1. Ventilator Check It’s a thorough process that should take longer than 2 minutes!

2. Step 1-Chart Review Verify Current ventilator settings with physicians orders Insure correspondence between the MD orders and actual values given in report and that are on the ventilator Contact MD for discrepant values Check orders for ventilator changes, ABGs…. Check current medications (sedation, blood presser medications, antiobiotics…)

3. Step 1- Chart Review Look at patients CXR, note tube placement Look at patients CBC and C/S results Look at last ABG result Read H & P, read pulmonary consult Know what the general plan is for the patient – Ex: weaning? Continue vent as is?...

4. Step 2-entering room You should have a good idea about why your patient is on the vent from report and chart review before actually seeing your patient Wash hands/gloves Enter room, assess the patient and ventilator by inspection first – Note medications hanging by IV – Note presence of a feeding tube – Note the monitor for HR, SpO2, BP, hemodynamics parameters – Look at the patient, note if they are awake/sedated

5. Step 2- entering the room Note if family is in the room, explain who you are and what you are doing Only comment on matters regarding the ventilator or respiratory, no lab tests… Now assess patient. First look at the vent circuit, if patient is on a humidifier you may have to drain the tubing, note water level on huidifier and refill as needed

6. Step 3- Pt. Assessment Note patients chest movement, tape on ETT and tube marking at lip or gum Re-tape as needed Change HME as needed Check MOV/MLT http://www.youtube.com/watch?v=NBKV3zuzlJE Check patient’s breath sounds, general appearance, chest movement

7. Step 4- Ventilator Check Note Heart Rate, SpO2, ECG tracing, BP on monitor, PETCO2, record where appropriate Check circuit for leaks, integrity On Ventilator monitor/record: – Ventilator settings (ensure they are what was ordered). Mode, FIO2, VT/PC, breath type, PEEP, I- time/flow, Alarms (adjust alarms as needed)

8. Step 4 Ventilator check Ventilator monitored data: – PIP (if high note increases in RAW/fix) – Total rate (if high note presence of fever, hypoxemia, anxiety/aggtation, low Vt) – Total PEEP (if higher than set= auto peep) – MAP (normal 10-12, increased = decreased compliance, higher distending pressures, set PEEP is high) – VTE / VTI (look for difference, if greater than +/- 50 may be a leak) – FIO2 (if analyzer is way off, take vent out of service for repair)

9. Step 4 Ventilator check Note graphics: – FLOW/TIME: assess for aitrapping – PRESSURE/TIME: assess for over distension, time it takes to reach pressure – VOLUME/TIME: Note if patient is receiving adequate flow on inspiration – PRESS/VOLUME LOOP: note compliance – FLOW/VOLUME LOOP: Note obstructive patterns

10. Step 4 Ventilator check Perform lung mechanics: – Inspiratory hold to get Static Compliance – Expiratory hold to get Auto-PEEP – RAW calculation

11. Step 4-Ventilator Check Suction patient as needed (noted by breath sounds, PIP and airway graphics) Give breathing treatment after all checks are done (adjust alarms as needed for treatment delivery)

12. Communication When you make a change to the ventilator, share your change with the RN The doctor should have been the one giving you the order to change the vent, however if not, share change with the MD as well During rounds (if they are present at the hospital you go to) communicate your ventilator settings and YOUR plan or recomendation

13. Troubleshooting High PIP (safety valve opens) – Agitation (sedation? Pain meds? Change in mode?) – Increase in airway secretions, suction/bronch – Bronchospasm- broncho dilator – Biting ETT (bite block) – Patient talking/coughing/holding breath

14. Troubleshooting Low VTE/low PIP: – Look for obvious leaks – Does the patient have a chest tube – Note cuff integrity – Did the patient self extubate – Is the patient on spontaneous mode without proper PSV or support

15. Troubleshooting High Rate/high Ve: – Pain, agitation, fear/anxiety? – Fever? – Low volumes? – Compensation for Metabolic acidosis? – Do they need sedation, change in mode, increased flow?

16. Troubleshooting Low rate: – Over sedated? – Compensating for a metabolic alkalosis? – Over ventilated with high Vte – Atrophy of diaphragm? – Neuromuscular impairment?

17. Weaning Weaning is done when parameters of interest improve. For example oxygenation improves as demonstrated by ABG and SpO2. Wean FIO2 down in increments tolerable by patient. – Wean to 60% first, then begin weaning PEEP – Wean to a minimum of about 40% before extubation is considered

18. Weaning Patients underlying condition must be improved or improving Look at CXR, labs and physician notes Note if patient is on sedation Note hemodynamic stability, should be off pressers Patient obviously should have drive and ability to breathe, and ability to cough

19. Weaning Note weaning parameters: – MIP – MEP – VC – RSBI – Vital signs within acceptable parameters – ABG within patient’s normal limit – Cuff pressure is normal

20. Weaning Strategies: – SBT (spontaneous breathing trials) – Taper down support (wean rate, change to less controlled modes- SIMV then Spontaneous modes) – Give minimum PSV or use ATC/VS – Extubate to BiPAP