Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Updated Evidence-Based Recommendations for Choosing Modes and Setting Parameters of Mechanical Ventilation.

Invasive mechanical ventilation remains a cornerstone in the treatment of critically ill patients suffering from acute respiratory failure, providing life-sustaining gas exchange while necessitating careful selection of modes and settings to maximize benefit and minimize harm. This guideline-derived review synthesizes updated, critically appraised, and evidence-based recommendations on choosing ventilatory modes and setting key parameters in adults with acute respiratory insufficiency. Building on a systematic GRADE process and presented digitally in the MAGICapp, the 2025 guideline for the German, Austrian, and Swiss healthcare context retains a pragmatic taxonomy of ventilatory modes and updates several clinical recommendations. In invasively ventilated patients with moderate-to-severe ARDS, early neuromuscular blockade is no longer favored; instead, early assisted strategies that allow spontaneous breathing are suggested when clinically appropriate. Pressure-controlled, minute ventilation-supporting modes that enable spontaneous breathing during both inspiration and expiration may be considered in hypoxemic respiratory failure, acknowledging very low certainty of evidence and notable heterogeneity across trials. For the first time, our guideline issues recommendations on adaptive ventilation modes. Some adaptive modes (e.g., ASV/INTELLiVENT-ASV) and neurally adjusted ventilatory assist may be considered on a case-by-case basis, whereas flow- and volume-proportional assist ventilation (e.g., PAV/PAV+) is not recommended given low-certainty evidence and frequent intolerance. Parameter recommendations emphasize lung-protective ventilation with VT ≈ 6 mL/kg predicted body weight (range 4-8 mL/kg), a plateau pressure ≤30 cm H2O, and a driving pressure ≤14 cm H2O. Positive end-expiratory pressure should be higher in moderate/severe ARDS and individualized using bedside physiology, while oxygen targets of SaO2/SpO2 92-96% or PaO2 70-90 mm Hg balance hypoxemia and hyperoxia risks. Continuous cardiorespiratory monitoring and capnography for tube placement confirmation and trend assessment are endorsed. Collectively, these recommendations aim to support safe, effective, and implementable ventilatory care while transparently conveying where certainty of evidence remains limited.