vent protocol

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Ventilator Management Protocol of the Adult Medical Patient

Version 16 - March 5, 20

Sutter Health Sacramento Sierra RegionVersion 16 (3/5/08)Developed: 2007

Approved: 2008


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Ventilator Parameters Protocol:

Pulse Oximetry, continuous

Capnography, continuous

Correlate PetCO2 with ABG; if the difference between PaCO2 and PetCO2 is less than or equal to 10 mm Hg, use

the PetCO2 values to adjust the minute volume. Subglottic suctioning every four hours (assess every two hours) or may use the Hi/Low Evac ET tube

Mechanical ventilator settings: PRVC (SIMV+PC/PS when PRVC not available) Mechanical VT of 6-8 ml/kg of predicted body weight Spontaneous VT of 6-8 ml/kg of predicted body weight Mechanical Respiratory Rate: 10-14/minute Call MD if Pplat greater than or equal to 30 cm H2O PEEP/CPAP of 5 cm H2O initially FiO2 and PEEP: Adjust to maintain SpO2 at or above 92%. Increase FiO2 first to maintain SpO2 at or above 92%. For FiO2 0.5 and 5 cm H2O PEEP, increase PEEP in 2-3 cm H2O increments to a high of 15 cm H2O

unless hemodynamically unstable

Assess for Auto PEEP upon initiation of the ventilator and at the beginning of every shift. If Auto PEEP is detecteassess Auto PEEP level every two hours with ventilator monitoring.

Obtain ABG within 30 minutes of initial ventilator settings (point of care testing may be utilized if available); repeatABGs after 30 minutes when there is a change of patient or ventilator status

After 30 minutes Maintain SpO2 at or above 92% using above parameters Adjust minute volume to keep pH 7.30 to 7.45 and PaCO2 30-50 cm H2O

Obtain chest radiograph for tube placement

If PaO2/FiO2 ratio between 200-300, contact MD for lung protective strategies to manage the ventilator.

If PaO2/FiO2 ratio less than 200, contact MD, discontinue this ventilator management protocol and obtain newventilator orders.

Perform comprehensive respiratory assessment, including success indications for ventilator discontinuance.

If hemodynamic stability is in question, discuss with RN and MD. If aerosol bronchodilators or aerosol steroids indicated, deliver aerosol medications every 4 hours and every 2

hours prn. Indications for sympathomimetic bronchodilator therapy are

Wheezing/Bronchospasm Asthma/Reactive Airways Disease Chronic Obstructive Pulmonary Disease

If inhaled sympathomimetic bronchodilator are indicated, give every 4 hours and every 2 hours prn. 2.5 mg of Albuterol (strength=0.083%) unit dose, or 4 puffs Albuterol MDI

Indication for anticholinergic bronchodilator therapy is Chronic Obstructive Pulmonary Disease Asthma Exacerbation If inhaled anticholinergic bronchodilator is to be added, give every 4 hours and every 2 hours prn:

0.5 mg of Ipratropium Bromide (Atrovent) (hold for allergyto peanuts or soy) unit dose, or 4 puffsIpratroprium Bromide MDI OR

4 puffs Combivent MDI If the patient has a 20% increase in heart rate, tremors, or is currently taking Levalbuterol (Xopenex) at hom

Replace Albuterol with 1.25 mg Levalbuterol (Xopenex)

If suctioned secretions are increased or exhibit a change of color from normal, collect a sputum culture.

If indications for ventilator discontinuance are met, perform spontaneous evaluation criteria BID.

If patient is nasally intubated, arrange for tube replacement to an oral ET Tube.

When spontaneous evaluation criteria are met, begin Ventilator Discontinuance Protocol.


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Patient Care Parameters

Elevate head of bed greater than or equal to 30 degrees unless contraindicated. IV Access

Perform neurological assessment (GCS-motor-pupils) every 4 hours regardless of sedation Implement pain and sedation protocol

Assess for restraints and obtain daily MD order if needed

OG tube

Foley Implement Glucose Control Protocol

Deep Venous Thrombosis prophylaxis: TEDs/SCDs Oral care every 2 hours

Turn patient every 1-2 hours

Provide Awakening Trial in conjunction with respiratory spontaneous evaluation criteria

Perform neurological assessment and Glasgow Coma Scale evaluation at the time of Awakening Trail Obtain nutrition consult

RN to call e-ICU physician for evaluation if no critical care-privileged physician with ventilator managementprivileges is available at bedside within 2-hours.

Laboratory / Diagnostic Testing

Obtain daily chest x-ray

Measure initial blood glucose on admit If


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Pain and Sedation Protocol:

Nursing Assessment:

Assess the need for analgesia and/or sedation. Rule out and correct reversible causes.

If there is a need for analgesia or sedation, assess patient for contraindications.

If not contraindicated and the patient has a need for pain control, follow the analgesia guidelines below. If not contraindicated and the patient has a need for sedation, follow the sedation/delirium guidelines.

Analgesia Guidelines:

Assess pain hourly; score will be documented using a scale of 0-10 (numeric, FLACC, or PAINAD scales). Fentanyl gtt 25 mcg/hr titrate by 5mcg/hr every 5 minutes to comfort (MAX 200 mcg/hr).

Once patient extubated, discontinue fentanyl drip. Initiate additional pain management interventions perphysician orders.

Sedation Guidelines:

Assess sedation hourly using the RASS sedation scale (RASS goal 0 to 1)

Acute sedat ion(less than 72 hours):o Propofol drip 5mcg/kg/min titrate every 2 to 5 minutes by 5mcg/kg/min (MAX 50mcg/kg/min).o If sedation is not achieved at 50mcg/kg/min of propofol add midazolam drip in addition to propofol.

Give midazolam 2mg IV every10 minutes until RASS/sedation goal achieved then begin thedrip at the total bolus dose given (i.e. 6mg total bolus dose given=6mg/hr drip rate MAX10mg/hr).

Perform a sedation holiday (awakening trial) as described below.o Note: maximum propofol use is 72 hours in non-neuro patients.o Triglyceride level 48 hours from the start of propofol.o Discontinue propofol and midazolam once extubated.

Ongoing sedation (greater than 72 hours):o Discontinue propofol and transition to midazolam drip 2-10mg/hr (dosing as described above).o

Note: Neuro patients with ongoing sedation will be continued on propofol.o Perform sedation holiday (awakening trial) as described below.o Discontinue midazolam once extubated.

SEDATION HOLIDAYS (AWAKENING TRIALS):

If patients RASS score is 0 to 1 no need to perform sedation holiday (awakening trial).

RN and RCP to co-ordinate awakening trials unless contraindicated (i.e. patients on a neuromuscularblocker, elevated intracranial pressures, significantly elevated airway pressures etc.).o Midazolam drip- stop dripo Propofol drip- decrease rate by 5mcg/kg/min every 2 to 5 minutes until able to follow commandso Fentanyl drip- decrease rate by 50 percent or as toleratedo Once neurologic exam is achieved, begin drips only if sedation/analgesia is still required

Fentanyl gtt titrate by 5mcg/hr every 5 minutes to comfort Midazolam rebolus with 2mg of midazolam every 10 min until RASS goal achieved, then begin

the drip based on the total bolus dose given Propofol gtt titrate by 5mcg/kg/min every 2 to 5 minutes to desired RASS goal

Delirium Guidelines:

Assess for delirium using CAM-ICU assessment tool if unable to sedate to RASS < -2.

If delirium present, contact physician for consideration of Haldol.


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Ventilator Discontinuance Protocol:

When the patient has successfully passed the spontaneous evaluation cr iteria, the rapidventilator discontinuance protocol can be initiated.

Success Indicators :Systolic blood pressure between 90-180 mm Hg.Heart rate less than 140 beats/minute and no more than a 20% changeNo increased anxietySpO2 greater than or equal to 92%Respiratory rate less than or equal to 35/minute and no more than a 50% change.

Conduct initial spontaneous breathing trial (SBT) for 30 minutes total. Parameters:o CPAP for 5 minuteso FiO2 less than or equal to 0.5o Assess for success indicators at the 5 minute mark. If not successful, return to initial ventilator setting

and attempt trial in 4 hours. If successful, continue for an additional 25 minutes (30 minutes total).

Patient should be hemodynamically stable. RCP and RN communication to verify hemodynamic stability.

If patient exhibits increased anxiety, consider T-mist at FiO2 of 0.5. Continue to assess for success indicatorsthroughout the entire protocol.

Obtain ABG (or Point of care testing for SMH) after initial 30 minute trial and 30 minutes after any change in patienstatus.

If patient passes the trial, contact physician with ABG results for extubation.

If patient does not pass, return to the previous ventilator settings for a 3-4 hour rest. Then place on the followingparameters:

o PS/PEEP for 30 minuteso PEEP of 5 cm H2Oo PS to maintain VT of 6-8 mL/Kg of predicted body weighto Maximum inspiratory pressure of 20 cmH2O (Press Support +PEEP)

Assess for success indicators. If not successful, return patient to initial ventilator settings and attempt trial in 3-4hours. If successful, leave patient on parameters and extend to 1 hour.

Assess for success indicators. If not successful, return patient to initial ventilator settings and attempt trial in 3-4hours. If successful, place on the following parameters:

o CPAP for 30 minuteso CPAP of 5 cmH2Oo T-mist if patient exhibits increased anxiety

Assess for success indicators. If not successful, return patient to PS/PEEP settings and attempt CPAP trial in 3-4hours. If successful, contact physician for extubation orders.

NOTE: If patient fails multiple aggressive attempts to discontinue from the ventilator with PS/PEEP settings and/or

SBTs, due to chronic disease process, contact the physician to create a modified discontinuance plan for care.


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200Version 16 - March 5,

Follow ARDSNetworkProtocol

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ARDS / ALI Lung Protective Strategies Protocol

October, 2007 Version 16

Ventilator Settings:PRVC (AC when PRVC not available)

Mechanical VT 6-8 ml/kg predicted body weightAdjust VT to maintain Plateau Pressure less than or equal to 30 cm H2O

Resp Rate not to exceed 35 bpm

PEEP of 5 cm H2OAdjust VT and Resp Rate to achieve pH between 7.30 7.45; increase or decrease VTin 1 ml/kg steps with a minimum 4 ml/ikg, maximum of 8 ml/hrRepeat ABG 30 minutes after a change in ventilator or patient status

pH Goal 7.30 7.45: Incrementally manage VT and Resp

Rate to achieve goalAcidosis Management:

If pH 7.15 7.30: Increase resp rate until pH greaterthan 7.30 or PaCO2 less than 25; maximum resp rateof 35/minuteIf pH less than 7.15: Increase resp rate to 35/min. IfpH remains less than 7.15 and Bicarb is considered orinfused, VT may be increased in 1 ml/kg steps until pHgreater than 7.15. Contact MD if Plateau Pressureneeds to be increased above 30 cmH2O to obtainventilator settings

Alkalosis management; pH greater than 7.45

First target VT to 6 ml/kg and then decrease resp rate

Oxygenation Goal: PaO2 55-80 mm Hg or

SpO2 88-95%Incrementally manage FiO2 and PEEPto achieve goal

If FiO2 less than .5 and PEEP of 5cmH2O: Increase FiO2 first in 0.1increments to achieve goalIf FiO2 greater than .5 and PEEP of 5cmH2O: increase PEEP first in 2-3 cm

H2O increments first to achieve goal toa high of 15 cm H2O (unlesshemodynamically unstable)

Estimated settings for PEEP is FiO2/5.If requirements for PEEP exceeds 15cmH2O, then call the MD.

Go toParameters

ProtocolPage

Plateau Pressure Goal: less than or

equal to 30 cm H2O

If Pplat greater than 30 cmH2O,decrease VT by 1 ml/kg steps(minimum of 4 ml/kg). lIf Pplat less than 25 cm H2O and VTless than 6 ml/kg, increase V by 1 ml/kg until Pplat greater than 25 cm H2Oor VT equals 6 ml/kg.If Pplat less than 30 and breathstacking occurs, may increase VT in 1ml/kg increments (maximum of 8 ml/kg).


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ARDS Lung Protection Strategies Protocol:

Mechanical Ventilator Settings:

o PRVC (or AC when PRVC is not available)o Mechanical VT 6 ml/kg predicted body weighto Adjust VT to maintain Pplat less than or equal to 30 cm H2Oo Respiratory Rate not to exceed 35 bpmo PEEP of 5 cm H2Oo Adjust VT and respiratory rate to achieve pH between 7.30 7.45; increase or decrease VT in 1 ml/kg steps with

a minimum of 4 ml/kgo Repeat ABG 30 minutes after a change in ventilator or patient status

pH Goal 7.30 7.45: incrementally manage VT and respiratory rate to achieve goalAcidosis Management:

o If pH 7.15 7.30: Increase respiratory rate until pH greater than 7.30 or PaCO2 less than 25; maximumrespiratory rate of 35/minute.

o If pH less than 7.15: Increase respiratory rate to 35/minute. If pH remains less than 7.15 and Bicarb isconsidered or infused, VT may be increased in 1 ml/kg steps until pH greater than 7.15. Contact MD if Pplatneeds to be increased above 30 cmH2O to achieve the above goals.

Alkalosis Management:o First target VT to 6 ml/kg and then decrease respiratory rate.

Oxygenation Goal: PaO2 55-80 mm Hg or SpO2 88-95%o Incrementally manage FiO2 and PEEP to achieve goal.o If FiO2 less than 0.50 and PEEP of 5 cm H2O: Increase FiO2 first in 0.1 increments to achieve goal.o If FiO2 greater than 0.50 and PEEP of 5 cmH2O: Increase PEEP first in 2-3 cm H2O increments to achieve goa

Do not increase PEEP above 15 cm H2O.

Pplat Goal: Less than or equal to 30 cm H2Oo

If Pplat greater than 30 cm H2O, decrease VT by 1 ml/kg steps (minimum of 4 ml/kg).o If Pplat less than 25 cm H2O and VT less than 6 ml/kg, increase VT by 1 ml/kg until Pplat greater than 25 cm H2Oor VT equals 6 ml/kg.

o If Pplat less than 30 and breath stacking occurs, may increase VT in 1 ml/kg increments (maxiumum of 8 ml/kg)


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Discontinuing Ventilation on Difficult Patients Who Have Failed MultipleDiscontinuance Attempts:

NOTE:

Some patients can successfully pass spontaneous evaluation criteria, but because of multiple other systemcomplications (COPD, Asthma, Sepsis, etc.), a SLOW ventilator discontinuance protocol may be preferred. If thepatient is not tolerating the rapid ventilator discontinuance protocol but meets the spontaneous evaluation criteria,continue with the slow discontinuance strategy:

Place patient on SIMV with PS/PEEP with the following parameters:o PEEP of 5 cm H2Oo PS to maintain VT of 6-8 mL/Kg of predicted body weight.o Maximum inspiratory pressure of 20 cmH2O (Pressure support +PEEP)

Decrease respiratory rate by 2/minute every 2-6 hours.

Assess for success indicators. If not successful, return patient to previous respiratory rate for 4 hours and thencontinue decreasing respiratory rate. If successful, continue decreasing respiratory rate by 2/minute every 2-6

hours until respiratory rate is 4/minute as long as success indicators are met. When set respiratory rate is at 4/minute, place patient on PS/PEEP for 30 minutes (or T-mist trial if patient exhibits

increased anxiety).

Assess for success indicators. If not successful, return to previous settings for 4-6 hours. If successful, contactphysician for extubation orders.


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Ventilator Parameters and Ventilator Discontinuance Citings

The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidalvolumes for acute lung injury and the acute respiratory distress syndrome. N Eng J Med. 2000; 342:1301-1307.

ARDS Network General Protocol Guidelines, Accessed Internet J une 20, 2006:www.ardsnet.org.

Ely EW, Bennett PA, Bowton KL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a resp therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999; 159:439-446.

Ely EW, Baker AM, Evans GW, Haponik EF. The prognostic significance of passing a daily screen of weaning parameters,Intensive Care Medicine. 1999;25:581-587.

Ely EW, Baker AM, Dunagan DP, et al: Effect on the duration of mechanical ventilation of identifying patients capable ofbreathing spontaneously. N Engl J Med, vol 335:1864-9, 1996.

El-Khatib, M, J amaledding, G, Khoury, Obeid, M: Effect of continuous positive airway pressure on the rapid shallow breathiindex in patients following cardiac surgery. Chest. 121:475-479, 2002.

Epstein, S. Weaning from Mechanical Ventilation. Respiratory Care, 2002:47(4); 454-468.

Esteban A, Alia I. Clinical management of weaning from mechanical ventilation. Intensive Care Medicine. 1998;24:95-1008.

Hurford, W. Sedation and Paralysis During Mechanical Ventilation. Respiratory Care, 2002:47(3); 334-246.

Kallet, R, Campbell, A, Dicker, A, Katz, J , Mackersie, R. Work of Breathing during lung-protective ventilation in patients withacute lung injury and acute respiratory distress syndrome: A comparison between volume and pressure-regulated breathing

modes. Respiratory Care 2005:50(12); 1623-1631.

Kress, J P, Pohlman, Oconnor, MF, Hall J B. Daily interruption of sedative infusions in critically ill patients undergoingmechanical ventilation. N Eng J Med 2000; 342: 1471-1477.

Krishnan, J , Moore, D, Robeson, C, Rand, C, Fessler, H. A prospective, controlled trial of a protocol-based strategy todiscontinue mechanical ventilation. Am J Respir Crit Care Med. 2004 169:673-678.

Kuhlen, R, Rossaint, R. The role of spontaneous breathing during mechanical ventilation. Respiratory Care, 2002:47(3);296-303.

MacIntyre, NR. Setting the Frequency-Tidal Volume Pattern. Respiratory Care, 2002:47(3); 266-278.

MacIntyre NR, Cook J F, Ely EW J r, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: acollective task force facilitated by the American College of Chest Physicians; the American Association of Respiratory Care;and the American College of Critical Care Medicine. Chest. 2001;120(6suppl):375S-395S.

Meade, M, Guyatt, G, Cook, D. Weaning from Mechanical Ventilation: The Evidence from Clinical Research. RespiratoryCare, 2001:46(12); 1408-1415.
http://www.ardsnet.org/http://www.ardsnet.org/


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Ventilator Parameters and Ventilator Discontinuance Citings (continued)

Pierson, D.: Indications for mechanical ventilation in Adults with Acute Respiratory Failure. Respiratory Care, 2002:47(3);249-265.

Saura, P, Blanch, L. How to Set Positive End-Expiratory Pressure. Respiratory Care, 2002:47(3); 279-292.

Yang, KL, Tobin, MJ : A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilatioN Engl J Med. 1991 May 23;324(21):1445-50

ARDS Network General Protocol Guidelines,www.ardsnet.org

Pain & Sedation Citings

Ely, E. Wesley et al. Monitoring Sedation Status Over Time in ICU Patients. J AMA, J une 11, 2003; 29983-2991


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Glossary:

VT: Tidal Volume

Pplat: Plateau Pressure

PetCO2: End-tidal Expired CO2PEEP: Positive End Expiratory Pressure

All references to weight measurements for titration of VT should be reflective ofpredicted body weight.

Formula:

Males: 2.3[height in inches-60] + 50Females: 2.3[height in inches-60] + 45.5

Placard on every ventilator with PBW:

ManHeight(inches)

62 64 66 68 70 72 74 76 78 80

PredictedBodyWeight(kg)

54.6kg 59.2kg 63.8kg 68.4kg

73kg 77.6kg 82.2kg

86.8kg

91.4kg 96kg

WomanHeight(inches)

54 56 58 60 62 64 66 68 70 72

PredictedBodyWeight(kg)

31.7kg 36.3kg 40.9kg 45.5kg 50.1kg 54.7kg 59.3kg 63.9kg 68.5kg 73.1kg

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