PEEP Residual Volume Forced Vital Capacity EPAP Tidal Volume A-a gradient IPAP PaCO2 RR ARDS BIPAP BiPAP NIV PaO2 IBW Plateau Pressure FiO2 A/C SIMV I:E ratio

Acute Pulm Edema, Pneumonia, OD, … everything except Asthma/COPD Asthma/COPD NIV/BPAP Mechanical Ventilation Mode: S/T PEEP 5 cm H2O IPAP(PSV) cm H2O (max 20) FiO2 100% Rate 14 (Backup Rate) CO2 +/- O2 Type 2 O2 +/- CO2 Type 1 Mode: S/T PEEP O cm H2O IPAP (PSV) cm H2O (max 20) FiO2 40% Rate 14 (Backup Rate) Mode: A/C Volume Vt 6-8 cc/kg IBW RR 18 bpm PEEP 5 cm H2O - initially FiO2 100% - initially After 5 min, do ABG, follow ARDSnet chart Goal: PaO or SaO2 90% Mode: A/C Volume Vt 8 cc/kg IBW RR 10 bpm PEEP O cm H2O FiO2 40% Goal: keep pH above 7.1

APE, Pneumonia), OD, … everything except Asthma/COPD Asthma/COPD NIV/BPAP Mode: S/T PEEP 5 cm IPAP (PSV) FiO2 100% (Backup) Rate 14 CO2 +/- O2 O2 +/- CO2 Mode: S/T PEEP O cm IPAP (PSV) FiO2 40% (Backup) Rate 14

Type 2 – failure of Ventilation = HYPERCAPNIA (“respiratory muscle fatigue” or “obstruction”) e.g.: COPD, Asthma Both Type 1 and 2 can be treated with non invasive or invasive (intubation) ventilation depending on patient condition

Remember Patients can obviously have combined failure!

Don’t worry, PEEP, EPAP and IPAP will be explained later! For patients in the ER, we will be using “Bilevel” positive pressure settings on the Ventilator.

The way to fix this is to keep the alveoli ‘open’ during expiration to allow time for the oxygen to get into the vascular system. Easiest way to do this is to provide continuous pressure into the lung, especially during expiration. (often referred to as ‘splinting’ the alveoli)

Since it is positive pressure, we can call it: Continuous Positive Pressure. We can specify that the pressure is going into the airways, so lets call it : Continuous Positive Airway Pressure – ie CPAP.

Since it is during expiration, we could also call it: Expiratory Positive Airway Pressure – or EPAP So basically: CPAP = PEEP = EPAP (conceptually, not mathematically)

In this scenario, the patient needs inspiratory help So if the patient is awake and breathing, we can use “Bilevel” ventilation. We want both ‘Inspiratory Positive Airway Pressure’ (sometimes call “Pressure Support Ventilation – PSV) along (maybe) with ‘Expiratory Positive Airway Pressure’ This is called IPAP (PSV) and EPAP respectively.

So for both Type 1 and Type 2 Respiratory Failure all we need to know is how to set up the S/T Mode! Then if we want we can ‘finesse’ some of the settings or easier yet, call the RT!

BiPAP and BIPAP are registered trade names from Ventilator companies. So we should actually be using the terms “Bi Level” or “BPAP” Or make it really simple and call anyone on a mask as getting Non Invasive Ventilation (NIV)!

If you are a purest though, for Oxygenation failure, you really only need PEEP – so you could actually set the IPAP to equal EPAP For Ventilation failure, you really need IPAP, which is using the S/T mode and setting the PEEP very low or zero – why?

Patients needing NIV with COPD or Asthma 1. Use S/T mode with IPAP and EPAP or 2. Use S/T mode but with low/nil EPAP setting, or call the RT

APE, Pneumonia), OD, … everything except Asthma/COPD Asthma/COPD NIV/BPAP Mode: S/T PEEP 5 cm IPAP (PSV) FiO2 100% (Backup) Rate 14 CO2 +/- O2 O2 +/- CO2 Mode: S/T PEEP O cm IPAP (PSV) FiO2 40% (Backup) Rate 14

APE, Pneumonia, OD, … everything except Asthma/COPD Asthma/COPD Mechanical Ventilation CO2 +/- O2 O2 +/- CO2 Mode: A/C Volume Vt 6-8 cc/kg IBW RR 18 bpm PEEP 5 cm FiO2 100% After 5 min, do ABG, follow ARDSnet chart Goal: PaO or SaO2 90% Mode: A/C Volume Vt 8 cc/kg IBW RR 10 bpm PEEP O cm FiO 40% Goal: keep pH above 7.1

The ‘control’ is that we set the rate, volume etc. The assist part is if the patient is able or does take an extra breath, that is fine. The ventilator will give an additional breath at whatever parameters we have set.

APE, Pneumonia, OD, … everything except Asthma/COPD Asthma/COPD CO2 +/- O2 O2 +/- CO2 Mode: A/C Volume Vt 8 cc/kg IBW RR 10 bpm PEEP O cm FiO 40% Goal: keep pH above 7.1 Mechanical Ventilation

Only FOUR settings you have to consider: 1.Tidal Volume (Vt) = lung protection 2.Respiratory Rate (RR) = ventilation (CO2) 3.FiO2 = oxygenation 4.PEEP (EPAP) = oxygenation

Height55’15’25’35’45'55’65’7”5’8”5’9”5’10”5’11”6’6’1”6’2”6’3”6’4” Male Kg Female Kg

Only FOUR settings you have to consider: 1.Tidal Volume (Vt) = lung protection 2.Respiratory Rate (RR) = ventilation (CO2) 3 & 4. FiO2/PEEP = oxygenation (the most important setting)

APE, Pneumonia, OD, … everything except Asthma/COPD Asthma/COPD Mechanical Ventilation CO2 +/- O2 O2 +/- CO2 Mode: A/C Volume Vt 6-8 cc/kg IBW RR 18 bpm PEEP 5 cm/FiO2 100% After 5 min, do ABG, follow ARDSnet chart Goal: PaO or SaO2 90% Mode: A/C Volume Vt 8 cc/kg IBW RR 10 bpm PEEP O cm FiO 40% Goal: keep pH above 7.1

Only FOUR settings you have to consider: 1.Tidal Volume (Vt) = lung protection cc/kg IBW 2.Respiratory Rate (RR) = ventilation & 4. FiO2/PEEP = oxygenation - 100% and 5

FiO PEEP

FiO PEEP So you have now set things to FiO2 of 40% (.4) and a PEEP of 5. If the SpO2 is say 75, then you move one step up to FiO2 0.4 and PEEP of 8. Then after a minute or so check the SpO2. You keep going up by steps until you get to your goal of SpO2 90 +/-

Note: the ‘magic handshake’ will only work with the Vent plugged in to wall outlet. This is to ensure battery life

Note: The Filter is for trapping the patient’s exhalation gases. It does NOT connect to the ETT/LMA/King tube. Remember to hook in line CO2 monitor here between tubing and ETT (not shown in this picture)

Port for suction catheter to go down. Clear T piece adaptor Medication nebulizer ETT suction connector

Blue MDI adaptor (i.e. for salbutamol puffer)

= Auto PEEP

Push the start button on the ventilator

APE, Pneumonia, OD, … everything except Asthma/COPD Asthma/COPD NIV/BPAP Mechanical Ventilation Mode: S/T PEEP 5 cmH2O IPAP (PSV) 5-10 cm H2O FiO2 100% (Backup) Rate 14 CO2 +/- O2 Type 2 O2 +/- CO2 Type 1 Mode: S/T PEEP O cm H2) IPAP (PSV) cm H2O FiO2 40% (Backup) Rate 14 Mode: A/C Volume Vt 6-8 cc/kg IBW RR 18 bpm PEEP 5 cm H2) FiO2 100% After 5 min, do ABG, follow ARDSnet chart Goal: PaO or SaO2 90% Mode: A/C Volume Vt 8 cc/kg IBW RR 10 bpm PEEP O cmH2O FiO 40% Goal: keep pH above 7.1

APE, Pneumonia, OD, … everything except Asthma/COPD Asthma/COPD NIV/BPAP Mechanical Ventilation Mode: SIMV/CPAP Set Breath rate to - - (or will be in SIMV) PEEP: 5 cm H20 (max 15) (*) PSV (IPAP): 10 cm H20 (max 20) Fi02: 100% initial CO2 +/- O2 Type 2 O2 +/- CO2 Type 1 Mode: SIMV/CPAP PEEP: O – 5 cm H20 IPAP: cm H2O (max 20) FiO2: 100% initially Mode: A/C Volume Set “Sensitivity” to 3 (**) Tidal Volume (Vt): 6-8 cc/kg IBW Resp. Rate: 18 bpm PEEP: 5 cm H2O FiO2: 100% initial IFR: lpm After 5 min, do ABG, follow ARDSnet chart Goal: PaO mmHg or SaO2 90% Mode: A/C Volume Tidal Volume (Vt): 8 cc/kg (***) Resp. Rate: 10 bpm PEEP: O cm H2O FiO2: 40 % IFR: 80 – 100 lpm Goal: Keep pH above 7.1