Mechanical Ventilation Algorithms Flashcards

Question

ICU Extubation Pathway

Answer 1

All patients will be placed in this pathway unless exclusion criteria are met or the physician has sound medical reason for using a different approach. In these circumstances, a clear order must be given to the Respiratory Therapists and the Nursing Staff.

Answer 2

All patients with a **head injury, unstable spinal injury, receiving inotropes/ vasopressors or a planned surgery within 24** hours will require a specific physician order before proceeding with weaning. Patients with head injuries, cerebral vascular accident or receiving inotropes/ vasopressors may be a candidate for this weaning pathway, but require a specific physician order.

Answer 3

* **Resolution of disease** acute phase and underlying indication for mechanical ventilation has resolved or significantly improved. * **Adequate oxygenation** as demonstrated by * PaO2 ≥ 60mmHg * PaO2/ FiO2 \> 150-200 or SpO2 \>= 90%, with PEEP ≤ 5-8 cmH2O and FiO2 ≤ 0.4 (or as otherwise described in the regional O2 Protocol). * For patients who have had an arterial blood gas, **no significant uncompensated respiratory acidosis (i.e. pH \< 7.30).** * **HR ≤ 140 bpm, stable** blood pressure, stable cardiac rhythm, no ongoing myocardial ischemia, and no uncompensated shock. * Adequate mentation **(GCS \>= 13) or tracheostomy in place.**

Answer 4

A SBT will be performed daily, preferably in the morning prior to rounds or sooner at the discretion of the RRT. Patients who are post-op may have a SBT performed every 4 hours. Important information can be gained by both successful and unsuccessful SBTs. To perform the SBT, the RRT will place the patient on **PSV of 7cmH2O and PEEP of 5 cmH2O. If Automatic Tube Compensation (ATC) is used, then set PSV to 0.**

Answer 5

In the first 5 minutes, the RRT must monitor the patient and terminate the trial if any of the following are present. The bedside RN must also be present during this time. * RR \> 38 * Rapid shallow breathing index (Tobin ratio) \> 105 * Sweating, anxiety or change in mental status SpO2 \< 90% for \> 5 minutes * Signs of distress or paradoxical breathing * HR \> 140 bpm or a 20% change * Systolic BP \< 90 or \> 180 mmHg * New dysrhythmia or myocardial ischemia If any of the above occurs, the RRT will increase PSV for patient comfort or return to previous ventilator settings as appropriate and inform the physician of the results. Duration of SBT and criteria for termination are to be properly documented in the patient’s chart.

Answer 6

If the patient has tolerated the initial SBT, the RRT can continue with the trial. For patients ventilated \< 72 hours, continue for 30 minutes. For patients ventilated \> 72 hours, continue the trial for 60-120 minutes. Monitoring should be done after the first 5 minutes and Q15 there after. If the patient exhibits any of the termination criteria (as listed in 3.0), the RRT must increase PSV for patient comfort and inform the physician of the results.

Answer 7

If the patient has tolerated the SBT for the specified time, the RRT will increase the PSV for patient comfort, then discuss the possibility of extubation with the physician. This discussion should include the patient’s ability to manage secretions and the patency of the upper airway (i.e. cuff leak).

Answer 8

To optimally oxygenate patients, the Respiratory Therapist will utilize the following protocol to evaluate, treat, and monitor appropriate oxygen administration for all mechanically ventilated patients. The optimal FiO2 for safe oxygen administration is the **lowest FiO2** that will maintain the **SpO2 ≥ 90%** or the patient’s physiologic norm.

Answer 9

Patients with a **head injury and a GCS \< 8** will require **specific physician orde**r for oxygen titration as per this protocol or for a specific oxygen concentration to be delivered.

Answer 10

Unless otherwise orderered by teh dr the RT when initiating Mechanical Ventilation will set FiO2 at 0.60 and then adjust to maintain SpO2 \> 90%. The physician must order a target SpO2 Note: Default values will be SpO2 ≥ 88% and ≤ 92% for patients with obstructive lungs and chronic CO2 retention, and SpO2 ≥ 90% for all other patients.

Answer 11

Arterial blood gases should be drawn **20-30 minutes following initiation of ventilation** to ensure good correlation between measured SaO2 and SpO2. After the ABG has been drawn and correlation established, the Respiratory Therapist will titrate the FiO2 to keep SpO2 ≥ target value.

Answer 12

The Respiratory Therapist will adjust the FiO2 within a range of 0.30 and 1.00 to maintain the target SpO2. The bedside nurse will be informed of all changes and all changes will be documented in the patient’s chart. The physician must be notified and order confirmed if one or more of the following occurs: a. The FiO2 has to be set at \> 0.60. b. The FiO2 has to be increased by \> 0.30. Note: The physician does not need to be notified of transient (\<30 minutes) increases in FiO2 associated with procedures or interventions (i.e. bronchoscopy, suctioning, proning, etc.).

Answer 13

* The Respiratory Therapist will watch the patient’s vital signs and evaluate the patient’s clinical status. The Respiratory Therapist **will not continue to wean the FiO2 if the patient develops one or more of the following:** * Heart rate \> 140 beats per minute or 20% change. * A rise or fall in systolic blood pressure of \< 90 or \> 180 mmHg that occurs with FiO2 adjustment. * ECG changes i.e. onset of arrhythmia or ischemic changes associated with the adjustment. * Clinical signs and symptoms of tissue hypoxia (tachypnea, dyspnea, cyanosis, diaphoresis, confusion, or chest pain). * O2 titration will resume once consultation with the physician has occurred.

Answer 14

If there is no arterial catheter If there is an arterial catheter and they are not ventilated Sudden deterioration refers to a patient exhibiting acutely at least two of the following : * SaO2/SpO2 \< 88%, * dyspnea, * mean blood pressure \< 55 mmHg, * change in baseline heart rate + 20%, * hourly urine output \< 0.4 ml/kg, * unexpected change in mentation, * FiO2 increase \> 0.30 or FiO2 \> 0.60.

Answer 15

The patient has a arterial catheter, ventilated, and are weaning ## Footnote Measure blood gases within 30 min of mode change if respiratory distress, paradoxical breathing pattern or hemodynamic changes are evident. Need to document alveolar ventilation (PaCO2) in an otherwise stable patient must be ordered by physician.

Answer 16

When the pt has an arterial catheter, is ventilated, is not weaning and is STABLE UNSTABLE: (3 or more of the following criteria) * FiO2 \< 0.60 * PEEP/CPAP \< 10 * pH = 7.25 - 7.50 * PCO2 \< 55 * PO2 \> 55 * SaO2/SpO2 \> 88% 24 hourly blood gas if stable with mechanical ventilation. No need for extra measurements on FiO2 change if SaO2/SpO2 \> 88%. Ventilation change -physician request.

Answer 17

When the pt has an arterial catheter, is ventilated, is not weaning and is UNSTABLE UNSTABLE: (3 or more of the following criteria) * FiO2 \> 0.60 * PEEP/CPAP \> 10 * pH \< 7.25 * PCO2 \> 55 * PO2 \< 55 * SaO2/SpO2\<88% Measure blood gases within 30 min of mode change if respiratory distress, paradoxical breathing pattern or hemodynamic changes are evident. Need to document alveolar ventilation (PaCO2) in an otherwise stable patient must be ordered by physician. Measure blood gases 30 minutes after ventilation or mode change until stable. Measure blood gases immediately if sudden deterioration

Answer 18

Mixed Venous samples will be drawn Q12h in a patient having a PA catheter as per Calgary Health Region policy. It is not mandatory to draw an arterial sample in conjunction with each mixed venous draw. Samples drawn for electrolyte and/or hemoglobin analysis, must be sent to the lab unless ordered STAT. Refer to the Regional Guidelines for the use of Inhaled Nitric Oxide when drawing samples on patients receiving Nitric Oxid

Answer 19

Standard practice should be used and weaning parameters should be performed through the vent Patient should be on **PEEP \< 8 cm H2 O and F1O2\< 0.60.** Patient’s own **minute ventilation should not be greater than 12Lpm.** Patient should be monitored with SpO2 during procedure. Try to place the pt in sitting position or elevate their head in order to optimize pulmonary mechanics The follow should be recorded * Respiratory rate ( f ) * Tidal Volume ( VT ) * Vital capacity ( VC ) * Minute Ventilation * Rapid Shallow Breathing Index (Tobin Ratio) = f (bpm) / VT (L)). * This ratio is determined after the patient had been breathing spontaneously for one minute. NIF or NIP measurements can be performed upon physician request. With the preferred method for NIF measured via the vent, but if using an external device perform it through the HMEF If possible use a dedicated external device for each patient. In exceptional circumstances when the device is to be shared it must be surface disinfected with a germicidal wipe prior to its next use. In those patients who show desaturation during measurement using an external device, oxygen can be added in through the inlet of the system.

Answer 20

RT and RT student

Answer 21

Measuring device(s) if applicable i.e. Ventilator, Wrights, Respiradyne, etc. Monitoring equipment i.e.: SpO2, ECG if available. Oxygen source if required. Gloves

Answer 22

Perform hand hygiene with an antiseptic agent Don clean gloves. I don’t think you need to glove unless you are attaching an external device. Explain procedure to patient. Measurement through the ventilator: Measurement of NIF or NIP using external measuring device:

Answer 23

Silence alarms. Switch to CPAP/Spontaneous mode of ventilation. Change Pressure Support level to zero and maintain PEEP levels. For VC maneuver on Drager ventilators, ensure the high VT alarm is set to maximum (4 L). Allow patients status to stabilize for at least 30 seconds. Observe closely with monitoring devices. Note RR, VT, Minute Volume during 60 seconds of observation. Instruct patient to perform VC maneuvers to obtain 2 reproducible values. If requested, and the ventilator option is is available, ask the patient to perform NIF or NIP. Numerous attempts may be required to get an optimal result. Return patient to previous ventilator and alarm settings. Document measured results, patient tolerance of procedure and level of cooperation.

Answer 24

Silence alarms Preoxygenate patient as required or provide supplemental oxygen. Disconnect patient from ventilator and place the circuit on the ventilator support arm. Attach external measuring device to HMEF. Ask the patient to perform NIF or NIP. Numerous attempts may be required for optimal value. Reconnect the patient to ventilator. Reset parameters. Document measured values, patient tolerance of procedure and level of cooperation. Surfacedisinfectthedevicewithagermicidalwipeafteruse. Remove gloves and Perform hand hygiene (antiseptic agents are only required before an invasive procedure)

Answer 25

Note patient tolerance/status during measurements. If desaturation occurs, return the patient to mechanical ventilation or provide the patient with supplemental oxygen.

Answer 26

The RT will be solely responsible for the set-up, monitoring, setting changes, troubleshooting, and discontinuing the mechanical ventilator in ICU. The attending MD or ICU Fellow may perform ventilator setting changes if the situation warrants it. Following these changes, the attending MD or ICU Fellow must immediately notify the responsible RT (if they were not present at the time of the changes) to ensure appropriate alarm settings and documentation. The RT is permitted to select an appropriate ventilator for the patient situation, unless a physician has given a specified order. The ventilator parameters are adjusted by the RT as per physician’s order or according to approved protocols.

Answer 27

Mode PEEP Tidal volume (based on Ideal Body Weight - IBW)• Pinsp (PC level) PS level I: E ratio or Tinsp (if inverse ratio) Rate Note: All other settings will be at the discretion of the RT unless ordered otherwise.

Answer 28

If using external analyzer, set alarm +/- 10% of set

Answer 29

2-3 cmH2O below set PEEP

Answer 30

In volume-based ventilation, to be set at 50 cmH20 or 15- 20 cmH20 above the peak inspiratory pressure. In pressure ventilation, set at 5-10 cmH20 above peak inspiratory pressure

Answer 31

Set to a minimum of 10 or 15-20 cmH20 below peak inspiratory pressure

Answer 32

Set to 150-200 ml below or 20% below set or delivered VT

Answer 33

In spontaneous modes, set to 1.5 - 2 times the set or delivered VT. In control modes, set 200 mL above the set or delivered VT

Answer 34

Set at 50% above set or delivered minute volume

Answer 35

Set to 20% below set or delivered minute volume

Answer 36

Set to 30 - 35 or 10 breaths/min above patient’s rate

Answer 37

Only applicable on spontaneous breaths on Evita 4 Set to 10 breaths/min above patient’s spontaneous rate or at upper acceptable limit for respiratory rate orders (i.e. PSV to maintain RR \< 35)

Answer 38

Set delay to 20 - 30 seconds

Answer 39

Adjust to set or delivered tidal volume

Answer 40

Adjust to set rate but not below 8 breaths/min.

Answer 41

Set to 1.00

Answer 42

Do not exceed 60 Lpm (Square waveform default)

Answer 43

Adjust to set I:E pressure control

Answer 44

Set 5-10 cmH2O above peak inspiratory pressure

Answer 45

Adjust to set pressure control level

Answer 46

A QS ventilator download (F7) must occur with every ventilator change and during arterial blood gas sampling. With significant setting changes (i.e. mode, major increase in FiO2, etc.) documentation in the RT respiratory notes must also occur.

Answer 47

Flow sensing or flow-by should be activated to reduce the work of breathing - where available.

Answer 48

If emergent ventilator changes are required (outside a protocol), the RT may adjust the ventilator or other respiratory device to attempt to correct the problem. These changes will be communicated as soon as possible to the patient’s care team as well as the attending MD.

Answer 49

To promote a combined infection prevention approach that will prevent the exogenous colonization of the baby’s airway and the aspiration of the baby’s own flora. Ventilator associated pneumonia (VAP) is a nosocomial infection occurring in patients receiving mechanical ventilatory support that is not present at the time of intubation and that **develops more than 48 hours after the initiation of that support**. VAP can derive from **endogenous bacteria** (the baby’s own oropharyngeal flora) or **exogenous bacteria** (eg: Pseudomonas aeruginosa). VAP is associated with prolonged hospitalization and increased mortality, especially in the very low birth weight infant.

Answer 50

**Continuously monitor the infant** for readiness for extubation, thus minimizing the duration of intubation and reducing the possibility of infection The head of the infant’s bed must be **elevated by 15 degrees** at all times, unless contraindicated and accompanied by a written order from the physician/Neonatal Nurse Practitioner The endotracheal tube suction set-up must remain a **closed system whenever possible** Whenever the ventilator circuit is **disconnected from the patient, it must be covered or capped to maintain sterility.** Perform hand hygiene before and after glove use. Clean nonsterile gloves must be worn when handling respiratory secretions or objects contaminated with respiratory secretions. Change gloves after performing tasks on a single patient; remove gloves and perform hand hygiene between patients. Endotracheal tube and/or oral suctioning devices (eg: sterile water, suction catheter) must be changed after each use Any **condensation** in the circuit must be **drained away from the patient** to prevent aspiration of flora. The **circuit cap must be stored on the manual resuscitator** when not being used to cap the circuit. The cap must be **cleaned with a chlorhexidine swab** after each use. The patient end of the **T-piece resuscitator (**with the appropriate sized mask attached) **must be covered with a polyethylene bag when not in use**. The ventilator circuit or its components must never be left on the bed when disconnected from the patient. Place in the circuit holder on the ventilator and cap/cover open end. When the closed in-line suction system is disconnected from the suction tubing, the end must be capped immediately. An audible v**entilator alarm must be activated at all times**, except during procedures when the **infant remains under constant observation by care providers.**

Answer 51

A Registered Respiratory Therapist (RRT) shall be responsible for changing the ventilator circuit as required. A ventilator used for 28 consecutive days on the same patient will be changed to allow for cleaning and routine maintenance.

Answer 52

Early endotracheal tube removal has been shown to reduce VAP; however, reintubation should be avoided if possible. All areas of the workspace, including the bagging unit, should be cleansed with disinfecting solution at the start of each shift, and following potentially contaminating procedures or contacts. Resuscitation bags are to be hung outside the incubator or radiant warmer when not in use. To reduce the possibility of contamination, resuscitation bags should never be placed on the countertop. Comprehensive mouth care is required and includes oral suctioning prior to: * endotracheal tube suctioning * significant repositioning of the infant * elective extubation. If possible, infants should be weighed using the in-bed scale to minimize the risk of accidental extubation.

Answer 53

To provide a procedure for the use of the T-Piece Infant Resuscitator when delivering positive pressure ventilation, CPAP or free flow oxygen to neonates both in the delivery room and in the neonatal intensive care unit (NICU).

Answer 54

T-piece resuscitators are an **easy to use resuscitator** which provides **consistent positive inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP)** during manual resuscitation. The T-piece resuscitator is an acceptable method to initiate and continue ventilation in the newborn infant, **particularly in the preterm infant** where control of peak inspiratory pressure (PIP) and positive-end expiratory pressure (PEEP) is crucial.

Answer 55

The T-piece resuscitator provides several benefits over conventional self-inflating and flow-inflating resuscitation bags. The device is able to **provide safe, controlled PIP, consistent PEEP, and free flow oxygen**. The pressure is set by the user prior to and during resuscitation to deliver consistent distending pressures **regardless of the skill level or experience of the operator.** Considering the potential complications of overdistension and under inflation of the alveoli during resuscitation, controlled PIP and PEEP is essential. Given that several studies have demonstrated the **inability of even skilled operators to provide accurate and effective PIP and PEEP with conventional resuscitation bags, a device that provides consistent inflation pressures is essential.**

Answer 56

The device may be used to **deliver CPAP and free flow oxygen** to **spontaneously breathing infants.** The time of **occlusion (inspiration) should be limited to approximately 0.5** seconds, regardless of the intended respiratory rate. Alternate manual resuscitation devices (flow inflating and self- inflating bags) will continue to be available. The T-piece resuscitator should be **used when transferring non-intubated infants requiring CPAP or free flow oxygen** from the resuscitation room to the NICU and, intubated infants when a transport ventilator is not available. The T-piece resuscitator will be **tested at the beginning of each shift, and prior to use.** The T-piece resuscitator will be **re-circuited and a leak test performed after each use.**

Answer 57

**Equipment failure:** Backup resuscitation devices must always be present. **Under-inflation** due to inadequate pressure can result in hypoxia. **Overdistention:** Potential for barotrauma leading to pneumothorax, pulmonary interstitial emphysema, pneumoperitoneum, pneumomediastinum or pneumopericardium. Note: The lowest possible PIP required to adequately oxygenate the neonate should be used. **These complications are observed with all ventilation devices.** However, the T-piece resuscitator allows the operator to accurately and consistently deliver safe and controlled PIP. Therefore, the **incidence of complications is less than with conventional manual ventilation methods.**

Answer 58

Staff working in the labor and delivery room, the NICU, and the postpartum unit who are NRP registered and trained in the use of the T-piece resuscitator.

Answer 59

T-piece resuscitator Single use patient supply circuit Infant mask - appropriately sized Flow meter T-piece Oxygen tubing Blended oxygen source Test lung

Answer 60

* Ensure the manometer reads zero with no gas flow. * If not, the manometer should be sent to Biomedical Services for adjustment. * Connect gas supply. The gas supply line should be connected to an oxygen/air blender whenever available. Otherwise, connect the gas supply line to an oxygen source. * Connect the patient supply line and patient T-piece to the gas outlet port of the resuscitator. * Adjust the gas supply to the appropriate flow rate. * A flow rate of 10 litres per minute is typical for neonates. * Check the maximum pressure relief setting. * Occlude the positive end **expiratory pressure cap (PEEP) and turn the inspiratory pressure control knob fully clockwise.** * **Adjust maximum pressure relief knob to set desired maximum pressure relief (Note: this is not the inspiratory pressure used for ventilation). The value should be set to 45 cm H2O.**

Answer 61

While continuing to occlude the PEEP cap, turn the inspiratory pressure control knob clockwise or counter-clockwise until the desired inspiratory pressure is set. The initial inspiratory pressure should be set at 20 cm H20, although, it may need to be individualized in certain situations. Timely adjustments after initiation of resuscitation should be made to ensure immediate improvements in heart rate. **PIP as high as 35 cm H20 may occasionally be required** in some infants. Weaning of PIP should be considered when possible, particularly post-surfactant administration.

Answer 62

Remove finger from the PEEP cap. While observing the manometer, adjust PEEP to desired level: Initial PEEP should be set at 5 cmH2O. Further PEEP and PIP adjustments may be necessary after initiation of resuscitation. If delivery is pending, leave gas supply on, remove test lung and apply appropriate sized face mask. Ensure the blender is set to room air.

Answer 63

* Ensure the flow rate is set to the appropriate level. * FiO2 should be set and titrated as per NRP guidelines. * Attach open end of the T-Piece to a face mask or an artificial airway. * To deliver manual ventilation: * To deliver inspiration - place finger over the PEEP cap. * To deliver expiration - remove finger from PEEP cap. * **NOTE: Inspiratory time is operator controlled. A longer expiratory time is optimal, therefore the PEEP cap occlusion should be limited to approximately 0.5 seconds, regardless of the intended respiratory rate.** * To achieve target **respiratory rate of 40-60** breaths/minute repeat * Observe manometer closely to ensure that appropriate PIP and PEEP levels are being achieved. * **Pressure adjustments should be made only after an adequate seal has been established by the operator.**

Answer 64

To deliver CPAP in spontaneous breathing infants: * Ensure a tight seal has been created between the mask and the baby's face. * Do not occlude the aperture on the PEEP cap. * Adjust PEEP cap until desired PEEP is displayed on the manometer. To deliver free flow oxygen without CPAP * Release seal between mask and infants face * Hold the mask close to the face and allow the continuous gas flow to circulate around infant's face. * Delivered FiO2 can be adjusted with the blender, if available.

Answer 65

Turn off gas supply, Remove the patient circuit from the machine and discard. Clean external device with approved disinfectant wipe as per IP&C Attach new circuit. Ensure appropriate pressure settings are reset on the T-Piece. Cover T-piece with clean bag.

Answer 66

To facilitate the safe administration of exogenous surfactant. Clinical judgment is not anticipated to be required in this [policy/procedure]. Any deviation from the standard or expectation within this [policy/procedure] must be carefully considered. Discussion with one’s direct report is expected prior to deviating and documentation shall beincluded on the patient’s health record to reflect both this discussion and to identify therationale for such deviation.

Answer 67

In Calgary we are currently using the exogenous surfactant BLES, which requires a volume of 5ml/kg.

Answer 68

Avoiding barotrauma, volutrauma and atelectotrauma Volume targeted ventilation to avoid barotrauma and volutrauma Initial Tidal volumes 4ml/kg (3.5-5ml/kg) in Extremely Low Birthweight (ELBW) infant Maintain Positive end expiratory pressure (PEEP) to avoid atelectotrauma

Answer 69

This device attaches to the **proximal end of the ETT using a wye connector,** the same as used for in-line suctioning. This device allows for a **closed system** to remain intact and the **surfactant bolus is delivered at the distal end** of the ETT into the trachea, **reducing the risk of obstruction** within the length of the ETT (9 cm) as can occur when the surfactant is instilled at the proximal end via the side port. **One port of the wye connects the ventilator to the ETT; the other port is connected to the MAC and later to in-line suction when the MAC is not required.** The in-line MAC for administration of surfactant is advanced into the ETT to the distal end, the surfactant aliquot is delivered, the catheter is withdrawn back to the proximal wye connector and the surfactant bolus is propelled distally into the lung using mechanical ventilator breaths. This is repeated until the entire volume of surfactant has been administered in **3-4 aliquots as necessary.**

Answer 70

A widely used surfactant administration set-up is the **multi-access catheter (MAC), a 5 Fr. In-line ET catheter.**

Answer 71

The in-line MAC for administration of surfactant is advanced into the ETT to the distal end, the surfactant aliquot is delivered, the catheter is withdrawn back to the proximal wye connector and the surfactant bolus is propelled distally into the lung using mechanical ventilator breaths. This is repeated until the entire volume of surfactant has been administered in 3-4 aliquots as necessary.

Answer 72

Obstruction of the ETT can be **assessed with the absence of flow on the ventilator flow/time scala**r and therefore **requires increased ventilator pressure to overcome the obstruction**. Resumption of the flow/time scalar indicates a recovery from obstruction and as tidal volume reaches set value, pressure is weaned. However, in a small percentage of infants with ETT obstruction that is not alleviated with a step wise increase in ventilator pressure, an algorithm detailing measures to rapidly respond to airway obstruction was developed. **Switching to the Neopuff for ventilation is a continued escalation for airway obstruction management before emergency measures are initiated.**

Answer 73

BLES administrations were audited with side port and MAC methods and complications were reduced from 25% with the side port method to less than 7% with the MAC. Complications defined during administration was a heart rate less than 70 bpm and/or SpO2 less than 60% or removal of ETT or chest compressions.

Answer 74

Registered Respiratory Therapist (RRT) Student Respiratory Therapist under the direct supervision of a RRT Neonatologist Fellow Neonatologist Neonatal Nurse Practitioner

Answer 75

Perform hand hygiene. Prepare surfactant-Add one milliliter of air, this will ensure no surfactant will remain in the catheter after delivery. (catheter volume is 0.4 ml) Ensure Neopuff is functioning and preset inspiratory pressures at 40 cmH2O and PEEP of 6 cmH2O (or equal to the PEEP setting on the ventilator). The Neopuff may be used for back up ventilation if surfactant delivery with the ventilator is insufficient having reached maximal peak inspiratory pressure (PIP) and tidal volume (Vt) on the ventilator. Ensure flow inflating bagger is set up and ready to use. Cut ETT on a diagonal to enable wye adapter to fit in more easily. Wedge wye adapter on cut edge of ETT. Each package comes with 3 adapters: 2.5, 3.0, and 3.5. Match the adapter with the size of the ETT. Suction infant prior to surfactant administration with a closed suction system, if available. Mucous plugs can impair ventilation shortly after surfactant administration. Attach syringe with surfactant dose to MAC luer lock. Remove blue cap and attach MAC to small opening of correct size wye adaptor. Determine desired depth of catheter by locating markings on catheter and ETT to determine depth of insertion (catheter end should line up slightly higher than the distal end of ETT). Position infant in a stable supine position, with the infant's head and ETT midline.

Answer 76

* If an airway obstruction alarm develops - essentially **no flow is measured by the ventilator,** this will cause the ventilator to behave according to an algorithm. This **alarm occurs frequently during surfactant administration - the result of a catheter in the airway and/or filling airway with fluid.** * Ventilator behaviour during "airway obstruction alarm" (VN and XL/Dura) * **High airway alarm pressure** - PEEP divided by 2 + PEEP * **Delivered breath given our settings would be approximately 22 cmH2O**

Answer 77

VN 500 manual breath is 5 cmH2O below high pressure alarm in conventional ventilation XL/Dura manual breath is last PIP delivered So utilizing the manual breath button during airway obstruction alarm with the XL/Dura provides no clinical benefit (PIP will not be increased and would be the same pressure) compared to the increased PIP of the VN manual breath.

Answer 78

While on volume target mode, increase ventilator high pressure alarm to 35 cmH2O and ventilator frequency to 60 breaths per minute for surfactant administration. FiO2 should be adjusted to maintain SpO2 at 90 - 95% during surfactant administration.

Answer 79

The goal is to deliver surfactant in rapid aliquots over 2-3 seconds, number of aliquots adjusted for size of ETT. For #2.5 ETT administer in 3-4 aliquots. For greater than or equal to #3.0 ETT administer in 2 - 3 aliquots.

Answer 80

When ready to administer surfactant, insert catheter to desired depth. Administer first aliquot, remove catheter from ETT to withdrawn position.

Answer 81

Watch ventilator flow waveform and tidal volume to determine ventilation. If ventilation is limited as observed with minimal flow on the ventilator graph and /or less than set tidal volume delivered: Provide 3 manual breaths.

Answer 82

A minimum recovery period of 40 - 60 seconds between aliquots should be allowed.

Answer 83

Resume volume targeted mode as soon as possible post surfactant administration, wean frequency as tolerated and decrease high pressure alarm to 30 cmH2O. No routine suctioning for two hours after surfactant administration. The RRT should remain in the immediate vicinity for a minimum of 30 minutes post surfactant administration to ensure constant evaluation of ventilator settings, assessment of lung dynamics and overall clinical status. Remove MAC from wye, cap the open end of the wye adapter with the white cap provided in the package.

Answer 84

While on volume target mode, note current PIP, switch to Pressure Control Ventilation (PCV) assist mode with current PIP from volume target ventilation (target 4-5 ml/kg Vt). Increase high pressure alarm to 40 cmH2O and ventilator frequency to 60 breaths per minute for surfactant administration. FiO2 should be adjusted to maintain SpO2 at 90 - 95% during surfactant administration.

Answer 85

Recommend Transcutaneous CO2 (TCPCO2) monitoring if possible

Answer 86

If on HFO-PC mode, note current average VtHF, DCO2 and chest wiggle If on HFO-VG mode, note current average amplitude, DCO2 and chest wiggle Change to HFO-PC using average amplitude used on HFO-VG mode Set the HFO sigh pressure at 1-2 cmH2O above the current mean airway pressure.

Answer 87

Deliver surfactant in aliquots over 2-3 seconds, number of aliquots adjusted for ETT size For #2.5 ETT administer in 3 - 4 aliquots For #3.0 ETT or greater, administer in 2 - 3 aliquots FiO2 should be adjusted to maintain SpO2 at 90 - 95% during surfactant administration

Answer 88

When ready to administer surfactant, insert catheter to desired depth Administer first aliquot, remove catheter from ETT to withdrawn position.

Answer 89

Watch ventilator flow waveform, tidal volume, and chest wiggle to determine ventilation Adjust amplitude to maintain VtHF and adequate chest wiggle throughout procedure with maximum amplitude of 40 cmH2O. (Lowering Hz maybe required to achieve set amplitude, temporary measure only) If ventilation re-established, wean amplitude in stepwise adjustments to desired HFVt with adequate chest wiggle. If ventilation NOT re-established, disconnect from the ventilator and provide ventilation with the Neopuff; PIP of 40 and PEEP 6. If ventilation does not improve with the Neopuff, increase PIP to 45 cmH2O, and consider emergency measures below. Switching from HFO mode to Neopuff to trouble shoot tube obstruction should occur in a time sensitive manner and should occur in 30 seconds.

Answer 90

A minimum recovery period of 40 - 60 seconds between aliquots should be allowed For remaining aliquots start with the amplitude that delivers the desired HFVt and chest wiggle. Give remaining aliquot(s) Post surfactant administration; wean amplitude as tolerated for desired HFVt and chest wiggle, trend DCO2 and TCPCO2 if applicable. Return to HFO+VG mode if that was the pre surfactant mode and ensure the maximum amplitude is set 10 cmH2O above the average amplitude (this limits the amplitude in the HFO+VG mode only). Draw a CBG or ABG 30 minutes post surfactant administration. No routine suctioning for two hours after surfactant administration. The RRT should remain in the immediate vicinity for a minimum of 30 minutes post surfactant administration to ensure constant evaluation of ventilator settings, assessment of lung dynamics and overall clinical status. Remove MAC from wye, replace with suction catheter in the wye adapter.

Answer 91

Patient complications immediately after surfactant bolus include: * Bradycardia and desaturation * Endotracheal tube obstruction If patient presents with signs of **clinical deterioration (SpO2 less than 80% and/or HR less than 100 bpm**) and **no improvement despite increased FiO2 and increased ventilating pressure, it is necessary to assure bilateral breath sounds and chest wall movements**. If there is no chest movement and continuing deterioration is observed, the ETT should be: * Manually ventilated with the Neopuff or a flow inflating bag. * Suctioned * Assessed for removal and a new ETT re-inserted.

Answer 92

Pre measured to 9 cm ETT marking (left number) and ALMOST at the 9 cm MAC marking (right number). MAC tip will end up slightly higher than the distal end of ETT. Lining up the numbers may extend catheter beyond the distal end of the ETT. Correct position of MAC tip slightly higher than the distal end of the ETT.

Answer 93

Closed in-line suction catheters will be used for routine secretion management for all mechanically ventilated infants whose expected duration of ventilation is greater than 12 hours. Closed in-line suction requires a dedicated suction regulator which will not be used for any other suctioning (eg. oral).

Answer 94

The infant’s hypopharynx must be suctioned prior to endotracheal suctioning to prevent aspiration.

Answer 95

Closed in-line suction catheters will be changed every 72h and prn. The following conditions will necessitate a non-routine catheter change * Visible soiling on the external or internal surface of the catheter * Mechanical failure of the suction control valve * Inability to move the catheter freely * Air filling of the closed in-line suction catheter’s sleeve * Mechanical failure of the one-way valve on the instill port. * If ETT secretions culture is positive for a pathogen, in-line suction catheters should be changed on a daily basis for at least 3 days. *

Answer 96

If the infant has been diagnosed with a ventilator associated pneumonia (VAP), continue daily in-line suction catheter changes until the infant’s condition improves (as evidenced by decreased FiO2 requirements, decreased ventilatory pressures, decreased secretions, etc), then return to changing the in-line suction every 72 hours. If the positive ETT culture is thought to be a result of colonization of the ETT, and if there are no signs or symptoms of VAP, change the in-line suction catheter every day for 3 days, and then return to changing it every 72 hours.

Answer 97

Care providers must perform hand hygiene and don personal protective equipment prior to open suctioning, including: * non-sterile gloves goggles * mask * a barrier gown is optional when body fluid exposure is anticipated performing care provider: * face protection: mask with shield or mask and goggles * non-sterile glove on the non-dominant hand * sterile glove on the dominant hand

Answer 98

If the closed in-line suction catheter does not adequately remove infant’s secretions, the following steps must be attempted prior to the use of open suction: * Ensure proper vacuum pressures * Rinse catheter with sterile normal saline * Ensure the valve is properly depressed * Verify patency of catheter (ie. not kinked) and of the suction system. 7. Care providers must perform hand hygiene and don personal protective equipment prior to open suctioning, including: Subject/Title: SUCTIONING ENDOTRACHEAL TUBES: NEONATAL Date Established: Jan 2010 Date Reviewed: Page: 2 of 7 7. 1. for the 7.1.1. 7.1.2. 7.1.3. 7.1.4. 7. 2. for the 7.2.1. 7.2.2. 7.2.3. 7.2.4. assisting care provider: non-sterile gloves goggles mask a barrier gown is optional when body fluid exposure is anticipated performing care provider: face protection: mask with shield or mask and goggles non-sterile glove on the non-dominant hand sterile glove on the dominant hand a barrier gown is optional when body fluid exposure is anticipated.

Answer 99

Closed in-line suction is the standard form of secretion clearance for use in mechanically ventilated infants. A sterile closed suction system is also preferred for endotracheal secretion sample retrieval.

Answer 100

Open endotracheal suctioning is intended for use when closed in-line suctioning is * unsuccessful at clearing secretions, * when an adequate sample cannot be obtained with a closed system, * or when a closed system is unavailable at sites that care for short term ventilation prior to extubation or transfer.

Answer 101

Ensure the appropriate sized catheter is selected for the specific size of airway present. A 6.0 French catheter is to be used on #2.5 ETT, while an 8.0 French catheter is to be used on a #3.0 or #3.5 ETT.

Answer 102

Instillation of saline is not to be done routinely. Instillation may be indicated if secretion removal is ineffective without it (ie. tenacious secretions).

Answer 103

For either open or closed suctioning, it is recommended that two trained personnel perform the procedure to prevent accidental extubation and to allow for changes in ventilator settings as indicated by patient status (eg. increasing FiO2 for desaturation).

Answer 104

Higher suction levels (100-120mmHg) are required with in-line suction catheters due to the higher resistance levels.

Answer 105

The suction tubing must be disconnected from the closed in-line catheter whenever the infant is being mobilized or is at high risk of self-extubation. The tip of the suction catheter connector and the end of the suction tubing must be kept sterile while disconnected. If either is contaminated in the process they must be replaced with new product. The suction control valve must be locked when the closed in-line catheter is not in use. Ensure that the blue directional indicator line on the endotracheal tube remains in a left facing position prior to and after the procedure.

Answer 106

* During Procedure: * Bradycardia * Hypoxia * Hypercarbia * Tracheal mucosal damage * Following Procedure: * De-recruitment and atelectasis * Decreased compliance resulting in hypercarbia * Increased oxygen requirements * Tracheal stenosis * Infection

Answer 107

Verify suction level to be 100-120 mmHg. Silence appropriate ventilator alarms. Increase FiO2 5-10% above the infant’s current level of oxygen. Allow sufficient time for the increase in FiO2 to reach the infant (approximately 20 seconds). Determine the appropriate depth of catheter insertion by using the suctioning guide or by utilizing the markings on the endotracheal tube. The catheter’s distal end should protrude approximately 0.25 – 0.50 cm past the distal end of the endotracheal tube. Insert the suction catheter to the appropriate depth, apply continuous suction for 1 to 3 seconds, then slowly withdraw the catheter. Pull out the catheter in a straight motion (without twirling) to prevent kinking. Time from insertion to complete withdrawal should not exceed 5 seconds. Rinse the catheter with 1-3 ml of sterile normal saline. If rinsing is not routinely done, the catheter will no longer function effectively. Always remove and discard the normal saline rinse from the instill port after completing the suction procedure.

Answer 108

The suction catheter must be completely withdrawn so that the tip of the suction catheter is visible outside the airway (ie. within the suction catheter elbow). Assess patient and allow 20 - 30 seconds of ventilation. Repeat procedure as required. Remove and discard normal saline rinse from the instill port. Reactivate ventilator alarms. If indicated, Respiratory Therapy may consider performing a recruitment maneuver with consultation with the attending physician/NNP. Wean FiO2 as tolerated. Note: If there is a change in the secretions, notify the physician to determine if sputum cultures are indicated.

Answer 109

It is recommended that two trained personnel perform this procedure.

Answer 110

Silence appropriate ventilator alarms. Disconnect and suspend ventilator circuit on the ventilator suspension arm. DO NOT turn the ventilator off and DO NOT allow the open end of the circuit to contact any surface. Initiate PPV using a bagging unit or T-piece resuscitator.

Answer 111

Insert the suction catheter into the endotracheal tube to the measured depth. Apply suction while withdrawing the catheter, using a twisting motion. Time from insertion to complete withdrawal should not exceed 5 seconds.

Answer 112

Aspirate several mLs of sterile water after each pass to clear catheter and suction line.

Answer 113

Contamination has occurred if the suction catheter comes in contact with anything other than the inner surface of the endotracheal tube or the sterile gloved hand.

Answer 114

Place patient back on the ventilator or bagging unit between suction attempts to ensure adequate ventilation and oxygenation. Aspirate several mLs of sterile water after each pass to clear catheter and suction line. Reassess patient and repeat suctioning as required. A new suction catheter and sterile water MUST BE used if contamination occurs. Contamination has occurred if the suction catheter comes in contact with anything other than the inner surface of the endotracheal tube or the sterile gloved hand. 17. When reconnecting the patient, ensure the ventilator is operational and functioning on pre- suctioning settings, as tolerated. Perform hand hygiene. Reactivate ventilator alarms. If indicated, Respiratory Therapy may consider performing a recruitment maneuver with consultation by the attending physician/NNP. Reassess patient’s respiratory status. Document procedure according to the unit specific documentation standards, including 22. 1. number of passes made with the suction catheter. 22. 2. characteristics of secretions, including amount, color, consistency, etc. 22. 3. patient’s tolerance of the procedure. • Note: If there is a change in the secretions, notify the physician to determine if sputum cultures are indicated.

Answer 115

Determine the appropriate depth of catheter insertion by using the suctioning guide or by measuring the endotracheal tube. The catheter’s distal end should protrude approximately 0.25 – 0.50cm past the distal end of the endotracheal tube.

Answer 116

Increase FiO2 5-10% above the infant’s current level of O2.

Answer 117

Adjust suction to 80-100mmHg and test by kinking tube and reading suction gauge