Ventilators
AC—> VC or PC
- AC= Can initiate own breath over vent
- VC pressures can vary, PC volumes can vary
Setting Vent
- TV (co2)
- RR (co2)
- PEEP (o2)
- Fio2 (o2)
Reporting Vent settings
- At my hospital they use ACPC
- Pressure over PEEP/PEEP/FiO2/RR/Tidal volume
- Want the delta close to 5/5 before extubating
Goal tidal volume
- 6-8cc/kg ideal body weight
IBW & Tidal Volume Calculator
After intubation
- Daily CXR
- Central line, A-lie, NG/OG tube
- FASTHUGS BID—> Feeding, Analgesia, Sedation, Thrombo prophylaxis, Hob>30 degrees, Ulcer prophylaxis, Sugars 140-180, spontaneous Breathing/Bowel regimen, Indwelling lines, De-escelate abx and other medications
- ABG 30 minutes after a change in vent settings
- VBG: to look at pco2/pH, pH is actually 0.05 higher than it reads on VBG
Monitoring
- P:F ratio—> Pao2 from ABG : FIO2 from ventilator
P/F Ratio Calculator
- BERLIN criteria for ARDS
- Resp failure within 7 days, bilateral opacities
- P:F< 300 mild ARDS
- P:F< 200 moderate ARDS
- P:F< 100 severe ARDS
- Peak pressures< 40 (airway resistance/obstruction)
- Plateau< 30 (platonic compliance)
- Driving pressure< 15 (plateau-peak—> alveoli opening and closing)
- PEEP prevents alveolar derecruitment
Berlin Criteria ARDS Calculator
Trials
- ARDS net—> TV 6cc/kg did better than TV 12 (allow permissive hypercapnia of pH> 7.20 to reduce pressures)
- PROSEVA—> proning improves outcomes when P:F<150 (decreases the collapsed posterior portion of lung)—> Prone 18:6
- ACURASYS—> paralysis improves outcomes when P:F<150
Extubation
- Want PAO2 55-80
- FIO2 less than 60% then decrease PEEP
- Want DELTA (CPAP over PEEP: PEEP close to 5:5)
- Daily SBT’s and daily sedation holidays (put on PS for 30 mins-1hr) or T-piece trial if very high risk
- RSBI (rapid shallow breathing index)= RR/TV > 105 then will fail SBT
RSBI Calculator
- Assess cuff leak-> absence of cuff leak OR no decrease in TV more than 110mL then laryngeal edema
- NIF <-25% good
- Patient following commands
- If high risk COPD/CHF then extubate to BIPAP
- Around day 10 start considering tracheostomy (will start to get tracheal stenosis around ET tube)-> need PEEP<10 and FIO2<60%