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

MEDICAL DIRECTIVE

Title: MAC MD - Neonatal Respiratory Care Medical Directive

Number:

83001

Activation Date:
Approved by:

Next review due by: March 2015

2004-06-14
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
Other: yes

no

Delegated Controlled Act: 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
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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 2 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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
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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 3 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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.

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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 4 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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

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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 5 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
Appendix A
Procedures
Controlled Acts and
Procedures

Indications

Nasal CPAP

Indications:

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

-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

Contraindications/
Considerations/Process for Implementing
Procedure
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

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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 6 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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 45 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

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Original Issue Date: 2004 06 14
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Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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

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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 8 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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
Procedures below
the Dermis
Capillary Blood Gas
or Arterial Blood Gas

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.

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

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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 9 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
Appendix B
Administering a Substance by Inhalation
Controlled Acts and
Procedures
Oxygen Therapy

Indications

-As required to correct

arterial hypoxemia and
maintain normal metabolic
function

Contraindications/
Considerations/Process for Implementing
Procedure
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
<32wGA population, HFNC is NOT a substitute
for CPAP and is NOT a standard weaning step
for CPAP.
Procedure:
Follow: HFNC Oxygen Therapy in NICU

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Authorizing Mechanisms
Original Issue Date: 2004 06 14
Page 10 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
Appendix C1
Invasive Conventional Mechanical Ventilation

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,

NO and
PaO2 45-60mmHg arterial / 30-60mmHg capillary
YES
DOVE guidelines met
NO
YES

Contact MRP
if unable to
obtain

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

to monitorYES
trends

Contact MRP
if PEEP > 6
cmH20

NO
Is pH 7.20 7.40 ?
YES

Adjust Minute
Volume

Are Oxygen Saturation Monitoring guidelines

met and is PaO2 at least 45mmHg arterial ?

NO
Adjust PEEP or FiO2

YES
Does the Infant meet weaning criteria?

NO

YES
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
YES
Consider further weaning

Infant tolerated parameter change?

NO

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Original Issue Date: 2004 06 14
Page 11 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
Appendix C2
Invasive High Frequency (Oscillatory) Ventilation

FAILURE ON CONVENTIONAL VENTILATION: as discussed by team with HFV agreed to by MRP or MRP
designate
Recruit post
suction or
disconnect:
Increase MAP
by 2cmH20
for 5 minutes

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,

NO and
PaO2 45-60mmHg arterial / 30-60mmHg capillary
YES
Oxygen Saturation Monitoring guidelines met
NO

Contact MRP
if unable to
obtain

Contact
MRP if Hz
change is
required

YES

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

to monitorYES
trends

Contact MRP if
MAP greater
than 20 cmH20

NO
Is pH 7.20 7.40 ?
YES
NO

Adjust P by 25cmH20 or Amp 510% for BL8000+

Are Oxygen Saturation Monitoring

guidelines met and is PaO2 at least
45mmHg arterial ?

Adjust MAP in 0.51.0 cmH20 steps

YES
Does the Infant meet weaning criteria?

NO

YES
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

YES
Consider further weaning

Infant tolerated parameter change?

NO

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Original Issue Date: 2004 06 14
Page 12 of 12
Title: MAC MD - Neonatal Respiratory Care Medical Directive #83001
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

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