Manage the Vent Like a Pro

Short Attention Span Ventilator Summary

Mechanical Ventilation Made Ridiculously Simple
Scott Weingart published a handy guide to managing the ventilator in a recent Annals of EM review article.  Here are the highlights.

• Lung Protection Strategy – ARDS and Acute Lung Injury

  • Mode: volume-assist control

  • Tidal Volume: 8 mL/kg starting; titrate to 6mL/kg as tolerated (see link below for ARDSnet protocol; use ideal body weight)

  • Flow: inspiratory flow rate at least 60L/min for patient comfort

  • RR: 15-16 breaths/min is a good start but must be titrated based on blood gases (EtCO2 is only a rough guide).

  • PEEP/FiO2: Titrate FiO2 down to 30-40% ASAP and start with PEEP at 5. Use ARDSnet PEEP/FiO2 combinations to achieve SpO2 88-95%. Do NOT aim for 100% because hyperoxia is deleterious.

  • Safety: Check plateau pressure by sedating and pressing the inspiratory hold button at the end of a breath. Goal is <30. If too high, decrease tidal volume 1 mL/kg. Watch blood gases, increase RR prn, and if the lungs are terribly stiff, allow permissive hypercapnea.

• Obstructive Ventilation Strategy – Asthma and COPD

  • “The best ventilatory strategy in the obstructive patient is to avoid intubation altogether.”

  • “The primary goal of the ventilator strategy for obstructive patients is to allow time to exhale.”

  • Mode: volume-assist control

  • Tidal Volume: 8 mL/kg

  • Flow: He recommends against markedly increasing inspiratory flow beyond the usual 60-80 L/min because it causes high peak pressures, alarms, and has only minimal effect on increasing exhalation time.

  • RR: RR is the key driver to allow time to exhale. 8-10 breaths/min is enough. Simply allow permissive hypercapnea. It will probably happen.

  • PEEP/FiO2: Go low. Shoot for FiO2 40% ASAP. He advocates for PEEP at zero the first few hours, then up to 5 later.

  • Peak pressures: Set limits high enough to deliver 8 mL/kg in full. High peak pressures are due to large airway resistance (i.e. bronchospasm) and are not transmitted to the alveoli. If plateau pressures are >30, reduce RR further if you can.

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Citation

Ann Emerg Med. 2016 Nov;68(5):614-617. doi: 10.1016/j.annemergmed.2016.04.059. Epub 2016 Jun 9.

Managing Initial Mechanical Ventilation in the Emergency Department.

Weingart SD1.

Author information:

1Division of Emergency Critical Care, Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, NY.

PMID: 27289336 [PubMed – in process]