Checklists - Doctors Basic Respiratory Care and Ventilator Support

Skills Checklists for Respiratory Care and Ventilator Support
The target audience for these checklists are clinicians working in intensive care units (ICUs) at
either the district hospital or tertiary hospital levels.
These checklists include:

o Manual ventilation
o Rapid sequence intubation
o Airway suctioning
o Volume mode settings
o Lung mechanics measurement
o Waveform interpretation
o Troubleshooting
 Ventilator inoperative
 Low tidal volume
 High pressure limit
o Weaning criteria
o Weaning process
REFERENCES
1. WHO Respiratory Care for Severe Acute Respiratory Infection Toolkit
https://apps.who.int/iris/bitstream/handle/10665/331736/WHO-2019-nCoV-SARI_toolkit-2020.1-eng.pdf?sequence=1&isAllowed=y
2. Model for Health Professionals’ Cross-Training for Mass Casualty Respiratory Needs
https://www.aarc.org/wp-content/uploads/2014/11/01-project-xtreme-model-for-health-professionals.pdf
3. Elsevier, Mosby’s Respiratory Care Skills. https://www.elsevier.com/about/press-releases/clinical-solutions/elsevier-adds-new-
respiratory-care-collection-to-mosbys-skills
4. National Registry of Emergency Medical Technicians Paramedic Psychomotor Competency Portfolio Manual
https://content.nremt.org/static/documents/FP415%20CPAP%20and%20PEEP%20Skill%20Lab%20Form.pdf?
4%2F6%2F2016+5%3A45%3A34+AM
Manual Ventilation
ITEMS YES NO COMMENTS
1 Performed hand hygiene and donned gloves. For patients with

isolation precautions, also donned a gown, mask, and eye
protection.
If suspect or confirmed COVID-19, use airborne precautions.
2 Identifies the indications for manual ventilation and identifies
hazards associated with over- and under-ventilation. Calls for
appropriate assistance.
3 Properly identifies appropriate size resuscitation device.
4 Properly assembles necessary equipment.

5 Tests function prior to patient application. Checks bag-mask
device. Ensures connected to 100% oxygen. Adjusts oxygen
flow and pressure relief valve.
6 Manually bags with appropriate frequency and pressure.
Provides 1 breath every 5-6 seconds, if appropriate.
7 Monitors appropriate signs of ventilation including visualization of

chest excursion. Watches for chest rise and fall.
Rapid Sequence Intubation

1 Preparation performed:
Performed hand hygiene and donned gloves. For patients with
protection.
Describes indication for intubation, appropriate consent
obtained and resuscitation status of patient.
2 Equipment obtained:
Suction with appropriate catheter
Oxygen, tubing, bag (checked), mask, reservoir
Airway, ET tube, lubricant, +/- stylet, 20cc syringe, tube tie,
checks ET tube balloon
Medications: BP and potassium level noted. Sedative and
neuromuscular blocker chosen
Monitoring: ECG and SpO2 monitored, stethoscope available
Laryngoscopes with two blades checked
Back-up: Bougie, Video, scalpel, 6.0 ETT
3 Team member roles assigned:
doctor 1: airway management and drug order
nurse 1: assistant and drug administration
nurse 2: ventilation assistance
Reviews plan with team
4 Preoxygenates patient
5 Positions head properly
6 Inserts laryngoscope blade properly
7 Inserts ETT to proper depth
8 Inflates cuff to proper pressure and immediately removes syringe

9 Ventilates and confirms placement by auscultation over epigastrum
and bilaterally over lungs
10 Secures ETT
Airway Suctioning

protection.
Describes hazards of suctioning
Describes desired appropriate outcomes of procedure
2 Identifies necessary resources
3 Assesses need for airway suctioning
4 Assembles appropriate equipment
5 Utilizes appropriate technique
6 Properly identifies outcomes and assesses ongoing need
Mechanical Ventilation – Volume Mode

1 Performed hand hygiene before patient contact. Introduced

self to the patient.
2 Before initiating mechanical ventilation, ensured that the

ventilator and associated equipment were functioning properly
per the manufacturer’s specifications and the organization’s
practice. Checked the system microprocessor or ventilation
system, circuit compliance, HME, humidifier, and filters, and
performed a circuit leak test.
3 Selected the most appropriate mode of volume mechanical

ventilation based on the patient’s needs.
4 Set the VT based on the patient’s size.
5 Selected a respiratory frequency.
6 For I:E times, selected TI. Adjusted the flow as necessary to

attain patient–ventilator synchrony.
7 Set the trigger sensitivity between –0.5 and –1.5 cm H2O pressure.
8 Placed the patient on 100% oxygen unless information was

available that identified a precise FIO2. Adjusted the FIO2
downward, as tolerated, using SaO2 and ABG values to guide level
selection. Titrated the FIO2 to obtained a PaO2 of 60 to 80 mm Hg
and an SpO2 or SaO2 of 90% or greater.
9 Selected the PEEP level.
10 Ensured that all ventilator alarms were set appropriately.
11 Provided circuit humidification.
12 Checked for secure stabilization and maintenance of the ET

tube. Confirmed ET tube placement, ideally by clinical
assessment and continuous waveform capnography. If
continuous waveform capnography was not available, used a
nonwaveform exhaled carbon dioxide monitor.
13 Monitored SpO2 continuously.
14 Explored any change in PIP or decreased VT on PSV.

Immediately explored the cause of high-pressure alarms. Always
considered the possibility of a tension pneumothorax if the
patient had a shift in the trachea, decreased breath sounds on
one side, and increased peak pressures. If a tension
pneumothorax occurred, performed a needle thoracotomy.
15 Placed a bite block between the teeth if the patient was biting on
the oral ET tube.
16 Evaluated for patient–ventilator dyssynchrony
17 Observed for hemodynamic changes associated with increased

VT, PEEP, or decreased cardiac output. Considered the potential
for pneumothorax with acute changes, such as a tracheal shift,
decreased breath sounds, and increased PIP readings on the
ventilator.
18 Suctioned the patient, using the closed technique if possible,

only when needed and not routinely.
19 Observed the patient for signs or symptoms of pain. If pain was

suspected, reported it to the authorized practitioner.
20 Discarded supplies, removed gloves, and performed hand

hygiene.
21 Documented the procedure in the patient’s record.
Mechanical Ventilation - Lung Mechanics Measurements


protection.
2 Introduced self to the patient and ensured that he or she agreed

to the treatment. Verified the correct patient using two identifiers.
3 Assessed the patient’s vital signs and oxygen saturation.
4 If the patient’s ventilator was set on a volume mode, assessed

PIP for gradual or acute airway compliance changes. If the
patient’s ventilator was set on a pressure mode, assessed the
VT for gradual or acute airway compliance changes.
5 Assessed the patient’s breath sounds.
6 Suctioned the patient’s airway.
7 Measured CD (dynamic compliance).
8 Found the Pplat (plateau pressure)

9 Measured CS (static compliance) and Raw (airways resistance).
10 Removed gloves and performed hand hygiene.
Mechanical Ventilation - Waveform Interpretation

1 Performed hand hygiene and donned gloves before patient

contact.
2 Introduced self to the patient. Assessed the patient’s comfort

level. Explained the procedure to the patient and ensured that
he or she agreed to treatment.
3 Ensured that a resuscitation bag with mask was at the bedside.

Ensured that suction was set properly and functioning at the
bedside.
4 Turned on the ventilator graphics to the selected waveform

measurement.
5 Interpreted waveforms to detect:

1. Leaks in the system
2. Lung compliance issues
3. Correct inspiratory time
4. Possible airway obstruction
5. Lung overinflation or inadvertent PEEP
6. Trigger asynchrony
7. Flow asynchrony
8. Cycling asynchrony
6 Monitored the patient’s vital signs, including heart rate, respiratory
rate (both mechanical and spontaneous), and blood pressure.
Monitored oxygen saturation by pulse oximetry and ETCO2 levels.
7 Carefully monitored the patient’s peak inspiratory pressure, mean

airway pressure, and inspiratory and expiratory volumes.
8 Observed the patient for signs and symptoms of pain. If pain was
9 Discarded supplies, removed gloves, and performed hand hygiene.
Mechanical Ventilation - Troubleshooting

Ventilator Inoperative (Vent INOP)

1 Performed hand hygiene and donned gloves.
2 Explained the procedure to the patient.
3 Immediately removed the patient from the ventilator and began

manual ventilation with an resuscitation bag.
4 Immediately removed the patient from the ventilator and began

manual ventilation with an resuscitation bag.
5 Followed the message instructions on the ventilator, if available.
6 If the ventilator failed to operate properly, tagged it for a

maintenance check and replaced it with another ventilator.
7 Ensured that the alarms were set properly.
8 Verified that the alarm had been corrected and the patient was
stable.
Low Tidal Volume (VT)

2 Explained the procedure to the patient.
3 Checked the circuit for leaks or disconnections. Tightened or

reconnected the connections.
4 Checked the artificial airway cuff for leaks or deflation.
5 Checked the humidifier for leaks or disconnections and tightened or

reconnected the connections.
6 Checked the inline suction system for leaks or disconnections.

Tightened or reconnected the connections. Replaced the inline
suction system if a leak persisted.
7 Checked inline adapters for an MDI or an SVN. Checked them for

leaks or disconnections and tightened or reconnected the adapter
connections.
8 Checked for chest tube leaks. If one was found, arrange for further
interventions.
stable.
High-Pressure Limit
2 Explained the procedure to the patient. Assessed the patient for

signs of respiratory distress.
3 Attempted to pass a suction catheter through the patient’s artificial
airway to check for an obstruction.
4 Checked the ventilator circuit for water. Drained condensation away

from the patient and toward the expiratory limb.
5 Checked the ventilator circuit for kinking or obstructions.
6 Checked breath sounds to determine if any of the following were

present:
1. Bronchospasm: Consulted the practitioner and considered
bronchodilator therapy.
2. Secretions: Suctioned the secretions to clear the patient’s
airway.
3. Pneumothorax: Immediately contacted the practitioner for further
interventions.
7 Checked the exhalation valve for failure; if it had failed, immediately

removed the patient from the ventilator and began manual
ventilation with an MRB.
stable.
Mechanical Ventilation – Weaning Criteria

1 Performed hand hygiene before patient contact.
2 Introduced self to the patient. Explained the procedure to the

patient and ensured that he or she agreed to treatment.
3 Assessed the patient for signs and symptoms of inadequate

ventilation.
4 Considered positioning the patient in a high semi-Fowler position,
if his or her condition allowed
5 Attached a portable respirometer to the airway via the adapter

and the series of one-way valves. If the patient was receiving
PPV, placed him or her back on the ventilator (or manually
ventilated with a self-inflating manual resuscitation bag) to rest
for a few minutes between all measurements
6 Measured VTS.
1. Instructed the patient to breathe normally.
2. Counted the frequency and recorded the minute ventilation.
3. Divided minute ventilation by f to obtain the average VTS.
7 Measured VC.
1. Verified that the respirometer was at the starting point.
2. Instructed the patient to inhale as deeply as possible.
3. Instructed the patient to exhale as much as possible.
8 Measured NIF.
1. Closed or capped the inspiratory one-way valve, ensuring a
closed system for measurement of inspiratory effort but allowing
exhalation.
2. Attached the pressure manometer to the airway with the
adapter and one-way valves.
3. Instructed the patient to inhale as deeply as possible.
4. Observed the manometer needle during inspiration.
5. After the patient had been attached to the closed system
manometer for a few seconds, instructed him or her to initiate a
series of breaths and generate a negative pressure.
6. Watched the manometer as the 20 seconds elapsed and
stopped the procedure after the NIF measurements peaked
within the maximum time allowed or if the patient did not tolerate
the procedure.
9 Measured PEP.
1. Capped the expiratory valve, ensuring the patient was able to
breathe in but had to exhale against a closed system.
2. Attached the pressure manometer to the airway via the
adapter and one-way valves.
3. Instructed the patient to take a deep breath and exhale
forcefully because PEP is effort dependent.
4. Instructed the patient to exhale forcefully a number of times
(not to exceed 20 seconds). Recorded the greatest positive
number.
10 Encouraged the patient throughout all measurements.

suspected then ordered appropriate treatment.
12 Discarded supplies, removed gloves, and performed hand

hygiene.
Mechanical Ventilation – Weaning Process

1 Performed hand hygiene before patient contact.
2 Introduced self to the patient. Ensured that the patient

understood preprocedure weaning instruction.
3 Evaluated factors that impede weaning in conjunction with factors

that measure respiratory muscle strength, endurance, and gas
exchange. Assessed the patient’s progress toward achievement of
individual short-term goals.
4 Assessed changes in level of consciousness or nonverbal

behavior and complaints of dyspnea or fatigue.
5 Assessed ABG values as needed. Assessed partial pressure of

ETCO2 levels.
6 Assessed oxygenation indices (SaO2 or PaO2) during trials.
7 Assessed the patient’s anxiety level.
8 Evaluated the patient’s stability and overall condition before

initiating active weaning trials.
9 Addressed all factors that might have impeded weaning

potential.
10 Established weaning screen criteria, if applicable.
11 Determined the duration of the weaning trial before beginning.
T-Piece or Tracheostomy Collar Trials

protection.
2 Explained the procedure to the patient and ensured that he or
she agreed to treatment.
3 Positioned the patient for optimum ventilation.
4 Communicated with the patient and family throughout the

weaning process.
5 Suctioned the artificial airway to ensure patency.
6 Connected the patient to a heated aerosol via a T-piece or

tracheostomy collar.
7 Informed the patient that the trial would feel different than when
on the ventilator and instructed him or her to try to breathe
normally.
8 Monitored the patient’s respiratory frequency, breathing pattern,

heart rate and rhythm, SaO2, and general appearance. Closely
tended to the patient.
9 After a predetermined time interval or with the emergence of

signs of intolerance, placed the patient back on resting ventilator
settings. Did not exceed the predetermined duration of the
weaning trial.
10 If the patient successfully met full trial criteria, notified the

practitioner and team regarding the patient’s response, and
considered extubation. If a protocol was in place, extubation may
have been the next step and may not have required such
notification.
11 Evaluated the patient for signs and symptoms of intolerance and

respiratory muscle fatigue. If signs of intolerance occurred,
promptly returned the patient to supported ventilation.

13 Discarded supplies, removed PPE, and performed hand hygiene.

CPAP Trials

protection
2 Explained the procedure to the patient and ensured that he or
she agreed to treatment.
3 Positioned the patient for optimum ventilation.
4 Communicated with the patient and family throughout the

weaning process.
5 Suctioned the artificial airway to ensure patency.
6 Changed the patient from resting ventilatory settings to CPAP
7 Instructed the patient to breathe normally and monitored for

signs and symptoms of intolerance. If using a protocol, referred
to specific criteria.
8 After a predetermined time interval on CPAP or if the patient

exhibited signs or symptoms of intolerance, placed the patient
back on resting ventilator settings. Did not exceed the
predetermined duration of the weaning trial.
9 Notified the team of the results of trials. If the last step of the
weaning plan or protocol was attained, considered extubation. If
a protocol was used, this step may have been automatic.

suspected, appropriate treatment ordered.
11 Discarded supplies, removed PPE, and performed hand hygiene.

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Skills Checklists for Respiratory Care and Ventilator Support

These checklists include:

1 Performed hand hygiene and donned gloves. For patients with

4 Properly assembles necessary equipment.

7 Monitors appropriate signs of ventilation including visualization of

Rapid Sequence Intubation

5 Positions head properly

6 Inserts laryngoscope blade properly

7 Inserts ETT to proper depth

8 Inflates cuff to proper pressure and immediately removes syringe

1 Performed hand hygiene and donned gloves. For patients with

3 Assesses need for airway suctioning

4 Assembles appropriate equipment

5 Utilizes appropriate technique

6 Properly identifies outcomes and assesses ongoing need

Mechanical Ventilation – Volume Mode

1 Performed hand hygiene before patient contact. Introduced

2 Before initiating mechanical ventilation, ensured that the

3 Selected the most appropriate mode of volume mechanical

5 Selected a respiratory frequency.

6 For I:E times, selected TI. Adjusted the flow as necessary to

8 Placed the patient on 100% oxygen unless information was

9 Selected the PEEP level.

10 Ensured that all ventilator alarms were set appropriately.

11 Provided circuit humidification.

12 Checked for secure stabilization and maintenance of the ET

13 Monitored SpO2 continuously.

14 Explored any change in PIP or decreased VT on PSV.

16 Evaluated for patient–ventilator dyssynchrony

17 Observed for hemodynamic changes associated with increased

18 Suctioned the patient, using the closed technique if possible,

19 Observed the patient for signs or symptoms of pain. If pain was

20 Discarded supplies, removed gloves, and performed hand

21 Documented the procedure in the patient’s record.

Mechanical Ventilation - Lung Mechanics Measurements

1 Performed hand hygiene and donned gloves. For patients with

2 Introduced self to the patient and ensured that he or she agreed

3 Assessed the patient’s vital signs and oxygen saturation.

4 If the patient’s ventilator was set on a volume mode, assessed

5 Assessed the patient’s breath sounds.

6 Suctioned the patient’s airway.

7 Measured CD (dynamic compliance).

8 Found the Pplat (plateau pressure)

10 Removed gloves and performed hand hygiene.

11 Documented the procedure in the patient’s record.

Mechanical Ventilation - Waveform Interpretation

1 Performed hand hygiene and donned gloves before patient

2 Introduced self to the patient. Assessed the patient’s comfort

3 Ensured that a resuscitation bag with mask was at the bedside.

4 Turned on the ventilator graphics to the selected waveform

5 Interpreted waveforms to detect:

7 Carefully monitored the patient’s peak inspiratory pressure, mean

10 Documented the procedure in the patient’s record.

Mechanical Ventilation - Troubleshooting

Ventilator Inoperative (Vent INOP)

2 Explained the procedure to the patient.

3 Immediately removed the patient from the ventilator and began

4 Immediately removed the patient from the ventilator and began

5 Followed the message instructions on the ventilator, if available.

6 If the ventilator failed to operate properly, tagged it for a

7 Ensured that the alarms were set properly.

10 Removed gloves and performed hand hygiene.

11 Documented the procedure in the patient’s record.