OVERVIEW OF VENTILATOR MODES

Goals for mechanical ventilation:

Define treatment goals 1. Oxygenation – support PaO2/SpO2

goals (e.g. permissive hypercapnia)

If unable to achieve, can redefine
Measurement and optimization:
2. Ventilation – maintain pH
3. Patient comfort – vent synchrony, ↓ seda on ABG Pulse Ox
Choose a ventilator mode & initial 4. Facilitate weaning – minimize muscle loss,
settings promote readiness to wean from support
Measure
ABG/SpO2
/ pH PCO2 / PaO2 / HCO3 SpO2
Ventilator Modes:
Measure ABG/VBG/Spo2 Fall into two broad categories: pressure and
Ask am I achieving my goals? Adjust VENTILATION OXYGENATION
volume modes. Each mode has three features: If you want to increase If you want to change the PaO2
• Trigger (T) – what initiates a breath? Settings or SpO2 adjust oxygenation
the pH  increase the
Try a • Cycle (C) – what ends a breath? ventilation parameters parameters (FiO2 and PEEP)
Adjust Try adjunct • Limit (L) – what stops a breath early?
different (sedation, NMB,
Settings Each mode has Pro’s and Con’s to consider.
mode bronchodilator, etc)

Mode Description Pro’s Con’s Major settings / example Monitor

Every breath delivered (mandatory and patient Good general-purpose mode; Requires you to Pressures
VC triggered) are all the same set volume Ensures a minimum MV is monitor pressures to RR, TV, PEEP, FIO2 (Ppeak,
Volume Control achieved. Good mode for lung avoid barotrauma. Pplat)
(a.k.a. assist control T – time/pressure/flow, C – volume, L – volume protective ventilation (LPV) (See my OnePager on 12 bpm, 450cc, +8, 60%
volume) ARDS for details.) (RR – respiratory rate, TV – tidal volume)

PC Every breath delivered (time & patient) are a set

pressure for a set time
Good for limiting pressure; may
be more comfortable for select
Requires you to
monitor volumes to
RR, IP, TI, Risetime, PEEP, FIO2 Volumes
(TV, MV)
Pressure Control patients. Also can be used for LPV avoid volutrauma or 12 bpm, 25 cmH2O, 0.9 sec, 0.15 sec, +8, 60%
(a.k.a. assist control T - time/pressure/flow, C – time, L - pressure (no difference in mortality) hypoventilation
pressure) (IP – inspiratory pressure, TI – inspiratory time)
Hybrid PC mode that dynamically changes Guarantees TV but delivers In patients who are Pressures
PRVC inspiratory pressure to deliver a desired volume pressure-controlled breaths; (e.g. struggling to breath RR, TV, TI, Risetime, Pmax, PEEP, FIO2 &
Pressure Regulated low risk of causing VILI), which the machine will volumes
Volume Control T - time/pressure/flow, C – volume, L - volume potentially may be more provide less support 12 bpm, 450cc, 0.9 sec, 0.15 sec, 30 cmH2O, +8,60%
(a.k.a. VC+) comfortable for patients (Pmax – maximum pressure)
Delivers mandatory breaths with a fixed volume May be useful for patients with Seldom used; not Pressure
SIMV but patient can’t trigger (patient breaths are not hiccups to avoid alkalemia effective for RR, TV, PEEP, FIO2 (Ppeak
Synchronous the same as mandatory breaths); can use PS weaning; often found Pplat)
Intermittent to be uncomfortable
Mandatory Ventilation T – time , C – volume, L - volume 12 bpm, 450 cc, +8, 60%

All breaths are patient initiated; ventilation Ideal weaning mode (used in SBTs Does not guarantee a Note that PS is Volumes
PS determined solely by patient (no backup rate). and for prolonged periods); most rate; need to monitor PS, PEEP, FiO2 above PEEP so (TV, MV)
comfortable because it allows to ensure adequate “Ten over Five”
Pressure Support
T – pressure/flow, C – flow, L - pressure patient to control ventilation ventilation +10, +5, 40% PIP = 15cmH2O

Inverse ratio ventilation (e.g. I time > E time) Great for ARDS patients who are Complex Volumes
THigh, TLow, Phigh, Plow, FIO2
APRV that allows patient to breath spontaneously; can spontaneously breathing (e.g. not mode/settings; Risk & gas
Airway Pressure combine w/ PS on NMB); may improve comfort & of VILI if settings are exchange
oxygenation (but no mortality done improperly;
5.5 sec, 0.5 sec, 25 cmH2O, 0 cmH2O, 60% PCO2 /
Release Ventilation
T – time, C – time, L - pressure benefit) doesn’t make sense if (Thigh/low – time high/low, Phigh/low – pressure EtCO2
(a.k.a. Bi-Vent)
on NMB high/lowNote that Plow is analogous to PEEP)
 Pulmonary Physiology Volume Control Pressure Control Pressure Support
Modes for Disease Measure of static lung compliance. If in AC-VC, perform “AC” Assist Control; AC-VC, ~CMV (controlled mandatory a.k.a. AC-PC; Assist Control Pressure Control; ~CMV-PC a.k.a PS (~BiPAP). Spontaneous: Pressure-present
inspiratory pause (when there is no flow, there is no effect of
a.k.a. ventilation = all modes with RR and fixed Ti)
PPlateau Resistance; Pplat Palv); or set Pause Time ~0.5s; Target: < 30, RR, Pinsp, PEEP, FiO2, Flow Trigger, rise time, I:E (set directly Settings Pinsp, PEEP, FiO2, Flow Trigger, Rise time
Optimal: ~ 25
Settings
RR, Vt, PEEP, FiO2, Flow Trigger, Flow pattern, I:E (either directly Settings or by inspiratory time Ti)
or via peak flow, Ti settings)
PIP: Total inspiratory work by vent; Reflects resistance & Decreasing Ramp (potentially more physiologic) Determined by:
- Decreasing Ramp (potentially more physiologic)
PPeak inspiratory compliance; Normal ~20 cmH20 (@8cc/kg and adult ETT); Resp Square wave/constant vs Decreasing Ramp (potentially more Flow 1) PS level, 2) R, Rise Time ( rise time
Flow - Peak Flow determined by 1) Pinsp level, 2) R, 3)Ti (shorter
peak flow and 3.) pt effort
failure 30-40 (low VT use); Concern if >40. physiologic) Flow = more flow), 4) pressure rise time ( Rise Time Peak Flow),
5) pt effort ( effort peak flow)
Pplat-PEEP: tidal stress (lung injury & mortality risk). Target Determined by set RR, Vt, & Flow Pattern (i.e. for any set peak Determined by patient effort & flow termination (“Esens” –
PDriving flow, Square ( Ti) & Ramp ( Ti); Normal Ti: 1-1.5s; 0.7-0.9sec
I:E see below “Breath Termination”)
< 15 cmH2O. Signif mort risk > 20 cmH2O. Determined by set Ti & RR (Volume & flow variable) Time
to airtrapping & asynchrony I:E cycled = Ti or I:E set, then flow adjusts to deliver Vt
I:E At rest ~1:2, exertion ~1:1; Obstructive pulmonary dz ~1:3 I:E -Increase flow rate will decrease inspiratory time (Ti) Pros Synchrony: allows pt to determine peak flow, VT and Ti
-Example: Vt 500/RR20/Flow 60 -Avoids high PIPs
--Cycle time = 3s; Ti = 0.5s = (0.5L/60LPM)(60s per minute) -Variable flow – pt effort causes flow to maintain constant No guaranteed MV; Vt determined by pt (big or small); high PS
Normal 4-6 LPM; may be lower if drug OD, hypothermic, deep
--Texp = 3-0.5 = 2.5s I:E = 0.5:2.5 = 1:5 airway pressure = Potentially better synchrony: pt effort and/or low Esens in COPD can incr air-trapping asynchrony.
Oxygen & Delivery Devices MinuteVent sedation; may be higher 8-14 LPM if OPD or ARDS. Target 6-8 Cons Muscle Weakness/Fatigue: effort or ability to sustain effort)
LPM OPD, 10-15 ARDS Pros flow & Vt
Guaranteed MV regardless of changing respiratory system hypoventilation, fatigue
Pros mechanics; Precise control of Vt to limit lung injury
-“Automated/active expiratory valves” - transiently opens
Pros: Ubiquitous, easy; Range 1-8LPM Clinical range: 50-80 LPM. With exertion or distress 100- 150; expiratory valve to vent off pressure w/ coughing,
NC Cons: Cold and dry if >4LPM,epistaxis Peak Flow ventilator default ~60LPM asynchrony. comfort & barotrauma risk Breath
FiO2: 2-4% /LPM; variable (mouth breathing, high minute ventilation) Delivers Vt at all cost = PIPs vary with C & R; breath stacking; Pt flow or pressure triggered
Cons fixed flow and Ti can increase asynchrony when pt Vt and flow Initiation
∆ v / ∆ p = VT/Plateau-PEEP VT and MV not guaranteed; Vt determined by C and R
-Static compliance: (Normal ~100 mL/cmH2O) = lung (50) +
demand > vent settings Cons (might be bigger or smaller than is optimal)
If no pt
Pros: Higher FiO2; Can be more comfortable than NC Compliance chest wall (50); measured at end inspiratory pause; Normal
Control: Time trigger (60s/set RR): fixed VE trigger
Apnea; (Most vents will have backup rate; all have alarm)
NRB/ Cons: Bad if high MV; difficult to estimate severity of hypoxemia intubated recumbent 60-80; ARDS < 40) Breath Assist: Pt effort triggers full breath at set Ti and fixed VT and Breath Control: Time trigger – (60s/set RR)
FM FiO2: Simple 5-10LPM (~FiO2 35-50%); NRB 10-15 LPM (~ FiO2 -Dynamic compliance: includes system resistance & inertia Initiation flowrate Initiation Assist: Pt trigger delivers Pinsp for inspiratory time cycle
Flow cycled: Delivers Pinsp until flow drops to
60-80% if MV not too high) Breath
predetermined % of initial peak flow ~Esens (Standard
R= PIP-Pplat/ inspir flow (square pattern, 60LPM) If no pt If no pt Termination setting ~25%; ~40-50% if OPD to prevent air trapping)
Resistance Normal< 10cmH2O/L/sec, Concern: > 15cmH2O/L/sec Delivers full set Vt at set rate Delivers Pinsp at set rate and Ti
Pros: Able to achieve high FiO2 even w/ high MV; washout CO2 (less trigger trigger
rebreathing); heated/humidified; Possible improved outcomes in acute Higher Pinsp, short rise time, low trigger sensitivity = less work
Notes or air hunger; PS does not = SBT
HFNC hypox resp failure 80 Time cycled = breath ends at Ti limit; Alarms if VT not achieved; Breath
Cons: Requires special device flow is set, breath ends once Vt delivered Pressure cycled = Time cycled = I:E or Ti set, breath ends at set time
FiO2: >90% FiO2 (variability with MV, mouth breathing)
Volume* (ml/kg) *adult male Breath (safety mechanism); breath termination by clinician set high termination
termination pressure limit; “pop-off” breath ends; Default set to 50 cmH2O
IRV -When changing from AC-VC, set Pinsp as Pplat-PEEP from
IC

Flow
Pros: Possibly decrease density = better ventilation AC-VC or consider half of PIP from AC-VC
Notes -Can Ti to allow pause or Ti to peak flow at the end
Cons: Requires special device; Caution w/ 80/20 mix in severe Inspiratory pause (~0.3s) can be built into each breath, will
Heliox 37 Notes inspiration ~decr asynchrony when VE demand is high
hypercarbic failure; not all NIPPV or IPPV can use VC increase mean airway pressure
FiO2: 20% or 30% mixes available; $$$ TV TLC
30 Decelerating Flow Constant Flow Decelerating Flow

Pressure
Pros: May avoid intubation (COPD, cardiogenic pulm edema, mild ARDS,
ERV

Flow
Flow

Flow
upper airway obstruction) by decr work of breathing & adding PEEP
FRC
Cons: Gastric insufflation (if PIP>20-25); Cannot use if aspiration 15
risk or unable to protect airway (or if can’t remove mask themselves);
uncomfortable/skin breakdown; may worsen lung injury due to increased
RV RV
transpulmonary pressure gradient; caution if RHF Confusing terminology: Ti too short Ti Appropriate Ti too long
IPAP (=driving pressure + PEEP) and EPAP (=PEEP). PS of “5 over 5” is the (flow to zero) Dual Mode

Pressure
Pressure

Pressure
same as PS delta 5 over 5, is the same as IPAP 10/EPAP 5
NIPPV FiO2: 1.0 Hypoxia Pressure regulated volume control (PRVC); VC+, AutoFlow
a.k.a. ~PC with a target Vt & variable Pinsp (∆1-3cmH2O per
Initial Settings: PS (∆P) 5 / PEEP (EPAP) 5-10; Titrate ∆P up to 15 to reduce Alveolar Gas Equation (A-a) breath) to meet goal Vt despite chagning C and R;
inspr work [(FiO2%/100) * (Patm - 47 mmHg) - (PaCO2/0.8)] - PaO2
Likelihood of hypo/hyperventilation associated with PC when
-Always small gradient = (age/4) +4; Patm sea level ~760mmHg SIMV Misc Vent Settings R or C changes. As C or R Pinsp . As C or R Pinsp.
*PAO2 = function of oxygen in air (Patm-Pwater)FiO2 and ventilation (PaCO2/0.8) Pros -Active expiratory valve present
*Remember, Patm not FiO2 changes with altitude (top of Everest, FiO2 = 0.21) a.k.a. Synchronized intermittent mandatory ventilation; mixed mode Insp Time If Time-cycled, set I:E or Ti; If Volume cycled, flow is set; ~0.9s
*Healthy subject on FiO2 1.0, ABG PaO2 ~660
Guaranteed MV (control breaths by PC, VC, Dual); Spont breath Aka slope or flow attack; Speed of rise of flow (VC) or pressure - C & R can change significantly without notification
Disclaimer: This card is intended to be educational in nature and is not a substitute for clinical decision
Causes of Hypoxemia (PaO2)
Pros (CPAP or PSV) = better synchrony; avoids breath stacking; Rise Time (PC); how quick PIP reached; too short = uncomfortable; too -Vent can’t discern if VT>target is due to Pt effort or C; vent
making based on the medical condition presented. It is intended to serve as an introduction to terminology. *Normal A-a: Not enough 02 (low Patm, or low FiO2), too much CO2 (hypercarbia), sometimes useful if vent triggering inappropriately
It is the responsibility of the user to ensure all information contained herein is current and accurate by using hypoventilation
long = low Vt (PCV) or higher P (VCV); ~0.2s fastest Cons response to both = Pinsp; Can lead to closed-loop ”runaway”
published references. This card is a collaborative effort by representatives of multiple academic medical
( Pinsp Pt Effort Pinsp); Pt work
*Elevated A-a: Diffusion defect, V/Q mismatch, shunt Note: If PIP<20; evaluate for “VT starvation” (VT>set VT)
centers. Cons Less ‘control’ over Vt and MV; May prolong weaning Insp Trigger Flow (3-5LPM) more sensitive than pressure trigger (-2cmH20)
 Obstructive Lung Disease ARDS Management ARDS Management
High Pressures Setting PEEP
-Similar to ARDSnet – permissive hypercapnea and avoid Berlin 1. Acute (<1 week)
*PEEP doesn’t recruit, it prevents de-recruitment, generally PIPs/Plts recruit barotrauma; Increase expiratory time (avoid breath stacking); 2. Bilateral opacities on CXR or Chest CT Ideal Body Weight:
High PIP ARDSnet PEEP Tables Definition
shorten inspiratory phase, lower RR, trend pressures closely; 3. P:F ratio< 300mmHg w/ >5cmH20 PEEP
Ensure pt is sedated + paralyzed, check plateau (insp hold): -In ARDS pts, use PEEP table; consider low PEEP if tenuous hemodynamics or Plat<40, pH>7.15, PaO2>60 (2012)
Goals 4. Must not be fully explained by cardiac failure or fluidoverload Males = 50 + 2.3 [height
Incr Pplat nl Pplat other concerns for hemodynamic consequences of higher PEEPs -Avoid ‘divots’ (premature drop in exp flow to zero) = uncaptured on clinical exam (inches) -60]
△Pplat-PIP <10 △Pplat-PIP >10 breaths that hinder exhalation; titrate sedation prn
Dx = lowcompliance Dx = highresistance Gestalt Method - Be patient, severe exacerbations (esp asthma) can take time
Incr Pplat ARDS Mild = P/F 200 – 300 = ~27% mortality Females = 45.5 + 2.3
-Despite existence of numerous techniques (below), mean PEEP to maintain Moderate = P/F 100 – 200 = ~32% mortality
△Pplat-PIP >10 Severity [height (inches) – 60]
Dx = low compliance+ oxygenation in most major ARDS trials spans a narrow and moderate range (9-13) Mode: VCV preferred as rapid changes in obstruction affect MV; Severe = P/F < 100 = ~45% mortality
high resistance - Many nuances and imprecisions to below methods make clinical utility limited consider PRVC if PIPs > 50
-Titrating PEEP to oxygenation is easy and reasonable, though pulmonary RR: ~10-14; Consider RR 6-9 if PEEPi still >5 despite E time 5s TV: 6- Ventilator 1. Calculate ideal body weight (IBW) to set VT – See box right
Troubleshooting Resistance: work mechanics must be utilized, especially if poor oxygenation response 9ml/kg 2. Select vent mode (Usually start w/AC-VC , can use PC)
- Default 5, cardiogenic pulmonary edema 10, OPD 0-3, ARDS (use table) Set-Up per
outside (machine) to inside (alveoli); Settings Insp Time/Flow: 0.7-0.9s / 60-80Lpm
ARDSNet 3. Set initial Vt = 8cc/kg IBW Selective Pulmonary Vasodilator Therapy
circuit problem, ETT kink/occlusion/biting, PEEP: start @0; may need 3-8 to work of breathing in recovery Exp 4. Reduce Vt by 1 cc/kg as able until Vt = 6cc/kg IBW
ETT obstructed/mainstem, large airway P Static compliance Method time: goal 4-5s Protocol 5. Adjust Vt and RR to achieve Pplat <30; pay attention to Inhaled Prostacyclin (aka: PGI2)*
obstruction (mucous plug), small/medium - Assess effect of PEEP changes in compliance Heliox: only works w/select vents; limited data; consider if severe preintubation minute ventilation as initial guide Dose: start at 50 ng/kg/min PBW (range: 10-50); should be weaned (10ng/kg/min
airway obstruction (bronchospasm); • If Crs (respiratory system) improves, then attributable to alveolar hyperinflation and/or acidosis; $$$ 6. PEEP >5; FiO2/PEEP as below (see PEEP Box) increments q30min) to avoid hemodynamic compromise
auscultation & passing a suction catheter recruitment; if Crs decreases, then overdistending; 7. Oxygenation goal: PaO2 55-80; SpO2 88-95% Notes: Possibly more beneficial in secondary ARDS and pts with baseline RV
• Crs during PEEP titration largely determined by Vt chosen
can quickly eliminate many of these. t - Goal is to set PEEP to match or exceed auto-PEEP (see auto-PEEP box) PEEPi-
-Gas trapping: expiratory flow not returning to baseline 8. Ventilation goal: pH>7.15, permissive hypercapnea dysfunction; incr surfactant production via cAMP pathway; antiplatelet activity only
(Quantified with expiratory pause; pt must remain apneic for demonstrated thus far for IV route; half-life = minutes;
Intrinsic ~5sec or more; assesses iatrogenic gas trapping best)
Tidal - Goal 6 cc/kg (range 4-6)
PEEP According to P-V Curves (“Open Lung Ventilation Strategy) - PEEPi trends with Vd/Vt (can be used to titrate PEEP) iNO*
End Expiratory Inspiratory Flow Inspiratory hold to - Reduced inflammation & improved outcomes (NEED SOURCE)
Peep Volumes
- Consider decreasing below 6cc/kg if not meeting plateau goals
- Pplat might be best method to assess dynamic gas trapping - EVERY CC/KG counts! Dose: 20ppm (range 2-80ppm); should be weaned (5ppm increments q30min) to (S
phase prior to 1
opens alveoli; measure Pplateau - Results in higher PEEP needed than when using Crs technique - Consider liberalization if/when: Oxygenation, C, Vd/Vt avoid hemodynamic compromise -
3)
breath Determine PIPs (force back against - Lower inflection point (LIP) = zone of recruitment Quantifies intrinsic peep Suggests intrinsic peep
improving (PEEP<10; FiO2<60) and dysynch/uncomfortable Notes: $, requires $ delivery equipment; no direct SVR effect; met-Hgb; half-life =
closed circuit) • Set PEEP ~2 above LIP seconds; free radicals; can cause acute LVEDP overload (caution if reduced LV
- Upper inflection point = decreased Crs from overdistension - ”birds beak” function); caution of pulm hemorrhage, plts<50 or anticoagulated
• Limit Vt so Pplat is below upper inflection point
Fluid FACTT Trial of conservative vs. liberal fluid strategy showed
Management conservative fluid strategy → improved oxygenation, more
- Limitations: accurate curves difficult to obtain unless patient paralyzed; LIP may
ventilator-free & ICU-free days, no increased shock, no mortality *No survival data; Caution: pulm vasodilators can cause incr LVEDP; do not use if
represent Ccw (chest wall); may represent overcoming intrinsic PEEP f/lung with effect pulmonary hemorrhage
prolonged time constants; may represent only beginning of opening rather than -concentrate drips, consider diuresis early if appropriate
optimal pressure for opening
Normal Normal
Pplt Pplateau & Plateau Pressure: check at least q4h Recruitment Maneuvers
Normal Compliance PIP PIP Pplt Dead Space Method Vent Liberation --if>30cmH20, consider decrease Vt by 1cc/kg steps
alveoli problem Normal -Vd/Vt sensitive to detecting recruitment/derecruitment and overdistension Pdriving
--If <30cmH20 and dysynchrony and unable to address with - Caution: can kill a pt. Check with attending and RT - many contraindications
Resistance PIP Pplt Esophageal Balloon
SBT ~Criteria Goals sedation (and can’t paralyze), consider increase by 1cc/kg - Must have arterial line; adequately sedated and/or paralyzed patient
problem Palv insp =Pplat 1) FiO2 < 0.50 and PEEP <8, 2) No  in PEEP/FiO2 requirements over past 24hrs
Driving Pressure: deltaP=Vt/CRS = Pplat-PEEP - Consider if (approximately): FiO2 >70%, 16 PEEP and P:F<150
- May be useful if high BMI, abd pressure
- Transpulmonary pressure (Ptp) ~stress Palv exp =PEEPtot
3) pH > 7.30. VE < 15 L/min, 4) ~MAP > 60 mmHg (minimal pressors), 5) ICP: non- - Threshold opening pressure <35 in most ARDS pts; AC-PC more stable and
--Uses Vt normalized to functional aerated lung
labile and < 20 mmHg w/ CPP > 60 mmHg, 6) No MI in previous~48hr
across lung - Allows PEEP and Vt titration Pes ~ Ppleural --Goal <15 (***each ∆7cmH2O =1.4 RR increase***) effective than sustained inflation RM
Deadspace Calculation Pes Weaning strategies
accounting for Ccw (chest wall) and lung Ptp = Palv - Ppl Example Protocol:
Gestalt Method compliance -Once daily SBT PS ∆ 7/PEEP 5-8 cmH2O x 2hr (2nd daily trial permissible if - AC-PC Pdr 15-20, PEEP 20; RR 20; I:E 1:1 (Ti 1.5s)
Paralysis ACURASYS Trial: Paralysis w/in 48h, x48h, severe ARDS, 24%
-Of 500mL VT, ~150mL = anatomic deadspace = normal (anatomic+alveolar = - Ppl = -2 resting; -5 nl Vt; -35 TLC
-Contraindications: varices, esoph
Palv failure was sedation-related or caused by some other transient issue)
vs 33% @30d mortality benefit; placebo got more BDZs; some
- Increase PEEP q2min by 5cmH20 to max 50/35 (if tolerated hemodynamically)
physiologic deadspace) - SBT x 30min ~probably as good as SBT x 2hr if <48h intubated - Return to 40/25 5-15min
trauma/surgery - SBT x 2hr better predictor if intubated >48h caveats w/data analysis
- During exhalation, at the alveolus, Palveolar CO2 ~ PaCO2; however, during - Then decremental PEEP trial
- If cardiogenic pulmonary edema risk: Consider 15min T-piece (ie d/c PS & PEEP) ROSE Trial: Similar to ACURASYS, larger (1006 pts), no
expiration Palveolar CO2 is mixed with gas from anatomic and physiologic -Titrate to end exp pressure (PEEP – Pes) = (If hypoTN or TBI, consider PEEP 16 and Pdr 20; Increase Pdr q2min by 5cmH20
0 -10 (higher pressure for higher FiO2 -RSBI (rapid Shallow Breathing Index) = f/Vt is unreliable; <80 goal for extubation; mortality difference
deadspace = diluted. Thus end tidal CO2 is always lower than PaCO2 to max 50/16 then back to 15-20/16)
requirement; if EIP negative ~ alv collapse) sensitive, not specific (if > 105, good predictor of failure) --Cisatracurium ($): Loading: 0.2 mg/kg; gtt: 0.5-10 mg/hr
- This difference (usually less than 5) can be used to estimate deadspace
-Titrate Vt to maintain end-inspiratory Pabd - Daily sedation interruption = faster extubation, shorter LOS --Vecuronium: Loading: 0.08-0.1 mg/kg; gtt dose: 1-10 mg/kg Post RM Stabilization:
transpulmonary pressure <25cmH20 Wean by decremental PEEP trial: f/25cmH20 by 2-3cmH20 q5-10min until desats
Extubation ‘criteria’ Vd/Vt Measure Vd/Vt w/ vent changes; can be used to predict mortality (target SpO2 90% throughout in order to be able to assess real-time effects)
Volume Capnography Method PetCO2 - Have you fixed the original problem? (>60% = sig incr mortality), assess volume status, assess
- PEco2 (Mixed expired CO2) Increased compliance - Adequate oxygenation? (PaO2 > ~60 on PEEP< 8 cmH2O, FiO2 <.50) optimal PEEP
‘Bird’s beak’
measured by integrating exhaled - Adequate ventilation w/o excessive work of breathing? (∆PaCO2  of < 10
(abnormal) Vent Associated Pneumonia
CO2 concentration and exhaled gas mmHg with remaining pH > 7.30 during SBT) PROSEVA – most recent RCT, mortality benefit of proning (16%
- Secretions? (assess cough strength, suction frequency & secretion volume) Proning
flow rate (NICO Monitor) vs 33% @28d)
Upper inflection point - Airway protection? (assess gag, spont cough and GCS) -Dx: PNA in pt intubated/ventilated x 48h prior to onset; new infiltrate plus >1 of (new
--Alveolar deadspace impacted by: --Patient selection: stabilized 12-24h severe ARDS
(UIP) • Assess risk of airway obstruction: intubation >6d, trauma or multiple fever, WBCs, >70yo w/AMS) AND >2 of (sputum, cough, SOB, worse P:F or exam
hypovolemia (ie increased west --Duration: ~17h prone at a time,
reintubations, large ETT, prolonged prone, flat, volume overload, findings); For additional/alternate PNA criteria see –
zone I), pulmonary hypotension, PE, Volume P:F>150 w/PEEP<10 supine x>4h
Decreased compliance head/necktrauma, among others Order trach asp (non quantitative Cx), though not required for Dx
non-vascular deadspace, Xp, Phase III --Equipment: Don’t necessarily need special bed
Zq, PhaseI PhaseII • Cuff Leak Test: pt must be sedated (interaction with vent = incr PIP = incr leak -Prevention measures: HOB>30, mouthcare, adequate ETT cuff pressure +
overdistension of alveoli (e.g. too Alveolarventilation
anatomic Transitionto = false reassurance); Mode: CMV-VC (VT: 8-10 mL/kg, RR: 12-15, TI: 1.5sec. subglottic suctioning*, decrease # of transports f/ICU.
much PEEP) deadspace alveolar deadspace Y, alveolardead Deflate cuff: Wait 6 breaths: expired VT should  by > 110mL. ECMO - Ongoing trials to determine if benefit of ECMO in ARDS
space - Tx: MSSA + pseudomonal coverage; MRSA tx if risk factors; double cover
Lower inflection point (LIP) • *Extubation criteria/goals for neuro patients may be different (e.g. visual - Some centers use ECMO over proning for all severe ARDS pseudomonas if MDR risk factors; de-escalate abx at 48-72h pnd cultures +
VD/VT = (PACO2 –PECO2)/PACO2 tracking, swallowing, GCS>10, <40yo)
- No upcoming procedures
-Existing data (CESAR Trial) support transfer to an ECMO
center (not necessarily receiving ECMO)
procalciitonin trend; <7d course or if pseudomonas consider 14d course
Bohr’s equation uses A = alveolar; Enghoff uses PaCO2; E = mixed expired (not end tidal)
Pressure - Hemodynamics - reintubation of an unstable patient can be lethal for pt’s not meeting ARDSnet goals
 TROUBLESHOOTING ON THEVENT

Troubleshooting High Peak Pressure Alarm

VARIABLES TO CONSIDER FOR MECHANICAL VENTLIATION
PULMONARY MECHANICS
Mode of Ventilation
Ventilation Variables
Respiratory Rate (RR)
Tidal Volume (VT)
Oxygenation Variables
Fraction inhaled Oxygen
(FiO2)
Positive End Expiratory
Pressure (PEEP)
Additional Variables
Inspiratory Flow Rate (V\)
Flow delivery pattern
Trigger for spontaneous
breath
Suggested Initial Ventilator SeHngs Post-Intubation
Mode: Assist Control-Volume Control (AC-VC)
Tidal Volume (VT)
Respiratory Rate (RR)
FiO2
PEEP
Peak Pressure (Peak Inspiratory Pressure, or PIP)
• Reflects how hard the ventilator must work to deliver a breath
MANUEVERS FOR ASSESSING • Normal < 40 cm H2O
Function of:
Controlled: Breath size and Minimum RR set by vent Inspiratory Pause to Assess Pplat Expiratory Pause to Assess autoPEEP
o Inspiratory flow (V\), flow pattern
Spontaneous: Breath size and RR set by patient o Airway resistance (including patient, ETT, and circuit)
Plateau pressure (Pplat): Pressure felt by the autoPEEP: Hyperinflation as a result of o Compliance of patient’s respiratory system
Adjust to maintain pH > 7.2 lungs, determined by Vt and lung compliance; incomplete emptying before next breath; Risk
Monitor for autoPEEP if RR high (esp > 35) Goal Pplat < 30 in ARDS (See ARDS Tip Sheet) of ↓BPs /PEA; See Management ofautoPEEP Initial approach to high peak pressure alarm…
Goal 6 or less cc/kg ideal body weight (IBW) for ARDS Step 1: Ask RT to temporarily increase the peak pressure
alarm setting (to ensure patient receives full VT)
Ranges 30%-100% Step 2: Check inspiratory pause for Pplat
Avoid > 60% for prolonged time, risk of toxicity
Optimize PEEP using PEEP tables or driving pressure Is Pplat elevated?
Risk of hypotension with high PEEP
Ventilator default ~60 LPM NO YES
↑V\ will ↓ Inspiratory time and ↑Peak Pressure (PIP)
Ramp / Decelerating Square Wave When to Check: When to Check:
Expiratory flow on ventilator not 0 at end Increased Resistance DecreasedCompliance
ARDS Management (see ARDS Tip Sheet);
Airway secretions Abdominal distention
Workup of Elevated Peak Inspiratory of exhalation; h/o COPD/asthma; Workup
Flow (standard) or pressure triggered (less sensitive) Bronchospasm Pleural effusions
Pressure (PIP) of ↓BPs of unclear etiology
Kinks in circuit tubing Pneumothorax
Patient biting on ETT Pulmonary edema / ARDS
Please see dedicated ventilator cards (QR Codes below) for instructions on checking an
inspiratory and expiratory hold maneuver for various ventilator brands.
AutoPEEPEvaluation
Step 1: Check hemodynamics
6 cc/kg (IBW) autoPEEP → hyperinflation → decreased preload → ↓BPs → PEA
Match pre-intubation RR If ↓BPs due to autoPEEP, disconnect ETT from from vent to
↓hyperinflation (requires airborne PPE in COVID+/PUI)
100% Step 2: Check an expiratory pauseand assess expiratory flow at
end of expiration
10 cm H2O (5 if hypotensive)
Step 3: Improve I:E ratio (↓RR, ↓VT, ↑flow rate, square wave )

Overview of Select Modes of Mechanical Ventilation

VENTADJUSTMENTS WEANING FROM THE VENT
MODE OF SETBYPROVIDER DETERMINED BY ADDITIONAL NOTES
VENTILATION PATIENTFACTORS Ventilation Oxygenation Ensure you have fixed underlying respiratory problem first

Assist-Control pH and PaCO2 PaO2 and SpO2 Proceed with a Spontaneous Breathing Trial
VT, Minimum RR, PEEP, FiO2, and Peak Inspiratory Pressure (PIP) o Delivers set VT (with a minimum RR)
Volume-Cycled* (SBT) and Spontaneous Awakening Trial (SAT)
and Plateau Pressure (Pplat) o
Fixed VM and low VT can lead tovent
Inspiratory Flow (V\) or
AC-
VC

*Preferred Mode dyssynchrony

Inspiratory:Expiratory ratio (I:E) Actual RR o Must monitor for barotrauma(Pplat) PSV 7/5 with FiO2 40% with sedation discontinued
for ARDS
PressureControl ACVC VT, RR PEEP,FiO2 (Consider 5 / 0 for COVID +)
PCV/AC-PC

o Delivers set Pinsp, PEEP (with a min RR)

Ventilation Inspiratory Pressure (Pinsp), PEEP,
VTand Inspiratory Flow(V\) o Variable VM with improved comfort and Assessfor Failure of SAT/SBT
(Assist-Control Minimum RR, FiO2, and I:E (through rise
Actual RR vent synchrony Pinsp
Pressure Cycled) time and inspiratory time, T )I o Risk of ↑↑ VT (>6cc/kg)
I:E(↓T PEEP,FiO2 ↑WOB? ↑ HR? ↓ SpO2? ↓ VT with ↑ RR?
PCV I,

For mandatory breaths: o Delivers set VT (for controlledbreaths) ↑rise time),

Spontaneous For mandatory breaths: o Allows for additional spontaneous RR Ensure No Other Barriers to Extubation
VT, RR, PEEP,
Intermittent PIP and P plat breaths (providing pressure support)
SIM

FiO2, Inspiratory Flow (V\) Secretions < Q3H and normal mental status
Mechanical For spontaneous breaths: o Risk of ↑↑ VT (>6cc/kg) with PEEP,FiO2
V

For spontaneous breaths: SIMV VT, RR

Ventilation VT, RR, I:E, Inspiratory Flow (V\) spontaneous breaths If AMS: Good cough, gag, withdraws to pain
Pinsp, PEEP, and FiO2 o May prolong weaning
o WEANING MODALITY
PressureSupport Inspiratory Pressure (P insp),
VT, RR, I:E, Inspiratory Flow (V\) o Variable VM and
Delivers set Pinsp andPEEP
PEEP,FiO2
PS

PSV Pinsp
o low VT per patient effort
V

Ventilation PEEP, and FiO2

o No minimum RR, requires respdrive