Section III

1. Section III The Therapist-Driven Protocol Program—The Essentials

2. Chapter 9 The Therapist-Driven Protocol Program and the Role of the Respiratory Care Practitioner

3. The days when a respiratory care practitioner was told what to do, and was expected to do it, almost irrespective of the outcomes, have long since past.

4. Today, in every accredited respiratory care program, students are routinely challenged with the following types of questions: • What signs and symptoms are manifested by the patient? • What respiratory care diagnostic procedures should be implemented? • What treatment modalities might be helpful? • How is the effectiveness of the therapy evaluated? • What should be done if the selected procedures and treatments do not work?

5. In fact, these types of questions are the very foundation of the modern day respiratory care education system—and, important—the very basis of the “case-based scenarios” tested in the NBRC advanced practitioner examination.

6. Fortunately, this fundamental therapeutic paradigm is readily transferable to the modern respiratory care practice in the form of therapist-driven protocols (TDPs).

7. The Purpose of TDPs • TDPs are an integral part of respiratory care health services. According to the American Association for Respiratory Care (AARC), the purposes of respiratory TDPs are to: • Deliver individualized diagnostic and therapeutic respiratory care to patients • Assist the physician with evaluating patients’ respiratory care needs and optimizing the allocation of respiratory care services

8. The Purpose of TDPs (Cont’d) • Determine the indications for respiratory therapy and the appropriate modalities for providing high-quality, cost-effective care that improves patient outcomes and decreases length of stay • Empower respiratory care practitioners to allocate care using sign- and symptom-based algorithms for respiratory treatment

9. Respiratory TDPs Give practitioner authority to: • Gather clinical information related to the patient’s respiratory status • Make an assessment of the clinical data collected • Start, increase, decrease, or discontinue certain respiratory therapies on a moment-to-moment basis

10. The Innate Beauty of Respiratory TDPs Is That: • The physician is always in the “information loop” regarding patient care • Therapy can be quickly modified in response to the specific and immediate needs of the patient

11. Clinical Research VerifiesThese Facts Respiratory TDPs: • Significantly improve respiratory therapy outcomes • Appreciably lower therapy costs

12. Figure 9-1. The promise of a good TDP program.

13. Figure 9-2. No assessment program in place.

14. The Knowledge Base Required for a Successful TDP Program The essential knowledge base includes the: • Anatomic alterations of the lungs • Pathophysiologic mechanisms activated • Clinical manifestations that develop • Treatment modalities used to correct the problem

15. Figure 9-3. Foundations for a strong TDP program. Overview of the essential knowledge base for assessment of respiratory diseases.

16. The Assessment Process Skills Required for a Successful TDP Program The practitioner must: • Systematically gather clinical information • Formulate an assessment • Select an optimal treatment • Document in a clear and precise manner

17. Figure 9-4. The way knowledge, assessment, and a TDP program interface.

18. Common Respiratory Assessments— (see Table 9-1) Clinical Data Assessment Wheezing Bronchospasm Rhonchi Secretions in large airways Weak cough Poor ability to mobilize secretions ABGs Acute ventilatory failure pH 7.24 PaCO2 73 HCO3 27 PaO2 53

19. Clinical Data Assessment Tx Plan Wheezing Bronchospasm beta2 agent Rhonchi and Secretions in large airwaysweak cough Poor ability to mobilize secretions CPT ABGs Acute ventilatory failure Mechanical ventilation pH 7.24 PaCO2 73 HCO327 PaO2 53 Common Respiratory Assessments and Treatment Plans—(see Table 9-1)

20. Severity Assessment

21. Respiratory Care Protocol Severity Assessment—(see Table 9-2) Item 0 point 1 point 2 points 3 points 4 points Total Points Breath sounds Clear Bilateral Bilateral Bilateral Absent and/or — crackles crackles wheezing, diminished and rhonchi crackles and bilateral and/or rhonchi severe wheezing, crackles, or rhonchi Cough Strong, Excessive Excessive Thick Thick — spontaneous, bronchial bronchial bronchial bronchial nonproductive secretions and secretions but secretions and secretions but strong cough weak cough weak cough no cough

22. SEVERITY ASSESSMENT CASE EXAMPLE A 67-YEAR-OLD MAN ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL YEARS BEFORE THIS ADMISSION(3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE WAS AMBULATORY, ALERT, AND COOPERATIVE(0 POINTS).HE COMPLAINED OF DYSPNEA AND WAS USING HIS ACCESSORY MUSCLES OF INSPIRATION(3 POINTS).AUSCULTATION REVEALED BILATERAL RHONCHI OVER BOTH LUNG FIELDS(3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK GRAY SECRETIONS(3 POINTS).A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE LEFT LOWER LUNG LOBE(3 POINTS).ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, PaCO2 54, HCO3− 41, AND PaO2 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY FAILURE(3 POINTS). ACCORDING TO THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: TOTAL SCORE:17 TREATMENT SELECTION:CHEST PHYSICAL THERAPY FREQUENCY OF ADMINISTRATION:FOUR TIMES A DAY; AS NEEDED Severity Assessment Case Example

23. The Essential Cornerstone Respiratory Protocols for a Successful TDP Program • Oxygen Therapy Protocol • Bronchial Hygiene Therapy Protocol • Lung Expansion Therapy Protocol • Aerosolized Medication Therapy Protocol • Ventilator Management Protocol • Mechanical Ventilation Weaning Protocol

24. Unnumbered Figure 9-1.

25. Unnumbered Figure 9-2.

26. Unnumbered Figure 9-3.

27. Unnumbered Figure 9-4.

28. Unnumbered Figure 9-5.

29. Unnumbered Figure 9-6P1.

30. Unnumbered Figure 9-6P2.

31. Unnumbered Figure 9-6P3.

32. Unnumbered Figure 9-6P4.

33. Unnumbered Figure 9-6P5.

34. Unnumbered Figure 9-6P6.

35. Unnumbered Figure 9-6P7.

36. Unnumbered Figure 9-7P1.

37. Unnumbered Figure 9-7P2.

38. Unnumbered Figure 9-7P3.

39. Unnumbered Figure 9-7P4.

40. (see Table 9-3. Common Ventilatory Management Strategies) Disorder: Normal Lung Mechanics but Patient Has Apnea • Disease characteristics • Normal compliance and airway resistance • Ventilator mode • Volume ventilation in the AC or SIMV mode • Or pressure ventilation—either PRVC or PC • Tidal volume and respiratory rate • 10 to 12 mL/kg • 10 to 12 breaths/min • 6 to 10 breaths/min when SIMV mode is used

41. (see Table 9-3. Common Ventilatory Management Strategies) Normal Lung Mechanics • Flow rate • 60 to 80 L/min • I:E ratio • 1:2 • FIO2 • Low to moderate • General goals and/or concerns • Care to ensure plateau pressure of 30 cm H2O or less • Smaller tidal volumes (<7 mL/kg) should be avoided because atelectasis can develop

42. (see Table 9-3. Common Ventilatory Management Strategies) Disorder: Chronic Obstructive Pulmonary Disease (COPD) • Disease characteristics • High lung compliance and high airway resistance • Ventilator mode • Volume ventilation in the AC or SIMV mode • Or pressure ventilation—either PRVC or PC • Noninvasive positive pressure ventilation (NPPV) is good alternative • Tidal volume and respiratory rate • Good starting point: 10 mL/kg and 10 to 12 breaths/min • A small tidal volume (8 to 10 mL/kg) and 8 to 10 breaths/min with increased flow rates to allow adequate expiratory time

43. (see Table 9-3. Common Ventilatory Management Strategies) COPD (Cont’d) • Flow rate • 60 L/min • I:E ratio • 1:2 or 1:3 • FIO2 • Low to moderate • General goals and/or concerns • Air trapping and auto-PEEP can occur when expiratory time is too short • ↑ Expiratory time to offset auto-PEEP • May ↑ inspiratory flow up to 100 L/min to ↑ expiratory time • May ↓ VT or rate to ↑ expiratory time • Do not overventilate COPD patients with chronically high PaCO2 levels

44. (see Table 9-3. Common Ventilatory Management Strategies) Disorder: Acute Asthmatic Episode • Disease characteristics • High airway resistance • Ventilator mode • SIMV mode is recommended to offset air trapping • Tidal volume and respiratory rate • Good starting point: 8 to 10 mL/kg • Rate of 10 to 12 breaths/min • When air trapping is extensive, a lower tidal volume(5 to 6 mL/kg) and slower rate may be required

45. (see Table 9-3. Common Ventilatory Management Strategies) Acute Asthmatic Episode (Cont’d) • Flow rate • 60 L/min • I:E ratio • 1:2 or 1:3 • FIO2 • Start at 100% and titrate downward per SpO2 and ABGs • General goals and/or concerns • In severe cases, the development of auto-PEEP may be inevitable. • With controlled ventilation, a small amount of PEEP to offset auto-PEEP may be cautiously applied.

46. (see Table 9-3. Common Ventilatory Management Strategies) Disorder: Acute Respiratory Distress Syndrome • Disease characteristics • Diffuse, uneven alveolar injury • Ventilator mode • Volume ventilation in the AC or SIMV mode • Or pressure ventilation—PRVC or PC • Tidal volume and respiratory rate • Typically, started at low tidal volumes and higher rates • 8 mL/kg and adjusted downward to 6 mL/kg; or 4 mL/kg • Respiratory rate as high as 35 breaths/min

47. (see Table 9-3. Common Ventilatory Management Strategies) Acute Respiratory Distress Syndrome (Cont’d) • Flow rate • 60 to 80 L/min • I:E ratio • 1:1 or 1:2 • Do what is necessary to meet a rapid respiratory rate • Fio2 • Less than 0.6 if possible • General goals and/or concerns • Goal is to limit transpulmonary pressures • 30 cm H2O or less if possible • PEEP is usually needed to prevent atelectasis • Permissive hypercapnia may be allowed

48. (see Table 9-3. Common Ventilatory Management Strategies) Disorder: Postoperative Ventilatory Support • Disease characteristics • Often normal compliance and airway resistance • Ventilator mode • SIMV with pressure support • Or AC volume ventilation • Or pressure ventilation—either PRVC or PC • Tidal volume and respiratory rate • Good starting point: 10 to 12 mL/kg • Rate of 10 to 12 breaths/min • However, larger tidal volumes (12 to 15 mL/kg) and slower rates (6 to 10 breaths/min) may be used to maintain lung volume.

49. (see Table 9-3. Common Ventilatory Management Strategies) Postoperative Ventilatory Support (Cont’d) • Flow rate • 60 L/min • I:E ratio • 1:2 • FIO2 • Low to moderate • General goals and/or concerns • PEEP or CPAP of 3 to 5 cm H2O may be applied to offset atelectasis.

50. (see Table 9-3. Common Ventilatory Management Strategies) Disorder: Neuromuscular Disorder • Disease characteristics • Normal compliance and airway resistance • Ventilator mode • Volume ventilation in the AC or SIMV mode • Or pressure ventilation—either PRVC or PC • Tidal volume and respiratory rate • Good starting point: 12 to 15 mL/kg • Rate of 10 to 12 breaths/min