Mechanical Ventilator Management Protocol

Ventilator Respiratory Therapy Consult Ventilator Management Protocol Respiratorytherapycave.blogspot.com 1. Scope: A Licensed Registered Respiratory Therapist (RRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Certified Respiratory Therapists, respiratory students and assistants may not adjust Mechanical ventilators per protocol. 2. Policy: A. The Mechanical Ventilator Management Protocol will only be initiated on patients ordered on Vent Management Protocol (VMP), or if the attending physician orders RT Consult on a mechanically ventilated patient. B. The attending physician may write “discontinue Vent Management Protocol” (VMP) or discontinue RT Consult at any time. C. The physician does not need to be notified if: a. Weaning FiO2 b. Increasing FiO2 if not going greater than 50% c. Increase in PSV of 5 or less to maintain adequate tidal volume d. Changing in and out of volume support D. The physician will be notified when: a. The respiratory therapist wishes to initiate VMP on a patient who is not Currently on the protocol b. If the patient’s condition is deteriorating. c. The respiratory therapist is unable to determine appropriate therapy. d. If the FiO2 is >60% and PaO2 < 60mmHg or SpO2 <90% with 5cmH20 PEEP. e. When pre-determined therapy limits are reached, i.e. FiO2, Vt, PEEP, RR, etc. f. When PEEP >5 is indicated. g. If PEEP >5 has been approved, and now PEEP >8 is indicated. h. A RR >30 or <8 is indicated i. A VT >10 ml/kg ideal body weight or < 6 ml/kg is indicated. j. If VT or PEEP is indicated that results in PIP >=40 or plateau pressure >30. k. Weaning success or failure l. Increasing FiO2 above 50% is indicated to maintain sats m. Change in PSV >5 cmH20 is made n. A change in tidal volume is made o. A change in respiratory rate is made E. For continuous monitoring of ABG values, an arterial line should be introduced, and/or the use of non-invasive monitoring (SpO2 & EtCO2)should be employed. Non-invasive monitoring is preferred.

F. Modify ventilator settings as indicated to maintain target values. G. Assure the non-invasive oxygen saturation (SpO2) and end tidal CO2 (EtCO2) values correlate with current ABGs. H. If rate of >30 is indicated, consider sedation prior to calling physician. I. Maximum PIP is determined by increasing PEEP in increments of 1cmH20. Stop increasing when BP, HR, SpO2 drop, or PaO2/Fio2 Ratio =<200. If the PaO2/FiO2 ratio increases you know PEEP therapy is working. J. When considering the adjustment of FiO2, hemoglobin should be checked to ensure the absence of anemia. Hemodynamic data should be checked to ensure adequate circulation. 2. Ventilator Management Protocol: The following are guidelines for use in stabilization and management of the patient on mechanical ventilation: A. The following values will be maintained, unless otherwise ordered by physician. a. Ph: 7.35 to 7.45 b. PaCO2: 35 to 45 mmHg (EtCO2: 30 to 50 mmHg), unless the patients “usual” PaCO2 is chronically elevated. c. PaO2: 60 to 100 mmHg (SpO2 > 90%) d. In patients with COPD, adjust parameters to the patient’s “normal” values B. Obtain ABG or non-invasive oxygen saturation (SpO2) and end tidal CO2 C. Adjust the ventilator settings to correct abnormal ABG and/or SpO2 and EtCO2 values. a. Abnormal PaCO2 > 45 mmHg (EtCO2) values: 1. Increase rate in increments of 2 to obtain acceptable values. 2. Increase Tidal Volume by increments of 50ml to obtain acceptable values b. Abnormal PaCO2 <35 mmHg (EtCO2) values: 1. Decrease rate in increments of 2 to obtain acceptable values. 2. Decrease Tidal Volume by increments of 50ml to obtain acceptable values. c. Abnormal PaO2/SpO2 values: 1. PaO2 <60 mmHg or SpO2 <90%, increase FiO2 in increments of 05% to obtain acceptable values. 2. For hypoxia (Sa02<92%) requiring >60% Fi02, increase PEEP in steps of 1 cmH20 at a time to PEEP max (Specific Dr. order required) 3. If hypoxia persists at PEEP max, increase the Fi02 in steps of 05% until 100% is reached or Sp02 > 92%. 4. For Sp02 >92% at PEEP maximum, Fi02 is first reduced in steps of 05% until <= 60%, then PEEP is reduced in steps of 1 to a minimum of 5 before further reduction in Fi02.

5. With PEEP =>5 & PaO2 > 100 mmHg or Spo2 > 95%, decrease FiO2 in increments of 05% to obtain acceptable values. 6. If the SpO2 or PaO2 is not adequate after any weaning attempt of the Fi02, increase the Fi02 to the previous setting. Continue weaning the Fi02 as tolerated by patient. D. Non-invasive monitoring or ABG criteria is not the absolute control for maintaining Ventilatory support. Sudden changes in cardiovascular status, respiratory rate, and color may mandate a change in ventilator parameters. E. Once patient is stabilized, and once the problem that resulted in the need for Ventilatory support has been resolved, the patient should be continuously monitored for indications for weaning (See Ventilator Weaning Protocol). 4. Documentation: A. Initial assessment a. An RT assessment will be performed within 15-45 minutes from start of ventilation. b. Assessment will include evaluation of the patient’s general appearance, blood pressure, heart rate, breath sounds, ventilating pressures, volumes and ABGs. c. Assessments may also include additional data, when available, such as EtCO2 and hemodynamic data. d. All therapy will be documented in Meditech. B. Re-assessments a. Regular assessment of general appearance, vital signs, breath sounds and Hemodynamic stability should be evaluated prior to and during any ventilator adjustment. B. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters. 5. References: 1. Mechanical Ventilator Protocol, Retrieved from: http://rtcorner.net/rt_forms.htm and http://rtcorner.net/rt_forms.htm 2. Mechanical Ventilator Protocols, Retrieved from: http://www.aarc.org/resources/protocol_resources/documents/general_vent.pdf 3. CTICU Weaning Protocol, retrieved from: http://www.dhmc.org/webpage.cfm? site_id=2&org_id=116&morg_id=0&sec_id=0&gsec_id=5560&item_id=7386