81M.

01 MECHANICAL VENTILATION
Date Originated: 08/31/2014 Primary Author: Bryan Winchell
Date Last Revised: 07/01/2022
Date Effective: 07/01/2022 ________________________
Page: 1 of 4 Approved By: Terri Hoffman, MD

81A.00
General Patient · Obtain stat blood gas and correlate with ETCO2 if possible.
Management CPG · Any patient with an advanced airway for >15 min should be
mechanically ventilated
· HOB should be raised to 30 degrees unless contraindicated
· An HME should be used whenever possible; remove or
replace if encountering pressure limitation, âVte, or áPIPs
CONTROLS:
ROUTINE
RATIONALE: cognitive offloading. Lets you set a
(standard lung (S)CMV+ ASV Vt and provide consistent Mve.
protective approach)
Evaluate
MODE pulmonary
mechanics
CHALLENGING RATIONALE: avoid waiting on the PRVC
(pulmonary disease,
obesity, extreme PCV+ DuoPAP algorithm. Clinician sets a consistent PIP for lung
acidosis, etc) safety. Will probably require a “strategy” (Pg 2-3)

ADULT 30 - 40 KG 20 - 30 KG 10 - 20 KG 6 - 9 KG 3 - 6 KG 1.5 - 3 KG
(>40 KG)

yyyy
RESP 15 17 20 25 30 35 45
RATE 8
bpm
25 12
bpm
30 15
bpm
35 20
bpm
40 20
bpm
40 25
bpm
50 40
bpm
60

GUIDANCE: minimum RR listed is for obstructive lungs (á Rinsp). Note how pediatric RRs start toward the lower end
of range; they have a higher percentage of mechanical deadspace. Increase Vt before RR to optimize Mve.

GUIDANCE: in general 6 mL/kg is considered lung protective, however this can be increased if
satisfactory PIP’s are demonstrated. In pediatrics/neonates with PIP <30, increase Vt before RR to
VT
optimize Mve.
(per kg 6
mL/kg
IBW) 4 10
EXCEPTIONS: severe metabolic acidosis with healthy lungs: may need massive minute volume.
May increase >10 mL/kg with medical control consult. MC

GUIDANCE: This is just a starting place. Above all, let the flow waveform guide your I:E ratio. Avoid
I:E 1:2 air trapping by ensuring the flow waveform is returning to baseline after exhalation.
1:8 3:1

GUIDANCE: Caution with hypotension and/or falling Vte’s as

PEEP increases. Aim for “optimal PEEP” by evaluating Cstat,
Vte, and driving pressure changes in response to PEEP titration
PEEP (see “ARDS/Hypoxia” strategy in references on Page 2).
PEEP/FiO2 Chart

GUIDANCE: start at 100% + 5 PEEP then

5
cmH20 get on track with PEEP/FiO2 chart. (Use
3 20 Difficult to minimal FiO2 to maintain SpO2 of 92-96%)
NO
oxygenate? FiO2: 40 50 60 70 Higher ratios indicate the
patient would likely
FiO2 100 benefit from severe
21
%
100 PEEP: 5 8 10 12 hypoxia strategy.

Proceed to Severe
YES Hypoxia Strategy (Pg 2)

MONITORED PARAMETERS:
CAUSES: ARDS/
PIP âCstat, bronchospasm/ GUIDANCE: Slow inspiratory time. Eliminate
(Ppeak) 30 40 MC causative factors. Contact Medical Control for
áRinsp, dysynchrony, ideas with sustained PIP >40 cmH2O.
saturated HME, obesity

GUIDANCE: Intubate with cuffed ETT or

CAUSES: uncuffed inflate ETT cuff to minimize leak, especially if
VLeak 10 20 ETT, cuff leak, mask
leak in NIV high levels of PEEP are required. May have
to inflate cuff > 30 cmH2O.

CAUSES: GUIDANCE: Long inspiratory time. Ensure

Rinsp bronchoconstriction, patient has time to exhale. Consider manual
(Resistance)
8 25 saturated HME, small decompression. Eliminate HME. May have to
or kinked ETT, mucus increase PIPs > 30 or 40 to ventilate

CAUSES: ARDS, GUIDANCE: Sit patients up, address

Cstat fibrotic lungs, obesity, seatbelts/HME/sedation. May decrease Vt to
(Compliance)
100 50 40 seatbelts, dysynchrony, protect lungs. PEEP may áCstat with
saturated HME recruitment, or may âCstat via overdistention
81M.01 MECHANICAL VENTILATION
Date Originated: 08/31/2014 Primary Author: Bryan Winchell
Date Last Revised: 07/01/2022
Date Effective: 07/01/2022 ________________________
Page: 2 of 4 Approved By: Terri Hoffman, MD

SEVERE HYPOXIA / ARDS STRATEGY:

1) Don’t be(ADULT)
afraid to invert I:E –use
Pedi/Neo: IRV alone should
MID-to-HIGH side ofnot induce hypercapnia
age-appropriate RR if expiratory
Severe flow waveform is returning
Hypoxia/ARDS Keys: to baseline
RESP
2) Find optimal PEEPon Page 1, then adjust based on Pmean and Mve goals.
3) Maximize
RATE 24pMean (mean airway
Rationale: pressure)
RR increases Pmean, and compensates for · Use Pmean as an indicator of
bpm tidal volumes < 6 mL/kg (very likely in ARDS) oxygenation, ind increase as high as
possible in severe hypoxia
Rationale: 15/10 will set PIP at 25, and Driving
Pressure <15: a good starting place for a lung that will
· ARDS will likeley decrease
PRESS compliance: try to maintain PIP 30 or
CTRL 15
cmH20
require high levels of Pmean and likely has
compliance. Room to increase Pcontrol or PEEP
poor
less if at all possible, even if Vtes are
carefully for a PIP of 30. 4-6 mL/kg.
Rationale: PEEP is an important part of Pmean, but
· Permissive hypercapnia is expected,
increasing PEEP may decrease tidal volumes. especially if pH is 7.2 or greater
PEEP 10
cmH20
Increase in 1-2 cmH2O increments to find “Optimal · Maintaining a Driving Pressure
3 20 PEEP” (~the highest PEEP with acceptable Vte’s) (Pplat minus PEEP) <15 is another
method of minimizing lung strain
Rationale: TI will be a huge part of increasing · Determine Optimal PEEP with careful
Pmean. Don’t be afraid to invert I:E – should not titration: stop increasing the PEEP if
I:E 1:1 induce hypercapnia if expiratory flow waveform is
Vtes fall to unacceptable levels,
1:8 3:1 returning to baseline Driving Pressure increases >15, or
Cstats begin to fall

pMean 15 25 30
4 FACTORS TO INCREASE pMEAN:
á Inspiratory Time
á PEEP
á PIP
á Respiratory Rate

OBSTRUCTIVE / HIGH RESISTANCE STRATEGY:

Examples: Asthma, severe COPD, small tracheostomy, etc
(ADULT) Pedi/Neo: use LOW side of age-appropriate RR on Page
RESP 1 for starting RR, then adjust based on flow waveform.
RATE 10 Rationale: A slow RR is required to facilitate the
exhalation, and the prolonged TI needed for Vte’s Obstructive / High Rinsp Keys:
Rationale: 27/3 will set PIP at 30, a good starting place · This strategy is ideal for asthma, tracheal
PRESS
CTRL 27 for a lung with high Rinsp. Do everything possible to
optimize settings with a PIP of 30, but be prepared to
stenosis, etc; a more routine strategy will
probably work for most COPD patients.
increase the PIP to 40 (or higher with MCOC) if needed
· Address hypercapnia by increasing Vte’s
Rationale: This pathology has prolonged exhalation, and before RR to minimze the impact of
adding PEEP will slow exhalation. A minimum of 3 of deadspace ventilation.
PEEP 3 PEEP is maintained to prevent atelectasis/collapse (more
prevalent in COPD than asthma). Do not increase to
· Be ready for PIPs to be above 30, or even
3 20 “match auto-PEEP”. above 40 (with MCOC).
· Permissive hypercapnia is expected,
Rationale: constricted airways will need áTI in order to especially if pH is 7.2 or greater
I:E 1:2 patiently push past the obstruction. Simply, áTI will · The flow waveform will dictate your settings
áVte’s. This I:E is only a starting place: rigorously adjust
1:8 3:1 RR and TI based on the flow waveform to optimize Mve. (see below). Don’t be surprised at a TI of 2".

- Detect air trapping (AutoPEEP) when the

expiratory flow doesn’t return to baseline
âRR first and then âTI if required
- If inspiratory section is wide, your first move to
increase Vt should be to áTI
- Leave no “time on the table” - if the patient is
hypercapnic, áRR, áTI and/or áPIP until all
the baseline is used up.

EXTREME METABOLIC ACIDOSIS STRATEGY:

Examples: DKA, ASA/TCA/Metformin Toxicity, etc Extreme Metabolic Acidosis Keys:
More routine examples of metabolic acidosis should have a
strategy somewhere between this (extreme) and a routine 1) Use Winter’s Formula to determine target PCO2
lung protective approach (page 1 defaults). (1.5 x HCO3)+8 = PCO2
(ETCO2 likely 2-5 less than PCO2)
(ADULT)
RESP 2) May need massive minute ventilation
Pedi/Neo: use HIGH side of age-appropriate RR on
to achieve goals
RATE 32
bpm
Page 1, then adjust based on flow waveform.
· Keep PIP <30 to protect the lungs
· Increase Vt/kg as high as PIP allows and is
required to meet Winter’s target
PRESS Rationale: 25/5 will set PIP at 30, a good starting · PCV+ or DuoPAP are the ideal modes to
CTRL 25 place for an otherwise healthy lung. Do everything
possible to optimize settings within a PIP of 30. accomplish these goals, or ASV with 200-
300 %MinVol

Rationale: Minimize exhalation time. Can decrease 3) The goal is to get off this strategy and back to a
PEEP 5 to a minimum of 3 of PEEP (don’t go below 3 to routine strategy as soon as the extreme acidosis
3 20 prevent atelectasis/collapse). is correcting.
81M.01 MECHANICAL VENTILATION
Date Originated: 08/31/2014 Primary Author: Bryan Winchell
Date Last Revised: 07/01/2022
Date Effective: 07/01/2022 ________________________
Page: 3 of 4 Approved By: Terri Hoffman, MD

PEDIATRIC/NEONATAL APPROACH:
This approach is used along with the appropriate Pedi/Neo Keys:
strategy (Routine, Severe hypoxia, High Resistance, etc) · In pedi/neo patients, you are working against two critical
for the underlying pathophysiology. concepts: áRinsp and ádeadspace
· You can think of these small airways almost like an asthma
Neonatal Circuit: <30 kg 15
KG
Adult/Pedi Circuit: >3 kg patient: slow rates and long inspiratory times.
- Ensure TI is long enough
- Increase Vt before RR when treating hypercapnia;
increase RR after PIP reaches 30 cmH2O.
Rationale: even with healthy lungs,
MODE PCV+ pediatric and neonatal patients have small · Children have higher deadspace-to-alveolar ventilation
ETTs and small airways that cause high ratios than adults. Ruthlessly eliminate deadspace.
Rinsp – not unlike an asthma patient.
- Use neonatal circuit when applicable, especially with
challenging mechanics
RESP See
Rationale: use LOW side of normogram - Look out for “tailing” on ETCO2 (rebreathing CO2 that
on Page 1 for starting RR. This facilitates
RATE Pg 1 longer TI’s needed to optimize Vte. was stored in mechanical dead space)

Rationale: start at 8 mL/kg and decrease

if PIP is >30. Prefer a slower rate and
higher Vt to minimize effect of deadspace.
TIDAL
VOL 8
mL/kg
Pcontrol and PEEP should be set by the
strategy chosen:
(IBW) 4 10 · Routine: 15/5
· Severe Hypoxia: 15/10
· High Resistance/Obstructive: 27/3
· Etc.

Rationale: small airways need time to

both inhale and exhale. Simply, áTI will
I:E áVte. This I:E is only a starting place: the
1:2 flow waveform should inform meticulous
1:8 3:1 RR and TI adjustments to optimize Mve.

TROUBLESHOOTING / ALARMS:
Low Oxygen Pressure Limitation
· This is different than the “Oxygen Supply Failed” · The pressure limit automatically 10 cmH2O below
alarm. This indicates the delivered FiO2 is >5% less the High Pressure Alarm (indicated by a blue line
than your set FiO2. on the pressure waveform; red line = high
· STEP 1: press the “Monitoring” tab and observe the pressure alarm)
delivered FiO2. Compare to the patient status to · This alarm indicates your settings are trying to
determine priority. exceed the blue line but the vent is not allowing it.
· RESOLUTION: if you have massive minute volumes · RESOLUTIONS:
or a large leak, this may occur becuase the plumbing 1) Fix mechanical obstructions: HOB 45 or
is not sufficient to deliver enough O2. Ensure D-tank more, loosen seatbelts, remove HME, suction
is all the way open. This alarm may also simply ETT, verify no right mainstem.
indicate an Oxygen Calibration is necessary. 2) Ensure adequate analgesia and sedation;
proceed to paralysis if needed
IRV (inverse ratio ventilation) 3) Optimize settings: increase RR, decrease
· Just a heads-up that you set an inverse I:E ratio. Vt or lower Pcontrol, increase TI
4) Increase high pressure alarm: carefully
Wrong Expiratory Valve monitor airway pressures to ensure lung
safety. Contact MCOC for advice if increasing
· This is not the clearest, but you are trying to use the above 50 cmH2O (= PIP of 40)
neonatal mode with an adult circuit, or vice versa.
· Either change the circuit, or your preset/mode.

TERMS: MODE TRANSLATIONS:

Cstat: Static Compliance (lungs' ability to expand) APRV: Airway Pressure Release Ventilation (set Phigh, Plow
Driving Pressure: Pplat minus PEEP (or Vte/Cstat) Thigh, Tlow as compared to conventioanl mode) very
ETS: Expiratory Trigger Sensitivity, or "Flow Term" inverse I:E, allows patient to breath through long TI.
IRV: Inverse Ratio Ventilation ASV: Adaptive Support Ventilation (combines RR, TI, Vt into
Mve: Minute Volume (RR x Vt) one dial, "%MinVol")
Pcontrol: pressure above PEEP during TI in pressure modes DuoPAP: Similar to APRV but with conventional dial names
PIP: Peak Inspiratory Pressure, also "Ppeak" NIV: Non-Invasive Ventilation (CPAP or BIPAP)
Pmean: Mean Airway Pressure NIV-ST: Same as NIV, just with a set RR
Pramp: How fast the breath reaches the PIP. Also "Rise Time" PCV+: Assist/Control Pressure
Psupport: only in SIMV. Like Pcontrol but for spont. breaths PSIMV+: SIMV Pressure Control
Rinsp: Inspiratory Resistance (in airwavs) SIMV+: SIMV PRVC
TI: Inspiratory Time (S)CMV+: Assist/Control PRVC
Vt: Tidal Volume SPONT: Pressure Support
Vti: Inspiratory tidal volume
Vte: Expiratory tidal volume
81M.01 MECHANICAL VENTILATION
Date Originated: 08/31/2014 Primary Author: Bryan Winchell
Date Last Revised: 07/01/2022
Date Effective: 07/01/2022 ________________________
Page: 4 of 4 Approved By: Terri Hoffman, MD

REFERENCES:
· Farcy, David A., et al. Critical Care Emergency Medicine. McGraw-Hill Education, 2017.
· Fuhrman, Bradley P., et al. Fuhrman & Zimmermans Pediatric Critical Care. Elsevier, 2017.
· Kliegman, Robert, et al. Nelson Textbook of Pediatrics. Elsevier, 2016.
· Marino, Paul L., and Kenneth M. Sutin. The ICU Book. Lippincott Williams & Wilkins, 2007.
· Parrillo, Joseph E., and R. Phillip. Dellinger. Critical Care Medicine: Principles of Diagnosis and Management in the Adult. Elsevier/Saunders, 2014.
· Rosen, Peter, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. Elsevier, 2018.
· Fuhrman BP, Zimmerman JJ, Carcillo JA, et al. Fuhrman & Zimmermans Pediatric Critical Care. Philadelphia, PA: Elsevier; 2017.
· Hess, Dean, and Robert M. Kacmarek. Essentials of Mechanical Ventilation. McGraw-Hill Education, 2019.
· Owens, William. The Advanced Ventilator Book. 1st ed., First Draught, 2017.
· “Operator’s Manual HAMILTON-T1.” 15 July 2021.

CHANGELOG:
03/06/2020 Revision:
· New header and logo, completely overhauled to match Hamilton T1 ventilator

07/01/2022 Revision:
· Page 1 - Update of modes (challenging/routine terminology)
· Page 1 - Revised 1:3 for pedi/neo starting I:E ratio to 1:2
· Page 1 - Truncated PEEP/FiO2 chart to refer to severe hypoxia strategy
· Page 2 - Revised 4 key strategy boxes to include starting settings, not just key theories
· Page 3 - Described Pedi/Neo strategy as one that also takes one of the other strategies into effect
· Page 4 - Added Troubleshooting/Alarms, Terms, and Mode Translation boxes