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AdjustingVentilatorSettings

AdjustingVentilatorSettings
Ventilatorsettingsareadjustedto(1)normalizebloodgases(ventilation,oxygenation)(2)improve
patientventilatorsynchrony/decreaserespiratorydistressand/or(3)weanapatientfromventilatorsupport.
Herewefocusprimarilyonnormalizingbloodgases,withanoverviewofventilatoradjustmentsto
improvesynchronyoralleviaterespiratorydistress.

NormalizingBloodGases
Abloodgasmayindicateeitherabnormalventilation,abnormaloxygenation,orboth.
AdjustingVentilation
AbnormalventilationisindicatedbyanabnormalpHduetoanabnormalPCO2.Withanormal
bicarbonate,restoringthePCO2tonormalwillresultinanormalpH.Ifthepatientisinrespiratory
alkalosis(hyperventilationhighpH,lowPCO2),youcanrestoreanormalPCO2bydecreasingtheminute
volume.Ifthepatientisinrespiratoryacidosis(hypoventilationlowpH,highPCO2),youcanrestorea
normalPCO2byincreasingtheminutevolume.Toestimatehowmuchyoushouldincreaseordecreasethe
minutevolume,usethefollowingformula:

Forexample,ifamechanicallyventilatedpatientwithaminutevolumeof6L/minhasapHof7.25anda
PCO2of60mmHg,youcanrestoreanormalPCO2byincreasingtheminutevolume.Thenewminute
volumewouldbe6.0Lx60/40=9.0L/min,with40mmHgbeingthedesirednormalPCO2.
Exactlyhowyouchangetheminutevolumedependsonthemodeofventilationbeingused.Thetable
belowindicatesthebestwaystoincreaseordecreaseminutevolumeforthecommonmodesofventilatory
support.
HowtoChangetheMinuteVolumeDependingonVentilatorMode
MODE

TOINCREASEVE

TODECREASEVE

VOLUMETARGETED

CMVControl

increaseVT

decreaserate

CMVAssist/Control

increaseVT

decreaserate
adddeadspace

SIMV

increaserate
addpressuresupport

decreaserate

PRESSURETARGETED

PCV

increase P
increaserate

decrease P
decreaserate

PSV

increase P

decrease P

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BiPAP

increase P
(IPAPEPAP)

decrease P
(IPAPEPAP)

APRV

increase P
decrease P
increasereleasefrequency decreaserelease
frequency

AdjustingOxygenation
WhereasPCO2variesmainlywithoneparameter(minutevolume),bloodoxygenlevelscanbeaffectedby
twotheFIO2andPEEPlevels.Ingeneral,thehighertheFIO2andPEEPlevel,thehigherthePO2/SaO2.
IfthePO2isexcessive(usually>100mmHg),youshouldlowertheparameter(FIO2orPEEP)thatis
potentiallymostdangeroustothepatient.Forexample,ifapatienton10cmH2OPEEPand75%oxygen
hasaPO2of150mmHg,thehighFIO2isofmostconcern(O2toxicity)andshouldbelowered.Onthe
otherhand,ifapatienton18cmH2OPEEPand45%oxygenhasaPO2of150mmHg,thehighPEEP
pressureisofmostconcern(barotrauma)andshouldbelowered.
IfthePaO2orSaO2islow(<60mmHgor<90%),hypoxemiaispresentandeithertheFIO2orthePEEP
levelshouldbeincreased.Whichyouchoosetoraisedependsonthecauseofthehypoxemia.Ifthe
problemisasimpleV/Qimbalance(indicatedbyanPO2>60mmHgonaFIO2<0.6),increasingthe
FIO2willprobablyduethejob.Iftheproblem,howeverisshunting(indicatedbyanPO2<60mmHgona
FIO2>0.6),simplyraisingtheFIO2won'thelp.Instead,PEEPmustbeaddedorincreased.Seethe
followingRuleofThumb:
Usethe"60/60Rule"todeterminethecauseandtreatmentofhypoxemia.IfthePO2is>60mmHg
onaFIO2<0.6,theproblemismainlyaV/Qimbalancethatwillrespondtoasimpleincreasein
FIO2.IfthePO2is<60mmHgonaFIO2>0.6,theproblemisshuntingandPEEP/CPAPmustbe
addedorincreased.(Avariationofthisruleuses50/50asthestandard)
ARDSNetworkGuidelines.Guidelinesforsettingthe'best'PEEPlevelwhenpatientshavehypoxemiadue
toshunting(asinARDS)havebeenestablishedbytheAcuteRespiratoryDistressSyndromeNetwork.
TheyrecommendusingoneofthefollowingspecificcombinationsofFIO2andPEEPtoachieveaPaO2of
5580mmHgoranSpO28895%
PEEP

FIO2

PEEP

FIO2

0.3

14

0.8

0.4

14

0.9

0.4

16

0.9

0.5

18

0.9

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10

0.5

18

1.0

10

0.6

20

1.0

10

0.7

22

1.0

12

0.7

24

1.0

14

0.7

Usingthistable,iflevelofoxygenationisbelowtheminimumtarget(PaO2<55mmHgorSpO2<88%),
theyrecommendmoving'up'onestep.Conversely,iflevelofoxygenationisabovethetargetedrange
(PaO2>80mmHgorSpO2>95%),theyrecommendmoving'down'1step.

Example:AdjustingOxygenationUsingARDSNetwork
Problem:Apatienton10cmH2OofPEEPwithanFIO2of0.60hasaPaO2of50anda
SPO2of83%.Ehaydoyuourecommend?
Solution:SincethislevelofoxygenationisbelowtheARDSNetworkrecommended
minimumtarget,youwouldconsulttheabovetableandmovethepatientuptothenext
higherlevelofsupport,i.e.from10cmH2OofPEEPwithanFIO2of0.60to10cm
H2OofPEEPwithanFIO2of0.70,andthenrepeatyourassessment.Ifthischangedoes
notbringthepatientabovetheminimumtargetlevels,thenextstepupwouldbetoraise
thePEEPfrom10cmH2Oto12cmH2O.

Amorecomplexprocessusedtodetermine'best'PEEPrequiresaccesstocardiacoutputandmixedvenous
bloodgasdata(viaapulmonaryarteryorSwanGanzcatheter).Inthismethod(oftencalleda'PEEP
study'),increasinglevelsofPEEPareappliedwhilesimultaneousmeasuresofoxygenation,pulmonary
mechanicsandhemodynamicsaremade(seeexamplebelow).Mostcriteriadefinethe'best'PEEPasthe
lowestpressurethatyieldssatisfactoryoxygendelivery/tissueoxygenationatasafeFIO2withminimal
cardiovascularcompromise.Intheexamplebelow,cardiacoutputandO2deliveryreachtheirmaximums
(4.5L/minand869mL/min,respectively)ataPEEPlevelof15cmH2O.However,thislevelofPEEP
resultsinwhatmostwouldconsiderpotentiallydangerouspeakandplateaupressures(51and48cmH2O
repectively).Comparablecardiacoutput(4.2L/min),O2delivery(811mL/min)andvenousPO2s(37mm
Hg)appearpossibleatlowerPEEP,peakandplateaupressures,inthiscase5cmH2OPEEP,which
probablyrepresentsthebeststartingpointforthispatient.

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Abovetablefrom:Pilbeam,SP.MechanicalVentilation:Physiologicaland
ClinicalApplications.3ed.St.Louis:Mosby1998.
Morerecently,thebestPEEPlevelhasbeenassociatedwiththelowestpressureneededtoexceedthelower
inflectionpoint(LIP)onthelung'spressurevolumecurve,i.e.,thepointatwhichtheslopeinitially
steepensandcompliancerises(seefigurebelow).Sincethispoint,alsocalledPflex,conceptuallyrepresents
maximumalveolarrecruitment,maintainingaslightlyhigherPEEPpressureshouldkeepalveoliopen,
whileavoidingoverdistentionassociatedwithhigherpressures.

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FromHicks,GHandScanlanCL.Initiatingandadjustingventilatorysupport.
InScanlan,CL,Wilkins,RL&Stoller,JK(Eds.).EgansFundamentalsof
RespiratoryCare(7thEd.).St.Louis,MO:Mosby,1999.
Unfortunately,todeterminethebestPEEPlevelusingthismethodisrathercomplex,requiringgeneration
ofastaticpressurevolumecurveforthepatient.Donemanually,thisnormallyinvolvessedationor
paralysisofthepatientandeitherincrementalorslowinflationusingacalibratedsupersyringe,while
measuringstaticairwaypressures.Analternativewaytogenerateastaticpressurevolumecurveisthe
rapidendinspiratoryocclusionmaneuver.Thistechniqueinvolvesmanuallyclampingthecircuitbetween
theYpieceandpressure/volumesensoratendinspirationovera10steprangeoftidalvolumes(usually
rbetween0.1and1.2L).Becausestaticpressurevolumecurvesaresometimesunobtainableusingeitherof
thesemethods,theyarenotcommonlyusedinclinicalpractice.However,theyshouldbeunderstoodby
NBRCexamtakers.
AmorereliableandlessriskyalternativetodeterminebestPEEPviapulmonarymechanicsistoassess
staticcomplianceoverarangeofPEEPlevels(withtheVTorPheldconstant).Basedottheresultsof
thistest,oneselectsthePEEPlevelatwhichthehighestcomplianceisobserved.Forexample,inthe
followingcase,onewouldselectaPEEPlevelof15cmH2O,correspondingtothethehighestobserved
staticcompliance(38mL/cmH2O)..
PEEP
(cmH2O)

StaticCompliance
(mL/cmH2O)

23

24

12

27

15

38

18

33

14

31

16

31

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Asimilarapproachtakesadvantaqgeofcurrentventilatorgraphicssoftware.Whenusedduringpressure
limitedventilation,itisreferredtoastheequalpressuremethod.Asshowninthefigurebelow,theequal
pressuremethodinvolvesmeasuringthevolumeexhaledafterinflatingthelungatthesamedistending
pressureof20cmH2OduringthecourseofthepressuresupportventilationatdifferentlevelsofPEEP
(equivalenttoBiPAP).Attheendofeachinflation,thepatientisdisconnectedfromtheventilator,andthe
exhaledvolume(VE)isrecorded.TheVEobtainedwiththismaneuverateachlevelofPEEPisthen
comparedwiththecorrespondingexhaledvolumeatZEEP,withthedifferencebeingthevolumerecruited
atthatlevelofPEEP.Intheexamplebelow,thevolumerecruitedaboveZEEP(a,b,c)increases
progressivelyasthePEEPlevelisincreased,withmaximumrecruitment(c)at15cmH2O.

ImprovingPatientVentilatorSynchrony/DecreasingRespiratoryDistress
Inadditiontoadjustingventilatorstoassureadequateventilationandoxygenation,onemayneedto
manipulateventilatorsettingstoimprovepatientventilatorsynchronyand/ordecreaserespiratorydistress.
Insomecases,suchaswhenstartingnoninvasiveventilation,alleviatingrespiratorydistressmaybethe
primarygoal.Themostcommonadjustmentshelpfulinimprovingpatientventilatorsynchronyand/or
alleviatingrespiratorydistressaresummarizedinthefollowingtable.Intermsofdecreasingrespiratory
distress,oneshouldfirsteliminatedpatientrelatedproblemsasthecausebeforeproceedingwithventilator
adjustments.
Problem/Need
InadequateFIO2

Triggerproblems

Action
TitrateFIO2toSpO2of9092%
Check/confirmforadequateO2deliveryHb,cardiacoutput,etc

Adjusttriggerleveltominimum(12cmH2O12L/min)

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CheckforandeliminateautoPEEP
Flowproblems

Rateproblems

Tidalvolume/
Pressurelimit

Inadequateminute
volume

Mode

autoPEEP

Ifusingflowlimitedventilation:
Increaseinspiratoryflowtoeliminateposttriggerpatienteffort
Useventilatorthatprovidesflowcompensation
Switchtopressurelimitedventilation
Ifusingpressurelimitedventilation:adjustrisetimetoprovidegoodpressure
plateauwithoutspiking
IfusingPSV,adjustoffcyclingtoassureeffortfreeandcompleteexhalation

IfusingCMV,setratetoassureadequateexpiratorytimeandproperI:Eratio
IfusingCMV,considerSIMV
IfusingSIMV,increasemandatoryrateuntilspontrateis<1520/min
IfusingSIMV,increasepressuresupportleveluntilspontrateis<1520/min

InspectpressurevolumecurveforoverdistentionlowerPorVif'beaking'
apparent

Assureaminimummandatoryventilationofatleast46L/minforadults(if
normalmetabolismhigherasneeded)

Givepreferencetopressurelimitedmodesand/orthosethatprovideflow
compensationduringinspiration

CheckforandeliminateautoPEEP

Adaptedfrom:Hicks,GHandScanlanCL.Initiatingandadjustingventilatorysupport.InScanlan,CL,
Wilkins,RL&Stoller,JK(Eds.).EgansFundamentalsofRespiratoryCare(7thEd.).St.Louis,MO:
Mosby,1999.
FIO2/PEEPrecommendationsforARDSpatientfromTheAcuteRespiratoryDistressSyndromeNetwork.
Ventilationwithlowertidalvolumesascomparedwithtraditionaltidalvolumesforacutelunginjuryand
theacuterespiratorydistresssyndrome.NEnglJMed342(18):13011308,2000.
EqualpressuremethoddescriptionandgraphfromWardNS,LinDY,NelsonDL,etal.Successful
determinationoflowerinflectionpointandmaximalcomplianceinapopulationofpatientswithacute
respiratorydistresssyndrome.CritCareMed30(5):9638,2002

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