• Calculate predicted body weight (PBW)

  • • Males = 50 + 2.3 [height (in) - 60]

    • Females = 45.5 + 2.3 [height (in) - 60]

• Select any ventilator mode

• Set vent settings to achieve initial VT = 8 ml/kg PBW

• Reduce VT by 1 ml/kg at intervals ≤ 2 hrs until VT = 6ml/kg PBW

• Set initial rate to approx baseline min vent (not > 35 bpm)

• PaO2 55-80 mmHg or SpO2 88-95%

• Use a min PEEP of 5 cm H2O

• Consider use of incremental FiO2/PEEP combinations such as this table (not required) to achieve goal

• Pplat ≤ 30 cm H2O

• Check Pplat (0.5 sec inspiratory pause), at least q4h and after each change in PEEP or VT

• If Pplat > 30 cm H2O: decrease VT by 1 ml/kg steps (min = 4 ml/kg)

• If Pplat < 25 cm H20 and VT < 6 ml/kg, increase V by 1 ml/kg until Pplat > 25 cm H20 or VT = 6 ml/kg

• If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O

pH Goal: 7.30-7.45

• If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Max RR = 35)

• If pH <7.15: Increase RR to 35

  • • If pH remains < 7.15, VT may be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30 may be exceeded)

    • May give NaHCO3

• If pH > 7.45: Decrease vent rate if possible

I:E Ratio Goal: Recommend that duration of inspiration be ≤ duration of expiration

Recommend that duration of inspiration be ≤ duration of expiration

Conduct spontaneous breathing trial when:

• FiO2 ≤ 0.40 and PEEP ≤ 8 OR FiO2 ≤ 0.50 and PEEP ≤ 5

• PEEP and FiO2 ≤ values of previous day

• Patient has acceptable spontaneous breathing efforts. (May decrease vent rate by 50% for 5 min to detect effort.)

• SBP ≥ 90 mmHg without vasopressor support

• No neuromuscular blocking agents or blockade

Spontaneous Breathing Trial (SBT)

• Place on T-piece, trach collar, or CPAP ≤ 5 cm H2O with PS ≤ 5

• Assess for tolerance as below for up to 2 hrs.

• SpO2 ≥ 90 and/or PaO2 ≥ 60 mmHg

• Spontaneous VT ≥ 4 ml/kg PBW

• RR ≤ 35/min

• pH ≥ 7.3

• No respiratory distress (distress = 2 or more)

  • • HR > 120% of baseline

    • Marked accessory muscle use

    • Abdominal paradox

    • Diaphoresis

    • Marked dyspnea 

• If tolerated for at least 30 min, consider extubation

• If not tolerated resume pre-weaning settings