2. Initiating Positive Pressure CMV A generic approach!

3. Do these BEFORE attaching the patient Assemble the ventilator circuit Attach humidifier and fill with water Attach high pressure O2 hose (may also need hose for air) Plug ventilator in

4. Set the FIO2 If no prior ABGs, start on 100%

5. Set desired Vt 6-12 ml/kg

6. Set rate Choose a rate that in conjunction with Vt, gives a minimum Ve of 6-8 LPM ALWAYS THINK OF MINUTE VENTILATION WHEN SETTING RATE

7. Set flowrate Start between 40-60 LPM Make sure it meets patients inspiratory demand –Steady rise on manometer Make sure it gives good I:E ratio The larger the Vt, the faster the flowrate!

8. Set sigh parameters ( if using) Sigh Vt = 1.5 x Vt Sigh rate = 6-10 per hour

9. Set sensitivity If pressure triggering, set for 1-2 cmH2O pressure drop If flow triggering, usually set for 3-5 LPM drop in flow

10. Turn ventilator on and attach patient Note: make sure high pressure alarms are set at 50 cmH2O to start the patient on CMV

11. Set high pressure alarms For Vt, set 5-10 cmH2O greater than peak pressure for Vt For sigh, set 5-10 cmH2O greater than peak pressure for sigh

12. Set low exhaled volume alarm Set 100 ml less than Vt

13. Set low pressure alarm Set 5-10 cmH2O less than peak pressure for Vt

14. Alarms and Monitors What they mean and what to do

15. Assist Light Shows patient triggered the breath If patient is not triggering and light is on, then ventilator is too sensitive –autocycling

16. Pressure Light Shows ventilator pressure limited the breath Also has audible alarm

17. Pressure limiting may be caused by: Secretions Water in the tubing Physical obstruction or a kink in tubing Change in patient position ET tube in right main stem bronchus Pneumothorax Maladjusted control

18. Indicates increased resistance Also a decrease in compliance

19. Remember: Flow =pressure/resistance

20. Ratio Light Indicates inverse I:E –Inspiration is as long or longer than expiration Increase flow!!!!!

21. Oxygen Lights Red = FIO2 set to greater than 21% but not hooked up to source of O2 –Usually has audible too Green = FIO2 is greater than 21% Many ventilators only check for pressure on the O2 line

22. Low exhaled Vt/Low pressure Indicates a leak between ventilator and patient The closer the leak is to the ventilator, the lower the manometer pressure

23. Low exhaled Vt/pressure causes: Patient disconnect Leaking humidifier (very common) Leak in exhalation valve Loose nebulizer Loose tubing connection Leak in ET tube Alarm maladjustment

24. Tubing compliance Tubing expands as it is pressurized Some of Vt from ventilator is lost to tubing expansion Nondisposable circuit compliance is about 3 ml/cmH2O

25. To figure out how much Vt is lost to tubing expansion: Multiply peak pressure by tubing compliance (usually 3 ml/cmH2O) Subtract this number (tubing expansion volume) from the set Vt The difference is known as effective or corrected Vt Effective or corrected Vt is the Vt the patient actually gets!

26. Flow sheet Accumulated data Makes sure patient is being ventilated effectively Allows trend analysis to aid in decisions about ventilator management Filled out periodically, eg every 2 hours

27. Time to Rock and Roll!