ࡱ>  @ bjbjVV 5r<r<%abKbKbK8KdKm&M&M 30 cm H2O. The initial VV settings (SIMV or A/C) should be determined based upon the patients Ideal Body Weight (IBW), Body Surface Area (BSA) and immediate clinical needs. Tidal Volume (VT) initial setting of 8 mL/Kg IBW while maintaining Pplateau < 30 cm H2O and delta P < 20 cm H2O. Necessary adjustments may range from 4 to 12 mL/Kg IBW to maintain the parameters of Pplateau < 30 cm H2O and delta P < 20 cm H2O. Consult physician if unable to maintain these parameters. Calculate IBW. Males IBW (kg) = 50 + 2.3 [height (inches) - 60]. Females IBW (kg) = 45.5 + 2.3 [height (inches) -60]. Minute Ventilation (MV) based upon Body Surface Area (BSA) = VE (L/min), to be achieved while maintaining Pplateau < 30 cm H2O and delta P < 20 cm H2O. Males = 4.0 x BSA = VE (L/min). Female = 3.5 x BSA = VE (L/min). Calculate BSA as follows: [(Height{in} x Weight{lbs}) / (3131)] x 0.5 . Rate (f): 8 to 26 breaths/minute adjusted to achieve I:E Ratio and maintain desired MV, while maintaining Pplateau < 30 cm H2O and delta P < 20 cm H2O. FIO2: Initial setting of 0.6 to 1.0 (may be less 0.4 to 1.0 for post anesthesia recovery) until ABG results are obtained. Initial ABG should be obtained 15 - 45 minutes from start of ventilation Pulse Oximetry (SpO2), and End-Tidal CO2 (ETC02 optional), should be correlated with initial ABG. Once ABGs are stabilized continue subsequent patient monitoring with continuous pulse oximetry to maintain SpO2 desired Saturation for patient s category as listed in table below. Once ABGs are stabilized continue subsequent patient monitoring with ETC02 to maintain patient s normal or within the normal ETC02 range. PEEP: Set initial PEEP at 5 cm H2O, unless otherwise indicated. Higher PEEP levels may be required with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). [Note: See ALI/ARDS Protocol]. Pressure Support (PS): Set initial PS at 8 to 20 cm H2O, adjusted to reduce work of breathing, patient fatigue and still support effective ventilation. I:E Ratio: Adjust to achieve an I:E ratio greater than 1:1 (example 1:3). The I:E ratio should be optimized to provide optimum mean airway pressure, lung filling, lung emptying (minimizing air-trapping/Auto-PEEP), and patient/ventilator synchrony. II. Initial Ventilator and Patient Assessment A. Initial ventilator and patient assessment will be performed within 15 - 45 minutes from setup. B. Assessment will include evaluation of the patients general appearance, breath sounds, ventilating pressures and volumes, ETCO SpO2 (optional), SpO2, ABGs, HR, BP, and other hemodynamic data (if available). C. Adjust the ventilator settings to achieve and maintain acceptable ABG results for the following patient categories. Patient CategorypHPaCO2PaO2SpO2Normal7.35 - 7.4535 - 45 mmHg> 80 mmHg92-97%Chronic CO2 Retention7.30 - 7.4545 - 55 mmHg55 - 75 mmHg> 89%ALI/ARDS7.25 - 7.45Adjust to pH range> 60 mmHg90-95% SECTION TWO - VENTILATOR MANAGEMENT SCOPE This policy incorporates, some degree, all members of the critical care team: physicians (MD), respiratory care practitioners (RCP, and registered nurses (RN). POLICY The MD and/or RCP shall make subsequent ventilator adjustments attempting to achieve and maintain the following parameters. (Note: Regular assessments of general appearance, vital signs, BS and hemodynamic stability should be evaluated a minimum of every four hours as well as prior to and during any ventilator adjustments.) Select the ventilation mode that best meets the ventilatory needs and goals set for the patient, as well as the patients general comfort. For a pH < 7.30, evaluate to determine if the cause is respiratory. If appropriate, increase rate to a maximum of 26 breaths/min until pH is > 7.30. If further adjustment is needed, incrementally increase VT until PIP = 40 cm H2O or Pplateau = 30 cm H2O. If adjustments are unable to achieve and maintain desired pH within the maximum parameters (PIP = 40 cm H2O or Pplateau = 30 cm H2O), consult physician and consider allowing permissive hypercapnia. For a pH > 7.45, evaluate to determine if the cause is respiratory. If appropriate, reduce rate to a minimum of 8 breaths/minute or until pH is < 7.45. After rate is decreased to 8 breaths/minute, if pH is still > 7.45, reduce volume to a minimum of 4 mL/Kg IBW. PaO2 or SpO2 should be maintained based on patients targeted values (see table). Hemoglobin should be checked to ensure the absence of anemia. Hemodynamic data should be checked to ensure adequate perfusion. Consult pulmonologist and consider the ARDS/ALI protocol if: If PaO2/FiO2 ratio is < 300 or Settings of FIO2 = 0.5 and PEEP = 12 cm H2O are insufficient to maintain appropriate oxygenation. Insert A-Line if patient requires, or is anticipated to require, more than one ABG per day. Change from Heat Moisture Exchange (HME) unit to heated circuit within 48 to 72 hours on ventilator. SECTION THREE - ARDS/ALI ventilator protocol SCOPE This ventilator protocol for Acute Respiratory Distress Syndrome (ARDS) and Acute Ling Injury (ALI) centers around tidal volumes based on the patients IBW, derived from the patients height. EXCLUSION This ventilator protocol is not appropriate for patients with raised intracranial pressure, spinal cord injury, tricyclic antidepressant overdose, Sickle cell disease, or other conditions where hypercapnoea would not be tolerated. ARDS/ALI INCLUSION CRITERIA I. Choosing to Initiate ARDS/ALI Protocol A. In the presence of the following criteria, the ARDS/ALI protocol is recommended. 1. PaO2/FiO2 d" 300. 2. Bilateral (patchy, diffuse, or homogeneous) infiltrates consistent with pulmonary edema. 3. No clinical evidence of left atrial hypertension. B. An arterial A-Line is strongly recommended due to the anticipation of multiple ABGs. II. Moving from Standard AVP to ARDS/ALI Ventilator Management A. Select desired ventilator mode. Unless current VT is lower the 8 ml/kg IBW, set VT to = 8 ml/kg IBW. Reduce VT by 1 ml/kg at intervals d" 2 hours until VT = 6ml/kg IBW. With a maximum respiratory rate (f) 35, set rate to achieve the required baseline MV before initiating ARDS/ALI protocol. If f > 35 is required to achieve the desired MV, consult physician and consider permissive hypercarbia. To maintain a VT > than 6 ml/kg the physician must write a medical order in the chart. Adjust VT and f to achieve desired pH and plateau pressures. Set the airway pressure alarm at 35 cm H2O to limit the maximal airway pressure to 30 cm H2O. Ensure that Autoflow is turned on and turn Flow Trigger On set to 2 L/min. Set Flow Rate (Inspiratory Time if applicable) to achieve an I:E ratio of 1:3 without setting off the pressure limit alarm. a. If pressure limit alarms, adjust Flow Rate (Inspiratory Time if applicable) to allow time for delivery of the set VT without exceeding the pressure limit (e.g. 1:2, 1:1.5, 1:1). If the I:E adjustment does not resolve the alarm reduce VT in increments of one ml/kg IBW. This may be repeated every few minutes to a minimal VT of 4 ml/kg IBW. Do not reduce VT below 4 ml/kg. If a VT of 4 ml/kg is necessary, notify the physician. If the patients requisite VT is less than 6 ml/kg IBW, regular attempts should be made to increase it in increments of 1 ml/kg IBW to achieve 6 ml/kg. If the patient is receiving 6 ml/kg IBW, attempts should be made to reduce the inspiratory time to give an I:E ratio of 1:3. III. Oxygenation Goal: to keep PaO2 55 - 80 mmHg or SpO2 88 - 95%. Use a minimum PEEP of 5 cm H2O. Consider the following incremental FIO2/PEEP combinations (not required) to achieve goal. Adjustment to oxygenation can be made on SpO2 alone. It is not necessary to obtain ABGs to change FIO2. However, if a PaO2 is available it shall supercede the SpO2. Lower PEEP/higher FiO2 FiO2 0.30.40.40.50.50.60.70.70.80.90.90.90.91.0PEEP558810101012141414161818-24 Higher PEEP/lower FIO2 FiO2 0.30.30.30.30.30.40.40.50.50.50.80.80.91.0PEEP58101214141616182022222224 IV. Plateau Pressure Goal: to keep Pplateau < 30 cm H20 Check Pplateau (0.5 second inspiratory pause) at least q 4h and after each change in PEEP or VT. Adjustments to achieve desired Pplateau. If Pplateau > 30 cm H2O, decrease VT in 1 ml/kg increments to a minimum of 4 ml/kg. If Pplateau < 25 cm H2O and VT < 6 ml/kg, increase VT by 1 ml/kg increments until Pplateau > 25 cm H2O or VT = 6 ml/kg. If Pplateau < 30 and breath stacking or dys-synchrony occurs, consider increasing VT in 1 ml/kg increments to 7 or 8 ml/kg if Pplateau remains < 30 cm H2O. V. pH Goal: to keep pH 7.30 - 7.45 Acidosis Management: (pH < 7.30). If pH 7.15 - 7.30: increase f to achieve pH > 7.30 or PaCO2 < 25 (Maximum set f = 35). If pH < 7.15: increase f to 35. If pH remains < 7.15, VT may be increased in 1 ml/kg increments until pH > 7.15 (Pplateau target of 30 may be exceeded). Consider NaHCO3. Alkalosis Management: (pH > 7.45). Decrease vent rate if possible. VI. I: E Ratio Goal: to achieve a duration of inspiration < duration of expiration. SECTION FOUR - WEANING FROM THE MECHANICAL VENTILATION SCOPE All changes are designed to move the patient safely toward liberation from ventilatory support. Each patient is different and thus will respond differently. Some will be able to wean from the ventilator swiftly, while others may take days or weeks. POLICY Once the underlining medical condition that resulted in the need for ventilatory support is resolved, the patient should be considered for a reduction in ventilatory support with the goal of weaning from the ventilator. When the patient assessment indicates the possibility for partial support or even discontinued ventalatory support may be appropriate, initiate the following weaning protocol. The MD and/or RCP shall make subsequent ventilator adjustments to achieve and maintain the following guidelines. I. Weaning Assessment Verify that underlying diseases process has been sufficiently resolved. ABGs should show adequate ventilation and oxygenation for the patients category (see table). Patient CategorypHPaCO2PaO2SpO2Normal7.35 - 7.4535 - 45 mmHg> 80 mmHg92-97%Chronic CO2 Retention7.30 - 7.4545 - 55 mmHg55 - 75 mmHg> 89%ALI/ARDS7.25 - 7.45Adjust to pH range> 60 mmHg90-95% Bedside Pulmonary Function Studies should show: VT 5 mL/kg. VC 10 ml/kg (Vt x 2). f 8 - 30 breaths per minute. VE 10 L/min. NIF -20cm H20. RSBI < 100 (f/ VT in L). Clinical Considerations: HR & BP normal. Adequate oxygenation (e.g. PaO2/FIO2 > 150-200 with PEEP 5- 8 cm H2O or SaO2 92% on 50% FIO2). Evidence that the underlying cause of respiratory failure is resolving. Temperature < 102. Hemodynamic stability as defined by: The absence of hypertension beyond patient s normal or Systolic BP > 180. The absence of hypotension Systolic < 90. The absence of active myocardial ischemia and the absence of clinically important hypotension (i.e. a condition requiring no vasopressor therapy; or minimally, a therapy of only low-dose vasopressors such as dopamine or dobutamine < 5 micro g/kg/min). A-a DO2 < 300 mmHg (utilization optional). QS/QT < 20% (utilization optional). VD/VT < 60% (utilization optional). II. Spontaneous Breathing Trials (SBT) A. SBT is accomplished utilizing unassisted breathing. Unassisted breathing (and therefore SBT) differs from the simple spontaneous breathing in that neither therapeutic levels of CPAP > 5 cm H20, nor PS levels > 5 cm H20 are allowed. CPAP d" 5 cm H20 merely emulates the natural physiologic PEEP provided by the epiglottis. PS d" 5 cm H20 merely serves to overcome the restricted lumen of the endotracheal tube, thereby better emulating ambient pressure. A. Criteria for SBT. Ability to maintain SaO2 92% on FI02 d" 0.4 and PEEP d" 8 cm H20. Ability to maintain SaO2 92% with PEEP and FIO2 d" values of previous day. Adequate spontaneous breathing efforts. If necessary, decrease set rate by 50% for 5 minutes to detect respiratory efforts. Haemodynamic stability. B. Maintain the following Weaning Cycle Parameters during SBT and throughout all stages of the weaning cycle regardless of weaning mode. Failure to stay with in these parameters is considered failure and patient should be returned to support mode used prior to weaning attempt. 1. VT 5 mL/kg. 2. f 8 - 35 breaths per minute. 3. VE 10 L/min. 4. RSBI < 100 (f/ VT in L). 6. BP Normal for patient. 8. Signs of respiratory distress (distress = 2 or more). Pay special attention to these outward physical sign that indicate inward changes. HR > 120% of resting AM baseline lasting > 5 minutes. Marked use of accessory muscles. Abdominal paradox. Diaphoresis and signs of anxiety. Marked complaints of dyspnea. F > 35. Sp02 <88%. B. Initializing SBT Initial SBT from 1 to 5 minutes. Assess patient based upon the Weaning Cycle Parameters criteria (above). If SBT fails return patient to stable, non-fatiguing, comfortable ventilatory support as used prior to SBT. Let patient rest 24 hours before attempting SBT again. Repeated 1 to 5 minute SBT daily until patient is able to tolerate 5 minutes. Once patient tolerates 5 minute SBT, proceed to formal SBT lasting 30 to 120 minutes. Initial SBT Settings: FIO2 to 0.5. PS d" 5 cm H2O (if using Spontaneous Mode/CPAP). 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Maximum pressure allowed PEEP + PS = 30 cm H2O. Set pressure airway alarm at 35 cm H2O. If f < 20 decrease PS by 2 - 5 cm H2O. If f > 35 and/or PEEP + PS > 30 cm H2O weaning has failed. Abort weaning attempt and return to settings prior to weaning trial. Abort PS weaning attempt if Weaning Cycle Parameters (above) are not maintained. Attempt weaning again the next day. 3. Subsequent Oxygen and PEEP adjustments are based upon Oxygenation Goals outlined above. If FIO2 > 0.5 and PEEP > 10 cm H2O are required while on PS ventilation, strong consideration should be given to reinitiating a volume mode. Inform the medical staff. D. Extubation should be considered if the following criteria are met. PEEP d" 5 cm H2O and FIO2 d" 0.4. f < 30. Oxygenation goals are met. Proceed toward extubation at the patient s pace as efficiently as possible. Premature extubation can endanger the patient and lead to the trauma of another intubation. 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