Goal is to find the derecruitment point
Before attempting, know when the<unk>  should be stopped
Stop and return to baseline PCV settings if:
HR < 60 bpm
HR > 140 bpm
New dysrhythmia on monitor (may indicate significant respiratory acid-base shift)
SBP < 80 mmHg
Sustained SaO2 < 85%
Drop in dynamic compliance (pneumothorax)
HR < 60 bpm
HR > 140 bpm
New dysrhythmia on monitor (may indicate significant respiratory acid-base shift)
SBP < 80 mmHg
Sustained SaO2 < 85%
Drop in dynamic compliance (pneumothorax)
May require increased sedation or paralysis
Optimize preload<unk>  decreases preload)
Maintain a very reliable, good waveform SpO2 (that matches ABG SaO2)
14 ga needles x2 in case of pneumothorax
Record baseline vital signs and initial ventilator settings
I:E to 1:1
Adjust FiO2 to SaO2 90-92%
Take note of dynamic compliance levels
Pressure control ventilation using current rate, PEEP, FiO2 before<unk> 
Adjust PC level above PEEP to start at TV of 6 cc/kg for 2 minutes
Then set PC level (Pi) to 15 cmH2O above PEEP and maintain this difference throughout initial<unk> 
Adjust RR to maintain appropriate minute ventilation
I:E to 1:1
Adjust FiO2 to SaO2 90-92%
Take note of dynamic compliance levels
Pressure control ventilation using current rate, PEEP, FiO2 before<unk> 
Adjust PC level above PEEP to start at TV of 6 cc/kg for 2 minutes
Then set PC level (Pi) to 15 cmH2O above PEEP and maintain this difference throughout initial<unk> 
Adjust RR to maintain appropriate minute ventilation
Adjust PC level above PEEP to start at TV of 6 cc/kg for 2 minutes
Then set PC level (Pi) to 15 cmH2O above PEEP and maintain this difference throughout initial<unk> 
Adjust RR to maintain appropriate minute ventilation
Increase PEEP to 15 cmH2O
Set PC level to 15 cmH2O above PEEP
Maintain this difference between PEEP and PC level (Pi)
Increase q2 minutes PEEP to 20 → 30 → 40 cmH2O
Pi will reach 55 cmH2O
Note maximum SaO2 obtained
Treat SBP drops as necessary, but halt procedure if > 20% SBP drop despite pressors/fluids
Increase PIP as necessary
Maintain minute ventilation
Reduce RR before PIP increase since TV will increase
Maintain this difference between PEEP and PC level (Pi)
Increase q2 minutes PEEP to 20 → 30 → 40 cmH2O
Pi will reach 55 cmH2O
Note maximum SaO2 obtained
Treat SBP drops as necessary, but halt procedure if > 20% SBP drop despite pressors/fluids
Increase PIP as necessary
Maintain minute ventilation
Reduce RR before PIP increase since TV will increase
Pi will reach 55 cmH2O
Note maximum SaO2 obtained
Treat SBP drops as necessary, but halt procedure if > 20% SBP drop despite pressors/fluids
Maintain minute ventilation
Reduce RR before PIP increase since TV will increase
Reduce q3 minutes PEEP to 25 → 22.5 → 20 → 17.5 cmH2O
Remember that SpO2 monitor displays results up to 1-2 min after clinical change
Until:
Decrease in SaO2 of 1% from maximum SaO2 observed, which is the derecruitment point
OR minimum of 15 cmH2O PEEP reached
Decrease in SaO2 of 1% from maximum SaO2 observed, which is the derecruitment point
OR minimum of 15 cmH2O PEEP reached
Increase PEEP step-wise q2 minutes to 40 cmH2O again
Maintain PEEP at 40 cmH2O for 2 minutes
Return to PEEP level 2-4 cmH2O above<unk>  point
Adjust TV 4-6 cc/kg and plateau pressures < 30 cmH2O
Tolerate permissive hypercapnia if pH > 7.15
May increase RR up to maximum of 38 bpm
Lung recruitment maneuver
Pulmonary antibiotics
High frequency oscillation ventilation
Airway pressure release ventilation
Needle cricothyrotomy
Thoracic lavage
Mechanical ventilation 
Bag valve mask ventilation