ventilation.pdf

HAMILTON HEALTH SCIENCES Authorizing Mechanisms Original Issue Date: 2004 06 14 Page 1 of 12 Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001

Copyright Hamilton Health Sciences For information, contact Authorizing Mechanisms, Policy and Document Management

Title: MAC MD - Neonatal Respiratory Care Medical Directive Number: 83001 Activation Date: 2004-06-14 Next review due by: March 2015 Approved by: MAC Date: 2013 03 28

Sponsoring/Contact Person(s) (name and position): Carrie-Lynn Meyer, NICU Clinical Manager ext. 73592 , Dr. Salhab El Helou, Neonatologist ext. 73903, Mike Kampen , Chief of RT Practice HHS ext. 44853 Order/Description of Procedure: Authorized Controlled Act: yes X no Delegated Controlled Act: yes no X Other: yes no This medical directive authorizes all Registered Respiratory Therapist (RRT) and Graduate Respiratory Therapists (GRT) working in the Neonatal Intensive Care Unit, Level 2 Nursery and Labour and Delivery Suite at McMaster site to perform the procedures listed below for patients under the care of an authorizing HHS Neonatologist. This directive enables the RRT / GRT to implement and manage invasive and non-invasive mechanical ventilation and the listed procedures, within the scope of their practice when all the conditions in this and the companion appendices (attached) are met.

1. Perform Procedure (Appendix A) a. Non Invasive CPAP b. Non Invasive Positive Pressure Ventilation (NIPPV) c. Invasive Conventional Mechanical Ventilation d. Invasive High Frequency (Oscillatory) Ventilation e. Repositioning an Endotracheal Tube as required (Level 2) f. Procedure below the dermis Procurement of CBG g. Extubation (Level 2)

2. Administering Substance by Inhalation (Appendix B) a. Oxygen Therapy b. High Flow Nasal Cannula (HFNC) Therapy

Authorized by: Sponsoring Physician/Health Professional: Dr. Salhab El Helou Approving Physician(s)/Health Professional(s) to Whom this Directive Applies: Dr. Sumesh Thomas, Dr. Chris Fusch, Dr. Mike Marrin, Dr. Connie Williams,, Dr. Sandesh Shivananda, Dr. Prashanth Murthy, Dr. Salhab El Helou, Dr. Muzafar Gani

MEDICAL DIRECTIVE



Authorized to: All RRT/GRTs working in the Neonatal ICU, Level 2 Nursery and Labour and Delivery Room who:

have successfully completed the Neonatal Ventilation and Weaning medical directive education and training program at HHS and

participate in the Quality Assurance Program. The education/certification requirements include achieving a minimum of 80% on a written quiz on the contents of this document. Indications: The RRT/GRT can only implement the procedures in this document, under authority of this medical directive when the following conditions are met: 1. The neonatal patient is requiring respiratory support including oxygen therapy, invasive or

non-invasive ventilation. 2. An authorizing HHS Neonatologist is accessible at least by phone.

Contraindications: Neonatal Ventilation and Weaning cannot be initiated under authority of this medical directive if:

a) The indications noted above are not fulfilled, or b) The Patient is enrolled in a conflicting ventilation research protocol),or c) There is a Team decision to not implement, or to discontinue implementation of the medical

directive in favor of implementing a patient-specific plan of care according to the attending physician or physician designate

Process for Implementing the Procedure: 1. Steps

1.1 RRT/GRT will assess the patient to ensure he/she meets the indications and discuss with the health care professionals present, the intention of implementing the

directive. indicate implementation of the directive in the medical order section of the health

record including the procedure/flowchart/protocol/guideline (Appendix A, B, C) to follow: 1. NICU NCPAP Practice Guidelines 2. NIPPV NICU Protocol 3. Invasive Conventional Mechanical Ventilation 4. Invasive High Frequency (Oscillatory) Ventilation 5. Repositioning an Endotracheal Tube as required 6. Requisitioning an ABG/CBG or Procuring a CBG 7. Extubation 8. RESIN Guidelines. 9. Oxygen Saturation Monitoring Guidelines (DOVE) 10. NICU HFNC Therapy Policy and Procedure

2. Management of Untoward Outcomes

The RRT/GRT will contact the attending physician or physician designate immediately in the following situations, unless a time frame is otherwise identified regarding complications and significant changes in the patients respiratory/ventilation status. These situations include:

a. Inability to maintain blood gases according to Appendix A, B and C , including a metabolic acidosis

b. Changes in breath sounds that are not resolved with routine care c. Inability to maintain peak airway pressure (e.g Leak greater than 50%) d. An increased work of breathing not associated with procedures being performed



e. A sustained increase in oxygen requirements by more than 15% from baseline for a period of greater than 1 hour

f. Increased number of apnea, bradycardia and desaturations spells in the past 4 hours g. Pulmonary Hemorrhage

Documentation/Communication Requirements: 1. All patients being intubated, non-invasively ventilated or on supplemental Oxygen will

automatically be provided care under authority of this medical directive if the indications are met. The RRT/GRT will indicate the implementation of the directive by selecting the medical directive number from the drop down within the electronic health record.

2. On the doctors order sheet the RRT/GRT will document that Neonatal Respiratory Care Medical Directive #83001 was implemented including the procedure/flowchart/protocol/guideline being followed. The documentation must include the date, time and the RRT/GRT full printed name , signature and designation.

3. The RRT/GRT will document their initial assessment including patients status (vital signs, breath sounds, transcutaneous CO2 and SpO2) as well as all ventilator settings and changes within the electronic health record.

4. The RRT/GRT will document the movement from one procedure/flowchart/protocol/guideline to another within the medical directive within the medical order section of the health record. (ie: moving from Non Invasive Conventional Mechanical Ventilation to Invasive High Frequency (Oscillatory) Ventilation)

5. The RRT/GRT will communicate to the physician and team, when there is a clinically significant escalation of ventilation settings.

6. Documentation by the RRT/GRT of each ventilator change will occur on the Ventilation Intervention screen within the electronic heath record or otherwise follow downtime procedures..

7. The responsible physician will take into account implementation of the directive, as documented in the chart by the person implementing it, in their medical management of the patient.

Quality Monitoring Processes: 1. The following processes will be used to maintain appropriate implementation of the directive

and guide action if inappropriate, unanticipated and/or untoward outcomes result:

a) The staff member who identifies any inappropriate, untoward or unanticipated outcomes resulting from implementation will immediately notify the physician responsible for care of the patient, the Chief of Respiratory Therapy Practice as appropriate, and the NICU Clinical Manager. The NICU Clinical Manager in collaboration with the sponsoring/authorizing physician will trigger an ad hoc review, if deemed appropriate, as per MAC Authorizing Mechanisms Protocol.

b) This medical directive will be reviewed routinely one year after initial activation and then biannually thereafter according to the Implementation Proposal for this directive and the processes identified in the Authorizing Mechanisms Protocol.

c) This medical directive can be placed on hold if routine review processes are not completed, or if indicated for an ad hoc review. During the hold, staff cannot perform the procedures under authority of the directive and must obtain direct, patient-specific orders for the procedure(s) until it is renewed. Program and Medical Directors or designates will notify staff of any hold on the directive.



Developed and Agreed to by: Carrie-Lynn Meyer NICU Clinical Manager Jennifer Watson, NICU Clinical Manager Mike Kampen Chief of Respiratory Therapy Practice Dr. El Helou, Neonatologist Shawna MacDonald, RT educator Respiratory Therapy Practice Committee Neonatal Operations Resources/References: http://www.cs.nsw.gov.au/rpa/neonatal/html/newprot.htm Respiratory Therapy. Neonatal Ventilator Management. Childrens Hospital of Eastern Ontario, Ottawa. 1993 Respiratory Therapy. Neonatal Ventilator Management. Sudbury Regional Hospital, 2000 Appendices: Appendix A Procedures Appendix B Administering a Substance by Inhalation Appendix C1 Flowchart Invasive Conventional Mechanical Ventilation Appendix C2 Flowchart Invasive High Frequency (Oscillatory) Ventilation Appendix D Abbreviation/Acronym Definitions Related Policies and Procedures: Clinical Guidelines (Neonatal Sharepoint): NIPPV NICU Protocol (2004) RESIN Guidelines (2011) Oxygen Saturation Monitoring Guidelines- DOVE (2006) Policy Library: NEO Capillary Blood Specimen Collection NEO Cardiorespiratory Oxygen and BP Monitoring Neonatal Nurseries NEO Endotracheal Tube Stabilization Neonate NEO Endotracheal Tube (ETT) Extubation in the Neonate Protocol NEO High Flow Nasal Cannula (HFNC) Therapy Protocol NEO Ventilator Monitoring Procedure MAC Authorizing Mechanisms Protocol



Appendix A Procedures

Controlled Acts and

Procedures Indications Contraindications/

Considerations/Process for Implementing Procedure

Nasal CPAP

Continuous Positive Airway Pressure (CPAP) that is delivered to an infant through bilateral

nasal prong, a nasal mask or a unilateral

nasal pharyngeal tube (NPT) system

Indications: -Infants with a sustained increase in respiratory rate of 20% above normal -Sustained increase in oxygen requirements of 15% or frequent desaturations -Apnea/bradycardia spells -Increased work of breathing -Indrawing -Retractions -Grunting -Nasal Flaring

Relative Contraindications: -Coma -Inability to protect airway -Severe acidosis -Orofacial and upper airway abnormalities such as choanal atresia, cleft palate, tracheoesophageal fistula -Severe cardiovascular instability -Gastrointestinal diseases: obstruction (atresias, malrotation, volvulus) or NEC Procedure: For infants less than 33 weeks gestation in the delivery room and NICU, follow the RESIN Guidelines Infants greater or equal to 33 weeks gestation in the delivery room or in the NICU follow the Practice Guidelines for NCPAP in NICU Conversation with MRP when CPAP levels

above 8cmH2O are required

Non Invasive Positive Pressure Ventilation A form of mechanical ventilation that delivers intermittent Positive Mandatory Breaths via a time cycled, pressure limited ventilator through a bilateral nasal prong, a nasal mask or a unilateral nasal pharyngeal tube (NPT) system

Indications: -A means of preventing the need for re-intubation or intubation in apnea of prematurity -Utilized immediately after extubation in spontaneously breathing premature infants 1250gms to decrease rate of extubation failure -Ventilatory assistance for

premature infants with impending ventilatory

failure

Relative Contraindications: -Coma -Inability to protect airway -Severe acidosis -Orofacial and upper airway abnormalities such as choanal atresia, cleft palate, tracheoesophageal fistula -Severe cardiovascular instability -Gastrointestinal diseases: obstruction (atresias, malrotation, volvulus) or NEC Procedure: NIPPV Protocol for NICU



Invasive Conventional Mechanical Ventilation The procedure of making incremental or decremental changes to the mechanical ventilator settings to maintain an intubated patients respiratory status until such time the patient is able to support their ventilation independently. Weaning: Each time patient is assessed, consider weaning The RRT/GRT will communicate to the physician and team, when there is a clinically significant escalation of ventilation settings, or a sudden need to maximize settings, as this reflects a change in pathophysiology

The intubated neonatal patient requires respiratory support. The intubated neonatal patient requires mechanical ventilation Physiologic Monitoring: Target Blood Gases: pH 7.20 7.40 PaCO2 50-70 mmHg PaO2 45-60 mmHg (arterial) PcO2 30-60 mmHg (capillary) HCO3 15-30 mEq/L Oxygen Saturation Monitoring: Transcutaneous Monitoring: Correlate Transcutaneous Monitor with two initial blood gases. If Transcutaneous CO2 Values do not correlate with blood gases, the RRT/GRT may continue to use it for trending purposes only. *Follow Appendix C: Flow Chart 1: Invasive Conventional Ventilation for guidance on Initiation and Weaning *

Settings: Mode: Assist Control Mode PC or (VC including PRVC after discussion with attending or fellow) if set Respiratory Rate is greater than 40 bpm.

SIMV Mode if set respiratory rate is less than 40bpm

Automode may be selected as clinically appropriate

Tidal Volume Range (Vt): 4-8 ml/kg, with a target of 4-5 ml/kg with compliance compensation:

Adjust PIP by increments of 1 cmH20 for birth weight less than 1500 grams

Adjust PIP by increments of 1-2 cmH20 for birth weights greater than 1500 grams

Peak Inspiratory Pressure (PIP) Range: 12-25 cmH20

Set PIP based on what PIP is required during manual ventilation

PIP should be titrated to establish Vt 4-5 ml/kg

Adjust PIP by increments/decrements of 1 cmH20 for birth weights less than 1500 grams

Adjust PIP by increments/decrements of 1-2 cmH20 for birth weights greater than 1500 grams

Pressure Support (PS) Range: 4-10 cmH20

Target spontaneous Vt of 2.5-5 ml/kg Adjust PS by increments/decrements of

1 cmH20 for birth weights less than 1500 grams

Adjust PS by increments/decrements of 1-2 cmH20 for birth weights greater than or equal to 1500 grams

Positive End Expiratory Pressure (PEEP) Range: 4-8 cmH20

Initial setting 5-6 cmH20. Should be titrated by increments/decrements of 1 cmH20 as clinically indicated

Conversation with physician when requiring greater than 6 cmH20

Respiratory Rate Range (RR): 15-60 bpm Inspiratory Time(It): 0.25 0.45 seconds Flow Rate Ranges: 5-25 L/min Fraction of inspired Oxygen (FiO2) Range: Titrate 0.21-1.0 FiO2 to appropriate range for corrected gestational age from Appendix B: Oxygen Therapy



Invasive High Frequency (Oscillatory) Ventilation A lung protective ventilation strategy that utilizes a MAP required to recruit adequate lung volume, RR greater than 80bpm and Vt equal to or less than the infants deadspace (1.8-2.2 mL/Kg) Recruitment Maneuver is to be performed with every ventilator disconnect or with clinical indicators of lung derecruitment The RRT/GRT will communicate to the physician and team, when there is a clinically significant escalation of ventilation settings, or a sudden need to maximize settings, as this reflects a change in pathophysiology

Indications: Invasive Conventional Mechanical Ventilation application cannot meet the needs of the infant and the team wants to engage in a lung protective strategy. Blood Gas required 15 minutes after initiation Physiologic Monitoring: Target Blood Gases: pH 7.20 7.40 PaCO2 50-70 mmHg PaO2 45-60 mmHg (arterial) PcO2 30-60 mmHg (capillary) HCO3 15-30 mEq/L Oxygen Saturation Monitoring: Transcutaneous Monitoring: Correlate Transcutaneous Monitor with two initial blood gases. If Transcutaneous CO2 Values do not correlate with blood gases, the RT may continue to use it for trending purposes only. *Follow Appendix C: Flow Chart 2: High Frequency (Oscillatory) Ventilation for Initiation and Weaning*

Relative Contraindications / Considerations:

Untreated Air leak(s) present on CXR Infants Blood pressure is labile Pulmonary hemorrhage

Settings: Mean Airway Pressure (MAP) Range / P mean: 8-20 cmH2O

If no air leaks are present, Initially set 2 cmH2O higher than what was achieved on conventional ventilation

In the presence of air leaks, set MAP at the level of MAP used with Conventional Ventilation (cmH2O)

Adjust by 0.5 1.0 cmH20 steps Contact physician and the team, if MAP

is greater than 20cmH2O Contact physician and the team if MAP

is being increased more than 4cmH20 in total within 24 hours, outside of recruitment maneuvers

Frequency Range/ RF Freq: 8 15 Hz Power/P Range/ HF Ampl: 15 40 cmH20, or Amp 35 - 100% on BL 8000+, targeting visible chest wall shake

Term Infants start at 30cmH20 Preterm Infants start at 20cmH20 Adjust by 2-5cmH20 steps or Amp by

5-10% for BL8000+ Contact the MRP if Power/P settings

are maximized and a Hz adjustment is required to maintain target Blood Gases

Flow Rate Range: 15 30 L/min, Leoni = 7L/min Inspiratory Time Target: 33 50%; initiate at 33% FiO2 Range: Titrate 0.21-1.0 FiO2 to appropriate range for corrected gestational age from Appendix B: Oxygen Therapy Recruitment Maneuvers:

Recruitment maneuvers upon initiation, after disconnects or suctioning are required by increasing MAP by 2cmH2O for 5 minutes

After recruitment, return MAP to previous setting & reassess infant



Repositioning the Endotracheal Tube as required With the babys head midline and in the neutral position, the tip of the ETT should be positioned halfway between the inferior clavicle and the carina, at the approximate level of T2 vertebrae

Indications: -ETT tip is too high or too low on CXR after initial intubation -As infant grows the ETT tip is found too high on CXR

Repositioning the ETT is a Type 2 procedure: -ETT position needs to be confirmed with a NICU Physician before the ETT can be repositioned. -Vital signs, chest excursion, auscultation and mechanical ventilator settings are to be assessed and documented post repositioning -The Discussion with the NICU Physician, ETT repositioning procedure and new location are to be documented - NEO - Endotracheal Tube Stabilization: Neonate is to be followed to secure the ETT.

Procedures below the Dermis Capillary Blood Gas or Arterial Blood Gas

Indications: To determine blood gas status after ventilator changes and to determine acid/base status

An Arterial Blood Gas (ABG) and/or Capillary Blood Gas (CBG) can be requisitioned by the RRT/GRT. A CBG can be drawn by certified RRT/GRTs as clinically indicated, to evaluate the acid-base and ventilatory status of the neonate Procedure: NEO - Capillary Blood Specimen Collection

Extubation: The removal of an endotracheal tube from the trachea

Indications: -Acceptable blood gases -pH greater than or equal to 7.25 - PaCO2 less than or equal to 70mmHg -RR 20-60pbm or as clinically appropriate for the infant -Hemodynamic stability (capillary refill less than 3 seconds, mean arterial pressure greater than gestational age, adequate urine output) -No apneas causing bradycardias -Minimal indrawing/retractions -Absence of infection -Reversal of indication for ventilation -Ability to protect airway -No need to reintubate anticipated (no scans or surgery planned)

Contraindications -Clinically significant patent ductus arteriosus -Known difficult intubation without airway expertise immediately available Relative Contraindications -Presence of Inotropes -Treatment with opioid analgesia Extubation is a Type 2 Procedure. A discussion and agreement with the NICU Physician, including a care plan, must occur and be documented before proceeding. Follow the protocol below for the extubation: NEO - Endotracheal Tube (ETT) Extubation in the Neonate Protocol



Appendix B Administering a Substance by Inhalation

Controlled Acts and

Procedures Indications Contraindications/

Considerations/Process for Implementing Procedure

Oxygen Therapy -As required to correct arterial hypoxemia and maintain normal metabolic function

Contraindications: -Complex Congenital Cardiac Physiology with risk of pulmonary overcirculation Procedure: For infants less than 33 weeks gestation in the delivery room , follow the RESIN Guidelines Infants greater than or equal to 33 weeks gestation in the delivery room and infants in the NICU, follow the Oxygen Saturation Monitoring Clinical Guideline (DOVE)

High Flow Nasal Cannula (HFNC) Therapy -Delivered by means of High Flow Nasal Cannula (HFNC) Therapy -Delivers a precise level of heated, humidified oxygen, with improved patient comfort along with the benefit of a low level of respiratory support

-SpO2 less than 88% in FiO2 0.35 (without known Cyanotic heart disease) -Sustained tachypnea -Mild to moderate retractions/indrawing -Occasional apnea with bradycardia and desaturations -Infant not apt to tolerate NCPAP or SiPAP because of size/vigor -A need to supply high FiO2 -CPAP interface challenges -Patient having low SpO2 with ROP issues

Relative Contraindications: -Frequent apnea with bradycardia -Post-op abdominal surgeries involved with NEC -Respiratory distress or increased WOB -Increasing PaCO2 with decreasing pH -Airway anomalies (eg. TEF, Lobar emphysema) -Untreated, clinically significant pneumothorax/pneumomediastinum -Need for surfactant therapy -May be limited by the presence of excessive mucus drainage, mucosal edema or deviated septum -Especially important with the Preterm



Appendix C1 Invasive Conventional Mechanical Ventilation

NO

YES NO YES

YES NO

YES NO

YES

YES

YES NO

Discussion with NICU team AND Infant meets Medical Directive Criteria

Select appropriate mode, Vt 4-5 ml/kg (compliance compensated), RR 15-60bpm, It 0.25 0.45sec, PEEP 5-6cmH20, FiO2 to maintain SpO2 within Oxygen Saturation Monitoring Guidelines.

Follow Appendix A: for Infants less than/greater than 1500gms

Stabilize/Maintain pH 7.20-7.40, PaCO2 50-70mmHg, PaO2 45-60mmHg arterial / 30-60mmHg capillary and

DOVE guidelines met

Draw BG 20-30 minutes after each change or use TcCO2 to monitor trends

Is pH 7.20 7.40 ?

Are Oxygen Saturation Monitoring guidelines met and is PaO2 at least 45mmHg arterial ?

Does the Infant meet weaning criteria?

Wean one parameter at a time and document responses to changes 10-30 minutes post each change in patient chart. Decrease using following increments: RR 5-10 breaths/change, FiO2 0.05 when target

Oxygen Saturation Monitoring guidelines maintained, PIP by 1-2 cmH2O if Vt 4-5 ml/kg (compliance compensated) and/or chest expansion is adequate, Mode change from full ventilation to SIMV when RR 40bppm or less, adding PS to target Vt of 2.5-5 ml/kg. Consider weaning PIP, PEEP or It when

FiO2 0.45 or less. Communicate with at least one of the following: RN, NP, Physician. Follow Appendix A: for Infants less than / greater than 1500gms

Infant tolerated parameter change? Consider further weaning

NO

Adjust Minute Volume

Adjust PEEP or FiO2

Contact MRP if unable to

obtain

Contact MRP if PEEP > 6

cmH20



Appendix C2 Invasive High Frequency (Oscillatory) Ventilation

NO

YES NO YES

YES NO

YES NO

YES

YES

YES NO

FAILURE ON CONVENTIONAL VENTILATION: as discussed by team with HFV agreed to by MRP or MRP designate

If no air leak(s) present, start with MAP 2 cmH2O above conventional ventilation; Frequency range 8-15Hz, P 15-40cmH20 or Amp 35-100% for BL8000+, targeting visible chest wall

shake, It% 33-may increase to 50%, Flow Rate 15-30 LPM, FiO2 as required, TcPCO2 monitoring applied. *Initial BG 15 minutes after initial stabilization*

Stabilize/Maintain pH 7.20-7.40, PaCO2 50-70mmHg, PaO2 45-60mmHg arterial / 30-60mmHg capillary and

Oxygen Saturation Monitoring guidelines met

Draw BG 20-30 minutes after each change or use TcCO2 to monitor trends

Is pH 7.20 7.40 ?

Are Oxygen Saturation Monitoring guidelines met and is PaO2 at least

45mmHg arterial ?

Does the Infant meet weaning criteria?

Wean one parameter at a time and document responses to changes 10-30 minutes post each change in patient chart. Decrease using following increments: Wean FiO2 first by increments of 0.05 to maintain Oxygenation Saturation Monitoring guidelines Wean MAP in increments of 0.5-1.0 cmH2O when FiO2 reaches less than 0.45 or hyperinflation is apparent on CXR Wean P by 2-5cmH2O or Amp 5-10% for BL8000+ (minimum amp% = 35%) if TcPCO2 is less than 45mmHg Change to Conventional Ventilation as per NICU team consensus

Infant tolerated parameter change? Consider further weaning

NO

Adjust P by 2-5cmH20 or Amp 5-10% for BL8000+

Adjust MAP in 0.5-1.0 cmH20 steps

Contact MRP if unable to

obtain

Contact MRP if MAP greater

than 20 cmH20

Recruit post suction or

disconnect: Increase MAP

by 2cmH20 for 5 minutes

Contact MRP if Hz change is required



Appendix D Abbreviation/Acronym Definitions

Amp = Amplitude setting on the Babylog 8000+ Mechanical Ventilator BL 8000+ = Babylog 8000+ Mechanical Ventilator made by Drager Medical cmH2O = Centimeters of water pressure CPAP = Continuous Positive Airway Pressure ETT = Endotracheal Tube FiO2 = Fraction of Inspired Oxygen HFNC = High Flow Nasal Cannula Hz = Hertz or Frequency setting on the Oscillator It = Inspiratory Time MAP = Mean Airway Pressure measured by the Mechanical Ventilator mmHg = Millimeters of Mercury Pressure NCPAP = Nasal Continuous Positive Airway Pressure NIPPV = Non Invasive Positive Pressure Ventilation NPT = Nasal Pharyngeal Tube P = Difference in Pressures or Delta P PaCO2 = Pressure of carbon dioxide in arterial blood, measured in mmHg PaO2 = Pressure of oxygen in arterial blood, measured in mmHg PC = Pressure Control Mode PEEP = Positive End Expiratory Pressure pH = is the measure of a solutions ability to release hydrogen ions PIP = Peak Inspiratory Pressure measured by the Mechanical Ventilator PRVC = Pressure Regulated Volume Control Mode PS = Pressure Support SIMV = Synchronized Intermittent Mandatory Ventilation Mode T2 = Thoracic Vertebrae number 2 TcCO2 = Transcutaneous Carbon Dioxide VC = Volume Control Mode Vt Tidal Volume

Contraindications:Documentation/Communication Requirements:Appendices:Related Policies and Procedures:

Documents

ventilation.pdf