Iowa Neonatology Handbook: Pulmonary

Protocol for Initial Respiratory Settings for Mechanical Ventilation of Infants

Jonathan M. Klein, MD
Peer Review Status: Internally Peer Reviewed

1. RDS
   1. After initial resuscitation and stabilization, the following should be the ventilator settings used:
      1. Rate: 30-40/minute
      2. Peak inspiratory pressure (PIP) - determined by adequate chest wall movement.
         1. An infant weighing less than 1500 grams: 16-28 cm H2O.
         2. An infant weighing greater than 1500 grams: 20-30 cm H2O.
      3. Positive end expiratory pressure (PEEP): 4 cm of H2O OR 5-6 cm if FiO2 > 0.90.
      4. FiO2: 0.4 to 1.0, depending on the clinical situation.
      5. Inspiratory time: 0.3-0.5 sec.
   2. After 15 to 30 minutes, check arterial blood gases and pH.
      1. If the PaO2 or the O2 saturation is below accepted standards, the FiO2 can be raised to a maximum of 1.0. If the PaO2 or O2 saturation is still inadequate, the mean airway pressure can be raised by increasing either the PIP, PEEP, inspiratory time or the rate, leaving inspiratory time constant.
      2. If the PaCO2 is elevated, the rate or peak inspiratory pressure can be raised.
   3. Arterial blood gases and pH must be checked 15 to 30 minutes after changing any setting of the respirator: rate, peak pressure, or inspiratory time. Changes in FiO2 may be monitored by pulse oximetry or transcutaneous oxygen monitor.
   4. When lowering the respiratory rate without a concomitant decrease in I:E ratio, the inspiratory time can become quite prolonged. The total inspiratory time should not exceed 0.6 second.
   5. When increasing the respiratory rate above 60/minute, the I:E ratio should be 1:1.
2. Other Respiratory Conditions
   Recommendations for the initial respiratory settings for other neonatal conditions will be found on the following table. The peak pressure used is a reflection of the anticipated compliance of the lung. Subsequent changes in settings will be determined by arterial blood gases and pH values and the clinical course. During the acute phase of the disease process, arterial blood gases and pH MUST be measured 15 to 30 minutes after a change in ventilatory settings.
3. When placing a neonate on mechanical ventilation, an order is written indicating:
   1. Conventional Mechanical Ventilation
      1. Mode (IMV or conventional sigh breaths when using HFV)
      2. Rate (breaths per minute)
      3. FiO2
      4. Inspiratory time (seconds) or I:E ratio
      5. Peak inspiratory pressure (cm H2O)
      6. PEEP (cm H2O)
   2. High Frequency Ventilation (HFV)
      1. Frequency (HZ)
      2. Amplitude or power
      3. PEEP or MAP (cm H2O)
   3. Synchronized Intermittent Mandatory Ventilation (SIMV)
      1. Rate (use up to 40 bpm when on Servo 300, up to 60 on Star Synch)
      2. PC (pressure control); set a peak pressure, Based on adequate chest wall movement
      3. PS (pressure support); number of cm H2O pressure above the PEEP, usually start at a PS = (PIP-PEEP)/2, minimal PS = 4-6 cm
      4. VC (Volume Control) set a tidal volume usually 5-7 cc/kg for premature infnats and 7-10 cc/kg for term infants:

Any change in the above parameters must be written as an order.

See the following Use of Mechanical Ventilation in the Neonate table for details.

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