What adjustments can be made to the ventilator (vent) to improve oxygenation?

From the Guidelines

To increase oxygenation on a ventilator, you should first increase the fraction of inspired oxygen (FiO2) to 1.0 as needed. This is based on the most recent guidance from the American Heart Association, as outlined in the 2022 interim guidance to healthcare providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19 1.

When adjusting ventilator settings to improve oxygenation, consider the following key points:

• Use either pressure or volume control ventilation and limit pressure or tidal volume to generate adequate chest rise, with targets of 4–6 mL/kg ideal body weight for adults and neonates, and 5–8 mL/kg for children 1.
• Adjust the trigger settings to prevent auto-triggering with chest compressions and possibly prevent hyperventilation and air trapping.
• Adjust the respiratory rate to 10 breaths/min for adults, 20 to 30 breaths/min for infants and children, and 30 breaths/min for neonates, as recommended by the American Heart Association 1.
• Assess the need to adjust the positive end-expiratory pressure (PEEP) level to balance lung volumes and venous return, which is crucial for maintaining adequate oxygenation and preventing complications.

It's essential to monitor the patient's response to these changes and adjust the ventilator settings accordingly to ensure optimal oxygenation and minimize the risk of complications, such as barotrauma, volutrauma, and hemodynamic instability. By following these guidelines and adjusting ventilator settings as needed, you can help improve oxygenation and patient outcomes.

From the FDA Drug Label

INOmax is a vasodilator indicated to improve oxygenation and reduce the need for extracorporeal membrane oxygenation in term and near-term (>34 weeks gestation) neonates with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension in conjunction with ventilatory support and other appropriate agents.

The FDA drug label does not answer the question.

From the Research

Adjusting Ventilator Settings to Increase Oxygenation

To increase oxygenation in mechanically ventilated patients, several adjustments can be made to the ventilator settings. The primary means of improving oxygenation include:

• Adjusting the positive end-expiratory pressure (PEEP)
• Adjusting the inspired oxygen fraction (FIO2)

PEEP and FIO2 Adjustments

• PEEP decreases intrapulmonary shunt by recruiting collapsed alveoli, but it is associated with important adverse effects 2.
• Prolonged exposure to high FIO2 may cause oxidative lung injury 2.
• The ARDS Network PEEP/FIO2 strategy is reasonable and supported by high-level evidence for most patients 2.
• A decision support, rule-based oxygenation advisor can provide guidance for setting PEEP and FIO2 to achieve and maintain pulse oximeter oxygen saturation (SpO2) ≥ 88 and ≤ 95% 3.

Titration of PEEP and FIO2

• The therapeutic range of PEEP is relatively narrow, and how best to adjust PEEP to prevent or ameliorate ventilator-associated lung injury is unknown and still under investigation 2.
• Rapid reduction of mean airway pressure (mPaw) and FIO2 in acute lung injury models can significantly reduce oxygenation and cause ventilator-induced lung injury (VILI) 4.
• Inhaled nitric oxide (INO) delivered during high-frequency oscillatory ventilation can increase Pao2/FIO2 and may be a safe and effective rescue therapy for patients with severe oxygenation failure 5.

Current Oxygen Management

• Current oxygen therapy practice may be suboptimal, with excess oxygen delivery and liberal oxygen therapy being common in mechanically ventilated patients 6.
• Patients often spend most of their time with their SpO2 > 98% and PaO2 between 80 and 120 mm Hg, and hyperoxemia is frequent 6.