Modifying ventilator settings based on arterial carbon dioxide (PaCO2) levels

14th Jan 2021

Now that we’ve set our patient on acceptable initial settings, it’s time to determine whether those initial settings provide adequate ventilation and oxygenation. 

First, we’ll assess for adequate ventilation (we’ll assess for adequate oxygenation in the next article).


How do I know if my patient is adequately ventilating?

One of the primary ways to assess the appropriateness of the initial settings is to analyze an arterial blood gas (ABG). An ABG test should be routinely ordered after the initial placement of the patient on a ventilator and each time any significant changes to settings have been made, in order to assess whether or not the ventilator settings are appropriate.

Remember, ventilation is the removal of carbon dioxide (CO2), and we can assess if our settings are providing adequate removal of CO2 by analyzing the arterial carbon dioxide levels, or PaCO2 , on the ABG.

Let’s suppose—for a hypothetical patient on a tidal volume (VT) of 400 mL and a respiratory rate (RR) of 15 breaths / min (i.e., a minute ventilation of 6 L / minute)—that the ABG results came back and the PaCO2 was 70 mmHg. Well, because an acceptable PaCO2 is generally anywhere between 35 and 45 mmHg, we would have to conclude that our set minute ventilation is not adequately removing CO2. Our patient is being hypoventilated or under-ventilated. 


Figure 1. To assess for adequate ventilation, or removal of CO2, check the patient’s arterial carbon dioxide levels (PaCO) on an arterial blood gas (ABG). Then adjust the minute ventilation—by increasing or decreasing the tidal volume (VT) or respiratory rate (RR) on the ventilator—accordingly.

So, what would you recommend? Well, the answer should be clear—we’ll need to remove ­­­­­more CO2. And this increase in ventilation can only be achieved by increasing the amount of minute ventilation—in other words, increasing the tidal volume, respiratory rate, or both.

So let’s say we’ve made the adjustment to increase minute ventilation by increasing the tidal volume to 500, and we ordered another ABG. Now the PaCO2 is 30 mmHg. What would you do?  

Table of PaCO2 results, interpretation, and recommendation.

Figure 2. Assessing adequate ventilation with PaCO2 from an arterial blood gas (ABG)—a table of results, their interpretation, and recommended course of action.

Now, the PaCO2 falls below the acceptable PaCO2 range (35–45 mmHg), and our patient is being hyperventilated, or over-ventilated. In other words, our settings are causing this patient to remove too much CO2. So, we should decrease the minute ventilation, which means we should decrease the tidal volume, respiratory rate, or both. This time, we’ll adjust the RR—we’ll reduce it from 15 to 10 breaths / min.



And, after reducing the minute ventilation, the ABG comes back and the PaCO2 is 41 mmHg, which is well within our acceptable range for PaCO2, meaning our minute ventilation setting of a VT of 500 mL and RR of 10 breaths / min, produced a desirable ventilation of CO2 and no further change is necessary.

So now that we know how to assess for adequate ventilation and the controls that would need to be adjusted, let’s turn our attention to assess for adequate oxygenation.

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Recommended reading

  • Esteban, A, Ferguson, ND, Meade, MO, et al. 2008. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 177: 170–177. PMID: 17962636
  • Hess, D. 2001. Ventilator modes used in weaning. Chest. 120: 474S–476S. PMID: 11742968
  • Tobin, MJ and Lodato, RF. 1989. PEEP, auto-PEEP, and waterfalls. Chest. 96: 449–451. PMID: 2670461
  • NIH NHLBI ARDS Clinical Network. 2021. Mechanical ventilation protocol summary. NHLBI ARDS Network.