What is PEEP? How to do a PEEP study?

PEEP is an abbreviation for Positive End Expiratory Pressure. It's a small amount of pressure above what is in room air that remains at the end of expiration.

The benefits of PEEP are.

1. Increased Residual Capacity. This essentially means that it increases the amount of air that stays in the lungs. This works to...
2. Recruit collapsed (atelectic) alveoli. This makes it so they participate in gas exchange. It also works to...
3. Keep alveoli from collapsing. It keeps alveoli open so the effects of fluid or atelectasis do not cause shunting. This also helps to reduce V/Q mismatching. This also makes it so you have an...
4. Increased PaO2 for a given FiO2. It's a good way of improving oxygenation. 
5. Decreases Cardiac preload and afterload. It reduces the amount of blood returning to the heart, and thereby reduces the amount of blood leaving the heart. In this way, it can help patients who are in heart failure (pulmonary edema) by reducing the amount of work their heart has to do to pump blood through your body. This also means that too much PEEP can be observed by drops in cardiac output, which can be measured by bloodpressure and oxygen saturation (SpO2). 
6. Reduction in tissue injury and inflammation. It prevents the alveoli from constantly opening and closing and thereby inuring them and causing inflammation, which may be associated with the development of ARDS. Studies have shown that it is protective against "ventilator induced lung injury." This is often called volutrauma. Volutrauma was more prevalent back in the days when it was thought that people on ventilators should be on higher tidal volumes, hence the old formula of setting tidal volumes based on 10-15cc/kg ideal body weight. This has now been lowered to 6-8cc/kg ideal body weight in order to prevent volutrauma. 

There are disadvantages of this.

1. Over-distention of alveoli. It causes too much air to stay in the lungs resulting in decreased cardiac output, as would be shown by blood pressure and SpPO2. There are certain instances where you would benefit from higher PEEP, although too much PEEP can lead to over-distention and volutrauma, which may mimic respiratory disease states. So, in such instances, you would want the highest PEEP that doesn't cause over-distention. (Described below is how to accomplish this with a PEEP study). Over-distention results in increased dead space, increased work of breathing, and medical disorders such as ARDS. 
2. Diminished Cardiac Function. As noted, PEEP that is set too high can decrease venous return and cardiac output. This can be measured by complex formulas, although the simplest way is by taking a blood pressure and monitoring pulse oximetry. 
3. Diminished Renal Function. May decrease renal blood flow resulting in diminished urinary output. So, this is another reason to keep PEEP as low as clinically possible, especially when you have a patient in heart or kidney failure. 
4. Increased Intracraneal Pressure. When venous return decreases, intracraneal pressure may increase. This is usually not clinically significant. However, if you have a patient who already has an elevated intracraneal pressure (ICP), such as due to a head trauma, this is something you'll need to watch out for. This is another reason to raise the head of the bed, as this may offset any increase in ICP (the other reason for raising the head is to prevent GERD, which can increase the risk for ventilator associated pneumonia). 

Now that you know about PEEP, along with its benefits and disadvantages, we can now get into how to perform a PEEP study. The purpose here is to determine the perfect PEEP for an individual patient at any given moment in time. Keep in mind here that the ideal PEEP may increase or decrease over time, especially as a patient's medical condition worsens or improves.

Here is the basics of any PEEP study.

1. Increase PEEP by 2-3 cwp every 20 minutes and continue to monitor the patient. You should write down the patients blood pressure and SpO2. If desired, you can also jot down the patients P/F Ratio and static compliance.
2. If static compliance, P/F Ratio &/or SpO2 increase, you know it's working. 
3. Stop when the patient's blood pressure and SpO2 start to drop. Also stop when the P/F Ration is equal or greater than 200. Also stop when the static compliance decreases. 
4. The required PEEP should be set at the PEEP setting used just prior to where the hazards of PEEP were observed. 
5. Do not increase PEEP if systolic BP is less than 90
6. Also, keep mean airway pressure (MAP) less than 15. This is one of the newer markers of too much PEEP. When it starts to drop, this is an early indicator that cardiac output is about to decrease. 
7. Ideally, static complliance should be between 60-100.

I also have a shortcut. Maybe I shouldn't teach you this, but here goes: essentially, based on the wisdom we learned above, all you really need to do is monitor pulse oximetry and blood pressure. If either starts to drop, then you know it's time to lower your PEEP by 2 cwp, which would be your ideal PEEP. This makes it simple. 

The optimal goal of any PEEP study is to find the optimal PEEP to maintain a desired SpO2 and PO2.

If any of my fellow respiratory therapists has anything further to add (any tips), please feel free to share.

(Post originally published on 8/9/08. It has been edited and updated by RT Cave Staff). 

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References:

1. Vincent, Jean Louis, editor, "Intensive Care Medicine: Annual Update 2002," 2002, Springer, pages 302-303
2. Criner, Gerard J., Rodger E. Barnette, Gilbert E. D’Alonzo, editors, “Critical Care Study Guide: Text and Review,” 2nd edition, 2010, Springer
3. Kacmarek, Robert M., James K. Stoller, Albert J. Heuer, “Egan’s Fundamentals of Respiratory Care,” 10th edition, 2013, Elsevier Mosby
4. Saura, Pilar, Lluis Blanch, "Conference Proceedings: How to set Positive End Expiratory Pressure," Respiratory Care, http://www.rcjournal.com/contents/03.02/03.02.0279.cfm, accessed 4/11/17
5. Respiratory Update: "Benefits, Contraindications, Adverse Effects for PEEP/CPAP," http://www.respiratoryupdate.com/members/Contraindications_for_PEEPCPAP.cfm, accessed 4/17/17
6. Valenza, et al., "Positive end-expiratory pressure delays the progression of lung injury during ventilator strategies involving high airway pressure and lung overdistention," Critical Care Medicine, 2003, July, 31 (7), pages 1993-08, https://www.ncbi.nlm.nih.gov/pubmed/12847394, accessed 4/11/17
7. Respiratory Therapy Cave: Respiratory Failure Lexicon
8. Respiratory Therapy Cave: ABG Lexicon

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).

1. Temperature greater than 100.4, <96 .8="" li="">
2. Fast heart rate, or greater than 90 beats per minute
3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)

C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Why protocols will not eliminate useless Ventolin orders

So one of my respiratory therapist friends, of whom I will not name here even though he said I could, sent me an email a while back explaining why it is that respiratory therapist driven protocols will never result in a decrease in treatment loads.

1. There will always be the belief that if the patient is short of breath we must do something
2. People sitting in leather chairs in Washington decided that in order to meet criteria for admission a patient must have needed at least 3 treatments in ER.  It eludes them that hospitals would have physicians order them just so the hospital can be reimbursed. 
3. People sitting in leather chairs in Washington decided that in order for a patient's stay to be reimbursed for certain respiratory conditions (pneumonia, CHF, COPD) the patient must have breathing treatments ordered.  This is under the fake belief that if treatments aren't needed why keep the patient.  It eludes them that there may be other reasons for keeping the patient, nor that ventolin does nothing for non-bronchospastic lung ailments. 
4. They are convinced ventolin cures pneumonia
5. They are convinced ventolin cures heart failure
6. They are convinced ventolin enhances secretion clearance

Generally, physicians and administrators and politicians tend to ask this question when making a decision regarding respiratory therapy: "Does it feel good."  For instance, should we order treatments for pneumonia? Well, does it make me feel good.  Yes!  I feel like I'm doing something important and helping people out.  Yes! It makes the patient feel better, or at least like we are doing something useful

Generally, respiratory therapists and nurses ask the following question: "Does it do good? For instance, should we order treatments for pneumonia?  Well, does it do any good?  No! So then we recommend it not be ordered.  

We are usually trumped by too many people ask the wrong question. If ever there came a time when "Does it feel good?" is replaced by "Does it do good?", then and only then with true bronchodilator reform occur. 

Need I go on.  

Ventilator Pressures: Static -vs- Plateau

With every ventilator check it is important to measure how much pressure is needed to deliver a tidal volume. There are two different pressures that we typically check: Peak Inspiratory Pressure (PIP), and Static Pressure, also known as plateau pressure (p-plat).

Now to define these two pressures:

• PIP:  This is the pressure at peak inspiration with flow.  
• p-plat:  This is the pressure at peak inspiration after holding your breath.  This is the measure of pressure without flow. 

The best way I can explain these two pressures is by having you take in a deep breath.  Take in a breath as deep as you can.  PIP is the pressure right at the end of inspiration.  Now, hold your breath and relax your chest while still holding your breath.  This is the pressure minus flow.  It is called static or plateau. 

These two pressures are important.  They should both be recorded with each ventilator check.  Now, here is how they can be used.

1.  To monitor resistance and compliance.  

• Both PIP and p-plat go up, or are trending up together, this is probably due to the fact that the patient's lungs are becoming stiff, or less compliant.  In this case, the static compliance may be decreasing.   Efforts should be made to keep the static compliance under 30, such as decreasing tital volume.  This is one reason why low tidal volume strategies are used on patients with ARDS. 
• PIP goes up and p-plat stays the same.  This indicates increased resistance.  It can be measured by taking PIP and subtracting p-plat = resistance.  It may indicate increased resistance, meaning the patient work of breathing (WOB) will be increased, or the patient has to work hard to obtain a desired tital volume.  There are three causes of this:
• Water in the circuit.  Solution is to empty this water (empty water traps)
• Secretions in airway.  Solution is to suction
• Bronchospasm.  Treatment is bronchodilator

Squiggly lines may indicate water in tubing or secretions in airway.

There is another simple method of observing if secretions or water in the circuit are the cause of increased resistance.  When this happens the you will probably observe squiggly lines on the graphics.  When the water is removed from the circuit, or after suctioning, the lines will be normal again.  

A rule of thumb is, if you see squiggly lines, check the circuit for water.  If that doesn't solve the problem, suction should be the next thing to try.  

A recheck of PIP and p-plat after resolving these problems SHOULD result in PIP decreasing, and thus lowering the resistance.  The patient should now be able to breathe easier, or work of breathing should be reduced.

2.  To determine readiness to wean.  Such as, if the patient is requireing more than resistance to obtain adequate ventilation, then the patient is not ready to wean.  Determine resistance by the formula PIP minus p-plat. This is one of the nice things about the servo ventilators, because they have volume support.  In this mode the patient determines his own PS and flow, and therefore you can see how much PS is needed to obtain a tidal volume.  When we want to see if a patient is ready to wean, we turn the patient into volume support.  If the support drawn in by the patient is greater than resistance, the patient is not ready to wean.

Example.  The patient is in assist control or pressure regulated volume support.  Check the PIP and p-plat. Use the formula: PIP minus p-plat = resistance.  PIP =15, P-plat = 10, resistance = 5.  Switch the patient to volume support.  If the pressure is using a PIP of 10, then you know this patient is requiring too much assistance to maintain an adequate tidal volume, and is not ready to wean.  If the patient is requiring only a PS or 5, then he is probably ready to wean.

However, determining readiness to wean involves more than just looking at numbers.

3.   To determine adequate pressure support (PS).  Frequently it occurs that a physician, or a therapist, just makes up a number for PS.  Yet the purpose of PS is to make up for resistance caused by the circuit and endotracheal tube, to make it so it doesn't feel to the patient that he is breathing through a straw.

• PIP minus p-plat = resistance of tubing, endotracheal tube, and airway.  
• Example.  PIP 20 and p-plat 15 = resistance of 5
• 5 should be more than what is needed to make up for the resistance of tubing and ETT, and should make ventilator breaths feel more like normal breathing.  
• Usually this number is somewhere around 5.  However, in patients with lung disease, it may be higher.
• If PS is set at lower than resistance, in this case 5, this results in increased WOB, and this can cause anxiety.  It may result in unnecessary sedation, and failure to wean. 

So, hopefully this information will help you better manage your ventilator patients.  If you find this useful, please let me know.  If you have more tips to add, please feel free to leave a comment below. 

This post was originally published on August 22, 2008 on respiratory therapy cave.  It was updated and edited for accuracy and simplicity by Rick Frea. 

Further reading:

• Medscape, Benjamin D. Singer, Basic Invasive Mechanical Ventilation
• Considerations for readiness to wean
• Acute Respiratory Distress Syndrome
• Respiratory Therapy Formulas and Normal Values

The idea RT Aerosol Protocol

I'm not a fan of protocols that are based on an algorithm.  I also do not like utilizing points systems to determine frequency of therapy.  I think the best approach is simple common sense.

In a points system you assess the patient and review the chart to determine breath sounds, pulse, respiratory rate, and level of shortness of breath.  Then you give the patient a points based on what you find.  The total points score will be between 0 and 12.  This will help you determine the frequency of therapy.

• A total point value of 0-4 = PRN
• A total point value of 5-7 = QID
• A total point value of 8-10 = Q4/ PRN
• A total point value of 11-12 = Q2

I'm not a fan of these systems at all.  First off, wheezes are totally over rated.  You could have someone with a throat wheeze, or laryngospasm, or a cardiac wheeze, and that can completely be confused for bronchospasm wheeze.  Plus dyspnea can be caused by an assortment of disorders, bronchospasm being just one.  

I think a better approach would be to determine need for treatment by giving one treatment, assessing whether or not it did any good, and then ordering subsequent treatments based on that.  

I also think that no one should get a treatment unless they are short of breath.  If you go into a room to assess a patient and he is sleeping, or otherwise is breathing fine, then you should not give the treatment.  If the doctor wants to give prophylactic beta adrenergic medicine, then he can order long acting beta adrenergic therapy.  

Bronchodilator aerosol therapies should be ordered as prn for most patients, and QID for patients who are difficult to assess, or who cannot tell you how they feel.  The only aerosolized medicines that should be given on a frequency are medicines like Pulmocort and Brovana, which need to be given twice a day.  

Emergency Room RT Consult

The following is an ideal emergency room RT Consult, or aerosolized medication protocol for ER, that we have been working on. If anyone has suggestions to make this even better, please feel free to suggest.

For a printable copy of this protocol, click here.

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EMERGENCY ROOM RESPIRATORY THERAPY CONSULT (RT CONSULT)

Protocol Content:

1. Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students and assistants may perform medicated aerosol therapy, they may not adjust therapy per protocol.

2. Emergency Room Aerosolized Medication Protocol

A. When a physician, physician’s assistant, RN, or RT orders RT Consult or RT to assess and treat, the RCP will be paged for a RT Consult. The RT may initiate this protocol working within the following guidelines.

B. Upon receiving the order, the respiratory therapist will assess patient and select appropriate therapy and medication.

C. The following conditions are accepted indications for bronchodilator therapy:

• a. Bronchospasm/ wheezing
• b. Asthma/ reactive airway disease
• c. Diminished lung sounds
• d. COPD
• e. Prolonged expiratory phase
• f. Obstructive defects of PFT
• g. Impaired mucous clearance

D. B. Medications available per protocol:

• a. Albuterol 0.25-0.5cc
• b. Duoneb 1 unit dose vial
• c. Atrovent 1 unit dose vial
• e. Xoponex 0.63-1.25mg
• f. Albuterol MDI

E. The following assessment and chart findings will be evaluated and documented as appropriate:

• a. Vital signs (HR, RR, BP)
• b. Current FiO2
• c. Pulse oximetry
• d. PEFR (if indicated)
• e. Patient assessment results (lung sounds, work-of-breathing, cough, secretions)

F. Peak Expiratory Flow Rates (PEFR) will be done on asthmatics before and after the initial treatment according to the patient’s tolerance to perform the maneuver, or this will be performed as soon as patient is able.

G. Following an initial assessment, an initial treatment will be given to patient’s who meet the indications for therapy. If patient does not demonstrate improvement in PEFR, relief in Dyspnea or reduction in expiratory rhonchi or wheezing, the treatment may be repeated. If necessary, a third treatment may also be given.

H. If there is no improvement after repeated treatments, the physician will be informed the patient is not responding to therapy. Further therapy will be given only with physician notification.

I. If respiratory therapy determines patient would benefit from a MDI bronchodilator for home use, and the patient meets the criteria for MDI use, an Albuterol MDI may be administered to patient, and patient will be instructed on correct use of this MDI. The recommended dose and frequency is Q4-6 hours as needed.

J. Criteria for MDI use:

• 1. Can physically perform the maneuver.
• 2. Can follow directions.
• 3. Is cooperative and alert.
• 4. Can take a slow deep inspiration.
• 5. Can hold breath for at least five seconds.
• 6. Is able to perform a return demonstration.
• 7. Respiratory rate less than or greater than= 25

3. Documentation:

A. Initial Assessment:

1. The respiratory therapist will write the order in the patients chart including medication, dose and frequency per RT Consult if the ordering physician did not already do so.

2. Initial orders written by the physician do not have to be rewritten by the respiratory therapist unless clarification or adjustments are required.

3. All therapy will be documented in the computerized charting system.

B. Re-assessments:

1. All patients will be assessed with every treatment to determine the patient’s current pulmonary status and effectiveness of the aerosol therapy.

2. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters.

REFERENCES:

1. Spectum Health (2005) Aerosolized Medication Protocol, Grand Rapids: Spectrum Health.

2. Northern Michigan Hospital (2004) Bronchodilator Protocol, Petosky, MI: Northern Michigan Hospital.

3. Covenant Health Care (2005) Respiratory Therapy Consult, Saginaw, MI: Covenant Health Care.

4. “Guidelines for Preparing a Respiratory Therapy Protocol.” Retrieved August 23, 2007, from http://www.aarc.org/members_area/resources/protocol_guidelines.html
5. “Respiratory Therapy Protocols.” Retrieved August 4, 2007, from http://www.st.alexius.org/about_stas/services/Resp_Care/protocols.asp?printable=1

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Word of the dayAttenuate: To make thinner or weaker; to make slender; to rarify; to enervate

A few stupid doctor's orders is all it takes to attenuate my energy supply.

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RT consult or aerosolized medication protocol

I am presently working on writing the ideal RT Consult, otherwise known as an aerosolized medication protocol. Please help me out by adding any ideas or recommendations for the protocol below:

(For a printable copy of the protocol click here. For a printable copy of the forms, click here for side one and here for side two)

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RESPIRATORY THERAPY CONSULT (RT CONSULT)

Protocol Content:

1. Scope: A Licensed Registered Respiratory Therapist (RRT) or Certified Respiratory Therapist (CRT) who has successfully completed and passed all competencies related to patient assessment and protocols. Although respiratory students and assistants may perform medicated aerosol therapy, they may not adjust therapy per protocol.
2. Policy:

A. The Respiratory Aerosolized Medication Protocol will be initiated on patients ordered on aerosolized medications, or when a physician orders “respiratory consult”, or RT Consult, or when the physician writes for “RT to assess and treat.”

B. The physician will be notified when:

• a. The respiratory therapist wishes to initiate the protocol on a patient who is not currently on therapy.
• b. An initial therapy of Q2 or greater is indicated.
• c. If the patient’s condition is deteriorating requiring more frequent therapy other than the occasional PRN treatment, or patient feels no relief after 24 hours.
• d. The patient refuses therapy that is indicated.
  e. The respiratory therapist wishes to adjust any non-protocol medications.
• f. The goal of therapy is not clear.
• g. The respiratory therapist is unable to determine appropriate therapy.

C. A respiratory therapist may initiate this protocol on any patient when asked for an assessment of respiratory distress. One treatment may be given, if deemed appropriate by the therapist, prior to a physician’s order for RT Consult. Once the treatment is given, the physician will be contacted with the results of the therapy, and to obtain an order for RT Consult.

D. The respiratory therapist will assess, order, monitor, adjust and terminate the patients medicated aerosol treatments according to the patient’s clinical needs and protocol boundaries.

E. The physician may write an order for “No Respiratory Aerosolized Medication Protocol” or “No RT Consult” if he or she does not want this protocol to be used. The order for no protocol should include an explanation in the progress notes and therapy monitoring criteria.

F. All changes regarding patient’s therapy are to be recorded on the RESPIRATORY THERAPY (RT) CONSULT FORM.

G. When treatment is not indicated, patient will be assessed at least every six hours for 24 hours for changes in respiratory status and indications for aerosol therapy.

H. If, after 24 hours, treatment is not indicated and is being discontinued, this will be recorded in the OTHER RECOMMENDATIONS/NOTES section of the RT CONSULT FORM, and a courtesy call to the physician may be made.

I. The RT CONSULT FORM will be placed in doctor’s orders section of patient’s chart.

3. Respiratory Aerosolized Medication Protocol:

A. The following conditions are accepted indications for aerosol therapy:

• a. Bronchospasm/ wheezing
• b. Asthma/ reactive airway disease
• c. Diminished lung sounds
• d. COPD
• e. Prolonged expiratory phase
• f. Obstructive defects of PFT
• g. Impaired mucous clearance
• h. History of Pulmonary disease

B. Medications available per protocol:

• a. Albuterol
• b. Duoneb
• c. Atrovent
• d. Xoponex

C. This protocol will be initiated anytime there is a request for aerosol therapy. Upon receiving the order, the respiratory therapist will establish the goals and indications for therapy and perform an assessment.

D. The following assessment and chart findings will be recorded on the RT CONSULT FORM as appropriate:

• a. Vital signs (HR, RR, BP)
• b. Current FiO2
• c. Pulse oximetry
• d. PEFR (if indicated)
• e. Most recent ABG results
• f. Other diagnostic evauation (Chest X-Ray, lab tests, etc.)
• g. Smoking history
• h. Patient assessment results (lung sounds, work-of-breathing, cough, secretions)

E. Appropriate treatment and frequency will be determined using the GUIDELINES FOR AEROSOL THERAPY AND FREQUENCY on the reverse side of the RT CONSULT FORM. Using these guidelines, and based on a patient and chart assessment, an assessment total will be assigned and used to determine a triage #, and this triage number will be used as a guideline to determining therapy and frequency as follows:

• a. Triage #1 patients will receive treatments Q2 & PRN 0.5cc Ventolin and Q4 0.5mg Atrovent.
• b. Triage #2 patients will receive treatments Q4 and PRN 0.5cc Ventolin and Q8 0.5mg Atrovent.
• c. Triage #3 patients will receive treatments QID & PRN 0.5cc Ventolin and/or 0.5mg Atrovent.
• d. Triage #4 patients will receive treatments Q6 PRN 2.5mg Ventolin or 2 puffs Ventolin Q6 PRN if MDI criteria are met (see MDI criteria below), or consider discontinuing aerosol therapy. Also consider 2 puffs Atrovent QID or 2 puffs Combivent QID.

F. Changes in frequency may be made without direct physician consultation. The patient will be assessed with each treatment and as needed to ensure tolerance of these changes.

G. All non-acute patients who are on home-aerosolized medications may have therapy initiated by the respiratory therapist under this protocol. The dosage and frequency of each medication should remain the same as taken at home, unless the patient’s physician specifies otherwise.

H. Peak Expiratory Flow Rates (PEFR) will be done on asthmatics before and after the initial treatment and then done twice a day, preferably in the morning and evening, and more frequently if necessary or as appropriate. The patient’s tolerance to perform this maneuver should be taken into account and documented.

I. Once the level of care is determined, the respiratory therapist will initiate the program by documenting on the RT CONSULT FORM the drug, dose and frequency. The RCP will then sign his or her name followed by credentials. The physician’s name does not have to be included once he or she has initiated the protocol.

J. With any changes to therapy the RT CONSULT FORM must be completed.

K. The respiratory therapist will decrease frequency of treatments when the goals of therapy have been met in accordance with the GUIDELINES FOR DETERMINING AEROSOL THERAPY AND FREQUENCY.

L. Criteria for MDI use:

• a. Can physically perform the maneuver.
• b. Can follow directions.
• c. Is cooperative and alert.
• d. Can take a slow deep inspiration.
• e. Can hold breath for at least five seconds.
• f. Is able to perform a return demonstration.
• g. Respiratory rate <= 25

M. If a patient has MDI for medications approved per this protocol ordered for home use, and a breathing treatment is not currently indicated, and/or the patient wishes to continue this home routine, this MDI may be ordered for in hospital patient use if the patient meets the criteria for MDI use listed above. The order must be for the same med as the patient uses at home (or the generic equivalent as determined by pharmacy), and the same dose and frequency.

N. After the initial instruct on proper MDI use, and the patient demonstrates effective technique, the MDI may be turned over to nursing.

5. Bronchopulmonary Hygiene Protocol:

A. Indications: Productive cough, pneumonia, rhonchi on auscultation, history of mucous producing disease, patient unable to deep breathe and cough spontaneously, post-op, difficulty with secretion clearance with increased sputum production.

B. If these indications are met, Chest Physical Therapy (CPT) may be performed as tolerated by patient. The recommended frequency is QID and prn.

C. Re-evaluate patient every 24 hours.

D. Assess outcomes to determine if goals have been achieved:

• a. Optimal hydration with improved sputum production.
• b. Lung sounds from diminished to adventitious with rhonchi cleared by cough.
• c. Patient subjective impression of less retention and improved clearance.
• d. Resolution/ improvement in chest x-ray.
• e. Improvement in vital signs and measures of gas exchange.
• f. Post-op patient shows no signs of distress and demonstrates good cough and/or is able to move around in bed or room with or without assistance.

E. Discontinue therapy if improvement is observed and sustained over a 24-hour period, and record this in the OTHER RECOMMENDATIONS/NOTES section of the RT CONSULT FORM. F. Patients with chronic pulmonary disease who maintain secretion clearance in their own home environment should remain on treatment no less than their home Frequency.

6. Hyperinflation Therapy Protocol:

A. Indications: Atelectasis, decreased lung sounds; the goal is to prevent Atelectasis; the patient had thoracic or abdominal surgery; prolonged bed rest, restrictive lung defect.

B. If these indications are met, the patient may be provided with an Incentive Spirometer (IS) and educated on its proper use.

C. Once the initial instruct is provided to the patient, the IS treatment may be turned over to the care of the patient and/or RN to be performed by patient Q1-2 W/A.

7. Documentation: A. Initial Assessment:

1. A Respiratory Care Assessment will be completed for all patients ordered on RT Consult.

2. The respiratory therapist will document this assessment on the RT CONSULT FORM. On this form, the RCP will mark all indications for therapy, and circle all recommended medications indicated for patient, the recommended doses for each medication, and the recommended frequency for each medication.

3. If a physician did not initiate the protocol, the physician must be notified and an initial order received and documented in the patient’s chart or, if the physician is available, he or she may sign the initial RESPIRATORY THERAPY CONSULT FORM and no further order need be written.

4. All therapy will be documented in Meditech.

B. Re-assessments:

1. All patients will be assessed with every treatment to determine the patient’s current pulmonary status and effectiveness of the aerosol therapy.

2. Adjustments of the patient’s therapy will be determined objectively by changes in the monitored parameters, and by using the GUIDELINES FOR DETERMINING BRONCHODILATOR THERAPY.

3. The respiratory therapist will fill out a new RESPIRATORY THERAPY CONSULT FORM for all patients whose frequency or therapy is adjusted.

8. REFERENCES:

1. Spectum Health (2005) Aerosolized Medication Protocol, Grand Rapids: Spectrum Health.

2. Northern Michigan Hospital (2004) Bronchodilator Protocol, Petosky, MI: Northern Michigan Hospital.

3. Covenant Health Care (2005) Respiratory Therapy Consult, Saginaw, MI: Covenant Health Care.

4. “Guidelines for Preparing a Respiratory Therapy Protocol.” Retrieved August 23, 2007, from

http://www.aarc.org/members_area/resources/protocol_guidelines.html

5. “Respiratory Therapy Protocols.” Retrieved August 4, 2007, from http://www.st.alexius.org/about_stas/services/Resp_Care/protocols.asp?printable=1

6. Phillips, Jan, “Bronchopulmonary Hygiene Protocol,” May 5, 2003. Retrieved from http://www.aarc.org/resources/protocol_resources/documents/broncho_hygiene_algorithm.pdf
7. “Hyperinflation Protocol.” Retrieved from http://www.aarc.org/resources/protocol_resources/documents/AARCpedHyp.pdf
8. Phillips, Jan, “Hyperinflation Protocol,” May, 5, 2003. Retrieved fromhttp://www.aarc.org/resources/protocol_resources/documents/hyperinflation_algorithm.pdf

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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)

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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: http://rtcorner.net/rt_forms.htm
and http://rtcorner.net/rt_forms.htm

2. Mechanical Ventilator Protocols, Retrieved from:
http://www.aarc.org/resources/protocol_resources/documents/general_vent.pdf
3. CTICU Weaning Protocol, retrieved from: http://www.dhmc.org/webpage.cfm?site_id=2&org_id=116&morg_id=0&sec_id=0&gsec_id=5560&item_id=7386

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

Here's why we don't have protocols

Ideally, according to Egan, a protocol would work like this:

1. Therapy can be adjusted more frequently in response to changes in patient status.


2. Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.


3. Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.


4. RCPs become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated qualified practitioners.

Doctors here at Shoreline don't want any of these, and therefore have elected to ignore pleas of lowly RTs.

1. They don't want frequency to be adjusted. Thus Q4ever for everyone.
2. They aren't worried about nuisance calls because when they get them they double the frequency and add IPPB that RTs hate.
3. Nonpulmonary physicians don't have to worry because Q4ever works for everyone regardless of diagnosis.
4. Physicians don't believe RTs have are smart enough to know who needs therapy. Likewise, RT Bosses don't have to worry about attracting and retaining qualified RTs because there are no other RT departments in this area for us RTs to go.
5. Our Doctors loved the year 1980, so why use 2010 wisdom.

The two types of protocols

I have determined that there are two different kinds of hospital protocols.

1. Professional Protocols: Protocols that allow the professional (RN or RT) the opportunity to assess and treat as appropriate based on the guidelines of the protocol (i.e. an RT assesses patient and determines indication and appropriate drug, dose and frequency.)

2. Order Sheet Protocols: Protocols that are basically a list of procedures that are automatically ordered for a particular diagnosis. (i.e. some patients don't meet criteria unless a breathing treatment is ordered. Such is the case with pneumonia and RSV)

Professional protocols are more like the RT Driven protocols whereby the RT is allowed to use his experience and education to make the best decision for the patient, and are the protocols I refer to frequently on this blog.

These protocols work to the benefit of the RT in that they allow these professionals to fully utilize their skills, the hospital in that it eliminates wasteful spending, and the patient in that appropriate therapies are given as indicated.

Order Sheet Protocols are made with the sole intention of making money for the hospital. Some person sitting in an office in Washington D.C. decided it will only reimburse for this particular disease if the patient was sick enough to need certain procedures, such as a breathing treatment.

In order to be reimbursed for said diagnosis (pneumonia, RSV), an order sheet the hospital calls a protocol is made up so that certain procedures are automatically ordered.

This type of protocol amounts to inappropriate usage of a professional's time, inappropriate use of hospital recourse's, and inappropriate procedures being ordered on patients. It is for this reason we end up with bronchodilator breathing treatments on all RSV and pneumonia patients.

Thus, under Order Sheet Protocols the hospital does not make money on each individual procedure as Medicaid, Medicare and Major Insurance Companies pay one flat fee regardless of how many procedures are completed.

Also, Order Sheet Protocols often result in RT burnout and frustration, apathy. Professional Protocols work to the benefit of all parties involved.

A good feeling for a humble RT

On the technical side of being an RT, one of the greatest joys is when you intubate a patient, and set up a vent based on your protocol and experience and common sense, and then you tell the doctor what you did and why.

"That sounds great," the doctor says. "Just try to keep the EtCO2 around 30."

Awesome, I think. So I titrate the rate and title volume a bit until that EtCO2 is just where the doctor wants it, and then turn down the FiO2 until the SpO2 is no longer 100%.

This is how it should be. This is awesome.

Tonight when I learned that a bad baby was coming to our ER, and the nurse told me how much the baby weighed, I grabbed my little cheat sheet and knew, based on our protocol, that I needed a 3.5 ETT and that it should be positioned approximately about 9-10 at the lip.

Once the doctor was done intubating, I said, "I think it should be 9-10 at the lip."

"No, I want it at 12," she said.

I listened for lung sounds and told her lung sounds were diminished on the left. She pulled it back to 11. "I don't want to pull out any further," she said. "Let's secure it right here."

Later, after we had secured that little tube with tons of sticky tape, the doc looked at the x-ray results. "Well, I think we need to pull it back to 9 or 10," she said.

I couldn't help but smile. She knew I was right.

A good feeling for a humble RT.

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.

Ventilator protocol: Setting up pt. on ventilator; and some information about EtCO2 monitoring

As I've been writing about the past few posts, we have a so-so Ventilator protocol here at Shoreline, and we are currently in the process of updating it.

Just for the record here, the ventilators we use are the Servo 300A and the Servo i.

While the majority of the protocol is actually an extubation protocol, we also have the ability to wean FiO2 to maintain an SpO2 of 92%. Which is nice, because before we used to have to sit on an SpO2 of 100 on a specified FiO2 all night long. Now I can wean it down as low as necessary.

This has got to be better for the patient, considering the hazards of oxygen therapy.

So, basically, when setting up a ventilator, we can pretty much determine the most appropriate respitatory rate, FiO2 and tidal volume for the patient based on the protocol, as opposed to just making up numbers.

Here are the initial vent settings per protocol:

1. FiO2: 40%, and increase to main SpO2 >92% (or as specified by physician).
2. VT: 6-10 ml/kg IBW (for Acute Lung Injury or ARDS use 6 ml/kg IBW)
3. PRVC: 10-14 BPM


4. PEEP: 5


5. ABG within 30 minutes post set-up


6. Automode: per RT discretion


7. Maintain cuff pressure >20


8. Suction and send sputum to lab


9. Perform oral care Q2 hours


10. elevate head of bed 40 degrees

There's a little more than just ventilator settings there, so allow me to explain.

First, our doctor who is championing the protocol has decided that lower tidal volumes are safer for patients than the 10-15cc/kg IBW that is taught in RT school. Actually, people with normal lungs may use 10-15cc/kg IBW, but it's better to be on the safe side with lower tidal volumes.

Likewise, studies have shown lower tidal volumes to be equally effective ventilation.

As per another hospital's ventilator protocol: "Recent literature has shown tidal volumes in the range of 7-10 cc/kg to be effective in ventilation while reducing the risk of barotrauma."

So, the going trend is to start low and increase as indicated, based on ETCO2 (see below) and SpO2 or ABG.

PEEP of 5 is a good place to start, and increase as indicated or as directed by a physician. I discussed PEEP studies a few days ago.

Along with an ABG, an X-Ray should be completed within 30 minutes. Soft wrist restraints as needed, Ativan as needed, NG, etc. are also included in the protocol.

While this is not a ventilator weaning protocol per se, the ability of the RT to turn on automode allows us to basically switch the patient over from PRVC to volume support. In VS, the patient determines his own flow and pressure support.

For the most part, in the aspect, we RTs are allowed to change modes, so long as the mode we choose to change it to is VS. The funny thing is, I think a lot of doctors have little understanding of automode, as even while the patient may have been in Volume Support for three days, some of our doctors continue to order for rate and tidal volume changes thinking that's what the patient will get.

Now this is fine, so long as they understand the changes are in order to maintain a minute ventilation, as opposed to guaranteeing the preset rate and tidal volume.

It can be safe to say that once the patient switches himself to volume support, he has taken the first step in the weaning process.

Basically, the pressure support in volume suport mode can be measured by subtracting static pressure from peak pressure. If PIP is 20 and static is 15, then the pressure support the patient is drawing in is 5, which is actually a good number. Anything under 10 is good. If a patient is sucking in more than 10, then you may be safe to assume the patient is not weanable.

Automode is nice for the patient, because as he wakes up, he is able to actually control the vent, instead of the vent controlling the patient. This was a big selling point for us in choosing to purchase the Servo vents.

When I explain the ventilator to nurses and patients, I tell them that it is "state of the art life support technology, and it actually has a brain that senses when the patient is ready to breath on his own."

And, when the patient stops breathing on his own, the vent will automatically switch back to the PRVC mode. And then back to VS after the patient takes three consecutive spontaneous breaths.

I wouldn't always turn the automode on. If the patient had a cardiac event, or if the patient is not breathing effectively on his own, I would keep the patient in PRVC.

Basically, once the patient is in automode, and stays there, the weaning process is started. The initial vent settings are assuring the patient maintains the desired minute ventilation, but otherwise determining his own settings.

While in school we were taught that the cuff pressure should always be maintained at less than 20 to make sure the circulation to the arteries are not cut off. However, with new research, it has been learned that most patients are intubated for such a short period of time now, that this is less of a concern.

As I've written about before on this blog, the average stay on a ventilator has significanly decreased since the advent of microprosessor ventilators that allow the patient to control the vent instead of the other way around.

So, now we want the cuff pressure to be >20. The reason here is we want to prevent VAP. Also, to prevent Ventilator Acquired Pneumonia (VAP), we make sure that we clean the oral cavity as often as possible. Our protocol recommends Q2 hours. Usually this job is shared between RTs and RNs.

Then, so we can prove later that the patient had pneumonia prior to being placed on the vent, or to prove that we caused it later on, we obtain a sputum as soon as possible and send it to the lab.

Also, we want to make sure the head of bed is elevated to protect the airway, and prevent aspiration, which is another VAP preventative measure.

Ultimately, however, "the guidelines listed above should be considered a starting point for most patients. Adjustments to rate, tidal volume, or inspiratory time should be made according to disease process or as changes in the patient's condition warrants. Closely monitor BP, HR, RR, EtCO2 (as needed), SpO2, and breath sounds for changes in patient status."

Shorter inspiratory times and longer expiratory times may be indicated for some asthma and COPD patients to prevent air trapping.

EtCO2 should be monitored on all ventilator patients. A normal EtCO2 is 40, however the EtCO2 should be coordinated with the ABG so it can be monitored instead of doing ABGs.

There are some conditions that may alter EtCO2 and cause it to read lower than the actual ABG due to shunting. These include:

1. Asthma


2. COPD


3. Severe Pneumonia


4. ARDS


5. Chest trauma


6. pulmonary embolism


7. decreased cardiac output

This is progress based on the latest studies. If you guys think our data is wrong, or if you have new information to add here, please feel free to respond. We RT are continuously trying to stay up to date, or to stay ahead of the curve.

ALI, ARDS Ventilator Strategy

Note: An error has occurred in this post, and parts of it are presently unavailable. I am aware of the problem and will correct is in the next few days. Rick Feb. 8, 2010

Being a smaller hospital, we RT here at Shoreline don't have many opportunities to take care of patients with Acute Lung Injuries (ALI) or Acute Respiratory Distress Syndrome (ARDS). However, we do on occasion. When this happens, it pays to be up to date on the best methods of caring for these patients.

After much research, we found that the larger hospital in this area has one of the better ALI or ARDS Ventilator strategies.

The gaol with ALI or ARDS is to ventilate at the lowest pressure possible. And, while our ventilator protocol calls for tidal volumes of 6-10cc/kg IBW, the target tidal volume for these processes is 6 cc/kg IBW.

Since pressures is a major issue with ALI & ARDS, it is critical to monitor ventilating pressures, and often the tidal volume must be adjusted based on the ventilating pressures. And, instead of basing the tidal volume on peak inspiratory pressure (PIP), plateau pressure (p-plat) should be used.

Why is this? PIP is a measurement of pressure while a patient is still inhaling, and it measures flow, secretions, and water in the circuit. Static, however, is a measure of pressure once a patient inhales and relaxes. It is a true measure of compliance.

With this in mind, this is why we use p-plat to determine static compliance, which should be in the ranges of 60-100. When the static compliance is <60,>100, then you know you have increased compliance, as you will see with emphasema.

This in mind, here is an abreviated version of an ALI or ARDS Ventilator Strategy, which is ultimately lung protective ventilation:

A. Ideal VT = 6 ml/kg IBW
B. Oxygenation target:

1. PaO2 55-80
2. SpO2 88-95%
3. If PsO2 greater than 80 or sustained SpO2 greater than 95%, decrease FiO2 by 0.1
4. If PaO2
5. Physician will order changes in PEEP as indicated.

C. pH Goal: 7.30-7.45

1. greater than 7.45: Decrease Rate
2. less than 7.30: increase rate
3. If rate greater than 35, or CO2 >
4. >

D. Plateau Pressure: Dr. to select target pressure

1. If greater than 30 & due to VT, decrease VT by 50cc Q1 hour until p-plat >
2. If >

E. Patients ventilated this way are usually tachypneic. Respiratory rate alone cannot be used as a measure of discomfort in these patients. Some patients require increased sedation to tolerate lung protection ventilation.

F. A patient can still meet lung protective criteria even while on low FiO2s, so lung compliance should not be a criteria for determining use of this protocol. DO NOT MISS AN OPPORTUNITY TO USE LUNG PROTECTIVE VENTILATION BECAUSE THE PATIENT'S LUNG INJURY DOESN'T LOOK THAT BAD.

G. Pt's on lung protective ventilation often are hypercapneic and acidemic. So do not treat abnormal CO2 or pH unless there are advers cardiac effects. Tolerate pH as low as 7.15 and consider the use of Bicarbonate, if necessary, to treat more severe levels of acidosis in order to allow for lung protective ventilation.

H. FiO2 should be maintained as low as possible, and a PEEP study should be completed if ordered by physician (see how to do a PEEP Study post tomorrow).

I. FiO2 can have consequences to the patients lungs, and therefore should be lowered to 60% before decreasing PEEP, so long as there are no complications to high PEEP develop.

Keep in mind I wrote this post not because we do this often at Shoreline, but because when we do have to take care of an ARDS or ALI patient, I am up to date on the latest stategies for taking care of these patients.

For more information, check out ARDS.net.

Ventilator extubation Protocol

Perhaps one of the best ways of preventing Ventilator-Associated Pneumonia is by creating and implementing a ventilator extubation protocol. This assures that caregivers begin thinking extubation almost immediately as soon as a person is intubated. Such a protocol my include the following:

1.  Weaning Screen.  In the past physicians wrote orders for weaning parameters, which include respiratory rate, tidal volume (Vt), forced Vital Capacity (FVC), and negative inspiratory pressure (NIF). Most modern protocols call for screening the patient for the following.

• Fio2 less than 40% 
• PEEP less than 5 cwp (oxygenation status stable)
• Heart Rate greater than 50 and less than 120 (heart rate stable)
• Temperature less than 100.5 (higher means something is not resolved)
• SpO2 greater than 90% (or specified by physician)
• Systolic blood pressure greater than 90
• Minimal or no sedation
• No signs of respiratory distress
• Able to follow commands
• Adequate cough
• Plateau pressure less than 30 cwp (higher may indicate ARDS)
• Patient's underlying condition resolved

Please note that these are general recommendations. Some common sense must come into play too, as you must consider the patient. For instance, some patients with chronic lung diseases will have a normal SpO2 less than 90%. So, this must be accounted for when considering whether or not to begin a spontaneous breathing trial (SBT). 

2.  Spontaneous Breathing Trial.  Here is where you place the patient in a spontaneous mode to see how he will do. Some protocols will call for placing the patient in CPAP alone, although others may also involve some pressure support (PS) to accommodate for airway resistance caused by the endotracheal tube (ETT) and the ventilator tubing. Whichever method is used is fine so long as you are consistent. One hospital decided on the following formula:

• 7.5 ETT or less: Set the patient on CPAP of 5 and PS of 5
• 8.0 ETT or greater: Set the patient on CPAP of 5 and PS of 0

Basically, you will want to eliminate the resistance of the tubing, although you don't want to set the patient up to fail either. For instance, if you set the PS at 10, the patient has a greater chance of passing the weaning screen, thereby looking good enough to extubate. Yet then require re-intubation later on. 

A good way of knowing where to set the PS if you don't have a protocol is to check the Peak Airway Pressure (PAP) and the Plateau Pressure (P-plat) prior to performing the SBT

Say the Peak pressure for a patient is 20 and the static pressure is 15. The difference between the two is the resistance. Pressure Support, therefore, should be set to equal resistance, which in this case would be five.

If, in our attempt to wean the patient, we turn the pressure support down to zero, then, some experts contend, we are setting the patient up to fail. Therefore, pressure support should never be turned below resistance.

So, that's kind of the thinking on whether or not to use pressure support. Whatever your hospital uses is fine so long as it is consistent. If one therapist is using pressure support and another is not, the values will not be consistent, and therefor will not be very useful.

An SBT entails using a mode like PS and CP, and then seeing how the patient does for about five minutes. Then a second weaning screen should be performed.

• Respiratory Rate less than 30
• SpO2 90% or less (or specified by physician)
• Heart rate less than 120
• Blood pressure within 20% of baseline
• RSBI (f/vt) less than 100
• No apnea
• No diaphoresis
• No anxiety
• No respiratory distress

Does the patient pass these? If no, then place the patient back on the original settings and notify the physician that patient is not ready to be weaned. If yes, then perform weaning parameters. 

• NIF equal to or greater than 20 cwp
• FVC less than 10 ml/kg
• VT of greater than 5 ml/kg (or appropriate for patient)
• Respiratory rate less than 30
• Minute Ventilation greater than 5 and less than 15
• RSBI (f/vt) less than 100

If the patient fails, then place patient back on original settings. 

3.  Extubation.  If the patient passes, then you continue the SBT for 30 minutes to a couple hours. Then you redo the screen. If the patient continues to do well, you can draw and ABG and discuss with the patient's nurse and doctor to see if the patient can be extubated. 

Every ventilator extubation protocol will have its differences from this one, although they should all be with the same goal of speeding time of intubation to extubation, and the overall goal is to prevent VAP and other ventilator associated events (VAE).

Note: This post was edited on July 5, 2016, by John A. Bottrell