Ventilator bundle to prevent Ventilator Associated Pneumonia

By the late 1990s it was known that about 15% of patients intubated and placed on a ventilator acquired what was then termed ventilator associated pneumonia (VAP), and that about 30% of those with VAP would ultimately die.  A major effort was then begun to try to reduce these numbers.

Solid data was now available that allowed the Centers for Disease Control and Prevention (CDC) to compile guidelines for combating VAT.  Considering the limited options for treating pneumonia, the main effort was aimed at prevention.

The initial guidelines included many of the following.  These are often referred to as the essential parts of a "Ventilator Bundle."

1. Mandatory Education:  Everyone involved in the care of the patient should be aware of VAP and how to prevent and treat it.
2. Mandatory Infection Control:  Everyone taking care of the patient, including visitors, should be aware of the hospitals infection policy.  The best method of spreading infections is by frequent and vigorous hand washing. This may also include wearing masks and gowns when necessary. Sterile technique should be followed when inserting lines or drawing blood.
3. Routine Oral Hygiene:  Since bacteria from the upper airway may pool over the cuff, it is essential to keep the upper airway clean.  Many guidelines recommend oral suctioning and cleaning at least every two hours. 
4. Regular Change-out policy:  Closed suction systems and suction canisters and tubing should be changed every 24 hours.  Ventilator circuits should remain closed at all times, and changed at least once a week.  
5. Maintain Closed circuit:  The ventilator circuit should remain closed at all times.  Special adapters can be added to the circuit to introduce breathing treatment and metered dose inhalers.  Closed suction systems such as a ballard can be introduced between the ETT and the "Y" to prevent the need to break the circuit in order to suction.  Heated circuits prevent condensation inside the circuit and reduce the need to open the circuit for water removal. Changing ventilator circuits weekly instead of daily may also help reduce the introduction of bacteria to the patient. 
6. Limit normal saline introduction:  The introduction of normal saline into the ETT to assist with the removal of thick secretions should not be routinely performed by nurses, and should only be done by respiratory therapists on an as needed basis. 
7. Stress ulcer prophylaxis:  Since gastric contents may work their way to the upper airway and into the lungs, efforts must be made to prevent this.  Since all patients on a ventilator are at increased risk for stress fracture, they should all be treated for this. 
8. Ventilator extubation protocols:  Creation of weaning protocols are shown to speed up time from intubation to extubation. This forces clinicians to start thinking about weaning the moment a patient is intubated. 
9. Maintain cuff pressure:  Studies show that a cuff pressure of 30 or greater prevents the micro-aspiration of secretions that pool over the cuff.  To read further about this read the post "What tracheal cuff pressure measurement is ideal?" Cuff pressure should be measured and recorded each shift. While the ETT should be rotated each shift, unnecessary maneuvering of the tube should be avoided.  Also, the cuff pressure should never be less than 20 in adults as this significantly increases the risk of aspiration.  Vigorous suctioning should be performed before rotating the cuff and prior to deflating the cuff.  (1, page 8)
10. Elevate head 30-45 degrees:  This should prevent the aspiration of stomach contents.  This should be required in all ventialtor care policies. 
11. Prevent early extubation:  ETT should be adequately secured, and the patient adequately sedated or watched in order to prevent inadvertent or purposeful early patient extubation.  Ventilator protocols should help guide clinicians as to the best extubation time.  
12. Consider tracheotomy:  If a patient should need to be on a ventilator more than a week, the patient should be trached. Trachs also allow for normal physiologic swallow mechanisms which prevent secretions and stomach contents from being inhaled.  They also make it easier to wean patients, make it so less sedation is required, reduced airway resistance, and enhances secretion removal. It allows application of speaking valves to allow patient to speak, even while on ventilator.  Studies show they also improve overall patient morale.  
13. Avoid heated moisture exchangers (HME):  Do not use HMEs unless absolutely necessary, such as when you need to transfer the patient. Studies have linked them with an increased risk for VAP. 
14. Limit sedatives:  This topic continues to be controversial and debated.  Some experts recommend limiting the use of sedatives in the early mornings to make sure the patient awake enough for weaning trials.  Ideally, sedatives should be stopped at least four hours prior to doing weaning parameters or weaning attempts.  However, some experts suggest that some sedatives allow patient to be alert enough to follow commands.  
15. Daily Chest X-Ray:  Since it is very difficult to know when a patient is developing pneumonia, it is important to have a chest x-ray every morning in order to monitor patient's lungs for signs of pneumonia.  
16. Prophylactic antibiotic therapy:  Some experts recommend automatically starting patients on a broad spectrum antibiotic to prevent the development of infection.  This is also recommended as the top line treatment for VAP.  
17. Obtain sputum ASAP after intubation:  Obtaining a sputum sample immediately after intubation will help determine if the patient already has pneumonia, or confirm that the patient did not have pneumonia.  This will help determine if a pneumonia is pre-existing or caused by the ventilator. 
18. Cleaning equipment: Equipment must be efficiently cleaned between patients in order to prevent contamination from one patient to the next. 
19. Lower tidal volumes:  These may reduce the inflammatory response seen by higher tidal volumes.  
20. Serial Lab tests:  Daily laboratory testing can help determine if white blood cell counts are increasing, or other markers, which will show that a patient has an infection. 

This post will be updated as new wisdom is obtained.  The following graphic from the CDC pretty much sums it up.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

What's the best way to do weaning parameters

When I was in RT School back in 1995 the Bennet 7200 was the most popular ventilator and some of the newer ones provided the ability to do weaning parameters on the machine without even disconnecting the patient from the ventilator.  Our teacher said doing parameters on the ventilator was a bad idea.

He said it was a bad idea because the parameters would be not as good as if the patient were taken off the ventilator.  For example, if you would get a 500 tidal volume by doing the parameters off the vent, you'd get a 450 on the vent.  For NIF it would be the same:  the value while on the vent will be less than if you did it by hand with the patient off the ventilator.

Fifteen years later we are fifteen years wiser.  And I have to say I agree with my teacher that weaning parameters on the vent are a litte less.  However, I don't agree that it's less effective.  Now that we have the Servo i's we are able to do all parameters (VT, NIF and FVC) without even disconnecting the patient from the vent.

As a rule, as long as everyone does it the same way, that's all that matters.  If my coworker does parameters one morning and gets a 400 tidal volume off the vent, and the next day I use the vent and get a 350, my 350 doesn't look so good.  It looks like the patient is going in the wrong direction.

However, if we both would have done it the same way, then we would have known  the patient was consistently getting the same tidal volumes.  So consistency is the key.

At our hospital we have a protocol that if the ETT is 7.5 or greater we put the patient on a PEEP of 5 and a PS of zero, and if the ETT is smaller than 7.5 we use a PEEP of 5 and a PS of 5 to make up for the resistance of the ETT.  We all use the Servo i (if the patient is on that ventilator).  All parameters this way are consistent because we're all doing them the same way.

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My answers to your RT queries

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.

And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. an ideal rsbi prior to weaning from a ventilator: RSBI is VT/RR. A result of anything less than 110 means that the patient has a 75% chance of not being re-intubated according to studies. At our hospital, we use 100. Each hospital is different.

2. soul therapy, stripping class: Soul therapy is good, but stripping in a hospital would be frowned upon, unless you are an old patient with a saggy butt.

3. cheer copd patients up: The company of an RT sometimes does this. There's this neat drug called PalButerol we RTs comically use to Cheer up our patients. If you don't believe me, see my ad on the right. There's a picture of santa.

4. best cigarettes for asthmatics: If you are an asthmatic and smoke you are a knucklehead. However,asthma cigarettes used to be a front line therapy for asthma. Check out this link and read more.

5. side effects of bipap: It's not a drug, so there really are no side effects. The pressures used are usually low, so it's not common to cause barotrauma, but it's still something to watch out for. Basically, the biggest side effect (if that's what you want to call it) is patient driven discomfort or non-compliance.

6. does copd mean your a co2 retainer: No. Most experts predict that fewer than 10% of COPDers are retainers. But don't tell doctors that, because many of them treat all COPDers as retainers, which is unfortunate for the patient because they are unnecessarily kept hypoxic (note: hypoxic means they aren't getting sufficient oxygen to their tissues).

7. what diagnosis use ventimask: A ventimask should be used when a patient has an irregular respiratory rate, or if the patient is labored. The reason for this is a ventimask is a high flow oxygen device that guarantees the dialed in FiO2 regardless of respiratory rate. Ideally, your goal as an RT is to use the lowest FiO2 to maintain an SpO2 of 92% or greater. Now, if you have a CO2 retainer who is laboring, and you want to guarantee an FiO2 to get his sats high as possible, a ventimask can work well. Usually we use 40% FiO2 or less for this to maintain an SpO2 that is appropriate for the patient (I prefer 92% or greater, but some patients live around the mid to upper 80s). For more information on CO2 retainers, check out this link.

8. miracle asthma drug: When I was a kid it was Susprin (I will write about this soon enough on my asthm blog), which is no longer even mentioned in the PDR. I would say that it is Ventolin, but most asthmatics shouldn't even need to use Ventolin if they take Advair. Singulair might be the new miracle allergy drug.

9. prolonged use of rescue inhalers instead of preventative medicines: Is foolish. This is what a Goofus Asthmatic would do.

10. diarrhea and cpap machine: There is nothing in common between the two. And if you have diarrhea, you do not have to take the mask off unless you want. Unless you are talking about diarrhea of the mouth.

Now, if you guys and gals have any further questions for me, serious or not, let me know and I well try to answer them for you. If I don't know the answer, I will seek out a sagacious RT who does, or maybe even a doctor.

You can email me at freadom1776@yahoo.com, or write a comment below.

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.

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

The six different types of respiratory therapists

There is much resistance to change inside the RT Cave. After much thought on the matter, I have figured out why. It has everything to do with the six different types of Respiratory Therapists (RTs).

Many RT Caves do not have protocols. I've heard every complaint

Very, very slowly I think doctors are becoming more and more receptive to the benefits of adding respiratory therapy patient driven protocols. In real time seems tortuously slow, but I think in ten or twenty years we might be talking about some major changes in the rolls of RTs.

While this is true, there are still many RTs themselves who don't seem to be receptive to change. This became ever more so apparent to me after reading an excellent column over at Snotjockeys Revisited, "Clinician Resistance to Adopting New Practices".

I agree with her, and have my own experience to add to the mix.

A fellow RT, Dale, is very fun to work with. He's intelligent, a great RT; but he is a constant complainer. He complains in a fun way, but nevertheless he is still a complainer.

"I circled all the indicated treatments on the board," he said the other day in report.

"Um," I said, looking over the list of patients, "there are none circled."

"That's my point," he said, and chuckled.

One day he handed me a list. I looked at it thinking it was serious at first, then I started to laugh. On it was a list of 'olins that he made up. (You can view parts that list at the bottom of this blog)

He said, "I bet that 60% of what we do here is absolutely not indicated."

I'm a firm believer that if you're not having fun with your job what's the point. So we make fun of our job. We make fun of doctors, we make fun of nurses, we joke around during a code. I think that's medical humor, and we do it to maintain our sanity.

I check doctor blogs and nurses blogs, and I see their humor all the time.

But humor is one thing, complaining is another. And complaining with Dale is fun, but most complaining in the RT Cave is simply annoying. I avoid it every chance I get. If I have no choice but to give report to a complainer, I give a quick report and scram.

I used to work with Dale a lot. In fact, I'm glad I had that opportunity to work with him because I learned much and he helped me develop my RT humor. However, I was never going to get anywhere via complaining. Complainers rarely get anything accomplished. But they are abounding in the department.

What's that old saying? "Complainers say more about themselves than the person they're complaining about."

I realized this, and I switched weekends. Now all the complainers work with Dale on the other weekend. The RTs who work on my shift are Jane Sage, a very optimistic, intelligent and fun to work with person. And we have Dee, who happens to be a complacent RT (see list below).

Jane had an epiphany one day, and decided the laid back RTs on our weekend are awesome, and she started referring to us at the "A" team. We called the RTs on the other weekend the "B" team. Once the "B" team got wind of this they decided that they were the New "A" team.

"That's fine," Jane said, "We won't tell them that "A" now stands for Anal and "B" now stands for Better than Anal."

Despite the complainers, we have enough "balance" of different personalities to make things work in our department. You need the complainers so we know of our faults, we need the anal people to make sure we get all our work done, we need the content people to boss around, the laid-back people to ease tensions, and the clowns to make us laugh.

I'd even go as far to say we have a great department. I suppose that means we have good balance. I'm sure the members of this RT Cave are no different than any other.

With this in mind, I created the following list. Based on my experience working with many RTs in the past 10 years, these are the six different types of RTs:

1. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.


2. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.


3. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.


4. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.


5. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.


6. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

I can give examples galore, but I'll give just one more.

Even though she had several protocols shot down years earlier, Jane wrote a new and updated ventilator set-up and weaning protocol. The complainers in our department all said it would never be approved by the doctors.

Jane trudged on nonetheless. She had the support of me, another optimist, and Dee, the easy going content on our weekend. Finally, with a bit of luck, the protocol was approved.

With our confidence on high after, Jane and I wrote a breathing treatment protocol we thought might work. We were very proud of our efforts. We thought we'd show it to our co-workers and get their support.

I showed it to Dale first. Surely he'd approve of it since he was the most outspoken RT about useless and not-indicated breathing treatments.

I couldn't have been more wrong.

"So what do you think?" I said after he stared at it for several long minutes, grunting and sighing often.

"Well," he paused while staring off, then spoke slowly, "The biggest offenders will still abuse the system. If it does anything it will just create more work."

"Okay," I said. I made no effort to change his mind. I walked away. No point in beating a dead horse.

Jane brought up the protocol at a department meeting. Gary, the department head and quintessential RT leader, said: "It is possible you might just be creating more work for yourselves by doing this."

He may be right; he may be wrong. Either way, Jane and I keep moving forward. And that's easier to do now that we know about the six different types of RTs.

Considerations for readiness to wean

Here are some things to consider when determining if an intubated patient is ready for a weaning trial.

1. Awake and alert

2. Able to follow commands

3. Spontaneously breathing

4. Adequate cough

5. Pain controlled

6. No obvious signs of respiratory distress

7. Little to no anxiety

8. FiO2 equal or less than 40

9. PEEP 5 or less

10. Temperature equal to or less than 100.4

11. Hemodynamically stable

• No Dopamine infusion greater than 5 mc/kg
• Systolic BP
• Pulse >50

12. ABGs normal for patient

13. A-a gradient less than 300

14. a-A ratio greater than 50%

15. PaO2/FiO2 greater than 150-200

16. Underlying condition resolved

17. Chest X-Ray improving

18. Adequately nourished (Albumin >2.5)

19. Electrolytes stable (CA, Mg, K)

20. Secretions thin and minimal

21. Adequate Hemoglobin (>8-10)

22. Adequate Hematocrit (>25% or baseline)

23. Absence of bowel problems (diarrhea, constipation, ileus)?

24. Weaning parameters within normal limits:

• NIF greater than 20
• VC >10ml/kg IBW (2*VT)
• VE less than 10- 5ml/kg IBW
• VC double VT
• RR less than thirty 30
• RSBI (VT/RR) less than 100

25. PS must be at patients weaning level:

• PS = Static minus PEEP
• Normal PS usually at least<=10

26. P0.1 = or less than 4.2.

27.   P0.1 > 4.2 is "associated with failure to become liberated from the ventilator... If under 4.2, weaning was successful 78% of the time."  (reference is Vent world)