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Initiating Positive Pressure CMV. A generic approach!. Do these BEFORE attaching the patient. Assemble the ventilator circuit Attach humidifier and fill with water Attach high pressure O2 hose (may also need hose for air) Plug ventilator in. Set the FIO2. If no prior ABGs, start on 100%.

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do these before attaching the patient
Do these BEFORE attaching the patient
  • Assemble the ventilator circuit
  • Attach humidifier and fill with water
  • Attach high pressure O2 hose (may also need hose for air)
  • Plug ventilator in
set the fio2
Set the FIO2
  • If no prior ABGs, start on 100%
set desired vt
Set desired Vt
  • 6-12 ml/kg
set rate
Set rate
  • Choose a rate that in conjunction with Vt, gives a minimum Ve of 6-8 LPM
  • ALWAYS THINK OF MINUTE VENTILATION WHEN SETTING RATE
set flowrate
Set flowrate
  • Start between 40-60 LPM
  • Make sure it meets patients inspiratory demand
    • Steady rise on manometer
  • Make sure it gives good I:E ratio
  • The larger the Vt, the faster the flowrate!
set sigh parameters if using
Set sigh parameters ( if using)
  • Sigh Vt = 1.5 x Vt
  • Sigh rate = 6-10 per hour
set sensitivity
Set sensitivity
  • If pressure triggering, set for 1-2 cmH2O pressure drop
  • If flow triggering, usually set for 3-5 LPM drop in flow
turn ventilator on and attach patient

Turn ventilator on and attach patient

Note: make sure high pressure alarms are set at 50 cmH2O to start the patient on CMV

set high pressure alarms
Set high pressure alarms
  • For Vt, set 5-10 cmH2O greater than peak pressure for Vt
  • For sigh, set 5-10 cmH2O greater than peak pressure for sigh
set low exhaled volume alarm
Set low exhaled volume alarm
  • Set 100 ml less than Vt
set low pressure alarm
Set low pressure alarm
  • Set 5-10 cmH2O less than peak pressure for Vt
alarms and monitors

Alarms and Monitors

What they mean and what to do

assist light
Assist Light
  • Shows patient triggered the breath
  • If patient is not triggering and light is on, then ventilator is too sensitive
    • autocycling
pressure light
Pressure Light
  • Shows ventilator pressure limited the breath
  • Also has audible alarm
pressure limiting may be caused by
Pressure limiting may be caused by:
  • Secretions
  • Water in the tubing
  • Physical obstruction or a kink in tubing
  • Change in patient position
  • ET tube in right main stem bronchus
  • Pneumothorax
  • Maladjusted control
indicates increased resistance

Indicates increased resistance

Also a decrease in compliance

remember

Remember:

Flow =pressure/resistance

ratio light
Ratio Light
  • Indicates inverse I:E
    • Inspiration is as long or longer than expiration
  • Increase flow!!!!!
oxygen lights
Oxygen Lights
  • Red = FIO2 set to greater than 21% but not hooked up to source of O2
    • Usually has audible too
  • Green = FIO2 is greater than 21%
  • Many ventilators only check for pressure on the O2 line
low exhaled vt low pressure
Low exhaled Vt/Low pressure
  • Indicates a leak between ventilator and patient
  • The closer the leak is to the ventilator, the lower the manometer pressure
low exhaled vt pressure causes
Low exhaled Vt/pressure causes:
  • Patient disconnect
  • Leaking humidifier (very common)
  • Leak in exhalation valve
  • Loose nebulizer
  • Loose tubing connection
  • Leak in ET tube
  • Alarm maladjustment
tubing compliance
Tubing compliance
  • Tubing expands as it is pressurized
  • Some of Vt from ventilator is lost to tubing expansion
  • Nondisposable circuit compliance is about 3 ml/cmH2O
to figure out how much vt is lost to tubing expansion
To figure out how much Vt is lost to tubing expansion:
  • Multiply peak pressure by tubing compliance (usually 3 ml/cmH2O)
  • Subtract this number (tubing expansion volume) from the set Vt
  • The difference is known as effective or corrected Vt
  • Effective or corrected Vt is the Vt the patient actually gets!
flow sheet
Flow sheet
  • Accumulated data
  • Makes sure patient is being ventilated effectively
  • Allows trend analysis to aid in decisions about ventilator management
  • Filled out periodically, eg every 2 hours