1. 1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Section III The Therapist-Driven Protocol Program—The Essentials

2. 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 9 The Therapist-Driven Protocol Program and the Role of the Respiratory Care Practitioner The Therapist-Driven Protocol Program and the Role of the Respiratory Care Practitioner

3. 3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  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. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  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. 5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  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. 6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Fortunately, this fundamental therapeutic paradigm is readily transferable to the modern respiratory care practice in the form of therapist-driven protocols (TDPs).

7. 7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. 8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. 9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. 10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Innate Beauty of Respiratory TDPs Is That: 1. The physician is always in the “information loop” regarding patient care 2. Therapy can be quickly modified in response to the specific and immediate needs of the patient

11. 11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Research Verifies These Facts Respiratory TDPs: 1. Significantly improve respiratory therapy outcomes 2. Appreciably lower therapy costs

12. 12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-1. The promise of a good TDP program.

13. 13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-2. No assessment program in place.

14. 14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. 15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-3. Foundations for a strong TDP program. Overview of the essential knowledge base for assessment of respiratory diseases.

16. 16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. 17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-4. The way knowledge, assessment, and a TDP program interface.

18. 18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Common Respiratory Assessments— (see Table 9-1) Clinical DataAssessment WheezingBronchospasm RhonchiSecretions in large airways Weak coughPoor ability to mobilize secretions ABGsAcute ventilatory failure pH7.24 pH7.24 PaCO 2 73 PaCO 2 73 HCO 3 27 HCO 3 27 PaO 2 53 PaO 2 53

19. 19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Common Respiratory Assessments and Treatment Plans— (see Table 9-1) Clinical DataAssessmentTx Plan WheezingBronchospasmbeta 2 agent Rhonchi andSecretions in large airways weak coughPoor ability to mobilize secretionsCPT ABGsAcute ventilatory failureMechanical ventilation pH7.24 pH7.24 PaCO 2 73 PaCO 2 73 HCO 3 27 HCO 3 27 PaO 2 53 PaO 2 53

20. 20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Severity Assessment

21. 21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Protocol Severity Assessment— (see Table 9-2) Item0 point1 point2 points3 points4 pointsTotal Points Breath soundsClearBilateralBilateralBilateralAbsent and/or — cracklescrackleswheezing,diminished and rhonchicrackles andbilateral and/or rhonchisevere wheezing, crackles, or rhonchi CoughStrong,ExcessiveExcessiveThickThick — spontaneous,bronchialbronchialbronchialbronchial nonproductivesecretions andsecretions butsecretions andsecretions but strong coughweak coughweak coughno cough

22. 22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Severity Assessment Case Example 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, PaCO 2 54, HCO 3 − 41, AND PaO 2 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

23. 23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. 24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-1.

25. 25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-2.

26. 26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-3.

27. 27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-4.

28. 28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-5.

29. 29 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P1.

30. 30 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P2.

31. 31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P3.

32. 32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P4.

33. 33 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P5.

34. 34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P6.

35. 35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-6P7.

36. 36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-7P1.

37. 37 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-7P2.

38. 38 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-7P3.

39. 39 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Unnumbered Figure 9-7P4.

40. 40 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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 6 to 10 breaths/min when SIMV mode is used (see Table 9-3. Common Ventilatory Management Strategies)

41. 41 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Lung Mechanics  Flow rate  60 to 80 L/min  I:E ratio  1:2  FIO 2  Low to moderate  General goals and/or concerns  Care to ensure plateau pressure of 30 cm H 2 O or less  Smaller tidal volumes (<7 mL/kg) should be avoided because atelectasis can develop (see Table 9-3. Common Ventilatory Management Strategies)

42. 42 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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 (see Table 9-3. Common Ventilatory Management Strategies)

43. 43 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. COPD (Cont’d)  Flow rate  60 L/min  I:E ratio  1:2 or 1:3  FIO 2  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 ↑ 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 PaCO 2 levels (see Table 9-3. Common Ventilatory Management Strategies)

44. 44 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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 (see Table 9-3. Common Ventilatory Management Strategies)

45. 45 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Acute Asthmatic Episode (Cont’d)  Flow rate  60 L/min  I:E ratio  1:2 or 1:3  FIO 2  Start at 100% and titrate downward per SpO 2 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. (see Table 9-3. Common Ventilatory Management Strategies)

46. 46 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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 8 mL/kg and adjusted downward to 6 mL/kg; or 4 mL/kg Respiratory rate as high as 35 breaths/min Respiratory rate as high as 35 breaths/min (see Table 9-3. Common Ventilatory Management Strategies)

47. 47 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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  F IO 2  Less than 0.6 if possible  General goals and/or concerns  Goal is to limit transpulmonary pressures  30 cm H 2 O or less if possible  PEEP is usually needed to prevent atelectasis  Permissive hypercapnia may be allowed (see Table 9-3. Common Ventilatory Management Strategies)

48. 48 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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. However, larger tidal volumes (12 to 15 mL/kg) and slower rates (6 to 10 breaths/min) may be used to maintain lung volume. (see Table 9-3. Common Ventilatory Management Strategies)

49. 49 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Postoperative Ventilatory Support (Cont’d)  Flow rate  60 L/min  I:E ratio  1:2  FIO 2  Low to moderate  General goals and/or concerns  PEEP or CPAP of 3 to 5 cm H 2 O may be applied to offset atelectasis. (see Table 9-3. Common Ventilatory Management Strategies)

50. 50 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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 (see Table 9-3. Common Ventilatory Management Strategies)

51. 51 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Neuromuscular Disorder (Cont’d)  Flow rate  60 L/min  I:E ratio  1:2  FIO 2  Low to moderate  General goals and/or concerns  PEEP of 3 to 5 cm H 2 O may be applied to offset atelectasis. (see Table 9-3. Common Ventilatory Management Strategies)

52. 52 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Ventilatory Management in Catastrophes

53. 53 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-5. Iron lungs in gym. Iron lungs were in high demand during the polio epidemic of 1951 to 1953.

54. 54 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Tier 1: Do not offer AND withdraw ventilatory support for patients with any one of the following:  Respiratory failure requiring intubation with persistent hypotension  Failure to respond to mechanical ventilation and antibiotics after 72 hours  Laboratory or clinical evidence of four or more organ systems failing Three Tiers of Criteria—Excerpts (See Box 9-2)

55. 55 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Tier 2: Do not offer AND withdraw ventilatory support from patients with respiratory failure requiring intubation with following conditions (in addition to those in tier 1):  Patients with pre-existing system compromise or failure, including: Known congestive heart failure with ejection fraction <25% Known congestive heart failure with ejection fraction <25% Acute renal failure requiring hemodialysis Acute renal failure requiring hemodialysis Severe chronic lung disease Severe chronic lung disease Acquired immunodeficiency syndrome Acquired immunodeficiency syndrome Active malignancy with poor potential for survival Active malignancy with poor potential for survival Three Tiers of Criteria—Excerpts (See Box 9-2) (Cont’d)

56. 56 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Tier 3: Specific protocols to be agreed on by guideline development committee. Possibilities include:  Restriction of treatment based on disease-specific epidemiology and survival data for patient subgroups  Expansion of preexisting disease classes that will not be offered ventilatory support  Applying Sequential Organ Failure Assessment scoring to the triage process and establishing a cutoff score above which mechanical ventilation will not be offered Three Tiers of Criteria—Excerpts (See Box 9-2) (Cont’d)

57. 57 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Overview Summary of a Good TDP Program

58. 58 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-6. Overview of the essential components of a good therapist-driven protocol program.

59. 59 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-7. Respiratory care protocol program assessment form.

60. 60 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Common Anatomic Alterations of the Lungs  Atelectasis  Alveolar consolidation  Increased alveolar-capillary membrane thickness  Bronchospasm  Excessive bronchial secretions  Distal airway and alveolar weakening

61. 61 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Scenarios Activated by the Common Anatomic Alterations of the Lungs

62. 62 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-8. Atelectasis clinical scenario.

63. 63 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-9. Alveolar consolidation clinical scenario. *Or increased when a fever is present.

64. 64 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-10. Increased alveolar-capillary membrane thickness clinical scenario.

65. 65 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-11. Bronchospasm clinical scenario.

66. 66 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-12. Excessive bronchial secretions clinical scenario.

67. 67 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-13. Distal airway and alveolar weakening clinical scenario. The Pulmonary Rehabilitation Protocol is not covered in the text.

68. 68 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 9-14. A three-component model of a prototype airway. A, Airway lumen; B, airway wall; C, supporting structure.