UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

TITLE: Adult Ventilation Protocol (AVP)

I. PURPOSE: The objective is to provide a safe and efficient standardized approach to ventilator set up, management and weaning. To achieve this objective the policies and procedures are based on current technology, recent studies, and the clinical guidelines for mechanical ventilation as set forth by the American Association for Respiratory Care (AARC).

II. SCOPE: These mechanical ventilation policies and procedures transcend the solely physician- driven approach to include the entire critical care team incorporating to some degree, all members: physicians (MD), respiratory therapists (RT), and registered nurses (RN). It has been established that using such protocols reduces the time of mechanical ventilation, thereby having a positive effect on ventilator complications and ultimately reducing the length of stay.

III. GUIDELINES FOR USING ADULT VENTILTOR PROTOCOL (AVP):

A. The use of the Adult Ventilation Protocol (AVP) shall be initiated by a physician’s order in the electronic medical record (EMR). 1. A physician’s order for initiation and weaning of mechanical ventilation protocol should be written in the electronic medical record. Initial ventilator parameters and subsequent ventilator parameter changes made based on AVP will be documented on the ventilator flowsheet in the EMR. 2. When ventilator changes are made based on AVP, the respiratory therapist will document compliance. Documentation of the AVP compliance will occur using the EPIC order mode of PAP. 3. Physician ventilator parameter orders and physician orders not covered by the AVP should be placed in the EMR. B. The attending physician may write, “Discontinue AVP” at any time. The patient may also meet AVP exclusion criteria and not be managed using the protocol. C. A patient that meets the AVP exclusion criteria shall not be managed using the protocol. D. Exclusion for the AVP includes the following criteria; these patients shall require direct physician management. 1. Patient less than 16 years old 2. A documented ventilator order from the primary or consulting physician that varies from the AVP and does not permit adjustment of ventilator parameter based on AVP. In such a scenario, the physician will be contacted for clarification as to whether further ventilator adjustments shall be made based on the AVP. The physician then has the choice to approve further use of the AVP or to discontinue AVP.

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

IV. DEFINITION OF BREATH TYPES AND MODES:

A. Definition – Mandatory Breath Types 1. Volume Ventilation: a preset volume is delivered. Volume ventilation is used in either assist control (AC), where every breath receives minimally the set volume; or Synchronized Intermittent Mandatory Ventilation (SIMV), where the minimum set volume is delivered at a rate based on the breath rate set for mandatory breaths. 2. Pressure Ventilation (PV) or pressure control ventilation (PCV): a preset pressure is delivered (∆ P). Used in either assist control, where every breath receives at minimal the set pressure; or SIMV, where the minimum set pressure is delivered at a rate based on the breath rate set for mandatory breaths. 3. Volume Control Plus (VC+/PRVC) [Note, this acronym and nomenclature may change from one ventilator manufacturer to another.]: pressure ventilation is delivered such that the pressure is automatically adjusted by the ventilator to provide a set tidal volume. Used in either assist control, where every breath receives at minimal the set pressure; or SIMV, where the minimum set pressure is delivered at a rate based on the breath rate set for mandatory breaths. 4. Airway Pressure Release Ventilation (APRV): [Note, this acronym and nomenclature may change from one ventilator manufacturer to another.]: A mode with pressure ventilation in which the following parameters are set: high pressure (PEEPH), low pressure (PEEPL), or PEEP/CPAP, time during which high pressure is delivered (THIGH), and release time at low pressure (TLOW). B. Definition – Support Breath Types: 1. Spontaneous Mode/CPAP: Spontaneous breathing through the ventilator, which allows for monitoring patient data, alarms, and baseline adjustment to CPAP and FiO2. This mode provides only pressure or flow assist to the patient. It can be used alone in patients with adequate respiratory drive and ventilation capabilities or in combination with mandatory breath types. 2. Pressure Support (PS): a patient-triggered, pressure limited, flow-cycled breath type. This can be a stand-alone breath in patients who have an intact respiratory drive, or it can be used in combination with mandatory breath types. 3. Volume Support (VS): a patient-triggered, volume targeted, flow-cycled breath type. This can be a stand-alone breath in patients who have an intact respiratory drive.

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

V. ADULT VENTILATION PROTOCOL:

A. Initiation Orders: Physician must place order for “Initiate & Weaning of Mechanical Ventilation Protocol.”

B. Ventilator Adjustments Based on Patient Assessment

• Initial and ongoing assessments will occur for the first 30 minutes and the assessment will be documented within 45 minutes from the start of ventilation. • Assessment will include evaluation of the patient’s general appearance, blood pressure, heart rate, breath sounds, ventilating pressures and arterial blood gasses (ABG). • Assessment will also include additional data, such as end-tidal PetCO2 (end- tidal CO2), SpO2, and hemodynamic data.

C. Mode: SIMV, Assist Control (AC), Adaptive Support Ventilation (ASV)

*Placing a patient in SIMV must be discussed with the Attending or Fellow before being initiated in Unit 82 & 11-4.

Breath Type:

Volume Control Plus (VC+/PRVC): may be used for the majority of patients, but Pressure Control Ventilation (PCV) or Bi-Level/APRV should be considered if peak pressures rise over 40 cmH2O or plateau pressures raise ≥ 30 cmH2O.

Pressure Control Ventilation (PCV): may be used if peak pressures rise over 40

cmH2O or plateau pressures rise ≥ 30 cmH2O; adjust ∆P: to achieve 6 -7ml/kg VT. The maximum level of ∆P is 30cmH2O.

Tidal Volume (VT): 6mL/Kg of ideal body weight (IBW), while maintaining plateau pressure ≤30 cmH2O and delta P ≤ 20cmH2O. If the plateau pressure (Pplat) is >30cmH2O, decrease VT by 1ml/kg to a minimum of 4 – 5 ml/kg. Notify attending, fellow, or APP should you have to reduce the tidal volume to decrease Pplat. Use IBW to determine tidal volume.

FiO2: Initial setting of 0.60 until results from arterial blood gas (ABG) can be obtained and the setting adjusted.

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

• Initial ABG should be obtained 15 – 45 minutes from start of ventilation. • Pulse oximetry should be correlated with initial ABG and the patient subsequently monitored with continuous pulse oximetry to maintain SpO2 at or above patient’s normal, >92% SpO2, and >88% in the MICU. • Increase FiO2 if SpO2 is less than 92% and >88% in the MICU. • Wen patient to the lowest level of FiO2 while maintaining minimal acceptable SpO2.

Rate (f) Set to achieve optimum total cycle time and maintain desired minute ventilation, while maintaining plateau pressure ≤ 30cmH2O.

• PetCO2 between 30 and 45 mmHg • Incrementally increase or decrease rate to achieve desired minute ventilation (8 - 10 L/min)

PEEP: Set initial PEEP to 5cmH2O, unless otherwise indicated. Higher PEEP may be required with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS).

• May increase to 10cmH2O to allow reduced FiO2. • May wean every 60 minutes by 2cmH2O to maintain above FiO2. • Oxygenation goal: FiO2 ≤ 40%, PEEP 5 cmH2O, SpO2 ≥ 92%, SpO2 ≥ 88% in MICU. If PEEP is greater than 5 cmH2O decrease in increments of 1-2 cmH2O every 30 minutes or as tolerated by maintaining SpO2 ≥92%, and SpO2 ≥ 88% in MICU. • If SpO 2 drops below minimum saturation, increase PEEP to previous level. Anytime the SpO2 does not respond to two consecutive increases in FiO2 or PEEP notify physician, fellow, or APP and document all information in the electronic medical record (EMR) including the name of the practitioner notified.

Inspiratory Time (Ti): Set Ti between .9s to 1.25s to avoid excessively high pressure. Titrate optimal Ti by observing inspiratory flow waveform for return to baseline.

Pressure Support (PS): Pressure support at 10cmH2O (adjust to maintain spontaneous VT of 5ml/kg IBW).

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

Alarms:

• High-pressure limit shall be maintained and set at 10 to 15 cmH2O above the peak inspiratory pressure generated on a consistent basis. • Low minute volume alarms shall be maintained at 4L/min. • Low limit for the mandatory tidal volume alarm shall be set at 50% of mandatory tidal volume generated on a consistent basis. • Low limit for the spontaneous tidal volume alarm should not be set less than 100ml. • High respiratory rate shall be maintained and set at 40. • Apnea interval shall be set to correspond to maximum acceptable apneic period.

Weaning:

• Order Daily Wake up plus BEST for weaning. To be ordered under (PAP) physician approved protocol. • Upon passing all extubation parameters, the respiratory therapist will discuss liberation from mechanical ventilation with the provider. • If the patient fails the spontaneous breathing parameters, return the patient to the previous ventilator settings and discuss with Attending, fellow on team, or APP. • If failed SBT, cause for failure should be determined, and discussed with Attending, fellow on team or APP.

Pressure Support Ventilation:

• Consider PSV as a part of SBT or for failed SBT or prolonged ventilator dependence. • Change mode to spontaneous with Pressure Support Ventilation (PSV) breath type with pressure support set to maintain exhaled tidal volume of 6-8 ml/kg of predicted body weight. • Monitor the patient’s appearance, respiratory rate, saturation, blood pressure and end-tidal CO2.

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

D. Airway Pressure Release Ventilation (APRV)

*Must be discussed with the Attending or Fellow before being initiated in Unit 82 & 11-4.

Initial Setup:

PEEPL: 0 - 5 cmH2O – Decrease PEEPL slightly to increase “release” VT.

PEEPH (CPAP level):

o Newly Intubated Patient: Initial setting at desired plateau level, 20 – 25 cmH2O. o Transition from Volume Control Ventilation: Set at plateau pressure. o Transition from Pressure Control or VC+ Ventilation: 3 – 5 cmH2O above mean airway pressure. • Maximum goal for PEEPH is 30 cmH2O. • Add pressure support at PEEPH to decrease CO2 and WOB – no more than 5 cmH2O above PEEPH Rate: 6 – 10 breaths/min.

o Increase rate (but hold TLOW constant) to decrease CO2 – May decrease MAP (may possibly require slightly higher PEEPH)

TLOW (Release time): Less than 1.0 sec (generally 0.5 – 0.8 seconds) should be short enough so as not to allow complete exhalation. For obstructed lung disease may need to set as high as 0.8 – 1.5 seconds.

THIGH: determined by TLOW and rate.

FiO2: Adjust for SpO2 > 92%, SpO2 > 88% in MICU, and/or PaO2 > 65 mmHg and a PaO2 > 60 mmHg in MICU.

Monitoring

o SpO2 greater than 92%, 88% in MICU or per physician order o Release tidal volume at least 5ml/kg, but not more than 8ml/kg o Minute ventilation may be 30-50% below conventional ventilation o Respiratory rate less than 25 o Mean airway pressure o EtCO2 o ABG 20 minutes after initial stabilization and PRN

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

Adjustments

Increasing PEEPH: Pressure High is increased to maximize oxygenation and ventilation.

o Increase PEEPH by increments of 1 – 2cmH2O o An increase of PEEPH may result in the following: • Increased mean airway pressure, oxygenation will improve as mean airway pressure is increased and alveolar recruitment is achieved up to a point of alveolar overdistention. To achieve lung protective ventilation, plateau pressure should be at levels less than 35cmH2O. • Increases alveolar recruitment • Increases release volume • Increases minute ventilation • May be associated with decreased spontaneous tidal volume if lung reaches over distention. May also be associated with increase spontaneous volumes as lung reaches a more compliant stage.

Decreasing PEEPH: Pressure High is decreased as patient compliance increases o Decrease PEEPH by increments of 1 – 2cmH2O o A decrease of PEEPH may result in the following: • Decrease mean airway pressure • Decrease alveolar recruitment • Decrease release volume • Decrease minute ventilation • Increase in spontaneous volumes

Increasing PEEPL: PEEPL is generally not changed.

o If necessary increase PEEPL by increments of 1 – 2cmH2O o An increase in PEEPL should be followed by the same increase in pressure of PEEPH; otherwise, the total ventilating pressure is decreased. o An increase of PEEPL may result in the following: • Increase CO2 retention • Decrease release volume • Increase mean airway pressure • Decrease minute ventilation • Increase resistance to exhalation

Decreasing PEEPL:

o Decrease PEEPL by increments of 1 – 2cmH2O Page 7 of 13

UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

o A decrease in PEEPL may result in the following: • Decrease CO2 retention • Increase release volumes • Decrease mean airway pressure • Decrease resistance to exhalation

Increasing THIGH

o THIGH is increased to eliminate CO2 and to maximize recruitment o Increasing THIGH, giving fewer release rates should be the first step for CO2 elimination o Increase THIGH by 0.5 – 1.0 seconds o An increase in THIGH may result in the following: • Increase mean airway pressure • Increase release volume • Increase time for spontaneous breathing • Increase length of actual CPAP time • Increases CO2 elimination (increase time for CO2 to collect in the airways)

Decreasing T HIGH

o THIGH may be decreased to lower release volumes and decrease mean airway pressure o Decrease THIGH by 0.50 – 1.0 seconds o A decease in THIGH may result in the following: • Decrease mean airway pressure • Decrease release volume • Decrease time for spontaneous breathing at CPAP • Decrease time for CO2 elimination

Decreasing T LOW: TLOW may be decreased to achieve expiratory flow limitation at 25 – 75%

o TLOW is set based on the expiratory flow graphics, TLOW is set to limit expiratory gas flow from falling to zero thus limiting expiratory derecruitment. o Decrease TLOW by 0.2s o Decreasing TLOW may result in the following: • Reduce TLOW to terminate “Release Flow” at a higher percentage of the peak expiratory flow rate, (should be 25 – 50%, not higher than 75%). Reducing TLOW may decrease release volumes causing a subsequent increase in CO2. • Reducing TLOW may increase mean airway pressure • Once TLOW is set it generally remains unchanged.

Increasing TLOW: TLOW may be increased to achieve expiratory flow limitation at 25 – 75%

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

o Increase TLOW by 0.2s o Increasing TLOW may result in the following: • Increase release volume • Increasing TLOW will increase release volumes and may lead to derecruitment. • Increase CO2 elimination • Decrease mean airway pressure • Decrease oxygenation • Decrease alveolar recruitment • To avoid complications that may be associated with auto PEEP, TLOW may be extended to greater than 1 second to allow unimpeded spontaneous ventilation at PEEP.

Weaning “Drop and Stretch”

o FiO2: Adjust for SpO2 > 92% and/or PaO2 > 65 mmHg. o Decrease PEEPH by 1.0 – 2.0cmH2O or as tolerates maintain a minimum release VT of 5ml/kg IBW. o Increase THIGH by 0.5 – 1.0 seconds. (Reduces ventilator rate) • THIGH determined by TLOW and Rate • Patients should be increasing their spontaneous rate to compensate. • If pressure support is added, decrease PEEPH, to avoid overdistention. o Patient may be extubated from APRV once PHIGH of 5 – 10cmH2O has been reached with 4 or fewer releases and patient meets extubation criteria. o Patient may be transitioned to VC+ or Pressure Control Ventilation (per Initial Settings), utilizing current FiO2.

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

E. Adaptive Support Ventilation (ASV) Startup Settings:

o ASV is a closed loop mode. ASV adapts to the patient’s respiratory drive, pulmonary mechanics and transitions between controlled mechanical ventilation and spontaneous breathing. o Respiratory Therapist – sets ideal body weight (IBW) o Respiratory Therapist – sets target V̇ E (minimum) with %MinVol control o ASV adapts pressure to maintain the tidal volume for both mandatory and spontaneous breaths. o ASV utilizes pressure support for spontaneous breaths and pressure control for mandatory breaths. o ASV adapts mandatory rate to ensure the MinVol target is met Contraindications o Bronchopleural fistula o Cheyne-stokes o Diabetic keto acidosis Initial Setup High Pressure limit (Pasvlimit): 45 cmH2O (50 cmH20 in COPD) Ideal Body Weight: Ventilator will use IBW to target guaranteed patient minute Volume. o IBW is based on the patient’s height. (If you dial in 70kg & 100% MinVol, ASV will deliver a minimum V̇ E of 7L. ASV delivers 100CC/kg V̇ E in adults. If %MinVol is decreased to 50%, it will now deliver 3.5L V̇ E.) %MinVol: % MinVol = (current MV x 1000)/IBW o Setting range is 25% to 350% o Setting 100%MinVol in a 70kg IBW patient guarantees “normal” predicted V̇ E of 7L. The G5 ventilator chooses V̇ E based on 0.1cc/min/kg. A 200% V̇ E setting would guarantee a predictive V̇ E of 14L. o If new patient: Normal lungs – 100% COPD – 90% ARDS – 120% Others – 110% Inspiratory time: ASV adapts inspiratory time for mandatory breaths. ASV “safety” Rules mandate a minimum expiratory time of 2 expiratory time constants P-ramp: 50ms Expiratory Trigger Sensitivity (ETS): 25% (min 40% if COPD) Trigger: 5lpm FiO2: Titrate FiO2 to maintain saturations >92%, >88% in MICU. PEEP: Set initial PEEP to 5cmH2O, unless otherwise indicated.

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

Initial adjustments:

Assess for adequate support/WOB

Increase %MinVol in increments of 20% for:

o Increases in %MinVol should occur in 20% increments and at a minimum of 10-minute intervals. The time between changes will allow for an assessment of the patient’s response to the previous %MinVol change. o Increased WOB – spontaneous rate is greater than the target rate o PaCO2 high with a spontaneous rate = 0 o PaCO2 high with a spontaneous rate greater than 0

Decrease %MinVol in increments of 10 – 20% for:

o PaC02 low, decrease %MinVol by 10 – 20%, not lower than 70%

Consider alternate mode

o If the required %MinVol is less than 70% or greater than 200%.

Monitoring

o Control rate vs. Spontaneous/trend rate o Inspiratory pressure/trend

Weaning

If control rate is 0

o Evaluate readiness for spontaneous breathing trial. o Assess respiratory drive/sedation o May decrease % MinVol by 10 – 20%. Not less than 70%.

Consider Extubation if:

o Inspiratory pressure <10cmH2O on 70% MinVol for 30 minutes o Other wean criteria are met

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

References

Andrews, P. L., Shiber, J. R., Jaruga-Killee n, E., Roy, S., Sadowitz, B., O’Toole, R. V., …

Habashi, N. M. (2013). Early application of airway pressure release ventilation may reduce

mortality in high-risk trauma patients. Journal of Trauma and Acute Care Surgery, 75(4),

635-641. doi:10.1097/ta.0b013e31829d3504

Daoud, E. G., Farag, H. L., & Chatburn, R. L. (2011). Airway Pressure Release Ventilation: What

Do We Know? Respiratory Care. doi:10.4187/respcare.01238

Haas, C. F., & Loik, P. S. (2012). Ventilator Discontinuation Protocols. Respiratory Care, 57(10),

1649-1662. doi:10.4187/respcare.01895

Jaber, S., Sebbane, M., Verzilli, D., Matecki, S., Wysocki, M., Eledjam, J., & Brochard, L. (2009).

Adaptive Support and Pressure Support Ventilation Behavior in Response to Increased

Ventilatory Demand. Anesthesiology, 110(3), 620-627. doi:10.1097/aln.0b013e31819793fb

Pham, T., Brochard, L. J., & Slutsky, A. S. (2017). Mechanical Ventilation: State of the Art. Mayo

Clinic Proceedings, 92(9), 1382-1400. doi:10.1016/j.mayocp.2017.05.004

Safe Initiation and Management of Mechanical Ventilation. (2016). AARC. Retrieved from

https://www.aarc.org/wp-content/uploads/2016/05/White-Paper-SAFE-INITIATION-AND-

MANAGEMENT-OF-MECHANICAL-VENTILATION.pdf

Sulzer, C. F., Chioléro, R., Chassot, P., Mueller, X. M., & Revelly, J. (2001). Adaptive Support

Ventilation for Fast Tracheal Extubation after Cardiac Surgery. Anesthesiology, 95(6),

1339-1345. doi:10.1097/00000542-200112000-00010

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UF HEALTH SHANDS Respiratory Care Services

POLICY #: RCS-VENT-9 CATEGORY: Ventilator DATE: November 7, 2018

HISTORY:

 Date of Origination: 11/1/2017  Date of Last Review: 11/7/2018

APPROVED:

______Director, CardioPulmonary Services Date

Signature on File

______Medical Director Date

Signature on File

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