ventilation [/fig_ref]. [bib_ref] Effect of noninvasive positive pressure ventilation on weaning success in patients receiving..., Zhu [/bib_ref] Use of noninvasive ventilation to prevent extubation failure (noninvasive ventilation as a preventive technique)
Recommendation -NIV should be used immediately after extubation, in a preventive manner, in patients identified as high risk, especially in hypercapnic patients [fig_ref] Figure 1 -: Use of noninvasive ventilation for discontinuation of mechanical ventilation [/fig_ref] and Chart 6). [bib_ref] Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients, Nava [/bib_ref] [bib_ref] Early noninvasive ventilation averts extubation failure in patients at risk: a randomized..., Ferrer [/bib_ref] [bib_ref] Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial, Keenan [/bib_ref] [bib_ref] Noninvasive positivepressure ventilation for respiratory failure after extubation, Esteban [/bib_ref] [bib_ref] Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure:..., Ornico [/bib_ref] Use of noninvasive ventilation in respiratory failure after extubation (noninvasive ventilation as a curative technique)
Recommendation -Avoid the use of NIV in extubated patients who again develop respiratory failure within 48 hours. Do not delay reintubation in this situation, except in surgical patients who develop respiratory failure in the postoperative period [fig_ref] Figure 1 -: Use of noninvasive ventilation for discontinuation of mechanical ventilation [/fig_ref]. [bib_ref] Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative..., Glossop [/bib_ref] How to manage patients with weaning failure (patients who fail their first spontaneous breathing trial)
Recommendation -Reinstate ventilatory support that provides patients with comfort and adequate gas exchange, maintaining it for 24 hours, so that the SBT can be repeated. Try to identify the causes of failure [bib_ref] A comparison of four methods of weaning patients from mechanical ventilation. Spanish..., Esteban [/bib_ref] (for difficult-towean patients and those requiring long-term weaning, see the related section of the present Recommendations).

# Gradual weaning methods
Recommendation -Avoid the use of synchronized inspiratory mandatory ventilation, because it can increase the time to discontinuation of invasive MV. [bib_ref] Comparison of pressure support ventilation (PSV) and intermittent mandatory ventilation (IMV) during..., Esen [/bib_ref] 6 hours, started at least 4 hours, more commonly 12 to 24 hours, before extubation. [bib_ref] Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of..., Jaber [/bib_ref] 

## Use of noninvasive ventilation in the discontinuation of mechanical ventilation
Use of noninvasive ventilation to facilitate discontinuation of mechanical ventilation -early weaning (noninvasive ventilation as a facilitation technique) Recommendation -It is recommended that NIV be used to facilitate early discontinuation of MV in patients with chronic obstructive pulmonary Chart 2 -Topics that are to be routinely assessed during active surveillance in mechanically ventilated patients. PaO 2  60mmHg on FIO 2  0.4 and PEEP  5 to 8 cmH 2 O Hemodynamic stability, with good tissue perfusion, with or without low doses of vasopressors, and absence of decompensated coronary artery disease or arrhythmias with hemodynamic effects Resolution or control of the cause of respiratory failure Capability to initiate an inspiratory effort Zero or negative fluid balance in the last 24 hours Normal acid-base and electrolyte balance Delay extubation when patients are scheduled to be taken to tests or surgery requiring general anesthesia in the next 24 hours finally, prolonged weaning (when patients fail more than three consecutive SBTs or require >7 days of MV following the first SBT). Suggestion -Use the concept of prolonged MV defined as MV that is needed for  21 consecutive days for 6 hours daily.
Recommendation -Identify causes of failure to discontinue MV (Chart 7). [bib_ref] Long-term mechanical ventilation: management strategies, White [/bib_ref] [bib_ref] National Association for Medical Direction of Respiratory Care. Management of patients requiring..., Macintyre [/bib_ref] [bib_ref] Petrak RA; Ventilation Outcomes Study Group. Post-ICU mechanical ventilation at 23 long-term..., Scheinhorn [/bib_ref] [bib_ref] Sedation, delirium and mechanical ventilation: the 'ABCDE' approach, Morandi [/bib_ref] [bib_ref] Depressive disorders during weaning from prolonged mechanical ventilation, Jubran [/bib_ref] [bib_ref] Failed weaning from mechanical ventilation and cardiac dysfunction, Porhomayon [/bib_ref] [bib_ref] Weaning patients from the ventilator, Mcconville [/bib_ref] [bib_ref] Inspiratory muscle strenght training improves weaning outcome in failure to wean patients:..., Martin [/bib_ref] [bib_ref] Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective, Martin [/bib_ref] [bib_ref] Effect of pressure support vs unassisted breathing through a tracheostomy collar on..., Jubran [/bib_ref] [bib_ref] Evidence-based assessments in the ventilator descontinuation process, Macintyre [/bib_ref] [bib_ref] Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and..., Garnacho-Montero [/bib_ref] [bib_ref] Inpatient and long-term outcomes of individuals admitted for weaning from mechanical ventilation..., Hannan [/bib_ref] [bib_ref] Respiratory system mechanics in sedated, paralyzed, morbidly obese patients, Pelosi [/bib_ref] [bib_ref] Effect of body position on spontaneous respiratory rate and tidal volume in..., Burns [/bib_ref] [bib_ref] Mechanisms underlying ICU muscle wasting and effects of passive mechanical loading, Llano-Diez [/bib_ref] [bib_ref] Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory..., Gosselink [/bib_ref] Muscle disorders Suggestion -Assess the possibility of critical illness polyneuropathy and of phosphorus, magnesium, calcium, and potassium disorders.

## Endocrine and metabolic diseases
Recommendation -Adequately control diabetes, hypothyroidism, and adrenal failure.

## How to manage patients with extubation failure
Recommendation -Reintubate patients as soon as possible; identify and treat the causes of failure; and, as soon as possible, restart the discontinuation process (exception: noninvasive ventilation as a curative technique may be tried in surgical patients).

## Patients with prolonged weaning
Suggestion -Use classification definitions for the duration of the weaning process to categorize your patients as undergoing simple weaning [bib_ref] Long-term mechanical ventilation: management strategies, White [/bib_ref] (when patients successfully complete their first SBT), difficult weaning (when patients fail their first SBT and require up to three SBTs or up to seven days of MV following the first SBT), and, Specific care for discontinuation of mechanical ventilation Suggestion -Transfer patients undergoing prolonged weaning to a unit specializing in discontinuation of MV, if available.
Recommendation -Tracheostomy is indicated in patients who repeatedly fail SBTs, from the tenth day of MV onward, as part of a discontinuation protocol and in accordance with specifications in the related section of the present Recommendations.
Suggestion -Perform SBTs daily, using a tracheostomy collar or T-piece. In cases of tolerance (f < 35 breaths/minute or over 35 breaths/ minute for less than 5 consecutive minutes; SaO2 > 90%; HR < 140 beats/minute or a sustained change of 20% in any direction; 90 mmHg > blood pressure < 180 mmHg with no anxiety or diaphoresis), gradually increase the duration of T-piece use and rest the patient overnight on assist-control ventilation. In cases of failure, return the patient to an assist-control mode for rest, in order to make a second attempt within 24 hours. [bib_ref] Effect of pressure support vs unassisted breathing through a tracheostomy collar on..., Jubran [/bib_ref] Suggestion -Long-term MV is characterized when there is failure of the entire discontinuation process, especially in patients with spinal trauma, end-stage COPD, advanced dementia, pulmonary fibrosis, and irreversible neuromuscular disease. In these situations, explain the concept of futile treatment and palliative care to patients and families in order to arrive at a joint decision regarding the best approach. [bib_ref] Long-term mechanical ventilation: management strategies, White [/bib_ref] Recommendation -Early physical therapy and passive mobilization should be performed during MV and also during the discontinuation process. These activities are considered safe and are associated with better functional results and shorter duration of MV [bib_ref] Inspiratory muscle strenght training improves weaning outcome in failure to wean patients:..., Martin [/bib_ref] [bib_ref] Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory..., Gosselink [/bib_ref] (see the related section of the present Recommendations).
Suggestion -Inspiratory muscle training can be considered in patients who fail to wean, in order to increase PImax and facilitate discontinuation of ventilatory support. [bib_ref] Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory..., Gosselink [/bib_ref] [bib_ref] Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of..., Rivers [/bib_ref] Hemodynamic changes and hemodynamic care in patients on invasive mechancial ventilation Comment -The cardiovascular effects of positive pressure MV are described in Chart 8.
Comment -Obesity can be an additional factor for prolonged weaning, because it is characterized by an increase in O 2 consumption (VO 2 ) and CO 2 production (VCO 2 ), a decrease in static compliance, VC, and TLC, and a possible increase in IAP and Raw.

## Electrolyte and acid-base disturbances
Recommendation -Monitor, diagnose, and treat states of hyperhydration, which are associated with increased morbidity, mortality, and ICU length of stay. Identify and treat cases of metabolic alkalosis, the most common causes of which are chronic respiratory acidosis and use of diuretics. Metabolic alkalosis is associated with increased mortality, decreased respiratory drive, decreased O 2 delivery (DO 2 ), shift of the oxyhemoglobin curve to the left, ventilation/perfusion (V/Q) mismatch, and systemic vasoconstriction. Provide an adequate means of nutrition (see the related section of the present Recommendations) to prevent malnutrition, increased protein catabolism, reduced body muscle mass and decreased effectiveness of the thoracic pump mechanism, with reduced strength and endurance and increased VO 2 , and perpetual dependence on the ventilator. Decreased albumin is associated with prolonged weaning and should be monitored. [bib_ref] Long-term mechanical ventilation: management strategies, White [/bib_ref] [bib_ref] National Association for Medical Direction of Respiratory Care. Management of patients requiring..., Macintyre [/bib_ref] [bib_ref] Petrak RA; Ventilation Outcomes Study Group. Post-ICU mechanical ventilation at 23 long-term..., Scheinhorn [/bib_ref] [bib_ref] Sedation, delirium and mechanical ventilation: the 'ABCDE' approach, Morandi [/bib_ref] [bib_ref] Depressive disorders during weaning from prolonged mechanical ventilation, Jubran [/bib_ref] [bib_ref] Failed weaning from mechanical ventilation and cardiac dysfunction, Porhomayon [/bib_ref] [bib_ref] Weaning patients from the ventilator, Mcconville [/bib_ref] [bib_ref] Inspiratory muscle strenght training improves weaning outcome in failure to wean patients:..., Martin [/bib_ref] [bib_ref] Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective, Martin [/bib_ref] [bib_ref] Effect of pressure support vs unassisted breathing through a tracheostomy collar on..., Jubran [/bib_ref] [bib_ref] Evidence-based assessments in the ventilator descontinuation process, Macintyre [/bib_ref] [bib_ref] Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and..., Garnacho-Montero [/bib_ref] [bib_ref] Inpatient and long-term outcomes of individuals admitted for weaning from mechanical ventilation..., Hannan [/bib_ref] [bib_ref] Respiratory system mechanics in sedated, paralyzed, morbidly obese patients, Pelosi [/bib_ref] [bib_ref] Effect of body position on spontaneous respiratory rate and tidal volume in..., Burns [/bib_ref] [bib_ref] Mechanisms underlying ICU muscle wasting and effects of passive mechanical loading, Llano-Diez [/bib_ref] [bib_ref] Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory..., Gosselink [/bib_ref] 

## Rehabilitation strategies and strategies to facilitate discontinuation from mechanical ventilation
Reassessment of the underlying disease and comorbidities echocardiography, which should show ejection fraction, velocity-time integral, as well as assess diastolic function [E/A, E/E', global end-diastolic volume]. [bib_ref] focused updates: ACC/ AHA guidelines for the management of patients with ST-elevation..., Kushner [/bib_ref] If you use a PAC, a pulmonary artery occlusion pressure >18 mmHg and a cardiac index < 2.2 L/min/m 2 characterize LV failure. [bib_ref] focused updates: ACC/ AHA guidelines for the management of patients with ST-elevation..., Kushner [/bib_ref] Recommendation -Use inotropes, vasopressors if necessary, diuretics, and vasodilators when possible. In selected cases, use mechanical circulatory support. [bib_ref] focused updates: ACC/ AHA guidelines for the management of patients with ST-elevation..., Kushner [/bib_ref] Suggestion -Favor the use of high PEEP (because of decreased LV preload and afterload). If there is concomitant RV failure, increase PEEP carefully (monitor the RV and RV flow). [bib_ref] Influence of positive end-expiratory pressure on left ventricular performance, Jardin [/bib_ref] Prevent severe hypercapnia (pH < 7.15 or PaCO 2 > 80 mmHg). [bib_ref] Hypercapnic acidosis increases oxygen cost of contractility in the dog left ventricle, Hata [/bib_ref] Consider kidney ultrafiltration for achieving a negative fluid balance in situations of refractoriness to diuretics. [bib_ref] Treatment of diuretic resistant cor pulmonale by continuous arteriovenous haemofiltration, Rowe [/bib_ref] 

## Mechanical ventilation in patients with right ventricular failure
Recommendation -Regarding diagnosis, use Doppler echocardiography (RV diastolic diameter > 3.5 cm, RV/LV ratio > 1, intraventricular septal flattening or paradoxical interventricular septal motion, pulmonary artery systolic pressure > 35 mmHg, tricuspid annular plane systolic excursion < 1.8 cm) [bib_ref] Diagnosis and assessment of pulmonary vascular disease by Doppler echocardiography, Roberts [/bib_ref] or a PAC (a volumetric PAC, if available): central venous pressure > pulmonary artery occlusion pressure; mean pulmonary artery pressure > 25 mmHg; systolic index < 30 mL.min -1 .m -2 ; RV end-diastolic volume index > 140 mL.m -2 . [bib_ref] French Pulmonary Artery Catheter Study Group. Incidence and prognostic value of right..., Osman [/bib_ref] Suggestion -Details regarding monitoring, treatment, and specific care are shown in Chart 9 and [fig_ref] PaO 2: partial pressure of oxygen [/fig_ref].

## Resources available for hemodynamic monitoring in mechanically ventilated patients
Suggestion -Suggested methods of hemodynamic monitoring in MV patients include predicting the response to fluid loading (a > 15% increase in the cardiac index) in patients with the following characteristics: PEEP < 10 cmH 2 O; Vt of 8-10 mL.kg-1 ideal body weight; f < 30 min-1; respiratory compliance > 30 mL.cmH 2 O; no arrhythmias; no respiratory effort; no cor pulmonale; delta pulse pressure > 13%; systolic volume variation > 10%; delta velocity time integral > 15%; superior vena cava collapsibility

## Hemodynamic care in mechanically ventilated patients
Recommendation -Resuscitation aimed at restoration of tissue perfusion begins in the early acute phase, in which resuscitation should be performed as soon as possible to achieve mixed venous O 2 saturation (SvO 2 ) > 65% or central venous saturation (SvcO 2 ) > 70%, blood lactate concentration < 2 mmol/L (18 mg/dL), and adequacy of DO 2 /VO 2 . [bib_ref] Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous..., Jones [/bib_ref] [bib_ref] Oxygen supply dependency can characterize septic shock, Friedman [/bib_ref] [bib_ref] Comparison of two fluid-management strategies in acute lung injury, Wiedemann [/bib_ref] The process should continue in the post-resuscitation phase (when adequate tissue perfusion is achieved), and fluid restriction should be performed to maintain a zero or negative fluid balance. [bib_ref] Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation:..., Vieillard-Baron [/bib_ref] Suggestion -In ARDS patients receiving PEEP  15 cmH 2 O and < 20 cmH 2 O, perform echocardiography at least once and, if necessary, monitor cardiac output. [bib_ref] French Pulmonary Artery Catheter Study Group. Incidence and prognostic value of right..., Osman [/bib_ref] [bib_ref] Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted..., Phillips [/bib_ref] In ARDS patients receiving PEEP  20 cmH 2 O or experiencing hemodynamic instability, perform monitoring with serial echocardiography and/or with a volumetric PAC, if available. [bib_ref] French Pulmonary Artery Catheter Study Group. Incidence and prognostic value of right..., Osman [/bib_ref] [bib_ref] Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted..., Phillips [/bib_ref] Suggestion -During MRS with decremental PEEP titration, use invasive blood pressure monitoring; perform echocardiography after 6 hours, or earlier if the patient exhibits hemodynamic instability, to assess RV dysfunction. [bib_ref] French Pulmonary Artery Catheter Study Group. Incidence and prognostic value of right..., Osman [/bib_ref] [bib_ref] Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted..., Phillips [/bib_ref] Suggestion -In moderate/severe ARDS, consider extravascular lung water monitoring (if available). [bib_ref] Prognostic value of extravascular lung water index in critically ill patients: a..., Zhang [/bib_ref] [bib_ref] Depression of hypoxic pulmonary vasoconstriction by sodium nitroprusside and nitroglycerine, D&apos;oliveira [/bib_ref] Suggestion -Avoid systemic systemic vasodilators in refractory hypoxemia (they inhibit hypoxic vasoconstriction). [bib_ref] Effects of arterial oxygen tension and cardiac output on venous saturation: a..., Zampieri [/bib_ref] Suggestion -Interpret SvO 2 by considering PaO 2 . High PaO 2 values can increase SvO 2 . [bib_ref] ACCF/AHA guideline for the management of heart failure: executive summary: a report..., Yancy [/bib_ref] [bib_ref] Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in..., Michard [/bib_ref] [bib_ref] Heart-lung interactions with different ventilatory settings during acute lung injury and hypovolaemia:..., Da Silva Ramos [/bib_ref] Also perform the expiratory port occlusion maneuver -in spontaneously breathing patients receiving PEEP  10 cmH 2 O, [bib_ref] Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive..., Monnet [/bib_ref] with a delta central venous pressure > 1 mmHg (1.36 cmH 2 O). [bib_ref] Respiratory variations in right atrial pressure predict response to fluid challenge, Magder [/bib_ref] In patients receiving high PEEP and/or low Vt, passive leg raising maneuver, [bib_ref] Passive leg raising predicts fluid responsiveness in the critically ill, Monnet [/bib_ref] fluid challenge with small aliquots of fluid (250 mL), and cardiac index monitoring can be used [fig_ref] PaO 2: partial pressure of oxygen [/fig_ref]. [bib_ref] Let's give some fluid and see what happens" versus the "mini-fluid challenge, Vincent [/bib_ref] Speech-language pathology care in the rehabilitation of patients after mechanical ventilation comment -The role of speech-language pathologists in the ICU is endorsed by Chart 9 -Suggestions for monitoring, treatment, and specific care in patients with right ventricular failure. [bib_ref] Treatment of diuretic resistant cor pulmonale by continuous arteriovenous haemofiltration, Rowe [/bib_ref] [bib_ref] The role of invasive techniques in cardiopulmonary evaluation, Backer [/bib_ref] [bib_ref] Management strategies for patients with pulmonary hypertension in the intensive care unit, Zamanian [/bib_ref] [bib_ref] Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS, Carvalho [/bib_ref] [bib_ref] Response to inhaled nitric oxide in patients with acute right heart syndrome, Bhorade [/bib_ref] [bib_ref] The incidence and pathogenesis of cardiopulmonary deterioration after abrupt withdrawal of inhaled..., Christenson [/bib_ref] Perform monitoring with a PAC (a volumetric PAC, if available). [bib_ref] The role of invasive techniques in cardiopulmonary evaluation, Backer [/bib_ref] Prevent hypervolemia (reverse Bernheim effect), promote a negative fluid balance. [bib_ref] Management strategies for patients with pulmonary hypertension in the intensive care unit, Zamanian [/bib_ref] Favor the use of a low PEEP (< 10cmH 2 O) and a Vt of 6 mL/kg predicted weight or lower. [bib_ref] Management strategies for patients with pulmonary hypertension in the intensive care unit, Zamanian [/bib_ref] Prevent hypoxemia (it increases pulmonary vascular resistance caused by hypoxic vasoconstriction). [bib_ref] Management strategies for patients with pulmonary hypertension in the intensive care unit, Zamanian [/bib_ref] Prevent severe hypercapnia (it increases RV afterload). [bib_ref] Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS, Carvalho [/bib_ref] Consider using dobutamine at low doses (to prevent tachycardia) or milrinone. [bib_ref] Management strategies for patients with pulmonary hypertension in the intensive care unit, Zamanian [/bib_ref] Use nitric oxide/sildenafil testing associated with monitoring with a PAC or transthoracic echocardiography. In centers where nitric oxide is unavailable, a therapeutic trial of sildenafil can be used. [bib_ref] Response to inhaled nitric oxide in patients with acute right heart syndrome, Bhorade [/bib_ref] Avoid abrupt withdrawal of inhaled nitric oxide. [bib_ref] The incidence and pathogenesis of cardiopulmonary deterioration after abrupt withdrawal of inhaled..., Christenson [/bib_ref] Consider kidney ultrafiltration for achieving a negative fluid balance in situations of refractoriness to diuretics. [bib_ref] Treatment of diuretic resistant cor pulmonale by continuous arteriovenous haemofiltration, Rowe [/bib_ref] PAC: pulmonary artery catheter; PEEP: positive end-expiratory pressure; Vt: tidal volume; and RV: right ventricular. 473 http://dx.doi.org/10.1590/S1806-37132014000500003 and/or in the saliva swallowing test, to evaluate the occurrence of discharge of blue saliva and/or secretions through the tracheostomy, characterizing an aspiration event. [bib_ref] Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of..., Donzelli [/bib_ref] [bib_ref] Simultaneous modified barium swallow and blue dye tests: a determination of the..., O&apos;neil-Pirozzi [/bib_ref] [bib_ref] The accuracy of the modified Evan's blue dye test in predicting aspiration, Belafsky [/bib_ref] Suggestion -Assess for signs and symptoms of dysphagia during the delivery of oral nutrition, especially those that may be associated with bronchial aspiration, such as choking, cough, and wet voice. [bib_ref] Wet voice" as a predictor of penetration and aspiration in oropharyngeal dysphagia, Warms [/bib_ref] [bib_ref] Evaluating swallowing dysfunction using a 100-ml water swallowing test, Wu [/bib_ref] Suggestion -Discuss with the medical team the use of xerostomic medications in patients on MV and/or with tracheostomy who do not tolerate cuff deflation or who experience significant aspiration of saliva. [bib_ref] Tratamento medicamentoso da sialorreia, Santoro [/bib_ref] Suggestion -Perform direct and indirect swallowing therapy in patients who have dysphagia and/or are at risk for aspiration. [bib_ref] Programas de reabilitacao em disfagia neurogenica. Sao Paulo: Frontis Editorial, Furkim [/bib_ref] Nursing care in patients receiving invasive or noninvasive ventilatory support Comment -The nursing team, as part of the multidisciplinary ICU team, actively participates in the administrative and healthcare activities involving invasive and noninvasive support in MV patients.

## Mechanical ventilation in patients with left ventricular failure

## Care of circuits, filters, and humidifiers
Recommendation -Maintain the lower airways warm and moist during MV.
Recommendation -Replace (hygroscopic and hydrophobic) heat and moisture exchangers every 7 days, provided that appropriate height and positioning of the devices relative to the endotracheal tube are maintained (the devices should be connected vertically to the tube and the circuit so that they are not flooded with droplets and dirt). If there is dirt, condensation, or damage, the filter should be replaced. [bib_ref] Efficacy of heat and moisture exchangers in preventing ventilator-associated pneumonia: meta-analysis of..., Kola [/bib_ref] Recommendation -Do not replace the mechanical ventilator circuit routinely; replace it only when there is dirt visible to the naked eye, when there is damage, or in cases of prolonged ventilation (> 30 days). [bib_ref] Periodically changing ventilator circuits is not necessary to prevent ventilator-associated pneumonia when..., Lorente [/bib_ref] [bib_ref] Effect of frequency of ventilator circuit changes (3 vs 7 days) on..., Samransamruajkit [/bib_ref] Cleaning and maintenance of the equipment Government Gazette) on December 9, 2008. In a multidisciplinary team, the speech-language pathologist evaluates the safety of oral feeding/ swallowing and manages swallowing difficulties, thereby contributing to the prevention of aspiration pneumonia and to the tracheostomy weaning process.
Suggestion -Request a speech-language pathology evaluation [bib_ref] Swallowing disorders in patients with prolonged orotracheal intubation or thacheostomy tubes, Devita [/bib_ref] [bib_ref] Pulmonary aspiration in mechanically ventilated patients with tracheostomies, Elpern [/bib_ref] [bib_ref] Incidence and type of aspiration in acute care patients requiring mechanical ventilation..., Leder [/bib_ref] [bib_ref] Characteristics of dysphagia in elderly patients requiring mechanical ventilation, Davis [/bib_ref] [bib_ref] Incidence and impact of dysphagia in open-label, randomized, controlled trial, Barker [/bib_ref] [bib_ref] The incidence of dysphagia following endotracheal intubation: a systematic review, Skoretz [/bib_ref] [bib_ref] Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness..., Macht [/bib_ref] for all patients who required OTI  48 hours, for patients who underwent repeated OTI, and for those with tracheostomy (whether or not they are mechanically ventilated).
Recommendation -Regarding the timing for speech-language pathology evaluations after extubation, it is recommended that patients be evaluated 24 [bib_ref] Alteration in swallowing reflex after extubation in intensive care unit patients, De Larminat [/bib_ref] to 48 hours after extubation and that those who have dysphagia and are at risk for aspiration be started on speech therapy. [bib_ref] Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management, Ajemian [/bib_ref] [bib_ref] Swallowing disorders post orotracheal intubation in the elderly, El Solh [/bib_ref] [bib_ref] Routine evaluation for aspiration after thoracotomy for pulmonary resection, Keeling [/bib_ref] [bib_ref] Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized,..., Barquist [/bib_ref] [bib_ref] Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in..., Leder [/bib_ref] Suggestion -Do NOT perform speech-language therapy in orotracheally intubated patients, because there is a lack of clinical evidence regarding its benefits to the swallowing function; however, early identification of patients who, even during OTI, have several associated risk factors that may compromise swallowing dynamics (patients with cardiovascular disease, patients with Parkinson's disease, post-stroke patients, and patients with dementia) is indicated.
Suggestion -Perform clinical speech-language evaluations (structural and functional) at the bedside [bib_ref] Incidence and impact of dysphagia in open-label, randomized, controlled trial, Barker [/bib_ref] and determine the need for instrumental examination of swallowing (functional nasal fiberoptic endoscopy and modified barium swallow test).Suggestion -The speech-language pathologist should define the type of food consistency and the need for the use of thickeners for the administration of fluids, in collaboration with the Nutrition Service, when the patient is ready to initiate oral intake.
Suggestion -Fit a speaking valve into the mechanical ventilator circuit or directly into the tracheostomy, with the aid of a physical therapist and/or a physician, provided that cuff deflation is feasible and patient tolerance is assessed. [bib_ref] Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow..., Suiter [/bib_ref] Suggestion -In tracheostomized patients, use a blue food dye in the food delivered orally homogeneously distributed in the trachea. Pay attention to lesions in the oral cavity, in the corners of the lips, and on the face. [bib_ref] Prone positioning in severe acute respiratory distress syndrome, Guerin [/bib_ref] Recommendation -The precautions to be followed during patient repositioning and while tilting the patient laterally in a bed bath are described in Chart 10. [bib_ref] Prone postioning in acute respiratory distress syndrome (ARDS): when and how, Roche-Campo [/bib_ref] Recommendation -In patients being placed in the prone position, it is recommended that the procedure be performed in the presence of at least five members of the ICU team, including at least one physician and one nurse. The skin of the frontal region, nose, knees, iliac crest, genitalia, and nipples should be protected. Patient rotation should be performed in two steps, with total attention being paid to the invasive devices. The dorsal electrocardiogram should be monitored, and the reverse Trendelenburg position may be used to decrease facial edema. [bib_ref] Prone positioning in severe acute respiratory distress syndrome, Guerin [/bib_ref] [bib_ref] Prone postioning in acute respiratory distress syndrome (ARDS): when and how, Roche-Campo [/bib_ref] Recommendation -Use a closed suctioning system to perform tracheal suctioning in hemodynamically unstable patients, in order to prevent desaturation in at-risk patients (i.e., patients with cardiovascular disease) and to maintain alveolar recruitment and prevent atelectasis in ARDS patients receiving PEEP  10 cmH 2 O. The system should be changed every 7 days. Closed suctioning systems have not been shown to reduce the occurrence of ventilatorassociated pneumonia, mortality, or ICU length of stay, when compared with open systems. [bib_ref] Clinical review: airway hygiene in the intensive care unit, Jelic [/bib_ref] Specific instructions for oral hygiene, oral feeding, and enteral feeding Recommendation -It is recommended that oral hygiene with brushing be performed every 12 hours, with an aqueous solution containing 0.12% chlorhexidine gluconate. In the intervals, oral hygiene should be performed with distilled or filtered water and/or alcohol-free mouthwash four times/day. [bib_ref] Clinical review: airway hygiene in the intensive care unit, Jelic [/bib_ref] Recommendation -Check the cuff pressure of the endotracheal tube or tracheostomy before performing oral hygiene. [bib_ref] Clinical review: Early patient mobilization in the ICU, Hodgson [/bib_ref] Recommendation -The gastric and postpyloric routes can be used for enteral feeding in MV patients, with post-pyloric tube placement being reserved for patients with gastric intolerance and/or contraindication.Recommendation -Secure the nasogastric tube with a securing device (a commercially available nasal bridle or an adhesive device) in hypochlorite and a contact time of 60 minutes) or sterilization. [bib_ref] Impact of an oil-based lubricant on the effectiveness of the sterilization processes, Rutala [/bib_ref] 

## Precautions during bed bath and patient repositioning
Recommendation -Assess the vital signs, analyze and record the MV parameters (ventilation mode, peak pressure, PEEP, f, Vt, and FIO 2 ), and check the alarms and clinical parameters before a bed bath and before patient repositioning. Continue cardiac monitoring and SatO 2 monitoring during the bed bath and during patient repositioning. Allow a 5-to 10-minute equilibrium period before determining hemodynamic intolerance/ instability due to patient repositioning and/or a bed bath. [bib_ref] Wash and wean: bathing patients undergoing weaning trials during prolonged mechanical ventilation, Happ [/bib_ref] [bib_ref] Clinical review: Early patient mobilization in the ICU, Hodgson [/bib_ref] Recommendation -Work with the multidisciplinary team to determine the most appropriate time to perform a bed bath in critically ill, clinically unstable patients. The nurse should assess the patient before allowing the bath, postponing it in cases of severity that can compromise patient safety.
Recommendation -Perform patient repositioning every 2 hours, with a lift sheet and at least two nursing professionals. [bib_ref] Manual turns in patients receiving mechanical ventilation, Winkelman [/bib_ref] Suggestion -Perform continuous lateral rotation therapy with the use of a bed for kinetic therapy, when available. [bib_ref] Head-of-bed elevation in critically ill patients: a review, Metheny [/bib_ref] Recommendation -Maintain the head of the bed between 30o and 45o in MV patients. The evidence is conflicting as to aspiration of gastric content (45o) and pressure ulcers (30o). Positioning at 30 is preferred as long as it does not pose risks to or cause conflict with medical and nursing procedures. [bib_ref] Acoes de enfermagem para a prevencao da extubacao acidental, Castelloes [/bib_ref] Suggestion -Use the beach chair position 2 to 4 times/day; it requires less personnel than do other interventions and therefore allows early mobility of ICU patients and improvement in pulmonary function.Recommendation -Maintain the cuff pressure of the endotracheal tube between 18 and 22 mmHg or between 25 and 30 cmH 2 O (cuff meter) in order to prevent air leaks without excessive compression of the tracheal mucosa. Avoid cuff pressures > 22 mmHg or 30 cmH 2 O. Check the cuff pressure at least 4 times/day and before performing oral hygiene.
Recommendation -Maintain the endotracheal tube secured and centralized by using an adhesive device or a shoelace so that the cuff pressure is 475 http://dx.doi.org/10.1590/S1806-37132014000500003 ICU and hospital length of stay, hospital costs, and mortality. [bib_ref] ICU early physical rehabilitation programs: financial modeling of cost savings, Lord [/bib_ref] 

## Physical therapy maneuvers and approaches in mechanically ventilated patients
Recommendation -Bronchial hygiene therapy (positioning, manual inflation, vibration, and chest compression): indicated in patients with increased Raw due to the presence of secretions, causing asynchrony of MV and/or reduced oxygenation; and mandatory in lobar atelectasis. [bib_ref] Physiotherapy in intensive care: an updated systematic rewiew, Stiller [/bib_ref] Suggestion -Lung expansion techniques can be used in the presence of lung collapse, with reduced compliance and oxygenation.Recommendation -Perform inspiratory muscle training in patients with inspiratory muscle weakness who are undergoing prolonged MV, in order to improve muscle strength. The role of inspiratory muscle training in reducing duration of MV and successfully discontinuing MV has yet to be established. [bib_ref] Analysis of standing up and sitting down in humans: definitions and normative..., Kralj [/bib_ref] 

## Early mobilization in noninvasive and invasive mechanical ventilation
Recommendation -Early mobilization should be initiated less than 72 hours following the initiation of mechanical ventilation, because it is feasible, safe, and results in significant functional benefits. [bib_ref] Physiotherapy in intensive care: an updated systematic rewiew, Stiller [/bib_ref] Suggestion -Neuromuscular electrical stimulation and a cycle ergometer can be considered as a complement to the early mobilization program. [bib_ref] Analysis of standing up and sitting down in humans: definitions and normative..., Kralj [/bib_ref] Suggestion -Training for transfer from sitting to standing can be included in the treatment plan and precede ambulation, taking the correlation with functional limitation into account, as consensually determined by the multidisciplinary team. [bib_ref] Comprehensive geriatric asssesment for older hospital patients, Ellis [/bib_ref] Suggestion -Intervention in functional decline can be used to increase the chances of a return to independent performance of activities of daily living after discharge. [bib_ref] Comprehensive geriatric asssesment for older hospital patients, Ellis [/bib_ref] Nutritional care in mechanically ventilated patients Determination of caloric needs Suggestion -Use indirect calorimetry or predictive formulas (equations or a pocket formula) order to reduce the rate of unintentional tube dislodgement. [bib_ref] Nasal bridling decreases feeding tube dislodgment and may increase caloric intake in..., Seder [/bib_ref] Suggestion -Monitor the difference between prescribed and delivered enteral nutrition as a marker of dietary compliance. [bib_ref] Enteral nutrition discontinuation and outcomes in general critically ill patients, Silva [/bib_ref] Physical therapy care in patients on ventilatory support Comments -ICU patients may experience respiratory and muscle dysfunction and, over time, develop neuromuscular weakness and complications of immobility, which can make discontinuation of MV difficult. Prolonged immobility leads to loss of motor function and loss of quality of life, both of which can be minimized with the institution of early mobilization and respiratory care. The incidence of ICU-acquired muscle weakness (neuromuscular weakness) in patients requiring prolonged MV ranges from 25 to 60%, [bib_ref] Diagnosis and treatment in physical therapy: an invetigation of their relationship, Dekker [/bib_ref] which contributes to increasing ICU and hospital length of stay. Physical therapy works to maintain and/or restore the functionality of the patient by preventing musculoskeletal changes and respiratory complications.
Recommendation -A physical therapy diagnosis should precede any intervention. [bib_ref] Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay,..., Castro [/bib_ref] Recommendation -Physical therapy in MV patients in the ICU should be delivered 24 hours/ day, having benefits in reducing duration of MV, Chart 10 -Precautions during patient repositioning and while tilting the patient laterally in a bed bath. Visualize all of the stretchers and equipment that are connected to the patient. Be careful not to pull the mechanical ventilator circuit during head-of-bed elevation, lateral tilting for patient repositioning and/or a bed bath, in order to prevent accidental extubations. Check whether the ventilatory device is fixed; release the ventilator circuit from the rack. Maintain the head of the bed at 30o. Pull the patient up in bed, keeping your eyes on the ventilator. Tilt the patient laterally with his/her head supported by the headrest. Perform hygiene of the patient's back and buttocks, most of it already with the patient placed in the lateral decubitus position, facing the side where the ventilator is. Elevate the head of the bed and fix the circuit to the ventilator rack loosely so that, if the patient is moved in bed, the ventilator circuit is not pulled. Strategy to optimize delivery of enteral nutrition and minimize risks in mechanically ventilated patients [bib_ref] Optimizing the benefits and minimizing the risks of enteral nutrition in the..., Heyland [/bib_ref] Elevation of the head of the bed

## Recommendation -
The head of the bed should be maintained between 30 o and 45 o , unless there is a contraindication, for all intubated patients receiving EN. [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] [bib_ref] Impact of patient position on the incidence of ventilatorassociated pneumonia: a meta-analysis..., Alexiou [/bib_ref] Tube placement for nutrition Recommendation -Two routes (gastric and/ or post-pyloric) should be considered in MV patients, with post-pyloric tube placement being reserved for patients with gastric intolerance and/or contraindication. [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] to determine the caloric needs of critically ill MV patients. Indirect calorimetry should be considered when available, but it is necessary to take the patient's clinical status into account, as well as the frequency it will be used. There is not enough evidence to indicate that any of the available formulas in the literature is superior to the others. [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Estimating energy needs in nutrition support patients, Frankenfield [/bib_ref] [bib_ref] Impact of energy deficit calculated by a predictive method on outcome in..., Faisy [/bib_ref] [bib_ref] Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill..., Weijs [/bib_ref] Chart 11 suggests the formulas most commonly used in daily practice.
Recommendation -Initiate the enteral diet by delivering a small amount (20 to 25% of the target dose) and progressively increase it until achieving the target dose within 48 to 72 hours, in order to avoid the risk of refeeding syndrome. Before each increase, assess tolerability.

## Determination of protein needs
Suggestion -Determine the amount of protein for MV patients on the basis of their BMI, [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Estimating energy needs in nutrition support patients, Frankenfield [/bib_ref] [bib_ref] Impact of energy deficit calculated by a predictive method on outcome in..., Faisy [/bib_ref] [bib_ref] Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill..., Weijs [/bib_ref] [bib_ref] Nutritional support for patients with acute kidney injury: how much protein is..., Krenitsky [/bib_ref] as shown in Chart 12.
Suggestion -Individualize the protein needs for critically ill MV patients with acute renal dysfunction. An important aspect to consider is that these patients should not receive a proteinrestricted diet as a means to prevent or delay renal replacement therapy. Consider that patients on renal replacement therapy experience a significant loss of amino acids (10 to 15 g) during a dialysis session. [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Estimating energy needs in nutrition support patients, Frankenfield [/bib_ref] [bib_ref] Impact of energy deficit calculated by a predictive method on outcome in..., Faisy [/bib_ref] [bib_ref] Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill..., Weijs [/bib_ref] [bib_ref] Nutritional support for patients with acute kidney injury: how much protein is..., Krenitsky [/bib_ref] [bib_ref] Influence of different routes of nutrition on the respiratory muscle strength and..., Chen [/bib_ref] In patients who are not candidates for dialysis, special diets formulated for nephropathic patients can be used.

## Routes of administration
Recommendation -Use the enteral route as the primary option, whenever there is viability of the gastrointestinal tract. [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Early enteral nutrition in acutely ill patients: a systematic rewiew, Marick [/bib_ref] Suggestion -Avoid using parenteral nutrition in critically ill MV patients until all strategies to optimize enteral nutrition (EN) have been attempted.

## Early enteral nutrition
Recommendation -Initiate early EN (within 24 to 48 hours after admission to the ICU), provided that the patient is hemodynamically stable. Early EN therapy has been shown to reduce the mortality rate in critically ill MV patients and has been associated with a reduction in infectious complications and hospital length of stay. [bib_ref] Analysis of standing up and sitting down in humans: definitions and normative..., Kralj [/bib_ref] [bib_ref] Comprehensive geriatric asssesment for older hospital patients, Ellis [/bib_ref] [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Early enteral nutrition in acutely ill patients: a systematic rewiew, Marick [/bib_ref] [bib_ref] Early enteral nutrition, provided within 24 h of injury or intensive care..., Doig [/bib_ref] 

## Phosphorus replacement
Suggestion -Correction of phosphorus deficit is desirable in MV patients. This is justified by the association between hypophosphatemia and failure to discontinue MV. [bib_ref] Association of hypophosphatemia with failure-to-wean from mechanical ventilation, Alsumrain [/bib_ref] Suggestion -Consider gastrostomy or jejunostomy in MV patients requiring EN < 4 weeks, according to the patient's clinical status. [bib_ref] Nutrition management for the patient requiring prolonged mechanical ventilation, Doley [/bib_ref] Monitoring of gastric residuals in mechanically ventilated patients Recommendation -Do not use monitoring of gastric residual volumes in MV patients with the aim of preventing ventilator-associated pneumonia. [bib_ref] Impact of not measuring residual gastric volume in mechanically ventilated patients receiving..., Poulard [/bib_ref] As a positive effect, early EN without monitoring of gastric residuals in MV patients has been shown to improve delivery of EN.

## Continuous enteral nutrition compared with other methods
Suggestion -The continuous method using an infusion pump [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] can be used in critically ill MV patients with intolerance to EN.

## Establishing a nutritional therapy protocol
Suggestion -Guidelines can be implemented in the facility to optimize EN in MV patients, in order to mitigate the calorie-protein deficit. [bib_ref] Implementation of a nutrition support protocol increases the proportion of mechanically ventilated..., Mackenzie [/bib_ref] Suggestion -Prokinetic agents (preferably metoclopramide) can be used to improve tolerance, in order to attain the enteral caloric goal. [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] 

## Specific care
Lipid-rich, carbohydrate-poor diet Suggestion -(Lipid-rich, carbohydratepoor) formulations designed to manipulate the respiratory quotient and reduce CO 2 production can be used in selected patients (COPD patients with CO 2 retention, patients with severe ARDS and permissive hypercapnia receiving borderline protective ventilation, those with CO 2 retention undergoing difficult or prolonged weaning). Efforts should be made to prevent excess total calories. [bib_ref] Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for..., Heyland [/bib_ref] [bib_ref] Nutritionally associated increased carbon dioxide production. Excess total calories vs high proportion..., Talpers [/bib_ref] Enteral feeding enriched with fish oil, borage oil, antioxidant vitamins Suggestion -Enteral formulations with an anti-inflammatory lipid profile and with oxidants can be used in MV patients with ARDS. [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid..., Singer [/bib_ref] [bib_ref] NIH NHLBI Acute Respiratory Distress Syndrome Network of Investigators. Enteral omega-3 fatty..., Rice [/bib_ref] [bib_ref] Effects of enteral feeding with eicosapentaenoic acid, gammalinolenic acid, and antioxidants in..., Pontes-Arruda [/bib_ref] High doses of omega-3 should be avoided in patients who have coagulation disorders. [bib_ref] ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral..., Kreymann [/bib_ref] [bib_ref] Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid..., Singer [/bib_ref] [bib_ref] NIH NHLBI Acute Respiratory Distress Syndrome Network of Investigators. Enteral omega-3 fatty..., Rice [/bib_ref] [bib_ref] Effects of enteral feeding with eicosapentaenoic acid, gammalinolenic acid, and antioxidants in..., Pontes-Arruda [/bib_ref] 
[fig] PaO 2: partial pressure of oxygen; FIO 2 : fraction of inspired oxygen; and PEEP: positive end-expiratory pressure. [/fig]
[fig] Figure 1 -: Use of noninvasive ventilation for discontinuation of mechanical ventilation. SBT -spontaneous breathing trial; NIV -noninvasive ventilation; COPD -chronic obstructive pulmonary disease; RF -acute or exacerbated respiratory failure. [/fig]
[fig] Figure 2 -: Hemodynamic management algorithm in mechanically ventilated patients. LV: left ventricular; RV: right ventricular; MV: mechanical ventilation; PEEP: positive end-expiratory pressure. [/fig]
[table] Chart 5 -: How to perform the endotracheal tube cuff-leak test in mechanically ventilated patients. 1. Before performing the cuff-leak test, perform suctioning of tracheal and oral secretions and set the ventilator to assist-control mode (VCV). 2. With the cuff inflated, record Vti and Vte and observe whether they are similar. 3. Deflate the cuff. 4. Record Vte during six consecutive breaths; observethat Vte will reach a plateau after the first breaths. 5. With the cuff deflated, Vte is expected to be < 90% of (the preset) Vti, situation in which the test is considered adequate. [/table]