III. Therapeutic Procedure Initiation and Modification

A. MAINTAIN RECORDS AND COMMUNICATE INFORMATION: using proper terminology

and approved abbreviations, make your charting understandable to other healthcare workers

about the pt. and the therapies you performed.

1. CHARTING: write down date and time of pt. interaction, medications used, what

therapies performed, and record pt's. reactions. Were there any adverse affects? How did

they act or look? What did they say about therapy--any benefit from treatment, etc?

Breath sounds, cough, sputum, vitals, SpO2, etc. are all useful info. to record.

REMEMBER: "if you didn't chart it, it didn't happen!" (See chart example)

2. VERIFICATION/CORRECTION OF DATA: make corrections obvious when charting---

put a single line through it, write "error" & initials with correction right next to it, if possible.

3. COMMUNICATION: give a thorough report of what is going on with that pt. to the next

RT that is coming on shift. Also, notify the nurse if you made any significant changes

(ex: different O2 device) or pt.'s condition has changed for worse. If it’s something urgent, have

nurse call Dr. so Dr. can make decision about pt.'s condition. Use your own judgement on how

important it is to notify a nurse or Dr.; you might want to leave a note in the chart for them if not

urgent. If you can't read an order, or don't understand it, always get a clarification from the Dr.---

don't assume or guess!

4. COMPUTER CHARTING: any info that would be appropriate to include in paper charting

should be entered into the computer. Different hospitals will have different computer programs

with different functions available, like treatment lists and O2 rounds. Make sure you are thoroughly

familiar with the ones you use (if any).

5. PROTOCOLS: make sure you fill out the forms for protocols appropriately and

follow them AS WRITTEN---any deviations in therapy from protocol would have to be approved

by the Dr. Protocols are orders.

6. PT. COMMUNICATION: let the pt. know what you are going to do in language the pt.

can understand. Good communication will improve pt. cooperation and decrease their anxiety.

7. COUNSELING/EDUCATION: RTs may educate the pt. and family about their lung

disease and/or smoking cessation as situation and time permits. In some cases, RTs in

Pulmonary Rehab may be consulted for further education, referrals to support groups, or to

enter a PR program. Sometimes, Dr. will write an order for a PR/RT consult.

B. MAINTAIN A PATENT AIRWAY INCLUDING THE CARE OF ARTIFICAL AIRWAYS:

a patent airway is the very first thing the therapist should take care of in order to assure the

pt. is ventilating---also, "Airway" is the first step in "ABC"s of CPR.

1.& 2: POSITIONING/INSERTING AIRWAYS: use head tilt/chin lift; similar to the

"sniff" position, use oral/nasopharyngeal airways to maintain patency for ventilating in an

emergency situation. Keeps base of tongue from causing an airway obstruction.

3. INTUBATION: to facilitate positive pressure ventilation, to facilitate suctioning,

to protect airway form aspiration, to maintain patent airway.

4. TUBE PLACEMENT: preliminary placement would be auscultated before taping.

A CXR should also be done to confirm proper placement---at least 2 cm above the

carina. Record the ET tube marking at the lips/teeth in the chart.

5. CHANGING TRACH TUBES: to larger diameter sizes for infants as they grow;

from an unfenestrated to a fenestrated so capping trials can begin. Make sure the stoma

is matured/healed before you attempt to change it yourself. When changing the trach tube,

be sure ties are undone and the cuff is deflated, new one will need to be lubricated before

insertion & use an obtrurator (usu. taped to wall by pt's bed)..

6. CUFF PRESSURES/HUMIDIFICATION:

use least pressure needed to form a good seal; no more then 25cm H20 to prevent trachea

wall damage (25 cm is approx. perfusion pressure of tracheal mucosa).

Need to know how to perform minimal leak technique and minimal occluding volume.

Humidification is very important due to by-passing the upper airway which normally humidifies

inhaled gases. HME for short term, or heated humidification if long term or secretions are thick.

7. EXTUBATION: have everything set up and ready to go---supplemental oxygen device

(post-extubation), suction equip. to suction down the ET tube before removal and suction the

mouth and the back of the throat (to minimize aspiration), remove tape, deflate the cuff completely,

and pull gently but quickly. Put new O2 device on pt., ask pt. to cough and speak, listen to breath

sounds afterwards for stridor (damage/inflammation to vocal cords) and monitor for a while.

C. REMOVE BRONCHOPULMONARY SECRETIONS:

When pt.cannot clear own secretions or having difficulty, RTs can perform certain therapies to

facilitate removal.

1. PD&P: ineffective if pt. is not in the proper position to drain a specific

lung segment, can either be done by hand or machine/percussor for a

minimum of 7 minutes on each segment.

NT suctioning: don’t have a trach or ET tube and weak or no

cough to clear own secretions. Place a nasopharyngeal airway ("trumpet")

to protect the nasal passage and make it easier to suction.

Yankauer: for oropharyngeal suctioning; after coughing or

to clear oral secretion build-up.

2. SUCTIONING: open or closed;

CLOSED: Ballard or "in-line" suction catheter used on a vent pt.; 100% O2.

OPEN: hyperoxygenate w/ 100% O2 via AMBU before and after you suction;

instill NS/lavage ONLY if you have made a pass without success and there are thick

secretions present. For proper catheter size, take the size of the ET

tube X 2 for French catheter size (if an odd number use the next smallest size).

Do not spend over 15 seconds coming back up trachea with suction on.

3. AEROSOL THERAPY:

Bronchodilators administered via hand-held nebulizer to increase diameter of bronchioles,

often used for asthma or COPD. ex: Albuterol, Atrovent.

Corticosteroids given to decrease inflammation of airways as in asthma or COPD; ex: Flovent.

Saline (hypertonic) is sometimes given to induce sputum production for sample collection.

Mucolytics given to decrease sputum viscosity; ex: Acetylcysteine (Mucomyst) which is

ALWAYS to be given with a bronchodilator due to its common side-effect of bronchospasm.

REMEMBER: anything aerosolized, even sterile water, can cause bronchospasms!

4. BRONCHOPULMONARY HYGIENE TECHNIQUES: pts that cannot clear own secretions

due to lack of knowledge or specific ability can be educated/coached about techniques, like deep

breathing and coughing, to remove bronchopulmonary secretions. Other techniques include

quad cough, autogenic drainage, or flutter.

D. ACHIEVE ADEQUATE RESPIRATORY SUPPORT:

Maintain oxygenation status and prevent infection by therapist. Use of oxygen and other therapies

to maintain good ventilation and oxygentation.

1. INSTRUCTION: to help instruct pts on proper breathing technique you could use

incentive spirometry or segmental breathing to help prevent or treat atelectasis.

Diaphragmatic breathing teaches COPD patients how to breathe more efficiently with less use of

accessory muscles in work of breathing.

2. INITIATE AND ADJUST:

IPPB therapy, an alternate form of pressure support, would be used for treating atelectasis

by increasing TV, secretion clearance in pts. with inadequate cough due to pain or neuromuscular

problems, & help in weaning from mechanical ventilation.

Continuous Mechanical Ventilation Settings: Be sure to know how to set initial settings on the

ventilator that are appropriate for that patient & pt.'s condition. Also be ready to change settings

as needed, & ordered, as pt.'s condition improves or worsens---look at blood gases, vital signs,

and other clinical data.

Noninvasive Ventilation is an airtight mask connected to a vent or bi-level pressure device.

An alternative to intubation & traditional ventilation & risks associated with it, like VAP, trauma

to trachea or glottis, etc. May be used for patients that are hard to wean off the vent like COPD

patients, those with an advance medical directive prohibiting intubation, or have OSA. Many pts.

find the tight-fitting mask uncomfortable or feel claustrophobic, so compliance is an issue. Tissue

breakdown of bridge of nose is also a problem.

Elevated Baseline Pressure---CPAP on NIPPV and PEEP on the vent---can help keep the alveoli

open for improved oxygenation and keep upper airways open, as in OSA. PEEP could also be

used to decrease bleeding after cardiac or thoracic surgery (tamponade effect).

Combinations of Ventilatory Techniques: Pressure support is applied during inspiration in order

to decrease the work of breathing and can be used in many different ventilator modes, except

assist control. Pressure support can also be used to deliver a desired tidal volume. The most

common vent modes used are Assist Control or SIMV. In AC, every breathe is the same volume

delivered by the machine, even any breaths triggered above the set rate. In SIMV, any breaths

triggered above the set rate, have variable tidal volumes depending on how patient is spontaneously

breathing. Pressure Control Ventilation is used with inverse I:E ratios (PC-IRV) to decrease PIP

and increase oxygenation; pt. must always be sedated & paralyzed when doing this. Inspiratory holds,

or pause time, can be added to most modes to improve oxygenation, by increasing Paw. Sigh breaths,

usu. about 1.5 times TV, are used in AC mode to prevent atelectasis.

3. VENTILATOR GRAPHICS: (show examples)

Square flow waves mean a constant flow with increased respiratory rate.

Sine flow waves are good for patients with increased airway resistance.

Decelerating flow waves are used for patients with low compliance.

Accelerating flow waves are for patients with narrowed or obstructed airways.

Volume wave forms that do not return to baseline at the end of exhalation, indicate leaks or air-trapping.

If volume goes below baseline, this is an indication of auto-PEEP or the patient may be coughing.

Obstructive lung disease can caused a flattening of the exhalation curve.

Pressure wave forms rise during inspiration and are determined by the tidal volume, airway

resistance, lung compliance, and inspiratory flow. The difference between peak pressure and

plateau pressure is airway resistance. If the wave form does not return to baseline during exhalation,

the patient is on PEEP or auto-PEEP is occuring.

4. ADMINISTRATION OF AEROSOLIZED DRUGS & OXYGEN:

Aerosolized drugs have already been discussed in the previous section.

Administer oxygen as if it were a drug, either by Dr.'s order, amt. pt. on at home, or titrated by

monitoring with pulse ox, ABGs, patient appearance, etc.

5. WEANING PROCEDURES:

Think about weaning patients as soon as they are put on the ventilator!

There are many different ways to wean; for example, by gradually decreasing ventilatory support

from AC to SIMV, then decreasing the rate or pressure support level, then to pressure support only

or T-piece trial. MMV mode is primarily a weaning mode; often used for post-op pts. w/o lung disease.

It is advisable to measure weaning parameters to evaluate readiness to wean. Two most commonly

performed are RSBI (freq/TV=105 or less, consider weaning) and MIP/NIF (20-25 cm H2O or more).

Some other weaning parameters would be spontaneous TV, VC, heart rate, breathing rate, overall WOB, etc.

No one weaning parameter can give a definite answer whether to extubate or not.

6. HYPOXEMIA POSITIONING:

Don't have a patient lie on their affected side, whether it be pneumonia or atelectasis, because although

blood flow will be adequate there, diffusion may be inadequate (physiological shunting). Many pts.,

COPDers are one example, benefit from a more upright position (semi-Fowlers), instead of lying down

flat (supine).

7. PREVENTING PROCEDURAL HYPOXEMIA:

Always keep in mind that, regardless of what we are doing to patients, we need to keep them

oxygenated. For this reason, we need to hyperoxygenate pts. before and after suctioning and do

equipment/circuit changes quickly to minimize possibility of hypoxemia.

8. INFECTION CONTROL:

Use Standard Precautions when working with patients---don't be source of infection in addition

to their existing health problems and protect ourselves from infection. For example, proper hand

washing before and after touching patients, and proper aseptic technique when suctioning. Always

observe isolation procedures, whether it be contact (MRSA, C-Diff), droplet (certain strains of pneumonia),

or airborne (TB). If any equipment being used touches the floor---replace it immediately or clean it

appropriately.

E. EVALUATE AND MONITOR PATIENT'S OBJECTIVE AND SUBJECTIVE

RESPONSES TO RESPIRATORY CARE: As RTs, we have to look at the whole picture to evaluate

the results of therapy. This includes lab results, patient assessment, and

the patient's own opinions/responses.

1. CXR: chest radiographs are useful in diagnosing pneumonia, atelectasis, pneumothorax,

pleural effusions, and follow-up x-rays to see if the affected lung fields are improving. Helps to know what

areas of lungs are affected : to put in chest tube, to do thoracentesis, where to percuss & how to position

when doing PD&P.

2. BLOOD GAS SAMPLING: an important diagnostic tool for determining oxygenation

status, adequacy of ventilation, and whether there is a metabolic problem going on. There are four

main ways to obtain an ABG sample: by puncture of the radial artery (most common), brachial

(2nd most common), femoral (last resort/emergency), or from an arterial line, if available. For neonates,

best to do a "heel stick" for arterialized capillary blood ("cap gas").

3. PULSE OX, ABG & CO-OX, CAPNOGRAPHY:

Pulse Ox: either by continuous monitor or sticking the probe on a finger to get a quick

reading/spot check. Inaccurate readings could becaused by: finger nail polish, hypothermia, low

perfusion, carbon monoxide poisoning, severe anema, hypotension and cardiac arrest and dark

skin pigmentation. The different places you could place a probe would be finger, toe or ear and

on infants, ankle or foot.

Blood gas and Co-oximetry: put blood sample into analyzer and input information such as:

temperature of patient, how much oxygen they are on, vent settings (if on vent). Be sure to have

all the air bubbles out of the sample before running it or you will get in incorrect blood gas reading.

If not going to run sample right away (more than 10 min.), place in ice water (up to 40 min or so).

Capnography is the measurement of exhaled CO2. Place end-tidal CO2 monitor on the end of an

ET tube to get a reading of exhaled CO2; to make sure the patient is intubated correctly. You

can either leave it on or take it off after intubation. The end-tidal CO2 is approximately the same

as PaO2. Noninvasive way of getting a CO2 value without having to draw a blood gas. Decreased

CO2 caused by: hyperventilation, apnea, total airway obstruction, decreased perfusion. Increased

CO2: caused by hypoventilation and hyperthermia. Be aware that end-tidal CO2 by itself should not

be used to predict PaCO2 in patients with L-V failure, PE, or COPD, because these conditions will

cause inaccurate readings.

4. INTERPRET BLOOD GAS AND CO-OX RESULTS (see example)

5. SPUTUM CHARACTERISTICS:

White and translucent is normal sputum.

Yellow indicates infection and contains WBCs; purulent.

Green contains old retained secretions, but if its green and foul-smelling it's Pseudomonas infection.

Brown is old blood.

Red is fresh blood.

Very thick secretions may indicate a need for humidification of inhaled gas, poss. heated.

Layers of different colored secretions usu. indicates bronchiectasis.

6. SIGNS OF PATIENT-VENTILATOR DYSYNCHRONY

High pressure alarms, "Volume Not Constant" messages, tachypnea, patient agitation.

Try to find out why this is happening & correct it. May need to increase flow for "air hunger" or

adjust your inspiratory/expiratory time to make pt. more comfortable. If pt. is waking up from

sedation and is in AC mode, may need to consider changing to a more spontaneous mode.

Pt. may need pain meds if pain is cause. A last resort would be to sedate pt.

7. MEASURE AND RECORD VITAL SIGNS, ETC.

You should know the normals of heart rate, breathing rate, blood pressure, respiratory pattern,

cardiac rhythm, for your particular pt. Normal urinary output would be about 40mL/hr, decreased

output could be due to decreased venous return caused by too much PEEP.

8. PERFORM SPIROMETRY, ETC.: some vents can measure Static Compliance by placing the

patient on inspiratory hold for 1-2 seconds or we can calculate it by dividing Tidal Volume by

Pause Pressure - PEEP. Dynamic Compliance is calculated by dividing Tidal Volume by PIP - PEEP;

a way to measure Paw. Increasing Pause Pressure indicates lung compliance is decreasing. If peak

pressures are increasing and the pause pressure stays the same = increased Raw. Normal Vital Capacity

is 65-75ml/kg; less then 15mL/kg & pt. is going to need mechanical ventilation. Need an alert,

cooperative, patient to do Vital Capacity measurement with a respirometer. To measure peak flow,

you also need an alert and cooperative patient to perform the forced max. exhalations into a peak flowmeter.

Take the best out of 3 attempts.

9. MONITOR MEAN AIRWAY PRESSURE, ETC:

Mean airway pressure: if it increases, then it means its harder to expand the lung (decreased compliance).

If Paw deceases, then it takes less pressure to expand the lungs. Paw above 12cm H2O is risking

barotrauma. Paw is affected by rate, PIP, inspiratory time, any inspiratory hold, PEEP level, type of

pressure waveform and I:E ratio. Increased Paw increases oxygenation.

Setting alarms is for the patient's protection, so don’t set them with too wide of a range or they won't

go off in case pt. is in trouble.

Tidal Volume is usu. set on vent @ 10-15ml/kg of ideal body weight.

Respiratory rate: if its higher than normal, the patient may be hyperventilating or in distress; caused by

pain, anxiety, hypoxemia, metabolic acidosis, increased work of breathing.

Airway pressures include PIP and PEEP, which should be set as low as necessary to get desired TV

(in pressure vent) or level of oxygenation and not so high as to cause barotrauma.

I:E ratio usu. 1:3 to 1:5.

MIP, or NIF: the maximum amount of negative pressure the patient can generate during inspiration. Some

vents have this as one of their function keys or you can connect an aneroid manometer to end of ET tube,

patient is instructed to inhale as deeply as possible with closed inspiratory valve. Normal MIP is

-50 to -100cm H2O. A patient that cannot generate at least -20cm H2O in 20 seconds, would not likely be

able to maintain spontaneous ventilation. Can also be used as a weaning parameter.

10. MEASURE FiO2 AND/OR LITER FLOW: to measure FiO2, you would need an oxygen analyzer.

To measure liter flow you would need a flowmeter.

11. MONITOR ET OR TRACH TUBE CUFF PRESSURES: Some hospitals require to check cuff pressures once a shift with a pressure manometer. Use the minimum pressure necessary for a good seal without

going over 25 cm H2O (when possible).

12. AUSCULTATION OF BREATH SOUNDS: (Play breath sounds)