Ventilator Settings Pulmonary Me

Ventilator Settings Pulmonary Medicine ISSN 1930-6741

VENTILATOR SETTINGS ON INTUBATION

NIH NHLBI ARDS Network Low Tidal Volume Ventilation Strategy

Part I: Ventilator Setup and Adjustment

Calculate predicted body weight (PBW)*

* Male PBW = 50 + 2.3[height (inches) − 60]; female PBW = 45.5 + 2.3[height (inches) − 60]

Use assist/control mode and set initial tidal volume (V_T) to 8 mL/kg PBW (if baseline V_T >8 mL/kg PBW)

Reduce V_T by 1 mL/kg at intervals

2 h until V_T = 6 mL/kg PBW

Set initial respiratory rate (RR) to approximate baseline minute ventilation (but not >35 bpm)

Adjust V_T and RR to achieve pH and plateau pressure (Pplat) goals below

Set inspiratory flow rate above patient demand (usually >80 L/min); adjust flow rate to achieve goal of I:E ratio of 1:1.0-1.3

Part II: Oxygenation Goal: PaO ₂ = 55-80 mm Hg or SpO ₂ = 88-95%

Use incremental FIO ₂/PEEP combinations to achieve oxygenation goal:

0.3/5, 0.4/5, 0.4/8, 0.5/8, 0.5/10, 0.6/10, 0.7/10, 0.7/12, 0.7/14, 0.8/14, 0.9/14, 0.9/16, 0.9/18, 1.0/0, 1.0/22, 1.0/24

Part III. Plateau Pressure (Pplat) Goal:

30 cm H₂O

Check Pplat (use 0.5 s inspiratory pause), SpO ₂, total RR, V_T and ABG (if available) at least every 4 h and after each change in PEEP or V_T

If Pplat >30 cm H₂O, decrease V_T by 1 mL/kg PBW steps (minimum 4 mL/kg PBW)

If Pplat <25 cm H₂O and V_T <6 mL/kg, increase V_T by 1 mL/kg until Pplat >25 cm H₂O or V_T = 6 mL/kg

If Pplat <30 cm H₂O and breath stacking occurs, one may increase V_T in 1 mL/kg PBW increments (to a maximum of 8 mL/kg PBW)

Part IV. pH Goal: 7.30-7.45

Acidosis Management: pH <7.30

If pH = 7.15 -7.30, increase RR until pH >7.30 or PaCO ₂ <25 mm Hg (maximum RR = 35); if RR = 35 and PaCO ₂ <25 mm Hg, may give NaHCO ₃

If pH <7.15 and NaHCO ₃ considered or infused, V_T may be increased in 1 mL/kg PBW steps until pH >7.15 (Pplat goal may be exceeded)

Alkalosis Management: pH >7.45

Decrease RR if possible

ABG = arterial blood gas; ARDS = acute respiratory distress syndrome; FIO ₂ = fraction of inspired oxygen; NaHCO ₃ = intravenous sodium bicarbonate; NHLBI = National Heart, Lung and Blood Institute; NIH = National Institutes of Health; PEEP = positive end-expiratory pressure; PBW = predicted body weight; RR = respiratory rate on ventilator; SpO ₂ = oxygen saturation by pulse oximetry; V_T = tidal volume.

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