Ventilator Settings Pulmonary Medicine                                  ISSN 1930-6741


Pulmonary Medicine                                




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 (VT) to 8 mL/kg PBW (if baseline VT >8 mL/kg PBW)
Reduce VT by 1 mL/kg at intervals <=2 h until VT = 6 mL/kg PBW
Set initial respiratory rate (RR) to approximate baseline minute ventilation (but not >35 bpm)
Adjust VT 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, VT and ABG (if available) at least every 4 h and after each change in PEEP or VT
If Pplat >30 cm H2O, decrease VT by 1 mL/kg PBW steps (minimum 4 mL/kg PBW)
If Pplat <25 cm H2O and VT <6 mL/kg, increase VT by 1 mL/kg until Pplat >25 cm H2O or VT = 6 mL/kg
If Pplat <30 cm H2O and breath stacking occurs, one may increase VT 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, VT 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; VT = tidal volume.



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