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Mechanical Ventilator Management Protocol

Mechanical Ventilator Management Protocol

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Published by Rick Frea
protocol devised to manage ventilators
protocol devised to manage ventilators

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Published by: Rick Frea on Dec 04, 2009
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06/27/2013

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Ventilator Respiratory Therapy ConsultVentilator Management ProtocolRespiratorytherapycave.blogspot.com1. Scope: A Licensed Registered Respiratory Therapist (RRT) who has successfullycompleted and passed all competencies related to patient assessment and protocols.Certified Respiratory Therapists, respiratory students and assistants may not adjustMechanical ventilators per protocol.2. Policy:A.The Mechanical Ventilator Management Protocol will only be initiated on patientsordered on Vent Management Protocol (VMP), or if the attending physician ordersRT Consult on a mechanically ventilated patient.B.The attending physician may write “discontinue Vent Management Protocol”(VMP) or discontinue RT Consult at any time.C. The physician does not need to be notified if:a.Weaning FiO2 b.Increasing FiO2 if not going greater than 50%c.Increase in PSV of 5 or less to maintain adequate tidal volumed.Changing in and out of volume supportD. The physician will be notified when:a. The respiratory therapist wishes to initiate VMP on a patient who is notCurrently on the protocol b.If the patient’s condition is deteriorating.c.The respiratory therapist is unable to determine appropriate therapy.d.If the FiO2 is >60% and PaO2 < 60mmHg or SpO2 <90% with 5cmH20PEEP.e.When pre-determined therapy limits are reached, i.e. FiO2, Vt, PEEP, RR, etc.f.When PEEP >5 is indicated.g.If PEEP >5 has been approved, and now PEEP >8 is indicated.h.A RR >30 or <8 is indicatedi.A VT >10 ml/kg ideal body weight or < 6 ml/kg is indicated. j.If VT or PEEP is indicated that results in PIP >=40 or plateau pressure >30.k.Weaning success or failurel.Increasing FiO2 above 50% is indicated to maintain satsm.Change in PSV >5 cmH20 is maden.A change in tidal volume is madeo.A change in respiratory rate is made E.For continuous monitoring of ABG values, an arterial line should be introduced,and/or the use of non-invasive monitoring (SpO2 & EtCO2)should be employed. Non-invasive monitoring is preferred.
 
F.Modify ventilator settings as indicated to maintain target values.G.Assure the non-invasive oxygen saturation (SpO2) and end tidal CO2 (EtCO2)values correlate with current ABGs.H.If rate of >30 is indicated, consider sedation prior to calling physician.I.Maximum PIP is determined by increasing PEEP in increments of 1cmH20. Stop increasing when BP, HR, SpO2 drop, or PaO2/Fio2 Ratio =<200.If the PaO2/FiO2 ratio increases you know PEEP therapy is working.J.When considering the adjustment of FiO2, hemoglobin should be checked toensure the absence of anemia. Hemodynamic data should be checked to ensureadequate circulation.2. Ventilator Management Protocol: The following are guidelines for use in stabilizationand management of the patient on mechanical ventilation:A. The following values will be maintained,
unless otherwise ordered by physician
.a.Ph: 7.35 to 7.45 b.PaCO2: 35 to 45 mmHg (EtCO2: 30 to 50 mmHg), unless the patients“usual” PaCO2 is chronically elevated.c.PaO2: 60 to 100 mmHg (SpO2 > 90%)d.In patients with COPD, adjust parameters to the patient’s “normal” valuesB. Obtain ABG or non-invasive oxygen saturation (SpO2) and end tidal CO2C.Adjust the ventilator settings to correct abnormal ABG and/or SpO2 and EtCO2values.a. Abnormal PaCO2 > 45 mmHg (EtCO2) values:1. Increase rate in increments of 2 to obtain acceptable values.2. Increase Tidal Volume by increments of 50ml to obtain acceptable values b.Abnormal PaCO2 <35 mmHg (EtCO2) 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 <90%, increase FiO2 in increments of 05% toobtain acceptable values.2.For hypoxia (Sa02<92%) requiring >60% Fi02, increase PEEP in steps of 1 cmH20 at a time to PEEP max (Specific Dr. order required)3.If hypoxia persists at PEEP max, increase the Fi02 in steps of 05% until100% is reached or Sp02 > 92%.4. For Sp02 >92% at PEEP maximum, Fi02 is first reduced in steps of 05%until <= 60%, then PEEP is reduced in steps of 1 to a minimum of 5 beforefurther reduction in Fi02.

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