Implementation of Lung Protective Ventilation in Patients With Acute Respiratory Failure
Conditions: Acute Respiratory Distress Syndrome, ARDS, Respiratory Distress Syndrome, Acute, Respiratory Insufficiency, Respiratory Distress Syndrome, Shock Lung, Severe Acute Respiratory Syndrome
Sponsor: Intermountain Health Care, Inc.

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Title: Implementation of Lung Protective Ventilation in 
Patients with Acute Respiratory Failure 
(IMPROVENT) 
Location: All 11 Intermountain Healthcare hospitals that manage 
mechanically ventilated patients 
PI: Colin K. Grissom, MD 
Sponsor: Pulmonary and Critical Care Department 
 
 
Co-Investigators: 
Samuel M. Brown MD MS  
Michael J. Lanspa MD MS  
Ithan Peltan MD  
Russ Miller MD 
Dave Collingridge 
 
Research Coordinators: 
Valerie Aston  
Mardee Merrill 
John Hermans 
Naresh Kumar 
 
Regulatory Coordinators: 
Anne Haroldsen  
Kimberly Rhodes  
David Tomer  
 
Data Analysts: 
Lydia Dong 
Juhee Peterson 
 
Statistician: 
Jeff Sorensen 
Emily Wilson 
 
 
 
 

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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 
IMC Intermountain Medical Center 
POD Persistent Organ Dysfunction  
GLMM Generalized Linear Mixed Model  
EMR Electronic Medical Records 
VC Volume Control 
PRVC Pressure Regulated Volume Control 
MMV PRVC Mandatory Minute Ventilation with Pressure Regulated Volume 
Control 
SIMV/PS Synchronized Intermittent Mandatory Ventilation Plus Pressure 
Support 
VFD Ventilator Free Days 
ROSE Reevaluation of Systemic Early Neuromuscular Blockade 
PETAL Prevention and Early Treatment of Acute Lung Injury 
PEEP Positive end Expiratory Pressure  
 
 
 
 

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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 proven standardized lung protective ventilation 
protocol in the new electronic medical record system iCentra across all 
Intermountain Healthcare hospitals. 
 
We hypothesize that implementation of a standardized computerized lung 
protective ventilation protocol across all Intermountain Healthcare hospitals will 
be feasible, will decrease initial tidal volumes to the target 6 ml/kg PBW, and will 
improve outcomes. 
 
The objectives of this study are to: 
 
• Determine if the implementation of lung protective ventilation (with a 6 ml/kg 
PBW tidal volume ventilation protocol on initiation of mechanical ventilation) 
improves outcomes in patients with acute respiratory failure requiring 
mechanical ventilation 
• Determine if the implementation of lung protective ventilation (with a 6 ml/kg 
PBW tidal volume ventilation protocol on initiation of mechanical ventilation) 
improves outcomes in the sub-group of patients with the acute respiratory 
distress syndrome (ARDS) 
• Measure compliance with the implementation of a computerized lung 
protective ventilation protocol at 11 Intermountain Healthcare hospitals 
 
Specific Aim #1: Determine if the implementation of lung protective ventilation 
with a 6 ml/kg PBW tidal volume ventilation protocol on initiation of mechanical 
ventilation improves ventilator free days (VFDs) to day 28 (primary outcome), 
mortality, and secondary outcomes in patients with acute respiratory failure 
requiring mechanical ventilation. 
• Process for Aim #1: Standardized management of mechanical 
ventilation and outcomes will be measured through electronic medical 
record data. A detailed plan on these metrics has been included (see 
research strategy for specific aims). 
• Hypothesis 1: Deployment of the ventilation protocol will result in 
improvements in the number of VFDs to day 28, mortality, hospital 
discharge disposition, healthcare utilization and costs of care in 
patients with acute respiratory failure requiring mechanical ventilation. 
 
 

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Specific Aim #2: Determine if the implementation of lung protective ventilation 
with a 6 ml/kg PBW tidal volume ventilation protocol on initiation of mechanical 
ventilation improves VFDs to day 28, mortality, and secondary outcomes in 
patients with ARDS requiring mechanical ventilation. 
• Process for Aim #2: Standardized management of mechanical 
ventilation for patients with ARDS and outcomes will be measured 
through electronic medical record data. A detailed plan on these 
metrics has been included (see research strategy for specific aims). 
• Hypothesis 2: Deployment of the ventilation protocol in patients with 
ARDS will result in improvements in the number of VFDs to day 28, 
mortality, hospital discharge disposition, healthcare utilization and 
costs of care. 
 
Specific Aim #3: Characterize protocol implementation of the high positive end 
expiratory pressure protocol (PEEP) and outcomes for mechanically ventilated 
patients with moderate or severe hypoxemia and ARDS. 
• Process for Aim #3: Patients with ARDS will be analyzed based on 
hypoxemia conditions (as defined by their PaO2 to FiO2 ratio) using 3 
classifications: mild (201-300), moderate (101-200), and severe 
(≤100). This subgroup analysis will evaluate protocol implementation of 
the high versus low positive end expiratory pressure (PEEP) protocol 
and assess relationship with patient outcomes. Data from 
Intermountain ICUs in 2014 have shown that approximately 500 
patients meet the criteria for “severe” hypoxemia. Patients with 
moderate and severe hypoxemia will be identified to determine the 
frequency of high PEEP protocol usage (which is the recommendation 
in the protocol). Implementation of the high PEEP protocol will be 
based upon clinician discretion. We will assess outcomes in the 4 
hypoxemia sub-groups noted above using a stratified Kaplan–Meier 
curve to determine differences in mortality using log rank statistics. 
• Hypothesis 3: A high PEEP strategy in patients with moderate to 
severe hypoxemia and ARDS will improve outcomes.  
 
Specific Aim #4: Measure compliance of the computerized lung protective 
ventilation protocol after implementation across Intermountain Healthcare’s 11 
 
 

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hospitals that manage mechanically ventilated patients with acute respiratory 
failure. 
• Process for Aim #4: Tool utilization and compliance will test the ability 
of a healthcare system to introduce this proven lung protective 
ventilation protocol in a new electronic medical record in a controlled 
clinical environment. To ensure that this is successful, Dr. Grissom will 
identify local champions to train and educate the healthcare providers.  
• Hypothesis 4: Healthcare providers will utilize the computerized 
ventilation protocol and will comply with protocol instructions. 
 
Study Design: 
 
This is an observational quality improvement study comparing outcomes before, 
and after, implementation of a proven lung protective ventilation protocol in an 
electronic medical record system, iCentra, that will be implemented in phases 
across Intermountain Healthcare hospitals. A phased implementation with a two-
month washout period will be used to evaluate the primary outcome of interest, 
ventilator free days (VFDs) to 28 days. Secondary outcomes will include: use of 
the protocol by clinicians, compliance with protocol instructions, hospital 
discharge disposition, hospital, 30-day, and 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. As the iCentra electronic medical record is implemented 
at Intermountain Healthcare hospitals, clinicians will have the opportunity to use 
the computerized lung protective ventilation protocol, or to order mechanical 
ventilation settings independently. This is an observational study designed to 
measure how often the computerized lung protective ventilation protocol will be 
ordered, compliance with the instructions of the protocol, and clinical outcomes 
among patients who are managed with the protocol. Physicians may choose to 
use the protocol on intubated patients requiring mechanical ventilation or they 
may choose to order other specific mechanical ventilator settings.  
 
A meta-analysis of mechanically ventilated patients without the acute respiratory 
distress syndrome (ARDS) reported that the cohort who received mechanical 
ventilation with initial tidal volumes between 6 and 10 ml/kg PBW had mean VFD 
of 21.9 (SD = 7.8). Using the distribution reported in the meta-analysis as the 
baseline for an a priori analysis, the current authors demonstrated that 3,900 
patients would be sufficient to detect a 1.5-day increase in mean VFD with 80% 
 
 

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power (ICC = 0.10). The team anticipates this study will require a total of 16 
months (two months of baseline during which the protocol will not have been 
implemented at any hospital, eight months of sequentially phasing in the protocol 
over two-month intervals across four sites along with a two-month washout 
period, and six months of follow-up once the protocol has been successfully 
implemented at every site) given that approximately 3,500 patients managed with 
volume control or pressure control ventilation are admitted each year to the 11 
Intermountain hospitals included in this study and each site will not enroll during 
their two-month washout period, resulting in a total expected enrollment of about 
4,000 over 16 months. This proposal will also follow each successive hospital 
that transitions to iCentra. Dr. Colin Grissom and his team will make certain that 
each site is prepared and has been provided the necessary educational 
materials. Dr. Grissom will be available for phone consultation from physicians 
and respiratory therapists for real-time assistance when utilizing the mechanical 
ventilation protocols. 
 
Collaboration  
This research will be conducted with committee identified above, in addition to 
Dr. Michael Lanspa, MD and Dr. Ithan Peltan, MD will provide medical oversight. 
Local site champions have been identified at the 11 hospitals where this protocol 
will be developed and these healthcare professionals will work closely with Dr. 
Grissom and his team. 
 
Background and Significance: 
 
Background 
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 
volutrauma (damage due to high tidal volume), barotrauma (damage due to high 
pressures), and biotrauma (release of inflammatory mediators due to high tidal 
volume).  
 
Lung protective ventilation for patients with the acute respiratory distress 
syndrome (ARDS) improves outcomes. In a prospective randomized clinical trial 
 
 

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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—thereby 
demonstrating the trend that is occurring in medical practice. One of these 
studies even showed that tidal volume size was an independent predictor for 
development of acute lung injury (ALI) in patients who did not have ARDS at 
onset of mechanical ventilation. The odds ratio for developing ALI/ARDS was 1.3 
for each millimeter of tidal volume more than 6 mL/kg PBW.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 A randomized controlled trial of intraoperative lung protective ventilation 
using 6-8 ml/kg versus 10-12 ml/kg PBW tidal volume in patients undergoing 
high-risk abdominal surgery resulted in significantly less pulmonary and non-
pulmonary complications.7 Taken together, these studies indicate that patients 
with acute respiratory failure requiring mechanical ventilation, but without ARDS, 
should be 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 of ≤6 ml/kg PBW.  
 
 
 

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Compliance with lung protective ventilation in the emergency department (ED)8,9 
and ICU10 is not optimal. In the International LUNG SAFE study that included 
more than 550 ICUs around the world, mean tidal volume in patients with ARDS 
was 7.5 to 8.0 ml/kg PBW,10 and tidal volumes in patients with severe acute 
respiratory failure and PaO2/FIO2 ratios <300 was over 8 ml/kg PBW. In Europe, 
a prospective clinical trial is underway to determine whether tidal volumes of 4 to 
6 ml/kg PBW improves outcomes as compared to 8 to 10 ml/kg PBW in patients 
with acute respiratory failure and ARDS.11 Interestingly, the senior investigator of 
that study has used electronic decision support since 2006 in his medical and 
surgical ICU to recommend a default tidal volume of 6 ml/kg PBW on all 
intubated patients regardless of diagnosis.12,13  
 
In the previous studies of electronic decision support to implement lung 
protective ventilation,12,13 the instructions were only purposed to provide the tidal 
volume calculated from 6 ml/kg of PBW when physicians and nurses were 
reviewing mechanical ventilation parameters. The computerized protocol that we 
propose herein to implement across Intermountain Healthcare provides specific 
instructions on management of mechanical ventilation with adjustment of 
respiratory rate, tidal volume, fraction of inspired oxygen (FiO2), and positive end 
expiratory pressure (PEEP) with lung protective targets of a tidal volume of 6 
ml/kg PBW and an inspiratory plateau pressure of < 30 cm H2O. We will also 
provide a computerized weaning protocol. This complete computerized lung 
protective mechanical ventilation protocol will allow standardization of care 
across Intermountain for all aspects of management of mechanical ventilation. 
 
Significance  
Data on initial set tidal volume in the ED and ICU across Intermountain 
Healthcare hospitals shows variability in compliance with lung protective 
ventilation—as represented by numbers of patients in different categories of 
initial set tidal volume measured in ml/kg PBW (Figure 1, Table 1, and Figure 3 
in the Supporting Documents section). These data include all patients who had 
initiation of mechanical ventilation in the ED or ICU with volume control 
ventilation and without a spontaneous breathing mode, such as pressure support 
or continuous positive airway pressure, at Intermountain Healthcare hospitals in 
2014 (Intermountain Medical Center, McKay Dee Hospital, LDS Hospital, Utah 
Valley Regional Medical Center, Park City, American Fork, Riverton, Alta View, 
Logan, Valley View, and Dixie Regional Medical Center). Results from this 
 
 

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investigation demonstrated that only 20% of initial tidal volume settings in the ED 
and ICU were ≤6.0 ml/kg PBW (Figure 1), 50% of patients in the ED and 57% of 
patients in the ICU had initial tidal volume settings of ≤7.0 ml/kg PBW and 22% of 
ED patients and 18% of ICU patients had initial tidal volume settings >8 ml/kg 
PBW. This represents about one in five patients who were ventilated with high 
tidal volumes that may injure the lung. There was no initial determination of 
whether patients had ARDS in the data set. 
 
Intermountain Healthcare will implement a computerized version of the ARDS 
Network 6 ml/kg PBW ventilation protocol in their new electronic medical record 
system from Cerner, called iCentra. This computerized ventilation, oxygenation, 
and weaning protocol will become the default mechanical ventilation protocol for 
use on all intubated patients at Intermountain Healthcare hospitals. Physicians 
will be free, however, to decline to use the computerized mechanical ventilation 
protocol and to provide instead alternative orders for mechanical ventilation. The 
computerized ventilation, oxygenation, and weaning protocols will be separated 
so that physicians may select any combination of the protocols for patient care. It 
is expected that most mechanically ventilated patients will be managed with the 
combination of ventilation, oxygenation, and weaning protocols. However, 
patients with elevated intracranial pressure may be excluded per the attending 
physician discretion from the 6 ml/kg PBW ventilation protocol. The oxygenation 
protocol will target a partial pressure of arterial oxygen (PaO2) of 55 to 67 mm Hg 
with a normal PEEP protocol using the ARDS Network low PEEP table or 
alternatively, for patients with moderate to severe ARDS, a high PEEP protocol 
based on the ARDS Network high PEEP table (Table 2).14 There is also a high 
range oxygenation protocol targeting a PaO2 of 68 to 80 mm Hg for patients with 
hypoxic brain injury or ischemia of other organs in which the physician may 
prefer a higher oxygen partial pressure. 
 
Based on a meta-analysis of high versus low PEEP clinical trials, there is a 
mortality benefit using a high PEEP strategy in patients with moderate to severe 
ARDS.15 Uncertainty exists, however, in how to implement a high PEEP 
strategy16 and review of the application of PEEP to patients enrolled in the ARDS 
Network 2 studies after publication of the meta-analysis do not show widespread 
adoption of a high PEEP strategy (Figure 2). Completed clinical trials of patients 
with moderate to severe ARDS, however, have safely employed a high PEEP 
strategy with good clinical outcomes17, and the proposed trial “Reevaluation Of 
 
 

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Systemic Early neuromuscular blockade (ROSE)” from the NIH/NHLBI 
Prevention and Early Treatment of Acute Lung Injury (PETAL) Network will use a 
high PEEP strategy for moderate to severe ARDS based on the ARDS Network 
High PEEP protocol (Table 2). Intermountain Healthcare leads the Utah Clinical 
Center of the PETAL Network, and the high PEEP protocol that will be 
computerized in iCentra matches the PETAL Network high PEEP protocol for 
ROSE. 
 
Based on current evidence, a lung protective ventilation strategy using the ARDS 
Network ventilation protocol with a target tidal volume of 6 ml/kg PBW is an 
accepted standard for all intubated patients at Intermountain Healthcare EDs and 
ICUs. Plans for implementation of the ARDS Network 6 ml/kg ventilation protocol 
into iCentra were made as an initiative to standardize care for mechanical 
ventilation across Intermountain Healthcare Hospitals. Lung protective ventilation 
has the potential to benefit patients who require mechanical ventilation for 
neurologic problems, surgery, drug overdose, or airway protection as well as 
hypoxemic respiratory failure. 
 
 
 
 
Table 1. Numbers of patients in initial tidal volume ranges in the ED and ICU 
 
≤ 4 
>4 
and
≤ 5 
>5 
and 
≤ 6 
>6 
and 
≤ 7 
>7 
and 
≤ 8 
>8 
and 
≤ 9 
>9 
and 
≤ 10 
>10 
and 
≤ 11 
>11 
and 
≤ 12 
>12 
and 
≤ 13 
>13 
and ≤ 
16 
ED 
3 
14 
191 
322 
289 
174 
40 
14 
0 
2 
4 
ICU 
5 
13 
377 
721 
480 
233 
71 
31 
7 
4 
2 
0
200
400
600
800
≤ 4 ≤ 5 ≤ 6 ≤ 7 ≤ 8 ≤ 9 ≤ 10 ≤ 11 ≤ 12 ≤ 13 ≤ 14 ≤ 15 ≤ 16 
≤ 24 
Number of Patients 
Tidal Volume Ranges in ml/kg Predicted Body Weight 
Figure 1. Initial Tidal Volume in Mechanically Ventilated Patients in the ED 
and ICU at Intermountain Healthcare in 2014 
IHC ED
IHC ICU
 
 

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Figure 2. Compliance with High PEEP Strategy 
in ARDS Network 2 Studies EDEN18, OMEGA19, and SAILS.20 
 
Table 2. Comparison of High and Low PEEP Strategies 
 
 
FIO2 
0.3 
FIO2 
0.4 
FIO2 
0.5 
FIO2 
0.6 
FIO2 
0.7 
FIO2 
0.8 
FIO2 
0.9 
FIO2 
1.0 
ROSE High 
PEEP 
5 
5-16 
16-20 
20 
20 
20-22 
22 
22-24 
ALVEOLI 
High PEEP14 
5-14 14-16 16-20 
20 
20 
20-22 
22 
22-24 
ALVEOLI Low 
PEEP14 
5 
5-8 
8-10 
10 
10-14 
14 
14-18 18-24 
 
 
 
 
 

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Research Subjects: 
 
Inclusion Criteria 
1. Initiation of mechanical ventilation in the emergency department or 
intensive care unit at an Intermountain Healthcare hospital 
2. 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 respiratory failure requiring intubation and 
initiation of mechanical ventilation. Patients will be divided into two different 
groups: those patients who are managed with the computerized lung protective 
ventilation protocol as ordered by the attending physician and those patients 
managed with physician specified mechanical ventilation settings.  
 
Compensation 
Subjects will not be compensated for participating in this study. 
 
Sample Size 
The minimum sufficient sample size to detect a significant change in VFD was 
computed across a range of effects and heterogeneity. We estimate about 3,900 
subjects would be sufficient to detect a 1.5-day increase in mean VFD with 80% 
power (ICC = 0.10) from a baseline of 21.9 VFD (SD=7.8) with a one-tailed test 
(Table 3).  
 
Table 3. Minimum sample size for increase in mean VFD 
 
ICC 
1 day 
1.5 
day 
2 day 
0.01 
6,800 
3,200 
2,300 
0.10 
8,500 
3,900 
2,300 
0.20 
8,300 
4,000 
2,400 
 
The baseline VFD data for the power analysis was based on reported data from 
a meta-analysis of the association between tidal volume size and sedation needs 
 
 

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in patients without ARDS25 among those who received initial tidal volumes 
between 6 and 10 ml/kg PBW – a demographic representative of our study 
population. The power analyses accounted for expected imbalance of patient 
enrollment (Table 4),26,27 heterogeneity among clusters,28 and allowed for a 
variety of time effects (Equation 1).29 This avoided artificial inflation of power at 
the study design stage.30 
 
The VFD 𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖 for each patient were simulated via a linear equation adapted from 
Hussy et al.31 with the addition of quadratic time effects: 
 
𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖= 𝜇𝜇+ 𝛼𝛼𝑘𝑘+ 𝛽𝛽1𝑡𝑡+ 𝛽𝛽2𝑡𝑡2 + 𝜃𝜃𝑥𝑥𝑖𝑖𝑖𝑖𝑖𝑖+ 𝑒𝑒𝑖𝑖𝑖𝑖𝑖𝑖,  
(1) 
 
where μ and 𝑒𝑒𝑖𝑖𝑖𝑖𝑖𝑖, were derived from the distribution of VFD reported in the meta-
analysis by Serpa Neto et al.25, 𝜃𝜃 varied from 1 to 2 per Grissom’s instructions, 
𝛼𝛼𝑘𝑘 are the hospital-level random intercepts, 𝛽𝛽= (𝛽𝛽1, 𝛽𝛽2) is a vector of quadratic 
time effects, 𝑥𝑥𝑖𝑖𝑖𝑖𝑖𝑖 is the initial tidal volume size for the ith subject in the kth cluster 
at time t. 
 
Table 4. Volume of mechanically ventilated patients in 2014 
 
  
Volume 
Proportion 
McKay-Dee 
542 
0.1584 
Utah Valley 
608 
0.1778 
American Fork 
68 
0.0199 
Dixie 
479 
0.14 
Valley View 
60 
0.0175 
IMC 
1409 
0.4119 
LDS 
206 
0.0602 
Riverton 
49 
0.0143 
 
 
Methods/Procedures: 
 
Research Strategy for Specific Aims 1 and 2 
Lung protective ventilation management using the computerized ARDS Network 
6 ml/kg PBW ventilation protocol will be phased in among 11 Intermountain 
Healthcare hospitals in the manner of a phased implementation design 
synchronized with the rollout of iCentra. This is a quality improvement initiative to 
introduce a best practices ventilation protocol across Intermountain Healthcare 
hospitals and we request waiver of informed consent from the Institutional 
 
 

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Review Board in order to measure the effect on clinical outcomes and change in 
practice associated with this implementation. With each successive hospital that 
transitions to iCentra, Dr. Grissom will provide educational presentations to the 
medical staff that manage mechanically ventilated patients. Dr. Grissom and Ms. 
Lori Carpenter, a respiratory therapist, will also educate the respiratory therapists 
at each hospital in the computerized ARDS Network ventilation protocol. Dr. 
Grissom will be available for phone consultation from physicians and respiratory 
therapists for real time assistance in utilizing the mechanical ventilation protocols. 
 
The primary outcome is ventilator free days (VFDs) to day 28. We will use the 
same definition for liberation from mechanical ventilation as used in ARDS 
Network studies2,14 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 as22:  
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 
 
Research Strategy for Specific Aim 3 
Efficacy of a high PEEP strategy for patients requires identifying patients with 
moderate or severe ARDS, determining protocol compliance, and measuring 
outcomes. Determination of ARDS using the Berlin Definition23 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. Applying these criteria to identify 
ARDS in a large pragmatic study with a target enrollment of approximately 3,500 
patients is a significant challenge. We will focus on defining ARDS among those 
patients with mild, moderate, or severe hypoxemia as defined by a PaO2 to FIO2 
ratio ≤ 300 and evaluate chest radiographs for bilateral infiltrates in that group. 
Then we will evaluate implementation of the high PEEP strategy and outcomes in 
the group of patients with ARDS who have a PaO2 to FIO2 ratio ≤ 200. Even 
though a high PEEP strategy is recommended for moderate to severe ARDS as 
 
 

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defined by a PaO2/FIO2 ≤ 200, this is not strictly applied clinically based on our 
review of ARDS Network study data (Figure 2). Implementation of the high 
PEEP protocol for moderate to severe ARDS is left up to the clinician in the 
computerized mechanical ventilation protocol. By performing a sub-group 
analysis we will characterize the utilization of a high PEEP strategy in patients 
with moderate or severe ARDS at Intermountain Healthcare hospitals. Lastly, the 
benefit of segmenting the data into categories “mild”, “moderate”, and “severe” 
hypoxemia, is that it will allow our team to use a stratified Kaplan–Meier curve to 
assess differences in mortality using log rank statistics. This will directly show the 
relationship between hypoxemia, treatment and mortality. New findings from 
Specific Aim #3 may drastically influence the standard of care within 
Intermountain Healthcare and internationally. 
 
Research Strategy for Specific Aim 4 
Evaluation of compliance with the ARDS Network computerized protocol and 
association with clinical outcomes will be performed with extraction of data from 
the EMR. This will require specific data queries to collect information on initial set 
tidal volume, mode of ventilation, FIO2, and PEEP as well as patient outcomes. 
Dr. Grissom along with Ms. Lydia Dong from the Intensive Medicine Clinical 
Program and Ms. Juhee Peterson from pulmonary and critical care research at 
Intermountain Medical Center have extensive experience with these types of 
queries of mechanical ventilation data from the Intermountain enterprise data 
warehouse (EDW). Transition to iCentra, however, will create challenges for 
extracting data from a new EMR system. Although this will require increased 
effort at creating new queries and mapping ventilator data, this will have long-
term benefits for data extraction from iCentra for the Intensive Medicine Clinical 
Program, quality assurance initiatives, and pulmonary and critical care research 
at Intermountain Healthcare. 
 
Study Duration 
16 months, 1/1/2016 - 5/31/2017 
 
Study Timeline 
Approximately 3,500 patients managed with volume control or pressure control 
ventilation are admitted each year to the 11 Intermountain hospitals included in 
this study. The team anticipates this study will require a total of 16 months (two 
months during which the protocol will not have been implemented at any hospital, 
 
 

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eight months of sequentially phasing in the protocol over two-month intervals 
across four sites over, and six months of follow-up once the protocol has been 
successfully implemented at every site) given that approximately 3,500 patients 
managed with volume control or pressure control ventilation are admitted each 
year to the 11 Intermountain hospitals included in this study. 
 
Note that although 11 hospitals will be included in the study (IMC, McKay-Dee, 
Utah Valley, American Fork, Dixie, Valley View, LDS, Riverton), only eight were 
included in the power analysis because three hospitals (Alta View, Park City, and 
Logan) were not featured in the baseline data set. The number of mechanically 
ventilated patients at Alta View, Park City, and Logan is very low, so their 
expected contribution to patient enrollment would not substantively change the 
results of the power analysis. These three hospitals will be included in the 
prospective implementation of a lung protective ventilation protocol for purposes 
of standardization of care. Critically ill patients with respiratory failure who are 
intubated at Alta View, Park City, and Logan may have initiation of lung 
protective mechanical ventilation for management in their ICU, or prior to transfer 
to an Intermountain tertiary hospital. With a two-month deployment period at 
each hospital – during which time data will not be collected – a sufficient number 
of patients could be enrolled in less than 16 months. This corresponds to two 
months of baseline data collection, eight months of phasing in the protocol, and 
six months of follow-up once the protocol has been successfully implemented at 
each of the sites. An example enrollment matrix simulated by a Poisson process 
is displayed in Table 5. 
 
Table 5. 
 16-month enrollment matrix (n = 4,127) 
 
 
 
 
Risks 
The risk of this study is a potential loss of confidentiality, which will be managed 
as detailed below.  
 
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
McKay-Dee
46
39
50
43
55
37
49
50
39
42
52
49
43
61
Utah Valley
52
60
57
57
54
45
72
38
57
54
46
60
48
49
American Fork
8
4
6
10
6
5
4
4
5
6
2
3
10
3
Dixie
45
43
37
34
31
52
33
38
41
43
37
36
47
52
Valley View
3
4
5
6
7
2
7
5
3
4
8
1
5
3
IMC
129
127
116
105
114
130
136
142
115
121
139
120
116
118
LDS
19
19
16
24
17
23
19
12
10
18
17
9
15
15
Riverton
3
3
5
3
1
5
4
5
2
6
7
5
4
1
 
 

IMPROVENT  
Page 17 
Sep 27 2016 
Benefits 
This is a quality improvement study evaluating the benefits of a proven lung 
protective ventilation protocol across Intermountain Healthcare hospitals. 
Application of the protocol at the discretion of the attending physician to patients 
with acute respiratory failure requiring intubation and mechanical ventilation is 
expected to improve outcomes.  
 
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 lung protective mechanical ventilation protocol will be available 
to clinicians as an order in iCentra, but will not be required. 
• The sample size required to detect a significant change in VFD is estimated 
to be about 3,900 subjects. Including only the data for which consent can be 
obtained would prevent accurate conclusions from being drawn. 
Consequently, the research could not practicably be carried out without a 
waiver of consent. 
 
Waiver of Authorization 
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 
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 evaluating the primary outcome of interest, VFDs to 28 days. 
 
 
 

IMPROVENT  
Page 18 
Sep 27 2016 
Data Collection: 
 
Data Elements Extracted from the EDW for the Mechanical Ventilation 
Study 
• Region 
• Hospital 
• Facility ID 
• Account Number 
• EMPI 
• Admit Date 
• Discharge Date 
• Admit Year 
• Age 
• Gender 
• ICD Diagnosis code 
• ICD Diagnosis description 
• ICD Diagnosis long description 
• ICU Stay 
• Length of Stay(Days) 
• Mortality Indicator 
• 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 
• Ventilator Mode 
• First Date of Ventilator Check 
• Intubation Date 
• Intubation Location(Same as Ventilator Location) 
• Room Trace(It is more detailed than the ones above) 
• In Hospital Mortality 
 
 

IMPROVENT  
Page 19 
Sep 27 2016 
• Ventilator Mode 
• Machine Corrected Volume 
• Set Tidal Volume 
• Spontaneous Volume 
• Height 
• Predicted Body Weight 
• Tidal Volume per Predicted Body Weight 
• Measured Volume per Predicted Body Weight 
• Difference between Tidal Volume per PBW and Measured Volume per PBW 
• Difference between admission date and death date 
• 30 Day Mortality 
• 60 Day Mortality 
• 90 Day Mortality 
• Initial Arterial Blood Gas recorded during hospital stay 
• PaO2 (measured) 
• PaO2 (corrected) 
• FiO2 
• PaO2 / FiO2 
 
Data Analysis: 
 
Primary Outcomes 
The primary outcome will be VFD to day 28. Patients who experience death 
within 28 days of ICU admission will be counted as having zero VFD.  
 
Secondary outcomes will include: hospital discharge disposition; hospital, 30-
day, and 90-day mortality; time to first ICU activity; hospital, ICU length of stay; 
protocol compliance; implementation of a high PEEP strategy in patients with 
PaO2/FIO2 ratios ≤ 200; heath care utilization; quality of life (SF-36 or similar); 
and costs of care. 
 
Data Analysis 
Descriptive analyses will include Fisher’s exact test and Pearson’s chi-square 
test for comparing pairs of binomially distributed variables with and without 
sparse cells, respectively. Wilcoxon rank sum test, a nonparametric analogue of 
Student’s t test, will be used to compare non-Gaussian, continuous distributions. 
Bootstrapped Kolmogorov-Smirnov (K-S) test will compare distributions of 
 
 

IMPROVENT  
Page 20 
Sep 27 2016 
ordinal, discrete data. The bootstrapped K-S test is able to handle instances in 
which many ties are present between distributions.24 
 
Generalized linear mixed models (GLMM) with hospital-level random intercepts 
and an identify link function will be used to measure the effect of initial tidal 
volume size on VFD. It is proposed to measure the treatment as a continuous 
variable (rather than as a dichotomous indicator of whether the mechanically 
ventilated patient was cared for at a post-intervention site) in order to account for 
the variable “usual care” practices of tidal volume size. The protocol will be 
phased sequentially in a non-randomized phased implementation manner. Since 
it is hypothesized that the bundle will improve care and, resultantly, decrease 
duration of time on ventilator, statistical significance will be determined by a one-
tailed, 5% significance test. Heterogeneity among clusters will also be measured 
and accounted for random intercepts. Potential secular trends will be adjusted for 
by inclusion of quadratic time effects, which would capture a variety of time 
effects – from linear to bell-shaped. Patient-specific confounders will be 
controlled for by additive inclusion of a matrix of patient-level covariates. 
 
Mitigation Plans and Interim Analysis 
We plan an interim analysis for futility and efficacy at the end of the third step, 
following the successful phasing in of the second cluster. If the mean VFD 
following implementation of the bundle is equivalent to the mean VFD prior to 
implementation (according to the two one-sided test procedure with 99% 
confidence having an equivalence margin of four hours) then futility will be 
declared and further data collection will cease. Conversely, if the mean VFD 
following implementation has increased by more than 2 days (according to a one-
sided hypothesis test with 99% confidence), efficacy will have been established 
and further data collection will also cease. 
 
Data Sharing: 
 
Development of the ventilation protocol in iCentra for mechanical ventilation will 
likely increase the number of VFDs, decrease healthcare utilization and decrease 
cost. To ensure that the proposal deliverables are met, we have designed the 
following dissemination plan: 
 
 
 

IMPROVENT  
Page 21 
Sep 27 2016 
Internal Strategic Planning 
The investigators have identified local site champions to educate and train the 
Intermountain Healthcare providers. The principal investigator intends to go on a 
“road show” to explain the utility of the ventilation strategy and will provide 
electronic media (PowerPoints, PDFs), etc. To reach a more general audience 
the team may also present at an Intermountain Research event (colloquium or 
summit) to showcase this Type 1 research.  
 
External Strategic Planning 
The study investigators will consult with Dr. Raj Srivastava, the Assistant Vice 
President for Research at Intermountain Healthcare, the Office of Research, and 
the internal communications team (via Craig Kartchner and Susan Gagnier) to 
reach the general community. Specific examples may include (but are not limited 
to): Twitter, Facebook post, institutional blog posts, hosting conferences, 
emailing network and insurance providers, etc.  
 
Conference Proceedings and Peer-Reviewed Publications 
The Office of Research will support this application by helping to write/edit/submit 
manuscripts, provide graphic design assistance, and grant full access to the 
statistical data department to ensure that data is analyzed using various 
parametric and non-parametric statistical tests. 
 
Funding: 
 
It is anticipated that this project will be funded by the Pulmonary and Critical Care 
Department at Intermountain Medical Center. 
 
 
 
 

IMPROVENT  
Page 22 
Sep 27 2016 
References 
 
1. 
Society AT. Patient Information: Mechanical Ventilation. 5 October 2015. 
2. 
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. May 4 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. Jan 15 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. Oct 24 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. Sep 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. Oct 
2015;43(10):2155-2163. 
7. 
Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative 
low-tidal-volume ventilation in abdominal surgery. The New England 
journal of medicine. Aug 1 2013;369(5):428-437. 
8. 
Allison MG, Scott MC, Hu KM, Witting MD, Winters ME. High initial tidal 
volumes in emergency department patients at risk for acute respiratory 
distress syndrome. J Crit Care. Apr 2015;30(2):341-343. 
9. 
Fuller BM, Mohr NM, Dettmer M, et al. Mechanical ventilation and acute 
lung injury in emergency department patients with severe sepsis and 
septic shock: an observational study. Acad Emerg Med. Jul 
2013;20(7):659-669. 
10. 
Laffey J. Large observational study to UNderstand the Global impact of 
Severe Acute respiratory FailurE (LUNG-SAFE). [pdf]. 2014; Preliminary 
results of the LUNG SAFE study. Available at: 
http://www.criticalcarecanada.com/presentations/2014/large_observational
 
 

IMPROVENT  
Page 23 
Sep 27 2016 
_study_to_understand_the_global_impact_of_severe_acute_respiratory_f
ailure.pdf. Accessed October 15, 2015. 
11. 
Simonis FD, Binnekade JM, Braber A, et al. PReVENT--protective 
ventilation in patients without ARDS at start of ventilation: study protocol 
for a randomized controlled trial. Trials. 2015;16:226. 
12. 
Eslami S, Abu-Hanna A, Schultz MJ, de Jonge E, de Keizer NF. 
Evaluation of consulting and critiquing decision support systems: effect on 
adherence to a lower tidal volume mechanical ventilation strategy. J Crit 
Care. Aug 2012;27(4):425 e421-428. 
13. 
Eslami S, de Keizer NF, Abu-Hanna A, de Jonge E, Schultz MJ. Effect of 
a clinical decision support system on adherence to a lower tidal volume 
mechanical ventilation strategy. J Crit Care. Dec 2009;24(4):523-529. 
14. 
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. Jul 22 2004;351(4):327-
336. 
15. 
Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory 
pressure in patients with acute lung injury and acute respiratory distress 
syndrome: systematic review and meta-analysis. Jama. Mar 3 
2010;303(9):865-873. 
16. 
Rubenfeld GD. How much PEEP in acute lung injury. Jama. Mar 3 
2010;303(9):883-884. 
17. 
Ferguson ND, Cook DJ, Guyatt GH, et al. High-frequency oscillation in 
early acute respiratory distress syndrome. The New England journal of 
medicine. Feb 28 2013;368(9):795-805. 
18. 
Rice TW, Wheeler AP, Thompson BT, et al. Initial trophic vs full enteral 
feeding in patients with acute lung injury: the EDEN randomized trial. 
Jama. Feb 22 2012;307(8):795-803. 
19. 
Rice TW, Wheeler AP, Thompson BT, et al. Enteral omega-3 fatty acid, 
gamma-linolenic acid, and antioxidant supplementation in acute lung 
injury. Jama. Oct 12 2011;306(14):1574-1581. 
20. 
National Heart L, Blood Institute ACTN, Truwit JD, et al. Rosuvastatin for 
sepsis-associated acute respiratory distress syndrome. The New England 
journal of medicine. Jun 5 2014;370(23):2191-2200. 
21. 
Sorenson D, Grissom CK, Carpenter L, et al. A frame-based 
representation for a bedside ventilator weaning protocol. Journal of 
biomedical informatics. Jun 2008;41(3):461-468. 
 
 

IMPROVENT  
Page 24 
Sep 27 2016 
22. 
Angus D MM. Reevaluation Of Systemic Early neuromuscular blockade. 
NHLBI Petal Network2015. 
23. 
Force ADT, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress 
syndrome: the Berlin Definition. Jama. Jun 20 2012;307(23):2526-2533. 
24. 
Wilcox R. Kolmogorov–Smirnov Test. Encyclopedia of biostatistics 2005. 
25. 
Serpa Neto A, Simonis FD, Barbas CS, et al. Association between tidal 
volume size, duration of ventilation, and sedation needs in patients without 
acute respiratory distress syndrome: an individual patient data meta-
analysis. Intensive care medicine. Jul 2014;40(7):950-957. 
26. 
Dean NC. Intermountain healthcare ed volumes of adults. 
27. 
Allen TL. Intermountain Healthcare Ed Summary Report. 2014-2014. 
28. 
Gelman A HJ. Data Analysis Using Regression and Multilevel/Hierarchical 
Models. 2006. 
29. 
Fox J. Applied Regression Analysis and Generalized Linear Model. Sage; 
2015. 
30. 
Baio G, Copas A, Ambler G, Hargreaves J, Beard E, Omar RZ. Sample 
size calculation for a phased implementation trial. Trials. 2015;16(1):354. 
31. 
Hussey MA, Hughes JP. Design and analysis of phased implementation 
cluster randomized trials. Contemporary clinical trials. Feb 
2007;28(2):182-191. 
32. 
Society of Critical Care Medicine. Accessed 3 November 2015. 
 
 
 

IMPROVENT  
Page 25 
Sep 27 2016 
Figure 3. Initial Tidal Volume on Initiation of Mechanical Ventilation at Intermountain Healthcare 
Hospitals (Intermountain Medical Center = IMC, Utah Valley = UV, McKay Dee = MK, Dixie = DX, and 
LD = LDS Hospital). 
 
 
 
 
 
 
 
 
 
0
100
200
300
≤ 4 
≤ 5 
≤ 6 
≤ 7 
≤ 8 
≤ 9 ≤ 10 ≤ 11 ≤ 12 ≤ 13 ≤ 14 ≤ 15 ≤ 16 
≤ 24 
IMC ED
IMC ICU
0
100
200
300
≤ 4 
≤ 5 
≤ 6 
≤ 7 
≤ 8 
≤ 9 ≤ 10 ≤ 11 ≤ 12 ≤ 13 ≤ 14 ≤ 15 ≤ 16 
≤ 24 
UV ED
UV ICU
0
100
200
300
≤ 4 
≤ 5 
≤ 6 
≤ 7 
≤ 8 
≤ 9 ≤ 10 ≤ 11 ≤ 12 ≤ 13 ≤ 14 ≤ 15 ≤ 16 
≤ 24 
MK ED
MK ICU
0
100
200
300
≤ 4 ≤ 5 ≤ 6 ≤ 7 ≤ 8 ≤ 9 ≤ 10 ≤ 11 ≤ 12 ≤ 13 ≤ 14 ≤ 15 ≤ 16 
≤ 24 
DX ED
DX ICU
0
100
200
300
≤ 4 ≤ 5 ≤ 6 ≤ 7 ≤ 8 ≤ 9 ≤ 10 ≤ 11 ≤ 12 ≤ 13 ≤ 14 ≤ 15 ≤ 16 
≤ 24 
LD ED
LD ICU
 
 

IMPROVENT  
Page 26 
Sep 27 2016 
Figure 4: An example of the weaning protocol that will be used in this study.  
 
 
 
 
 
 

IMPROVENT  
Page 27 
Sep 27 2016 
Figure 5: Process Flow Map for Supporting the Weaning Protocol 
 
 
 
 
 

IMPROVENT  
Page 28 
Sep 27 2016 
Rules for I Centra Ventilator Protocol 
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.  
 
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) 
 
 

IMPROVENT  
Page 29 
Sep 27 2016 
 
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. 
 
 
 
 
 

IMPROVENT  
Page 30 
Sep 27 2016 
Table B.1. Tidal Volumes from Predicted Body Weight from Height and Gender 
 
 
 
 
 

IMPROVENT  
Page 31 
Sep 27 2016 
Table B.2. 
1. 
VT > 6 ml/kg 
2. 
VT = 6 ml/kg 
VT > 4 ml/kg and < 6 ml/kg 
pH 
3. 
Pplat 
< 25 
cm H2O 
Pplat 25 – 30 
cm H2O 
4. 
Pplat 
> 30 
cm H2O 
5. 
Pplat 
< 25 
cm H2O 
Pplat 25 – 30 
cm H2O 
Pplat > 30 
cm H2O 
6. 
Pplat < 
25 
cm H2O 
Pplat 25 – 30 
cm H2O 
Pplat > 30 
cm H2O 
> 7.45 
 
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 
7.30 – 7.45 
 
10. 
 
↓ VT by 1 ml/kg 
11. 
 
↓ VT by 1 ml/kg 
 
12. 
 
↓ VT by 1 ml/kg 
 
13. 
 
No Change in 
Therapy 
14. 
 
No Change in 
Therapy 
15. 
 
↓ VT by 1 ml/kg 
16. 
 
↑ VT by 1 ml/kg 
17. 
 
No Change in 
Therapy 
18. 
 
↓ VT by 1 ml/kg 
but do not ↓ < 4 
ml/kg 
7.15 – 7.29 and 
VR < 35 bpm 
(measured rate) 
19. 
 
↑ VR by 20% 
incrementsa ↓ VT 
by 1 ml/kg 
 
20. 
 
↑ VR by 20% 
incrementsa 
↓ VT by 1 ml/kg 
21. 
 
↑ VR by 20% 
incrementsa 
↓ VT by 1 ml/kg 
22. 
 
↑ VR by 20% 
incrementsa 
 
23. 
 
↑ VR by 20% 
incrementsa 
24. 
 
↓ VT by 1 ml/kg 
↑ VR by 20% 
incrementsa 
 
25. 
 
↑ VR by 20% 
incrementsa 
↑ VT by 1 ml/kg 
26. 
 
↑ VR by 20% 
incrementsa 
27. 
 
↑ VR by 20% 
incrementsa 
7.15 – 7.29 and 
VR = 35 bpm 
(measured rate) 
28. 
 
↓ VT by 1 ml/kg 
Check with MD to 
consider Bicarb 
29. 
 
↓ VT by 1 ml/kg 
Check with MD 
to consider 
Bicarb 
30. 
 
↓ VT by 1 ml/kg 
Check with MD to 
consider Bicarb 
31. 
 
Check with MD to 
consider Bicarb 
32. 
 
Check with MD 
to consider 
Bicarb 
33. 
 
↓ VT by 1 ml/kg 
Check with MD 
to consider 
Bicarb 
34. 
 
↑ VT by 1 ml/kg 
Check with MD to 
consider 
Bicarb 
35. 
 
Check with MD 
to consider 
Bicarb 
36. 
 
↓ VT by 1 ml/kg 
but do not ↓ < 4 
ml/kg 
Check with MD 
To consider 
Bicarb 
< 7.15 and 
VR < 35 bpm 
(measured rate) 
37. 
 
↑ VR by 20% 
increments 
Check with MD to 
consider Bicarb 
 
38. 
 
↑ VR by 20% 
increments 
Check with MD 
to Consider 
Bicarb 
39. 
 
↑ VR by 20% 
increments 
Check with MD to 
Consider Bicarb 
40. 
 
↑ VR by 20% 
increments 
Check with MD to 
Consider Bicarb 
41. 
 
↑ VR by 20% 
increments 
Check with MD 
to Consider 
Bicarb 
42. 
 
↓ VT by 1 ml/kg 
Check with MD 
to consider 
Bicarb 
43. 
 
↑ VR by 20% 
incrementsa 
↑ VT by 1 ml/kg 
Check with MD to 
consider Bicarb 
 
44. 
 
↑ VR by 20% 
increments 
Check with MD 
to Consider 
Bicarb 
45. 
 
↑ VR by 20% 
increments 
Check with MD 
to Consider 
Bicarb 
< 7.15 and 
VR = 35 bpm 
(measured rate) 
46. 
 
Check with MD to 
consider Bicarb 
prior to 
↑ VT by 1 ml/kg 
 
47. 
 
Check with MD 
to consider 
Bicarb prior to 
↑ VT by 1 ml/kg 
 
48. 
 
Check with MD to 
consider Bicarb 
prior to 
↑ VT by 1 ml/kg 
 
49. 
 
Check with MD to 
consider Bicarb 
prior to 
↑ VT by 1 ml/kg 
 
50. 
 
Check with MD 
to consider 
Bicarb prior to 
↑ VT by 1 ml/kg 
 
51. 
 
Check with MD 
to consider 
Bicarb prior to 
↑ VT by 1 ml/kg 
52. 
 
↑ VT by 1 ml/kg 
Check with MD to 
consider Bicarb 
53. 
 
Check with MD 
to consider 
Bicarb prior to 
↑ VT by 1 ml/kg 
54. 
 
Check with MD 
to consider 
Bicarb prior to 
↑ VT by 1 ml/kg 
 
 
 

IMPROVENT  
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Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range) 
Normal Oxygenation on High PEEP Table 8/04/2015 
 
PaO2 < 50 or SpO2 < 85% 
 
(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 > 88% is achieved 
 
PEEP 
FiO2 = 
.3 
FiO2 = .4 
FiO2 = 
.5 
FiO2 = .6 
FiO2 = .7 
FiO2 = .8 
FiO2 = 
.9 
FiO2 = 
1.0 
24 
↑ FiO2 
0.3 
↑ FiO2 0.3 
↑ FiO2 
0.3 
↑ FiO2 0.3 
↑ FiO2 0.3 
↑ FiO2 0.2 
↑ FiO2 
0.1 
PEEP 
↑Trial 
22 
↑ FiO2 
0.3 
 
↑ FiO2 0.3 
 
↑ FiO2 
0.3 
 
↑ FiO2 0.3 
 
↑ FiO2 0.3 
 
↑ FiO2 0.2 
↑PEEP 2 
↑ FiO2 
0.1 
↑PEEP 
2 
 
↑PEEP 2 
20 
↑ FiO2 
0.3 
 
↑ FiO2 0.3 
 
↑ FiO2 
0.3 
 
↑ FiO2 0.2 
↑PEEP 2 
↑ FiO2 0.2 
↑PEEP 2 
↑ FiO2 0.2 
↑PEEP 2 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
18 
↑ FiO2 
0.2 
↑PEEP 
2 
↑ FiO2 0.2 
↑PEEP 2 
↑ FiO2 
0.2 
↑PEEP 
2 
↑ FiO2 0.2 
↑PEEP 2 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
16 
↑ FiO2 
0.2 
↑PEEP 
2 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
14 
↑ FiO2 
0.2 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
12 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
10 
 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
8 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 0.1 
↑PEEP 4 
↑ FiO2 
0.1 
↑PEEP 
4 
 
↑PEEP 4 
5 
↑ FiO2 
0.1 
↑PEEP 
5 
↑ FiO2 0.1 
↑PEEP 5 
↑ FiO2 
0.1 
↑PEEP
5 
↑ FiO2 0.1 
↑PEEP 5 
↑ FiO2 0.1 
↑PEEP 5 
↑ FiO2 0.1 
↑PEEP 5 
↑ FiO2 
0.1 
↑PEEP 
5 
 
↑PEEP 5 
 
 
 
 
 
 

IMPROVENT  
Page 33 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range)  
Normal Oxygenation on High PEEP Table 8/04/2015  
 
PaO2 50 to 54 or SpO2 85 to 87% 
 
(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 > 88% is achieved 
 
PEEP 
FiO2 = .3 
FiO2 = .4 
FiO2 = .5 
FiO2 = .6 
FiO2 = .7 
FiO2 = .8 
FiO2 = .9 
FiO2 = 1.0 
24 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
Consider 
PEEP 
Increase 
Trial 
22 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 2 
20 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 2 
18 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 2 
16 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 2 
14 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 2 
12 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 2 
10 
 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 2 
8 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ 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 
 
 
 
 
 
 
 
 
 
 
 

IMPROVENT  
Page 34 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range)  
Normal Oxygenation on High PEEP Table 8/04/2015   
 
PaO2 = 55 – 67 or SpO2 88 – 93% 
 
(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 
24 
↑ 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 
↑ FiO2 
0.1 
↓PEEP 2 
 
↓PEEP 2 
Maintain 
22 
↑ 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 
Maintain 
Maintain 
Maintain 
20 
↑ FiO2 
0.1 
↓PEEP 2 
↑ FiO2 
0.1 
↓PEEP 2 
Maintain 
Maintain 
Maintain 
Maintain 
↑ PEEP 
2 
↓ FiO2 
0.1 
↑PEEP 2 
18 
↑ FiO2 
0.1 
↓PEEP 2 
↑ FiO2 
0.1 
↓PEEP 2 
Maintain 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
16 
↑ 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 
14 
↑ FiO2 
0.1 
↓PEEP 2 
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 
↓ FiO2 
0.1 
↑PEEP 2 
12 
↑ FiO2 
0.1 
↓PEEP 2 
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 
↓ FiO2 
0.1 
↑ PEEP 
2 
10 
↑ FiO2 
0.1 
↓PEEP 2 
Maintain 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 0.1 
1. 
↑PEEP 
2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 2 
↓ FiO2 
0.1 
↑PEEP 
2 
8 
↑ FiO2 
0.1 
 
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 
↓ 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 
 
 
 

IMPROVENT  
Page 35 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range)  
Normal Oxygenation on High PEEP Table 8/04/2015 
 
PaO2 > 68 or SpO2 > 93% 
 
(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 
24 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
22 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
20 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
18 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
16 
↓ PEEP 2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
14 
↓ PEEP 2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
12 
↓ PEEP 2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
10 
↓ PEEP 2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ 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 
 
 
 
 

IMPROVENT  
Page 36 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range) 
Normal Oxygenation Low PEEP Table 8/04/2015  
 
PaO2 < 50 or SpO2 < 85% 
 
(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 > 88% is achieved 
 
PEEP 
FiO2 = 
.3 
FiO2 = .4 
FiO2 = 
.5 
FiO2 = .6 
FiO2 = .7 
FiO2 = .8 
FiO2 = 
.9 
FiO2 = 
1.0 
24 
↑ FiO2 
0.3 
↑ FiO2 0.2 
↑ FiO2 
0.2 
↑ FiO2 0.2 
↑ FiO2 0.2 
↑ FiO2 0.2 
↑ FiO2 
0.1 
PEEP 
↑Trial 
22 
↑ FiO2 
0.3 
 
↑ 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 
20 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
18 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
16 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
14 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
12 
↑ 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 
4 
 
↑PEEP 4 
10 
 
↑ 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 
4 
 
↑PEEP 4 
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 
4 
 
↑PEEP 4 
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 
 
 
 
 
 

IMPROVENT  
Page 37 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range)  
Normal Oxygenation Low PEEP Table 8/04/2015 
 
PaO2 50 to 54 or SpO2 85 to 87% 
 
(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 > 88% is achieved 
 
PEEP 
FiO2 = .3 
FiO2 = .4 
FiO2 = .5 
FiO2 = .6 
FiO2 = .7 
FiO2 = .8 
FiO2 = .9 
FiO2 = 
1.0 
24 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
Consider 
PEEP 
Increase 
Trial 
22 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
20 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
18 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
16 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
14 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
12 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
10 
 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
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 
 
 
 
 
 
 
 
 
 
 
 

IMPROVENT  
Page 38 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range)  
Normal Oxygenation Low PEEP Table 8/04/2015   
 
PaO2 = 55 – 68 or SpO2 88 – 93% 
 
(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 
24 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
22 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
20 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
18 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
Maintain 
16 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
14 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
Maintain 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
12 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑ PEEP 
2 
10 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
Maintain 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑PEEP 
2 
8 
↑ FiO2 0.1 
↓PEEP 3 
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 
 

IMPROVENT  
Page 39 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol (high altitude target range) 
Normal Oxygenation Low PEEP Table 08/04/2015 
 
PaO2 > 68 or SpO2 > 93% 
 
(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 
24 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
22 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
20 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
18 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
16 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
14 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
12 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
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 
 
 
 
 
 
 

IMPROVENT  
Page 40 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol  
Low PEEP High Oxygenation Table 3/25/15 
 
PaO2 < 55 or SpO2 < 88% 
 
(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 
24 
↑ FiO2 
0.3 
↑ FiO2 0.2 
↑ FiO2 
0.2 
↑ FiO2 0.2 
↑ FiO2 0.2 
↑ FiO2 0.2 
↑ FiO2 
0.1 
PEEP 
↑Trial 
22 
↑ FiO2 
0.3 
 
↑ 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 
20 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
18 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
16 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
14 
↑ FiO2 
0.3 
 
↑ 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 
4 
 
↑PEEP 4 
12 
↑ 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 
4 
 
↑PEEP 4 
10 
 
↑ 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 
4 
 
↑PEEP 4 
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 
4 
 
↑PEEP 4 
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 
 
 
 
 
 

IMPROVENT  
Page 41 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol   
Low PEEP High Oxygenation Table 3/25/15 
 
PaO2 55 to 67 or SpO2 88 to 92% 
 
(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 
24 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
Consider 
PEEP 
Increase 
Trial 
22 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
20 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
18 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
16 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
14 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
12 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
10 
 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ FiO2 
0.1 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
↑ PEEP 
2 
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 
 
 
 
 
 
 
 
 
 
 
 

IMPROVENT  
Page 42 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol  
Low PEEP High Oxygenation Table 3/25/15  
 
PaO2 = 68 – 80 or SpO2 93– 95% 
 
(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 
24 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
22 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
20 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
18 
↑ 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 
 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
Maintain 
16 
↑ 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 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
14 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
Maintain 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
12 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑ PEEP 
2 
10 
↑ FiO2 0.1 
↓PEEP 2 
↑ FiO2 0.1 
↓PEEP 2 
Maintain 
Maintain 
Maintain 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑PEEP 2 
↓ FiO2 0.1 
↑PEEP 
2 
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 
 
 
 

IMPROVENT  
Page 43 
Sep 27 2016 
Utah Tool Box: Salt Lake City Protocol   
Low PEEP High Oxygenation Table 3/25/15 
 
PaO2 > 80 or SpO2 > 95% 
 
(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 
24 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
22 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
20 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
18 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
16 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
14 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
12 
↓ PEEP 2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ PEEP 
2 
↓ FiO2 .1 
↓ FiO2 .1 
↓ FiO2 .1 
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