1. This document provides protocols for ventilator settings for adults, children aged 1-10 years, and neonates/infants. It includes guidelines for initial settings, adjusting settings based on blood gas results, criteria for weaning and extubation. 2. The protocol outlines steps for changing settings from initial pressure-regulated volume control (PRVC) to synchronized intermittent mandatory ventilation (SIMV) and lists criteria for determining readiness for a spontaneous breathing trial. 3. Special considerations are provided for various clinical situations like post-cardiac surgery patients, pulmonary issues, and open sternum cases.

1. PROTOCOL FOR VENTILATORY SETTINGS
1. First ABG 10min after connecting to ventilator
2. pCO2 value: Increase /Decrease RR
3. Vt: Do not change until mean Paw cross upper limits
4. On PRVC: up to 25 mean Paw is acceptable
Adult Child (1-10yr) Neonate/infant
Vt 8ml/kg 8ml/kg 8ml/kg
I:E 1:2 1:2 1:1.5
PEEP 5 cmH2O 5 cmH2O 3 cmH2O
RR 14 (up to 24) 16 (up to 30) 25 (up to 40)
Initial PRVC settings
SIMV settings
Check-list for early extubation (PRVC SIMV)
1. Stable Hemodynamics (BP, HR, U/O)
2. Rhythm (regular or AF with CVR )
3. Hemostasis (drain output within limits )
4. Neurologic status (awake, oriented)
5. ABG within acceptable range
6. Temperature (Per. temp>30˚c, Core temp- Per. temp ≤ 10)
7. Chest X ray (within normal limits)
• Change from initial PRVC to SIMV
• Initial PS above PEEP- Adults: 7 cmH2O, Infants 10 cmH2O
• Trigger- Adults: Flow ( -2L/min), Infants Pressure (-2cm H2O)
• Reduce RR by 3- 5, PS above PEEP by 2, PEEP by 1 [every 15-30 min]
• Repeat ABG every 30 min after changing settings
• TARGET: PEEP 5, FiO2 0.5, PS above PEEP 5, RR 5 (Minimal SIMV)
Weaning failure signs
Change in
• RR >10
• pCO2 >10
• SaO2 >10

2. 1. Minimal SIMV
2. PS+CPAP (in adults and infants) / CPAP (in adults only)
3. T piece (Briggs)
• Trial for 30 min Clinical evaluation, ABG
Check list for Successful Spontaneous Breathing Trial
• Neurological
• awake without stimulation
• Eye opening
• Tongue protrusion
• Good hand grip
• Head raise
• ABG
• SaO2 > 92%
• pO2 >80 mmHg (FiO2 ≤ 0.5)
• pCO2 : 30-50 mmHg
• pH 7.35- 7.45 (Base Excess <4)
• Mechanics
• Vt >5mL/kg
• RR < 24 (adult), <35 (infant)
• Stable BP, HR, rhythm
• Chest tube drainage within normal limits
Extubation
• Head end elevation to at least 30˚
• Final suctioning of ET tube
• Suctioning of oral cavity
• Ask to cough as ET tube is removed in adult patients
• Oral lavage following removal of ETT
• Put on Humidified O2 by mask 10L/min
• Repeat ABG after 30 min
Transition ventilation
• Post extubation support by CPAP/ BiPAP: If respiratory efforts are borderline and
pCO2 retention on ABG or known cases of restrictive airway disease
Spontaneous Breathing Trials

3. General directions & Special situations
• Baer hugger can be applied if there is suspected coagulopathy (on going bleeding) and
blood pressure is above normal
• Active rewarming can be done if MAP >110 mmHg
• Core and peripheral temperature difference >10˚c  LCOS
• All neonates should have core temp monitoring
Rewarming
BT shunt
• Keep pCO2 40, Hct 40, FiO2 40 (SaO2 ~ 80%)
• Any unexplained hypoxia, tachycardia, hypotension note down shunt flow
BD Glenn and Fontan
• Vt 8mL/kg (increase in intra thoracic pressure impedes venous return)
• RR 18-20
• Extubate early as possible
• BD Glenn (may keep pCO2 40-50 mmHg i/v/o cerebro-pulmonary circuit)
Pulmonary oedema, ETT bleed, Residual LR shunt
• Raise PEEP by 1-2 cmH2O (max 10-15 cmH2O) every 15 min, until lower inflection
point is reached on flow volume loop
• Minimize ET suction if there is no obstruction to airflow (Acute rise in Peak Paw)
Bronchospasm in infants
• Rule out cardiac cause (MC: volume overload)
• Tube hitting carina
• Local (secretions, mucus plug)
Open sternum
• High compliance and risk of barotrauma and volutrauma
• Keep normal settings if ventilation parameters and ABG report is good
• May need to set higher PEEP (5-7 cmH2O)