2024-2025 © Uva Clinical Anaesthesia and Intensive Care ISSN 2827-7198 / ICU / Mechanical Ventilation 2024-2025 © Uva Clinical Anaesthesia and Intensive Care ISSN 2827-7198 / ICU / Mechanical Ventilation 2024-2025 © Uva Clinical Anaesthesia and Intensive Care ISSN 2827-7198 / ICU / Mechanical Ventilation 1 Comprehensive Strategies for Ventilator Management: Indunil Karunarathna 1 , N Perera 1 , S Gunathilake 1 , Kapila De Alvis 1 , K Gunawardana 1 , S Rajapaksha 1 , A Warnakulasooriya 1 , P Athulgama 1 , Sanjeewa Dius 1 , R Ranwala 1 , Sau Bandara 1 , Sanjaya Godage 1 , PN Rodrigo 1 , Asoka Jayawardana 1 , U Vidanagama 1 , C Fernando 1 , U Ekanayake 1 , T Hapuarachchi 1 , P Gunasena 1 , P Aluthge 1 , 1. Ministry of Health / Teaching Hospital Badulla / University of Colombo. 2024-2025 © Uva Clinical Anaesthesia and Intensive Care ISSN 2827-7198 / ICU / Mechanical Ventilation Abstract: Mechanical ventilation is a cornerstone of critical care, essential for managing patients with respiratory failure and acute lung injury. This review explores the clinical significance of various ventilatory strategies, including lung-protective, obstructive, and intermediate approaches, emphasizing their application in diverse patient populations. The lung-protective strategy focuses on minimizing ventilator-induced lung injury (VILI) through low tidal volume ventilation, optimizing PEEP, and mitigating alveolar overdistension. In contrast, the obstructive strategy is designed to accommodate prolonged exhalation in conditions such as asthma and COPD to prevent auto-PEEP and dynamic hyperinflation. The intermediate strategy, which allows moderate tidal volumes, is useful in patients without ARDS or obstructive pathology. Beyond ventilation strategies, this review highlights adjunctive measures crucial to optimizing patient outcomes. These include sedation management, spontaneous breathing trials, venous thromboembolism prophylaxis, gastrointestinal protection, airway maintenance, and ventilator bundle implementation to prevent ventilator-associated pneumonia (VAP). The role of an interprofessional healthcare team, including respiratory therapists, intensivists, and nursing staff, is emphasized in ensuring precise ventilatory adjustments, monitoring for complications, and improving patient safety. This article provides evidence-based recommendations for ventilator management and explores key challenges, including the balance between lung protection and adequate oxygenation, the risk of hemodynamic compromise, and complications associated with prolonged mechanical ventilation. By integrating best practices from recent trials and guidelines, this comprehensive review aims to support clinicians in optimizing mechanical ventilation strategies for critically ill patients. Key Words: Mechanical ventilation, Lung-protective strategy, Obstructive lung disease, Acute respiratory distress syndrome (ARDS), Auto-PEEP, Ventilator-induced lung injury (VILI), Plateau pressure, Driving pressure, Ventilator- associated pneumonia (VAP), Sedation in critical care, Spontaneous breathing trials, Pulmonary compliance, Permissive hypercapnia, Respiratory failure, Dynamic hyperinflation Key Points Lung-Protective Strategy: Essential for ARDS and acute lung injury patients, involving low tidal volume ventilation (6 mL/kg IBW) and controlled PEEP to prevent VILI. Obstructive Strategy: Designed for COPD and asthma patients, emphasizing prolonged expiratory time, permissive hypercapnia, and minimizing auto-PEEP. Intermediate Strategy: Suitable for patients without lung injury or obstructive disease, utilizing moderate tidal volumes (8–10 mL/kg) without significant compromise in oxygenation. PEEP/FiO2 Protocol: Incremental PEEP adjustments based on ARDSnet guidelines help optimize oxygenation while preventing alveolar collapse. Sedation Management: An analgesia-first approach, with fentanyl or propofol, minimizes agitation and promotes ventilator synchrony.