Setting up ventilator on neonate

Here are guidelines used for setting up a neonatal ventilator.  Please not that these are guidelines, not orders.  This is meant to be a step by step guide.

Guidelines for setting up a Neonatal Ventilator:

1. Patient range: If the option exists, make sure you set it to neonate (Maximum VT = 40cc)

2. Mode: Pressure Control (works best for un-cuffed ETT)

3. Tidal Volume (VT)*:

• less than33 weeks gestation 4 – 6 cc/kg
• greater than33 weeks gestation or chronic 5 – 7 cc/kg

4. Peak Inspiratory Pressure (PIP)*:

• less than27 weeks gestation set at 24 CWP
• 27 – 32 weeks gestation set at 26 CWP
• 33 – 40 weeks gestation set at 28 CWP
• Start low (best to err on low side to prevent barotraumas.)
• Increase to obtain target VT and adequate chest rise
• Frequently monitor & adjust PIP to accommodate changes in lung compliance altering tidal volume.

5. Positive End Expiratory pressure (PEEP):

• Start at minimum 4 – 5 CWP
• Increase to 6 – 7 CWP if FiO2 needs greater than 60%
• Adjust to maintain acceptable PaO2 and SpO2
• 8 – 10 CWP PEEP if directed by physician
• Remember that Pressure Control (PC) setting is “above PEEP”

6. Fraction of Inspired Oxygen (FiO2)**:

• Start low at 40%
• Adjust to maintain target SpO2
• If SaO2 less than target range, FiO2 may be increased by 2–5, & then allowing 4 minutes for stabilization after each change. (consider adjustment of PIP and PEEP also.)
• Continue assuring AW patent, HR greater than100 & baby not apneic.
• If SaO2 greater than target range, FiO2 may be decreased by 2 – 5,
  allowing 4 minutes for stabilization after each change.
• Consider increasing PEEP prior to FiO2
• Maintain neonate on ROOM AIR whenever possible.

7. Rate:

• 50 – 60 if less than 34 weeks gestation or less than 3 kg
• 40 – 50 if greater than 34 weeks gestation or greater than 3 kg
• 30 – 40 if 40 weeks gestation; slightly higher if indicated.
• Watch for air trapping at rates greater than 40 (adjust I-time).

8. I-time:

• Start at 0.3 plus or minus 0.5 (post-term may need more.)
• Neonatal initial I-time setting
• less than 1kg 0.25 – 0.30 sec minimum 0.20 seconds
• 1-2kg 0.30 – 0.40 sec minimum 0.20 seconds
• 2-3kg 0.35 – 0.45 sec minimum 0.25 seconds
• 3-4kg 0.40 – 0.60 sec minimum 0.30 seconds
• Ideally set using Flow-time graphics
• This alters I-time and I:E ratio
• Increase & decrease to reach target settings as appropriate
• Watch for air trapping at rates greater than 40 in neonates greater than 3kg; they may need I-time greater than 0.40 to complete inspiration & prevent air trapping.
• If neonate using expiratory muscles, try decreasing I-time
  slightly (increasing flow).
• If I-time gets too short, consider switch to PRVC.

9. I-Rise time:

• 10 if less than 33 weeks gestational age
• greater than 5 if greater than 33 weeks gestational age
• Basically, the smaller the ETT the higher this should be to
  create laminar flow and a pseudo sign wave.
• Increase for bronchospasm (slow rise time, longer e-time)

10. PIP limit: 2 – 3 greater than PIP (all other alarms as appropriate.)

*Note: Higher PIP and VT may be needed in certain cases. Consult physician if unable to ventilate at recommended settings. Settings may also be unique to particular ventilator, guidelines, or protocol.

**Note #2: New studies show that high levels of oxygen, even in term babies and even for periods of less than a minute, can result in long term consequences to the child such as Retnopathy of Prematurity. Proper ranges to strive for will be the topic of a future post.

Note #3: The above information may be slightly different for your institution and the equipment available, yet the principle remains the same regardless of where you work.
For a cheat sheet with the above information, click here.