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Monday, August 25, 2008

The five levels of a good ventilator protocol

I have found from my studies that there are five different levels of a ventilator protocol.

Level 1: Ventilator set-up
Level 2: Ventilator management
Level 3: Ventilator weaning
Level 4: Ventilator extubation
Level 5: Other

So, the first level of a true ventilator protocol is the set-up. Pretty much here you need a standard range of settings to be adjusted for each particular patient, and each particular disease state.

For example, we have a standard tidal volume range of 6-10cc/kg ideal body weight. If a patient presents with an acute lung injury (ALI), we start at the low end. Otherwise, we adjust this range depending on the patient.

Basically, a vent set-up protocol has in it anything you need to set up a ventilator: RR, VT, PEEP, FiO2, and mode.

Whether you start at 40% FiO2 like we do and adjust accordingly to maintain an SpO2 of 92% (or an appropriate sat for the patient), or whether you start at 100% and work down depends on your particular institution.

What else do you need to set-up a vent. Well, you need more than your basic ventilator settings. You also might want some sedation, an NG, soft restraints if needed, etc.

So, level one is the set-up level. We have this in our protocol that is already enacted (see ventilator set-up link above).

Level 2 is a ventilator management protocol. This, I am afraid to admit, is something that is missing from our ventilator protocol.

Ventilator management would require allowing the RT to make changes in the original ventilator settings without directly talking with the physician. This we cannot do at Shoreline.

I will go into more detail on a ventilator management protocol that I would like to see enacted here in a later post.

Level two would include something like the following:
  1. If CO2 is greater 45, increase rate. If ABG still not normalized, increase VT in increments of 50cc
  2. If CO2 is less than 35, decrease the rate. If ABG still not normalized, decrease the VT in increments of 50cc.
  3. FiO2 should be adjusted to maintain an SpO2 of 92% or to maintain a value normal for patient or condition, or as directed by physician.
  4. If FiO2 at 100% and PO2 less than 60, PEEP should be implemented. I suppose here you might add a PEEP study as part of the protocol.

I'm not writing a protocol here, just providing some examples of what might be seen in a ventilator management protocol.

Level 3 would include anything that would allow you to wean a patient off the above mentioned settings once the patient is normalized. Here you would need to have some type of criteria for weaning, of which we do at Shoreline (check out this link to see the basic weaning criteria).

Now, our weaning criteria does not include everything that is mentioned in that link, but the basic idea is there: The patient is not on any vasopressors, the HR has to be within a particular range, the BP cannot be >20% of patient normal, the condition that placed the patient on the vent must be resolved, the patient must be awake and alert, secretions must be thin and minimal to name a few.

The patient also must require less than 40% FiO2 and have an PEEP of 5 or less while maintaining an appropriate SpO2.

Whatever weaning criteria your particular hospital has will basically depend on the physicians at your institution, or the requirements recommended by your hospital committee.

So, once the patient meats weaning criteria, you have the ability to wean a patient's rate and tidal volume to encourage a patient to breath on his or her own.

Now, we do not have the ability to decrease rate or VT, but we do have the ability to put a patient in automode. So, kind of in a roundabout way, we do have a weaning protocol. Still, it would be nice to be able to adjust the VT and RT, which would allow me the ability to adjust the patients minute ventilation even while a patient is in VS mode.

Because, ideally, the minute ventilation the patient is maintaining on the ventilator should be equal to the minute ventilation he would have if he were off the ventilator. Sometimes, however, especially on the Servo 300A, this minute ventilation is not the same as what is dialed into the machine, and must be adjusted by the RT -- but this doesn't always happen.

Anyway, once the patient is in volume support, the weaning process begins. Yet still, at my hospital, it is up to the doctor and not the RT to make the next step. Thus, we do not have a true ventilator weaning protocol.

While we cannot wean RR and VT, we do have the ability to wean FiO2 to maintain an appropriate SpO2.

Thus, we kind of have a weaning protocol, but we aren't quite there all the way yet. This, however, is something we will be working on in the coming weeks -- this and a true ventilator management protocol.

Level 5 is a ventilator extubation protocol. We do have this, and you can check out the link above to see a good extubation protocol. This affords us RTs the ability to assess the patient daily for weaning criteria, and perform weaning parameters if the patient meets criteria.

Once a patient meets criteria, we have the ability to do a spontaneous breathing trial (SBT). Once the patient passes that, we do weaning parameters again, draw ABGs, and call for order to extubate.

Of course the patient could fail, and this would require the patient to stay on the vent another day. However, just because a patient fails a daily weaning trial does not mean the physician, RT and RN should stop thinking about weaning -- that should never stop.

In fact, the weaning process should start as soon as the patient is placed on the ventilator. And that is why I think it would work out to the benefit of the patient if all hospitals afforded RTs with the ability to do at least the first four levels of a ventilator protocol.

Level 5 would pretty much depend on what kind of a hospital you have, and whether your doctors have faith in your RT department to be independent in the care of certain types ventilated patients, such as ARDS, ALI, Sepsis, trauma, neuro, cardiac, etc.

For example, an ARDS/ALI ventilator protocol would be included here. This would allow the RT to adjust the ventilator strategy according to the type of patient on the vent. Being a smaller hospital that transfers most of these patients, I doubt our doctors would approve of this type of protocol for my particular hospital.

However, for the larger hospital in the Bigger Cities, I know the ARDS/ALI protocol that I wrote about in the link above is implemented and working well.

Still, I would be flabbergasted if it were incorporated here at Shoreline. But, even though it's not, I think it's important for us RTs here to have an understanding of such a protocol, as we too can participate in making recommendations on the patient's behalf to the physician -- or at the very least have an understanding what the doctor is up to.

We don't need a cardiac, neuro or trauma protocol here as most of those patients are shipped to whatever larger hospital will take them. Maybe that will change some day, but currently it's been a challenge to draw in those types of physicians (mainly because if we get one, he will have to be on call for himself 24-7, which is not a good selling point).

Well, there you have it: the five levels of a ventilator protocol. Not counting level five, we here at Shoreline are about 70% of the way to a full fledged ventilator protocol. What percent of the way is your hospital?

An RT department that has all of steps 1-4 would be at 100%. An RT department that has all five levels would be at 125%. I suppose if you have all of levels 1-4 and a cardiac, and a neuro, and an ALI/ARDS, and whatever other protocols there are for ventilators out there, you might get all the way up to 200+%.

That would be really cool.

If we had that, and a full fledged RT Treatment protocol that allowed us to only do
breathing treatments on those patient's who need them, this RT would be in RT Heaven.


Amy said...

An asthma blog, huh? Terrific idea--let me know when you get it started!

Respiratory Therapy eBlog said...

Excellent post! This type of information is useful for those of us that are just starting out. Keep us updated as your hospital protocol develops.

DD2 aka Debonair Dude said...

Great post, keeps me

Glenna said...

In one of your paragraphs on weaning you said something the FiO2 must be less than 40% and the "FiO2" must be 5 or less. Did you mean the second FiO2 to be Peep?

Just you start with 0 Peep and then only add Peep if the patient has a low PO2?

Freadom said...

NOPE. It was an honest typo. Where did my editor go? I mean to write 5 of PEEP. Usually that's where we start. Thanks.

Glenna said...

So you guys start at 5 of Peep and wean down to zero? I'm just curious. This is very different from our protocols so I'm curious how other people do it.

Freadom said...

No. We never go below 5 of PEEP. For some reason our protocol says that PEEP should be 5 or less for patient to meet weaning criteria. But, NO, PEEP should never be less than 5 in my opinion. However, I suppose it's worded such in case some doctor gets a crazy idea.

Glenna said...

Okay. GOOD! We're the same way. Actually, we rarely go below 7 of Peep except in neonates. Although...I have heard that some of my colleagues at hospitals where the docs don't like peep and don't understand Bivent mode will say "How about we go to Bivent since the peep is set to zero?" The doc will say "sounds great!" and the RT's will all snicker. And the patient gets well.

Freadom said...

Hm, I think you got me there, Glenna. We do have one Servo i, but it's relatively new to our department. I'll have to look into this BiVent feature.