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Wednesday, May 12, 2010

Ventilator Management Protocol

I am presently working on writing the ideal ventilator management protocol to go with our extubation protocol. Please help me out by adding any ideas or recommendations for the protocol below:

(For a printable copy, click here)

1. Scope: A Licensed Registered Respiratory Therapist (RRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Certified Respiratory Therapists, respiratory students and assistants may not adjust Mechanical ventilators per protocol.

2. Policy:

A. The Mechanical Ventilator Management Protocol will only be initiated on patients ordered on Vent Management Protocol (VMP), or if the attending physician orders RT 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 volume
  • d. Changing in and out of volume support

D. The physician will be notified when:

  • a. The respiratory therapist wishes to initiate VMP on a patient who is not Currently 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 greater than 60% and PaO2 less than 60mmHg or SpO2 less than 90% with
5cmH20 PEEP.
  • e. When pre-determined therapy limits are reached, i.e. FiO2, Vt, PEEP, RR, etc.
  • f. When PEEP greater than 5 is indicated.
  • g. If PEEP greater than5 has been approved, and now PEEP less than 8 is indicated.
  • h. A RR greater than 30 or less than 8 is indicated
  • i. A VT greater than 10 ml/kg ideal body weight or less than 6 ml/kg is indicated.
  • j. If VT or PEEP is indicated that results in PIP greater than or = 40 or plateau pressure greater than 30.
  • k. Weaning success or failure
  • l. Increasing FiO2 above 50% is indicated to maintain sats
  • m. Change in PSV greater than 5 cmH20 is made
  • n. A change in tidal volume is made
  • o. 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 greater than 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 = or less
    than 200. If the PaO2/FiO2 ratio increases you know PEEP therapy is working.

    J. When considering the adjustment of FiO2, hemoglobin should be checked to ensure the absence of anemia. Hemodynamic data should be checked to ensure adequate circulation.

    3. Ventilator Management Protocol: The following are guidelines for use in stabilization and 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 greater than 90%)
    • d. In patients with COPD, adjust parameters to the patient’s “normal” values

    B. Obtain ABG or non-invasive oxygen saturation (SpO2) and end tidal CO2

    C. Adjust the ventilator settings to correct abnormal ABG and/or SpO2 and EtCO2 values.

    a. Abnormal PaCO2 greater than 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 less than 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 less than 60 mmHg or SpO2 less than90%, increase FiO2 in increments of 05% to obtain acceptable values.
    • 2. For hypoxia (Sa02 less than 92%)requiring greater than 60% FiO2, increase PEEP in steps of 1 cmH20 at a time to PEEP max (specific Dr. order required)
    • 5. With PEEP = or greater than 5 & PaO2 greater than 100 mmHg or Spo2 greater than 95%, decrease FiO2 in increments of 05% to obtain acceptable values.
    • 6. If the SpO2 or PaO2 is not adequate after any weaning attempt of the Fi02, increase the Fi02 to the previous setting. Continue weaning the Fi02 as tolerated by patient.

    D. Non-invasive monitoring or ABG criteria is not the absolute control for maintaining Ventilatory support. Sudden changes in cardiovascular status, respiratory rate, and color may mandate a change in ventilator parameters.

    E. Once patient is stabilized, and once the problem that resulted in the need for Ventilatory support has been resolved, the patient should be continuously monitored for indications for weaning (See Ventilator Weaning Protocol).

    4. Documentation:

    A. Initial assessment

    • a. An RT assessment will be performed within 15-45 minutes from start of ventilation.
    • b. Assessment will include evaluation of the patient’s general appearance, blood pressure, heart rate, breath sounds, ventilating pressures, volumes and ABGs.
    • c. Assessments may also include additional data, when available, such as EtCO2 and hemodynamic data.
    • d. Ventilator checks will be completed every two hours and documented accordingly. Checks will include ventilator settings, pressures, and essential alarms
    • e. Cuff pressure will be checked once per shift, and a minimum cuff pressure of 20 cwp will be maintained in order to minimize VAP.
    • f. All therapy will be documented in computer charting.

    B. Re-assessments

    • a. Regular assessment of general appearance, vital signs, breath sounds and Hemodynamic stability should be evaluated prior to and during any ventilator adjustment.
    • B. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters.

    5. References:

    1. Mechanical Ventilator Protocol, Retrieved from:

    2. Mechanical Ventilator Protocols, Retrieved from:
    3. CTICU Weaning Protocol, retrieved from:

    For a related article, check out "Ventilator Weaning Protocols" by Bill Croft @

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