ED Ventilator Settings

Quality Control editors at work.

Quality Control editors at work.

All excited for intubation but forget to optimize the ventilatory settings?

Important for those that are not rapidly taken away to the ICU.

Ventilation
Tidal Volumes: low tidal volumes 6 ml/kg (ideal body weight) even without acute lung injury is even beneficial.  Study by Determann et al. 2010 Critical Care.  Looked at 150 patients, randomized trial of 10 vs 6 ml/kg.  Development of Acute lung injury in 13.5 in the 10 ml/kg group and 2.6 in the 6 ml/kg group.  Stopped early because of difference.
Respiratory Rate: Minute ventilation is RRxTV.  You want a MV of 5-6L/min in a normal patient, but if need to increase for metabolic derrangement may need much higher.  Permissive hypercapnea is okay in those with ARDS.  Caution in those with brain injury and severe metabolic acidosis.  Don’t go higher than RR of 35.  Keep ph>7.15, as done in ARDSnet.

***In an asthmatic: you may need to increase the flow rate to 80-100 L/min which will decrease the I:E ratio and allow for more time in exhalation.  You will also want to decrease the expiratory rate.

Oxygenation
Stratagies to improve oxygenation: you want to get the Fi02 <60% but may not be able to if other pathology causing hypoxia.  You may put the good side down to increase blood flow to that lung (DONT DO IN BLOOD FILLED LUNG), increase the PEEP but takes 10-15 min to see difference, recruitment exercise with 30 for 30 (30 mmH20 for 30 seconds) with subsequent increase in PEEP to keep alveoli open, increase the I:E ratio (ie I time) but caution as this can increase peak pressures and lead to autopeep.

Dyssynchrony
#1: Look for serious condition such as hypoxia, tension pneumo, dynamic hyperinflation
#2: Give sedation/analgesia
#3: Adjust I:E time or PEEP

Acutely Unstable Vented Patient
DOPE: Dislodgement, Obstruction, Pneumothorax, Equipment malfunction
#1: disconnect the patient from the vent and BVM with 100% oxygen
#2: if having bag ventilation difficulty: look for tension pneumo, dynamic hyperinflation (let exhale and squeeze the chest wall), abdominal compartment syndrome (bladder pressures >20 mmHg by bladder cath).

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