WESTERN MARYLAND HEALTH SYSTEM
PROTOCOL
REMINDER: ALL MEDICATION ORDERS REQUIRE DOSE, ROUTE, FREQUENCY
DO NOT USE ABBREVIATIONS
Page 1 of 2
PROTOCOL
CHECK OFF/
Post-op Open Heart Respiratory Care/Distress Protocol
INITIALS
1. Initial ventilator settings if not specified by the Anesthesia/Surgeon: Assist control mode with a rate
of 15 breaths per minute, peep 5, tidal volume 6-8 mL/kg of predicted weight. Initial FI02 50% with
titration by oximetry to a hemoglobin saturation greater than 90%, followed by arterial blood gases in
30 minutes.
2. Continuous pulse oximetry.
3. ABG (arterial blood gases) as needed.
4. Respiratory Therapists to titrate FI02 to a hemoglobin saturation of greater than 90% after initial
arterial blood gas.
5. Assessment Trial for Spontaneous Breathing
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Patient awakens and follows commands
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Critical Care Nurse in agreement
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FI02 greater than or equal to 50%
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O2 saturation greater than or equal to 90% or PO2 greater than or equal to 60 mmHg
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Peep less than or equal to 5cm
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Stable Cardiac Rhythm and HR less than or equal to 130
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Systolic and/or MAP (mean arterial pressure) greater than or equal to 60 mmHg
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Temperature greater than or equal to 35.0
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Chest Tube Drainage less than 200mL/hr
6. Spontaneous breathing trial (SBT)
If Respiratory Rate, less than or equal to 35breaths per minute and RR/VT less than or equal to
105; place patient on CPAP 5cm and PS 5cm and current FI02, do ABG’s in 60 minutes
7. Return to vent support at previous settings if during SBT:
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Patient c/o chest pain not related to surgical sites
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Change in mental status (agitation, lethargy, etc.)

RR greater than 35breaths per minute
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HR greater than 130 beats per minute or new arrhythmia ok
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O2 Sat less than 90%
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Blood Pressure systolic less than 90 mmHg
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Chest tube drainage greater than 200/hr
8. May reattempt SAT/SBT PRN until extubation criteria met
Physician/Date/Time:
Original to Patient’s Chart
Original: 10/13
Nurse/Date/Time:
Secretary/Date/Time:
Fax to Pharmacy
Form # 25.21
Western Maryland Health System
Physician Orders
Page 2 of
PROTOCOL
Post-op Open Heart Respiratory Care/Distress Protocol
9. Extubation Criteria (RN and/or Respiratory Therapist may proceed with extubation)
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Patient meets SBT trial criteria
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CHECK OFF/
INITIALS
Results of ABG’s after 60 minutes of CPAP and PS
1. pO2 greater than 70 or as indicated by physician orders
2. pCO2 less than or equal to 45
3. pH 7.35-7.45
Patient is awake, alert and following commands
Respiratory rate less than or equal to 35 per minute
Spontaneous tidal volume greater than or equal to 350 cc
Hemodynamic stability as described above
Stable Cardiac Rhythm and HR less than or equal to 130
Lack of copious secretions
10. Extubate to nasal cannula high flow NC and titrate to O2Sat greater than or equal to 90%
11. POST-EXTUBATION:

Pulmonary toilet

HOB elevated at least 30 degrees
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Encourage coughing with sternum splinted

Suctioning of expectorated secretions
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Incentive spirometer use 10 times every 1-2 hours
12. Respiratory Distress
*If Post-operative patients develop respiratory distress, (respiratory rate greater than 35 beats per
minute, sustained (O2)oxygen saturation less than or equal to 90%) initiate Bipap therapy

Place on Bipap with full face mask initial settings ipap/epap 15/5, may increase to 20/10

Titrate Oxygen for Oxygen Saturation less than 90%

Spontaneous timed backup rate 15

ABG’s in 30 minutes

Stat Portable Chest X-ray
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Notify cardiothoracic Surgeon
P. DOCUMENTATION:
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All patient and family education.
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Patient response to weaning.
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Patient readiness to wean and weaning methods.

Unexpected outcomes
Physician/Date/Time:
Nurse/Date/Time:
Secretary/Date/Time:
Physician is required to date, time and sign every page and only one nurse and one clerical
signature is required.
Original to Patient’s Chart
Original: 10/13
Fax to Pharmacy
Form # 25.21