Setting up ventilator on neonate

Guidelines for setting up a Neonatal Ventilator:

1. Patient range: Set to neonate (Maximum VT = 40cc)

2. Mode: Pressure Control (works best for un-cuffed ETT)

3. Tidal Volume (VT)*:

 less than33 weeks gestation 4 – 6 cc/kg

 greater than33 weeks gestation or chronic 5 – 7 cc/kg

4. Peak Inspiratory Pressure (PIP)*:

 less than27 weeks gestation set at 24 CWP

 27 – 32 weeks gestation set at 26 CWP
 33 – 40 weeks gestation set at 28 CWP
 Start low (best to err on low side to prevent barotraumas.)
 Increase to obtain target VT and adequate chest rise
 Frequently monitor & adjust PIP to accommodate changes in lung compliance
altering tidal volume.

5. Positive End Expiratory pressure (PEEP):

 Start at minimum 4 – 5 CWP

 Increase to 6 – 7 CWP if FiO2 needs greater than 60%
 Adjust to maintain acceptable PaO2 and SpO2
 8 – 10 CWP PEEP if directed by physician
 Remember that Pressure Control (PC) setting is “above PEEP”

6. Fraction of Inspired Oxygen (FiO2)**:

 Start low at 40%

 Adjust to maintain target SpO2
 If SaO2 less than target range, FiO2 may be increased by 2–5, & then allowing 4
minutes for stabilization after each change. (consider adjustment of PIP and PEEP
also.)
 Continue assuring AW patent, HR greater than100 & baby not apneic.
 If SaO2 greater than target range, FiO2 may be decreased by 2 – 5,
allowing 4 minutes for stabilization after each change.
 Consider increasing PEEP prior to FiO2
 Maintain neonate on ROOM AIR whenever possible.

7. Rate:
  50 – 60 if less than 34 weeks gestation or less than 3 kg
 40 – 50 if greater than 34 weeks gestation or greater than 3 kg
 30 – 40 if 40 weeks gestation; slightly higher if indicated.
 Watch for air trapping at rates greater than 40 (adjust I-time).

8. I-time:

 Start at 0.3 plus or minus 0.5 (post-term may need more.)

 Neonatal initial I-time setting
 less than 1kg 0.25 – 0.30 sec minimum 0.20 seconds
 1-2kg 0.30 – 0.40 sec minimum 0.20 seconds
 2-3kg 0.35 – 0.45 sec minimum 0.25 seconds
 3-4kg 0.40 – 0.60 sec minimum 0.30 seconds
 Ideally set using Flow-time graphics
 This alters I-time and I:E ratio
 Increase & decrease to reach target settings as appropriate
 Watch for air trapping at rates greater than 40 in neonates greater than 3kg; they
may need I-time greater than 0.40 to complete inspiration & prevent air trapping.
 If neonate using expiratory muscles, try decreasing I-time
slightly (increasing flow).
 If I-time gets too short, consider switch to PRVC.

9. I-Rise time:

 10 if less than 33 weeks gestational age

 greater than 5 if greater than 33 weeks gestational age
 Basically, the smaller the ETT the higher this should be to
create laminar flow and a pseudo sign wave.
 Increase for bronchospasm (slow rise time, longer e-time)

10. PIP limit: 2 – 3 greater than PIP (all other alarms as appropriate.)

*Note: Higher PIP and VT may be needed in certain cases. Consult physician if unable to
ventilate at recommended settings. Settings may also be unique to particular ventilator,
guidelines, or protocol.

**Note #2: New studies show that high levels of oxygen, even in term babies and even
for periods of less than a minute, can result in long term consequences to the child such
as Retnopathy of Prematurity. Proper ranges to strive for will be the topic of a future post.

Note #3: The above information may be slightly different for your institution and the
equipment available, yet the principle remains the same regardless of where you work.