Inappropriate interactions between the ventilator and patient are referred to as patient–ventilator asynchrony. This is a mismatch between what the patient desires in breath and what the ventilator provides. Detecting asynchrony at the bedside requires a rigorous examination of the flow and airway pressure waveforms and a clinical examination of the patient's breathing pattern. Unfortunately, many asynchronies are treated with sedation before a thorough graphical analysis of the ventilator waveforms and clinical assessment are conducted. It is well known that the overuse of sedatives leads to a longer duration of mechanical ventilation. This lecture will explore how to identify the various asynchronies and discuss methods to optimize patient-ventilator synchrony, emphasizing using sedation as a last resort.

The evidence-based approach to lung protective ventilation has evolved with recent updates to the management of ARDS published in 2023. Though the application of these guidelines can and should be broadly applied in patients with ARDS, recent research points towards potential mechanisms of injury despite the application of these lung protective strategies as well as the possible benefits of individualizing the approach to mechanical ventilation in ARDS. Evidence for individualization of tidal volume, plateau pressure and PEEP to enhance a protocolized lung protective approach will be discussed.

There is a lack of consideration for patients’ physiology when they are systematically weaned from mechanical ventilation, a process colloquially known as a trach collar trial. Often, a time-goal is applied, with periodic patient assessments conducted during the patient’s removal from the ventilator. However, a prescribed time goal may underestimate the patient's ability to be liberated from mechanical ventilation, potentially prolonging recovery. This lecture will discuss the potential use of non-invasive bedside imaging to guide the liberation of tracheostomized patients from mechanical ventilation in the intensive care setting.

Much controversy remains about the setting of PEEP in patients with ARDS. PEEP can be set based on population studies or individualized based on the use of techniques such as esophageal manometry and electrical impedance tomography. The debate will address the issues related to these approaches.