Mechanical Ventilation Initiation/Setup Procedure Note

Date/Time of Ventilator Initiation: [Date and time]

Location: [ED / ICU / OR / transport / ward / procedural area / other]

Author/Role: [RT / MD / APP / other]

Encounter Context: [Encounter context] (Specify if post-intubation, transfer from another location, or assumption of ventilator care from another team, naming the source if applicable.)

[Brief banner summary stating that invasive mechanical ventilation was initiated or assumed, the primary indication, airway confirmation status, and that initial settings and alarms were verified] (Distinguish personally verified versus reported confirmation methods.)

(Safety-critical documentation rule: Do not omit airway size/depth, cuff pressure, placement verification method, ventilator mode, FiO2, PEEP, key alarm status, and initial SpO2 response. If any item is unknown at the time of documentation, explicitly state "unknown" and include the plan and timing to verify. Clearly label information as personally verified versus reported.)

Indication & Clinical Context

[Indication for invasive mechanical ventilation] (Select or state: hypoxemic respiratory failure, hypercapnic respiratory failure, airway protection, altered mental status, shock, procedural, or other.) [Working diagnosis or clinical syndrome]. [Immediate ventilatory goals including oxygenation target and ventilation target]. [Intubation context if relevant: who performed, where performed, difficult airway or complications reported, pre-ventilator status]. (If a separate intubation procedure note exists, reference it here.)

Airway Device & Verification

• Airway device type: [oral ETT / nasal ETT / tracheostomy / other]
• ETT/trach size (ID): [Size in mm]
• Depth marking: [Depth in cm at teeth/gums / cm at nare / stoma position reference]
• Securement: [Securement method and condition]
• Cuff management: [Cuff pressure in cm H2O measured by manometer]. [Air leak: present / absent]. [Corrective action if leak noted].
• Placement verification:
  • Personally verified now: [Verification methods and findings] (Include: waveform capnography/exhaled CO2 detected, bilateral chest rise, bilateral breath sounds, absence of epigastric sounds, ventilator waveforms consistent with tracheal placement.)
  • Reported by prior team: [Reported methods and findings]
  • Chest X-ray: [confirmed correct tracheal position / pending] (If pending, state interim verification methods and plan to confirm with imaging.)
• Unknown parameters and plan: [Any unknown airway details with specific plan and timing to verify] (Omit line if all parameters are known.)

Ventilator Mode & Initial Settings

• Patient sizing: Height [measured / estimated, with units], sex at birth [female / male / intersex / unknown], predicted body weight [PBW in kg] (State if system-calculated.)
• Ventilator and circuit: [Ventilator make/model], [circuit configuration], [humidification method: heated humidifier / HME]
• Mode and control settings:
  • Mode: [VC-AC / PC-AC / SIMV / PSV / PRVC / other]
  • Set respiratory rate: [breaths/min]
  • Set tidal volume: [mL] ([mL/kg PBW])
  • FiO2: [%]
  • PEEP: [cm H2O]
  • Inspiratory time or I:E ratio: [value]
  • Pressure support: [cm H2O / not applicable]
  • Trigger: [type and sensitivity]
• Observed baseline mechanics:
  • PIP: [cm H2O]
  • Plateau pressure: [cm H2O / not measured at initiation] (If not measured, state plan and timing to assess.)
  • Driving pressure: [cm H2O / not assessed]
  • Measured exhaled tidal volume: [mL]
  • Minute ventilation: [L/min]
  • Auto-PEEP: [cm H2O / not assessed]
• Clinical targets: SpO2 [target range] (note if adjusted for chronic hypercapnia/COPD), ventilation target [PaCO2 and/or pH goals, permissive hypercapnia if applicable], plateau pressure goal [if applicable]

Alarms & Safety Verification

• Alarm limits reviewed and individualized:
  • High pressure alarm: [cm H2O]
  • Low pressure/disconnect alarm: [verified functional: yes / no] [threshold if applicable]
  • Apnea alarm: [on / off] [apnea interval]
  • Minute ventilation alarm: [low/high limits]
• Bedside safety checks:
  • SpO2 monitor [functioning with adequate signal / issue noted]
  • ETCO2 monitoring [in place / not used] (If used, include current value or waveform quality.)
  • Suction [setup and functional / not available]
  • Bag-valve-mask with oxygen source [available at bedside / not available]
  • Humidification [functioning / issue noted]
  • Head-of-bed elevation [elevated to ≥30° / contraindicated / not applicable] (If contraindicated, state reason.)

Initial Physiologic Response

• Time of assessment: [Time from initiation or exact timestamp]
• Vitals: HR [bpm], BP/MAP [mmHg], RR [breaths/min]
• SpO2: [%] on FiO2 [%]
• ETCO2: [mmHg / not monitored]
• Patient-ventilator interaction: [Synchrony, tolerance, and comfort assessment]
• Breath sounds and chest rise: [Findings]
• Hemodynamic response to positive pressure: [none / hypotension / vasopressor initiation or adjustment]
• ABG: [Time obtained, pH, PaCO2, PaO2, actions taken based on results / not obtained] (If not obtained, state reason.)

Immediate Problems & Interventions

(Include this section only if problems occurred during or immediately after initiation. Use problem-oriented format.)

• [Problem name]: [Evidence including relevant signs, measurements, alarms, or waveforms]. [Actions taken]. [Response and current status].

(If no problems occurred, include only this line:) No immediate complications; patient tolerated initiation.

Prevention Measures

(Document VAP/VAE prevention bundle elements per local institutional protocol.)

• Head-of-bed elevation: [initiated / contraindicated / deferred / not applicable]
• Oral care: [initiated / contraindicated / deferred / not applicable]
• Sedation minimization plan: [initiated / contraindicated / deferred / not applicable]
• Ventilator liberation readiness assessment: [initiated / contraindicated / deferred / not applicable]
• Subglottic secretion drainage: [initiated / contraindicated / deferred / not applicable / tube type not equipped]

Plan

• Reassessment schedule: [ABG timing, plateau pressure and auto-PEEP assessment timing, FiO2 weaning plan, ventilator setting reassessment cadence]
• Pending imaging or verification: [Chest X-ray or other studies and timing]
• Consults/notifications: [Teams notified and purpose]
• Disposition: [Location, level of care, continuous monitoring parameters]

Complications

Complications: [None / list complications with actions taken and current status]

Attestation

• RT Attestation: [Ventilator setup completed, alarms verified and individualized, airway check completed and documented] (Edit to reflect tasks personally completed.)
• Provider Attestation (MD/APP): [Clinical indication confirmed, oxygenation and ventilation targets established, initial assessment and plan documented] (Edit to reflect provider actions.)
• Handoff/Assumption of Care: [Ventilator care assumed from team/location, prior settings reviewed, current settings personally verified, discrepancies identified and corrected] (Include only if assuming care from another team.)