Mechanical ventilation protocol

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]

Mechanical Ventilation Protocol

Inclusion Criteria

Ventilator Setup

  • Calculate predicted body weight. It is calculated using the formula
Males = 50 + 2.3[height(in inches)-60]
Females = 45.5 + 2.3[height(in inches)-60]
  • Selecting the ventilator mode
  • Set ventilator settings to achieve initial Vt = 8 ml/kg of predicted body weight
  • Reduce VT by 1 ml/kg at intervals ≤ 2 hours until VT = 6ml/kg PBW.
  • Set initial rate to approximate baseline minute ventilation (not > 35 breaths per minute).
  • Adjust VT and respiratory rate to achieve pH and plateau pressure goals below.

Oxygenation Goal

  • PaO2 55-80 mmHg or SpO2 88-95% is the goal.
  • Use a minimum PEEP of 5 cm H2O.
  • Consider use of incremental FiO2/PEEP combinations to achieve goal.
Lower PEEP/Higher FiO2
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
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24
Higher PEEP/Lower FiO2
FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.5 - 0.8 0.8 0.9 1.0 1.0
PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24

Plateau Pressure Goal

  • Plateau pressure goal(Pplat) is <= 30 cm H2O
  • Check Pplat every 4th hourly after change in PEEP ot VT
  • If Pplat > 30 cm of H2O
Decrease VT by 1ml/kg
  • If Pplat < 25 cm of H2O and VT < 6ml/kg
Increase VT by 1ml/kg unbtil Pplat > 25 cm H2O or VT = 6 ml/kg
  • If Pplat < 30 cm and breath stacking or dys-synchrony occurs
Increase VT in 1 ml/kg increments to 7 or 8 ml/kg, if Pplat remains <=30 cm of H2O

PH Goal

  • pH should be maintained at 7.30 - 7.45
  • If pH is less than 7.30 (acidosis)

a. Range of 7.15 - 7.30

Increase respiratory rate until pH > 7.30 or PaCO2
Maximum rate can be 35

b. Less than 7.15

Increase respiratory rate to 35
VT can be increased in 1 ml/kg until pH >7.15 (Pplat target of 30 may be exceeded)
Bicarbonate can be given
Decrease the ventilation rate if possible

I:E Ratio Goal

Recommend that duration of inspiration be less than equal to duration of expiration.

Weaning

A spontaneous breathing trial has to be done daily when

  • FiO2 ≤ 0.40 and PEEP ≤ 8.
  • PEEP and FiO2 ≤ values of previous day.
  • Patient has acceptable spontaneous breathing efforts. (May decrease vent rate by 50% for 5 minutes to detect effort.)
  • Systolic BP ≥ 90 mm Hg without vasopressor support.
  • No neuromuscular blocking agents or blockade.

Spontaneous Breathing Trial

If all above criteria are met and patient has been in the observed for at least 12 hours, initiate a trial of upto 120 minutes of spontaneous breathing with FiO2 < 0.5 and PEEP < 5

1. Place on T-piece, trach collar, or CPAP ≤ 5 cm H2O with PS < 5

2. Assess for tolerance as below for up to two hours.

a. SpO2 ≥ 90: and/or PaO2 ≥ 60 mm Hg b. Spontaneous VT ≥ 4 ml/kg predicted body weight c. RR ≤ 35/min d. pH ≥ 7.3 e. No respiratory distress (distress= 2 or more)

HR > 120% of baseline
Marked accessory muscle use
Abdominal paradox
Diaphoresis
Marked dyspnea

3. If tolerated for at least 30 minutes, consider extubation.

4. If not tolerated resume pre-weaning settings.

References

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