Mechanical Ventilation Guide

Home , Airway obstruction, Chest tube, Compartment syndrome, Spinal shock, Thoracentesis

MAYO CLINIC MECHANICAL VENTILATION GUIDE RESP GOALS INITIAL MONITORING TARGETS FAILURE SETTINGS 6 P’s BASIC HEMODYNAMIC 1 BLOOD PRESSURE SBP > 90mmHg STABILITY PEAK INSPIRATORY 2 < 35cmH O PRESSURE (PIP) 2 BAROTRAUMA PLATEAU PRESSURE (P ) < 30cmH O

PREVENTION PLAT 2

SAFETY SAFETY 3 AutoPEEP None

VOLUTRAUMA Start Here TIDAL VOLUME (V ) ~ 6-8cc/kg IBW PREVENTION T

Loss of AIRWAY Female ETT 7.0-7.5 AIRWAY / ETT / TRACH Patent

Airway MAINTENANCE Male ETT 8.0-8.5

AIRWAY AIRWAY

FiO2 21 - 100% PULSE OXIMETRY (SpO2) > 90% Hypoxia OXYGENATION 4 PEEP 5 [5-15] pO2 > 60mmHg

5’5” = 350cc [max 600] pCO2 40mmHg TIDAL 6’0” = 450cc [max 750] 5 VOLUME 6’5” = 500cc [max 850] ETCO2 45 Hypercapnia VENTILATION

pH 7.4 GAS GAS EXCHANGE BPM (RR) 14 [10-30] GAS EXCHANGE MINUTE VENTILATION (VMIN) > 5L/min SYNCHRONY WORK OF BREATHING Decreased High Work ASSIST CONTROL MODE VOLUME or PRESSURE of Breathing PATIENT-VENTILATOR AC (V) / AC (P) 6 Comfortable Breaths

(WOB) SUPPORT SYNCHRONY

COMFORT COMFORT

2⁰ ASSESSMENT PATIENT CIRCUIT VENT Mental Status PIP RR, WOB Pulse, HR, Rhythm ETT/Trach Position Tidal Volume (V ) Trachea T Blood Pressure Secretions Minute Ventilation (V ) SpO MIN Skin Temp/Color 2 Connections Synchrony ETCO Cap Refill 2 Air-Trapping

1. Recognize Signs of Shock Work-up and Manage 2. Assess 6Ps If single problem Troubleshoot Cause

3. If Multiple Problems QUICK FIX Troubleshoot Cause(s)

PROBLEMS

Bleeding Hemostasis, Transfuse, Treat cause, Temperature control

HYPOVOLEMIA Dehydration Fluid Resuscitation (End points = hypoxia, ↑StO2, ↓PVI) 3rd Spacing Treat cause, Beware of hypoxia (3rd spacing in lungs)

Pneumothorax Needle D, Chest tube

Abdominal Compartment Syndrome FLUID Treat Cause, Paralyze, Surgery (Open Abdomen) OBSTRUCTED BLOOD RETURN Air-Trapping (AutoPEEP) (if not hypoxic) Pop off vent & SEE SEPARATE CHART

PEEP Reduce PEEP Cardiac Tamponade Pericardiocentesis, Drain. Avoid mechanical ventilation if possible

BP) EPINEPHRINE Stun, Contusion, Chronic HF Time, Rest (Sedate), Avoid cardiac stress

↓ (if not tachy)

Cardiac Cardiac Output (

Ischemia/Infarction ASA (if no trauma), Maintain SBP >90, SpO2 > 90%, ?Transfuse ↓ CARDIAC FAILURE Arrhythmia ↓PEEP Treat cause (i.e. ischemia, electrolytes), Anti-arrhythmic, Cardiovert

HYPOTENSION Diastolic or Valve Dysfunction (if not hypoxic) Treatment dependent on cause Right Heart Failure Treat cause (i.e. PE). Avoid high PEEP, hypoxia, acidosis Infection Treat infection, Source control, Consider Epi

VASODILATION Spinal Shock & Anaphylaxis Treat cause, ?Epi. Diphenhydramine Tone

Medications Avoid / Adjust precipitating meds (i.e. sedatives, narcotics, TIVA) ↓ Lung Injury / ARDS / Contusion Treat cause (i.e. Blast, Infection, Inhalation, Trauma)

Pneumonia Antibiotics, Pulmonary/Oral hygiene, Aspiration prevention LUNG DISEASE / INJURY Cardiogenic Pulmonary Edema ↑PEEP (& ↓Tidal Volume), Treat HF cause Alveolar Hemorrhage POP OFF Treat cause, Consider ↑PEEP, Limit suctioning, Fix coags Pneumothorax VENT Needle D, Chest tube Hemothorax / Effusion Thoracentesis, Chest tube, Fix injury/Surgery, Transfuse PIP) LUNG COMPRESSION (if air-trapping) Abdominal Compartment Syndrome Treat Cause, Sedate/Paralyze, Surgery

↑ ( Atelectasis SUCTION Bag w/ PEEP valve, Recruitment, Patient re-positioning DYSSYNCHRONY SEE SEPARATE CHART SEE SEPARATE CHART

BAROTRAUMA BAROTRAUMA AIR-TRAPPING Incomplete Exhalation & Airway Obstruction SEE SEPARATE CHART ↑ PEEP BAG Weigh risk & need for current PEEP VENTILATOR SETTINGS ↑ Tidal Volumes VENTILATE Weigh risk & need for current Tidal Volume

DYSSYNCHRONY SEE SEPARATE CHART SEDATE & SEE SEPARATE CHART ETT Obstruction Suction, Adjust ETT / Trach, Stop biting (Sedate), Bronchoscopy AIRWAY DISEASE Airway Secretions / Debris PARALYZE Pulmonary Toilet, Oral hygiene, Bronchoscopy Severe Bronchoconstriction Bronchodilator, ↑ Exhalation time (↓ i-Time) ↑ I:E Ratio ↓ i-Time (Minimum is 0.6 seconds) VENTILATOR SETTINGS autoPEEP ↑ RR ↓ RR Pain, Anxiety, Agitation Treat pain, anxiety, agitation

Metabolic Acidosis Treat cause, ?NaHCO3, Hypoxia POP OFF SEE SEPARATE CHART Low Set Tidal Volume / PIP ↑Tidal Volume / PIP TACHYPNEA (↑RR) Inadequate Support (Mode) VENT Change mode (Consider AC), ↑RR CNS Injury (if air-trapping) Treat underlying cause

Thoracic/Lung Injury or Irritation Treat cause (i.e. Pneumothorax, ARDS, Inhalation Injury) Auto-Cycling / Auto-Triggering SUCTION Adjust trigger setting on vent

Gag / Cough / Hiccups Sedate, Suction, Treat Hiccups BREATH-STACKING Short i-Time SEDATE & Lengthen i-Time Long i-Time PARALYZE Shorten i-Time DYSSYNCHRONY DEMAND-SUPPORT MISMATCH Inadequate flow (except w/ CNS injury) Change Mode, Unlock flow

Low VT Increase Tidal Volume, PC, or PS AIR-TRAPPING Incomplete Exhalation & Airway Obstruction SEE SEPARATE CHART

LOW OXYGEN SUPPLY Low FiO2 (Supply) ↑ FiO2 ETT / Trach Mal-position Adjust, replace ETT / Trach, Ensure cuff inflation

Upper Airway Obstruction Adjust ETT/Trach, Stop biting (Sedate)

) AIRWAY DISORDER 2 Secretions / Debris SUCTION Pulmonary Toilet, Oral hygiene

Severe Bronchoconstriction Bronchodilator, ↑Exhalation time (↓ i-Time)

/ pO /

2 Lung Disease BAG ↑PEEP & Treat Cause (SEE ↑PIP CHART) (ARDS, ALI, ILD, Pneumonia, Pulmonary VENTILATE In severe cases, consider: Paralysis, iNO, Positional therapy, ECMO SpO AIR SAC (ALVEOLAR) DISEASE Edema, Contusion, Alveolar Hemorrhage)

HYPOXIA HYPOXIA (unless ETT/Trach ↓

( (↓ Ventilation) Lung Compression in false passage) Treat Cause (i.e. Needle D, Chest tube) (Pneumothorax, Hemothorax, Effusion, ↑PEEP if not in shock (i.e. w/ Tension Pneumothorax or Bleeding) Abdominal Compartment Syndrome, Atelectasis) ↓ BLOOD FLOW (Perfusion) Pulmonary Embolus Anticoagulation, O2, Monitor for RH failure, iNO, ?TPA if no bleeding

ETT / Trach Mal-position Adjust, replace ETT / Trach, Ensure cuff inflation Upper Airway Obstruction Adjust ETT / Trach, Stop biting (Sedate), Bronchoscopy

AIRWAY HYPOVENTILATION POP OFF

Airway Secretions / Debris Pulmonary Toilet, Oral hygiene, Bronchoscopy Bronchoconstriction VENT Bronchodilator, ↑Exhalation time (↓ i-Time)

) Lung Disease (ARDS, ALI, Pneumonia, ↑Tidal Volume, ↑RR, ↑PEEP (to recruit lung) 2 Pulmonary Edema, Contusion, Alveolar SUCTION Treat Cause (SEE ↑PIP CHART)

AIR SAC (ALVEOLAR) Hemorrhage Maintain lung protective ventilation

Tidal Tidal Volume

/ pCO /

2 HYPOVENTILATION Lung Compression BAG ↓ Treat Cause (i.e. Needle D, Chest tube, Surgery, PEEP) (↓ Compliance) (Pneumothorax, Hemothorax, Effusion, ACS, VENTILATE (SEE ↑PIP CHART) Atelectasis)

ETCO (unless ETT/Trach in

Air-Trapping (AutoPEEP) false passage) SEE SEPARATE CHART ↑ ( VENTILATOR SETTINGS Low Set Tidal Volume ↑ Tidal Volume or PIP (goal 6-8cc/kg IBW)

HYPOVENTILATION HYPOVENTILATION Medications Re-consider sedative need & dose ↓ RESPIRATORY DRIVE CNS Injury ↑RR Treat cause/injury, Re-consider pCO goal