Mechanical Ventilation Algorithms Flashcards
Consider Extubation When
RR > 40 with a set RR= 20 bpm AND
Vt= 4ml/kg with PIP <18 cmH2O AND
MAP 7-8 cmH2O AND
FiO2 <0.30 AND
Patient breathign comfortably, hemodynamically stable, no significant increase in TcPCO2, EtCO2 for 1 hour prior to extubation
How to Prepare for Extubation
Optimize caffine
Prepare for minimial handling 1 hours propr to extubation
Once the extubation order to reciveved the goal is to have the infant extubation within 60 min
Once extubated fo to CPAP alogirithm
Criteria for Possible HFV
You only need one of these but will probably have more than one
RR > 80 bpm
Vt >5ml/kg
PIP >25 cmH2O
MAP >12 cmH2O AND FiO2 >0.40
Considerations Before moveing to HFV
Consider reason for tachypnea
Ensure surfactant and PEEP have been optimized
Do CXR
Do ABG
Rule out PPHN
Convenctional Mechanical Ventilation
Infants = 32 Weeks 1st Week of Life
Principals
Intubated by senior practictioner and less than 28 weeks
- For infants who are = 32 weeks focus on volume targeted modes
- A/C Volume Guarenteed
- Auto weans PIP but not PEEP
- PEEP is required for lung recruitment pre surfactant must be weaned appriopraitely
- Tidal Volume = 4 ml/kg (3.5-5 ml/kg)
- higher volume required for initial lung recruitment
- For ELBW infants during 1st week of life post surfactant target volume 4 ml/kg
- A/C Volume Guarenteed
Convenctional Mechanical Ventilation
Infants = 32 Weeks 1st Week of Life
Ongiong Evaulation to Optimize Ventilation Status
CXR and blood gases to guide vent adjustments
Changing compliance post surfactant
Esculation of respirtory support
Convenctional Mechanical Ventilation
Infants = 32 Weeks 1st Week of Life
Failed Primary CPAP
Initial Settings
RR= 50 bpm
PEEP= 6
Vt=5
Ti=0.3
PIP High 40 (wean to 25 as approppraite)
Upon admission to NICU do CXR, give surfactant within 60 min, do blood gas
Convenctional Mechanical Ventilation
Infants = 32 Weeks 1st Week of Life
<26 Weeks or intubated in caseroom
Initial Settings
RR= 50 bpm
PEEP= 5
Vt=5
Ti=0.3
PIP High 40 (wean to 25 as approppraite)
Upon admission to NICU do CXR, give surfactant within 60 min, do blood gas
Convenctional Mechanical Ventilation
Infants = 32 Weeks 1st Week of Life
Order of Weaning
Wean volume to 4 ml/kg- If using PCV wean to PIP to <18 cmH2O
Adjust PEEP and Ti based on waveforms and CXR
Wean set rate in 5-10 bpm increments to 20 bom
Convenctional Mechanical Ventilation
Infants = 32 Weeks 1st Week of Life
Target blood gas
Blood GAs >/= 7.20
PCO2 = 45-55 (40-50 in 1st 48 hours of life)
SpO2= 88-92%
Do not treat metabolic acidosis with hyperventilaion
Difficult to Oxygenate Algorithm
First Step
- Identify if the patient is hypoxemic
- Low SO2 and PaO2
- PvO2 <35 mmHg
- O2 Delivery <8 ml/kg/min
- High lactate >2.8
Next Define the cause
Difficult to Oxygenate Algorithm
Define the Cause
Can be due to
Lung Disease
Cardiac Failure, Poor Perfusion, Shock
Low Content
Difficult to Oxygenate Algorithm
Define the Cause-Lung Disease
Indications: P(A-a)O2, PaO2/PAO2, FiO2/PaO2
Increase Pulmonary Blood Flow: Nitric Oxide, hyperventilation
Increase MAP: Optimal PEEP (ARDS Net), Increase I:E (increase Ti), Mode Change (pressure control limit Pplat <30 or pressure release with inverse I:E, or high frequency osscillator)
Difficult to Oxygenate Algorithm
Define the Cause-Cardiac Failure, Poor Perfusion, Shock
Indications: Low BP, Cold Extremities, Low UO
Consider: Fluid challange, Cardaic pharmacology, Vasoconstrictors
Difficult to Oxygenate Algorithm
Define the Cause-Low Content
Indication: Low Hgb (<8 gm/dL), low hematcrit (<35%)
Consider: Blood products
ARDSnet Algorithm
Inclusion
PaO2/FiO2<=300
CXR showing bilateral infiltrates
ARDSnet Algorithm
Modes
- PRVC
- Vt =6 ml/kg IBW
- Rate 12-16
ARDSnet Algorithm
ABG
Oxygenation: PaO2 55-90 and SpO2 88-95%
Ventilation: pH 7.30-7.45
ARDSnet Algorithm
ABG-pH is High
pH > 7.45
Decrease Rate
Make sure that Ti <= Te
ARDSnet Algorithm
ABG-pH is Low
pH 7.15-7.30 then increase RR
pH < 7.15 then increase RR to 35. If ph remain <7.15 then increase Vt by 1 ml/kg (Pplat may exceed 30)
Make sure Ti< = Te
ARDSnet Algorithm
ABG-Pplat <= 30
Lower: Pplat <25, Vt <6 ml/kg, increase Vt by 1 ml/kg
High: Pplat >30, decrease Vt by 1 ml/kg
ARDSnet Algorithm
ABG-Pplat <= 30
ARDSnet Algorithm
Higher PEEP Lower FiO2
- FiO2 0.3
- PEEP 5-14
- FiO2 0.4
- PEEP 14-16
- FiO2 0.5
- PEEP 16-18
- FiO2 0.7
- PEEP 19-20
- FiO2 0.8
- 20-22
- FiO2 0.9
- 22
- FiO2 1
- PEEP 22-24
ARDSnet Algorithm
Lower PEEP High FiO2
- PEEP 5
- FiO2 0.3-0.4
- PEEP 8
- FiO2 0.4-0.5
- PEEP 10
- FiO2 0.5- 0.7
- PEEP 12
- FiO2 0.7
- PEEP 14
- FiO2 0.7-0.9
- PEEP 16
- FiO2 0.9
- PEEP 18-24
- FiO2 1
ICU Extubation Pathway
All patients will be placed in this pathway unless exclusion criteria are met or the physician has sound medical reason for using a different approach.
In these circumstances, a clear order must be given to the Respiratory Therapists and the Nursing Staff.
ICU Extubation Pathway
Extubation
All patients with a head injury, unstable spinal injury, receiving inotropes/ vasopressors or a planned surgery within 24 hours will require a specific physician order before proceeding with weaning.
Patients with head injuries, cerebral vascular accident or receiving inotropes/ vasopressors may be a candidate for this weaning pathway, but require a specific physician order.
ICU Extubation Pathway
Criteria to Consider SBT
- Resolution of disease acute phase and underlying indication for mechanical ventilation has resolved or significantly improved.
-
Adequate oxygenation as demonstrated by
- PaO2 ≥ 60mmHg
- PaO2/ FiO2 > 150-200 or SpO2 >= 90%, with PEEP ≤ 5-8 cmH2O and FiO2 ≤ 0.4 (or as otherwise described in the regional O2 Protocol).
- For patients who have had an arterial blood gas, no significant uncompensated respiratory acidosis (i.e. pH < 7.30).
- HR ≤ 140 bpm, stable blood pressure, stable cardiac rhythm, no ongoing myocardial ischemia, and no uncompensated shock.
- Adequate mentation (GCS >= 13) or tracheostomy in place.
ICU Extubation Pathway
Initiation of spontaneous breathing trial
A SBT will be performed daily, preferably in the morning prior to rounds or sooner at the discretion of the RRT.
Patients who are post-op may have a SBT performed every 4 hours.
Important information can be gained by both successful and unsuccessful SBTs.
To perform the SBT, the RRT will place the patient on PSV of 7cmH2O and PEEP of 5 cmH2O. If Automatic Tube Compensation (ATC) is used, then set PSV to 0.
ICU Extubation Pathway
First 5 min of SBT
In the first 5 minutes, the RRT must monitor the patient and terminate the trial if any of the following are present. The bedside RN must also be present during this time.
- RR > 38
- Rapid shallow breathing index (Tobin ratio) > 105
- Sweating, anxiety or change in mental status SpO2 < 90% for > 5 minutes
- Signs of distress or paradoxical breathing
- HR > 140 bpm or a 20% change
- Systolic BP < 90 or > 180 mmHg
- New dysrhythmia or myocardial ischemia
If any of the above occurs, the RRT will increase PSV for patient comfort or return to previous ventilator settings as appropriate and inform the physician of the results. Duration of SBT and criteria for termination are to be properly documented in the patient’s chart.
ICU Extubation Pathway
After first 5 min of SBT
If the patient has tolerated the initial SBT, the RRT can continue with the trial.
For patients ventilated < 72 hours, continue for 30 minutes.
For patients ventilated > 72 hours, continue the trial for 60-120 minutes.
Monitoring should be done after the first 5 minutes and Q15 there after.
If the patient exhibits any of the termination criteria (as listed in 3.0), the RRT must increase PSV for patient comfort and inform the physician of the results.
ICU Extubation Pathway
Extubation
If the patient has tolerated the SBT for the specified time, the RRT will increase the PSV for patient comfort, then discuss the possibility of extubation with the physician.
This discussion should include the patient’s ability to manage secretions and the patency of the upper airway (i.e. cuff leak).
Oxygen Protocol For Ventilated Patients
Objectives
To optimally oxygenate patients, the Respiratory Therapist will utilize the following protocol to evaluate, treat, and monitor appropriate oxygen administration for all mechanically ventilated patients.
The optimal FiO2 for safe oxygen administration is the lowest FiO2 that will maintain the SpO2 ≥ 90% or the patient’s physiologic norm.
Oxygen Protocol For Ventilated Patients
Exclusion
Patients with a head injury and a GCS < 8 will require specific physician order for oxygen titration as per this protocol or for a specific oxygen concentration to be delivered.
Oxygen Protocol For Ventilated Patients
Initiating Mechanical Ventilation
Unless otherwise orderered by teh dr the RT when initiating Mechanical Ventilation will set FiO2 at 0.60 and then adjust to maintain SpO2 > 90%.
The physician must order a target SpO2
Note: Default values will be SpO2 ≥ 88% and ≤ 92% for patients with obstructive lungs and chronic CO2 retention, and SpO2 ≥ 90% for all other patients.
Oxygen Protocol For Ventilated Patients
ABG
Arterial blood gases should be drawn 20-30 minutes following initiation of ventilation to ensure good correlation between measured SaO2 and SpO2.
After the ABG has been drawn and correlation established, the Respiratory Therapist will titrate the FiO2 to keep SpO2 ≥ target value.
Oxygen Protocol For Ventilated Patients
Adjusting FiO2
The Respiratory Therapist will adjust the FiO2 within a range of 0.30 and 1.00 to maintain the target SpO2.
The bedside nurse will be informed of all changes and all changes will be documented in the patient’s chart.
The physician must be notified and order confirmed if one or more of the following occurs:
a. The FiO2 has to be set at > 0.60.
b. The FiO2 has to be increased by > 0.30.
Note: The physician does not need to be notified of transient (<30 minutes) increases in FiO2 associated with procedures or interventions (i.e. bronchoscopy, suctioning, proning, etc.).
Oxygen Protocol For Ventilated Patients
Warnings
- The Respiratory Therapist will watch the patient’s vital signs and evaluate the patient’s clinical status. The Respiratory Therapist will not continue to wean the FiO2 if the patient develops one or more of the following:
- Heart rate > 140 beats per minute or 20% change.
- A rise or fall in systolic blood pressure of < 90 or > 180 mmHg that occurs with FiO2 adjustment.
- ECG changes i.e. onset of arrhythmia or ischemic changes associated with the adjustment.
- Clinical signs and symptoms of tissue hypoxia (tachypnea, dyspnea, cyanosis, diaphoresis, confusion, or chest pain).
- O2 titration will resume once consultation with the physician has occurred.
Arterial Blood Gas Protocol
When do you need a physician request or only do if sudden deterioration
If there is no arterial catheter
If there is an arterial catheter and they are not ventilated
Sudden deterioration refers to a patient exhibiting acutely at least two of the following :
- SaO2/SpO2 < 88%,
- dyspnea,
- mean blood pressure < 55 mmHg,
- change in baseline heart rate + 20%,
- hourly urine output < 0.4 ml/kg,
- unexpected change in mentation,
- FiO2 increase > 0.30 or FiO2 > 0.60.
Arterial Blood Gas Protocol
When is the use of a pulse ox preferred
The patient has a arterial catheter, ventilated, and are weaning
Measure blood gases within 30 min of mode change if respiratory distress, paradoxical breathing pattern or hemodynamic changes are evident.
Need to document alveolar ventilation (PaCO2) in an otherwise stable patient must be ordered by physician.
Arterial Blood Gas Protocol
When are ABG done Q24h
When the pt has an arterial catheter, is ventilated, is not weaning and is STABLE
UNSTABLE: (3 or more of the following criteria)
- FiO2 < 0.60
- PEEP/CPAP < 10
- pH = 7.25 - 7.50
- PCO2 < 55
- PO2 > 55
- SaO2/SpO2 > 88%
24 hourly blood gas if stable with mechanical ventilation. No need for extra measurements on FiO2 change if SaO2/SpO2 > 88%. Ventilation change -physician request.
Arterial Blood Gas Protocol
When are ABG done Q6h
When the pt has an arterial catheter, is ventilated, is not weaning and is UNSTABLE
UNSTABLE: (3 or more of the following criteria)
- FiO2 > 0.60
- PEEP/CPAP > 10
- pH < 7.25
- PCO2 > 55
- PO2 < 55
- SaO2/SpO2<88%
Measure blood gases within 30 min of mode change if respiratory distress, paradoxical breathing pattern or hemodynamic changes are evident. Need to document alveolar ventilation (PaCO2) in an otherwise stable patient must be ordered by physician.
Measure blood gases 30 minutes after ventilation or mode change until stable. Measure blood gases immediately if sudden deterioration
Arterial Blood Gas Protocol
PA Catheter
Mixed Venous samples will be drawn Q12h in a patient having a PA catheter as per Calgary Health Region policy. It is not mandatory to draw an arterial sample in conjunction with each mixed venous draw.
Samples drawn for electrolyte and/or hemoglobin analysis, must be sent to the lab unless ordered STAT.
Refer to the Regional Guidelines for the use of Inhaled Nitric Oxide when drawing samples on patients receiving Nitric Oxid
Weaning Parameters
POINTS OF EMPHASIS
Standard practice should be used and weaning parameters should be performed through the vent
Patient should be on PEEP < 8 cm H2 O and F1O2< 0.60.
Patient’s own minute ventilation should not be greater than 12Lpm.
Patient should be monitored with SpO2 during procedure.
Try to place the pt in sitting position or elevate their head in order to optimize pulmonary mechanics
The follow should be recorded
- Respiratory rate ( f )
- Tidal Volume ( VT )
- Vital capacity ( VC )
- Minute Ventilation
- Rapid Shallow Breathing Index (Tobin Ratio) = f (bpm) / VT (L)).
- This ratio is determined after the patient had been breathing spontaneously for one minute.
NIF or NIP measurements can be performed upon physician request. With the preferred method for NIF measured via the vent, but if using an external device perform it through the HMEF
If possible use a dedicated external device for each patient. In exceptional circumstances when the device is to be shared it must be surface disinfected with a germicidal wipe prior to its next use.
In those patients who show desaturation during measurement using an external device, oxygen can be added in through the inlet of the system.
Weaning Parameters
Personanell Permitted to do it
RT and RT student
Weaning Parameters
Equitment
Measuring device(s) if applicable i.e. Ventilator, Wrights, Respiradyne, etc.
Monitoring equipment i.e.: SpO2, ECG if available.
Oxygen source if required.
Gloves
Weaning Parameters
Procedure
Perform hand hygiene with an antiseptic agent
Don clean gloves. I don’t think you need to glove unless you are attaching an external device.
Explain procedure to patient.
Measurement through the ventilator:
Measurement of NIF or NIP using external measuring device:
Weaning Parameters
Procedure-Measurement of NIF or NIP through the ventilator
Silence alarms.
Switch to CPAP/Spontaneous mode of ventilation. Change Pressure Support level to zero and maintain PEEP levels. For VC maneuver on Drager ventilators, ensure the high VT alarm is set to maximum (4 L).
Allow patients status to stabilize for at least 30 seconds. Observe closely with monitoring devices.
Note RR, VT, Minute Volume during 60 seconds of observation.
Instruct patient to perform VC maneuvers to obtain 2 reproducible values.
If requested, and the ventilator option is is available, ask the patient to perform NIF or NIP. Numerous attempts may be required to get an optimal result.
Return patient to previous ventilator and alarm settings.
Document measured results, patient tolerance of procedure and level of cooperation.
Weaning Parameters
Procedure-Measurement of NIF or NIP through an external device
Silence alarms
Preoxygenate patient as required or provide supplemental oxygen.
Disconnect patient from ventilator and place the circuit on the ventilator support arm.
Attach external measuring device to HMEF.
Ask the patient to perform NIF or NIP. Numerous attempts may be required for optimal value.
Reconnect the patient to ventilator. Reset parameters.
Document measured values, patient tolerance of procedure and level of cooperation.
Surfacedisinfectthedevicewithagermicidalwipeafteruse.
Remove gloves and Perform hand hygiene (antiseptic agents are only required before an invasive procedure)
Weaning Parameters
Pt Tolerance
Note patient tolerance/status during measurements.
If desaturation occurs, return the patient to mechanical ventilation or provide the patient with supplemental oxygen.
Continuous Mechanical Ventilation
Policy
The RT will be solely responsible for the set-up, monitoring, setting changes, troubleshooting, and discontinuing the mechanical ventilator in ICU.
The attending MD or ICU Fellow may perform ventilator setting changes if the situation warrants it. Following these changes, the attending MD or ICU Fellow must immediately notify the responsible RT (if they were not present at the time of the changes) to ensure appropriate alarm settings and documentation.
The RT is permitted to select an appropriate ventilator for the patient situation, unless a physician has given a specified order.
The ventilator parameters are adjusted by the RT as per physician’s order or according to approved protocols.
CMV Policy
The following parameters will require a physician order (in the absence of a protocol):
Mode
PEEP
Tidal volume (based on Ideal Body Weight - IBW)• Pinsp (PC level)
PS level
I: E ratio or Tinsp (if inverse ratio)
Rate
Note: All other settings will be at the discretion of the RT unless ordered otherwise.
CMV Policy
Alarms FiO2
If using external analyzer, set alarm +/- 10% of set
CMV Policy
Alarms Low PEEP
2-3 cmH2O below set PEEP
CMV Policy
Alarms High Pressure
In volume-based ventilation, to be set at 50 cmH20 or 15- 20 cmH20 above the peak inspiratory pressure.
In pressure ventilation, set at 5-10 cmH20 above peak inspiratory pressure
CMV Policy
Alarms Low pressure
Set to a minimum of 10 or 15-20 cmH20 below peak inspiratory pressure
CMV Policy
Alarms Low exhaled tidal volume
Set to 150-200 ml below or 20% below set or delivered VT
