ICU Map

Mechanical Ventilation Initiation Workflow

From post-intubation verification and lung-protective settings to mechanics optimization.

RecognizeAssessDecideDifferentialInterveneReassess
Post-Intubation / Invasive Ventilation Required
Assessment StepVerify endotracheal tube position & cuff seal
Confirm bilateral breath sounds, end-tidal CO2 detection, chest radiography (tip 3–5 cm above carina), and cuff pressure 20–30 cmH2O.
Decision PointSelect primary ventilation mode
Choose Volume Assist-Control (precise Vt and lung protection) or Pressure Assist-Control (peak pressure limitation) based on lung pathology.
Clinical ActionCalculate predicted body weight & set Vt 6–8 mL/kgExplore Topic
Use height-based PBW equation. In ARDS or stiff lungs, target 6 mL/kg PBW immediately to prevent volutrauma.
Clinical ActionSet initial PEEP (5–8 cmH2O) and FiO2 (1.0 titrated down)
Titrate FiO2 rapidly to achieve SpO2 92–96% (88–92% in ARDS/COPD) to minimize hyperoxic lung injury.
Assessment StepPerform inspiratory hold: measure Pplat & Driving PressureExplore Topic
Maintain Plateau Pressure <= 30 cmH2O and seek lower Driving Pressure (Pplat - PEEP) within a lung-protective framework.
Reassessment / LoopObtain arterial blood gas at 30 minutes
Evaluate pH, PaCO2, and PaO2/FiO2 ratio. Adjust respiratory rate for pH 7.30–7.45 (permissive hypercapnia in ARDS/asthma).
Differential Branches (2)
1Branch
Reassessment / LoopMechanics & gas exchange acceptable
Maintain lung-protective settings, synchronize sedation to RASS -1 to 0, and assess daily for liberation readiness.
2Branch
Critical AlertPplat > 30 cmH2O or markedly elevated/rising driving pressureExplore Topic
Escalate lung protection: reduce Vt to 4–5 mL/kg PBW, optimize PEEP, evaluate chest wall compliance, or consider neuromuscular blockade.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Sudden high peak and plateau pressure rise with hemodynamic instability — evaluate immediately for tension pneumothorax or mainstem intubation.
  • Hypotension following intubation in obstructive lung disease — disconnect ventilator circuit briefly to allow complete exhalation and exclude dynamic hyperinflation (Auto-PEEP).

Related Bedside Clinical Problems (9)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

View Bedside Problem →
Acute Hypercapnia & Ventilatory Failure

Triaging rising PaCO2: distinguishing acute uncompensated acidemia from chronic compensation, identifying central vs pump vs dead-space failure, and titrating noninvasive ventilation.

View Bedside Problem →
Sudden Ventilator Deterioration & High Airway Pressures

Algorithmic troubleshooting of acute patient-ventilator collapse: the DOPE framework, peak vs plateau pressure differentiation, auto-PEEP evaluation, and manual bagging separation.

View Bedside Problem →

Linked Deep-Dive Topics (3)

Reference Knowledge
Invasive Mechanical Ventilationrespiratory

Complete clinical topic overview. For the full 10-level interactive course, visit Master MV. Covers core ventilator modes, respiratory mechanics (Cstat, Raw, driving pressure), waveform dyssynchrony analysis, VILI prevention, and liberation protocols.

Explore Topic →
Acute Respiratory Distress Syndromerespiratory

Acute, diffuse inflammatory lung injury causing hypoxemia and bilateral infiltrates not fully explained by cardiac failure or fluid overload.

Explore Topic →
Respiratory Failure: Basic Principlesrespiratory

Core taxonomy (Types I–IV), alveolar gas exchange physiology, work-of-breathing mechanics, and escalation thresholds in acute respiratory failure.

Explore Topic →

Evidence status

Review metadata not yet recorded.

Status, review dates and guideline versions appear here once editorial metadata is authored for this content.

References & Guidelines

ARMA (ARDSNet)

New England Journal of Medicine, 2000

RCT