Mechanical Ventilator Management

1. PURPOSE:

 1.1 To provide a standard, rational approach to ventilator care and eventual liberation from the ventilator in a
   safe and efficient manner
 1.2 To reduce the chances of ventilator complications and substantial costs associated with ventilator care.

2. POLICY:

 2.1 To provide a standard, evidence base approach to ventilator care
 2.2 This protocol involves the entire critical care team, which includes physicians, respiratory therapists and
  registered nurses
 2.3 To guide Island Home Health Care Staff in practices and interventions that will promote prevention of VAP
  in home care settings

3. SCOPE:

 3.1 This policy applies to all mechanically ventilated patients.

4. DEFINITION:

 4.1 Mechanical Artificial Ventilation refers to any methods to deliver volumes of gas into a patient's lungs over
  an extended period of time to remove metabolically produced carbon dioxide.
 4.2 It is used to provide the pulmonary system with the mechanical power to maintain physiologic
  ventilation, to manipulate the ventilator pattern and airway pressures for purposes of improving the efficiency
  of ventilation and/or oxygenation, and to decrease myocardial work by decreasing the work of breathing.
 4.3 It is indicated when the patient is unable to maintain safe levels of oxygen of carbon dioxide by
  spontaneous breathing even with the assistance of other oxygen delivery devices.
 4.4 Phases of Ventilator Care:
   4.4.1 Initial Stabilization phase of the critically ill patient with attention to correcting the causes of
     respiratory failure such as: infection, metabolic derangements, congestive heart failure, coronary
     ischemia, bronchospasm, and changes in ventilator drive i.e. neurological status.
   4.4.2 Post Stabilization Phase which will be initiated as soon as the patient is stable; this will involve
     usually transitioning the patient from a controlled mode (ex. Assist control) to a lower level of support
     allowing for the patient to rest, and at the same time begin taking over spontaneous ventilation. This
     aspect of ventilator care will usually be more physicians directed, but may be prompted by
     non-physicians as well. There is no time limit for this phase; it may occur within hours of admission.
   4.4.3 Long Term/Maintenance phase –Patients who are unable to wean from mechanical ventilation
     and/or have disease progression. Those who require ventilation as life support under conditions that
     patient can be safely and appropriately discharged from the hospital. Such condition includes:
     4.4.3.1 Assessment of patient’s disease and that patient would highly gain from continuing
        ventilator care at home.
     4.4.3.2 The desire of the family .
     4.4.3.3 The ability of the patient and the family to manage the daily requirements of home ventilator
        care.
     4.4.3.4 The resources available and technologies required for support outside the hospital such as
        provision of skilled clinician.

5. PROCEDURE:

 5.1 Initial orders for therapy must include:
   5.1.1 Mode (See appendix C)
   5.1.2 Pressure control
   5.1.3 Respiratory rate
   5.1.4 Tidal volume
   5.1.5 FiO2
   5.1.6 Oxygen concentration and should include a desired level of Positive End Expiratory Pressure
     (if applicable)
   5.1.7 Pressure Support if applicable. Pressure modes will include inspiratory time and level of
     pressure control.
   5.1.8 Any other parameters, depending on the mode of ventilation

 5.2 Equipment and documents for mechanical ventilation shall consist of:
   5.2.1 Two (2) mechanical ventilators in case there is a ventilator failure, set up with appropriate ventilator
     tubing and HME, or humidification accessories, if using active humidification through
     the heated wire circuitry. (Including manuals and modules on equipment usage)
   5.2.2 Self-inflating resuscitation bag with 02 tubing and flow meter.
   5.2.3 Ballard Suction catheter/ Suction catheters
   5.2.4 Oxygen Supply system (stationary and portable)
   5.2.5 Airway suctioning equipment
   5.2.6 Pulse Oximetry

 5.3 Ventilator system pre-initiation operational check.
   5.3.1 Ventilators to be used shall be cleaned then disinfected before connection of a disposable
     ventilator circuit.
   5.3.2 Ventilator settings must be ordered and set by the Respiratory therapist of the discharging hospital:
   5.3.3 Alarm settings: Alarm settings should be tailored to the individual patient as determined by the RT