Mechanical ventilation protocol
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Candidacy for mechanical ventilation is based on specific criteria and clinical condition of the patient. Body weight of the patient and height also play important role in determining the optimal ventilator settings. Similar to initiation of mechanical ventilation there are specific criteria for weaning the patient off from the ventilator and doing a spontaneous breathing trial.
- PaO2 <= 300 ( corrected for altitude)
- Bilateral (patchy, diffuse or homogenous) infiltrates consistent with pulmonary edema
- No clinical evidence of left atrial hypertension
- 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.
- 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.
- 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
- 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|
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 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
- Maximum rate can be 35 breaths/min
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
- If pH is more than 7.45 (alkalosis)
- Decrease the ventilation rate if possible
I:E Ratio Goal
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)
3. If tolerated for at least 30 minutes, consider extubation.
4. If not tolerated resume pre-weaning settings.
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