Implementation of Neuro Lung Protective Ventilation in Patients With Acute Brain Injury
Phase: NA
Conditions: Acute Brain Injury, Traumatic Brain Injury, Intracerebral Hemorrhage, Stroke, Cerebral Edema, Anoxic Brain Injury
Sponsor: Colin Grissom

NEUROVENT 
 
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July 14, 2017 
 
 
Title: Implementation of Neuro Lung Protective Ventilation 
in Patients with Acute Brain Injury (NEUROVENT) 
Location: Intermountain Medical Center Neuro Intensive Care Unit 
(Neuro ICU), Shock Trauma Intensive Care Unit 
(STICU), and Respiratory Care Intensive Care Unit 
(RICU) 
PI: Colin K. Grissom, MD 
Sponsor: Pulmonary and Critical Care Department 
 
Co-Investigators: 
Don VanBoerum, MD 
Sarah Majercik, MD 
Katherine Thomas, MD 
Michael J. Lanspa, MD MS  
Ithan Peltan, MD 
Russ Miller, MD 
Samuel Brown, MD 
Lori Carpenter, RRT 
Dave Collingridge, PhD 
Brad Isaacson, PhD 
 
Data Analysts: 
Jason Jacobs, PhD 
 
Statistician: 
Jeff Sorensen, MS 
Emily Wilson, MS 
 
Cerner Physician Consultant: 
James Sanders 
 
 
 
 
 
 

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Abbreviations, Acronyms and Symbols 
 
ARDS Acute Respiratory Distress Syndrome 
ALI Acute Lung Injury  
PBW Predicted Body Weight 
ICU Intensive Care Unit 
ED Emergency Department 
STICU Shock Trauma Intensive Care Unit 
Neuro ICU Neuro Intensive Care Unit 
RICU Respiratory Intensive Care Unit 
IMC Intermountain Medical Center 
GLMM Generalized Linear Mixed Model  
EMR Electronic Medical Records 
VC Volume Control 
PRVC Pressure Regulated Volume Control 
PS Pressure Support 
CPAP Continuous Positive Airway Pressure 
VFD Ventilator Free Days 
PEEP Positive end Expiratory Pressure  
ICP Intracranial Pressure 
PaCO2 Partial Pressure of Carbon Dioxide in Arterial Blood 
TBI Traumatic Brain Injury 
 
 
 
 

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Purpose of the Study and Hypotheses: 
 
This is a quality improvement study with the purpose of observing and measuring 
the effects of implementation of a computerized neuro lung protective ventilation 
protocol, oxygenation protocol, and weaning protocol for mechanically ventilated 
patients with acute brain injury (TBI, intracerebral hemorrhage, stroke, cerebral 
edema, or anoxic brain injury) in the new electronic medical record system, 
iCentra, at IMC in the Neuro ICU, STICU, and RICU. 
 
We hypothesize that implementation of a computerized neuro lung protective 
ventilation protocol, oxygenation protocol, and weaning protocol for patients with 
acute brain injury (TBI, intracerebral hemorrhage, stroke, cerebral edema, or 
anoxic brain injury) will achieve a target normal PaCO2 of 35 to 40 mm Hg, 
decrease initial tidal volumes toward the target 6 ml/kg PBW (range 6 to 8 ml/kg 
PBW), improve ventilator free days (VFDs), and improve 28-day mortality. 
 
The objectives of this study are to: 
 
• Measure compliance, percent on target PaCO2 of 35 to 40 mm Hg, and 
percent on target tidal volumes with a lung protective tidal volume of 6 ml/kg 
PBW, after implementation of computerized neuro lung protective ventilation 
protocol in patients with acute brain injury (TBI, intracerebral hemorrhage, 
stroke, cerebral edema, or anoxic brain injury). 
• Measure compliance with a neuro oxygenation protocol limiting PEEP to 10 
cm H2O and a weaning protocol using PS and CPAP spontaneous breathing 
that are included in the neuro lung protective ventilation protocol. 
• Determine if the implementation of a computerized neuro lung protective 
ventilation protocol, targeting a normal PaCO2 with a 6 ml/kg PBW target tidal 
volume but allow up to 8 ml/kg PBW tidal volume, will improve outcomes in 
patients with acute brain injury requiring mechanical ventilation. 
• Determine if the implementation of a neuro lung protective ventilation protocol 
and targeting a normal PaCO2 will improve outcomes in the sub-group of 
patients with the ARDS and acute brain injury. 
 
Specific Aim #1: Measure compliance with the computerized neuro lung 
protective ventilation protocol and percent of time each patient has an on target 

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PaCO2 of 35 to 45 mm Hg and a tidal volume of 6 ml/kg PBW after 
implementation at Intermountain Medical Center (primary outcome). 
• Process for Aim #1: Tool utilization and compliance will test the ability 
to introduce this neuro lung protective ventilation protocol in a new 
EMR in a controlled clinical environment and whether implementation 
of the protocol is successful in targeting a normal PaCO2 of 35 to 45 
mm Hg and a 6 ml/kg PBW lung protective tidal volumes (allowing up 
to 8 ml/kg PBW tidal volume to achieve normal PaCO2). To ensure 
that this is successful, Dr. Grissom will identify local ICU physicians 
and respiratory care champions to act as a resource for 
implementation of the protocol in the IMC Neuro ICU, STICU, and 
RICU.  
• Hypothesis 1: Healthcare providers will utilize the computerized neuro 
lung protective ventilation protocol and will comply with protocol 
instructions and achieve a target normal PaCO2 and lung protective 6 
ml/kg PBW tidal volumes at higher rates post implementation of the 
protocol. 
 
Specific Aim #2: Determine if the implementation of neuro lung protective 
ventilation, oxygenation, and weaning protocols with a 6 ml/kg PBW tidal volume 
and targeting normal PaCO2 in patients with acute brain injury (TBI, intracerebral 
hemorrhage, stroke, cerebral edema, or anoxic brain injury) who require 
mechanical ventilation improves ventilator free days (VFDs) to day 28, mortality, 
and secondary outcomes. 
• Process for Aim #2: Standardized management of mechanical 
ventilation and outcomes will be measured through EMR data. A 
detailed plan on these metrics has been included (see Research 
Strategy). 
• Hypothesis 2: Deployment of the computerized neuro lung protective 
ventilation, oxygenation, and weaning protocols in patients with acute 
brain injury (TBI, intracerebral hemorrhage, stroke, cerebral edema, or 
anoxic brain injury) will increase VFDs to day 28 and reduce mortality. 
 
Specific Aim #3: Determine if implementation of neuro lung protective 
ventilation, oxygenation, and weaning protocols with a 6 ml/kg PBW tidal volume 
ventilation protocol and targeting normal PaCO2 increases VFDs to day 28 in 

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patients with acute brain injury (TBI, intracerebral hemorrhage, stroke, cerebral 
edema, or anoxic brain injury) and ARDS. 
• Process for Aim #3: Standardized management of mechanical 
ventilation and outcomes for patients with acute brain injury (TBI, 
intracerebral hemorrhage, stroke, cerebral edema, or anoxic brain 
injury) and ARDS will be measured through EMR data. A detailed plan 
on these metrics has been included (see Research Strategy). 
• Hypothesis 3: Deployment of the computerized neuro lung protective 
ventilation, oxygenation, and weaning protocols in patients with acute 
brain injury (TBI, intracerebral hemorrhage, stroke, cerebral edema, or 
anoxic brain injury) and ARDS will increase VFDs to day 28 and 
reduce mortality. 
 
Study Design: 
 
This is an observational quality improvement study comparing pre- and post- 
implementation outcomes of neuro lung protective ventilation, oxygenation, and 
weaning protocols in the iCentra EMR system at Intermountain Medical Center in 
the Neuro ICU, STICU, and RICU. Retrospective data and outcomes on 
mechanical ventilation in patients with acute brain injury (TBI, intracerebral 
hemorrhage, stroke, cerebral edema, or anoxic brain injury) prior to 
implementation of the neuro mechanical ventilation protocol will be compared to 
outcomes post implementation, excluding data during a one-month washout 
period immediately following protocol implementation. The one-month washout 
period after implementation will allow physicians and respiratory therapists time 
to accommodate to the new neuro mechanical ventilation protocols that will be 
implemented as part of standard care with the iCentra EMR. Post-implementation 
data will be collected retrospectively from patients in the ICUs and compared with 
retrospectively queried pre-implementation data. 
 
Outcomes will include: use of the protocol by clinicians, compliance with protocol 
instructions, percent on target normal PaCO2, percent on target low tidal volume 
ventilation, hospital discharge disposition, 28-day mortality, 90-day mortality, time 
to first ICU activity, hospital length of stay, ICU length of stay, heath care 
utilization, quality of life, and costs of care. When the iCentra EMR is 
implemented at Intermountain Medical Center, clinicians will have the opportunity 
to use the computerized neuro lung protective ventilation protocols in patients 

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with acute brain injury, or clinicians may choose to order mechanical ventilation 
settings independently. This is an observational study, designed to measure the 
frequency with which neuro computerized lung protective ventilation protocols will 
be ordered, compliance with the instructions of the protocols, and clinical 
outcomes among patients who are managed with the protocols. Physicians may 
choose to use the protocols on intubated patients with acute brain injury (TBI, 
intracerebral hemorrhage, stroke, cerebral edema, or anoxic brain injury) 
requiring mechanical ventilation or they may choose to order other specific 
mechanical ventilator settings.  
 
Dr. Colin Grissom and Lori Carpenter RRT have already provided education for 
the lead physicians and respiratory therapists in each ICU at IMC participating in 
this study of the neuro lung protective ventilation, oxygenation, and weaning 
protocols in iCentra. Dr. Colin Grissom and Lori Carpenter RRT developed the 
neuro protective lung ventilation paper protocols for management of ventilation, 
oxygenation, and weaning in acutely brain injured patients and have used the 
paper protocols and the computerized protocols in selected patients at IMC who 
have traumatic brain injury with oversight from the IMC trauma team and Director 
of Trauma, Dr. Don VanBoerum. In addition, the protocol was reviewed and 
approved for implementation for patient care by Dr. Katherine Thomas, Medical 
Director of the Neuro ICU, Dr. Don VanBoerum, Surgical Director of the STICU, 
and Dr. Sarah Majercik, Director of Trauma Research, as a standard of care for 
mechanical ventilation of patients with acute brain injury. Selection of the 
protocols is an encouraged option, but not required, for attending physicians 
caring patients with acute brain injury requiring mechanical ventilation.  Dr. 
Grissom and Lori Carpenter, RRT, will be available for phone consultation from 
physicians and respiratory therapists for real-time assistance when utilizing the 
neuro lung protective mechanical ventilation protocols. 
 
Background and Significance: 
 
Mechanical ventilation with high tidal volumes may cause mechanical damage to 
the lung, trigger inflammation, and release cytokines into the systemic 
circulation.1 This process may cause fever, leukocytosis, new pulmonary 
infiltrates, prolong duration of mechanical ventilation, and increase mortality. 
Lung protective ventilation is an approach that limits tidal volume and distending 
pressure on the alveolus in order to prevent mechanical ventilation induced 

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volutrauma (damage due to high tidal volume), barotrauma (damage due to high 
pressures), and biotrauma (release of inflammatory mediators due to high tidal 
volume). The balancing factor for lung protective ventilation in patients with acute 
brain injury is the goal to maintain a PaCO2 in the normal range to mitigate low 
PaCO2 causing cerebral vasoconstriction and decreasing delivery of oxygen to 
acutely injured brain, or high PaCO2 causing cerebral vasodilation and 
increasing ICP.  
 
Lung protective ventilation for patients with the acute respiratory distress 
syndrome (ARDS) improves outcomes. In a prospective randomized clinical trial 
performed by the National Institutes of Health, National Heart Lung and Blood 
Institute (NIH/NHLBI) ARDS Network, ventilation with volume control using a tidal 
volume of 6 ml/kg as compared to 12 ml/kg predicted body weight (PBW) and 
targeting a plateau pressure of <30 cm H2O as compared to <50 cm H2O 
decreased mortality in patients with ARDS.2 Among patients with ARDS, 
evidence supports that the timing of initiation of low tidal volume ventilation also 
influences mortality. A retrospective study of patients with ARDS showed that an 
increase in initial tidal volume of 1 ml/kg above 6 ml/kg PBW in patients with 
ARDS was associated with a 23% increase in intensive care unit (ICU) mortality 
risk.3 This finding suggests that initial tidal volume should be strictly set at 6 ml/kg 
PBW in patients with ARDS. 
 
Mounting evidence also indicates that lung protective ventilation in intubated 
patients without ARDS may decrease the development of ARDS, pulmonary 
complications, and mortality. A meta-analysis of patients who were intubated and 
mechanically ventilated, but did not have ARDS, showed that ventilation with a 
mean tidal volume of 6.5 ml/kg as compared to 10.6 ml/kg PBW resulted in less 
development of acute lung injury or ARDS, less pulmonary infections, and lower 
mortality.4 Furthermore, of the 20 studies included in that meta-analysis, 15 set 
initial tidal volume in the intervention group to ≤6 ml/kg PBW. Higher tidal 
volumes are an independent predictor for development of acute lung injury (ALI) 
in patients who did not have ARDS at onset of mechanical ventilation.5 Further 
evidence of benefit from tidal volume limitation has been supported by a recent 
patient level data analysis that showed a lower incidence of ARDS and fewer 
pulmonary complications in patients without ARDS treated with a tidal volume of 
<7 ml/kg PBW.6 Taken together, these studies indicate that patients with acute 
respiratory failure requiring mechanical ventilation, but without ARDS, should be 

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supported with volume control ventilation using a tidal volume of no more than 8 
ml/kg PBW upon initiation of mechanical ventilation, and may have the best 
outcomes using an initial tidal volume targeting 6 ml/kg PBW.  
 
Patients with acute brain injury who have respiratory failure are also at risk for 
worsening lung injury and ARDS with high tidal volume ventilation. Respiratory 
failure requiring mechanical ventilation is common in acutely brain injured 
patients7 and ARDS occurs in about 25% of patients with acute brain injury and 
respiratory failure.8 In acutely brain injured patients, ventilation with high tidal 
volumes is associated with worse outcome9 and development of ARDS8 Lung 
protective ventilation in patients with acute brain with a low tidal volume strategy, 
limitation of PEEP, and a weaning protocol improve VFDs.10 Lung protective 
ventilation and optimal PEEP are recommended for acutely brain injured patients 
as long as goals for control of ICP are maintained.11 Lung protective ventilation in 
patients with acute brain injury is commonly applied and reduces risk for 
development of ARDS.12 The challenge in implementing lung protective 
ventilation with low tidal volume in patients with acute brain injury is to maintain a 
normal PaCO2 to mitigate effects of cerebral vasodilation from high PaCO2 that 
may contribute to increased ICP. The current evidenced based standard 
mechanical ventilation protocols based on the ARDS Network studies2 for 
patients with acute respiratory failure with, or without, ARDS, do not control 
PaCO2, which may result in undesirable high PaCO2 levels in patients with acute 
brain injury. Lung protective ventilation strategies for patients with acute brain 
injury, therefore, require a modified approach to target a normal PaCO2 when 
using lung protective low tidal volume ventilation.  
 
A previous before-versus-after implementation quality improvement study of 744 
acutely brain injured patients in 20 ICUs in France evaluated a paper protocol 
prescribing a lung protective low tidal volume ventilation strategy (≤7 ml/kg 
PBW), moderate PEEP, and criteria for weaning and extubation.10 This study 
found that implementation of the paper protocol resulted in application of lower 
tidal volumes and an increase in VFDs. Based on this study, and prior studies 
showing that lung protective ventilation improves outcome in patients with acute 
brain injury, our group at Intermountain Healthcare has developed a 
computerized protocol that targets a normal PaCO2, targets low tidal volume, 
uses moderate PEEP (≤10 cm H2O), and prescribes parameters to guide 
weaning and extubation from mechanical ventilation. These computerized neuro 

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ventilation, oxygenation, and weaning protocols will be implemented in the Neuro 
ICU, STICU, and RICU at Intermountain Medical Center in the iCentra electronic 
medical record on July 15, 2017 as an option for use by physicians caring for 
patients with acute brain injury. This computerized neuro lung protective 
mechanical ventilation protocol will allow standardization of care for patients with 
acute brain injury and respiratory failure at Intermountain Medical Center. 
 
Research Subjects: 
 
Inclusion Criteria 
1. Acute brain injury due to non-traumatic causes (stroke, spontaneous 
intracranial hemorrhage, cerebral edema, anoxic brain injury) or traumatic 
brain injury. 
2. Initiation of mechanical ventilation in the emergency department or 
intensive care unit at an Intermountain Healthcare hospital 
3. Age ≥ 18 years 
 
Exclusion Criteria 
1. Transition to comfort care in the emergency department or on the same 
day of admission to the ICU 
2. Death on the same day of admission to the emergency department or ICU 
 
Patient Selection 
Those to be enrolled must have acute brain injury (TBI, intracerebral 
hemorrhage, stroke, cerebral edema, or anoxic brain injury) and respiratory 
failure requiring intubation and initiation of mechanical ventilation. Patients will be 
divided into two different groups after implementation of the computerized neuro 
lung protective ventilation protocols (after July 15, 2017 iCentra go live at IMC): 
patients managed with the computerized neuro lung protective ventilation 
protocols as ordered by the attending physician and patients managed with 
physician-specified mechanical ventilation settings. These groups will be used in 
secondary subgroup analyses among post-implementation patients comparing 
outcomes of patients on protocol-guided mechanical ventilation with the 
outcomes of patients on physician-guided mechanical ventilation. Prior 
experience with implementation of a computerized lung protective ventilation 
protocol across Intermountain Healthcare suggests that even if relatively low 

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compliance with the computerized lung protective ventilation protocol were to be 
observed post-implementation, the average set tidal volume would still be 
expected to decrease, presumably because of education of clinicians and 
respiratory therapists regarding the benefits of lung protective mechanical 
ventilation (unpublished data collected as part of the IMPROVENT study, 
Intermountain IRB # 1050159, an ongoing study at Intermountain Healthcare 
evaluating the impact of implementation of a lung protective ventilation protocol 
in iCentra across Intermountain Healthcare Hospitals). 
 
Compensation 
Subjects will not be compensated for participating in this study. 
 
Sample Size 
Retrospectively querying data from 1 Jan 2016 through 31 Dec 2016 at IMC, 364 
brain injured patients with complete data were identified in the Intermountain 
EMR. Accordingly, we estimate that 728 patients (24 months) will be identified 
and included for analysis.  
 
Methods/Procedures: 
 
Research Strategy 
Lung protective ventilation management in patients with acute brain injury (TBI, 
intracerebral hemorrhage, stroke, cerebral edema, or anoxic brain injury) using 
the computerized neuro lung protective ventilation protocol (See attachments 
Neuro Vent Protocol Ventilation, Neuro Vent Protocol Oxygenation, Neuro Vent 
Protocol Weaning Assessment, and Neuro Vent Protocol Weaning) will be 
implemented at IMC on July 15, 2017 synchronized with the rollout of iCentra at 
IMC. This is a quality improvement initiative to introduce a best practice for 
ventilation, oxygenation, and weaning in mechanically ventilated patients with 
acute brain injury in the Neuro ICU, STICU, and RICU. We request waiver of 
informed consent from the Intermountain IRB in order to measure the effect on 
clinical outcomes and change in practice associated with this implementation. 
Retrospective data from one year prior to implementation of iCentra on July 15, 
2017, will be compared with retrospectively collected data for one year after 
implementation of the neuro ventilation, oxygenation, and weaning protocols in 
iCentra starting on August 15, 2017, after a one-month wash-out period. The one 
month wash-out period from July 15 to August 15, 2017, will allow physicians and 
respiratory therapists time to acclimate to the new computerized neuro ventilation 

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protocols as well as the new iCentra EMR. Dr. Grissom and Lori Carpenter RRT, 
will educate physicians, advanced practice clinicians, and respiratory therapists 
in use of the protocols, and will be available for phone consultation. Co-
Investigators Dr. Katherine Thomas, Medical Director of the Neuro ICU, Dr. Don 
VanBoerum, Surgical Director of the STICU, and Dr. Sarah Majercik, Director of 
Trauma Research, are all co-investigators on this study and will provide 
leadership in implementation of the neuro lung protective ventilation protocols. 
 
Percent Time on Lung Protective Tidal Volumes 
Determination of percent time each patient achieves a normal PaCO2 and is on a 
tidal volume of ≤6.5 ml/kg PBW, ≤7.5 ml/kg PBW, and ≤8.5 ml/kg PBW over the 
first week of mechanical ventilation will require extraction of data from the EMR. 
This will require specific data queries to collect information on initial set tidal 
volume and mode of ventilation from each episode of ventilator charting on each 
patient and arterial blood gases performed during mechanical ventilation. Jason 
Jacobs, the lead technical data analyst for pulmonary and critical care research 
at IMC has extensive experience extracting this data from the legacy EMR and 
from iCentra for the IMPROVENT study (Intermountain IRB # 1050159). 
 
Protocol Compliance 
As part of the data collection for the ongoing IMPROVENT study (Intermountain 
IRB # 1050159) Jason Jacobs, data analyst, and James Sanders, Cerner 
Physician Consultant, have led an effort to establish a data table in iCentra that 
specifies when a mechanical ventilation protocol is used and stores individual 
data on different elements of the protocol that allows automated data extraction. 
This will allow specific data collection on which patients are placed on the 
computerized Neuro Lung Protective Ventilation Protocols, which specific parts of 
the protocols were used (ventilation, oxygenation, or weaning), and whether 
protocol instructions were accepted and implemented, or declined, and the 
reason for declining a specific protocol instruction. 
 
Ventilator Free Days (VFDs) 
For determination of VFDs to day 28 we will use the same definition for liberation 
from mechanical ventilation as used in ARDS Network studies2,13 and in the 
proposed ROSE study from the NIH/NHLBI PETAL Network. Initiation of 
ventilator free days begins with two ventilator free days once unassisted 
breathing is present for 48 hours. Unassisted breathing is defined as14:  

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a. Extubated with face mask, nasal prong oxygen, or room air, OR 
b. T-tube breathing, OR 
c. Tracheostomy mask breathing, OR 
d. CPAP ≤ 5 without PS or IMV assistance 
e. Use of CPAP or BIPAP solely for sleep apnea management 
f. Use of a high flow oxygen system 
 
Determination of ARDS 
Determination of ARDS using the Berlin Definition15 requires acute respiratory 
failure not fully explained by cardiac failure or fluid overload within one week of a 
known clinical insult, bilateral opacities on chest radiology imaging not fully 
explained by effusions, lobar/lung collapse, or nodules, and PaO2/FIO2 ≤300 mm 
Hg with PEEP or CPAP ≥5 cm H2O. We will focus on defining ARDS among 
those patients with mild, moderate, or severe hypoxemia as defined by a PaO2 to 
FIO2 ratio ≤ 255 (altitude corrected by multiplying 300 by the ratio of ambient 
barometric pressure in Salt Lake City to sea level barometric pressure, 300 x 
0.85 = 255) and evaluate chest radiographs for bilateral infiltrates in that group.  
 
Study Duration 
25 months, 7/15/2016 - 8/15/2018 with a one-month peri-implementation wash-
out period. 
 
Risks 
The risk of this study is a potential loss of confidentiality, which will be managed 
as detailed below.  
 
Benefits 
This is a quality improvement study evaluating the benefits of implementation of 
computerized neuro lung protective ventilation protocols at IMC in the Neuro ICU, 
STICU, and RICU for patients with acute brain injury (TBI, intracerebral 
hemorrhage, stroke, cerebral edema, or anoxic brain injury). Application of the 
protocol is at the discretion of the attending physician for patients with acute 
brain injury and acute respiratory failure requiring intubation and mechanical 
ventilation. Based on best practices and the evidenced based medical literature, 
implementation of the neuro ventilation protocols is expected to improve 
outcomes.  
 

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Waiver of Informed Consent 
This study seeks a waiver of informed consent for these reasons: 
• The risk of this study is a potential loss of confidentiality. The study involves 
no more than minimal risk to the subject, as the study is observational only 
and the study will not alter the care that enrolled subjects receive. The 
computerized neuro lung protective mechanical ventilation protocols will be 
available to clinicians as an order in iCentra, but will not be required. 
• The implementation of the neuro lung protective ventilation, oxygenation, and 
weaning protocols is part of an intent to standardize clinical practice for 
mechanical ventilation of acutely brain injured patients (TBI, intracerebral 
hemorrhage, stroke, cerebral edema, or anoxic brain injury) and is supported 
by the Medical Director of the Neuro ICU, Dr. Katherine Thomas, and the 
Surgical Director of the STICU, Dr. Don VanBoerum. The implementation of 
this process of standard of care for mechanical ventilation of patients with 
acute brain injury is intended as a quality assurance project using evidence 
based literature. The use of the protocol is not mandated, but is encouraged. 
The computerized neuro ventilation, oxygenation, and weaning protocols will 
be implemented regardless of whether this observational study occurs. The 
investigators on this observational study are using implementation of these 
computerized neuro lung protective ventilation protocols to formally evaluate 
compliance with the protocol, effectiveness of the protocol at targeting normal 
PaCO2 and decreasing tidal volume, and clinical outcomes. The intent of the 
investigators is to publish our experience with implementation of this protocol 
in the peer reviewed medical literature, and therefore IRB review is 
appropriate. Waiver of informed consent is requested because the 
implementation of the computerized neuro lung protective ventilation protocol 
is primarily a quality improvement clinical initiative, not a research initiative, 
and is not mandated, but is left up to the attending physician for each patient. 
 
Protection of Subject Confidentiality 
PHI will be collected as a part of this study. The PHI will be used only for study 
purposes and will not be reused or disclosed except as required by law. The 
information obtained from medical records will be kept separate from clinical 
records. 
 
All digital study records will be kept within the Intermountain Healthcare firewall in 
a location that is only accessible to authorized members of the study team. All 

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paper study records will be maintained on a floor with secure badge access that 
only the research team can access. 
 
After the study is complete, study identifiers will be removed from the dataset. 
 
The data to be collected is detailed below. In particular, the dates to be collected 
are important for the specific aims of the study. 
 
Data Collection: 
 
Data Elements Extracted from the EDW for the NEUROVENT Mechanical 
Ventilation Study 
• Account Number 
• EMPI 
• Admit Date 
• Discharge Date 
• Admit Year 
• Admit ICU 
• Age 
• Gender 
• ICD Diagnosis code 
• ICD Diagnosis description 
• ICD Diagnosis long description 
• ICU Stay 
• Length of Stay (Days) 
• Mortality Indicator (Data required for calculation of Acute Physiology Score 
and Charlson Comorbidity Index) 
• Patient Type (inpatient(I) vs outpatient(O)) 
• Patient Type (Detailed code) 
• Patient Type Description 
• Death Location 
• Discharge Disposition Description 
• Discharge Reason (same as above) 
• ED Admit Date 
• ED Discharge Date 
• Total Cost 
• Ventilator Location (First Vent Check Location) 
• First Date of Ventilator Check 

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• Ventilator Mode 
• First Date of Ventilator Check 
• Intubation Date 
• Intubation Location (Same as Ventilator Location) 
• All Parameters Included in the Ventilator Checks During the Hospitalization 
• Room Trace (It is more detailed than the ones above) 
• In Hospital Mortality 
• Height 
• Predicted Body Weight 
• Difference between admission date and death date 
• 28 Day Mortality 
• 60 Day Mortality 
• 90 Day Mortality 
• Arterial Blood Gases recorded during hospital stay 
 
Data Analysis: 
 
Primary Outcomes 
The primary outcome will be the patient-level proportion of time on mechanical 
ventilation with a tidal volume ≤ 6.5 ml/kg PBW. 
 
Secondary outcomes will include: proportion of time with a target PaCO2 of 35 to 
45 mm Hg; protocol compliance; hospital discharge disposition; hospital, 28-day, 
and 90-day mortality; ventilator-free days to day 28; time to first ICU activity; 
hospital, ICU length of stay; health care utilization; quality of life (SF-36 or 
similar); and costs of care. 
 
Statistical Analysis 
Univariable analyses will use Fisher’s exact test and Pearson’s chi-square test 
for comparing pairs of Bernoulli-distributed variables with and without sparse 
cells, respectively. Wilcoxon rank-sum test will be used to compare pairs of non-
Gaussian, continuous distributions. Bootstrapped Kolomogorov-Smirnov test will 
be used to compare pairs of distributions of ordinal, discrete data.  
 
Multivariable analyses will use linear parametric regression models within the 
exponential family adjusted for a vector of covariates, having link functions 
determined by the distribution of the dependent variable. Specifically, Bernoulli-

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distributed outcomes will use the logit link function, Poisson-distributed outcomes 
will use the log link function, multinomial outcomes will use the multi-class logit 
link function, normally distributed outcomes will use the identity link function, and 
other continuous outcomes (including the primary outcome) whose distributions 
can be transformed such that they are bounded by zero and one will be treated 
as quasibinomial dependent variables using the logit link function. The primary 
outcome (viz., patient-level proportion of time on lung protective ventilation), for 
example, can be treated as a quasibinomial dependent variable because it can 
take any value within the unit interval [0,1], and as such can be compared pre- 
and post-implementation using multivariable quasibinomial logistic regression 
analysis adjusting for the set of patient-level confounders and effect modifiers, 
with regression equation taking the form 
 
                                            𝑔𝑔(𝑦𝑦) = 𝛽𝛽0 + 𝛽𝛽1𝑡𝑡+ 𝐗𝐗𝜽𝜽,                                   (1) 
 
where 𝑔𝑔(. ) is the link function – quasibinomial logit in the case of the primary 
analysis – 𝑦𝑦 is the percent time on lung protective ventilation, 𝑡𝑡 is a binary 
indicator of post-implementation period, and 𝑿𝑿 is a matrix of potential patient-
level confounders and effect modifiers.  
 
The secondary outcomes will be analyzed using the same linear predictor, but 
with the appropriate link function as specified above.  
 
Power Analysis 
We empirically estimated the baseline distribution of the primary outcome – viz., 
patient-level percent time on lung protective ventilation (LPV) – by pulling data 
from the Intermountain EMR of all brain injured patients seen at IMC in 2016, and 
computed the patient-level percent time on mechanical ventilation. In so doing, 
we observed the primary outcome LPV to be distributed such that about 50% of 
patients had LPV = 0, 25% had LPV = 1, and the LPV distribution of the 
remaining 25% closely followed a beta distribution with α and β shape 
parameters having values 0.6 and 0.5, respectively.  
 
This information was incorporated into a multidimensional, Monte Carlo 
simulation-based power analysis of a quasibinomial logistic regression model of 
the effect of implementation on LPV, assuming total enrollment of 728 patients. 
The support of the space was determined ex ante in collaboration with the 

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primary investigator in order to ensure the candidate effect sizes were of clinically 
reasonable magnitude. In so doing, it was found that an odds ratio of 1.5 for the 
effect of implementation on LPV corresponded to a relative increase in mean 
LPV of 16% (from baseline mean LPV of 0.429), and a relative increase in 
complete compliance (LPV=1) of 43.3% (from a baseline rate of complete 
compliance of 0.248), and would be sufficient to achieve 80% power.   
 
Funding: 
 
It is anticipated that this project will be funded by the Pulmonary and Critical Care 
Department at Intermountain Medical Center. 
 
 

NEUROVENT 
 
Page 18 
July 14, 2017 
References 
 
1. 
Society AT. Patient Information: Mechanical Ventilation. 5 October 2015. 
2. 
ARDSNetwork. Ventilation with lower tidal volumes as compared with traditional tidal 
volumes for acute lung injury and the acute respiratory distress syndrome. The Acute 
Respiratory Distress Syndrome Network. The New England journal of medicine. 
2000;342(18):1301-1308. 
3. 
Needham DM, Yang T, Dinglas VD, et al. Timing of low tidal volume ventilation and 
intensive care unit mortality in acute respiratory distress syndrome. A prospective 
cohort study. American journal of respiratory and critical care medicine. 
2015;191(2):177-185. 
4. 
Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lung-protective 
ventilation with lower tidal volumes and clinical outcomes among patients without 
acute respiratory distress syndrome: a meta-analysis. Jama. 2012;308(16):1651-1659. 
5. 
Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without 
acute lung injury at the onset of mechanical ventilation. Crit Care Med. 2004;32(9):1817-
1824. 
6. 
Neto AS, Simonis FD, Barbas CS, et al. Lung-Protective Ventilation With Low Tidal 
Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute 
Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data 
Analysis. Crit Care Med. 2015;43(10):2155-2163. 
7. 
Zygun DA, Kortbeek JB, Fick GH, Laupland KB, Doig CJ. Non-neurologic organ dysfunction 
in severe traumatic brain injury. Crit Care Med. 2005;33(3):654-660. 
8. 
Elmer J, Hou P, Wilcox SR, et al. Acute respiratory distress syndrome after spontaneous 
intracerebral hemorrhage*. Crit Care Med. 2013;41(8):1992-2001. 
9. 
Mascia L, Zavala E, Bosma K, et al. High tidal volume is associated with the development 
of acute lung injury after severe brain injury: an international observational study. Crit 
Care Med. 2007;35(8):1815-1820. 
10. 
Asehnoune K, Mrozek S, Perrigault PF, et al. A multi-faceted strategy to reduce 
ventilation-associated mortality in brain-injured patients. The BI-VILI project: a 
nationwide quality improvement project. Intensive Care Med. 2017;43(7):957-970. 
11. 
Lowe GJ, Ferguson ND. Lung-protective ventilation in neurosurgical patients. Curr Opin 
Crit Care. 2006;12(1):3-7. 
12. 
Luo XY, Hu YH, Cao XY, et al. Lung-protective Ventilation in Patients with Brain Injury: A 
Multicenter Cross-sectional Study and Questionnaire Survey in China. Chin Med J (Engl). 
2016;129(14):1643-1651. 
13. 
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory 
pressures in patients with the acute respiratory distress syndrome. The New England 
journal of medicine. 2004;351(4):327-336. 
14. 
Angus D MM. Reevaluation Of Systemic Early neuromuscular blockade. NHLBI Petal 
Network2015. 
15. 
Force ADT, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the 
Berlin Definition. Jama. 2012;307(23):2526-2533. 
 
 

NEUROVENT 
 
Page 19 
July 14, 2017 
APPENDICES 
 
 
Appendix 1. Ventilation Protocol 
Appendix 2. Oxygenation Protocol 
Appendix 3. Weaning Assessment 
Appendix 4. Weaning Protocol 
Appendix 5. Tidal Volumes from Predicted Body Weight from Height 
and Gender 
Appendix 6. Rules for iCentra Neuro Ventilator Protocol 

        
 
VR = Actual 
Vent Setting 
VT > 6 ml/kg 
VT = 6 ml/kg 
VT > 4 ml/kg and < 6 ml/kg 
pCO2 
Pplat < 25 
cm H2O 
Pplat 25 – 30 
cm H2O 
Pplat > 30 
cm H2O 
Pplat < 25 
cm H2O 
Pplat 25 – 30 
cm H2O 
Pplat > 30 
cm H2O 
Pplat < 25 
cm H2O 
Pplat 25 – 30 
cm H2O 
Pplat > 30 
cm H2O 
< 35 
1. 
↓ VT by 1 
ml/kg 
2. 
↓ VT by 1 
ml/kg 
3. 
↓ VT by 1 
ml/kg 
4. 
↓ VR by 20% 
5. 
↓ VR by 20% 
6. 
↓ VT by 1 ml/kg 
7. 
↑ VT by 1 ml/kg 
↓ VR by 20% 
8. 
↓ VR by 20% 
9. 
↓ VT by 1 ml/kg 
but do not ↓ < 4 
ml/kg 
35 – 40 and 
VR < 28 bpm 
10. 
↓ VT by 1 ml/kg 
↑ VR by 20% 
11. 
↓ VT by 1 ml/kg 
↑ VR by 20% 
12. 
↓ VT by 1 ml/kg 
↑ VR by 20% 
13. 
No Change in 
Therapy 
14. 
No Change in 
Therapy 
15. 
↓ VT by 1 ml/kg 
↑ VR by 20% 
16. 
No change in 
Therapy 
17. 
No Change in 
Therapy 
18. 
↓ VT by 1 ml/kg 
↑ VR by 20% 
35- 40 and 
VR = 28-35 
19. 
No change 
20. 
No change 
21. 
No change 
22. 
No change 
23. 
No change 
24. 
No change 
25. 
No change 
26. 
No change 
27. 
No change 
35 – 40 and 
VR = 35 bpm 
28. 
No change 
29. 
No change 
30. 
No change 
31. 
No change 
32. 
No change 
33. 
No change 
34. 
No change 
35. 
No change 
36. 
No change 
41 - 45and  
VR < 28 bpm 
37. 
↑ VR by 30% 
↓ VT by 1 ml/kg 
38. 
↑ VR by 30% 
↓ VT by 1 ml/kg 
39. 
↑ VR by 30% 
↓ VT by 1 ml/kg 
40. 
↑ VR by 20% 
41. 
↑ VR by 20% 
42. 
↓ VT by 1 ml/kg 
↑ VR by 30% 
43. 
↑ VT by 1 ml/kg 
44. 
↑ VR by 20% 
45. 
↑ VR by 20% 
41-45 and 
VR = 28-35 
46. 
↑ VR to 35 
47. 
↑ VR to 35 
48. 
↑ VR to 35 
49. 
↑ VR to 35 
50. 
↑ VR to 35 
51. 
↑ VR to 35 
52. 
↑ VT by 1 ml/kg 
53. 
↑ VR to 35 
54. 
↑ VR to 35 
41- 45 and 
VR = 35 bpm 
55. 
↑ VT by 1 ml/kg 
but do not ↑ > 
8ml/kg 
56. 
↑ VT by 1 ml/kg 
but do not ↑ > 
8ml/kg 
57. 
↑ VT by 1 ml/kg 
but do not ↑ > 
8ml/kg 
58. 
↑ VT by 1 
ml/kg 
59. 
↑ VT by 1 ml/kg 
60. 
↑ VT by 1 ml/kg 
61. 
↑ VT by 1 ml/kg 
62. 
↑ VT by 1 
ml/kg 
63. 
↑ VT by 1 ml/kg 
>45 and  
VR < 28 bpm 
64. 
↑ VR by 30% 
65. 
↑ VR by 30% 
66. 
↑ VR by 30% 
67. 
↑ VR by 30% 
68. 
↑ VR by 30% 
69. 
↑ VR by 30% 
70. 
↑ VR by 20% 
↑ VT by 1 ml/kg 
71. 
↑ VR by 20% 
↑ VT by 1 
ml/kg 
72. 
↑ VR by 30% 
↑ VT by 1 ml/kg 
>45 and 
VR = 28-35 
73. 
↑ VR to 35 
↑ VT by 1 ml/kg 
74. 
↑ VR to 35 
↑ VT by 1 ml/kg 
75. 
↑ VR to 35 
↑ VT by 1 ml/kg 
76. 
↑ VR to 35 
↑ VT by 1 
ml/kg 
77. 
↑ VR to 35 
↑ VT by 1 ml/kg 
78. 
↑ VR to 35 
↑ VT by 1 ml/kg 
79. 
↑ VR to 35 
↑ VT by 1 ml/kg 
80. 
↑ VR to 35 
↑ VT by 1 
ml/kg 
81. 
↑ VR to 35 
↑ VT by 1 ml/kg 
>45 and  
VR = 35 bpm 
82. 
↑ VT by 1 ml/kg 
but do not ↑ > 
8ml/kg 
83. 
↑ VT by 1 ml/kg 
but do not ↑ > 
8ml/kg 
84. 
↑ VT by 1 ml/kg 
but do not ↑ > 
8ml/kg 
85. 
↑ VT by 1 
ml/kg 
86. 
↑ VT by 1 ml/kg 
87. 
↑ VT by 1 ml/kg 
88. 
↑ VT by 1 ml/kg 
89. 
↑ VT by 1 
ml/kg 
90. 
↑ VT by 1 ml/kg 
Appendix 1. Ventilation Protocol

Page 1 of 2 
Utah Tool Box: Salt Lake City Protocol  
 Neuro High Oxygenation Table 6/15/17 
PaO2 < 60 or SpO2 < 91% 
(Use PaO2 if available, only use SpO2 if PaO2 not available) 
When PaO2 or SpO2 are in this low range, repeated sequential adjustments may be made as 
guided by the cells in the table until adequate oxygenation with a SpO2 > 92% is achieved 
PEEP 
FiO2 = 
.3 
FiO2 = .4 
FiO2 = 
.5 
FiO2 = .6 
FiO2 = .7 
FiO2 = .8 
FiO2 = 
.9 
FiO2 = 
1.0 
10 
↑ FiO2 
0.2 
↑ FiO2 
0.2 
↑ FiO2 
0.2  
↑ FiO2 
0.2 
↑ FiO2 
0.2 
↑ FiO2 
0.2 
↑ FiO2 
0.1 
Call MD 
8 
↑ FiO2 
0.2 
↑PEEP 
2 
↑ FiO2 
0.2 
↑PEEP 2 
↑ FiO2 
0.2 
↑PEEP 
2 
↑ FiO2 
0.2 
↑PEEP 2 
↑ FiO2 
0.2 
↑PEEP 2 
↑ FiO2 
0.2 
↑PEEP 2 
↑ FiO2 
0.1 
↑PEEP 
2 
↑PEEP 
2 
5 
↑ FiO2 
0.2 
↑PEEP 
3 
↑ FiO2 
0.2 
↑PEEP 3 
↑ FiO2 
0.2 
↑PEEP 
3 
↑ FiO2 
0.2 
↑PEEP 3 
↑ FiO2 
0.2 
↑PEEP 3 
↑ FiO2 
0.2 
↑PEEP 3 
↑ FiO2 
0.1 
↑PEEP 
5 
↑PEEP 
5 
Utah Tool Box: Salt Lake City Protocol   
Neuro High Oxygenation Table 6/15/17 
PaO2 60 to 69 or SpO2 91 to 94% 
(Use PaO2 if available, only use SpO2 if PaO2 not available) 
When PaO2 or SpO2 are in this low range, repeated sequential adjustments 
may be made as guided by the cells in the table until adequate oxygenation 
with a SpO2 > 92% is achieved 
PEEP 
FiO2 = 
.3 
FiO2 = 
.4 
FiO2 = 
.5 
FiO2 = 
.6 
FiO2 = 
.7 
FiO2 = 
.8 
FiO2 = 
.9 
FiO2 = 
1.0 
10 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
Contact 
MD 
8 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ 
PEEP 2 
↑ 
PEEP 2 
↑ 
PEEP 2 
↑ 
PEEP 2 
↑ 
PEEP 2 
↑ PEEP 
2 
5 
↑ FiO2 
0.1 
↑ 
PEEP 3 
↑ 
PEEP 3 
↑ 
PEEP 3 
↑ 
PEEP 3 
↑ 
PEEP 3 
↑ 
PEEP 3 
↑ PEEP 
3 
Appendix 2. Oxygenation Protocol

Page 2 of 2 
Utah Tool Box: Salt Lake City Protocol  
Neuro High Oxygenation Table 6/15/17  
PaO2 = 70 – 79 or SpO2 95– 96% 
(Use PaO2 if available, only use SpO2 if PaO2 not available) 
PEEP 
FiO2 = 
.3 
FiO2 = 
.4 
FiO2 = 
.5 
FiO2 = 
.6 
FiO2 = 
.7 
FiO2 = 
.8 
FiO2 = 
.9 
FiO2 = 
1.0 
10 
↑ FiO2 
0.1 
↓PEEP 2 
↑ FiO2 
0.1 
↓PEEP 2 
Maintain Maintain Maintain 
↓ FiO2 
0.1 
↓ FiO2 
0.1 
↓ FiO2 
0.1 
8 
↑ FiO2 
0.1 
↓PEEP 2 
Maintain Maintain 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
5 
Maintain Maintain 
↓ FiO2 
0.1 
↑PEEP 3 
↓ FiO2 
0.1 
↑PEEP 3 
↓ FiO2 
0.1 
↑PEEP 3 
↓ FiO2 
0.1 
↑PEEP 3 
↓ FiO2 
0.1 
↑PEEP 3 
↓ FiO2 
0.1 
↑PEEP 3 
Utah Tool Box: Salt Lake City Protocol   
Neuro High Oxygenation Table 6/15/17 
PaO2 > 79 or SpO2 > 96% 
(Use PaO2 if available, only use SpO2 if PaO2 not available) 
PEEP 
FiO2 = 
.3 
FiO2 = 
.4 
FiO2 = 
.5 
FiO2 = 
.6 
FiO2 = 
.7 
FiO2 = 
.8 
FiO2 = 
.9 
FiO2 = 
1.0 
10 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
8 
↓ PEEP 
3 
↓ PEEP 
3 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
5 
Maintain 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 
↓ FiO2
.1 

Weaning Assessment
2016, 12 13
START
FO1:NOO
SO1
FiO2 < = .5 and PEEP < = 10 cmH2O?
AO3
Do not prompt for a 
weaning trial
SO2 
Receiving neuromuscular 
blocking agent or with 
neuromuscular blockade?
SO3
Total VR is greater than set VR? 
AO1
Decrease set VR by 50%
Observe for 5 minutes
AO2
Measure spontaneous parameters: 
VE, VR, VT, VC, MIP
END
No
Yes
No
Yes
No
SO4
Total VR is greater than set VR? 
AO4 
Increase set VR by 50%
Return to previous 
settings
AO3 
Do not prompt for a 
weaning trial 
SO5
Spon VR < 35 bpm and 
Spon VT > 4ml/kg/IBW?
AO5
Return to Volume 
Control Ventilation 
at previous settings. 
Continue with 
Oxygenation and 
Ventilation tables.
AO6
Change mode to 
CPAP. 
CPAP = current level
FiO2 = current level 
END
No
Yes
No
Yes
From 
Decrease Set VR
FO1:NO1
From 
Measure spontaneous 
parameters 
FO1:NO2
End
F01 Weaning Assessment
SO6
pH < 7.30
Yes
No
Yes
Appendix 3. Weaning Assessment

CPAP/PS Oxygenation
2016, 12 13
FO2
START
SO1
PaO2 within the last 30 
minutes?
SO2
SpO2 > = 88%?
SO6
PaO2 > = 55 
mmHg? 
SO3
PEEP > 8 
cmH2O?
SO4
PEEP = 5 
cmH2O? 
AO1
Decrease PEEP to 5 
cmH2O
SO7
PEEP < 10 
cmH2O? 
AO3
Decrease PEEP to 8 
cmH2O
SO5
FiO2 >.3?
AO2
Decrease FiO2 0.1 
to a minimum of .3
SO8
FiO2 > .4?
AO5
Increase FiO2 by 0.1 
to a maximum of 
0.5
AO6
Return to Volume 
Control Ventilation 
at previous settings. 
Continue with 
Oxygenation and 
Ventilation Tables
Yes
No
No
No
Yes
 AO4
Increase PEEP to 8 
cmH2O if on 5 
cmH2O. Increase 
PEEP to 10  cmH2O 
(maximum) if on 8 
cmH2O
END
No
No
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Go to CPAP/PS 
Weaning
SO9
FiO2 > .4?
No
Yes
FO2 CPAP/PS Oxygenation
Appendix 4. Weaning Protocol

CPAP/PS Weaning
2016, 12 13
FO3
START
END
SO1
pH measured within the last 20 minutes?
SO2
pH > = 7.30?
SO3 
Average 
spontaneous tidal 
volume > = 4 ml/kg 
PBW?
SO4
Spontaneous 
respiratory rate < = 
35  /min? 
SO5
Two of the following present?
1. heart rate > = 120% of 06:00 rate
2. Marked use of accessory muscles
3. Abdominal paradox
4. Diaphoresis
5. Marked subjective dyspnea
SO6
Mode = CPAP?
AO1
Continue to monitor
Contact MD to 
assess readiness to 
extubate
AO2
Change Mode to CPAP
Set CPAP to current 
PEEP level
SO7
PS = 5 cmH2O?
AO3
Decrease PS by 5 
cmH2O
AO7
Return to Volume 
Control Ventilation 
at previous settings. 
Continue with 
Oxygenation and 
Ventilation tables
AO4
Return to Volume 
Control Ventilation 
at previous settings. 
Continue with 
Oxygenation and 
Ventilation tables
SO8
Mode = PS?
SO9
PS = 15 cmH20?
AO6
Increase PS by 5  
cmH2O
AO5
Change Mode to PS 
Set PS 5 cmH2O
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
FO3 CPAP/PS Weaning

Appendix 5. Tidal Volumes from Predicted Body Weight from Height and Gender

Definitions: 

BWP: Body weight predicted (formula below)
o
Males: PBW (kg) = 50 + 2.3[height (inches) – 60]
o
Females: PBW (kg = 45.5 + 2.3 [height (inches) – 60]

ABG: arterial blood gas

VR: respiratory rate (breaths per minute)

VT: tidal volume (milliliters)

VE: minute volume (liters per minute)

CMV: continuous mandatory ventilation

VC: Volume Control

PEEP: positive end expiratory pressure (cmH2O)

Measured Pplat: actual measured plateau pressure
General: 

If the PBW does not appear or is too small or too large, check the height and gender
in the computer – they could be entered wrong or not at all. 

The protocol will not generate new instructions if it has been 2 or more hours since a
complete ventilator assessment has been entered. 

Always do a ventilator assessment before drawing an ABG.

Check for typos. The computer relies on accurate and timely charting.

The protocol will run off arterial blood gas or oxygen saturation measured by the
pulse oximeter.

Protocol suspensions can be entered proactively or retroactively.

Suspend the protocol when the patient will be receiving a procedure, traveling, going
to surgery or hyperbaric.

Unsuspend the protocol when back in the unit

Enter at the previous settings

Enter at the current settings charted (patient may have different needs after the
procedure)

The protocols are orders. Deviation from the protocol requires a physician order.
ABG Recommended For: 

Change in Mode.
ABG Required For: 

10% change in VT setting.

Change in VR setting if patient is not assisting.

Receive ventilation protocol instructions.
Ventilation: 

The low range for the set ventilatory rate is 6 breaths per minute for all protocols.

Ventilation instructions are only given after an ABG.
Appendix 6. Rules for iCentra Neuro Ventilator Protocol


The protocol will set a back up VR if the patient is breathing over the set rate.
Backup VR is based on a calculated VE goal.

Set VT at 6ml/kg PWB

VE goal = Current VE *(PaCO2/50 * HCO3- /24)

Backup set VR = VE goal / set VT

Volume control ventilation will be required unless FiO2 < = 0.5 and PEEP < =
10cmH2O, then the patient can be evaluated for pressure support weaning.

Tidal Volume (VT) Goal is 6 ml / kg / PBW

Measure and record inspiratory plateau pressure (Pplat) with every ventilator
assessment and after changes in VT and PEEP.

If Pplat is > 30 cmH2O an ABG is recommended to determine if a VT reduction is
indicated.

If unable to measure a Pplat when in PRVC, change the mode to A/C for 2 to 3
minutes. Measure the Pplat. Return the patient to previous mode.

Do not increase ventilator rate (VR) above 35 bpm.

Do not decrease VT below 4 ml/kg

If the patient is not over breathing the set rate do not decrease VT and VR at the
same time.
Oxygenation: 

The protocol will not decrease PEEP for 6 hours after it has been increased.

If PEEP is > 10 cmH2O, do not decrease > 2cmH2O every 2 hours.

If the SpO2 or PaO2 fall below the target ranges after a decrease in FiO2 and/or
PEEP and it has been less than 30 minutes, the patient will be returned to the
previous FiO2 and PEEP settings.

Each subsequent repeat of therapy reduction followed by therapy increase will result
in waiting periods (4, 8, and 24 hours).
Night time: 

Night rests on CMV will start at 22:00 and end at 06:00 when ordered.
Weaning: 

Weaning may occur 24 hours a day.

Weaning may be initiated at any time.

Entry criteria for weaning:

FiO2 < = .5

Peep < = 10 cmH2O

Without neuromuscular blockade

Total VR > set VR

Weaning assessment will be attempted every 4 hours.