Ventilator Basics – all you need to know in just 2 pages!

;)

Vents can get fairly complicated but all interns and residents rotating through the ICU should be able to understand the
basic principles, settings, and modes used in our medical intensive care unit. This is our very basic overview, GL!

Principles:

 C=V/P (Compliance=Volume/Pressure) (I remember this bc “CVP”)

o Very simple formula, but the main principle behind the ventilator
o Compliance = the ventilator system itself, the airways, the lungs (the patient)
 Initially, consider compliance to be fixed. However, appreciate that we diurese, optimize sedation
and vent settings to improve comfort, and even paralyze a patient in part to improve compliance.
These aspects are beyond the scope of this basic discussion.
o Volume = this could be your DEpendent or INdependent variable, depending on your mode
o Pressure = same as volume (it’s either your dependent or independent variable), because you will always set
either volume or pressure, not both (for this basic overview)
 The ventilator does just 2 things: 1 it oxygenates, 2 it ventilates
o Oxygenation: depends on MAP (mean airway pressure) and FiO2
 MAP can be adjusted by:
 PEEP (and inspiratory pressure if in pressure control mode)
 Adjusting the inspiratory time, which changes the proportion of time the vent system is at
the higher, inspiratory pressure.
o Ventilation: depends on tidal volume (Vt) and respiratory rate (RR)
 Note that, depending on your mode, you may set the volume or the volume may depend on
pressure  If your volume depends on pressure then the PEEP affects your ventilation as well
(will explain below in “mode” section)
 Also consider: Physiologic dead space may effectively decrease tidal volume. While generally
accurate, the Vt is only what the machine reports.
 pH ~ bicarb/CO2 AKA pH is proportionate to the bicarb (measured on the BMP, NOT the ABG!) divided by the CO2
(measured on the ABG performed at a similar time to the BMP)
o This principle is to help you adjust your ventilator settings to adjust your pH (basically, ventilation)
o The CO2 is dependent on the minute ventilation (volume of each breath x RR)
o Adjust volume or RR (within reasonable limit) to increase or decrease CO2
 Be aware that increasing RR will decrease the expiratory time, diminishing effective ventilation.
This is much more of a concern for patients with COPD.
Modes:

 Assist Control, Volume Control (AC/VC): This is the mode we use most commonly here. Assist control means that
you get the breaths set for you PLUS you get assisted (with the full settings) on breaths that you initiate yourself.
Volume control means that in this mode, your volume is your INdependent variable, therefore making pressure your
DEpendent variable. The inspiratory pressure is determined by the compliance of the system to accept that volume
(going back to C=V/P)!
o Settings: Volume/RR/PEEP/FiO2 (this is how you’ll report the settings on daily rounds)
 Volume: At the most basic level we set the Vt at 6-8cc/kg for ideal height based on the ARDSnet
protocol, however you should set Vt based on clinical scenario. Ie, for patients with severe acidemia,
a higher MV may be needed requiring increase in RR and occasionally tidal volume (Vt).
 RR:
 If the patient was intubated primarily for hypoxemic respiratory failure, then consider
setting the rate just below the patient’s actual RR once they’re intubated. Ideally watch
the patient after intubation, and adjust the RR until they are initiating a few breaths
themselves (RT can help you determine this).
 If the patient is acidemic, increase their rate to achieve an appropriate minute ventilation
that allows them to blow off adequate CO2.
 If they’re alkalemic, they should have a depressed respiratory drive, so they may just
breathe with the machine until their pH normalizes.
 PEEP: Set based on ARDSnet. We generally start at a PEEP of 5 and adjust.
 There’s a high PEEP/low FiO2 strategy and vice versa. Print out the ARDSnet protocol
and keep it in your white coat pocket to help you out!
 FiO2: Also use ARDSnet as above. We generally start at 100% but you may start lower if the patient
is not intubated for hypoxemia (for example, in DKA or AMS).
  One good tip, PaO2 should be about 5x the set FiO2 if the patient has NO lung
problems. Therefore, if your FiO2 is 20% (room air) your PaO2 should be 100. If your
FiO2 is 100%, your PaO2 should be 500. Thus, if your patient is set on an FiO2 of 100%
and their PaO2 is 100 - this is not good!!!
>AC/VC continued…
o Things to check: MV, actual RR, peak and plateau pressures
 MV: You’ll need to report your patients’ average minute ventilation over the night each AM on rounds
 It’s important to know if your patient’s pH has changed despite their MV being unchanged
 step 1, check the BMP to see if the changing pH is due to a metabolic cause; step 2, if
this is not the case, look out for new dead space that may have been created by a PE or
other lung pathology, be thoughtful!
 RR: Always check your patient’s ACTUAL RR, not just the SET RR!!!
 Peak pressure: This will generally appear at the top left of the screen (on PB 840 vents)
 Plateau pressure: To check this, you’ll need to perform an inspiratory hold
 During inspiratory hold, all valves remain closed after the full breath has been given,
pressure measured at this time represents the pressure across the alveoli
 Our goal is usually to keep this pressure under 30-35
 A difference in peak and plateau pressure indicates something is wrong with the system
itself, tube, or large airways of the patient
 When both the peak and plateau pressures are elevated, this indicates a more
“parenchymal” process or a chest wall issue (most commonly obesity) is going on
(remember C=V/P, high pressure means low compliance)
 Assist Control, Pressure Control (PC): In this mode, you set the pressure (INdependent variable) making volume
your DEpendent variable. The “delta” pressure (called “pressure control”/PC determines your volume) – and of
course as always, compliance matters! C=V/P!!! This mode is more complicated at first, you probably need to ask for
help from your resident/fellow/attending before setting this on your own.
o Settings: PC/PEEP/RR/FiO2
 PC: Pressure control, also delta pressure. Set this to maintain the same goal volume as above, 6-
8cc/kg. You’ll have to adjust the settings for a bit and watch the patient’s response.
 PEEP: Positive end expiratory pressure, same as in VC! Set according to ARDSnet again.
 Remember, PC/PEEP (ie 20/8) is how you’ll present these settings on rounds
 BUT you MUST present the corresponding volumes your patient is getting with these
pressures as well as the minute ventilations as mentioned above!
 RR: Same as above.
 FiO2: Same as above.
o Things to check: MV, actual RR, NOT pressures (they’re set) > Because pressure is your DEpendent variable
now, your peak pressure will equal your PC + your PEEP (ie a patient set on 20/8 will have peak
pressures of 28).
 MV: Same as above.
 RR: Same as above.
 Pressure Support (PSV): Our usual weaning mode. Unlike the 2 assist control modes mentioned above, pressure
support depends on the patient initiating breaths. PSV provides a small amount of pressure during inspiration to help
the patient draw in a spontaneous breath. Pressure support makes it easier for the patient to overcome the resistance
of the ET tube and is often used during weaning because it reduces the work of breathing.
o Settings: They’ll look the same as pressure control (PS/PEEP/RR/FiO2)
 PS similar to PC, is the delta pressure (the amount of additional pressure above the PEEP that
your patient will get with each spontaneous breath)
 PEEP in this mode is almost always 5 (if you’re looking to extubate your patient, they should not
be requiring more than a minimal PEEP of 5 anyway!)
 RR is just a back up rate in this setting so is usually set ~8-10
 FiO2 should be minimal or you shouldn’t be trying to extubate your patient!
o The RTs are usually in charge of weaning and will use PSV during their daily SBTs so long as the patient
has passed their AM SAT and has met requirements for an SBT, for more on this topic please see the
separate SAT/SBT notes.

By no means is this a comprehensive discussion of pulmonary physiology and ventilator modes/settings BUT we hope
that now you feel a little less afraid to present your vent settings each morning and we encourage you to learn from every
vented patient you have and to suggest setting changes when you feel they are indicated. Good luck and have fun! 
Vent management for nurses who have never seen a
vent befo
Let's not overthink things. Here's the down and dirty. You all know why this is here. Hopefully no one will need it, but
without proper PPE we're gonna run out of native ICU nurses sooner or later. Please feel free add suggestions and
changes as needed. In no way is this meant to be a comprehensive guide, just a little crash course to get you
familiar with some of the ideas and acronyms.
Intubation
ETTs (Endo-tracheal tubes) comes in different sizes. For adults, usually 7-9 with most being 8. It is inserted into the
trachea after visualizing the vocal chords. Mac blade is curved ("C"), Miller blade is straight ("L"). After placement:
auscultate for bilateral breath sounds, check etco2 detector (it turns from purple to yellow/gold
[thanks /u/ughwhateva] when it detects co2 (indicates it's in the lung not the esophagus)) and obtain a chest xray.
Tip should terminate 5 +/-2 cm above carina where the right and left main bronchus bifurcates. Once confirmed,
secure and measure external length at the teeth or lip (usually 20-25 cm). During rapid sequence intubation (non-
cardiac arrest) two medications are given. An induction agent such as fentanyl, propofol, ketamine, or etomadate is
given first followed by a paralytic such as succylncholine or rocuronium. Verify dosage and push speed with the
provider. Things move fast. Meds given. Assessed for effect. Cricoid pressure and suction. Blade in. Tube in. Stylet
out. Be aware very unstable patients may code during this process.
Maintenance
Machines vary so verify with your RT or native ICU nurse what each number on your screen corresponds to
Vent parameters and values
 f = respiratory rate. There are two values. The set rate and the actual rate. Depending on the vent setting
the patient may have no set rate or a minimum mandatory rate. Always watch your patients actual rate and if
they are "breathing over" the vent (faster than your set rate)
 Vt = Tidal volume. Also two values. A set rate volume which the vent delivers and the patient exhaled tidal
volume which the patient gives back.
 Minute ventilation = Patient's Tidal Volume in mL x Patient respiratory rate. Usually at least 4L/min.
 FiO2 = O2 concentration. Room air is 21% at sea level.
 PS = Pressure support. When patient inhales, the vent gives positive pressure to assist the patient to take a
breath. This value setting is usually 8-15 sometimes up to 20 and as low as 5.
 PEEP = Positive End Expiratory Pressure. This value setting represents the minimum positive airway
pressure the vent delivers throughout the respiratory cycle. It helps keep the alveoli open, increases alveolar
recruitment. Minimum of 5 because the ETT forces open the epiglottis so anatomic PEEP is lost. With ARDS
patients you will see PEEP as high as 15 or more. This is uncomfortable so patients are usually sedated or
sedated and paralyzed.[edit] High PEEP - High PEEP increases intrathoracic pressure (the pressure in your
chest) which decreases pressure gradient in venous system, decreasing venous return thus decreasing
preload thus decreasing cardiac output thus decreasing blood pressure.
Vent settings
I could talk about vent settings for hours and indeed you should familiarize yourself more with whatever setting your patient is
on but here's a basic rundown.
 ACVC - patient receives a mandatory/minimum amount of breaths. Each breath the vent delivers a set tidal
volume. If patient takes more breaths than the minimum (overbreathing) then the vent will deliver the set
 tidal volume. Ex: Rate is set to 12, tidal volume is set to 450, patient wants to take 16 breaths. Patient gets
16 breaths of 450 volume.
 SIMV - Same as ACVC but when patient takes more breaths than the set rate the machine will not give any
volume assistance. You can (should) add pressure support to these spontaneous breaths. Ex: Rate is set to 12,
tidal volume is set to 450, patient wants to take 16 breaths. Patient gets 12 breaths with a tidal volume of
450 and takes 4 breaths completely on their own (however much they try to breath in the machine gives
them).
 Pressure Support - spontaneous breaths are augmented by extra pressure support on inhalation. Kind of
like bipap, when patient inhales they get the PS, when they exhale they get the PEEP. Not totally accurate
but it's the apocalypse don't sweat there won't be a quiz. You should always use pressure support when patient is
on spontaneous breathing because they need assistance overcoming the resistance inherent due to the length and width
of tubing (like breathing through a straw).
 ACPC - like ACVC except each breath the lung is given air until the vent is satisfied there's enough pressure
in the lung. Remember, Volume and Pressure in a closed system are related but not equivalent.
 [Edit] IRV - Inverse ratio ventilation. Not technically a ventilation mode, more like a vent strategy or theory. In
normal breathing, your inhalation phase is 1/2 your exhalation phase for an I:E (Inhale:Exhale) ratio of 1:2.
In mechanical ventilation we typically stick to I:E ratios of 1:2 or 1:3 depending on the indication. In IRV, we
modify the I:E ratio to something like 2:1 or 3:1, sometimes even 4:1. This is very unnatural and your patient
will buck the vent unless paralyzed. The purpose of this is to increase the Mean Airway Pressure (MAP) to
help increase oxygenation time. You can read more about it here
( https://www.ncbi.nlm.nih.gov/books/NBK535395/ ).
ARDS
Massive inflammation causes capillaries leakage and destruction of surfactant producing cells. Alveoli collapse
causing massive atelectasis, pulmonary congestion, V/Q mismatch and shunting occurs. Blood moves from right
side of heart through lungs back into left side of heart without receiving oxygen. Why? Because there's no functional
alveoli for gas exchange to occur. Additionally, with the massive capillary leak and pulmonary edema caused by
inflammation coupled by the lack of open alveoli, pulmonary compliance dramatically decreases (lung doesn't
stretch easily) increasing work of breathing. This all leads to life threatening hypoxemia or lack of oxygen in blood.
Keep PEEP high, at least 15 initially. Keep tidal volume low, 4 mL/kg. Nitric oxide gas can also be used to help
expand lungs/increase compliance. Prone positioning is common in ARDS, it really helps. How? Not a clue, but it
does. Watch videos on manual proning for technique.
Read more on proning here: ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026253/ )
Evaluation
Read up on ABGs. In viral pneumonia you will encounter mixed metabolic and respiratory acidosis. Inflammation
and poor oxygenation cause lactic acidosis. Poor ventilation will cause respiratory acidosis. If the patient is not
vented and hyperventilating to compensate as seen in early hypoxemia you may see respiratory alkalosis. Keep in
mind in this disease we want a touch of acidosis as acidosis is actually good for tissue oxygenation (oxyhemoglobin
dissociation curve). A pH greater than 7.25 is generally still okay. Also read up on PF ratios as they will help
evaluate the severity of ARDS and effectiveness of treatment.
Sedation
Each facility varies but common drugs include precedex, fentanyl, propofol and benzos of which versed is the most
common. I've seen literature stating intermittent/PRN push doses are favored over continuous titrated drips but I
personally have never encountered this so I'm not sure if it's actually done in practice. Regardless, I encourage you
to read up on those drugs. Specifically, look at their hemodynamic effects, whether or not they also have any
analgesic effects as well as their duration and onset. Here's a quick and dirty:
  precedex: produces cooperative sedation and mild analgesia. Patient is awake but chill, like they don't care
what's going on with them but still able to follow commands. Can produce bradycardia and consequently
hypotension. Do not bolus. You can actually extubate the patient on this drug as it usually doesn't produce
much respiratory depression compared to other sedatives.
 fentanyl - powerful analgesic with decent sedation effects. When given as a continuous drip it actually
doesn't lower blood pressure too much. It does produce some respiratory depression. Very short half life.
You can turn it off and patient should awaken within 15-30 min unless you had them completely zonked out.
 propofol - all sedation, no pain relief, strong amnesia effect. Also has a short half life (10-15 min). Lipid
based emulsion is a breeding ground for bacteria. Change tubing every 12 hours or per facility policy. High
risk for hypotension.
 versed - I don't typically use benzos in my ICU because post surgery we want to extubate asap and with
benzos, the longer they run the longer it takes to wear off. Some benzo drips can take days to wear off. That
said, a lot of the aforementioned literature mentions intermittent push dose benzos so meh, maybe that's a
thing where you live.
[edit] As requested, some words on paralytics:
 Differences between different specific paralytics are not typically clinically significant and I won't focus much
on them. However, as a prudent nurse, I encourage you to always use your facility drug index to look up
medications you're not familiar with to see any adverse effects and interactions etc. before administering.
 Train of Four - Nerve stimulation applied to either the hand or forehead to assess twitches. Typical goal is
2/4. A button is pressed and a current is passed between the two leads. A light will blink each time the
current passes. If you see 0/4 twitches then your patient is under-paralyzed, 4/4 and they are likely over-
paralyzed (check your order!)
 SEDATE YOUR PATIENT. Do not administer a paralytic unless you are certain your patient is sedated. We
even sedate post-cardiac arrest hypothermia patients who we're 99% sure are brain dead before we
paralyze them.
 Many ARDS patients will require paralysis as a consequence of the therapies required to treat them. IRV,
high PEEP, and pronating are all uncomfortable and the patient is likely to fight the vent, even if sedated.
Weaning and extubation
Speak with your provider. Make sure there is clear communication on how they want you to wean and if they even
want you to wean. I don't care if there is a task that fires every shift telling you to do a SAT/SBT. These are sick
patients and you do what the doctor wants, not what some bean counting bloke in accounting says.
Typically FiO2 can be titrated down based on the PaO2 on the ABG and/or the SpO2 on the monitor. Again, read up
on PF ratios. Rate can also be adjusted if need be if patient is hypo or hyperventilating based on the gas. Do not
adjust the vent mode or PEEP unless you absolutely know what you are doing or if the physician orders it. RT or an
experienced ICU nurse can do respiratory mechanics to evaluate if patient is able to be successfully extubated.
Once you have the order and are ready, suction oropharynx and in-line airway one last time. Deflate the balloon and
pull all the way out in one swift motion. Have the patient cough out any secretions. Obviously, you don't do this by
yourself - usually the RT is actually the one pulling the tube and the doctor is either in the room or somewhere on
the unit. Monitor the patient. Stay in the room for 15 minutes, stick around for 30. Rarely will you extubate to room
air - at the minimum place a nasal cannula on but be prepared to start high-flow, vapotherm, bipap, or even
reintubate.
What happens if my patient self extubated? Don't freak out. I've seen patients absolutely zonked out on sedation
and restrained still manage to extubate. Assess your patient, do they need to be bagged or not? If not, place them
on a non-rebreather or other non-invasive support while you call the doctor. Be prepared to reintubate. While you
wait for the doctor, read up on paralytics...