Initial mechanical ventilation settings: Difference between revisions
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== Initial == | ==Overview== | ||
{{Initial ventilation settings table}} | |||
==Traditional== | |||
*FiO2 100% (1.0) and ween down | *FiO2 100% (1.0) and ween down | ||
*Rate 8-12/min | *Rate 8-12/min | ||
**consider 5-6 for asthma | **consider 5-6 for asthma with permissive hypercapnea | ||
*[[Ventilation (Main)|Mode]] | *[[Ventilation (Main)|Mode]] | ||
**A/C = default (most) | **A/C = default (most) | ||
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**PC = with intact respiratory effort and non-severe respiratory failure (prefered in chronic vent) | **PC = with intact respiratory effort and non-severe respiratory failure (prefered in chronic vent) | ||
*PEEP 0-5 mmH20 | *PEEP 0-5 mmH20 | ||
* | *Tidal volume: 5-8 cc/kg (eg. 500-600cc) | ||
**(adjust to plateau pressure <35 cmH20) | **(adjust to plateau pressure <35 cmH20) | ||
*I/E 1:2 | *I/E 1:2 | ||
* | *Pressure support: 5-8cm to overcome endotracheal tube | ||
==Lung Protective Strategy== | |||
===Background=== | |||
*Focuses on low-tidal volume ventilation to reduce ventilator-associated lung injury (e.g. barotrauma and volutrauma worsening/causing [[ARDS]])<ref>Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617</ref> | |||
*Based on [[EBQ:ARDSnet|ARDSnet]] trial with demonstrated mortality benefit | |||
*Indicated for all intubated patients who do not have obstructive lung disease ([[COPD]], [[asthma]])<ref>Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617</ref> | |||
===Settings<ref>[[EBQ:ARDSnet|The 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. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.]] </ref>=== | |||
=== Settings | |||
#'''Mode''' | #'''Mode''' | ||
#* | #*Volume-assist control | ||
#'''Tidal Volume (lung protection)''' | #'''Tidal Volume (lung protection)''' | ||
#*Start 6-8cc/kg predicted body | #*Start 6-8cc/kg [[ideal body weight estimation|predicted body weight]] | ||
#*Predicted body weight is used because a | #**Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight. | ||
# | #*Titrate down if peak pressure >30 mmHg | ||
#Inspiratory Flow Rate (comfort) | #Inspiratory Flow Rate (comfort) | ||
#*More comfortable if higher rather than lower | #*More comfortable if higher rather than lower | ||
#*Start at 60-80 LPM | #*Start at 60-80 LPM | ||
#'''Respiratory Rate (titrate for ventilation)''' | #'''Respiratory Rate (titrate for ventilation)''' | ||
#* | #*Average patient on ventilator requires 120mL/kg/min for eucapnia | ||
#*Start 16-18 breaths/min | #*Start 16-18 breaths/min | ||
#*Maintain pH = 7.30-7.45 | #*Maintain pH = 7.30-7.45 | ||
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#*PaO2 BETWEEN 55-80 | #*PaO2 BETWEEN 55-80 | ||
===Lung Protective FiO2 and PEEP Scale<ref>[[EBQ:ARDSnet|The 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. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.]] </ref>=== | |||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
| FiO2 | | '''FiO2''' | ||
| 0.3 | | 0.3 | ||
| 0.4 | | 0.4 | ||
Line 58: | Line 62: | ||
| 1.0 | | 1.0 | ||
|- | |- | ||
| PEEP | | '''PEEP''' | ||
| 5 | | 5 | ||
| 5 | | 5 | ||
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==Obstruction Strategy== | ==Obstruction Strategy== | ||
===Background=== | ===Background=== | ||
Goal = | *For patients with active bronchoconstriction (e.g. [[COPD]], [[asthma]]) | ||
*The best ventilatory strategy for these patients is to avoid intubation if possible; mechanical ventilation will often make the pulmonary situation worse, rather than better.<ref>Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617</ref> | |||
*Goal = adequate time for expiration | |||
*Frequently requires deep sedation and analgesia (first-line); may required paralysis (second-line)<ref>Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617</ref> | |||
===Settings=== | ===Settings=== | ||
*1. | #Mode | ||
** | #*Volume-assist control | ||
#Tidal Volume | |||
#*Vt = 6-8 cc/kg of Ideal Body Weight | |||
#**Ideal Body Weight used because lung parenchyma does not increase in size as the person gains more weight | |||
#Inspiratory Flow Rate | |||
#*60-80 L/minute | |||
#**Some advocate for higher rates (e.g. 80-100 LPM) to allow more expiration time, however this will increase the peak pressures and has not shown to produce any clinically meaningful change in the expiration time<ref>Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617</ref><ref>Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med. 2004;32:1542-1545.</ref> | |||
#FiO2/PEEP | |||
#*Titrate FiO2 to desired SpO2 | |||
#*Set PEEP 0-5 | |||
#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<ref>20. Oddo M, Feihl F, Schaller MD, Perret C. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med. 2006; 32(4):501-510.</ref> | |||
#***If >30 go down on rate | |||
==Hypovolemic== | |||
* | *Consider reducing PEEP to maintain adequate preload and prevent/minimize hypotension | ||
==Miscellaneous== | |||
''Normally already set'' | |||
*Inspiratory flow rate = 60L/min<ref>Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617</ref> (100 L/min with asthma) | |||
* | |||
*Sensitivity = 1-2 cmH2O | *Sensitivity = 1-2 cmH2O | ||
== See Also == | ==See Also== | ||
{{Mechanical ventilation pages}} | {{Mechanical ventilation pages}} | ||
*[[Ideal_body_weight_estimation|Ideal Body Weight Estimation]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category: | [[Category:Pulmonary]] |
Revision as of 15:23, 27 September 2019
Overview
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% |
Traditional
- FiO2 100% (1.0) and ween down
- Rate 8-12/min
- consider 5-6 for asthma with permissive hypercapnea
- Mode
- PEEP 0-5 mmH20
- Tidal volume: 5-8 cc/kg (eg. 500-600cc)
- (adjust to plateau pressure <35 cmH20)
- I/E 1:2
- Pressure support: 5-8cm to overcome endotracheal tube
Lung Protective Strategy
Background
- Focuses on low-tidal volume ventilation to reduce ventilator-associated lung injury (e.g. barotrauma and volutrauma worsening/causing ARDS)[1]
- Based on ARDSnet trial with demonstrated mortality benefit
- Indicated for all intubated patients who do not have obstructive lung disease (COPD, asthma)[2]
Settings[3]
- Mode
- Volume-assist control
- Tidal Volume (lung protection)
- Start 6-8cc/kg predicted body weight
- Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight.
- Titrate down if peak pressure >30 mmHg
- Start 6-8cc/kg predicted body weight
- Inspiratory Flow Rate (comfort)
- More comfortable if higher rather than lower
- Start at 60-80 LPM
- Respiratory Rate (titrate for ventilation)
- Average patient on ventilator requires 120mL/kg/min for eucapnia
- Start 16-18 breaths/min
- Maintain pH = 7.30-7.45
- FiO2/PEEP (titrate for oxygenation)
- Move in tandem to achieve:
- SpO2 BETWEEN 88-95%
- PaO2 BETWEEN 55-80
Lung Protective FiO2 and PEEP Scale[4]
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
- For patients with active bronchoconstriction (e.g. COPD, asthma)
- The best ventilatory strategy for these patients is to avoid intubation if possible; mechanical ventilation will often make the pulmonary situation worse, rather than better.[5]
- Goal = adequate time for expiration
- Frequently requires deep sedation and analgesia (first-line); may required paralysis (second-line)[6]
Settings
- Mode
- Volume-assist control
- Tidal Volume
- Vt = 6-8 cc/kg of Ideal Body Weight
- Ideal Body Weight used because lung parenchyma does not increase in size as the person gains more weight
- Vt = 6-8 cc/kg of Ideal Body Weight
- Inspiratory Flow Rate
- FiO2/PEEP
- Titrate FiO2 to desired SpO2
- Set PEEP 0-5
- 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[9]
- If >30 go down on rate
Hypovolemic
- Consider reducing PEEP to maintain adequate preload and prevent/minimize hypotension
Miscellaneous
Normally already set
- Inspiratory flow rate = 60L/min[10] (100 L/min with asthma)
- Sensitivity = 1-2 cmH2O
See Also
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous
- Ideal Body Weight Estimation
References
- ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
- ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
- ↑ The 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. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
- ↑ The 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. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
- ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
- ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
- ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
- ↑ Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med. 2004;32:1542-1545.
- ↑ 20. Oddo M, Feihl F, Schaller MD, Perret C. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med. 2006; 32(4):501-510.
- ↑ Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617