1. New Protocols for 2006 Protocols: Provide consistent predictable care for 90% of patients Development of protocols is a dynamic and ongoing process

2. Nitric Oxide Weaning 1.Complicated cardiac or thoracic surgery with evidence of right ventricular failure based on at least one of the below: a. Known or suspected pulmonary artery (PA) hypertension Mean PA pressure (mPAP) > 25 mmHg b. Echocardiographic evidence of moderate to severe right ventricular dysfunction; severe RA or RV enlargement PLUS at least one of criteria a and b a. CI < 2.5 liters/minute/m 2 b. Mixed venous O2 saturation < 60% 2. Pulmonary ischemia – reperfusion injury

3. Nitric Oxide Weaning III. Weaning 1. Decrease INO by 10 ppm. Note: If initial INO setting is 80 ppm wean directly to 40 ppm. 2. Observe pulmonary artery pressures. 3. If patient has a negative response (see below) to decreased INO, return to pervious dose. 4. If no negative response is noted within 30 min., decrease NO by 10 ppm. 5. Continue to wean by 10 ppm as tolerated Q 30 min. to a concentration of 10 ppm, then to a concentration of 5 ppm. 6. Continue to wean by 1 ppm as tolerated Q 30 min. to zero. 7. Notify physician when INO is off.

4. Nitric Oxide Weaning A negative response is defined as: a. 20% increase in mPAP from baseline b. 20% decrease on PaO2 or SaO2 from baseline c. other clinical or diagnostic indications of increased pulmonary artery pressure d. PAP increase beyond physician ordered limits

5. Cuff Pressure Manometry Cuff Pressures > 30cmH2O = tracheal damage Cuff Pressures < 20 cmH2O = VAP risk MOV consistently overestimates cuff pressure Two recent cases of tracheal wall collapse

6. Cuff Pressure Manometry Draw 5cc of air into syringe, connect syringe to stopcock, turn stopcock “off” to the open port. Inject 1cc of air into the manometer GENTLY connect stopcock to pilot balloon and turn stopcock “on” to all ports. Pressure in cuff must be between 20 and 30 cmH2O. If adjustment is needed, inject or aspirate air as necessary Recheck cuff pressure, disconnect pilot balloon

7. Patient/Ventilator System Check Patient/ventilator system monitoring will consist of the following: a. verify respiratory care orders b. review patients chart and CXR history diagnosis progress notes ABG reports

8. Patient Ventilator System Check d. perform respiratory assessment e. assess airway size, type, and placement stability and mucosal breakdown (re-secure if necessary) cuff pressure in cmH2O adequacy of humidification trach care/oral applications as indicated

9. Patient Ventilator System Check f. assess need for removal of pulmonary secretions g. perform spontaneous breathing trial h. attend physicians rounds i. document ventilator parameters, alarm settings, and care plan All elements of patient/ventilator system monitoring will occur at the time of ventilator initiation and a minimum of once in a 12 hour shift thereafter.

10. Patient Ventilator System Check Limited patient/ventilator system documentation will occur PRN for the conditions listed below: a. parameter changes b. airway suctioning c. patient transport d. prior to obtaining ABG (FiO2 and PEEP) e. compliance curve calculation or PEEP trial f. spontaneous breathing trial g. ASAP following acute deterioration of patient condition h. any time that ventilator performance is questionable i. aerosolized medication administration j. at the discretion of the RCP

11. Apnea Trial An apnea trial will be conducted in the presence of the ordering physician. Normalize PaCO2 – 35 mmHg to 45 mmHg Hyperoxygenate 10 min. Suction ETT Connect cardiac monitor and pulse oximeter Estimate time required to reach an apneic PaCO2 of approx. 60 mmHg or 20 mmHg greater than baseline

12. Apnea Trial Disconnect patient from ventilator and place on manual resuscitator with adequate oxygen flow Undrape patients chest Observe or palpate chest for spont. respirations for the calculated period of time Draw an ABG Reconnect patient with previous settings

13. Apnea Trial Reconnect patient if: patient makes repeated respiratory efforts O2 Saturation <.90 mean BP < 55 mmHg dangerous arrhythmia

14. Disaster Supplies

15. 25 single patient use ventilators 25 Ballard in-line suction kits Box 1 25 HCHs 5 instruction cards 1 box N-95 masks 1 packet ventilator documentation sheets 25 single patient use ventilators 25 Ballard in-line suction kits Box 225 HCHs 5 instruction cards 1 box N-95 masks 1 packet ventilator documentation sheets

16. Lung Protective Ventilation Where To Start: Calculate Ideal Body Weight Physician to order mode, initial FiO2, and PEEP Slowly wean Vt to 8cc/kg, at the same time increase rr to maintain consistent Ve Check ABG

17. Lung Protective Ventilation Re-learn your ABG norms: pH 7.25 – 7.45 PaO2 55 – 80 All OK!!! SaO2 88 – 95 Notice total lack of concern for PaCO2!!

18. Lung Protective Ventilation Goal #1 – acid/base 7.25 to 7.45 If pH is 7.15 – 7.25, increase rr to a maximum of 35 If pH is < 7.15, increase Vt 50cc q 30 min.

19. Lung Protective Ventilation Goal #2 – Vt of 6 cc/kg and P plat less than 30 cmH20 Check P plat Q4 and with each Vt or PEEP change If P plat > 30 x2 the decrease Vt 50cc q hr. until P plat is < 30 but do not go lower than 4 cc/kg Check with MD if pH < 7.25 or PaO2 < 70 If P plat is 25 x2, increase by 50cc q 30 min. to a Vt of 6cc/kg

20. Lung Protective Ventilation Oxygenation Goals PaO2 < 55 or SaO2 < 88 increase O2 PaO2 > 80 or SaO2 > 95 decrease O2 Either physician will order PEEP changes or… Use PEEP Ladder