Volutrauma and driving pressure travel. A 45-minute rotor ride at 10 mL/kg is a second hit.
Targets that travel
Adults: VT ≈ 6 mL/kg PBW (4–8), Pplat ≤30 (ARDSNet / ATS). ARDS: SpO2 88–95 or PaO2 55–80 and PEEP from the FiO2 table. Other adults: this trainer uses 92–96% (avoid hyperoxia — not BTS 94–98). 88–92% if COPD / chronic hypercapnia (BTS). TBI: BTF 35–45. PALICC-2 children: 6–8 mL/kg if PIP ≤28 or ΔP ≤15; 4–6 if those pressures cannot be met. SpO2 92–97%. Permissive hypercapnia is fine while pH stays ≥ 7.15–7.20 (not if they are herniating).
Driving pressure
ΔP ≈ Pplat − total PEEP (set PEEP + AutoPEEP) ≈ VT / Cstat. Amato 2015 associated ΔP >14–15 with worse outcome. ATS 2024 mentions driving pressure; it does not strongly recommend a 14 cmH2O target. This trainer still scores adults at ΔP ≤14 so you notice strain early. If Cstat is 20, a 480 mL breath is already a ΔP of 24 — cut the breath. Do not chase 6 mL/kg through a brick wall.
Open the paperPEEP
ARDSNet: PEEP is not a vibe — it is a pair with FiO2 (lower table ARMA, higher table ALVEOLI for moderate–severe). ATS 2024 recommends against prolonged recruitment maneuvers. A 2 cm PEEP step is not a 40-second hold. If MAP tanks at higher-table PEEP, you stay on the lower table and you own that.
Spontaneous breathing
Prefer early assisted / SPONT when drive is back. NMB is conditional and short-term in early severe ARDS — not a transport default.
ASV
Recognize it. Do not default to it. If you inherit ASV, convert to PCV+ or (S)CMV+ at 6 mL/kg and a rate you can defend.