Management of Ventilation

- 1) If blood gas analysis is not available, a general EtCO2 goal of 35 mm Hg +/- 5, is adequate. However, if blood gas analysis is available (i.e. i-STAT), recommend obtaining a baseline PCO2 and correlate with EtCO2, especially since the gradient between the two is much wider in patients with significant lung disease (i.e. an EtCO2 of 40 may actually represent a PCO2 of 60 with a pH around 7.24).
- 2) The manual breath button on the bottom left of EMV+ 731 allows for manual measurement of plateau pressure (Pplat). The Pplat goal is less than 30 cm H2O with a secondary goal of maintaining driving pressure (Pplat minus PEEP) below 15 cm H2 In the absence of Pplat, a PIP target of less than 35 cm H20 is also reasonable.
- 3) If Pplat is greater than 30 cm H20, decrease set tidal volume by 1 mL/kg steps (about 50-80 mL). Titrate set respiratory rate (RR) up increments of 2 bpm to maintain pH and EtCO2 at goal. Avoid RR above 35 bpm given significant risk for breath stacking and auto PEEP (which will eventually make the patient hemodynamically unstable).
- 4) If i-STAT with blood gas cartridges are available, consider serial blood gas evaluation (adjusting frequency depending on patient stability).