Equipment 8-936 - Ventilator

CMH EMS & MIH Protocols

Scope of Practice:

Registered Nurse
Paramedic

Indications:

Need for ventilation of an intubated patient.
Equipment 8-198 - Continuous Positive Airway Pressure (CPAP).

Contraindications:

None.

Precautions:

Demand setting requires constant patient monitoring.
If patient condition deteriorates, consider extubation and BVM.

Definitions and Terminology:

ParaPAC Ventilator Procedures

Ventilation

Adjust settings (may be based on existing Ventilator settings or anticipated patient needs).

Relief pressure is maximum delivered pressure.
Air mix is set at either "No Air Mix (100% Oxygen)" or "Air Mix (45% Oxygen).
Frequency is the breaths per minute.
Tidal volume is the volume of air per breath.

Connect supply hose to Oxygen, turn on Oxygen, and check visual alarm.
Connect patient hose and patient valve to ETT.
Confirm ventilation with auscultation and Capnography. Confirm oxygenation with pulsoximeter.
Constant patient monitoring is made more critical if Ventilator is in demand mode.
Consider NG/OG Suction.

O-Two Ventilator Procedures

Circuit Layout

Ventilator	Elbow	Filter	Optional	EtCO2	Patient
			see optional below

Optional
Nebulizer	Spacer	Adapter (Jesus Piece)

Modes of Operation

Patient Description

Procedure

Cardiac Arrest

Mode	CPR
Set PEEP	0 cm H2O
Set Trigger	- (none)
Set PMax	60 cm H2O
ROSC	After ROSC, refer to RSI settings below.

Pulmonary Edema (CPAP/BiPAP)

Mode	CPAP or CPAP with PSV (same as BiPAP, do not use BiLVL)
Adjust CPAP (expiratory support)	5-15 cm H2O
Adjust PSV (inspiratory support)	0-15 cm H2O
Adjust Trigger	P (patient)

Pulmonary Edema (intubated)

Mode	A/CV
Set Vt (tidal volume)	See tables below
Set BPM (rate)	Titrate to EtCO2 and patient comfort: Infant: 20-40 BPM Child: 12-25 BPM Adult: 10-20 BPM
Set PEEP	10-24 cm H2O
Adjust Waveform	Use FLOW waveform to see if breath stacking or spontanious breathing.
Sedation and Paralysis	Refer to Protocol 2-044 - Airway: RSI for continued sedation and paralysis during the transport.

Patient Description

Procedure

RSI or DSI

Mode	A/CV
Set Vt (tidal volume)	See tables below
Set BPM (rate)	Titrate to EtCO2: Infant: 20-40 BPM Child: 12-25 BPM Adult: 10-20 BPM
Set PEEP	5-15 cm H2O (refer to Pulmonary Edema above, if applicable)
Adjust I:E ratio	Longer exhalation to prevent air-trapping (i.e. Asthma patients) (1:2 = normal) (1:4 = long exhalation)
Adjust Ti (inspiration time)	0.8-1.0 seconds
Adjust Waveform	Use FLOW waveform to see if breath stacking or spontanious breathing.

Transfer (COVID)

Mode

A/CV

Set Vt (tidal volume)

See tables below

Set BPM (rate)

Copy from RT ventilator OR
Titrate to EtCO2 and patient comfort:

Infant: 20-40 BPM
Child: 12-25 BPM
Adult: 10-20 BPM

Set PEEP

Adjust PEEP to match FiO2 and PEEP goals:

PEEP goal	60% FiO2	100% FiO2
lower PEEP	10 cm H2O	18-24 cm H2O
higher PEEP	20 cm H2O	22-24 cm H2O

Adjust Ti (inspiration time)

0.8-1.0 seconds

Adjust Waveform

Use FLOW waveform to see if breath stacking or spontanious breathing.

Sedation

Ensure patient is fully sedated prior to movement to ambulance cot. Refer to Protocol 2-924 - Universal Patient Care for Ketamine dosage.
#sedatewhatyouintubate

Paralysis

Refer to Protocol 2-044 - Airway: RSI for continued sedation and paralysis during the transport.

Patient Description

Procedure

Transfer (non-COVID)

Copy settings	From RT ventilator
Sedation	Ensure patient is fully sedated prior to movement to ambulance cot. Refer to Protocol 2-924 - Universal Patient Care for Ketamine dosage. #sedatewhatyouintubate
Paralysis	Refer to Protocol 2-044 - Airway: RSI for continued sedation and paralysis during the transport.

Tidal Volume Based on Ulnar Length

Start with the middle tidal volume (in Bold) and adjust up or down within the range indicated.

Ulnar Length	Female (less than 65 yr old)	Female (greater than 65 yr old)	Male (less than 65 yr old)	Male (greater than 65 yr old)
19 cm	290 (240-330) ml	250 (210-290) ml	320 (270-370) ml	300 (250-350) ml
20 cm	300 (250-350) ml	270 (230-310) ml	350 (300-400) ml	330 (280-390) ml
21 cm	320 (270-370) ml	290 (240-330) ml	350 (300-400) ml	350 (300-400) ml
22 cm	340 (280-390) ml	320 (270-370) ml	400 (300-450) ml	350 (300-450) ml
23 cm	350 (300-450) ml	350 (250-400) ml	400 (350-500) ml	340 (280-390) ml
24 cm	400 (300-450) ml	350 (300-450) ml	450 (350-500) ml	400 (350-500) ml
25 cm	400 (300-500) ml	350 (300-450) ml	450 (350-550) ml	450 (350-500) ml
26 cm	400 (350-500) ml	400 (300-500) ml	500 (400-550) ml	450 (350-550) ml
27 cm	450 (350-500) ml	400 (350-500) ml	500 (400-600) ml	450 (350-550) ml
28 cm	450 (350-550) ml	450 (350-500) ml	550 (450-650) ml	500 (400-600) ml
29 cm	450 (350-550) ml	450 (350-550) ml	550 (450-650) ml	500 (400-600) ml
30 cm	500 (400-550) ml	500 (400-550) ml	600 (450-700) ml	550 (450-650) ml
31 cm	500 (400-600) ml	500 (400-600) ml	600 (500-700) ml	550 (450-650) ml
32 cm	500 (400-600) ml	500 (400-600) ml	600 (500-700) ml	600 (450-700) ml

Tidal Volume Based on IDEAL Body Weight (7 ml/kg)

Start with the middle tidal volume (in Bold) and adjust up or down within the range indicated.

Height	Pediatric		Adult Female		Adult Male
Height	Weight	Tidal Volume	Weight	Tidal Volume	Weight	Tidal Volume
Preemie (Broslow: Grey)	2 kg	15 (10-20) ml
Newborn (Broslow: Grey)	4 kg	30 (20-35) ml
4 mo old (Broslow: Pink)	6 kg	40 (30-50) ml
6 mo old (Broslow: Red)	8 kg	60 (40-70) ml
1 yr old (Broslow: Purple)	10 kg	70 (60-80) ml
2 yr old (Broslow: Yellow)	12 kg	80 (70-100) ml
3 yr old (Broslow: White)	14 kg	100 (80-120) ml
4 yr old (Broslow: White)	16 kg	110 (90-130) ml
4 yr old (Broslow: White)	18 kg	130 (100-150) ml
5 yr old (Broslow: Blue)	20 kg	140 (120-160) ml
6 yr old (Broslow: Blue)	22 kg	150 (130-180) ml
7 yr old< (Broslow: Orange)	24 kg	170 (140-200) ml
7 yr old< (Broslow: Orange)	26 kg	180 (150-210) ml
8 yr old (Broslow: Orange)	28 kg	200 (160-230) ml
9 yr old (Broslow: Green)	30 kg	210 (180-240) ml
9 yr old (Broslow: Green)	32 kg	220 (190-260) ml
10 yr old (Broslow: Green)	34 kg	240 (200-280) ml
10 yr old< (Broslow: Green)	36 kg	250 (210-290) ml
11 yr old (Broslow: Green)	38 kg	270 (220-310) ml
11 yr old (Broslow: Green)	40 kg	280 (240-320) ml
11 yr old (Broslow: Green)	42 kg	290 (250-340) ml
4'-8"			36 kg	250 (210-290) ml
4'-10"			41 kg	290 (240-330) ml	45 kg	320 (270-370) ml
5'-0"			46 kg	320 (270-370) ml	50 kg	350 (300-400) ml
5'-2"			50 kg	350 (300-450) ml	55 kg	400 (300-450) ml
5'-4"			55 kg	400 (300-450) ml	59 kg	400 (350-500) ml
5'-6"			59 kg	400 (350-500) ml	64 kg	450 (350-550) ml
5'-8"			64 kg	450 (350-550) ml	68 kg	500 (400-550) ml
5'-10"			69 kg	500 (400-550) ml	73 kg	500 (400-600) ml
6'-0"			73 kg	500 (400-600) ml	78 kg	550 (450-650) ml
6'-2"			78 kg	550 (450-650) ml	82 kg	600 (450-700) ml
6'-4"			82 kg	600 (450-700) ml	87 kg	600 (500-700) ml
6'-6"			87 kg	600 (500-700) ml	91 kg	650 (500-750) ml
6'-8"			92 kg	650 (500-750) ml	96 kg	650 (550-800) ml
6'-10"					101 kg	700 (600-850) ml

Troubleshooting

General Guidelines:

Remember to click twice when changing settings. #dontgettrickedjustclick
Use 60% FiO2 whenever the patient condition allows.
Ventilator takes approximately 8-10 breaths or 30 seconds to meet settings entered.
Set P-Max 10 cm H20 above Paw (peak airway pressure).

P-Max alarm above 35 cm H2O: Stiff lung.

Dislodged: Check EtCO2, lung sounds, epigastium, SpO2.

Obstructed: Check suction need, kinked tubing, SpO2, EtCO2.

Pneumothorax: Check lung sounds, blood pressure, SpO2.

Equipment: Check cuff inflation, circuit connections.

Citations:

Protocol 9-010 - References
Flynn, 2020.
Mercy, 2014.
Miller, 2020.
National Institutes of Health, 2020.
O-Two Medical Technologies, Inc., 2017.
OKeefe, 2020.
Snyder, 2018.

Change Log:

Date	Link to previous version	Description of change
12/15/13	pdf	Changed to BLS skill.
01/29/14		Changed back to ALS skill.
12/29/14	pdf	Added this protocol from 8-270 (ParaPac Ventilator) and removed 8-270.
07/04/20		Renumbered the section to allow for future additions.
08/08/20	pdf	Added content (without substantive modification) from old Section 8-330 - Portable Ventilator.
10/05/20		Significant additions for O-Two ventilator with input from Mercy LifeLine Protocols.
10/09/20		Significant additions for O-Two ventilator with input from Bobby OKeefeCox Air Care Protocols.
10/27/20	pdf	Updates to settings based on conversations with CMH Respiratory TherapyHospitalists. Switched from SIMV to A/CV. Also added content from ARDSnet.
11/06/20	pdf	Added comments from Dr. Nicholes about ensuring continued paralysis if Ketamine is not enough.
11/09/20	pdf	Approved by Dr. Nicholes
06/15/21	pdf	Moved to emsprotocols.online

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