Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Achieve Adequate Respiratory Support

2. Instruct Patients in Deep Breathing / Muscle Training Used in Acute Care: • Aid secretion clearance • Prevent or treat post-op atelectasis • Improve aerosol drug delivery Used in rehabilitation to improve: • Efficiency of ventilation • Exercise tolerance

3. Instruct Patients in Deep Breathing / Muscle Training Deep Breathing Exercises: • Inspiratory Breathing Exercises • Diaphragmatic (abdominal) breathing • Lateral costal breathing • Promote effective use of diaphragm • Improve efficiency of ventilation by increasing VT and decreasing respiratory rate • Expiratory Breathing Exercises • Pursed-lip breathing • Increases back pressure in the airways during exhalation • Can help lessen air-trapping

4. Instruct Patients in Deep Breathing / Muscle Training Incentive Spirometry • Used primarily in the acute care setting for patients at risk for or diagnosed with atelectasis, (typically following thoracic or abdominal surgery) • If the patient cannot cooperate or cannot generate an inspiratory capacity at least 33% of predicted, recommend IPPB as an alternative • Recommend discontinuation when clinical signs indicate resolution of atelectasis • Resolution of fever • Improvement of breath sounds • Normal chest X-ray • Improved arterial oxygenation Inspiratory Muscle Training Techniques (IMT)have largely replaced manual breathing exercises as the method of choice for COPD patients. • Flow and threshold resistors

5. Initiate and Adjust Mechanical Ventilation IPPB Therapy Indicated to: • Improve lung expansion in patients with atelectasis who cannot use other methods, such as incentive spirometry. • Aid in delivery of aerosolized drugs (usually when other methods have failed) • Provide short-term ventilatory support for patients with acute hypercapnic respiratory failure or chronic muscle weakness Only absolute contraindication: • Untreated pneumothorax

6. IPPB initial settings: • Sensitivity of about -2 cm H2O • Cycle pressure between 10 and 20 cm H2O with a moderate flow • Approximate the O2% during the IPPB to the patient’s O2 therapy prescription • Attach to O2 blender with machine set to deliver pure source gas to deliver precise FiO2 Goal To achieve quick and near-effortless on-triggering, followed by a relatively rapid pressure rise and ending in a short plateau.

7. Initiate and Adjust Mechanical Ventilation Continuous Mechanical Ventilation Settings Candidates who cannot properly select appropriate modes and set and adjust ventilator parameters will not be able to pass the CRT exam The NBRC hospital expects you to be familiar with: • All common modes, including control mode, assist/control mode, SIMV, pressure support ventilation, CPAP, and bi-level positive airway pressure (BiPAP) • Dual breath modes such as pressure-regulated volume control (PRVC) and airway pressure release ventilation (APRV)

8. MODES • Mechanical ventilation should be tailored to each patient’s needs • In the early stages of acute respiratory failure, you should select or recommend a mode that provides full ventilatory support (A/C or normal-rate SIMV) • As patient improves and is able to carry more of the ventilatory load, you should begin using modes that allow or encourage spontaneous breathing (partial ventilatory support) NBRC hospital • Expect the NBRC to emphasize selection of either volume- or pressure-oriented assist/control or SIMV (with or without pressure support) for most patients needing ventilatory support • Also apply PEEP to patients if they require more than 50% O2 to maintain adequate arterial oxygenation • CPAP (with backup ventilation) is the mode of choice for critically ill patients who have adequate ventilation but who due to shunting need extra support for oxygenation

9. Select volume-targeted ventilation if CO2 elimination is the primary goal and the patient comfort and lung distention are secondary issues. Select pressure-targeted ventilation if patient-ventilator synchrony is important and CO2 elimination is of lesser concern. Primary goals for adjusting ventilator settings: • Achieve acceptable arterial blood gases • Minimize dyspnea, accessory muscle use, and paradoxical breathing. Review AARC Clinical Practice Guidelines for initial adult ventilator settings and adjustments.

10. Initiate and Adjust Mechanical Ventilation Noninvasive Ventilation The delivery of assisted mechanical ventilation without the need for an artificial tracheal airway. • Negative Pressure: iron lung or tank ventilator, chest curiass, pneumosuit • Positive Pressure: bi-level positive pressure support Application of NPPV requires that the patient have control over upper airway function, be able to manage secretions, and be cooperative and motivated.

11. Initiate and Adjust Mechanical Ventilation Elevated Baseline Pressure (CPAP, PEEP) • CPAP • Mode of ventilation • Involves spontaneous breathing at an elevated baseline pressuure • Indicated to treat sleep apnea, acute cardiogenic pulmonary edema, manage refractory hypoxemia in patients with adequate ventilation • PEEP • Add-on that can be applied to any mode • Used in patients for whom additional “machine” breaths are needed to assure adequate ventilation • Helps lower FiO2 needs • Helps improve patient-ventilator synchrony (by decreasing auto-PEEP)

12. NBRC Hospital standard of care is the application of low levels of PEEP (typically 5 cm H2O) to all adult patients receiving ventilatory support. • Helps maintain FRC and prevent airway closure/auto-PEEP • Maximize benefits and minimize risks to patient by determining “optimum” PEEP • Four methods to determine optimum PEEP • Maximize O2 delivery to the tissues • Highest static total compliance • Maximum volume change for a given change in pressure • Lowest pressure needed to exceed lower inflection point (LIP or Pflex) on the pressure-volume curve

13. Select Ventilator Graphics Select Ventilator Graphics Scalar Graphics (time-based) • Flow vs. Time • Identify presence of auto-PEEP (expiratory) • Identify flow starvation (VCV) • Assess / adjust rise time (PCV, PSV) • Identify asynchrony • Pressure vs. Time • Confirm PIP and PEEP level • Visually assess mechanics using PIP-Pplat (~ Raw) and Pplat-PEEP (~Cstat) • Assess sensitivity/trigger response • Identify asynchrony • Volume vs. Time • Identify leaks • Identify asynchrony

14. X-Y Loop Graphics (loops) • Pressure (X-axis) vs. volume (Y-axis) • Assess overall work of breathing • Identify overdistension • Assess trigger work • Adjust PSV levels • Volume (X-axis) vs. flow (Y-axis) • Assess bronchodilator response • Identify presence of auto-PEEP • Identify leaks

15. Apply Disease-Specific Ventilator Protocols National Heart, Lung, and Blood Institute (NHLBI) ARDS protocol • Consider implementing this protocol for any patient who exhibits an acute onset of respiratory distress not associated with heart failure and has: • A PaO2/FiO2 less than 300 (signifying acute lung injury) • Bilateral diffuse infiltrates on X-ray consistent with pulmonary edema

16. Initiate and Select Appropriate Settings for High-Frequency Ventilation You need to be familiar with both infant/child and adult applications • Indicated for hypoxemic respiratory failure for infants/children/adults who have not responded to more conventional methods of improving oxygenation. • Decreasing HFOV frequency tends to lower the PaCO2, while increasing the HFOV frequency tends to raise the PaCO2

17. Initiate and Modify Weaning Parameters Carefully monitoring the SBT provides the most valid information for deciding whether or not a patient can stay off the ventilator. NBRC will assess your ability to independently implement a SBT protocol: • Straight T-tube breathing • CPAP • Pressure support • Pressure support + CPAP

18. Administer Medications Aerosolized Drugs: • If the patient is receiving several inhaled medications, the recommended order is bronchodilator first, followed by mucolytic, then bronchial hygiene therapy, then steroids, and then the aerosolized antibiotic. Endotracheal Instillation • Lidocaine, epinephrine, atropine, or naloxone (LEAN) • Mucolytics • Surfactant

19. Treating and Preventing Hypoxemia Administer Oxygen • In otherwise normal patients, adjust the flow/FiO2 to the lowest level needed to maintain normal oxygenation (PaO2 of 80 – 100 torr with a saturation ≥ 95%) • If you cannot maintain normal oxygenation on less than 50% oxygen, accept a PaO2 ≥ 55-60 torr with a SaO2 (SpO2) ≥ 88% • When treating patients with carbon monoxide poisoning, cyanide poisoning, acute pulmonary edema, shock, trauma, or acute myocardial infarction in emergency settings, provide the highest possible FiO2 • For patients with chronic hypoxemia, aim to keep the PaO2 in the 55-60 torr range to prevent depression of ventilation • In low birth weight or preterm infants at risk for ROP, your goal should be a PaO2 in the 50-70 torr range.

20. Position Patient to Minimize Hypoxemia • Semi-Fowler’s position (head of bed elevated 30 degrees) • To minimize ventilator-associated pneumonia in patients receiving mechanical ventilation • Lateral rotation therapy • To prevent or minimize respiratory complications associated with immobility in bedridden patients • “Keeping the good lung down” • To improve the oxygenation in patients with unilateral lung disease • Prone positioning • To improve oxygenation in patients with ARDS and refractory hypoxemia Prevent Procedure-Associated Hypoxemia • Always monitor the patient’s SpO2 with a pulse oximeter prior to, during, and after any procedure that can cause hypoxemia.

21. Common Errors to Avoid on the Exam • Never use or recommend incentive spirometry for patients who cannot cooperate • Never administer IPPB to a patient with an untreated tension pneumothorax • Never use or recommend noninvasive positive pressure ventilation (NPPV) for patients who do not have control over upper airway function or cannot manage their secretions • Whenever possible, avoid plateau pressures above 30 cmH2O during mechanical ventilation • Do not use or recommend high-frequency oscillation ventilation for patients with obstructive lung disease

22. More Common Errors to Avoid on the Exam • Never administer a mucokinetic agent without also providing appropriate bronchial hygiene measures to facilitate secretion removal • Do not use or recommend mast cell stabilizers (cromolyn sodium, nedrocromil) for acute bronchospasm • Never mix Tobramycin (Tobi) with other drugs for inhalation • Avoid suctioning (if possible) for 6 hours following surfactant instillation • Never withhold supplemental oxygen from a patient who needs it

23. Exam Sure Bets • To confirm patient understanding of muscle training, incentive spirometry, or IPPB, always require a “return demonstration” of the procedure by the patient • To prevent hyperventilation during IPPB, always instruct the patient to avoid forceful exhalation and to breathe slowly. • When initiating mechanical ventilation, always use a high FiO2 (0.60 - 0.90) until an ABG can be obtained. • Except with ARDS patients, when initiating mechanical ventilation, set the initial VT to 8 – 10 ml/kg IBW when targeting volume or set the pressure limit to 20 - 30 cm H2O when targeting pressure

24. More Exam Sure Bets • To adjust a patient’s PaCO2 / pH during mechanical ventilation, always change the rate first; change the VT / pressure limit only if rate changes exceed the recommended adult limits (8 – 24 breaths/min) or if you do not achieve the desired results. • Unless contraindicated, always use an oronasal / “full” face mask when initiating NPPV on patients with acute respiratory failure • To avoid esophageal opening / gastric distention, always keep IPAP levels during NPPV below 20 – 25 cm H2O • Whenever a patient’s cardiac output or blood pressure falls when raising the PEEP level, decrease PEEP back to its prior setting

25. More Exam Sure Bets • Always give the bronchodilator first when ordered in combination with a mucokinetic or anti-infective agent • To prevent pharyngitis and oral candidiasis with inhaled steroids, always have patients rinse their mouth out after administration • When treating patients with carbon monoxide poisoning, cyanide poisoning, acute pulmonary edema, shock, trauma, or acute myocardial infraction in emergency settings, always provide the highest possible FiO2

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