Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Act As an Assistant to the Physician Performing Special Procedures

2. NBRC expects you to be • Especially familiar with the therapist’s role when assisting with intubation and bronchoscopy. • Have a basic understanding of how the therapist assists with thoracentesis, tracheostomy, chest tube insertion, and cardioversion. • Know how moderate sedation and ultrasound can facilitate some of these procedures.

3. Endotracheal Intubation Indications: conditions that include impending or actual • Airway compromise • Respiratory failure • The need to protect the airway Contraindications: • Lack of adequate facilities or trained personnel • DNR order or other properly documented evidence of the patient’s desire not to be resuscitated. Required Equipment (typically included in intubation tray) • Local anesthetic spray • Lubricating jelly • Laryngoscopes (2) with assorted blades, batteries, and bulbs • Endotracheal tubes (at least 3 different sizes) • Stylets • Magill forceps • Syringes • Tape and/or ET tube holders • Oropharyngeal airways and/or bite blocks

4. Endotracheal Intubation Selecting and Testing the Equipment • Laryngoscope • Select blade size appropriate to age • Large adult: size 4 • Small adult: size 3 • Pediatric: size 2 • Connect to handle and confirm illumination • ET tube • Select appropriate size • Adult male: 8.0 – 9.0 mm • Adult female: 7.0 – 8.0 mm • Average 16 -year-old: 7.0 mm • 3-year-old: 4.5 mm • Check cuff for leaks then fully deflate • Ensure functioning vacuum source and properly set up suction device(s)

5. Endotracheal Intubation Preparing and Monitoring the Patient • Properly position patient • Clear airway of secretions if necessary with Yankauer tip • Apply local anesthetic spray to posterior oropharynx, or nasal passages • Preoxygenate patient with BVM with oxygen reservoir • Monitor vital signs before, during and immediately following intubation. Assisting with Insertion • Clarify and assist in the use of intubation aides (stylet for oral intubation, Magill forceps for nasal intubation) • Lubricate proper-sized tube • Apply moderate cricoid pressure • Communicate elapsed time, vital signs, and SpO2 during intubation • Be prepare to manually ventilate the patient, suction airway • Inflate cuff and temporarily secure tube

6. Endotracheal Intubation Assessing tube placement: • Auscultate • Esophageal detection device (EDD) • Colorimetric CO2 detector • Tape tube in position and note centimeter depth at the incisors • Confirm with chest x-ray and re-secure tube with appropriate device.

7. Bronchoscopy Assisting Indications for fiberoptic bronchoscopy include conditions that require: • Secretion and foreign body removal • Collection of fluid / tissue specimens for microbiologic or cytologic assessment • Tube position, airway injuries • Difficult intubation Contraindications: • Lack of adequate facilities or trained personnel • Absence of documented patient consent or physician’s order. • Inability to adequately oxygenate the patient • Coagulopathy or uncontrolled bleedng • Severe obstructive airway disease • Severe refractory hypoxemia • Unstable hemodynamic status including dysrhythmias.

8. Bronchoscopy Assisting Patient preparation • NPO • Evaluate lab studies for contraindications • Evaluate PFT / ABG if available • Be aware of preparatory medications to be administered (narcotic, anxiolytic/sedative Equipment • Bronchoscope • Suction • Specimen containers, wash solutions Procedure • Patient positioned either supine or sitting • Anesthetize pharynx with 2% centacaine spray or 4% lidocaine aerosol • Local anesthetic instilled through bronchoscope to anesthetize vocal cords and tracheobronchial tree. • Administer supplemental oxygen (a 20 torr drop in PaO2 is common during bronchoscopy)

9. Tracheotomy Indications • To bypass a partial or complete upper airway obstruction • To provide access for secretion removal • To facilitate prolonged mechanical ventilation Contraindications: • No absolute contraindications • Severe coagulopathies should be corrected first, and patients stabilized as much as possible Required Equipment • Necessary surgical equipment to perform the procedure • Extra tracheostomy tube one size smaller than tube being inserted • 10 ml syringe for ET tube cuff deflation / tracheostomy tube cuff inflation • Scissors for removing ET tube securing device • BVM, flow meter and O2 source • Intubation equipment on standby • Hazardous waste receptacle Hazards and Complications • Procedural Adverse reaction to sedation Tissue trauma at incision site Airway compromise or loss of patent airway Excessive bleeding Hypoxemia Aspiration • Post-Procedural Infection Bleeding Pain or discomfort Tracheal stenosis

10. Thoracentesis Indications • Diagnostically, to help determine presence of underlying conditions such as infection, malignancy, CHR, or cirrhosis • Therapeutically, to remove excess pleural fluid that interferes with lung expansion and impairs oxygenation and/or ventilation Contraindications: • Absence of properly signed physician’s order or informed consent • Absence of an experienced clinician to perform or supervise the procedure • Inadequate facilities or personnel to handle hazards such as pneumothorax or bleeding • An uncooperative patient • Inability to identify the top to the rib • Severe coagulopathy (platelet count < 50,000/mm3. • Severe bullous lung disease • Mechanical ventilation with PEEP • Status post pneumonectomy • Markedly elevated hemidiaphragm Role of the Respiratory Therapist • Prior to the procedure: bedside assessment may identify need for thoracentesis (dull percussion, decreased breath sounds in the presence of predisposing factors) • During the procedure: assist with the equipment, monitoring, stabilizing and positioning patient • After the procedure: monitor the patient, assist with preparing samples for lab Hazards and Procedural Considerations • Hypoxemia • Pneumothorax and hemothorax • Hemorrhage/bleeding • Puncture of the liver or spleen • Infections

11. Chest Tube Insertion Indications • Pneumothorax, hemothorax, empyema, chylothorax, and pleural effusion • Administration of drugs / chemicals into pleural space Contraindications: • Absence of significant air or fluid in the pleural space Role of the Respiratory Therapist • Monitor patient and equipment • Identify and respond to adverse reactions Hazards and Procedural Considerations • Bleeding • Tissue trauma • Secondary pneumothorax • Post tube removal: recurrence of pneumothorax

12. Cardioversion Indications • Immediate cardioversion is needed if a ventricular rate greater than 150 persists despite efforts to control it with applicable drugs • Arrhythmias: • Atrial fibrillation • Atrial flutter • Other supraventricular tachycardia • Monomorphic ventricular tachycardia (if stable) • Polymorphic ventricular tachycardia (irregular form and rate) and unstable Contraindications: • Lack of properly trained personnel • Patient’s desire not to be treated Role of Respiratory Therapist • Monitor and respond to any adverse reactions • Have suction, intubation, O2 equipment and BVM ready

13. Moderate (Conscious Sedation) Indications • Helps minimize patient discomfort during procedures while maintaining respiratory drive Contraindications: • Known adverse reaction to sedating agents Role of the Therapist • Assess vital signs, cardiopulmonary and airway status, pulse oximetry, and any adverse side effects from the procedure or medications • Must be familiar with common medications and their major side effects and hazards • Know proper reversing agents for sedating drugs

14. Common Errors to Avoid on the Exam • To minimize tissue trauma during intubation, never permit the tip of the stylet to extend beyond the end of the endotracheal tube • Never perform bronchoscopy in the presence of absolute contraindications such as refractory hypoxemia, unstable hemodynamic status, or inability to oxygenate patient. • Never attempt potentially uncomfortable procedures such as cardioversion, chest tube insertion, or bronchoscopy unless the patient has been premedicated with a medication such as Versed to achieve moderate sedation • When assisting with a tracheostomy procedure, never remove the endotracheal tube until just before the insertion of the tracheostomy tube.

15. More Common Errors to Avoid on the Exam • Never attempt to assist with an intubation unless you have a complete intubation tray that includes a fully functional laryngoscope with multiple blades, several different-size endotracheal tubes, a stylet, suction source and catheter(s), and a device to confirm tube placement • Never rely on only one means of verifying successful intubation. Instead, confirm success with at least two methods, including auscultation of the lungs and epigastric region, end-tidal capnography, colorimetry, esophageal detector device, and chest x-ray. • Never place patients with neck trauma in a “sniffing position” for intubation • Never use a stylet for nasal intubation • Never use more than 100 joules for initial attempts at synchronized cardioversion, initial energy levels of 50 joules are appropriate for A-flutter and supraventricular tachycardia (SVT)

16. Exam Sure Bets • Always announce “clear” several times and verify that no on is in contact with the patient before attempting cardioversion • When positioning patients for a thoracentesis procedure, always ensure that they are adequately supported in front to help prevent them from falling and being injured • Always confirm proper functioning of endotracheal tube cuff, pilot balloon, and valve by first inflating the cuff with a syringe prior to intubation • After each attempt of cardioversion, always activate “sync” mode again, in addition to selecting the appropriate change in energy level

17. More Exam Sure Bets • Always recommend a tracheostomy for an orally intubated patient who is expected to remain mechanically ventilated for some time • Always recommend an immediate chest tube insertion (or needle decompression) for a patient with a tension pneumothorax • Always recommend the use of the correct-size endotracheal tube when assisting with intubation • Always suggest diagnostic ultrasound prior to a thoracentesis to determine the specific location of the fluid and to identify the ideal insertion site for the needle or catheter • Always closely monitor patient’s vital signs, pulse oximetry, and ECG before, during, and immediately following cardioversion or bronchoscopy

18. More Exam Sure Bets • Always monitor a patient’s vitals signs, pulse oximetry, and other clinical indicators during procedures such as tracheostomy, chest tube insertion, bronchoscopy, and cardioversion. If necessary, administer supplemental oxygen to address or prevent hypoxemia during or immediately following such procedures. • Always ensure that a manual resuscitator bag-valve-mask and oxygen source are nearby in case a patient experiences severe adverse effects of procedures such as bronchoscopy, chest tube insertion, thoracentesis, or cardioversion • Always make sure that the patient is NPO for at least 8-12 hours prior to bronchoscopy to minimize aspiration risk. • Always recommend that an X-ray be ordered after certain special procedures such as intubation and chest tube insertion.

19. Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers