From the Guidelines
Initial ventilator settings for an intubated patient should include a tidal volume of 4-6 mL/kg of ideal body weight, with a respiratory rate of 10 breaths/min for adults, and FiO2 of 1.0, as recommended by the American Heart Association in 2022 1. When setting up the ventilator, consider the following key points:
- Use either pressure or volume control ventilation and limit pressure or tidal volume to generate adequate chest rise.
- Adjust the trigger settings to prevent the ventilator from auto triggering with chest compressions and possibly prevent hyperventilation and air trapping.
- Assess the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return.
- Ensure endotracheal tube/tracheostomy and ventilator circuit continuity to prevent unplanned airway dislodgement or tubing disconnections. For adults, a tidal volume of 4-6 mL/kg is often targeted, while for children and neonates, the targets are 5-8 mL/kg and 4-6 mL/kg, respectively 1. It is essential to individualize these settings based on the patient's condition and adjust according to arterial blood gas results, monitoring for signs of adequate ventilation, including chest rise, oxygen saturation, end-tidal CO2, and plateau pressures 1.
From the FDA Drug Label
When administered during the induction of adequate anesthesia using propofol, nitrous oxide/oxygen, and co-induction agents (e.g., fentanyl and midazolam), GOOD or EXCELLENT conditions for tracheal intubation occurred in 96/102 (94%) patients in 1.5 to 2 minutes following 0.15 mg/kg cisatracurium and in 97/110 (88%) patients in 1.5 minutes following 0. 2 mg/kg cisatracurium.
The FDA drug label does not provide specific information on vent settings for intubation. However, it does discuss the conditions for tracheal intubation following administration of cisatracurium under different anesthesia regimens.
- Key points:
- GOOD or EXCELLENT intubation conditions were achieved in the majority of patients.
- The time to intubation was typically 1.5 to 2 minutes after cisatracurium administration.
- The dose of cisatracurium (0.15 mg/kg or 0.2 mg/kg) affected the frequency of EXCELLENT intubation conditions. However, vent settings are not mentioned in the provided text. 2
From the Research
Vent Settings for Intubation
- The initial ventilator settings for critically ill patients, including those with acute respiratory distress syndrome (ARDS), involve a lung-protective mechanical ventilation strategy 3.
- This strategy includes:
- Prevention of volutrauma with a tidal volume of 4 to 8 ml/kg predicted body weight and plateau pressure <30 cmH2O
- Prevention of atelectasis with positive end-expiratory pressure (PEEP) ≥5 cmH2O and recruitment maneuvers as needed
- Adequate ventilation with a respiratory rate of 20 to 35 breaths per minute
- Prevention of hyperoxia by titrating inspired oxygen concentration to peripheral oxygen saturation (SpO2) levels of 88 to 95%
- For patients with ARDS, the use of electrical impedance tomography (EIT) can help individualize PEEP and tidal volume settings, leading to improved oxygenation and reduced alveolar cycling without promoting global overdistension 4.
- Neuromuscular blocking agents (NMBAs) such as cisatracurium may be used in patients with severe ARDS to improve outcomes, with a recommended dosage based on train-of-four (TOF) monitoring to ensure a profound neuromuscular block and decrease cisatracurium consumption 5.
- The choice of NMBA, such as cisatracurium versus vecuronium, may affect outcomes, with cisatracurium associated with improvements in ventilator days and ICU days, but not mortality 6.
Key Ventilator Settings
- Tidal volume: 4 to 8 ml/kg predicted body weight
- Plateau pressure: <30 cmH2O
- PEEP: ≥5 cmH2O, adjusted based on EIT-derived information on recruitability, overdistension, and alveolar cycling
- Respiratory rate: 20 to 35 breaths per minute
- Inspired oxygen concentration: titrated to SpO2 levels of 88 to 95%