Ventilators

Question 1

Newly vented patient settings

Answer 1

Mode: CMV+ or A/C
Vt: 6 cc/kg IBW
Rate: Initially 14; adjust to achieve target EtCO2 not to exceed >35BPM
I/E: 1:2 for normal patient; 1:4 or 1:5 for COPD
FiO2: 1.0 initially and reassessed after 5 mins to target an SpO2 of 92-96%
PEEP: 5 cmH2O

Question 2

Plateau pressure goal

Answer 2

25<30 cmH2O

Check Pplat (0.5 second inspiratory pause), at least q4h and after each change in PEEP or Vt

• Pplat >30 cmH2O: decrease Vt in increments of 1ml/kg to a minimum of 4 ml/kg
• Pplat <25 cmH2O and Vt <6 ml/kg: Increase Vt by 1 ml/kg until Pplat >25 cmH2O or Vt = 6 ml/kg
• Pplat <30 cmH2O and breath stacking or dys-synchrony occurs: Increase Vt in 1ml/kg increments to a maximum of 7 or 8
  ml/kg if Pplat remains <30 cmH2O

Question 3

Alarm settings

Answer 3

High pressure alarm: 10 cmH2O above peak airway pressure
Low pressure alarm: 5 cmH20 below peak airway pressure

Question 4

DOPE

Answer 4

Displacement
* Ensure ETT is at the proper depth
* DO NOT attempt to advance without palacement of a bougie
* If ETT moves freely, check cuff pressure and assess for bulb rupture
* If in doubt remove airway and bag the patient

Obstructions
* Kinked ET tube
* Patient is biting on the tube
* Mucus plug; assess for secretions and suction

Pressure
* Tension pneumo/hemothorax; if chest tube in place ensure it is functioning and not kinked or clamped
* Bronchospasm
* Assess the need for escharotomy if circumferential burn
* Consider additional paralysis and sedation

Equipment
* Ensure that vent is functioning properly
* Check O2 tank pressure
* Trace all tubes to the patient
connection ensuring patency and connections

Question 5

Troubleshooting high pressure alarms

Answer 5

Assess for problems causing increased airway resistance and decreased lung compliance
* Pneumo/hemothorax
* Pulmonary edema
* Increased IAP
* Kinked tubing
* Biting the tube
* Bronchospasm
* Mainstem intubation
* Ensure ventilator is delivering the prescribed volume

Question 6

Troubleshooting low pressure alarms

Answer 6

• Assess for air leaks in the ETT,
  tracheostomy cuff, ventilator system
• Recheck ventilator to make sure prescribed tidal volume is delivered