Initial mechanical ventilation settings

Initial

• FiO2 100% (1.0) and ween down
• Rate 8-12/min
  • consider 5-6 for asthma w/ permissive hypercapnea
• Mode
  • A/C = default (most)
  • SIMV = with obstructive airway disease and an intact respiratory effort (e.g. some COPD, asthma)
  • PC = with intact respiratory effort and non-severe respiratory failure (prefered in chronic vent)
• PEEP 0-5 mmH20
• TV 5-8 cc/kg (eg. 500-600cc)
  • (adjust to plateau pressure <35 cmH20)
• I/E 1:2
• PS (pressure support) 5-8cm to overcome endotracheal tube

Initial ventilation settings

Disease	Tidal Volume (mL/kg^)	Respiratory Rate	I:E	PEEP	FiO2
Traditional	8	10-12	1:2	5	100%
Lung Protective (e.g. ARDS)	6	12-20	1:2	2-15	100%
Obstructive (e.g. bronchoconstriction)	6	5-8	1:4	0-5	100%
Hypovolemic	8	10-12	1:2	0-5	100%

^Ideal body weight

Lung Injury Strategy

Background

• Ok for all pts except for obstructed

Settings

• 1. Mode
  • Assist control Volume

• 2. Tidal Volume (lung protection)
  • Start 6-8cc/kg ideal body wt
    • Ideal body weight is used because a persons lung parenchyma does not increase in size as the person gains more weight.
    • Titrate down if peak pressure >30

• 3. Inspiratory Flow Rate (comfort)
  • More comfortable if higher rather than lower
  • Start at 60-80 LPM

• 4. Respiratory Rate (CO2)
  • Avg pt on ventilator requires 120mL/kg/min for eucapnia
  • Start 16-18 breaths/min
  • Maintain pH = 7.30-7.45

• 5. FiO2/PEEP (O2)
  • Move in tandem to achieve:
    • SpO2 BETWEEN 88-95%
    • PaO2 BETWEEN 55-80

FiO2	0.3	0.4	0.4	0.5	0.5	0.6	0.7	0.7	0.7	0.8	0.9	0.9	0.9	1.0	1.0	1.0
PEEP	5	5	8	8	10	10	10	12	14	14	14	16	18	20	22	24

Obstruction Strategy

Background

Goal = Adequate time for expiration

Settings

• 1. Mode
  • Assist Control Volume

• 2. Tidal Volume
  • Vt = 8 cc/kg ideal body wt

• 3. Inspiratory Flow Rate
  • Set at 80-100 LPM to allow more expiration time

• 4. FiO2/PEEP
  • Titrate FiO2 to desired SpO2
  • Set PEEP 0-4

• 5. Respiratory Rate
  • Set low - 10 BPM
  • Adjust for I:E 1:4 or 1:5
  • Permissive hypercapnia to avoid breath stacking
    • Ok as long as pH > 7.00-7.10
    • Maintain plateau pressure <30
      • If >30 go down on rate

Making Setting Changes

O2

• PaO2 (ween to SaO2 >90% and PaO2 >60)
• FiO2 (ween to <0.5 if poss)
• PEEP (see ARDS schedule; if >10, should have arterial line)
  • (rule of 7s: decrease 1 FiO2 = 7 pO2)

CO2

• PCO2
  • TV
  • Rate
• (VE-1 x pCO2-1 = VE-2 x pCO2-2)
  • VE = minute ventilation (RR x TV)

pH

to increase pH 0.01 --> decrease pCO2 by 1

MISC (normally already set)

• Inspiratory flow rate = 60L/min (100L/min with asthma)
• Sensitivity = 1-2 cmH2O

See Also

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation