Ventilator Management

Question 1

Non-invasive Indications

Answer 1

• Spontaneous breathing, able to protect airway reflexes
• Conscious
• Inadequate response to first-line interventions where WOB is unrelieved; fatigue, persistent hypoxia, or hypercarbia

Question 2

Non-invasive Absolute Contraindications

Answer 2

• Inability to achieve a good seal
• Suspected pneumothorax/barotraumas
• Inability to maintain airway patency: Cardiac/respiratory arrest, obtunded
• Major trauma, especially head injury w/ increased ICP
• Vomiting

Question 3

Non-invasive Relative Contraindications

Answer 3

• Inability to cooperate, tolerate, or understand the use of device
• Claustrophobia
• RR > 30 bpm

Question 4

BiPAP Settings

Answer 4

• Set patient gender and height & then select “NIV” as the mode
• To calculate IPAP add the ^Psupport & the PEEP. (i.e on interfacilities to set the
  ventilator to an IPAP 12/ EPAP 6 you subtract the EPAP from the IPAP to find the
  ^Psupport. To provide report to receiving facilities add the ^Psupport & PEEP to obtain
  the IPAP.)
• Set ^Psupport: 6cmH2O
• Set PEEP(EPAP): 6cmH2O
• IPAP is the sum of PEEP & ^Psupport, titrate to a max additive pressure of 20 cm
  H2O
• If currently on BiPAP: Mirror facility’s settings
• Press “Confirm” & then press “Start Ventilator”
• Adjust FiO2 to maintain SPO2 >92%
• Adjust P-ramp to 50-100ms
• Adjust ETS to 40%
• Place on standby mode
• Apply mask to patient, using correct size, & close external vent ports
  ^Psupport may be adjusted based on exhaled tidal volumes. Titrate ^Psupport from
  6 cmH2O in increments of 2cmH2O every 2 minutes until the goal tidal volume of 6-8mL/Kg.
  EtCO2 may be unreliable but may be used for trending. Simply monitor to ensure improving EtCO2, mentation, & WOB. Intubate if the sum of the ^Psupport & PEEP are at a max of
  20cmH2O & the patient is worsening as this indicates failure of BiPAP.

PEEP(EPAP) may be adjusted from 5-14cmH2O to achieve adequate oxygenation if FiO2 is unable to be weaned less than 60%.

Question 5

Initial vent settings Adults/Peds >10 kg

Answer 5

• Tidal volume: 6-8 mL/kg IBW
• Mode: APVcmv
• Rate: 16-25 bpm (Adults)
  18-30 bpm (peds)
  30-40 bpm (neo)
• I-time: Achieve I:E ratio of 1:2
• PEEP: 5-8 cmH2O **Max PEEP 14 cmH2O (before md direction)
• FiO2: 100%, titrate to maintain SpO2 ≥ 92%
• PIP alarm: 40 cmH2O (adults)
  20 cmH2O (peds/neo)