Version May 2024
| Reduce both mean airway pressure and the number of positive-pressure breaths, using the lowest number of mechanical breaths that permits acceptable alveolar ventilation |
| Wean patient completely if possible |
| Partial ventilatory support (eg, low-rate SIMV or pressure support) is preferable to total ventilatory support (eg, assist/control, high-rate SIMV, or pressure control ventilation) |
| Avoid or correct respiratory alkalosis (to minimize minute ventilation) |
| Consider use of permissive hypercapnia (reducing minute ventilation and allowing arterial PCO2 to rise) |
| Limit effective (returned) tidal volume to 5 to 8 mL/kg |
| Minimize inspiratory time, and hence mean airway pressure: |
| Keep inspiration-to-expiration ratio low (eg, 0.33) |
| Use high inspiratory flow rate (eg, 70 to 100 L/min) |
| Avoid inflation hold (end-inspiratory pause) and inverse-ratio ventilation |
| Use low-compressible-volume (non-disposable) ventilator circuit |
| Minimize PEEP (both dialed-in and auto-PEEP) |
| Use least amount of chest tube suction that maintains lung inflation |
| If spontaneous movement exacerbates leak, keep patient heavily sedated (in unusual circumstances neuromuscular blockade may also be necessary) |
| Explore position differences, and avoid patient positions that increase the leak |
| Treat bronchospasm and other causes of expiratory airflow obstruction |
| Consider specific or unconventional measures (eg, independent lung ventilation, high-frequency jet ventilation, PEEP to chest tubes, etc) only if the air leak per se is clinically felt to be worsening the patient's condition (eg, intractable hypotension or arrhythmias in association with respiratory acidosis) |
| Treat underlying cause of respiratory failure, maintaining nutritional and other support, with goal of discontinuing mechanical ventilation as soon as possible |
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