Initial mechanical ventilation settings: Difference between revisions

(/* SettingsThe 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 Netwo...)
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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 w/ permissive hypercapnea
**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  
*TV 5-8 cc/kg (eg. 500-600cc)  
*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  
*PS (pressure support) 5-8cm to overcome endotracheal tube
*Pressure support: 5-8cm to overcome endotracheal tube


{{Initial ventilation settings table}}
==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>


== Lung Injury Strategy ==
===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>===
=== Background ===
*Ok for all pts except for obstructed
=== Settings ===
''These settings are based on a lung protective strategy<ref>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>''
#'''Mode'''
#'''Mode'''
#*Assist control Volume
#*Volume-assist control
#'''Tidal Volume (lung protection)'''
#'''Tidal Volume (lung protection)'''
#*Start 6-8cc/kg predicted body wt
#*Start 6-8cc/kg [[ideal body weight estimation|predicted body weight]]
#*Predicted body weight is used because a persons lung parenchyma does not increase in size as the person gains more 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
#*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)'''
#*Avg pt on ventilator requires 120mL/kg/min for eucapnia
#*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
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| 1.0
| 1.0
|-
|-
| PEEP
| '''PEEP'''
| 5
| 5
| 5
| 5
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==Obstruction Strategy==
==Obstruction Strategy==
===Background===
===Background===
Goal = Adequate time for expiration
*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
#Mode
**Assist Control Volume
#*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


*2. Tidal Volume
==Hypovolemic==
**Vt = 8 cc/kg predicted body wt
*Consider reducing PEEP to maintain adequate preload and prevent/minimize hypotension


*3. Inspiratory Flow Rate
==Miscellaneous==
**Set at 80-100 LPM to allow more expiration time
''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)  
*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<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
 
==Making Setting Changes ==
=== O2 ===
*PaO2 - ween to O<sub>2</sub> >90% and PaO<sub>2</sub> >60 mmHg)
*FiO2 - ween to < 50% if possisble while maintaining adequate PaO2
*PEEP - refer to ARDsnet protocol to avoid barotrauma
 
=== 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
*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:Pulm]]
[[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%

^Ideal body weight

Traditional

  • FiO2 100% (1.0) and ween down
  • Rate 8-12/min
    • consider 5-6 for asthma with 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
  • 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]

  1. Mode
    • Volume-assist control
  2. 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
  3. Inspiratory Flow Rate (comfort)
    • More comfortable if higher rather than lower
    • Start at 60-80 LPM
  4. 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
  5. 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

  1. Mode
    • Volume-assist control
  2. 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
  3. 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[7][8]
  4. FiO2/PEEP
    • Titrate FiO2 to desired SpO2
    • Set PEEP 0-5
  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

References

  1. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  2. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  3. 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.
  4. 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.
  5. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  6. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  7. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617
  8. 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.
  9. 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.
  10. Weingart SD. Managing Initial Mechanical Ventilation in the Emergency Department. Ann Emerg Med. 2016;68:614-617