Intensive Care Protocols:

Conventional (out dated way)
1. Oxygen administrated arbitrarily in concentrations that maintain SaO2 well above 95%.
2. Frequent airway suctioning via the tube.
3. Supplemental oxygen increased when desaturations occur.
4. Ventilator weaning attempted at the expense of hypercapnia.
5. Extubation not attempted unless the patient appears to be ventilator weaned. 6. Extubation to CPAP or low span bi-level positive airway pressure and continued oxygen therapy.
7. Deep airway suctioning by catheterizing the upper airway along with postural drainage and chest physical therapy.
8. With increasing CO2, retention or hypoxia supplemental oxygen is increased and ultimately the patient is reintubated.
9. Following re-intubation, tracheostomy is thought to be the only long-term option ...or following successful extubation, bronchodilators and ongoing routine chest physical therapy are used.
10. Eventually discharged home with a tracheostomy, often following a rehabilitation stay for family training.  

Dr. Bach’s Protocol:

1. Oxygen administration limited only to approach 95% SaO2.
2. Mechanical insufflation-exsufflation used via the tube at 25 to 40 cm H2O to -25 to -40 cm H2O pressures up to every 10 minutes as needed to reverse oxyhemoglobin desaturations due to airway mucus accumulation and when there is auscultatory evidence of secretion accumulation. Abdominal thrusts are applied during exsufflation. Tube and upper airway are suctioned following use of expiratory aids as needed.
3. Expiratory aids used when desaturations occur.
4. Ventilator weaning attempted without permitting hypercapnia.
5. Extubation attempted whether or not the patient is ventilator weaned when meeting the following:
    A. Afebrile
    B. No supplemental oxygen requirement to maintain SaO2 >94%
    C. Chest radiograph abnormalities cleared or clearing
    D. Any respiratory depressants discontinued
    E. Airway suctioning required less than 1-2x/eight hours
    F. Coryza diminished sufficiently so that suctioning of the nasal orifices is        required less than once every 6 hours (important to facilitate use of nasal prongs/mask for post-extubation nasal ventilation)
6. Extubation to continuous nasal ventilation and no supplemental oxygen.
7. Oximetry feedback used to guide the use of expiratory aids, postural drainage, and chest physical therapy to reverse any desaturations due to airway mucus accumulation.
8. With CO2 retention or ventilator synchronization difficulties nasal interface leaks were eliminated, pressure support and ventilator rate increased or the patient switched from BiPAP-ST™ to using a volume cycled ventilator. Persistent oxyhemoglobin desaturation despite eucapnia and aggressive use of expiratory aids indicated impending respiratory distress and need to re-intubate.
9. Following re-intubation the protocol was used for a second trial of extubation to nasal ventilation ...or following successful extubation bronchodilators and chest physical therapy were discontinued and the patient weaned to nocturnal nasal ventilation.
10. Discharge home after the SaO2 remained within normal limits for 2 days and when assisted coughing was needed less than 4 times per day.

Jeni- Now, as for the pulmonologist thing, Annah (type 2 almost 7) sees her pulmo every 3 months without fail.  She had her first bout of pneumonia in March of 98 (2 yrs. old) and it was ROUGH. If we had been seeing a pulmo, it may have been avoided. I do have a few suggestions. Aside from the albuterol nebs, when she is congested but it is not time for another treatment, do normal saline nebs.  The saline alone will help loosen congestion and make it easier for her to expel.  In addition, I NEVER give Annah anything with a cough suppressant. I learned my lesson on that one early. It may seem to help for the moment when she is not coughing so much, but it just allows all of the mucous to settle deeper into the chest. As for how forceful you need to be about getting her into the pulmo, ask them if they would rather see her when she is admitted because they won't schedule her an appointment!!! Be as aggressive as you need to be to get her seen.  The earlier she starts seeing a pulmo and getting set up with BI-pap, in-exsufflator and all of the other "stuff" that she might need, the better. I go with the school that uses things as a preventative measure rather than waiting until crisis strikes.

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