Protocol for ventilator settings
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1. This document provides protocols for ventilator settings for adults, children aged 1-10 years, and neonates/infants. It includes guidelines for initial settings, adjusting settings based on blood gas results, criteria for weaning and extubation. 2. The protocol outlines steps for changing settings from initial pressure-regulated volume control (PRVC) to synchronized intermittent mandatory ventilation (SIMV) and lists criteria for determining readiness for a spontaneous breathing trial. 3. Special considerations are provided for various clinical situations like post-cardiac surgery patients, pulmonary issues, and open sternum cases.
![PROTOCOL FOR VENTILATORY SETTINGS
1. First ABG 10min after connecting to ventilator
2. pCO2 value: Increase /Decrease RR
3. Vt: Do not change until mean Paw cross upper limits
4. On PRVC: up to 25 mean Paw is acceptable
Adult Child (1-10yr) Neonate/infant
Vt 8ml/kg 8ml/kg 8ml/kg
I:E 1:2 1:2 1:1.5
PEEP 5 cmH2O 5 cmH2O 3 cmH2O
RR 14 (up to 24) 16 (up to 30) 25 (up to 40)
Initial PRVC settings
SIMV settings
Check-list for early extubation (PRVC SIMV)
1. Stable Hemodynamics (BP, HR, U/O)
2. Rhythm (regular or AF with CVR )
3. Hemostasis (drain output within limits )
4. Neurologic status (awake, oriented)
5. ABG within acceptable range
6. Temperature (Per. temp>30˚c, Core temp- Per. temp ≤ 10)
7. Chest X ray (within normal limits)
• Change from initial PRVC to SIMV
• Initial PS above PEEP- Adults: 7 cmH2O, Infants 10 cmH2O
• Trigger- Adults: Flow ( -2L/min), Infants Pressure (-2cm H2O)
• Reduce RR by 3- 5, PS above PEEP by 2, PEEP by 1 [every 15-30 min]
• Repeat ABG every 30 min after changing settings
• TARGET: PEEP 5, FiO2 0.5, PS above PEEP 5, RR 5 (Minimal SIMV)
Weaning failure signs
Change in
• RR >10
• pCO2 >10
• SaO2 >10](https://image.slidesharecdn.com/protocolforventilatorsettings-200917145941/85/Protocol-for-ventilator-settings-1-320.jpg)
Protocol for ventilator settings
- 1. PROTOCOL FOR VENTILATORY SETTINGS 1. First ABG 10min after connecting to ventilator 2. pCO2 value: Increase /Decrease RR 3. Vt: Do not change until mean Paw cross upper limits 4. On PRVC: up to 25 mean Paw is acceptable Adult Child (1-10yr) Neonate/infant Vt 8ml/kg 8ml/kg 8ml/kg I:E 1:2 1:2 1:1.5 PEEP 5 cmH2O 5 cmH2O 3 cmH2O RR 14 (up to 24) 16 (up to 30) 25 (up to 40) Initial PRVC settings SIMV settings Check-list for early extubation (PRVC SIMV) 1. Stable Hemodynamics (BP, HR, U/O) 2. Rhythm (regular or AF with CVR ) 3. Hemostasis (drain output within limits ) 4. Neurologic status (awake, oriented) 5. ABG within acceptable range 6. Temperature (Per. temp>30˚c, Core temp- Per. temp ≤ 10) 7. Chest X ray (within normal limits) • Change from initial PRVC to SIMV • Initial PS above PEEP- Adults: 7 cmH2O, Infants 10 cmH2O • Trigger- Adults: Flow ( -2L/min), Infants Pressure (-2cm H2O) • Reduce RR by 3- 5, PS above PEEP by 2, PEEP by 1 [every 15-30 min] • Repeat ABG every 30 min after changing settings • TARGET: PEEP 5, FiO2 0.5, PS above PEEP 5, RR 5 (Minimal SIMV) Weaning failure signs Change in • RR >10 • pCO2 >10 • SaO2 >10
- 2. 1. Minimal SIMV 2. PS+CPAP (in adults and infants) / CPAP (in adults only) 3. T piece (Briggs) • Trial for 30 min Clinical evaluation, ABG Check list for Successful Spontaneous Breathing Trial • Neurological • awake without stimulation • Eye opening • Tongue protrusion • Good hand grip • Head raise • ABG • SaO2 > 92% • pO2 >80 mmHg (FiO2 ≤ 0.5) • pCO2 : 30-50 mmHg • pH 7.35- 7.45 (Base Excess <4) • Mechanics • Vt >5mL/kg • RR < 24 (adult), <35 (infant) • Stable BP, HR, rhythm • Chest tube drainage within normal limits Extubation • Head end elevation to at least 30˚ • Final suctioning of ET tube • Suctioning of oral cavity • Ask to cough as ET tube is removed in adult patients • Oral lavage following removal of ETT • Put on Humidified O2 by mask 10L/min • Repeat ABG after 30 min Transition ventilation • Post extubation support by CPAP/ BiPAP: If respiratory efforts are borderline and pCO2 retention on ABG or known cases of restrictive airway disease Spontaneous Breathing Trials
- 3. General directions & Special situations • Baer hugger can be applied if there is suspected coagulopathy (on going bleeding) and blood pressure is above normal • Active rewarming can be done if MAP >110 mmHg • Core and peripheral temperature difference >10˚c LCOS • All neonates should have core temp monitoring Rewarming BT shunt • Keep pCO2 40, Hct 40, FiO2 40 (SaO2 ~ 80%) • Any unexplained hypoxia, tachycardia, hypotension note down shunt flow BD Glenn and Fontan • Vt 8mL/kg (increase in intra thoracic pressure impedes venous return) • RR 18-20 • Extubate early as possible • BD Glenn (may keep pCO2 40-50 mmHg i/v/o cerebro-pulmonary circuit) Pulmonary oedema, ETT bleed, Residual LR shunt • Raise PEEP by 1-2 cmH2O (max 10-15 cmH2O) every 15 min, until lower inflection point is reached on flow volume loop • Minimize ET suction if there is no obstruction to airflow (Acute rise in Peak Paw) Bronchospasm in infants • Rule out cardiac cause (MC: volume overload) • Tube hitting carina • Local (secretions, mucus plug) Open sternum • High compliance and risk of barotrauma and volutrauma • Keep normal settings if ventilation parameters and ABG report is good • May need to set higher PEEP (5-7 cmH2O)