Ventilator Settings for Nurses: Demystifying ICU Ventilator Modes

by | Feb 21, 2024 | Critical Care | 0 comments

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Understanding ventilator settings for nurses is not just a technical skill. It’s vital to providing safe and effective care for critically ill patients. It’s not just about flipping switches and reading numbers. It’s about knowing the science behind each setting, how it affects the patient’s physiology, and how to adjust them to optimize their breathing.

Let’s unravel the complexities of both foundational and advanced knowledge of ventilator settings and ventilator modes for nurses, empowering those new to the ICU to deliver exceptional care in this high-stakes environment.

ventilator settings for nurses

A quick note ➡️ In this post, we’ll chat about the ventilator. But if you’d like to know how to intubate someone or a rapid sequence intubation, check this post out.

Ventilator Basics 🫁

A mechanical ventilator is a medical device that provides mechanical ventilation (delivering oxygen to the lungs and removing carbon dioxide from the body) by assisting or replacing the patient’s spontaneous breathing. It is commonly used in the Intensive Care Unit (ICU).

Here’s how it works:

  • Airflow: The ventilator has a compressor that pushes air through a tube and into the patient’s airway, often through a mask or a tube inserted into the trachea (windpipe).
  • Pressure and Volume: The ventilator can be set to deliver specific volumes of air at different pressures to ensure proper lung inflation and oxygen exchange.
  • Oxygen: The air delivered by the ventilator can be supplemented with additional oxygen to meet the patient’s needs.

In patient care, ventilators prove essential for those facing conditions such as acute respiratory failure, pneumonia, neuromuscular diseases, sepsis, trauma, and injuries or surgeries. By delivering controlled amounts of air (and oxygen, if necessary) to the lungs, ventilators alleviate the respiratory workload on patients, allowing them the necessary time to recover from underlying health issues.

Ventilator Settings vs. Modes

You will notice that during report, you will be told what mode the ventilator is in as well as the settings.

ICU Ventilator Modes

Mechanical ventilator modes refer to the method by which the ventilator delivers support to the patient. These modes define how breaths are initiated, controlled, and cycled—that is, how they start, what parameter (pressure or volume) is controlled during the breath, and how the breath ends. Modes can be broadly categorized based on whether they are volume-controlled, pressure-controlled, or a hybrid of both, and they determine the overall strategy of ventilation.

A few examples of ICU ventilator modes are:

  • Assist-Control Ventilation (ACV)
  • Pressure Support Ventilation (PSV)
  • Continuous Positive Airway Pressure (CPAP)

We’ll go into more detail of these shortly.

Ventilator Settings For Nurses

Now, let’s explore ventilator settings for nurses. Ventilator settings, on the other hand, are the adjustable parameters within a chosen ventilator mode. These settings allow healthcare providers to customize the support provided by the ventilator based on the patient’s specific respiratory needs.

Note ➡️ Nurses often do not decide to adjust these settings. This is done by a critical care physician or advanced practice provider

Ventilator settings for nurses include: Tidal Volume (Vt), Inspiratory Pressure (IP), Respiratory Rate (RR), FiO2 (Fraction of Inspired Oxygen), and PEEP (Positive End-Expiratory Pressure).

In summary, the mode of a ventilator determines the overall approach to providing respiratory support—how the ventilator breathes for the patient—while the settings are the specific parameters that control the details of that support, such as the volume of air or the pressure used. Adjusting these settings within a given mode allows healthcare providers to tailor the ventilator’s support to the patient’s changing needs.

Key 🔑 ICU Ventilator Modes

Let’s dig deeper into the modes we just mentioned. Each has a unique way of delivering breaths and providing support to the patient’s spontaneous breathing. There are two types of modes: Volume modes and pressure modes.

Volume modes provide a set amount of volume, while pressure modes provide a set amount of pressure. Basically:

Volume = how much

Pressure = how forceful

Please note the difference between spontaneous and mandatory ventilation. Spontaneous ventilation is when a spontaneous breath may be assisted or unassisted. Conversely, when the machine intiates a breath, that would be sconsidered mandatory breaths.

Volume Control Modes

  • Assist-Control Ventilation (ACV or AC): Delivers a set number of breaths (respiratory rate) and tidal volume; assists with additional breaths if initiated by the patient.
  • Synchronized Intermittent Mandatory Ventilation (SIMV): Allows spontaneous breathing and delivers a set number of mandatory breaths.

Pressure Control Modes

  • Pressure Support (PS): Provides support to patient’s spontaneous breaths with a preset level of pressure
  • Pressure Control (PC): No set tidal volume, set pressure control
  • Airway Pressure Release Ventilation (APRV): Reversed ratio of inspiration to expiration, very helpful in ARDS patients
  • Pressure Regulard Volume Control (PRVC): Lowest amount of pressure programed to deliver a set tidal volume, allows for spontaneous breathing

Key 🔑 ICU Ventilator Settings for Nurses

The mode and settings will both be determed by the ICU provider and/or respiratory therapist. These are based on the patient’s unique respiratory needs. You will hear certain settings communicated in report and there may be additional settings that are active, but not always verbally communicated from nurse to nurse.

Here’s what you’ll hear in report:

  • Tidal Volume (Vt): The volume of air delivered to the patient with each 💨 breath.
    • Typical range: 6-8 mL/kg
  • Respiratory Rate (RR): The number of breaths per minute deleveried by the ventilator.
    • Typical range: at minimum, 8-12 breaths
  • FiO2 (Fraction of Inspired Oxygen): The concentration of oxygen in the air mixture delivered to the patient.
    • Typical range: 21-100%
    • For reference, room air is 21%
  • PEEP (Positive End-Expiratory Pressure): The pressure maintained in the lungs at the end of expiration to keep alveoli open.
    • 5 (low/normal) – 24 (extreme) cm H20

Having this information readily available is helpful to the ICU nurse to be able know the degree of respiratory compromise. If a patient needs a lot of FiO2 and PEEP, we know they’re pretty sick. On the contrary, if you hear the patient has a Tidal Volume of 6, Rate of 12, Fi02 of 21% and PEEP of 5, you know they’re getting minimal support. Maybe it will be time to extubate them soon!

How You Will Hear This In Report 📝

When recieving a patient on a ventilator, you should be informed of the following information in report:

  • The mode
  • The current settings (and respiratory rate if they are breathing spontaneously, or “over the vent”)
  • If the mode and/or settings have changed recently
  • The size of the endotracheal tube (ETT)
  • Where the ETT is taped
  • How the patient is doing with it
  • What secretions are like
  • Breath sounds
  • Oxygen saturation range

This is how it will sound:

“Alright, so the patient is on a vent. PRVC  PEEP 5 FiO2 40 Rate 16, ETT is 23 at the lip. Secretions are white, thick, and creamy but not copious. Sating 93-97% with coarse lung sounds.”


Additional Ventilator Settings For Nurses

There are more ventilator settings for nurses to consider in addition to the ones more frequently communicated during report. Let’s go through those.

  • PS: Inspiratory pressure
    • Normal values: 5-30 cmH20
  • Ve: Total volume per minute
    • Normal values: 5-8 L/min
  • PIP: Pressure for air movement
    • Normal values: < 40 cmH20
  • I:E Ratio: Inspiration to expiration time
    • Normal values: 1:3 – 1:5

Adjusting the Ventilator Settings

Adjusting ventilator settings based on patient needs requires a thoughtful and dynamic approach. Nurses can alert the medical team of concerns and assessment changes, however they cannot independently adjust ventilator settings. This should be done together with the providers and respiratory therapists.

Here are practical tips to guide nurses and clinicians in optimizing ventilator parameters:

  1. Assess Patient Response:
    • Regularly monitor the patient’s oxygen saturation, arterial blood gases, respiratory rate, and other respiratory parameters like tidal volume, minute ventilation, and airway pressures.
    • Adjust settings based on the patient’s response to ensure adequate oxygenation and ventilation.
  2. Tidal Volume and Respiratory Rate:
    • Individualize settings by considering the patient’s lung compliance and disease severity.
    • Increase or decrease tidal volume and breaths per minute / respiratory rate to achieve appropriate ventilation while avoiding lung overdistension.
  3. Positive End-Expiratory Pressure (PEEP):
    • Gradually adjust PEEP to maintain optimal lung recruitment without causing barotrauma.
    • Consider higher PEEP levels for patients with conditions like ARDS to improve oxygenation.
  4. FiO2 (Fraction of Inspired Oxygen):
    • Titrate FiO2 to achieve target oxygen saturation levels.
    • Minimize FiO2 to reduce the risk of oxygen toxicity while maintaining adequate oxygenation.
  5. Flow and Inspiratory Time:
    • Adjust inspiratory flow rates based on patient comfort and synchrony.
    • Modify inspiratory time to optimize gas exchange and prevent patient-ventilator dyssynchrony.
  6. Pressure Support and Assist-Control Modes:
    • Individualize pressure support levels to reduce the work of breathing.
    • In assist-control modes, adjust the inspiratory pressure to balance support and avoid excessive tidal volumes.
  7. Regularly Reassess and Modify:
    • Continuously reassess the patient’s clinical status and adjust settings accordingly.
    • Collaborate with the healthcare team to incorporate evolving patient needs into the ventilator management plan.

Making small changes and carefully monitoring the patient’s response minimizes risks and prevents sudden complications. 

Monitoring and Responding to Ventilator Alarms ⏰

As nurses, it is crucial to understand the common ventilator alarms and their meanings to effectively monitor and respond to any potential issues.  Each alarm indicates a specific issue that requires attention, such as a blockage in the airway, a disconnect in the ventilator circuit, or a change in the patient’s respiratory status.

We want to be able to idetnify the issue and respond promptly.

Common Ventilator Alarms

Here’s an overview of some common ventilator alarms and their potential causes:

  1. Low-Pressure Alarm ➡️ This alarm indicates that the pressure in the breathing circuit has fallen below the set limit.
    • Possible causes: leak in the breathing circuit, disconnection of the circuit, shallow breathing by the patient, or increased airway resistance due to secretions or bronchospasm.
  2. Volume Alarms ➡️ These could be low or high
    1. Low ⬇️ Volume Alarm: This alarm indicates that the volume of air delivered to the patient has fallen below the set limit.
      • Possible causes: leak in the breathing circuit, kinks or blockages in the circuit, or increased airway resistance due to secretions or bronchospasm.
    2. High ⬆️ Volume Alarm: This alarm indicates that the volume of air delivered to the patient has exceeded the set limit.
      • Possible causes: incorrect ventilator settings, leak in the breathing circuit, or shallow breathing by the patient.
  3.  Rate Alarms: ➡️ These could be low or high
    1. High-Rate Alarm: This alarm indicates that the ventilator is delivering breaths at a rate higher than the set limit.
      • Possible causes: incorrect ventilator settings, patient anxiety or pain, or metabolic acidosis.
    2. Low Rate Alarm (Apnea): This alarm indicates that the ventilator has not delivered a breath within the set apnea window.
      • Possible causes: oversedation of the patient, neuromuscular weakness, or disconnection of the ventilator.
  4. Other Alarms:
    1. PEEP Alarms: These alarms indicate that the level of positive end-expiratory pressure (PEEP) has fallen below or exceeded the set limit.
      • Possible causes: leak in the breathing circuit or incorrect ventilator settings.
    2. Battery Alarms: These alarms indicate that the ventilator’s battery is running low. Plug 🔌 that baby in!

It’s crucial to consult the ventilator manual and have a thorough understanding of the equipment before providing care to a ventilated patient.

Step to Follow When a Ventilator Alarm Sounds

When a ventilator alarm sounds, it’s crucial to act quickly and calmly to assess the situation and ensure the patient’s safety. Here’s a breakdown of the initial steps you should take:

  1. Prioritize the Patient: Look for any signs of distress, such as changes in breathing patterns, level of consciousness, or skin color. Glance at the bedside monitor to see their current pulse, oxygen saturation and latest blood pressure reading.
  2. Identify the Alarm:
    • Locate the alarm on the ventilator: Different alarms may have different tones or lights.
    • Silence the alarm: The purpose of the alarm is to make you aware of a problem. You are aware of it now! Wonderful! Let’s silence it so the patient doesn’t have to hear the alarm going off (this is important even if the patient is sedated, as alarms can increase delirium and confusion). This takes one second.
    • Call for help, if needed: If it is a complex issure, like the patient’s not tolerating the tidal volume and needs the settings adjusted, call respiratory therapy (RT) to help optimize the settings. If the patient is in severe distress or coding, call a code!
  3. Take Immediate Action:
    • High/low-Pressure Alarms: Check for leaks in the circuit, for and disconnection of tubes, or suction secretions if needed.
      • This is the most common alarm; you simply need to reconnect the patient and often need to suction once or twice and the alarm will resolve.
      • Note ➡️ Your hospital policy may require you to preoxygentate with 100% Fi02 before suctioning. It is referred to as “giving breaths” at the bedside, and that mean you’d press a button on the vent to give 100% Fi02 for a few moments prior to suctioning.
    • High/low Volume Alarms: Modify tidal volume based on the patient’s lung compliance, or troubleshoot ventilator malfunction. (This would require the assistance of an RT.)
    • Apnea Alarms: Check for airway obstruction, stimulate the patient to breathe, or consider bag-mask ventilation if needed and call for reinforcements.
  4. Document and Communicate:
    • If the alarm was related to a simple disconnection, you may not need to document it or communicate it
    • If the issue was that settings needed to be changed or suctioning needed to occur, document that
    • Ensure that any communication to the medical team is prompt and documented appropriately
      • Please note that the medical team does not need to notified if routine care was provided. They need to know about changes that impact the plan of care.

Regular monitoring and documentation of ventilator settings and alarm responses are essential for maintaining the patient’s respiratory status and preventing complications. This includes recording the ventilator settings, alarm events, interventions taken, and the patient’s response. 

ICU Ventilator Modes and Settings in Special Situations

Handling complex cases like Acute Respiratory Distress Syndrome (ARDS) or Chronic Obstructive Pulmonary Disease (COPD) requires careful and precise ventilator management. (We talk a lot about these issues in my prep course for new ICU nurses.) Let’s talk about a few theoretical situations and possible approaches.

In ARDS, the ventilator settings must be adjusted to prevent further lung injury and promote oxygenation, this may involve;

  • Using Low Tidal Volumes: Aim for 6-8 mL/kg tidal volume to minimize alveolar stress and prevent ventilator-induced lung injury (VILI).
  • Plateau Pressures:  These are the pressure in the lungs at the end of inspiration when the ventilator stops delivering gas. They are measured in centimeters of water (cmH2O). Keep plateau pressures below 30 cmH2O to protect the vulnerable lung tissue.
  • Using High PEEP: Set appropriate PEEP levels to improve oxygenation and prevent alveolar collapse.
  • Prone Positioning:  To improve oxygenation and prevent barotrauma.

(You can preview my module on ARDS for free here.)

In COPD, the focus is on preventing air trapping and dynamic hyperinflation, this may involve;

  • Airflow Support:
    • Non-invasive Ventilation (NIV): Consider NIV as first-line support for mild-to-moderate exacerbations to avoid ventilator-associated complications.
    • Pressure Support Ventilation (PSV): Utilize PSV to allow the patient to participate in breathing and reduce the work of breathing.
    • Expiratory Time: Ensure adequate expiratory time to allow for lung emptying, especially in patients with hyperinflation.
  • PEEP: Apply low levels of PEEP to improve ventilation-perfusion matching and reduce air trapping.
  • Humidification: Maintain adequate airway humidity to prevent airway secretions from thickening and increasing airway resistance.

Adjusting Ventilator Settings for Patients with Specific Conditions

Modifying ventilator parameters for patients with particular conditions such as brain injury or pulmonary hypertension is something that you also need to learn. Here’s a breakdown of considerations for two specific conditions:

Brain 🧠 Injury

Protective Ventilation is often the goal, as patients with brain injuries often cannot maintain their own airway due to a brain issue rather than a lung issue. While some patients with brain injuries have lung problems too, often the main issue is related to the brain. For more neuro nursing tips, check out this page.

Lower Tidal Volumes ➡️ Aim for 4-6 mL/kg tidal volume to minimize intracranial pressure (ICP) fluctuations and cerebral blood flow (CBF) variations.

Plateau Pressures ➡️ Keep plateau pressures below 25 cmH2O to prevent cerebral hyperperfusion and edema.

PEEP ➡️ Set PEEP cautiously, as high levels can increase ICP. Consider lung-protective PEEP strategies to improve oxygenation without elevating ICP.

Hyperventilation (Permissive Hypercapnia) ➡️ Allow some degree of CO2 rebreathing if ICP is elevated, balancing oxygenation with the need to avoid exacerbating intracranial hypertension.

Pulmonary 🫁 Hypertension

Right Ventricular (RV) Function ➡️ Prioritize settings that support RV function and prevent RV strain.

Lower PEEP ➡️ Start with low PEEP levels and gradually increase if tolerated to improve oxygenation without overloading the RV.

Inspiratory Time ➡️ Use longer inspiratory times to allow for adequate RV filling.

Expiratory Flow ➡️ Avoid excessive expiratory flow rates to prevent RV pressure swings.

Pulmonary Vasodilators ➡️ Consider pulmonary vasodilator therapy in specific cases to reduce pulmonary artery pressure and improve RV workload.

Case Scenarios for Adjusting ICU Ventilator Modes and Settings

The following are simplified examples, and actual ventilator adjustments would depend on specific patient factors and ongoing monitoring.

ARDS with High Plateau Pressures

  • Patient: 52-year-old male with pneumonia-induced ARDS.
  • Initial Settings: Tidal volume (TV) 8 mL/kg, PEEP 10 cmH2O, Pressure Support Ventilation (PSV) 10 cmH2O.
  • Problem: Plateau pressures at 32 cmH2O, increasing the risk of Ventilator-Induced Lung Injury (VILI).
  • Adjustment:
    • Decreased TV to 6 mL/kg: Reduce alveolar stress and lung injury risk.
    • Increased PEEP to 15 cmH2O: Improve oxygenation, and prevent alveolar collapse.
    • Maintained PSV at 10 cmH2O: Allow patient effort and minimize ventilator dependence.
  • Outcome: Plateau pressures decreased to 28 cmH2O, oxygenation improved, the patient was successfully weaned from the ventilator after 7 days.

Brain Injury with Elevated ICP

  • Patient: 25-year-old male with traumatic brain injury requiring mechanical ventilation.
  • Initial Settings: TV 8 mL/kg, PEEP 10 cmH2O, Assist-Control Ventilation (ACV) mode.
  • Problem: ICP elevated at 25 mmHg, concerns about cerebral hyperperfusion.
  • Adjustment:
    • Decreased TV to 6 mL/kg: Minimize ICP fluctuations and CBF variations.
    • Reduced PEEP to 5 cmH2O: Avoid further ICP increase due to high intrathoracic pressure.
    • Considered Permissive Hypercapnia: Allow mild CO2 rebreathing to lower ICP, balancing oxygenation with intracranial pressure control.
  • Outcome: ICP decreased to 20 mmHg, cerebral perfusion maintained, patient showed signs of neurological improvement.

Troubleshooting Common Ventilator Issues

Let´s learn how to identify and address common ventilator issues in the intensive care unit: 

Patient-Ventilator Asynchrony

This occurs when there is a mismatch between the patient’s spontaneous breathing efforts and the ventilator-delivered breaths. Adjustment of ventilator settings, including inspiratory and expiratory times, can help improve synchronization, reducing the risk of complications and enhancing the overall efficacy of respiratory support.


Bariotrauma Is a lung injury caused by a difference in pressure between a gas space inside or in contact with your body and the surrounding gas or liquid. The main causes are rapid changes in pressure, mechanical ventilation, underlying lung conditions, or air trapping.

If barotrauma is suspected, the first step involves reducing ventilator pressures, particularly peak inspiratory pressure (PIP) and plateau pressure, to prevent further lung overdistension. Adjustments to tidal volume and positive end-expiratory pressure (PEEP) may be considered to optimize lung protection. 


Volutrauma refers to injury to the lungs caused by overdistension during mechanical ventilation. Several factors can contribute to volutrauma: high tidal volume, low PEEP, heterogeneous lung compliance, or underlying lung disease.

If volutrauma occurs the primary step involves reducing tidal volume to prevent overdistension of the alveoli. Simultaneously, optimizing Positive End-Expiratory Pressure (PEEP) settings is essential to maintain lung recruitment and prevent alveolar collapse. Considering permissive hypercapnia and avoiding aggressive ventilation contribute to minimizing further lung injury. 

Managing Ventilator Complications

Complications related to ventilator settings, such as hypoventilation or hyperventilation, can also arise. ICU nurses should be prepared to quickly recognize and address these issues by adjusting settings in coordination with the respiratory therapist.

Here are strategies to manage these issues.


  • Symptoms: Low blood oxygen levels (hypoxemia), increased carbon dioxide levels (hypercapnia), respiratory acidosis, increased work of breathing / patient effort, decreased alertness.
  • Management:
    • Increase tidal volume cautiously to improve oxygenation, while monitoring for volutrauma risk.
    • Increase respiratory rate if not contraindicated (e.g., high ICP in brain injury).
    • Adjust PEEP cautiously to balance oxygenation and lung inflation.
    • Address airway obstruction with suctioning, bronchodilators, or positioning changes.
    • Assess and potentially improve muscle effort with neuromuscular assistance or weaning strategies.


  • Symptoms: High blood oxygen levels (hyperoxemia), low carbon dioxide levels (hypocapnia), respiratory alkalosis, lightheadedness, dizziness, anxiety, tremors, tetany.
  • Management:
    • Decrease tidal volume cautiously to avoid atelectasis (collapsed lung).
    • Decrease respiratory rate unless hypoxemia or respiratory acidosis occurs.
    • Increase PEEP to improve oxygenation and reduce air leaks.
    • Identify and address air leaks through circuit connections or chest tubes.

it’s essential to emphasize that patient care is highly individualized, and decisions should be based on a thorough assessment of each patient’s unique clinical condition.

Communicate 🗣️ Effectively With  the Respiratory Therapist

Respiratory therapists (RTs) are invaluable partners in managing critically ill patients on ventilators, especially in complex situations. Here are some tips for effective collaboration:

  • Clear and concise communication: Communicate patient information, concerns, and desired outcomes to the RT. Ask clarifying questions about their assessments and recommendations.
  • Open and frequent communication: Maintain open communication channels, updating each other on changes in patient status, ventilator settings, and treatment plans.
  • Respectful and collaborative tone: Foster a respectful and collaborative environment where both professionals can voice their expertise and concerns constructively.
  • Regular team huddles: Hold regular team huddles to discuss patient progress, address challenges, and coordinate care plans.
  • Documentation and records: Maintain clear and concise documentation of shared decisions, ventilator settings, and interventions. If you have questions, check the chart before calling to make sure that information isn’t already readily available. For example, if you see the vent settings have changed, instead of calling them to ask what time it was done, look in the chart to see when it was documented.

Weaning from Mechanical Ventilation

Transitioning a patient from invasive mechanical ventilation (IMV), which involves stopping IMV and taking out the endotracheal tube or tracheostomy, is a crucial step in ICU patient care.

According to research, these are the most common factors to wean a patient: 

  • Reversal or improvement of the underlying condition necessitating mechanical ventilation. Oxygen demand below 40% or 50% fractional inspired oxygen (FIO2)2,4.
  • Positive end-expiratory pressure (PEEP) at or below 8 cm H2O2,4.
  • Resolution of ventilation and acid-base balance irregularities.
  • Stabilized cardiovascular and hemodynamic condition.
  • The existence of natural respiratory drive limited or absence of sedation.

Several factors may influence the patient’s ability to undergo a successful weaning process from mechanical ventilation. These factors include sedation, psychological status, level of consciousness, and nutritional considerations.

Need help determining level of consciousness? Check out this video.

Techniques Used in The Weaning Process

The main techniques and monitoring strategies for successfully performing a weaning process in mechanical ventilation are the following.

A Spontaneous Breathing Trial (SBT) is a critical step in the process of weaning a patient from mechanical ventilation. It is essentially a test to assess a patient’s ability to breathe on their own without the assistance of a ventilator. The trial aims to evaluate the patient’s respiratory muscle strength, lung function, and overall readiness to resume independent breathing. SBTs are an integral part of the process in determining whether a patient can be safely extubated (removal of the breathing tube) and transitioned to breathing without mechanical support.

A physician will order the SBT, and this will be conducted with both the nurse and respiratory therapist.

How an SBT is Conducted

The specifics of conducting an SBT can vary based on clinical protocols and patient needs, but the general process includes the following steps:

  1. Assessment for Readiness: Before starting an SBT, healthcare providers assess the patient for readiness. Criteria may include stable vital signs, adequate oxygenation and ventilation on minimal ventilator support settings, and evidence of resolving or stable underlying disease that necessitated mechanical ventilation. The patient should not be on any sedation at the time of an SBT.
  2. Reducing or Modifying Ventilator Support: The patient is switched to a mode of ventilation that allows them to initiate all breaths spontaneously. This could be through a T-piece trial, where the patient breathes through a T-shaped tube connected to the ventilator circuit without assistance, or a minimal support mode like CPAP (Continuous Positive Airway Pressure) with or without pressure support ventilation (PSV). These settings reduce or eliminate the mechanical assistance, forcing the patient to use their respiratory muscles.
  3. Monitoring: Throughout the SBT, the patient is closely monitored for signs of fatigue or inability to maintain adequate breathing. Monitoring includes measuring respiratory rate, heart rate, blood pressure, oxygen saturation, and levels of consciousness. Some trials may last from 30 minutes to 2 hours, depending on the patient’s condition and institutional protocols.
  4. Evaluation of Trial Outcome: At the end of the SBT, the healthcare team evaluates the patient’s performance. Successful completion of an SBT indicates that the patient might be ready for extubation. Criteria for success include stable vital signs, adequate oxygenation and ventilation (e.g., maintaining a satisfactory blood oxygen level without signs of increased work of breathing), and the patient’s subjective feeling of being able to breathe comfortably.
  5. Decision on Extubation: If the patient successfully completes the SBT, the medical team may decide to proceed with extubation. However, if the patient shows signs of respiratory distress, fatigue, or other concerning symptoms during the trial, they might remain on the ventilator for a longer period and possibly undergo further rehabilitation or repeated SBTs at a later time.

Quick note ➡️ “Extubation” means to remove the breathing tube. (More ICU lingo is here.)

Post-Extubation Care and Monitoring

Post-extubation care is a critical phase in patient management, focusing on ensuring a smooth transition and recovery after the removal of the endotracheal tube. The following considerations are necessary to monitor and prevent complications:

Respiratory assessment: This plays a central role, involving close observation for signs of distress such as increased respiratory rate, use of accessory muscles, or abnormal breath sounds.

Continued monitoring: Watch the oxygen saturation levels, as this let’s us know how the patient is oxygenating. A follow-up arterial blood gas (ABG) will likely be ordered. Regarding the necessity of supplemental oxygen, if necessary to maintain adequate oxygenation, these are the options for advanced oxygenation therapies:

  • Oxygen Monitoring and Therapy: After extubation, the traditional approach to prevent hypoxia involves using controlled oxygen therapy (COT), typically administered through a facemask with the fraction of inspired oxygen adjusted based on physiological parameters. However, facemask oxygen delivery has limitations, including variability linked to the user’s peak inspiratory flow and the potential for mucosal drying due to a lack of humidification.
  • High-flow Nasal Oxygen Therapy (HFNOT): This represents a recent advancement in adult care, providing humidified and warmed oxygen at flow rates up to 60 L/min. This newer method offers potential benefits to recently extubated patients, offering more precise oxygen concentrations, creating positive end-expiratory pressure, and enhancing gas exchange.

We want to avoid extubating and reintubating repeatedly, however this is occasionally unavoidable. If a patient is unable to be successfully exubated and breathe on their own, they may need a tracheostomy.

More Tips For Managing Recently Extubated Patients

  1. Hemodynamic stability is important. This is assessed through monitoring blood pressure, heart rate, and rhythm.
  2. Maintaining airway patency is essential, with careful attention to prevent obstruction and ensure comfortable breathing. Watch for stridor right after extubation. This is an indication that reintubation might be necessary.
  3. Cough and secretion management techniques are employed to prevent respiratory complications.
  4. Pain management strategies to relieve discomfort. 
  5. Assessment of consciousness levels and neurological status to detect any changes that may require attention.
  6. Swallowing evaluation, especially for those with prolonged intubation. 

Ethical Considerations in Ventilator Use

The ethical considerations surrounding prolonged ventilator use are intricate, involving a delicate balance between life-sustaining interventions and honoring patient autonomy. Decisions often require collaborative discussions among healthcare providers, patients, and families, contemplating factors such as quality of life, potential for recovery, and end-of-life preferences.

Respecting patient autonomy entails effective communication to understand their values, preferences, and care goals, considering the benefits and burdens of continued ventilation.

Understanding the implications of Do Not Resuscitate (DNR) orders and the withdrawal of ventilatory support is paramount in end-of-life care. A DNR order signifies the patient’s decision or medical directive to forgo cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory failure.  Similarly, the withdrawal of ventilatory support involves a deliberate choice to cease mechanical assistance in breathing, acknowledging that continued intervention may not align with the patient’s goals or wishes.

These decisions carry profound ethical and emotional implications, necessitating clear communication among healthcare providers, patients, and families to ensure alignment with the patient’s values and to provide dignified and compassionate end-of-life care.

Interdisciplinary Collaboration

ICU nurses play a vital role in coordinating care by collaborating with respiratory therapists, physicians, and other healthcare professionals. Serving as a central point of contact, they facilitate communication, share critical information, and contribute to the interdisciplinary team’s synergy. 

Case conferences and interdisciplinary meetings provide a platform for healthcare professionals to discuss and collaborate on the care of ventilated patients. These meetings allow for the sharing of best practices, learning from different disciplines, and addressing any challenges or concerns that may arise. Nurses play a crucial role in these meetings, providing valuable insights and perspectives from their direct patient care experiences. Additionally, these meetings provide a platform for shared decision-making, allowing for collaborative adjustments to the ventilation plan based on the evolving needs of the patient.

By working together with a multidisciplinary team, nurses can ensure that ventilator settings are optimized, and patient care is coordinated and comprehensive. This collaborative approach ultimately leads to better patient outcomes and improved quality of care in the intensive care unit.

Continuing Education and Resources

As ICU nurses, ongoing education in ventilator management is crucial for providing the best care for our critically ill patients. Ventilator management is a dynamic field that continually incorporates new techniques, equipment, and evidence-based approaches. It is essential to stay up-to-date on the latest ventilator settings and modes.

Here are some recommendations for workshops, webinars, and certification courses on ICU nurses’ ventilation management:

Final Thoughts on Ventilator Setting For Nurses 

The dynamic evolution of ventilator technology and nursing practices reflects the constant progress within the healthcare landscape. As we witness breakthroughs in medical science, it is crucial for nurses to proactively stay informed about the latest research and advancements in their field. Embracing a commitment to continuous learning ensures that nurses are well-equipped to deliver high-quality care in an ever-changing healthcare environment.

The critical role of nurses in patient outcomes in the Intensive Care Unit (ICU) cannot be overstated. Nurses serve as the bridge between advanced technologies, like ventilators, and the compassionate care that patients require. Their expertise, vigilance, and dedication directly influence the recovery and well-being of critically ill patients. 

To foster a culture of continuous learning and engagement, we encourage our readers to actively participate in the conversation. Feel free to ask questions, share your experiences, and exchange insights in the comments section below. Your input contributes to the collective knowledge of our community and enhances the learning experience for everyone.

For those seeking ongoing updates and information on ventilator technology, nursing practices, and ICU advancements, I invite you to check my courses and podcast. 

Additional Resources For ICU Nurses

Picture of Kati Kleber, founder of FRESHRN

Hi, I’m Kati.

Kati Kleber, MSN RN is a nurse educator, author, national speaker, host of the FreshRN® Podcast, and owner of FreshRN® – an online platform created to educate, encourage, and motivate newly licensed nurses in innovative ways.

Connect with her on YouTube, Pinterest, TikTok, Instagram, and Facebook, and sign-up for her free email newsletter for new nurses.


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