5-13 MECHANICAL VENTILATION

Purpose: To facilitate airway management in patients with airway compromise. This is not meant as a substitute for other appropriate therapeutic measures per standing operating procedures.

Appropriate Personnel: EMT Paramedics in approved services.

Indications:

1. Post Rapid Sequence Intubation (RSI) patients.
2. Cardiac Arrest/Respiratory Arrest patients what have airway secured with intubation or cricothyrotomy.

Potential Exclusion Criteria:

1. Inability to adequality secure patient’s airway with intubation or cricothyrotomy.
2. Pediatric patients age less than 8 years or less than 24kg of ideal body weight.
3. Required tidal volume of less than 170mL.
4. Patient unable to tolerate mechanical ventilator therapy.
5. Poor oxygenation/perfusion with mechanical ventilator therapy.
6. Unable to maintain sedation during transport.
7. Pneumothorax - tension pneumothorax (actual or suspected).
8. Pulmonary over-pressurization syndrome (blast injury, water ascent injury, etc.).

Considerations:

1. Patients who are already ventilator dependent and have their own ventilators with them should (if possible) be transported with their own equipment.
2. If the patient is 28 weeks pregnant or greater contact medical control.

Pre-treatment:

1. Connect Ventilator tubing.
2. Connect ventilator to oxygen source.
3. Perform pre-operations tests.

Initial ventilator settings for adult male in cardiac arrest:

1. Determine need for mechanical ventilation.
2. Set mode to AC-Volume.
3. Set rate to 12 BPM.
4. Set tidal volume to 6-8mL/kg of ideal body weight(based on height).
5. Set PEEP to 5 cmH2O.
6. Ensure flow trigger is set to off.
7. Set FiO2 to 100%.
8. Connect patient to ventilator.

Initial ventilator settings for adult female in cardiac arrest:

1. Determine need for mechanical ventilation.
2. Set mode to AC-Volume.
3. Set rate to 12 BPM.
4. Set tidal volume to 6-8mL/kg of ideal body weight (Based on height).
5. Set PEEP to 5 cmH2O.
6. Ensure flow trigger is set to off.
7. Set FiO2 to 100%.
8. Connect patient to ventilator.

Initial Ventilator settings for Adult Post-RSI:

1. Determine need for mechanical ventilation.
2. Set mode to AC-Volume.
3. Set rate to 12-20 BPM titrate to maintain ETCO2 between 35-45 mmHg (If suspected head-injury with signs of herniation target ETCO2 of 30-35 mmHg by increasing respiratory rate).
4. Set tidal volume to 6-8 mL/Kg of ideal body weight (based on height).
5. Set PEEP to 5 cmH2O
6. Set FiO2 to 100% (Titrate FiO2 down by 10% every 10 minutes to maintain and SpO2 of >95%).
7. Connect patient to ventilator.
8. Monitor patient for Peak Inspiratory Pressure (PIP) less than 40 cmH2O. If PIP is above 40 cmH2O follow DOPES pneumonic.  

Adult Ventilator Volumes-Based on ideal body weight per patient height

Male (mL) 6mL/kg	Male (mL) 8mL/kg	Height	Female (mL) 6 mL/kg	Female (mL) 8mL/kg
250	325	56 inches (4’8”)	225	275
275	360	58 inches (4’10”)	250	325
300	400	60 inches (5’0”)	275	350
330	425	62 inches (5’2”)	300	400
350	475	64 inches (5’4”)	325	425
375	500	66 inches (5’6”)	350	475
400	550	68 inches (5’8”)	375	500
425	575	70 inches (5’10”)	425	550
450	625	72 inches (6’0”)	450	600
500	650	74 inches (6’2”)	475	625
525	700	76 inches (6’4”)	500	650
550	725	78 inches (6’6”)	525	700

• Men: IBW (kg) = 50 + 2.3 x (Height (in) - 60)
• Women: IBW (kg) = 45.5 + 2.3 x (Height (in) - 60)

Post-Mechanical ventilation sedation

1. Sedation Options:
   1. Ketamine (Ketalar) 1mg/kg IV/IO every 30 minutes or as needed.
   2. Midazolam (Versed) 2 mg IV/IO every 30 minutes or as needed.
   3. Fentanyl (Sublimaze) 50mcg.
2. Ketamine is favored in hypotensive patients
3. Be certain to watch for hypotension or shock with Versed and Fentanyl.
4. Close monitoring of the patient is required, and adequate minute ventilation must be maintained and close monitoring of airway patency, including appropriate suctioning should be performed. End-tidal CO2 monitoring should be performed on all intubation patients if available.
5. Signs for under sedated patient include but are not limited to:
   1. Elevated heart rate
   2. Elevated blood pressure
   3. Spontaneous movement
   4. Patient-ventilator dyssynchrony

If the patient does not tolerate the ventilator or if there are issues ventilating, disconnect, manually bag, and reevaluate the patient.