Continuous Mechanical Ventilation

SECTION F:

CONTINUOUS MECHANICAL VENTILATION

Subject:Page:

Equipment Available3

Physician's Order3

Indications5

Patient Ventilator Monitoring6

Ventilator Parameter Changes7

Infection Control8

Discontinuing/Withdrawal of mechanical Ventilation8

Transport Policy9

Home Ventilator Use in VUMC10

Monitoring Guidelines Non-Invasive CMV 12

(BiPAP, Cuirass, Blow-by, ET CPAP)

High PEEP Resuscitator Bag14

Ventilator Clean-up/Equipment Prep.15

Hazards of Mechanical Ventilation17

Calculation for Static Compliance18

Optimal PEEP Study19

Spontaneous Volume Measurements20

Vital Capacity measurement21

NIF Measurements22

Set-up Procedure for Siemens 900C23

Set-up procedure for SERVO 30028

Fisher Pakyl Heater Humidifier33

Management Endotracheal Tube Cuffs34

Apnea Test29

Trauma Unit Weaning Protocol38

CT Weaning protocol41

Post-op Protocols for CT Patients43

Independent Lung Ventilation 46

w/Servo 900C and Servo 300

Servo I Ventilator

VDR Instructions

BI-Vent Mode on Servo I48

HT-50 Newport Transport Ventilator53

Section Reviewed Date:

July 20, 1993, July 6, 1994, January 15, 1996 July 19, 1997, January 13, 2000, and April 23, 2000, May 2002, May 2003, October 2005, May 3, 2006, January 2007

May 2007- Apnea Test

Approved By:

Anna M. Ambrose, MS RRT Director

Vanderbilt University Hospital Respiratory Care Department

Policy and Procedure Manual

Section: F Continuous Mechanical Ventilation

Reviewed/Revised date: July 6, 1994, January 15, 1996, July 18, 1997,

June 1998, April 18, 2000, June 2003, May 2006, January 2010

Policy:Mechanical ventilation for all patient populations:

a) Equipment Available

b) Physician’s Order

c) Indications

d) Patient/Ventilator Monitoring

e) Ventilator Parameter Changes

f) Infection Control (see section M)

g) Transport Policy

h) Discontinuing/Withdrawal of Mechanical Ventilation

a). Equipment available:

Siemens 300
Siemens I Adult Only software application
VDR Percussionaire Ventilator

Operational manuals are located in the Respiratory Care Department

b). Physicians Initial Order:

Volume-Cycled Ventilation

1.Mode of ventilation

2.FiO2

3.Frequency

4.Tidal Volume

5.Positive End-Expiratory Pressure (when appropriate)

Time/Pressure-Cycled Ventilation

Typically used in the Newborn population.

1.Mode of ventilation

2.Peak inspiratory pressure

3.Inspiratory time

4.FiO2

5.Frequency

6.Positive End-Expiratory Pressure (when appropriate)

Pressure Controlled Ventilation

1.Mode of Ventilation

2.Peak Inspiratory Pressure

3.Inspiratory Time or I:E ratio

4.Frequency

5.FiO2

6.PEEP

7.Pause Time if using

Pressure Support Ventilation

1.Mode of Ventilation

2.Pressure Support

3.FiO2

6.PEEP

Section: F Continuous Mechanical Ventilation (Continued)

c). Indications:

Diseases and conditions leading to Respiratory Failure. These are categorized in three large groups: The following indications are appropriate to any patient population.

1.Those that cause impaired ventilation.

2.Those that impair alveolar-capillary gas exchange.

3.Those that cause ventilation-perfusion abnormalities and venous admixture.

Clinical Signs of Respiratory Distress /Respiratory Failure

The following clinical signs may be observed in any patient population. The last 3 are especially prominent in the pediatric patient but not limited to these.

1.Poor chest expansion

2.Diaphoresis

3.Mild hypertension

4.Tachycardia

5.Tachypnea

6.Bradypnea

7.Apnea

8.Peripheral vasoconstriction

9.Mental confusion (usually late)

10.Bradycardia (usually late)

11.Cyanosis (usually late)

12.Hypotension (usually late)

13.Chest retractions (Pediatric)

14.Nasal Flaring (Pediatric)

15.Stridor/Grunting (Pediatric)

Monitoring and Maintaining Patients on Mechanical Ventilation:

d). Patient/Ventilator Monitoring:

1.All mechanical ventilators (with the only exception being those ventilators used to deliver anesthetic gases) in this institution will be monitored and maintained by the Respiratory Care Department.

2.Ventilators will be routinely checked at least every 4 hours around the clock. This check will include but not be limited to:

a.All set parameters with written/ physician orders

b.Appropriate delivery and mechanical function of the set parameters

c.Alarm status - appropriately set, functional, and audible

d.adequate heat and humidity

e.Presence of a functioning manual resuscitator, PEEP valve if appropriate

f.Patients breath sounds, chest excursions, heart rate

Oxygen saturation
DO NOT UNDER ANY CIRCUMSTANCES SCRATCH OUT ERRORS. The correct way to note an error is to draw a single line through it and write error next to it and your initials.

i.Bronchial hygiene

j.End tidal CO2 (when in use)

3.Measurements of spontaneous Tidal Volume, Minute Volume, Vital Capacity, and NIF will be done as per physician order. Record the values on ventilator flow sheet at the bedside

4.When ABGs are drawn by an RCP on a ventilator patient, a complete check of the monitored parameters is to be done.

5.FiO2 must be analyzed during the first ventilator check for each shift, unless the ventilator has a built in oxygen analyzer.

Cuff pressures are to be checked at the beginning of the day shift and when airway pressure changes dictate. Maintain pressure as low as possible with a no leak seal (leak should be present when using the VDR ventilator). The goal is to maintain a cuff pressure at or below 20 cmH2O. Anytime cuff pressure has to be maintained at a pressure greater than 30 cmH2O the Attending Intensivist is to be notified. The physician, date and time notified should be documented on the ventilator flow sheet.

Section: F Continuous Mechanical Ventilation (Continued)

7.Gas delivery temperature should be monitored at a point as close to the patient as possible. Temperature of the inspired gas should be maintained between 30-35oC unless a HME device is in use (heat moisture exchanger).

8.Plateau pressures are measured with the first ventilator (pending mode of ventilation being used) check of each shift and as clinically indicated. Any significant changes in these pressures notify the physician.

e). Ventilator Parameter changes:

1.Ventilator settings do not guarantee optimum ventilator performance, and for continuity of patient care, a respiratory care practitioner must make all routine physician orders for ventilator changes. An Attending physician may make Stat or emergency orders. All ventilator changes must be thoroughly documented on the ventilator flow sheet by the individual making the changes.

The respiratory care practitioner must be notified as soon as possible when a physician has made a ventilator change to insure delivery of the desired settings.

All ventilator changes will require a physician's order unless using an approved protocol.

3.With ALL VENTILATOR CHANGES you must document as a minimum (with the exception of FiO2 changes):

 parameter you changed

 other parameters affected by that change

 date and time.

FiO2 changes-a complete check is not required when a FiO2 change has been made. Document the SPO2 reading after the change has been made and analyzed.

4.Changing Pressure Support levels and SIMV rates can significant y affect a patient’s minute volume. To adequately evaluate the patient’s response to the change, you should note their tidal volume after (PS change), minute volume and frequency.

f). Infection Control-Mechanical Ventilation

See Section M

Exterior cleaning and preparation of the ventilator:

1.Cover and remove equipment from the patient’s room. Remove all external circuitry and dispose. VDR ventilators- bring the entire unit to the department for Support Staff to disassemble and pasteurization.

Spray and wipe off entire surface with an approved hospital disinfectant.

3.Replace all disposable filters. Prepare ventilators for patient use with new circuitry. Place clean equipment cover over the ventilator.

g). Discontinuing/Withdrawal of Mechanical Ventilation

After successful ventilator weaning has been completed the Respiratory Therapist with physician's orders may remove a patient from the ventilator and extubate patient.

Withdrawal from mechanical ventilation support must be done by the ordering Physician on any patient that has not been through a weaning trial.
Respiratory Care Department Policy/Procedure Manual

h). Transport Policy for ventilator patients: Revised 6/10/98

In house transports:

To Radiology etc. Respiratory Therapist accompanies the patient that requires mechanical ventilation and brings a portable pulse oximeter if one is not part of the portable monitoring equipment. When going to CT or MRI you may use the ventilator in the corridor by CT scan or you may use the transport ventilator. The Respiratory Therapist is to accompany the patient during the transport off the unit; they are to maintain the airway and ventilation. Upon arrival at your destination connect to wall oxygen and air source.

Monitoring-Documentation- the ventilator flow sheet is to accompany the patient during the transport to document ongoing assessments. Prior to leaving the area the patient is to be assessed for adequate ventilation and oxygenation after being placed on the transport ventilator. This is to be done by documenting if portable transport ventilator used: Alarms set and checked, Tidal Volume set, Resp. Rate set, FiO2, Breath sounds, SaO2. When a manual resuscitator bag is used document: breath sounds, SaO2, bag and oxygen used, then complete a ventilator check when you get to your destination and upon return the intensive care unit. In Mediserve use the ventilator transport template only once, all other check uses the routine ventilator check template.

Outside of the Hospital transports for Ventilator patients:

Patients receiving mechanical ventilation that need to be TRANSFERRED from Vanderbilt to another institution whenever possible should have a Respiratory therapist accompany them in the ambulance unless ambulance staff are adequately trained. At no time is a Vanderbilt Transport Ventilator to be placed on the patient in an ambulance without a RT present in the ambulance.

Monitoring-Documentation:

Prior to leaving the area the patient is to be assessed for adequate ventilation and oxygenation after being placed on the transport ventilator. This is to be done by documenting if a portable transport ventilator used: Alarms set ,checked and audible. Tidal Volume set, Resp. Rate set, FiO2, Breath sounds, SpO2.

When a transport team with a Resp. Therapist or a RN comes to pick up a patient the VUH RT staff need not accompany the patient. Remember the overall purpose of this policy is to ensure there is appropriately trained personnel and equipment transporting these patients safely to their destination.

Revised August 24, 2000

Heat Moisture Exchanger Guidelines (HME) Protocol

Appropriate uses of a HME:

 Adult Ventilator patients

Tidal Volumes greater than or equal to approximately 500mls

Endotracheal tubes greater than or equal to 7.5 mm

Each shift the therapist must assess the patient for the following items that may decrease the efficacy of a Heat Moisture Exchanger, and the patient may need to be placed on Heated Humidity. Insuring adequate humidification is a very important assessment to be made at each ventilator check by the Respiratory Therapist.

Bloody secretions
Large amounts of secretions
Tidal volumes less than 500 mls
Minute ventilation greater 10 LPM
Endotracheal tubes smaller than 7.5 mm
Patients prone to have mucous plugging

Policy/Procedure:Home Ventilator use in VUMC

Objective:To provide patients with ventilator support that they currently use or will be using in the home setting.

Equipment:Patient’s existing home ventilator or home ventilator from a Vanderbilt approved home care company.

One non-heated wire ventilator circuit

One heater/humidifier unit supplied by the selected Home Care Company

Wright’s respirometer

O2 supply tubing, flowmeter and tee adapter with nipple for patients receiving supplemental oxygen

External PEEP valve if applicable

Procedure:

All life support equipment must be tested for functionality and electrical safety prior to use in VUH. Patient’s bringing ventilators from home or other health care facilities must have their ventilators checked for functionality and electrical safety prior to use inside VUH. For adult patient’s: patient should only be placed on these home ventilator 24 hours prior to discharge- see hospital Policy regarding Mechanical Ventilation.

Verify physician order. The physician order should include the following at minimum;

Respiratory rate
Tidal Volume
FIO2
PEEP level if applicable.

Assemble the ventilator circuit, humidifier and PEEP valve assembly

(If required)

Attach the tee adapter with nipple if supplemental oxygen is to be added to the system. Connect o2 supply tubing from flowmeter on wall to nipple adapter if adding O2 to system. Attach analyzer near the patient on the inspiratory limb of circuit to analyze sample. Note: this is only an approximation of the FiO2, as the patient’s minute ventilation changes for any reason this FiO2 will change, therefore it is imperative that the patient’s SaO2 be closely monitored. The initial flowrate will have to be titrated to the affect on patient’s oxygen saturation.

Pressure check the ventilator, explain procedure to patient and connect ventilator circuit to patient.

Adjust inspired gas temperature between 33-37 degrees C or use an HME.

Stay with patient to ensure adequate SPO2 and general comfort with ventilator.

Set all alarm limits

An arterial blood gas (venous at MD discretion) may be drawn 30 minutes after the patient is placed on the home ventilator, or ETCO2 and SpO2 may be used in place.

Attach Wright’s respirometer to expiratory port on circuit, measure expired tidal volume and perform a complete ventilator check on the patient’s bedside ventilator flowsheet.

Complete documentation and charging by charting the procedure in the Medilinks application. Charges are the same for the home ventilator as they are for all other ventilators.

Infection Control

The ventilator circuit, heater chamber and PEEP valve assembly will be changed on a PRN basis.

Respiratory Care Department

Policy and Procedure Manual

Section: F Continuous Mechanical Ventilation

Effective Date: January 15, 1996

Reviewed/Revised Date: July 18, 1997, April 18, 2000, June 2003, December 2008

Policy/Subject:Monitoring guidelines:

BI-PAP “Non-Invasive Mechanical Ventilation”
Blow-by
Mask/ET CPAP

BI-PAP and Chest Cuirass (Turtle Shell)

These patients need to have a ventilator flowsheet kept at the bedside.
They are to be monitored at least every 4 hours just as Continuous Mechanically ventilated patients are.
Parameters to be monitored or measured will be determined by the type of equipment being used.

BI-PAP monitor the following parameters:

Inspiratory and Expiratory pressures, IPAP and EPAP
Amount of Oxygen added to circuit or FiO2
Total Respiratory Frequency
SaO2/HR
Breath sounds

Turtle Shell Cuirass:

Set Respiratory frequency/Total if on IMV
Negative Pressure
SaO2/HR
Breath sounds

Trach collar or Spontaneous breathing trial

These patients need to have a ventilator flowsheet kept at the bedside.
They are to be monitored at least every 4 hours just as Continuous Mechanically ventilated patients are.

Minute Ventilation
Tidal Volume
Total respiratory frequency
SaO2/HR
FiO2
Breath sounds

Initial assessment should be done of Minute Volume, Tidal Volume. These parameters need to be reassessed at the end of all Spontaneous

breathing trials.

Upon initiation and completion of all Blow-by trials and CPAP trials, there should be measurements made of the patient's minute volume, tidal volume, respiratory rate, heart rate and oxygen saturation.

This information will be important to determine how well the patient tolerated the trial other than just an arterial blood gas. Frequently arterial blood gases do not match the clinical picture of many patients and the physician will require further information. Use the Routine Ventilator check template in MediLinks.

Home CPAP Use NOTE:

For patients admitted with their own home CPAP Unit (established Home CPAP User) Bio-Med must check the device prior to placing the patient on the unit. If this occurs on a weekend or at night, the unit will be checked on the next working day. The patient will be placed on one of the Vanderbilt BI-PAP devices. They will be charged for any supplies used, and the daily rental of the device.

Once the patients are placed on their own device and they are they are on the general floor and stable we do not need to monitor these patients. Should a problem arise the patient’s nurse will call the Respiratory Care Department.

If their is a problem with their unit place patient on our unit and then we will need to monitor the patient Q4H as stated above and they will be charged as all other patients.

Respiratory Care Department

Policy and Procedure Manual

Section: F Continuous Mechanical Ventilation Discontinuation

Effective Date: 7/11/94

Revise/Review Date: June 1997, April 18, 2000, June 2003

Policy:

All patients that are successfully extubated are to have the ventilator removed from the bedside, cleaned and placed in the unit's storage area prior to the end of the current shift.

If overtime is necessary please notify your supervisor.

Purpose:

To prevent any additional charges billed to the patient when the ventilator is not in use.

Exceptions:

A physician may enter an order to have the ventilator left at the bedside on Stand By.

The patient is charged the same charge, there is no Stand by ventilator charges.

Respiratory Care Department Policy

HAZARDS OF CONTINUOUS MECHANICAL VENTILATION

Airway:

The hazards of any artificial airway (tracheostomy tube or Endotracheal) always are relevant when discussing the hazards for CMV. Airway obstruction due to kinking, secretions, or movement of the tube into the right main stem bronchus.

Therapist Response: Monitor breath sounds with each ventilator check, and significant changes for example diminished on left side of chest. Notify physician. Maintain adequate humidity and temperature of inspired gases. To be monitored with in-line temperature probe.

Power/Gas Failure:

All ventilators have an audible, visual or both indicator alarm(s).

Therapist Response: Have manual resuscitator bag set up at the bedside of all patients on mechanical ventilators. Manually ventilate patient and notify supervisor to assist you.

Hypotension:

Decreased venous return to the right heart may cause a decrease in blood pressure.

Therapist Response: Notify physician, check ventilator parameters to use the best I: E ratio, and smallest tidal volume tolerated, or any other maneuvers to lower MAP if the patient will tolerate them.

Tension Pneumothorax:

The presence of air in the thoracic cavity under pressure. The presence of subcutaneous emphysema, while not necessarily dangerous in itself, should alert the therapist to the possibility of barotrauma. Again frequent chest auscultation and monitoring vital signs and physicians reviewing serial chest roentgenogram are all necessary for detection of complications. If the patient does exhibit the clinical signs of tension Pneumothorax (a. change in vital signs, b. Unequal breath sounds, c. Dramatic color change, d. Increased ventilating pressures) notify physician immediately, e. decreasing SpO2.