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Initial ventilator settings

Introduction. The choice of ventilator settings

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Initial ventilator settings

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    1. Initial ventilator settings Dr Chaitanya Vemuri Int.Med M.D Trainee

    2. Introduction The choice of ventilator settings – guided by clearly defined therapeutic end points. In most of cases : primary goal is to correct abnormalities of arterial blood gas tensions Accomplished by adjusting minute volume - to correct hypercapnea oxygen supplementation – to correct hypoxemia

    3. General aspects of ventilator management Choice of inspired gas composition Means to ensure the machine’s sensing of patient’s demand Definition of machine’s mechanical output

    4. INITIATION

    5. Confirm indication for mechanical ventilation Invasive / Non invasive Check Connections & Circuit Self test Select mode Set variables Alarm settings Connect to patient Monitor and reassess

    6. indications Patient not breathing Patient breathing but not enough Patient breathing enough, but pt hypoxemic / hypercapneic Patient breathing with normal gas exchange, but working hard Airway protection

    7. Indications LABORATORY CRITERIA CLINICAL CRITERIA OTHER CRITERIA

    8. LABORATORY CRITERIA Blood gases : PaO2 < 55 mm Hg PaCo2 > 50 mm Hg pH < 7.32 PFT : Vital Capacity < 10 ml/Kg -ve inspiratory force <25cm H20 FEV 1 < 10 mL/Kg

    9. Clinical criteria Apnea / Hypopnea Respiratory distress with altered mentation Clinically apparent increasing work of breathing unrelieved by other interventions Need for airway protection

    10. Other criteria Controlled hyperventilation ( eg head injury ) Severe circulatory shock THERE IS NO ABSOLUTE CONTRAINDICATION FOR MECHANICAL VENTILATION

    11. Connections

    12. connections

    13. Connections

    14. Self test To check : - leak - compliance - resistance of circuit - sensors Needs to be done : - before connecting to patient - once in 2 weeks - whenever circuit is changed

    15. Select mode Depends on : Patients requirement User comfort Availability

    16. Basic principles For PO2 : adjust FiO2, PEEP For PCo2 : adjust TV , RR

    17. Set variables

    18. MODE OF VENTILATION Tailored to need of the patient SIMV / A/C – versatile modes for initial settings In pts with good resp drive & mild – mod resp failure – PSV

    19. Tidal volume Initial TV : 5 – 8 ml/Kg of ideal bd wt Lowest values are recommended in presence of Obstructive airway ds & ARDS Goal : to adjust TV so that plateau pressures are less than 35 cm H20

    20. Respiratory rate 8 – 12 breaths per minute : pts not requiring hyperventilation for treatment of toxic/metabolic acidosis or intracranial injury Initial rate may be low ( 5 – 6 breaths per min ) in asthmatic pts where permissive hypercapnic technique is used

    21. Supplemental o2 therapy Lowest FiO2 that produces an Sp02 > 90 % PaO2 > 60 mm Hg is recommended

    22. Inspiration : expiration ratio Normal I:E ratio to start is 1:2 Reduced to 1:4 or 1:5 in presence of obstructive airway disease in order to air trapping Inverse I:E – in ARDS

    23. INSPIRATORY FLOW RATE 60 L/min is typically used Increased to 100 L/min : to deliver TVs quickly and allow for prolonged expiration in presence of obstructive airway ds

    24. Positive end expiratory pressure ( peep ) Titrated according to PEEP and BP High PEEP ( > 10 H20 ) – pneumonia, ards PEEP – reduces risk of atelectasis - increase no of open alveoli ( decrease V/Q mismatch ) - in CHF : decrease venous return Physiological PEEP ( 3-5 cm H20 ) : to prevent decrease in FRC in normal lungs

    25. Sensitivity ( TRIGGER ) Set at -1 to -2 cm H20 NEWER VENTILATORS SENSE INSPIRATORY FLOW and thereby reduce work of breathing associated with ventilator triggering

    26. SET VARIABLES Mode : Complete / Partial . VCV/PCV Rate : titrate to Pco2 Tidal Volume : 5 – 8 ml / Kg Flow rate & Pattern : 4 – 8 times Minute Ventilation I:E = 1:2 to 1:4 FiO2 : titrate to O2 Saturation / Pa O2 PEEP : titrate to PaO2 & BP Trigger : Adjust to synchronize

    27. Alarm settings Fixed alarms : disconnection o2 sensor Set alarms : volume pressure rate apnea

    28. Monitor & reassess Patient Monitor : pulse , bp , rr, spO2 Ventilator Abg Volume Pressure Rate Patient comfort / synchrony

    29. Ventilatory settings in various diseases

    30. For Paralysed pts : CMV or A/C mode For Non paralysed pts : SIMV mode Pts with normal resp effort mild resp failure : PSV mode

    31. Asthma & copd Hypoxia corrected by High FiO2 Increase Expiratory Flow Time to max : to prevent increase intrinsicPEEP RR : 6 -8 breaths / min ( permissive hypercapnia ) I : E : increased 1:2

    32. ards A/C mode Tidal Volume : 6 ml/Kg PEEP : 5 Ventilatory rate : 12 titrated to maintain Ph > 7.25

    33. Chf Respond well to positive pressure ventilation (opens alveoli, reduces preload) Many benefit from trial of noninvasive CPAP / BiPAP Intubated pts usually manage to oxygenate well But PEEP can be increased to improve oxygenation and reduce preload

    34. Thank you

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