Guidelines for setting up a Neonatal Ventilator: Indications to intubating neo

1. Pt range: Neonate (Maximum VT = 40cc) 1. PaO2 < 45mmHg while

2. Mode: Pressure Control (works best for un-cuffed ETT) breathing 80 – 100% FiO2
3. VT: a. <33 weeks gestation 4 – 6 cc/kg 2. PaCO2 > 65mmHg
b. >33 weeks gestation or chronic 5 – 7 cc/kg 3. Intractable metabolic
4. PIP: a. Maximum PIP settings: acidosis(B.E. < -10 meq.)
- <27 weeks gestation 24 CWP 4. Marked retractions on
- 27 – 32 weeks gestation 26 CWP CPAP
- 33 – 40 weeks gestation 28 CWP 5. Frequent episodes of apnea
b. Start low (best to err on low side to prevent barotraumas.) and bradycardia on CPAP.
c. Increase to obtain target VT and adequate chest rise
d. Frequently monitor & adjust PIP to accommodate
Normal Neo ABGs & Vitals:
changes in lung compliance altering tidal volume.
1. Target ABG:
5. PEEP: a. Start at minimum 4 – 5 CWP PH 7.25 – 7.40
b. Increase to 6 – 7 CWP if FiO2 needs > 60% PCO2 = 45 – 59
c. Adjust to maintain acceptable PaO2 and SpO2 PaO2 = 50 – 70
d. 8 – 10 CWP PEEP if directed by physician BE = 0 – -4
2. SpO2: 82–92% if <27 wks
e. Remember that PC setting is “above PEEP”
85–93% if <33 wk
6. FiO2: a. Start low at 40% 88 – 95% if >33 wks
b. Adjust to maintain target SpO2 2. RR: Term = 30–50
c. If SaO2 < target range, FiO2 may be increased by 2–5, Premie = 40 - 70
& then allowing 4 minutes for stabilization after each 3. HR: Term =120 – 160
change. (consider adjustment of PIP and PEEP also.) 4. BP: 50 – 90 systolic
25 – 60 diastolic
d. Continue assuring AW patent, HR>100 & baby not apneic.
e. If SaO2 > target range, FiO2 may be decreased by 2 – 5,
allowing 4 minutes for stabilization after each change. Ideal Tidal Volume for neonates
f. Consider increasing PEEP prior to FiO2 <33 weeks gestation
g. Maintain neonate on ROOM AIR whenever possible. (Based on 4-6 ml/kg IBW)
7. Rate: a. 50 – 60 if < 34 weeks gestation or < 3 kg Weight Min VT Max VT
b. 40 – 50 if >34 weeks gestation or > 3 kg (kg)
c. 30 – 40 if 40 weeks gestation; slightly higher if indicated. 0.5 2 3
d. Watch for air trapping at rates > 40 (adjust I-time). 1 4 6
8. I-time: a. Start at 0.3 plus or minus 0.5 (post-term may need more.) 1.5 6 9
b. Neonatal initial I-time setting 2 8 12
- <1kg 0.25 – 0.30 sec minimum 0.20 seconds 2.5 10 15
- 1-2kg 0.30 – 0.40 sec minimum 0.20 seconds 3 12 18
- 2-3kg 0.35 – 0.45 sec minimum 0.25 seconds
- 3-4kg 0.40 – 0.60 sec minimum 0.30 seconds
c. Ideally set using Flow-time graphics Ideal tidal volume for neonates
d. This alters I-time and I:E ratio > 33 weeks gestation
e. Increase & decrease to reach target settings as appropriate (Based on 5-7ml/kg IBW)
f. Watch for air trapping at rates >40 in neonates >3kg; Weight Minimum Maximum
they may need I-time >0.40 to complete inspiration & (kg) VT VT
prevent air trapping. 1 5 7
g. If neonate using expiratory muscles, try decreasing I-time 2 10 14
slightly (increasing flow). 3 15 21
h. If I-time gets too short, consider switch to PRVC. 4 20 28
9. I-Rise time: a. 10 if < 33 weeks gestational age 5 25 35
b. >5 if >33 weeks gestational age 6 30 42
c. Basically, the smaller the ETT the higher this should be to 7 35 49
create laminar flow and a pseudo sign wave.
d. Increase for bronchospasm (slow rise time, longer e-time)
10. PIP limit: 2 – 3 > PIP (all other alarms as appropriate.) Respiratorytherapycave.blogspot.com