TDP REVIEW and APPLICATION

1. TDPREVIEW and APPLICATION

2. Therapist-Driven Protocols (TDPs) Are an Integral Part of Respiratory Care Health Services

3. The Purpose of TDPs • Deliver individualized diagnostic and therapeutic respiratory to patients • Assist the physician with evaluating patients’ respiratory care needs and to optimize the allocation of respiratory care services

4. The Purpose of TDPs • Determine the indications for respiratory therapy and the appropriate modalities for providing 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

5. 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

6. 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

7. Clinical Research VerifiesThese Facts Respiratory TDPs • Significantly improve respiratory therapy outcomes, and • Appreciably lower therapy costs

8. 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

9. 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

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

11. Overview Summary of a Good TDP Program

12. Figure 9-5. Overview of the essential components of a good TDP program.

13. Figure 9-5. Close-up.

14. Figure 9-5. Close-up.

15. Figure 9-6Respiratory Care Protocol Program Assessment Form— Excerpts

16. Oxygen Therapy Clinical Indicators • History • SpO2 <80% • PaO2 <60 mm Hg • Acute hypoxemia • ↑ Respiratory rate • ↑ Pulse • Cyanosis • Confusion Figure 9-6. Respiratory care protocol program assessment form—Example Excerpts

17. Respiratory Assessment Examples • Mild hypoxemia • Moderate hypoxemia • Severe hypoxemia • Severity score: __________ Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.

18. Treatment Plan Oxygen Therapy Examples: • Nasal cannula • Oxygen mask • 28% Venturi mask Frequency: _______________ Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.

19. Common Anatomic Alterationsof the Lungs • Atelectasis • Alveolar consolidation • ↑ Alveolar-capillary membrane thickness • Bronchospasm • Excessive bronchial secretions • Distal airway and alveolar weakening

20. Box 9-2. PathophysiologicMechanisms Commonly Activatedin Respiratory Disorders • Decreased V/Q ratio • Alveolar diffusion block • Decreased lung compliance • Stimulation of oxygen receptors • Deflation reflex • Irritant reflex • Pulmonary reflex • Increased airway resistance • Air-trapping and alveolar hyperinflation (See clinical scenarios.)

21. Severity Assessment

22. Table 9-2. Respiratory Care Protocol Severity Assessment—Excerpts 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, diminish & rhonchi crackles & bilateral and/or rhonchi severe wheezing, crackles, or rhonchi Cough Strong, Excessive Excessive Thick Thick ______ spontaneous, bronchial bronchial bronchial bronchial nonproductive secretions & secretions but secretions & secretions but strong cough weak cough weak cough no cough

23. SEVERITY ASSESSMENT CASE EXAMPLE A 67-YEAR-OLD-MALE 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). USING 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

24. The Top Four Respiratory Protocols • Oxygen therapy protocol • Bronchopulmonary hygiene therapy protocol • Hyperinflation therapy protocol • Aerosolized medication therapy protocol

25. Common Respiratory Assessments—Excerpts (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

26. Clinical Data Assessment Tx Plan Wheezing Bronchospasm beta2 agent Rhonchi & Secretions in large airwaysWeak cough Poor ability to mobilize secretions CPT ABGs Acute ventilatory failure Mechanical ventilation pH 7.24 PaCO2 73 HCO3- 27 PaO2 53 Common Respiratory Assessments and Treatment Plans—Excerpts (see Table 9-1)