f VENT-CDSS 2026 | Ventilator Weaning, Troubleshooting, PEEP, Proning & ECMO Escalation

VENT-CDSS 2026

Ventilator weaning, troubleshooting, PEEP titration, proning and ECMO escalation support for adult ICU use.

Author: Prof. (Dr) Jyotirmay Kirtania | Copyright © 2026 | GNU GPL v3.0-or-later

Patient & Ventilator Data

Clinical safety: Bedside cognitive aid only. It does not replace consultant judgement, institutional protocol, ABG review, imaging, airway assessment or ECMO-centre discussion.

Daily focus

Enter current ventilator and patient data. The app will show the next safe bedside action.

Enter valid height: 90–230 cm.
Enter valid weight: 1–300 kg.

Primary indication(s) for mechanical ventilation

Current settings and monitoring

Calculated Dashboard

PBW
—
VT / PBW
—
P/F ratio
—
Driving pressure
—
BMI
—

Immediate interpretation

Enter data and press Calculate.

Weaning & Extubation: ISCCM 2024-aligned Workflow

Plan liberation from day 1 of mechanical ventilation, but start SBT only after preparedness criteria are met. The app separates ventilator liberation, extubation readiness, post-extubation support, and difficult-weaning evaluation.
Checklist completion
0%
Next bedside action
Enter data

Step 1 — Daily liberation screen

Step 2 — SBT and RSBI

Step 3 — Extubation safety screen

High-risk airway / stridor screen

Step 4 — Difficult-weaning evaluation before repeated SBTs

ARDS Rescue & Escalation Ladder

Use this screen when oxygenation is worsening or P/F ratio is below 300. Confirm ARDS, protect the lung, then escalate deliberately.

Berlin ARDS confirmation

Lung-protective bundle

Rescue readiness

Ventilator Troubleshooting

Unstable patient rule: call help, increase FiO₂ to 1.0, assess pulse/capnography/chest rise, and disconnect from ventilator for manual ventilation if ventilator/circuit failure or severe auto-PEEP is possible.

1. Immediate problem definition

2. Safety flags

3. Mechanics and waveform inputs

Bedside interpretation guide
PatternMost likely mechanismCommon causesFirst checks
Peak ↑, plateau unchangedResistanceKink/bite, secretions, bronchospasm, HME/filter obstruction, small ETT, water in circuitPass suction catheter, inspect tube/circuit/filter, bronchodilator, check ETCO₂
Peak ↑ and plateau ↑Compliance / total PEEPARDS/edema, atelectasis, pneumothorax, mainstem, pleural effusion, abdomen/obesity, auto-PEEPInspiratory pause, CXR/US, ETT depth, abdomen, expiratory hold
Flow not returning to zeroAuto-PEEPCOPD/asthma, high RR, short expiratory time, high minute ventilation, overbreathingReduce RR/VT, increase expiratory time, bronchodilate, sedation if needed
Double trigger / stacked breathsDyssynchrony with excessive neural inspiratory time or air hungerLow VT strategy with high drive, pain, acidosis, hypoxemia, inadequate flow/Ti settingsTreat cause of drive, optimize flow/Ti, avoid injurious delivered VT, call help if persistent
Absent ETCO₂ + collapseDisplacement / arrest / circuit failureExtubation, esophageal displacement, disconnect, cardiac arrestPulse check, bag with 100% O₂, tube position, circuit, call help

PEEP Titration Support

Aim for adequate oxygenation with lung protection: avoid derecruitment and overdistension; monitor plateau pressure, driving pressure, compliance, blood pressure and right-ventricular tolerance.

Response to recent PEEP change, if any

Proning Decision Support

Criteria

Contraindications / cautions

ECMO Escalation Screen

Severe respiratory failure criteria

Contraindications / risk modifiers

Notes, Audit Trail and Export

Evidence base & key references

Lung-protective ventilation & ARDS

  1. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8.
  2. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-55.
  3. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327-36.
  4. Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):637-45.
  5. Cavalcanti AB, Suzumura ÉA, Laranjeira LN, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318(14):1335-45.
  6. ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-33.
  7. Fan E, Del Sorbo L, Goligher EC, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-63.

Prone positioning

  1. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-68.
  2. Munshi L, Del Sorbo L, Adhikari NKJ, et al. Prone position for acute respiratory distress syndrome: a systematic review and meta-analysis. Ann Am Thorac Soc. 2017;14(Supplement_4):S280-8.

Neuromuscular blockade

  1. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107-16.
  2. National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380(21):1997-2008.

Weaning & liberation from mechanical ventilation

  1. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991;324(21):1445-50.
  2. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033-56.
  3. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-34.
  4. Schmidt GA, Girard TD, Kress JP, et al. Official executive summary of an American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017;195(1):115-9.
  5. Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position statement of ISCCM Committee on weaning from mechanical ventilator. Indian J Crit Care Med. 2024;28(S2):S233-48.
  6. Sengupta S, Chakravarty C, Rudra A. Evidence-based practice of weaning from ventilator: a review. Anaesthesia Tutorial of the Week 372; 6 Feb 2018. Available from: https://www.wfsahq.org/resources/anaesthesia-tutorial-of-the-week

PEEP titration & recruitment

  1. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327-36. [ARDSNet ALVEOLI trial]
  2. Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):646-55. [EXPRESS trial]
  3. Goligher EC, Kavanagh BP, Rubenfeld GD, et al. Oxygenation response to positive end-expiratory pressure predicts mortality in acute respiratory distress syndrome: a secondary analysis of the LOVS and ExPress trials. Am J Respir Crit Care Med. 2014;190(1):70-6.
  4. Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359(20):2095-104.
  5. Heunks L, van der Hoeven J, Strauch U, et al. How we approach titrating PEEP in patients with acute hypoxemic failure. Crit Care. 2023;27:415. doi: 10.1186/s13054-023-04694-1.

Fluid management in ARDS

  1. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-75. [FACTT trial]

ECMO for severe ARDS

  1. Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378(21):1965-75. [EOLIA trial]
  2. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351-63.
  3. Munshi L, Walkey A, Goligher E, et al. Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med. 2019;7(2):163-72.

Troubleshooting & ventilator emergencies

  1. Lucangelo U, Bernabè F, Blanch L. Respiratory mechanics derived from signals in the ventilator circuit. Respir Care. 2005;50(1):55-65.
  2. Tobin MJ. Advances in mechanical ventilation. N Engl J Med. 2001;344(26):1986-96.
  3. Peñuelas O, Frutos-Vivar F, Fernández C, et al. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med. 2011;184(4):430-7.
  4. Owens W. Ventilator management and troubleshooting in the emergency department. EM Crit Care. 2014;4(5):1-16.
  5. Steinbach TC, Albert TJ, Carmona HD, Johnson NJ, Kritek PA, Lee JD, et al. Just-in-time tools for training non-critical care providers: troubleshooting problems in the ventilated patient. ATS Scholar. 2020;1(2):178-85. doi: 10.34197/ats-scholar.2020-0038IN.

International guidelines

  1. Griffiths MJD, McAuley DF, Perkins GD, et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019;6(1):e000420.
  2. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426.
  3. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-247.
  4. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2026. Intensive Care Med. 2026. doi: 10.1007/s00134-026-08361-1.

Evidence grading & limitations: This tool synthesizes Level 1 evidence (RCTs, meta-analyses) and international guidelines. Individual patient factors may necessitate deviation from protocol recommendations. Clinical judgment and senior consultation remain paramount. All citations verified via primary sources as of May 2026.

Program: VENT-CDSS 2026. Author: Prof. (Dr) Jyotirmay Kirtania. Copyright: © 2026 Prof. (Dr) Jyotirmay Kirtania. License: GNU General Public License version 3.0 or later (GPL-3.0-or-later).