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 no t adjust Mechanical ventilators per protocol. 2. Policy: A. The Mechanical Mechanical Ventilator Ventilator Management Management Protocol Protocol will only only be initiated 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 attending physician physician may write write “discontinu “discontinuee Vent Management Management Protocol” Protocol” (VMP) or discontinue RT Consult at any time. C. The physician does not need to be notified notified if: a. Weaning FiO2 b. Increa Increasin sing g FiO2 if if not going going great greater er than than 50% c. Increase Increase in PSV of 5 or less to maintain maintain adequat adequatee tidal tidal volume volume d. Changin Changing g in and out out of volume volume supp support ort 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 patient’s condition condition is deteriorati deteriorating. ng. c. The respirat respiratory ory therapi therapist st is unable unable to to determine determine appropri appropriate ate therapy. therapy. d. If the the FiO2 is >60% >60% and PaO2 < 60mmHg 60mmHg or SpO2 <90% <90% with with 5cmH20 5cmH20 PEEP. e. When pre-deter pre-determined mined therapy therapy limits limits are are reached, reached, i.e. FiO2, FiO2, Vt, PEEP, PEEP, RR, etc. etc. f. When When PEEP PEEP >5 is indi indica cate ted. d. g. If PEEP PEEP >5 has been been approved, approved, and and now PEEP PEEP >8 >8 is indicat indicated. ed. h. A RR >30 >30 or <8 is is indi indica cate ted d i. A VT >10 ml/ ml/kg kg ideal ideal body body weight weight or or < 6 ml/kg ml/kg is indi indicat cated. ed. j. If VT or PEEP is is indicated indicated that that results results in in PIP >=40 or platea plateau u pressure pressure >30. >30. k. We Wean anin ing g succe success ss or or fail failur uree l. Increa Increasin sing g FiO2 FiO2 above above 50% is is indica indicated ted to to maintai maintain n sats sats m. Change Change in PSV PSV >5 cmH2 cmH20 0 is made made n. A chang changee in tidal tidal volume volume is made made o. A change change in in respi respirat ratory ory rate rate is made made E. For continuous continuous monitor monitoring ing of ABG values, values, an arterial arterial line line should be introduce introduced, d, and/or the use of non-invasive monitoring (SpO2 & EtCO2)should be employed. Non-invasive monitoring is preferred.
F. Modify Modify ventilator ventilator settin settings gs as indicated indicated to mainta maintain in target values values.. G. Assure Assure the non-invasive non-invasive oxygen saturati saturation on (SpO2) and end tidal CO2 (EtCO2) (EtCO2) values correlate with current ABGs. H. If rate of >30 is is indicated, indicated, consider consider sedation sedation prior to to calling calling physician. physician. I. Maximum Maximum PIP PIP is determined determined by increas increasing ing PEEP PEEP in in increment incrementss of 1cmH20. Stop increasing when BP, HR, SpO2 drop, or PaO2/Fio2 PaO2/Fio2 Ratio =<200. If the PaO2/FiO2 ratio increases you know PEEP therapy is working. J. When conside considering ring the the adjustme adjustment nt of FiO2, FiO2, hemoglobin hemoglobin should 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 stabilization and management of the patient on mechanical ventilation: A. The following values will be maintained, unless otherwise ordered by physician. a. Ph: Ph: 7.35 7.35 to 7.45 7.45 b. PaCO2: 35 to 45 mmHg mmHg (EtCO2: (EtCO2: 30 to 50 mmHg), mmHg), unless unless the patients patients “usual” PaCO2 is chronically elevated. c. PaO2 PaO2:: 60 to 100 mmHg mmHg (SpO (SpO2 2 > 90%) 90%) d. In patients patients with with COPD, adjust adjust paramet parameters ers to the the patient’s patient’s “normal” “normal” values values B. Obtain ABG or non-invasive oxygen saturation saturation (SpO2) and end tidal CO2 CO2 C. Adjust Adjust the ventilato ventilatorr settings settings to correct correct abnormal abnormal ABG ABG and/or SpO2 SpO2 and EtCO2 EtCO2 values. a. Abnormal PaCO2 > 45 mmHg mmHg (EtCO2) (EtCO2) values: 1. Increase rate in increments of 2 to obtain acceptable values. values. 2. Increase Tidal Volume by increments of 50ml to obtain acceptable values b. Abnorma Abnormall PaCO2 PaCO2 <35 <35 mmHg mmHg (EtCO2 (EtCO2)) values 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 SpO2 <90%, increase FiO2 in increments increments of 05% to obtain acceptable values. 2. For hypoxia hypoxia (Sa02<9 (Sa02<92%) 2%) requiri requiring ng >60% Fi02, Fi02, increas increasee PEEP in steps steps of 1 cmH20 at a time to PEEP max (Specific Dr. order required) 3. If hypoxia hypoxia persist persistss at PEEP PEEP max, max, increase increase the Fi02 Fi02 in steps of 05% until until 100% is reached or Sp02 > 92%. 4. For Sp02 >92% at PEEP PEEP maximum, Fi02 is first reduced in steps 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 PEEP =>5 =>5 & PaO2 > 100 mmHg mmHg or Spo2 Spo2 > 95%, 95%, decrease decrease FiO2 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, Fi02, increase the Fi02 to the the previous setting. Continue weaning the Fi02 as tolerated by patient. D. Non-invasiv Non-invasivee monitoring monitoring or ABG ABG criteria criteria is not not the absolute absolute control control for for maintaining Ventilatory Ventilatory support. Sudden changes in cardiovascular cardiovascular status, respiratory rate, and color may mandate a chang e in ventilator parameters. E. Once patient is stabilized, 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 assessm assessment ent will will be performed performed within within 15-45 15-45 minutes minutes from from start start of ventilation. b. Assessment Assessment will will include include evaluatio evaluation n of the patient’s patient’s general general appearan appearance, ce, blood pressure, heart rate, breath sounds, ventilating pressures, volumes and ABGs. c. Assessment Assessmentss may also also include include additi additional onal data, data, when availab available, le, such as EtCO2 EtCO2 and hemodynamic data. d. All ther therapy apy wil willl be docume documente nted d in Medite Meditech. ch. B. Re-assessments a. Regular Regular assessment assessment of of general general appearance, appearance, vital vital signs, signs, breath breath sounds sounds and and Hemodynamic stability should be evaluated prior to and during any ventilator adjustment. B. Adjustments of the patient’s patient’s therapy will be determined objectively by changes in the monitored parameters. 5. References: 1. Mechanical Ventilator Protocol, Retrieved Retrieved from: http://rtcorner.net/rt_forms.htm and http://rtcorner.net/rt_forms.htm 2. Mechanical Ventilator Protocols, Retrieved Retrieved from: http://www.aarc.org/resources/protocol_resources/documents/general_vent.pdf 3. CTICU Weaning Protocol, retrieved 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