Setting Up the Ventilator

• Start with A/C volume control, VT 6–8 mL/kg PBW, RR 12–16, PEEP 5, FiO₂ 100%, then wean to SpO₂ 92–96%.
• Work out PBW as 50 + 2.3 kg/inch over 5 ft (men) or 45.5 + 2.3 (women); NEVER use actual weight.
• Check an ABG 15–30 min post-intubation and keep plateau <30; in obstructive lungs slow the RR, lengthen expiratory time, and watch auto-PEEP.
• Confirm the tube with continuous ETCO₂ and start sedation plus DVT/GI prophylaxis.
• Track driving pressure (plateau − PEEP), aiming for ≤15 cmH₂O where achievable.

Managing High Peak Airway Pressures

• High peak airway pressure alarm with inadequate minute ventilation
• Possible causes: mucus plugging · coughing · bronchospasm · ETT occlusion intrinsic or extrinsic (biting, secretions, blood) · right mainstem intubation · patient–ventilator asynchrony · excessive tidal volumes · pneumothorax
• Disconnect from the ventilator and bag with 100% O₂
• Difficult to bag?
• Can a suction catheter pass through the ETT?
• Diagnose by examination, then treat:
• Bronchospasm — wheezing → bronchodilators, steroids · tracheal obstruction — no bilateral air entry → emergent bronchoscopy · right mainstem intubation — no left-sided air entry → pull back ETT · pneumothorax — hyperresonance and diminished air entry on the affected side → decompress with a large-bore needle in the 4th–5th intercostal space, anterior axillary line (ATLS 11th), then chest tube
• Check for biting — if present, increase sedation
• Check for ETT occlusion or tip malposition: consider emergent bedside bronchoscopy, or if deteriorating, call airway-experienced personnel for reintubation with a new ETT
• Return to the ventilator · correct patient–ventilator asynchrony via settings or sedation · treat bronchospasm