36 RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY Appendix C: Wean Protocol for VentilatorDependent Quadriplegic Patients The following protocol is a policy/procedure used by Craig Hospital, Englewood, Colorado (December 1996). Rationale: To establish guidelines to be followed for weaning all ventilator protocol patients. Scope: Respiratory care practitioners (RCPs) and other clinicians with demonstrated competencies. Policy Statement: All patients who are placed on wean protocol by physician order shall be weaned according to the following criteria. Wean protocol may be ordered independently of other protocols. 10 minutes TID 20 minutes TID 30 minutes TID 60 minutes TID 2 hours TID 3 hours BID 4 hours BID 8–10 hours QD 12 hours QD 14 hours QD 16 hours QD 18 hours QD 20 hours QD 22 hours QD 24 hours QD B. On the judgment of the RCP a patient can , have time increased a maximum of two steps at a time on the wean protocol schedule. V . Weans are to be done with cuff down and trach talk as tolerated. Titrate to >92%. Procedure: I. Physician writes “Wean Protocol” after admission to hospital. II. Criteria to begin or to increase weans: A. Chest x-ray is clear or improving. B. Patient agrees to the procedure. III. Each change should be maintained for 1–3 days and may be increased under the following conditions: A. Patient agrees to an increase. B. Chest x-ray is clear or improving. C. ABGs or pulse oximetry is within acceptable limits. IV Schedule for weans: Respiratory care practitioners . write wean protocol orders. Physician signs off on orders within 24 hours. A. 2 minutes TID 5 minutes TID VI. Weans may be discontinued or reduced in length of time if the patient has persistent atelectasis. Reasons for discontinuing or reducing the length of weans are to be documented in the progress notes and the physician is to be notified. VII. Discontinuing the ventilator. A. RCPs may discontinue the wheelchair ventilator when patient is weaning greater than 14 hours per day. B. RCPs may change bedside 7200 or Star to portable bedside ventilator when the patient ventilator parameters and ABGs are stable. C. RCPs may discontinue bedside ventilator when the patient has been off for 48 hours and there is no sign of distress.