Initiating or Maintaining Mechanical Ventilation - Respiratory

Question 1

What are the ventilation safety parameters for:
1. SpO2? If pt is known CO2 retainer?
2. ETCO2? If pt has increased ICP?
3. Vt?
4. FiO2?
5. PEEP range?
6. PIP?
7. I:E ratio range?

Answer 1

1. SpO2 94-98%, if pt is known CO2 retainer 88-92%
2. ETCO2 35-45mmHg, If pt has increased ICP 33-38mmHg
3. Vt 6-8 mL/kg IBW
4. FiO2 0.6 or less
5. PEEP range 5-10 cm H2O
6. PIP <30 cm H2O
7. I:E ratio range of 1:1.5-3.0

Question 2

When does a CCP have to patch for initiating or maintaining mech ventilation as per the MDSO?

Answer 2

1. If ventilation settings are outside the safety parameters
2. If FiO2 at sending facility is >0.6 and medics unable to lower it while maintaining SpO2 of 94-98%
3. Use of adjuncts: heliox, nitric oxide, inhaled flolan or prone
4. Bicarb from ABG/VBG <15 or >35 (clarify pH/ETCO2 with TMP)

Question 3

What is the maximum cuff pressure in an ETT?

Answer 3

20-30 cm H2O

Question 4

COPD/Asthma Ventilation Strategies per MDSO:
RR?
I:E ratio?
Vt?
PEEP
Inspiratory time (Ti)?
Plateau pressure?

Answer 4

RR: 8-12 (low to normal frequency)
I:E of 1:4 - 1:5
Vt of 4-6 ml/kg IBW
PEEP 5 cm H2O
Ti of <1 second (0.7-1.0)
Plateau pressure <30 cm H2O

Question 5

If difficult to ventilate or oxygenate COPD/asthma patients optimize analgosedation & paralysis and consider permissive hypercapnia and/or these 2 medications…

Answer 5

Magnesium sulfate IV infusion (bronchodilation)
Ketamine IV (minor bronchodilation, reduced agitation)

Question 6

ALI/ARDS Ventilation Strategies as per the MDSO suggests what parameters for the following:
RR
Vt (if pplat >30 and < 30)
FiO2
PEEP
ETCO2
I:E ratios

Answer 6

RR 20-26/min initially, adjust for target ETCO2
Vt: start at 6ml/kg IBW, if pplat <30 increase to 8ml/kg, if pplat >30 reduce Vt to 4-5 ml/kg (no less than 4 ml/kg!)
FiO2: start at 1.0, decrease from there
PEEP: 5-10, if SpO2 <90% increase by 2 cmH2O to max 20 (refer to ARDSnet table)
ETCO2 45-80 mmHg (permissive hypercapnia, target pH 7.2-7.25)
I:E ratios: consider <1:2 (eg. 1:1.8 - 1:1)