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CO2 Changes : RR * TV
O2 Changes : FiO2 & PEEP
AC = Assistant control = CMV
1. Tidal volume setting by IBW (6-8mL/kg)
Minute Ventilation = Tidal Volume x RR
Increasing tidal volume makes your ABG look really good, but worsens the patients outcomes !
If you cannot maintain a SaO2 > 90% with a 30% FiO2, consider if your patient is in ARDS.
PaO2 / FiO2 = 60 / 0.3 = 200 考慮 Low tidal volume
( SaO2 90% 約等於 PaO2 60 )
https://www.mdcalc.com/ideal-body-weight-adjusted-body-weight
https://www.mdcalc.com/endotracheal-tube-ett-depth-tidal-volume-calculator
Minute Ventilation = Tidal Volume x RR
Increasing tidal volume makes your ABG look really good, but worsens the patients outcomes !
If you cannot maintain a SaO2 > 90% with a 30% FiO2, consider if your patient is in ARDS.
PaO2 / FiO2 = 60 / 0.3 = 200 考慮 Low tidal volume
( SaO2 90% 約等於 PaO2 60 )
https://www.mdcalc.com/ideal-body-weight-adjusted-body-weight
https://www.mdcalc.com/endotracheal-tube-ett-depth-tidal-volume-calculator
2. RR 16 -24
Need CO2 wash out 可以設高一點
Lung 沒問題, 因為其他原因 protect airway 插管, 可以設低一點
Need CO2 wash out 可以設高一點
Lung 沒問題, 因為其他原因 protect airway 插管, 可以設低一點
3. Start with the lowest FiO2 possible to keep SpO2 > 90% 越低越好
FiO2 對應到相對的 PEEP (If you increase the FiO2, then remember to increase the PEEP as well)
FiO2 對應到相對的 PEEP (If you increase the FiO2, then remember to increase the PEEP as well)
4. Inspiratory time 0.8
Inspiratory flow 70 LPM
Inspiratory flow 70 LPM
< Managing Initial Mechanical Ventilation in the Emergency Department 2016 >
Lung protective strategy :
Low-tidal volume to reduce barotrauma and volutrauma
This strategy should be chosen for patient intubated in the ED who does not have
obstructive disease (Asthma or COPD)
Tidal Volume Is for Alveolar Protection
Inspiratory Flow Rate Is for Patient Comfort
Respiratory Rate Is for Titrating Ventilation
An initial rate of 15 - 16 breaths/min should allow normocapnia in most patients.
Inspiratory Flow Rate Is for Patient Comfort
Respiratory Rate Is for Titrating Ventilation
An initial rate of 15 - 16 breaths/min should allow normocapnia in most patients.
After 20 to 30 minutes, blood gas testing to allow further titration
EtCO2 can be used as a spur to increase the RR if the EtCO2 value is greater than the PaCO2 goal;
EtCO2 can be used as a spur to increase the RR if the EtCO2 value is greater than the PaCO2 goal;
however, a low ETCO2 level should not trigger a decreasing of the RR
PEEP and FiO2 Are for Titrating Oxygenation
Once the FiO2 reaches greater than 50%, any continuing hypoxemia is due to physiologic shunt
The solution to this shunt is PEEP.
Rapidly titrate to PEEP-FiO2 combinations that result in an SpO2 of 90%
Once the FiO2 reaches greater than 50%, any continuing hypoxemia is due to physiologic shunt
The solution to this shunt is PEEP.
Rapidly titrate to PEEP-FiO2 combinations that result in an SpO2 of 90%
Checking for Alveolar Safety
Every 30 - 60 minutes, a plateau pressure should be checked.
If the plateau pressure > 30 cm H2O, there is the potential for alveolar injury.
Every 30 - 60 minutes, a plateau pressure should be checked.
If the plateau pressure > 30 cm H2O, there is the potential for alveolar injury.
The solutionis to decrease the tidal volume by 1 mL/kg until a plateau pressure < 30 cmH2O.
Tidal volumes as low as 4 mL/kg are acceptable, although rarely necessary in the ED.
Tidal volumes as low as 4 mL/kg are acceptable, although rarely necessary in the ED.
In such cases, you will likely need to increase the RR to maintain PaCO2 goals.
If you have reached the limit of respiratory rate titration,
the patient should be allowed to maintain permissive hypercapnia.
Obstructive Strategy :
The best ventilatory strategy in the obstructive patient is to avoid intubation altogether.
The best ventilatory strategy in the obstructive patient is to avoid intubation altogether.
These patients often respond to aggressive pharmacologic and noninvasive ventilatory strategies.
If forced to intubate because of worsening mental status,
be aware that the ventilator will often make the pulmonary situation worse rather than better.
The primary goal of the ventilator strategy for obstructive patients is to allow time to exhale.
Tidal Volume : 8 ml/kg, not need to be titrated.
Decreasing the RR allows more time for expiration. 慢比較好
Tidal Volume : 8 ml/kg, not need to be titrated.
Decreasing the RR allows more time for expiration. 慢比較好
These patients will inevitably become hypercapnic when the respiratory rate is set properly.
In severe asthma or COPD exacerbations the I:E ratio can be 1:3 – 1:5
In severe asthma or COPD exacerbations the I:E ratio can be 1:3 – 1:5
This hypercapnia should be permitted.
A starting rate of 8 - 10 should be used and then titrated as discussed below.
There are no compelling data to suggest any benefit in the application of PEEP within the first few hours postintubation.
As such, a PEEP of 0 is my recommendation
(也有這個說法 : Low amount of PEEP, and a PEEP set to 5mm Hg to start should be perfect.)
As such, a PEEP of 0 is my recommendation
(也有這個說法 : Low amount of PEEP, and a PEEP set to 5mm Hg to start should be perfect.)
Applied PEEP can mitigate the effects of auto-PEEP in patients who have an expiratory airflow limitation
Obstructive Disease 的病人肺泡的塌陷比較不是主要的問題
但有時PEEPi已經會影響病人trigger 呼吸，此時可以考慮將PEEPe設在PEEPi 的 75%-80%
可以平衡掉病人 PEEPi 造成的額外負擔
Flow versus time graph : Ensure the absence of breath stacking
Obstructive Disease 的病人肺泡的塌陷比較不是主要的問題
但有時PEEPi已經會影響病人trigger 呼吸，此時可以考慮將PEEPe設在PEEPi 的 75%-80%
可以平衡掉病人 PEEPi 造成的額外負擔
Flow versus time graph : Ensure the absence of breath stacking
If the plateau pressure is > 30 cm H2O or the flow graph demonstrates breath stacking,
then the RR should be decreased.
then the RR should be decreased.
Normally a starting inspiratory flow rate may be 60-80 L/minute.
In the obstructive patient, who you may want to allow more time to expire,
then you can increase your inspiratory flow rate to deliver your tidal volume more quickly allowing more time to expire.
In the obstructive patient, who you may want to allow more time to expire,
then you can increase your inspiratory flow rate to deliver your tidal volume more quickly allowing more time to expire.
Please warn everyone that the PIP may be very high (40-60 mm Hg) and reset your pressure ventilator alarm as this will constantly alarm due to high PIP, but explain to not worry as this pressure is not being transmitted to the alveoli and as long as the PPlat is less than 30 mm Hg.
In very severe obstructive lung disease,
you need to allow time for you therapies to work and the ventilator is just a supportive device
Do not target a perfect blood gas ~ Permissive hypercapnia
A pH > 7.2 with a pCO2 < 90 may be the best you can get your patient safely, so don’t panic.
The pressure will need be set very high to overcome upper airway resistance
and the patient will likely not get adequate tidal volumes. (Volume breaths rather than pressure)
and the patient will likely not get adequate tidal volumes. (Volume breaths rather than pressure)
https://rebelem.com/simplifying-mechanical-ventilation-part-4-obstructive-physiology/
http://internalmeddoc.blogspot.com/2017/05/ventilator-basic.html
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