2.02 Mechanical Ventilation: Adult & Pediatric
Category: UWHC Clinical Policy
Effective Date: June 1, 2017
Section: Respiratory Care Services
A. Mechanical ventilation is used to assist breathing when patient’s cannot do so on their own.
This policy pertains to mechanical ventilation applied through an artificial airway.
B. The mechanical ventilator (MV) generates and regulates the flow of gas into the lungs until a
preset volume or pressure level has been achieved. There are a variety of ventilatory modes
available on mechanical ventilators that range from full to partial support. Please refer to the
user’s manual of each ventilator for a full description of the modes available.
C. To ensure proper placement, observation and monitoring of patients requiring respiratory
support by experienced personnel.
A. A Respiratory Care Practitioner (RCP) will initiate the ventilator upon arrival to a unit when the
patient presents requiring ventilatory support and has an artificial airway in place.
1. Set up and operate MV’s and make changes of parameters in accordance with a providers
2. Follow protocol when indicated for appropriate settings and initiatives.
B. A complete ventilator system check will be done every four hours to evaluate, verify and
document the following:
1. The patient's status at the time that the check is performed.
2. The proper operation of the ventilator.
3. Appropriate alarms are activated with appropriate settings, and are sufficiently audible
with respect to distances and competing noise.
4. Inspired gas is properly heated and humidified.
5. Ventilator settings comply with provider orders.
6. Tidal volume is within 10% of the order volume.
C. All new post-operative and/or new admission patients must have a complete system check
and patient assessment upon arrival to the unit.
D. All mechanically ventilated patients with cuffed artificial airways must have a cuff pressure
check utilizing minimum occluding volume (MOV) technique.
1. Adult: assessment twice daily and before and after patient transports.
2. Peds: assessment post-intubation, pre- extubation and as needed.
E. Any patient on mechanical ventilation receiving intrapulmonary percussive ventilation (IPV)
therapy must have a complete system check following therapy.
F. All ventilator changes will be recorded on the doc flow sheet and should include the following:
1. Mode changes.
2. Ventilator parameters that are functional in that mode.
3. High airway pressure alarm setting requiring MD order.
3.1 Adult: If patient peak airway pressure is =/> 50 cm H20.
3.2 Peds: If patient peak airway pressure is =/> 30 cm H20
4. Turning off any alarm requires MD order.
5. The ventilator alarm volume will be preset to 80%. In the event of low stimulation
concerns an order must be written by the MD indicating the desired volume.
G. Emergency Department patients that are mechanically ventilated and have a confirmed
mortal injury/illness may be transferred to F4/4 or B6/6 to begin the terminal wean process.
One RCP will be delegated by the charge therapist to transport the patient to the assigned unit
and will remain at bedside throughout the entire terminal wean and including extubation.
Refer to the related link titled, “Transfer to Comfort Measures for the Intubated Patient in the
H. Back-up mode will be enabled on all modes of ventilation.
I. Patients who require respiratory/ventilatory support must use a hospital-owned device
provided through the Respiratory Care (RC) department unless an exception has been granted
1. It is used for a stable, chronic condition and no adjustments in settings are anticipated. If
it becomes necessary to make adjustments the patient may be required to use a hospital
owned device. This will be determined by the RC department and will be based on staff
familiarity with the patient owned device.
2. Patient is transitioning to the home setting and it is necessary to use the device for
purposes of patient/family instruction. RC personnel must be trained on the operation of
these devices prior to use.
3. All patient owned or rented devices must pass the equipment safety check prior to use.
J. The ventilator should be linked to the nurse call system either directly or through an external
alarm. An exception to this rule may be made for patients being ventilated on B6/6 or F4/4
with an order for terminal ventilator wean.
K. Heat Moisture Exchange Filters (HMEF) may be utilized on all patients 16 years and older
unless the following conditions are present:
1. Minute Ventilation greater than10 LPM
2. Thick or bloody secretions
3. Pulmonary edema.
4. Burn or post lung transplant
5. Patients receiving continuous nebulized medications.
6. Hypothermic patients (temperature less than 35 C)
7. Patients with a VT of less than 250 mls or 4 times the dead space volume of the HME.
8. Patients with an expired tidal volume of less than 75% of delivered tidal volume.
L. Heated humidification is the preferred method for humidification at Clinical Science Center
(CSC) and American Family Children’s Hospital (AFCH). Patients at The American Center (TAC)
will be humidified with an HMEF unless the above conditions are present.
M. All mechanically ventilated patients with an artificial airway are eligible for implementation of
the appropriate weaning protocol. Please see RT Policy 1.53 for unit-specific weaning
1. RT will initiate the appropriate weaning protocol upon receiving a provider’s order.
2. RT will assess all patients at least once a day to determine their ability to wean.
3. Patients that don’t meet the criteria to wean per protocol will require a specific provider’s
order for an alternative weaning strategy.
A. A mechanical ventilator with a humidification system appropriate for the patient.
B. External alarm or direct alarm cable.
C. Posey Cufflator
A. Monitor and document all set ventilator parameters.
B. Monitor and document all measured values and pressures assuring that the tidal volume is
within 10% of the ordered value.
C. Dynamic Compliance will be documented if the ventilator has the ability to measure the value.
D. Providers may request static compliance measurement. See related link ‘Measuring
E. Monitor and document airway pressures
1. Peak airway pressure
2. Dynamic compliance.
3. PEEP and autoPEEP levels
4. Mean airway pressure
F. Monitor and document all alarms.
1. High pressure alarms
a. Adults: high pressure alarms will be set less than or equal to 50 centimeters of water
pressure unless documented as needing to be higher to allow delivery of the
prescribed tidal volume. Airway pressures greater than 50 centimeters of water
pressure require an MD order.
b. Pediatrics: high pressure alarms will be set 10-15 centimeters of water pressure above
the peak pressure but not to exceed a maximum high pressure alarm of 30cmH20.
Airway pressures greater than 30 centimeters of water pressure require an MD order.
2. Alarms should be set so that significant variation in tidal volume or minute volume would
3. Low minute volume alarm set at a level equal to 85% to 90% of the patient’s mandatory
V. EMERGENCY PROCEDURES
A. In the event of failure or malfunction of a mechanical ventilator the patient will be
immediately assessed and manually ventilated with a resuscitator bag.
1. Malfunctioned equipment will be maintained in its entirety and set aside in the used
equipment room in C5/115 for assessment by Clinical Engineering.
2. The RCP that removed the equipment will complete a Patient Safety Net and Equipment
3. If failure or malfunction of the mechanical ventilator results in irreversible harm or death
to a patient, the Administrator on Call MUST be notified.
B. In the event of medical gas loss please refer to UWHC Respiratory Care Policy #1.25,
Emergency Plan for Loss of Piped Gas.
C. In the event of an electrical outage, ventilators owned by UWHC have a minimum of 30
minutes of battery back-up power.
D. The Administrator on Call will determine when it is necessary to rent additional ventilators.
A. Refer to the ventilator user’s manual, department directed learning or fact sheets for
ventilator specific information.
B. Related Policies & Procedures:
1. 1.53 Respiratory Care Protocols
2. 2.05 Transportation of Patients Supported by Mechanical Ventilator
3. 2.06 Breathhold of Mechanically Ventilated Patients in CT scan
4. 2.09 Mechanical Ventilation or CPAP for Nuclear Medicine Procedures
5. 3.27 Apnea Test to Assess Brain Function
6. 3.33 PEEP of Maximum Compliance/Saturation
7. 8.14 Guidelines for Mechanical Ventilation” (Hospital Administrative Policy).
Approved by Director and Medical Director of Respiratory Care.
A copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].