Patient ID

Daily Screen and Spontaneous Breathing Trial (SBT) Flowsheet

Intubation date: _______________________
DAILY SCREEN (performed before 9:00 a.m.)
Intact/Adequate cough
Temperature less than 38C
PaO2/FIO 2 greater than 150 ___________

Trach date: ________________________

PEEP equal or less than + 5 cmH2O

Rapid Shallow Breathing Index < 105 ___________

Yes ___
Yes ___
Yes ___

No ___
No ___
No ___

Yes ___
Yes ___

No ___
No ___

Yes ___
Yes ___
Yes ___

No ___
No ___
No ___

(RSBI= Spontaneous respiratory rate / spontaneous tidal volume)

Hemoglobin (greater than 8 gm/dL) ___________

Hemodynamic stability (Off or Low Dose Vasopressor)
Patient alert & interactive

If No to 2 or more, continue current ventilator settings.

If No to only one item, ask house officer to assess patient.
Physician notified: ________________________________
If Yes to all, begin Spontaneous Breathing Trial @ CPAP= 5 cmH2O & PSV= 7 cmH2O.
2 Hour Spontaneous Breathing Trial (monitor patient continuously)
Start time: ______________
End time: _______________
Comments: _________________________________________________________________
___________________________________________________________________________
Respiratory rate greater than 35/min for more than 5 minutes
Yes ___ No ___
SpO2 less than 90% on FIO2 less than 0.5
Yes ___ No ___
Heart rate greater than 140/min or 20% above baseline
Yes ___ No ___
Systolic blood pressure greater than 180 mmHg or
Yes ___ No ___
less than 90 mmHg
Use of accessory muscle
Yes ___ No ___
Dyspnea
Yes ___ No ___
Anxiety
Yes ___ No ___
Diaphoresis
Yes ___ No ___
Note:
If No to all at 2hrs, notify house officer & recommend extubation.
If Yes to any item at any time, return patient to prior comfortable ventilator settings
and notify the house officer.
Attending approving extubation: __________________________________
Outcome:
___ Passed-Extubated
___ Passed, Not Extubated. Reason:______________________________________
___ Failed, returned to ventilator. Reason: ___________________________________
___ Reintubated, Time: __________, Reason:_______________________________
___Other: ____________________________________________________________
Date: _________________

SBMC 169
Section: PCR

RCP/RN signature: __________________________