Trau·ma  Junk· ie  ( 'trau-m&  'j&[ng]-kE) n. Slang
  1. One who has an insatiable interest, devotion or addiction to responding and assisting people with serious injury or shock to the body, as from violence or an accident.

Go Forth and Ventilate: Initiation

Look at this thing. Pretty intimidating, right?

When it finally reached the point that we started covering ventilators in RT school, I was a mix of emotions. Excited, nervous, intimidated, and confident all at the same time. Okay, well maybe not confident. But I am now.

You see, when it comes to ventilators, you can't be intimidated. Yes, the machine is breathing for your patient, and yes, you are the one to apply the settings and make the changes to benefit the patient, but you have to take a deep breath. Don't let it scare you.

Some of the best advice I've heard about ventilators came from an RT student who recently graduated. "Don't fear the vent. You can always bag your patient. The vent changes don't take effect until you apply them."

Since we are covering initiation of mechanical ventilation in lab this week, I'd like to share with all of you some tips/tricks I've found to help make this a bit easier. For the purposes of this post, I'm going to describe setting up a vent in Volume Control, Assist/Control mode (VC/AC).

1. When setting the ventilator controls without prescribed settings from the physician, always remember the "rule of 10s":

Preliminary settings
-Respiratory rate (f) of 10-12
-FIO2 at 1.0 or 100% in emergency situations (cardiac arrest, etc.), or 40-50% for post-op/overdose. See? Intervals of 10.
-Tidal volume (VT) at 10-12 mL/kg of the patient's ideal body weight (IBW)

IBW male= [(height in inches - 60) x 2.3)] + 50Align Center
IBW female= [(height in inches - 60 x2.3) +45.
Note: Once the IBW is determined, set the tidal volume in intervals of 50. Say your patient has an IBW of 66kg, so the VT at 10 mL/kg, would be 660. Set it at 650 to make it easier.
-Peak Flow: Set at 40-60 L/min (again, intervals of 10) to achieve an appropriate inspiratory:expiratory ratio (I:E ratio), which is typically 1:2. (10/10=1. See?)
-Sensitivity: For patient-triggered sensitivity, set at 1.5-2. For flow-triggered sensitivity, set at 2-3. Okay, this has nothing to do with the rule of 10...but work with me here.
-PEEP of 5. (10/2=what?)

Preliminary alarms:
-Normal pressure limit (also called peak pressure, Ppeak, peak inspiratory pressure, or PIP) at 50 cmH2O
-Respiratory rate high limit at 10-15 bpm > set respiratory rate
-Low exhaled volume at 10-15% < set or targeted minute volume or 5 L/min (1/2 of 10 is 5. Remember that.)
-Low exhaled minute volume at 100 mL < set tidal volume. Again with the intervals of 10.
-Apnea alarm at 20 seconds (10 x 2=20. Woo!)

Still with me? Okay.

So you now have the ventilator set up and the patient arrives to the ICU. It's time to place them on the vent. (Don't forget your humidifier, if needed! Remember 30-35°C for the temp.) Next, it's time to adjust the alarms after connection to the patient so the blasted thing isn't screaming at you every two minutes for something that isn't important. This part is simple enough. As easy as A, B, and C. (Get it? Airway, breathing, and circulation?).

A. Determine the peak inspiratory pressure or PIP.
B. Set the low inspiratory pressure alarm at 5-15 cmH2O < PIP. (Still with the rule of 10s? Just remember 5, 10, 15.)
C. Set the low PEEP alarm at 3-5 cmH2O < set PEEP. This one still follows the rule of 10, because a good place to set the PEEP is 5 to begin with, so 5-3=2. 10/5=2. See? See?

Have you made it this far? Good. We're ALMOST done with initiating mechanical ventilation. (I swear!)

Next, assure the patient's airway. This is the simplest part, to me. 4 steps:
1. Note placement of the ET tube (it's easier if you document at the teeth). 23cm at the teeth, etc.)
2. Check the cuff pressure (18-27 is ideal, but you'll do okay if you still want to go with the rule of 10s and remember 20-30.)
3. Make sure there are no cuff leaks by auscultation. While you're at, auscultate to make sure you have good bilateral breath sounds.
4. Assess the patient for oral secretions and suction as needed. (Most of the time, it WILL be needed, so have that Yankeur ready at bedside). By the way, for an adult, you can use the rule of 10 to set the vacuum pressure. A good vacuum pressure is about 120 inHg (forgive me if I've got the wrong unit of measurement here, but just look for 120 on the dial). 10 x 12= 120. Yep.

Last step-- chart it. A few pieces of advice from fellow RTs, nurses, and others to remember when charting (I'm sure you've heard them all before):
If it wasn't documented, it was never done.
Always, always CYA (cover your ass).
Chart consistently so that if it comes back to you in the future, you'll remember doing it.

That being said, here are the things to chart, in no particular order:
1. Date/Time of initiation
2. Ventilator parameters
3. Airway placement/cuff pressure
4. Adequacy of ventilation (breath sounds)
5. Patient complaints
6. Anything else that you feel is pertinent.

Remember, chart in the same order every time. It doesn't matter how you fit all of this in your documentation, as long it is documented. Here's an example of how I always chart vent setup:

"09/05/09 mechanical vent initiated at 1310 with Draeger Evita 4, ETT at 23cm at teeth, cuff pressure 22cmH2O, vent settings as prescribed on orders. BBS auscultated in all ant. lobes/bases. Ventilator/alarms functioning properly. Pt sedated with bil wrist restraints in place and no s/sx of distress noted. "

Well, ladies and gentlemen, there you have it.

Go forth and ventilate.

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