HOW TO PICK INITIAL SETTINGS FOR A MULTIPLE CHOICE TEST Mechanical Ventilation

Key words  Disease  Height and/or weight  ABG  Age  Gender

Answer Components  Mode  Vt  RR  FiO2  PEEP

Tidal Volume  8-10 ml/kg normal  6-8 ml/kg ARDS  4-8 ml/kg Asthma  Determine IBW based on given height  Or use weight given  Find the range

RR and Minute Ventilation  RR x Vt determine minute ventilation  After determining the Vt choose a RR that will create the MV you want  5-10 lpm normal range  7-8 for average patient  Low end for COPD  High end for CHI

Mode  Either A/C or SIMV for full control  SIMV for COPD and Asthma  PCV in either A/C or SIMV for ARDS

Example patient  You have a 48 year old male with pneumonia who has developed sepsis. He is currently on a NRB mask with a RR of 25 and shallow breathing. His ABG’s are pH 7.28, PaCO2 58, HCO3 26, and PaO2 63, SpO2 91%. Which of the following initial vent settings would be appropriate?

Example patient  A) Assist Control, RR 10, Vt 600ml, FiO2 1.0, PEEP 5  B) SIMV, RR 14, Vt 700ml, FiO2 0.5, PEEP 5  C) Assist Control, RR 14, Vt 600ml, FiO2 0.5, Peep 10  D) SIMV, RR 12, Vt 650ml, FiO2 1.0, PEEP 5

Example patient  You have a 48 year old, 5’8” male with pneumonia who has developed sepsis. He is currently on a NRB mask with a RR of 25 and shallow breathing. His ABG’s are pH 7.28, PaCO2 58, HCO3 26, and PaO2 63, SpO2 91%. Which of the following initial vent settings would be appropriate?

Example patient  You have a 48 year old, 5’8” male with pneumonia who has developed sepsis. He is currently on a NRB mask with a RR of 25 and shallow breathing. His ABG’s are pH 7.28, PaCO2 58, HCO3 26, and PaO2 63, SpO2 91%. Which of the following initial vent settings would be appropriate?

Example patient  You have a 48 year old, 5’8” male with pneumonia who has developed sepsis. He is currently on a NRB mask with a RR of 25 and shallow breathing. His ABG’s are pH 7.28, PaCO2 58, HCO3 26, and PaO2 63, SpO2 91%. Which of the following initial vent settings would be appropriate?

IBW  Male IBW [6 x (height in inches-60)]  [6 x (68 – 60)]  [6 x 8]   154 pounds  ÷ 2.2 = 70 kg

Easier IBW  [(Height in inches – 60) x 6]  [(68 – 60) x 6]  (8 x 6) = 106   154 lbs  ÷ 2.2 = 70kg

Tidal Volume  70 kg IBW  Use normal range for pneumonia 8-10ml/kg  70 x 8 = 560ml  70 x 10 = 700ml  Tidal volume should be between ml

example  Once you have determined Vt range you need to check your options  A) Assist Control, RR 10, Vt 800ml, FiO2 1.0, PEEP 5  B) SIMV, RR 14, Vt 500ml, FiO2 0.5, PEEP 5  C) Assist Control, RR 14, Vt 600ml, FiO2 0.5, Peep 10  D) SIMV, RR 12, Vt 650ml, FiO2 1.0, PEEP 5

Find the right Vt  A) Assist Control, RR 10, Vt 800ml, FiO2 1.0, PEEP 5  B) SIMV, RR 14, Vt 500ml, FiO2 0.5, PEEP 5  C) Assist Control, RR 14, Vt 600ml, FiO2 0.5, Peep 10  D) SIMV, RR 12, Vt 650ml, FiO2 1.0, PEEP 5  Both A and B can be eliminated due to the Vt being out of range  That leaves C and D

Minute ventilation  C) Assist Control, RR 14, Vt 600ml, FiO2 0.5, Peep 10  D) SIMV, RR 12, Vt 650ml, FiO2 1.0, PEEP 5  Minute ventilation for C is 8.4L  Minute ventilation for D is 7.8L  Because both C and D meet the Vt range and the Minute Ventilation range it is time to look at FiO2

FiO2  C) Assist Control, RR 14, Vt 600ml, FiO2 0.5, Peep 10  D) SIMV, RR 12, Vt 650ml, FiO2 1.0, PEEP 5  The patient is already on an FiO2 of 1.0  That makes D the best choice to maintain the FiO2 of 1.0  It is also not a good choice to start with a PEEP above 5, such as in C, unless the patient was on more than 5 before intubating

Mode  Assist Control and SIMV are both acceptable for a pneumonia patient as long as they are giving a full minute ventilation