GENERAL or SURGICAL Initial Ventilator Parameters Ventilator Management (see appendix I) Assess Patient Data (see appendix II) Data Collection Mode: Tidal Volume: FIO2: PEEP: Rate: I:E Ratio: ACUTE PHASE All modes available 5-8cc/kg IBW (males) = 50 + 2.3 (Height inches 60) IBW (females) = 45.5 + 2.3 (Height inches 60) Sufficient to maintain Sa02>92% 5-10 cmh20 14 or as low as possible to meet ventilatory goals Normal STABILIZATION PHASE Keep plateau pressure <30cm H20 Maintain ABG s within normal limits Mild hyperventilation for Neuro per Physician orders For patients with VAD keep PEEP at 5cmH2O unless directed Consider recruitment maneuvers Patient comfort / Hemodynamics / Pulmonary mechanics / Oxygentation / Ventilation See data collection sheet. Ventilatory Goals Reversal of indication for ventilation Absence of severe metabolic imbalance Hemodynamic Stability Secretion management Adequate oxygenation (FI02 <50% with PEEP <8; Pa02/FI02>200) Adequate ventilation (ph 7.35 7:45; PC02 30-55; PIP <45: Plateau <30) WEANING PHASE Weaning Considerations Spontaneous respirations without apnea Level of consciousness/sedation (i.e. issues to keep in mind Nutrition/fluid status Secretions/Airway patency when weaning but not Patient temperature <39 Hemodynamic stability necessarily an indication Balanced electrolytes No muscle relaxants not to wean) Labs (CBC, blood gases, electrolytes, infection/sepsis) Extubation Goals Resolution/significant improvement of indication for ventilation. Successful spontaneous breathing trial for 30 minutes with acceptable blood gases. Recovery Room patients without significant pulmonary problems need only acceptable mechanics (RSBI <100, NIF <-20, FVC 10-12cc/kg ibw) Extubate *If patient is on ventilator for >24 hours, daily screening, and spontaneous breathing trial must be utilized as outlined below.
Spontaneous Breathing Trials (For all guidelines) Assess Patient s Ability to Wean per Shift (see appendix III) Spontaneous Breathing Trial Criteria for Termination Of SBT Ventilator Discontinue (see appendix V) SPONTANEOUS BREATHING TRIAL Pa02 / Fi02 >200 Yes No PEEP < 5cm H20 Yes No RSBI < 105 Yes No Coughs during suctioning/ adequate NIF Yes No Less than 2 vasopressors and hemodynamically stable Yes No Off sedation or on sedation with physician approval (sedative infusion is not a contraindication to weaning if meets criteria) Yes No Consider SBT - SBT with CPAP/PS or T-Tube (no longer than 1 hour) with adequate FiO2 - Monitor at 15-minute intervals for 30 minutes and then every 30 minutes for the duration. - If SBT criteria not met, call physician to evaluate patient and/or stop trial. - RR >35/min for more than 5 minutes or increase >10bpm - Sat <90% (sustained) - Sustained increase or decrease in SBP of 20% - Development of cardiac arrhythmia, deterioration of mental status, or deterioration of arterial blood gases - Intolerable dyspnea, diaphoresis, excessive use of accessory muscles or development of paradoxical respirations - After successful spontaneous breathing trial - Acceptable blood gases. - Extubate
OBSTRUCTIVE Acute Phase Initial Ventilator Parameters Mode: All modes available Rate: As low as possible to obtain clinical goals (be aware of Auto-PEEP) Tidal Volume: 5-8cc/kg (Ideal body weight) IBW (males) = 50 + 2.3 (height inches 60) IBW (females = 45.5 + 2.3 (height inches 60) Fi02: sufficient to maintain Sa02 >92% PEEP: Match Auto-PEEP if present, contact physician if >8cmH20. I:E Ratio: Normal to extended Maintenance Phase Ventilator Management (see appendix I) - Attempt to keep plateau pressure <30cmH20 - Monitor peak inspiratory pressure to plateau pressure gradient - Adjust rise time/flow pattern to patient demand/comfort - Allow permissive hypercapnia to reduce PIP s with Ph>7.30 (abrupt changes >0.05 requires physician contact) - Keep Sp02 > 92% - Utilize bronchodilators (continuous), corticosteroids, and anti-cholinergics - Graphics monitoring Assess Patient Data Patient comfort / Hemodynamics / pulmonary mechanics / oxygenation / ventilation (see appendix II) Ventilatory Goals - Reversal of acute disease process - Pa02/FI02 ration >200 - FI02 <60% - Peak pressure to plateau pressure gradient improving - Temp <39 - Hemodynamic stability - Secretion management - Wean ASAP - ph >7.30
Long Term Ventilator Weaning Phase Weaning Indicators ABGs within acceptable limits, F102 =/<50% PEEP </=8 cmh20 Improved aeration on chest x-ray Hemodynamic stability Neurological stability (ICP<15) normal: 10-12 mmhg Improved pulmonary profile Minimal Sedation Spontaneous breathing Weaning Phase When indicators are met or approved by MD to begin weaning: - Begin BID trials on CPAP/PS with PS low as possible but high enough to keep patient comfortable (may be as high as 20-25cmH20) wean PS for comfort. - When PS has been weaned to 10-12 cmh20 begin ATC trials BID as tolerated with VS stable. - At night return to control mode with rate high enough to relieve WOB. - When patient is able to remain off vent 7a 11p. The following night, begin to allow patient to remain off through night as tolerated. Note: Earn patients trust by limiting first CPAP/PS and ATC trials to 30-60 minutes if patient tolerates that long. Goal is not to tire patient out, but monitor for signs of distress.
RESTRICTIVE ACUTE PHASE Initial Ventilator Parameters Mode: All modes available Tidal Volume: 5-8cc/kg (Ideal body weight) IBW (males) = 50 + 2.3 (height inches 60) IBW (females) = 45.5 + 2.3 (height inches 60) Rate: As low as possible to meet ventilatory goals Fi02: To keep Sa02 85-92% PEEP: Optimal Peep Consider recruitment maneuver I:E Ratio: Normal to Inverse (notify physician if inversed) Consider HFOV/BiVent (see appendix VI and VII) Ventilator Management - Keep plateau pressure <30cm H20 - Allow permissive hypercapnia to keep ph >7.28 (not indicated with increased ICP) - Ventilator graphics to monitor - Obtain ABG 30 minutes after admission - Wean FiO2 for sats > 85%, PO2 > 60 mmhg - Increase FiO2/PEEP if indicated Assess Patient Data Patient comfort / Hemodynamics / Pulmonary Mechanics / Oxygenation / Ventilation (see appendix II) Ventilatory Goals - Absence of severe metabolic imbalance Minimal circuit disconnects - Hemodynamic Stability Maintain plateau pressure < 30 mmhg - Keep Pa02/Fi02 ratio >200 Optimal Peep - Keep ph 7.28-7.40 Considerations - Prone positioning - Steroids - HFOV (see appendix VI) - Recruitment maneuvers when indicated with open lung tool (see appendix IV) - BiVent (see appendix VII)
RESTRICTIVE MAINTENANCE PHASE Indicators ph> 7.32 FI02 < 60% with Sa02 > 90% I:E ratio 1:1 1:3 Improved ventilatory status Stable patient/ventilatory settings Stable ABG s with minimal ventilator changes Ventilator Management Ventilator graphics monitoring Maintain optimal PEEP while weaning F102 to maintain Sa02 > 90% Recruitment maneuvers for ventilator disconnects Keep ph 7.32 7.40 Ventilatory Goals Hemodynamic stability PH 7.32 7.40 Sp02 > 90% Keep P/F ratio >200 Minimal circuit manipulation (suction, transport) Maintain plateau pressure < 30 mmhg Evaluate Nutritional status Tracheostomy (per physician) Ventilator Management Spontaneous mode if tolerated Reviewed by: Manuel Castresana 9/30/09