Mechanical ventilation in obese patients according to the i-STAR Algorithm

Intubate

 • Anticipate difficult airway management and difficult mask ventilation 

 • Preoxygenate with Fi02100% and non-invasive positive pressure ventilation 

 • Fluids and vasoactive drugs readily available for possible haemodynamic impairment 

Set - Up Initial Ventilation 

 • Tidal volume: 4-6 mL'kg PBW in ARDS, 6-8 mL4(g in non-ARDS, volume controlled/guarantee modes 

 • Low-moderate PEEP (ARDSnet low-PEEP table in ANDS, start with 5 cmH20 in non-ARDS) 

 • Gradually lower Fi02 (to target normoxya in ARDS and non-ARDS) 

Titrate Ventilation Parameters 

 • Respiratory rate: to keep pHa > 7.25 in non-ARDS and ARDS, tolerate mild hypercapnia in ARDS 

 • PEEP: minimal to keep PaO2 55-80 mmHg or SatO2 88-92% in ARDS and non ARDS, no routine recruitment 

 • FiO2: avoid hyperoxia, if desaturation prioritise FiO2 increase over PEEP increase 

Assess Harmfulness of Ventilation 

 • Plateau pressure: target below 27 cmH20 + (IAP - 13)/2 in ARDS, 20 cmH2O + (IAP - 13)/2 in non-ARDS 

 • Driving pressure (plateau-PEEP): target below 17 cmH2O in ARDS and 15 cm H2O in non-ARDS 

 • Mechanical power: target below 17-20 J/m 

Rescue Strategies 

 • Recruitment Maneuvers: only as rescue, stepwise increase in airway pressure 

 • Prone positioning: also safe and feasible in obese ARDS 

 • ECMO: consider in selected ARDS patients 



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