Ventilation Management

Initial Ventilation Settings

Ensure tidal volume is 4-6 mL/kg ideal body weight for neonates, and 6-8 ml/kg predicted body weight for other patients 1, 2
Maintain PEEP at 5-8 cmH2O for most patients 1, 3, 2
Initial inflation pressure of 20-25 cmH2O is adequate for most preterm infants 3
Peak inspiratory pressure should be kept ≤28 cmH₂O in normal lungs, ≤29-32 cmH₂O with increased chest wall elastance, and ≤30 cmH₂O in obstructive airway disease 1
Driving pressure should be kept ≤10 cmH₂O for healthy lungs 1
Tidal volume should be kept ≤10 mL/kg ideal body weight, with consideration for lower volumes in lung hypoplasia syndromes 1
The formula for predicted body weight is:
Sex Formula
Males 50 + 0.91(height[cm] - 152.4) kg
Females 45.5 + 0.91(height[cm] - 152.4) kg

Sex	Formula
Males	50 + 0.91(height[cm] - 152.4) kg
Females	45.5 + 0.91(height[cm] - 152.4) kg

Increase respiratory rate by 5-10 breaths/minute, with higher rates beneficial in restrictive lung disease 1
Target respiratory rate of 30 breaths/min for neonates 5
Set inspiratory time according to respiratory system mechanics and underlying disease 1
Monitor flow-time scalar to avoid inspiratory or expiratory flow interruption 1
Respiratory rate should be set based on underlying disease, with higher rates used in restrictive disease 1
Inspiratory time should be set according to respiratory system mechanics and underlying disease 1

Consider high-frequency ventilation if conventional ventilation fails 1
For severe cases, consider ECMO if available and conventional/HFOV fails 1
CPAP or NIV may be considered in mild-to-moderate disease, but not in severe disease 1
High-flow nasal cannula (HFNC) may be considered in mild-to-moderate cardiorespiratory failure 1
Contraindications to non-invasive ventilation include hypotension, vomiting, possible pneumothorax, and depressed consciousness, according to the European Heart Society 6, 7

Measure PCO2 in arterial or capillary blood samples after each adjustment 1
Consider transcutaneous CO2 monitoring for continuous assessment 1
Monitor end-tidal CO2 1
Target pH >7.20 1, 8
Oxygenation targets should include SpO₂ ≥95% for healthy lungs, and SpO₂ ≤97% for disease conditions or cardiac patients 1
Ventilation targets should include PCO₂ 35-45 mmHg for healthy lungs, with higher PCO₂ acceptable for acute pulmonary and non-pulmonary patients 1
The American Thoracic Society recommends maintaining arterial pH >7.20 and monitoring end-tidal CO2 in all ventilated patients 8, 1

The Society of Critical Care Medicine recommends placing patients in a semi-recumbent position (head of bed elevated 30-45°) unless hemodynamically unstable, to reduce the risk of aspiration and ventilator-associated pneumonia 9
Prone positioning for >12 hours/day is recommended for severe ARDS, as suggested by the American Journal of Respiratory and Critical Care Medicine 4
Humidification should be used for all ventilated infants, and cuffed endotracheal tubes should be used with cuff pressure ≤20 cmH₂O 1
Endotracheal tube management should involve minimizing dead space and using double-limb circuits for invasive ventilation 1
Positioning should involve maintaining the head of bed elevated 30-45° 1
Suctioning and secretion management should involve not performing endotracheal suctioning routinely, and considering the use of cough-assist devices in neuromuscular patients 1

Weaning strategy should involve starting weaning as soon as possible, with daily extubation readiness testing 1
Components of the spontaneous breathing test include:
Prone positioning for >12 hours/day is recommended for severe ARDS, as suggested by the American Journal of Respiratory and Critical Care Medicine, and weaning should begin as soon as the patient's condition allows, with daily extubation readiness testing, and a spontaneous breathing trial with a 30-120 minute test, assessment of respiratory muscle strength, and evaluation of secretion management capacity, as recommended by the Society of Critical Care Medicine 4, 1

Patient-ventilator synchrony should be targeted, with monitoring of gas exchange, acid-base status, and ventilator mechanics 1
Auto-PEEP monitoring is crucial, as recommended by the American Heart Association, and the DOPE approach (Displacement of endotracheal tube, Obstruction of tube, Pneumothorax, Equipment failure) should be considered when troubleshooting ventilator issues, as recommended by the American Heart Association 11, 12

The American Thoracic Society recommends that discussions about goals of care and quality of life should occur early in the course of mechanical ventilation, and early discussions about mechanical ventilation and end-of-life care are crucial, and should include assessments of quality of life and goals of care, as recommended by the American Thoracic Society 13
Failure to address advance care planning can lead to poor outcomes, and discussions about goals of care should occur early and be repeated throughout the course of care, as recommended by the American Thoracic Society 13