Title: Standards of Care: Mechanical Ventilation Page 1 of 7

CentraCare Health (CCH) adopts the following policy/procedure for: St. Cloud Hospital

Original: 6/84 Minor Revision: 9/12 Full Review: 2/15 Responsible Person: Department Director, Intensive Care Approving Committee(s): Intensive Care Nurse Practice Committee; Respiratory Care Practice Committee; CentraCare Heart and Vascular Center Nurse Practice Committee Category: Intensive Care; Cardiac Care Cross Reference: Extubation Policy; Endotracheal Tube Securement Device and Care; Oral Care Protocol for Ventilated Patients; Tracheostomy Care Policy; Patient Supplied Medical Equipment, Use of During Hospitalization Policy; Home Ventilator Use Policy; Tracheostomy/Endotracheal Cuff: Pressure Management Policy; Delirium: Prevention, Assessment, and Monitoring in the Intensive Care Unit Type: Standard I. PURPOSE: To provide guidelines to trained clinical nurses and Respiratory Therapists (RT) caring for patients requiring mechanical ventilation. II. POLICY: A. Mechanically ventilated patients will be cared for in the Intensive Care Unit (ICU) and the Cardiac Care Unit (CCU). B. Clinical nurses and RT will adhere to these standards for all patients receiving mechanical ventilation. C. Clinical nurses/RTs will be educated on the function of the mechanical ventilator, along with the process and outcome standards outlined in this document. D. Assessment findings, ventilator settings and alarms, interventions, progress towards goals, patient/family education, and other pertinent information will be documented in the electronic medical record (EMR). E. Providers will be notified with significant changes outside goals. III. GUIDELINES:

OUTCOME STANDARDS (Goals) PROCESS STANDARDS (Interventions) Reduction of anxiety. • Perform initial and ongoing assessments of patient and family anxiety and level of knowledge related to mechanical ventilation. o Patient/family will be informed of reasons for mechanical ventilation. A mechanical ventilation education handout will be provided. o In collaboration with the provider, the patient/family will be informed of progress towards goals of care. • Patient/family will have opportunities to verbalize any fears, questions or concerns with nurses. • Establish means of communication with patient, if applicable. o A call light will be within reach or some type of communication system will be in place if unable to use call light. (i.e. bell) o A letter board or pad and pencil will be available, if appropriate. Maintenance of a patent airway. • Perform initial and ongoing assessment for ineffective

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airway clearance related to secretions. o The nurse will assess the need and perform suctioning as the condition warrants. Routine suctioning will not be done. o The patient will be educated on the need for and practice of suctioning. o Pre-oxygenation with 100% oxygen will be performed prior to suctioning to prevent or minimize desaturation. o A closed suction system will be used on all patients. Either an in-line suction catheter for patients expected to be intubated for greater than 24 hours or a "PEEP Saver" device will be present on all adult ventilatory patients. o Support tubing and maintain endotracheal (ET) tube in proper alignment during suctioning. o Saline should not be routinely instilled into the ET tube before suctioning. • Perform initial and ongoing assessment for malposition of ET or tracheostomy (trach) tube. o A chest x-ray will be obtained following initial placement of the ET tube. o The ET/trach tube will be securely positioned. o Lungs will be auscultated after repositioning of the ET tube and as needed (prn) for the presence of bilateral air movement. o The chest will be visualized for symmetrical movement. o An assessment will be made for the need of an ET tube bite block, if not already in place. o Assessment and position of the ET/trach tube will be documented in the EMR. Adequate gas exchange. • Lung auscultation and respiratory pattern will be assessed every 4 hours, with ventilator changes, and prn for the presence of normal or abnormal/ adventitious sounds. • SpO2 and EtCO2 monitoring will be done on all ventilated patients. Notify provider if outside of ordered parameters. • Clinical nurses will be knowledgeable about signs and symptoms of hypoxia including respiratory rate (RR), use of accessory muscles, increased heart rate (HR) and blood pressure (BP), skin color, and change in level of consciousness (LOC). Maintenance of a properly • The clinical nurse will be knowledgeable of ventilator functioning ventilator system. settings, including mode, rate, FiO2, tidal volume (TV), positive end expiratory pressure (PEEP), and pressure support. • RT will perform initial ventilator setup and subsequent ventilator changes.

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• RT will be notified if ventilator setting changes are necessary. o In collaboration with RT, the clinical nurse may make changes in FiO2 settings. o Clinical nurses can make mode changes if necessary for patient safety. When mode changes are made the RT personnel must be contacted to evaluate the need for flow rate and alarm adjustments. • Observation and validation of settings will be done by the clinical nurse or RT. Prevention of ventilator-associated • All patients on mechanical ventilation will be placed on events. the Ventilator Bundle. • Monitor for potential infective breathing pattern related to barotrauma. o Maintain low tidal volumes and normal peak pressures. o Be aware of high risk patients, especially those with COPD, emphysematous blebs, intrinsic PEEP and elevated prescribed PEEP. o Observe for patient and ventilator asynchrony. Minimize through the use of sedation and/or notify RT to make possible ventilator adjustments. o Monitor patient for an increase in airway rub pressures, subcutaneous emphysema, decreased/absent breath sounds, sudden restlessness, or a decrease in SpO2. o If signs of a tension pneumothorax are present; notify provider immediately and request RT to assist with possible need to disconnect from ventilator and manually ventilate. Prepare for chest tube insertion. • Monitor for potential decrease in cardiac output related to increased intrathoracic pressure related to positive pressure ventilation and/or PEEP resulting in decreased venous return. o BP, HR, and SpO2 will be monitored within 15 minutes after increases in RR, TV, or PEEP. o Monitor intake and output, skin color, temperature, and moisture. o Observe for patient and ventilator asynchrony. Minimize through the use of sedation. o Notify provider of significant changes in patient condition. • Monitor for potential altered gastrointestinal (GI) function related to stress ulcers and bleeding, swallowed air with gastric distention, and ileus. o GI assessment will be completed every 12 hours and prn. o Monitor for abdominal pain, nausea, vomiting, and signs of bleeding.

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o Note color, amount, consistency, and frequency of stools. o Stress ulcer prophylaxis should be considered for mechanically ventilated patients. • Monitor for potential development of delirium. Refer to the Delirium: Prevention, Assessment, and Monitoring in the Intensive Care Unit policy. o Minimize sedation; titrate or administer the least amount of sedation to meet clinical goals. o Clinical nurses will complete a sedation vacation (SV) each shift to assess for patient neurological function and the continued need or reduction of sedative medications. Do not complete SV if patient on neuromuscular blockade or per provider order. o Clinical nurse, RT, and PT will collaboratively implement early exercise and progressive mobility. Refer to Critical Care Progressive Mobility Guideline. • Prevention of ventilator-associated pneumonia through application of best practices. o Head of bed (HOB) elevated to 30-45⁰ unless contraindicated to prevent aspiration of secretions. o Complete meticulous hand hygiene prior to and maintain sterile technique while suctioning ET/trach tube. o Perform hand hygiene before and after donning gloves and ventilator management. o Cleanse “PEEP Saver” with betadine solution after suctioning, if applicable. o Provide oral care and suctioning according to the Oral Care Protocol for Ventilated Patients. o Resuscitator bags are for single patient use. They will be stored by capping the end or in a plastic bag. Dispose if become soiled or malfunction. o Change canister, tubing, and Yankauer every 24 hours; coordinate with change in 24 hour oral care kits. Oral care kits will be dated and timed. o Change closed in-line suction catheter every 72 hours. o Change the heat, moisture exchange filter (HMEF) every 48 hours and prn. o Individual suction catheters (non in-line) will be used once and discarded. o Sterile water will be used for rinsing suction tubing. o Do not routinely change ventilator circuits; change when visibly soiled or a mechanical malfunction has occurred. o Periodically drain and discard condensation in tubing of the mechanical ventilation circuit, if active humidification is used. Drain towards the in-line drain bottle; take precaution not to allow condensate

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toward the patient or the heater chamber. o Inform provider if signs of infection are present, including an elevation in temperature or a change in color, amount, consistency, or odor of secretions. Maintenance of skin integrity • Inspect mouth, nose, lips, tongue, trach site, if related to devices associated with applicable, and beneath securing device or tape for mechanical ventilation. impaired skin integrity every 2 hours. • Refer to the Endotracheal Tube Securement Device and Care policy. • Follow the Tracheostomy Care policy for trach care. Safe mechanical ventilation and • Clinical nurses and RT will assess for improper prevention of complications. positioning of the ET tube. o If the ET tube is positioned on the carina; frequent forceful coughing may occur. o If the ET tube inadvertently advances; it will advance into the right mainstem bronchus and subsequently cause absent or diminished breath sounds on the left. o If the ET tube inadvertently withdraws from proper position; it may require more air in the cuff to create a seal. o The clinical nurse and RT may reposition the ET tube or will notify anesthesia/provider. • Clinical nurses and RT will prevent potential injury related to accidental extubation. o Secure ET tube with securement device or tape, if patient condition warrants, and trach securement device or ties. Tape, securement device, or tie changes will be completed by two people. Refer to the Endotracheal Tube Securement Device and Care policy and Tracheostomy Care policy. o Allow slack in the ventilator tubing to accommodate patient movement. o To improve patient compliance or tolerance to mechanical ventilation judicious use of restraints, sedation and pain relief, frequent orientation, and explanation of procedures will be implemented. o A resuscitator bag mask and 12 ml syringe will be present in patient room. o Care should be taken to observe and support the airway during procedures and movement. The transport safety kit will be brought with the patient whenever leaving the unit. o If extubation occurs, apply oxygen, if necessary manually ventilate patient. Notify anesthesia/provider immediately. Assess patient as defined in the Critical Care Standards of Care. • Clinical nurses and RT will prevent Potential injury related to inadequate cuff care. Refer to the Tracheostomy/ Endotracheal Cuff: Pressure

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Management Policy. Ventilator weaning and extubation, • Perform sedation vacations and spontaneous breathing if applicable. trials twice a day unless otherwise directed by provider. Use Sedation Vacation & Spontaneous Breathing Trial Guideline to aid process. • Explain the weaning process to the patient and family. • Obtain baseline vital signs (VS) which include; BP, HR, RR, SpO2, and EtCO2. • Elevate the HOB for better lung expansion during weaning, when possible. • The appropriate criteria for a spontaneous breathing trial (SBT)/weaning will be utilized per the Ventilator Bundle orders or as ordered by the provider. • Clinical nurses and RTs will collaborate to coordinate SV and SBT, remain present to monitor SBT tolerance, and coach patient through process. • SBT settings will be performed by RTs. Clinical nurses will be aware of SBT criteria. • Monitor BP, HR, RR, SpO2 and EtCO2 within 15 minutes of each ventilator change (reduction of FiO2, PEEP, or rate). • The clinical nurse and RT will recognize SBT failure signs according to the Ventilator Bundle. If one or more SBT failure signs are present the patient should be placed back on precious ventilator settings. Transition to home ventilator, • A provider order will be obtained for use of patient when appropriate. equipment and ventilator settings. • Refer to Home Ventilator Use policy and Patient Supplied Medical Equipment, Use of During Hospitalization policy. • Patient specific information should be documented in the EMR, including cuffed or uncuffed airway, trach care and frequency, and the ability of patient to be off ventilator.

IV. REFERENCES Research Klompas, M., Branson, R., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee, G., & ... Berenholtz, S. M. (2014). Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 35 Suppl 2S133-S154.

Literature Bonten, M. M. (2011). Healthcare epidemiology: Ventilator-associated pneumonia: preventing the inevitable. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 52(1), 115-121. doi:10.1093/cid/ciq075 Burns, S. (2011). Invasive mechanical ventilation: Volume and pressure modes. In D. Lynn-McHale Wiegand (Ed.), AACN procedure manual for critical care (6th ed., pp. 262-284). St. Louis, MO: Saunders.

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Burns, S. (2011). Weaning process. In D. Lynn-McHale Wiegand (Ed.), AACN procedure manual for critical care (6th ed., pp. 291-302). St. Louis, MO: Saunders. Ellstrom, K. (2006). Pulmonary system: Patient assessment. In J. Grif Alspach (Ed.), Core curriculum for critical care nursing (6th ed., pp 68-91). St. Louis, MO: Saunders. Ellstrom, K. (2006). Pulmonary system: Patient care. In J. Grif Alspach (Ed.), Core curriculum for critical care nursing (6th ed., pp 92-132). St. Louis, MO: Saunders. Sedwick, M. B., Lance-Smith, M., Reeder, S. J., & Nardi, J. (2012). Using evidence- based practice to prevent ventilator-associated pneumonia. Critical Care Nurse, 32(4), 41-51. doi:10.4037/ccn2012964

Experts Minnesota Hospital Association. (2011). Device-related pressure ulcer prevention – respiratory devices recommendations and guidance. Retrieved from http://www.mnhospitals.org/Portals/0/documents/ptsafety/skin/respiratory- recommend.doc Manufacturer’s Guidelines Hollister Incorporated. (2014). AnchorFast Guard oral endotracheal tube fastener. Retrieved from https://www.hollister.com/us/critical-care-training/anchor-fast/

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