Transcript Recommend_Procedures_Additional_Data

PATIENT DATA EVALUATION AND
RECOMMENDATIONS
Recommend Procedures to Obtain Additional
Data
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The respiratory therapist often will make recommendations
to others in order to improve the outcomes of care
You should demonstrate knowledge needed to recommend
the following diagnostic procedures:
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Radiographic and other imaging studies
Diagnostic bronchoscopy
Sputum Gram stain, culture, and sensitivities
Bronchoalveolar lavage
PFT
Lung Mechanics
ABG, pulse oximetry, transcutaneous monitoring
Capnography
Electrocardiogram
Hemodynamic monitoring
Sleep studies
NBRC EXPECTATIONS
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You have the knowledge to recommend needed
diagnostic procedures for your patients.
DIAGNOSTIC BRONCHOSCOPY
Recommend whenever the need exists to:
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Assess lesions of unknown etiology that appear on the chest X-ray
film
Evaluate recurrent atelectasis or pulmonary infiltrates
Assess the patency of the upper airway
Investigate the source of hemoptysis
Evaluate unexplained cough, localized wheeze, or stridor
Follow up on suspicious or positive sputum cytology results
Obtain lower respiratory tract secretions, cell washings, or biopsies
for cytologic or microbiologic assessment
Determine the location and extent of injury form toxic inhalation or
aspiration
Evaluate problems associated with artificial airways – e.g., tube
placement or tracheal damage
Facilitate endotracheal tube insertion during difficult intubations
Locate / clear mucus plugs causing lobar or segmental atelectasis
Remove abnormal endobronchial tissue by forceps, basket, or laser
Remove foreign bodies from the airway (although rigid bronchoscopy
is preferred)
Recommend against performing diagnostic
bronchoscopy in patients who:
 Cannot be adequately oxygenated during the
procedure due to severe refractory hypoxemia
 Have a bleeding disorder that cannot be corrected
 Have severe obstructive airway disease
 Are hemodynamically unstable
BRONCHOALVEOLAR LAVAGE
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Indicated in patients with the following
problems:
Nonresolving pneumonia
 Unexplained lung infiltrates (interstitial and/or
alveolar
 Suspected alveolar hemorrhage
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One of the best tools to diagnose bacterial
ventilator-associated pneumonia (VAP)
 Can be helpful in confirming a diagnosis of
various lung cancers.
 Only contraindication is predisposition for
bleeding.
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SPUTUM GRAM STAIN, CULTURE, AND
SENSITIVITY
Recommend on any patient suspected of having a
respiratory tract infection and for whom focused
antibiotic therapy might be needed.
PULMONARY FUNCTION TESTING
Monitor response to therapy
 Screen for lung dysfunction
 Quantify severity and prognosis associated with
lung or chest wall disease
 Assess potential pulmonary effects of
environmental or occupational exposures
 Assess the degree of pulmonary impairment for
rehabilitation placement or disability claims
 Evaluate and follow course of obstructive and
restrictive lung disorders
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LUNG MECHANICS (COMPLIANCE / AIRWAY
RESISTANCE)
Monitor patients during patient-ventilator
system check
 Detect trends in patients subject to rapid changes
in lung “stiffness”
 Detect trends in patients subject to rapid changes
in airway caliber
 Detect suspected overinflation (“beaking” on
pressure-volume curve)
 Determine optimum PEEP level
 Assess response to bronchodilator therapy
 Detect auto-PEEP
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ABG
If the goal is the most accurate
evaluation of oxygenation, ventilation,
and acid-base status, always recommend
ABG analysis
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ABG limitations:
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Does not measure actual hemoglobin content and
saturation
Does not reveal the presence of abnormal hemoglobins
Recommend hemoximetry (CO-oximetry) when
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Patient scenario is smoke inhalation/CO poisoning
Need to calibrate pulse oximetry reading against actual
arterial saturation
PULSE OXIMETRY
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Pulse oximetry should never be substituted for
ABG or hemoximetry when the clinical situation
demands accurate assessment of blood
oxygenation.
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Recommend AGAINST reliance on pulse ox data:
for patients with poor peripheral perfusion
 when there is a need to monitor for or warn of
hyperoxemia (premature infant)
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TRANSCUTANEOUS MONITORING
Traditionally reserved for infants and small
children, however PtCO2 may be used on
hemodynamically stable adults for continuous
monitoring of ventilation when capnography is
not available or impractical
 Should never be recommended to assess
oxygenation in emergencies due to long
calibration and warm-up times.
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CAPNOGRAPHY
Recommend when the need exists to:
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Noninvasively monitor the effectiveness (PETCO2) and
efficiency (PaCO2 - PETCO2) of ventilation, usually during
mechanical ventilation
Monitor the severity of pulmonary disease and assess the
response to therapies intended to lower physiologic deadspace
and/or better match ventilation to perfusion (V/Q)
Determine endotracheal tube placement (tracheal vs.
esophageal intubation)
Monitor levels of therapeutically administered CO2 gas
Measure CO2 production (to assess metabolic rate)
Provide graphic data useful in evaluating the ventilatorpatient interface
AARC recommends against using capnography on all
patients receiving mechanical ventilation
Simple colorimetric CO2 detectors are sufficient to help
determine tube placement
End-tidal CO2 analysis should be confirmed with ABG
ELECTROCARDIOGRAPHY
Recommend obtaining a 12-lead ECG to:
 Screen for heart disease (e.g. CAD, left
ventricular hypertrophy)
 Rule out heart disease in surgical patients
 Evaluate patients with chest pain
 Follow the progression of patients with CAD
 Evaluate heart rhythm disorders (using rhythm
strips)
HEMODYNAMIC MONITORING
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Noninvasive BP measurement
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Monitor routinely on all patients
Invasive Hemodynamic Monitoring
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Arterial Lines
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To continuously monitor arterial pressure in unstable /
hypotensive patients
To continuously monitor patients receiving vasoactive drugs
To obtain frequent ABGs to assess patients in respiratory
failure or receiving mechanical ventilation
CVP
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To monitor central venous pressure/right ventricular function
in unstable or hypotensive patients
To provide volume resuscitation
To infuse drugs that can cause peripheral phlebitis
To provide a route for total parenteral nutrition (TPN)
To provide venous access in patients with poor peripheral veins
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Pulmonary Artery Line (Swan-Ganz)
To identify the cause of various shock states
 To identify the cause of pulmonary edema
 To diagnose pulmonary hypertension
 To diagnose valvular heart disease, intracardiac shunts,
cardiac tomponade, and pulmonary embolus
 To monitor and manage complicated myocardial infarction
 To assess the hemodynamic response to therapies
 To manage multiple organ failure and/or severe cardiac
surgery
 To manage hemodynamic instability after cardiac surgery
 To optimize fluid and inotropic therapy
 To measure tissue oxygenation and selected hemodynamic
indices, including cardiac output
 To perform arterial and ventricular pacing
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SLEEP STUDIES
Recommend overnight oximetry to
 Help identify patients with obstructive sleep
apnea-hypopnea syndrome (SAHS)
 Help assess SAHS patients’ response to therapy,
such as CPAP
 Identify whether serious desaturation occurs in
COPD patients during sleep
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Focus on patients with hypercapnia, erythrocytosis,
and/or evidence of pulmonary hypertension
Recommend Polysomnography
 For patients who complain of or exhibit signs or
symptoms associated with sleep-disordered
breathing.
Daytime somnolence and fatigue
 Morning headaches
 Pulmonary hypertension
 Polycythemia
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To help diagnose certain neurologic and
movement disorders.
 To assess the adequacy of sleep-related
interventions
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Titrating CPAP levels
 Determining BiPAP levels
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Specifically indicated in patients with:
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COPD whose daytime PaO2 exceeds 55 torr and whose condition includes
one or more of the following complications:
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Chest wall or neuromuscular restrictive disorders and whose condition
includes one or more of the following complications:
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Chronic hypoventilation
Polycythemia
Pulmonary hypertension
Disturbed sleep
Morning headaches
Daytime somnolence
Fatigue
Disorders of respiratory control with chronic hypoventilation (datime
PaCO2 >45 torr) or whose illness is complicated by:
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Pulmonary hypertension
Right heart failure
Polycythemia
Excessive daytime sleepiness
Pulmonary hypertension
Disturbed sleep
Morning headaches
Daytime somnolence
Fatigue
Nocturnal cyclic brady or tachyarrthythmias, nocturnal AV conduction
abnormalities, or ventricular ectopic beats that increase during sleep
Excessive daytime sleepiness or sleep maintenance insomnia
Snoring associated with observed apneas and/or excessive daytime
sleepiness
COMMON ERRORS TO AVOID ON THE EXAM
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Never recommend diagnostic bronchoscopy in
patients who are hemodynamically unstable or cannot
be adequately oxygenated during the procedure due
to severe refractory hypoxemia
Never let pulse oximetry substitute for ABG analysis
or hemoximetry when the clinical situation demands
accurate assessment of blood oxygenation
Never use a capnograph to verify endotracheal tube
placement when simpler methods (such as
colorimetric CO2 detectors) are available
Never recommend or insert a radial arterial line
when the Allen test indicates inadequate collateral
circulation on that side
EXAM SURE BETS
Always recommend a sputum Gram stain and
culture and sensitivity on any patient suspected
of having a respiratory tract infection.
 To determine if a change in the dose or frequency
of administration of an aerosolized
bronchodilator is needed, always recommend pre/post-bronchodilator spirometry
 To assess the presence and severity of restrictive
abnormalities, always recommend both TLC/FRC
measurement and the diffusing capacity test
(DLCO).
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MORE EXAM SURE BETS
Always recommend ABG analysis whenever the
need exists to evaluate ventilation, acid-base
balance, and/or oxygenation status.
 Always recommend CO-oximetry for patients
suspected of suffering smoke inhalation
 Always recommend polysomnography for
patients who complain of or exhibit signs or
symptoms associated with sleep-disordered
breathing, such as daytime somnolence, and
fatigue.
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REFERENCE:
Certified Respiratory Therapist Exam Review
Guide, Craig Scanlon, Albert Heuer, and Louis
Sinopoli
Jones and Bartlett Publishers