Don’t like YOUTUBE? Here is a photo version
1) Approach the ventilator. Don’t be scared! It should be on and the standby screen should be what you see. As you can see, the standby mode of ventilation for all the ventilators is VOLUME CONTROL with a FIO2 OF 60%, RR 16, PEEP 5 and a TV of 500 ml. Quite reasonable for some patients, but really far from optimal for many.
If you are super keen you will notice that there is a button that has NIV (NON-INVASIVE) ventilation. Although this is what you want to set up, this really confuses the machine when you want to swap over to an INVASIVE mode once you have paralyzed the patient. As such, I think it is easiest to use an INVASIVE mode of ventilation (SIMV) with the rate dropped down really low instead of using a pure NON-INVASIVE mode.
2) My plan is to use a SIMV mode of ventilation with the RR dropped really low as the patient is breathing spontaneously. As such, you want to switch the mode of ventilation from PRVC to SIMV. Just touch the screen and you find another menu.
3) Voila. Look at all those choices. There is actually THREE different SIMV choices. Choose the SIMV (Volume Control) with pressure support.
4) Choosing this option brings up a bunch more options. Touch the SIMV RATE and bring it down to it’s lowest setting.
6) Then push the POWER/GO button on the bottom of the vent to fire up the settings you just chose.
7) Sweet. Now your sick patient is getting some awesomely controlled and supported breaths. They can breath as fast as they want and each breath is going to be delivered. The could have a RR of 30 or 60 with these settings. You may want to play with the inspiratory time if you think the patient is receiving the breaths too fast and a larger tidal volume if you feel there is a large mask leak and/or the pressures you are seeing on the graph are getting high. However, this really isn’t going to be on the patient for too long so these settings are really a starting point and you can’t do your fine tuning once they are intubated. If you have the end-tidal on the patient you can also see what this is reading to get an estimate of their really venous CO2. If you see this number climbing you are not matching their demand and will need to increase the tidal volume.
8) Here is a simulated screen shot of a wicked sick patient with a RR of 42 who is breathing on their own. That little pink bar on the second graph shows you that all these breaths are trigged by the patient.
9) So you push your induction agent +/- paralytic. Some people would take the mask off the patient as they are concerned about ventilating the patient when their airway isn’t protected and distending the stomach. The feeling is by some that this is such a controlled way of moving air as compared to a BVM that the risks of the patient becoming hypercarbic is much higher than the patient having some gastric distension. This isn’t the case for all patients, but for critically ill acidotic patients I would most definitely keep this on. To not over do it however, the feeling is you can move their SIMV Rate up to 12 or so.
10) High Fives all around!