Recommended Initial Delta Pressure Support Settings for Mechanical Ventilation
For acutely hospitalized patients requiring mechanical ventilation, the initial delta pressure support should be set at 5-8 cm H2O. 1
Understanding Pressure Support Ventilation
Pressure support ventilation (PSV) is a commonly used assisted breathing mode where the ventilator provides a set pressure to augment the patient's spontaneous breathing efforts. The delta pressure support refers to the pressure above PEEP that assists each breath.
Initial Settings Based on Evidence
- Initial pressure support level: 5-8 cm H2O 1
- Initial PEEP: 5 cm H2O 1
- Tidal volume target: 6-8 ml/kg predicted body weight 1
Clinical Benefits of Appropriate Pressure Support
Setting the correct initial pressure support has significant clinical implications:
- Increases likelihood of successful spontaneous breathing trials (SBTs) 1
- Produces higher rates of extubation success 1
- Associated with a trend toward lower ICU mortality compared to SBTs without pressure augmentation 1
- Helps prevent alveolar collapse while avoiding excessive work of breathing 2
Considerations for Different Patient Populations
Critically Ill Adults
- Begin with 5-8 cm H2O pressure support 1
- Monitor for successful SBTs and adjust as needed 1
- Consider individual patient factors such as respiratory mechanics and work of breathing
Pediatric Patients
- Pressure support settings should be adjusted based on disease severity and patient size 1
- Monitor parameters including PCO2, SpO2, and respiratory mechanics 1
Surgical Patients
- Initial ventilator settings should deliver tidal volumes of 6-8 ml/kg PBW with PEEP of 5 cm H2O 1
- PEEP should be individualized to avoid increases in driving pressure while maintaining low tidal volumes 1
Monitoring and Adjustment
When using pressure support ventilation, monitor:
- Dynamic compliance
- Driving pressure (Plateau pressure - PEEP)
- Plateau pressure
- Tidal volume
- Respiratory rate
- Work of breathing
Potential Pitfalls and How to Avoid Them
Excessive pressure support
- Can lead to patient-ventilator asynchrony
- May cause excessive tidal volumes (>6 ml/kg) increasing risk of ventilator-induced lung injury 3
- Solution: Titrate pressure support to achieve appropriate tidal volumes and respiratory rate
Insufficient pressure support
- May increase work of breathing
- Can lead to respiratory muscle fatigue
- Solution: Ensure adequate support to maintain comfortable breathing pattern
Failure to adjust for changing patient condition
- Patient requirements may change over time
- Solution: Regularly reassess ventilator settings and patient response
Overlooking driving pressure
- Driving pressure (Plateau pressure - PEEP) is an important parameter for lung protection 4
- Solution: Monitor and maintain driving pressure at appropriate levels
Weaning Considerations
- Start weaning as soon as possible 1
- Perform daily extubation readiness testing 1
- Consider conducting SBTs with pressure support (5-8 cm H2O) rather than without (T-piece or CPAP) 1
- For patients at high risk of extubation failure who have passed an SBT, consider extubation to preventive non-invasive ventilation 1
By following these evidence-based recommendations for initial delta pressure support settings, clinicians can optimize mechanical ventilation strategies to improve patient outcomes, including successful liberation from mechanical ventilation and reduced mortality.