Ventilator Management Note (Critical Care)

Date/Time: [date and time of assessment]

Author/Service: [physician/APP/RT and service]

Location: [ICU/unit and bed]

Clinical Context

[One- to two-sentence respiratory problem statement specifying indication for ventilatory support: hypoxemic failure, hypercapnic failure, airway protection, work of breathing]

Airway: [ETT / tracheostomy]; Placed: [date]; Days on MV: [number]; Position: [ETT depth at teeth/lip or trach position]; Cuff: [inflated / deflated / cuff leak present / cuff leak absent] (Include cuff status only if relevant to extubation planning.)

Modifying comorbidities: [conditions affecting today's ventilator targets or strategy, e.g., COPD with chronic hypercapnia, pulmonary hypertension, intracranial pathology, neuromuscular weakness / none] (Omit routine history not affecting current management.)

Ventilator Status

Mode & Settings: [ventilator mode]; FiO2 [value]%; PEEP [value] cm H2O; [additional mode-specific settings: set RR, VT or pressure target, PS, I-time as applicable] (Use compact semicolon-separated format; include only settings relevant to current mode.)

Measured: Total RR [value] bpm; MV [value] L/min; Exhaled VT [value] mL; PIP [value] cm H2O; Plateau [value cm H2O / not measurable—state reason]; Driving pressure [value] cm H2O (If plateau cannot be obtained, state why rather than omitting.)

Lung Protection: PBW [value] kg (height [value], sex [M/F]); VT = [value] mL/kg PBW (Document for ARDS or lung-protective ventilation. If height unavailable: "PBW not calculated—height not recorded; please measure.")

Oxygenation: SpO2 [value]% on FiO2 [value]% and PEEP [value] cm H2O; ABG PaO2 [value] mmHg at [timestamp] (if available). Target: [individualized SpO2 and/or PaO2 range].

Ventilation: pH [value], PaCO2 [value] mmHg at [timestamp] [or EtCO2 trend if ABG unavailable]. Target: pH [range], PaCO2 [goal] [with permissive hypercapnia strategy if applicable].

Patient–Ventilator Assessment

• Work of breathing/comfort: [accessory muscle use / tachypnea / air hunger / agitation / comfortable and synchronous]
• Synchrony: [synchronous / dyssynchrony present: type and supporting observations] (If dyssynchrony, note suspected mechanism.)
• Secretions/airway: [burden and impact] (Include only if clinically significant.)
• Sedation: [RASS / SAS] [score] at [time]; Target: [goal range]; [NMB status if applicable]
• SAT: [performed—tolerated or failed with reason / not performed—specific contraindication]
• SBT: [meets criteria / not ready—limiting factors]. If attempted: [method, duration, FiO2/PEEP, outcome, failure reason if applicable]. If passed: [airway protection assessment and post-extubation plan].

Assessment

[Two- to five-sentence synthesis: why the patient needs ventilatory support today; whether oxygenation and ventilation are at target; whether lung protection is achieved; liberation candidacy and key barriers or facilitators] (Write as concise narrative; do not copy forward prior assessments without updates.)

Plan

• Oxygenation: [FiO2/PEEP changes or maintain current] with [rationale and monitoring plan]
• Ventilation: [RR/VT/pressure adjustments] with [rationale]; [permissive hypercapnia parameters if applicable]; [next gas check timing]
• Synchrony/Sedation: [ventilator adjustments for synchrony] and [sedation plan to achieve target]; [NMB plan if applicable]
• Liberation: [SAT/SBT timing for tomorrow]; [extubation criteria]; [post-extubation support]. If not a candidate: [what must improve and reassessment timing]
• Contingencies: [actions if worsening]; [weaning steps if improving]

(Document data gaps with reason and plan to obtain. Omit VAP bundle unless deviation affects vent management. Omit critical care time attestation unless provided.)