Transcript Section_3_Recommend_Modifications_Care

Initiation and Modification of
Therapeutic Procedures
Recommend Modifications in the Respiratory
Care Plan
Modifying Respiratory Care Plan
Recommending Changes in Bronchial Hygiene Therapy
 Conditions where modifications would be appropriate
 Preexisting conditions (e.g. increased ICP)
 Recent procedures (e.g. surgery)
 Patient demographics (e.g. age)
 Adverse reaction to therapy ( e.g. hypoxemia)
 Modifications may include
 Altering the duration of therapy
 Altering the positions used
 Using a different bronchial hygiene strategy
Bronchial Hygiene Modification
 Shorten the duration for a given postural drainage position for
patients who become anxious or otherwise do not tolerate the
procedure.
 Avoid a head-down position for patients with elevated ICP and
instead rotate the patient laterally to approximate the position
as closely as possible.
 Discourage strenuous coughing for stroke patients or those
otherwise predisposed to increased ICP. Instead, instruct these
patients to use a “huff cough or sit them up until the cough
subsides.
 If you think a patient might become hypoxemic during the
procedure, provide appropriate supplemental O2 and monitor
the SpO2 throughout the procedure.
 If bronchospasm occurs, stop therapy, return patient to original
position monitor him or her closely, administer supplemental O2,
contact physician, and recommend bronchodilators.
 If complications or adverse events occur during the therapy
(e.g. hypoxemia, arrhythmias), stop the therapy, return the
patient to the original position, monitor him or her closely,
administer oxygen as necessary, and promptly contact the
physician.
Recommending Changes in Patient Positioning
 Proper positioning can optimize patient care by enhancing
oxygenation and ventilation, assisting with secretion removal
and other therapeutic procedures, as well as facilitating
diagnostic procedures.
Recommending Insertion and/or Modifications of Artificial
Airways
 Based on patient assessment and the major indications for
insertion of the various forms of artificial airways (oro- and
nasopharyngeal airways, LMA, oral and nasal ET tubes,
cuffed/unfenestrated and uncuffed/fenestrated
tracheostomy tubes, tracheostomy button)
Recommending Treatment of a Suspected Pneumothorax
 Placing the patient on 100% oxygen therapy
 Ordering a stat chest x-ray
 Doing a needle decompression in the appropriate side if the
patient’s condition becomes life threatening.
 Change ventilator settings to minimize peak inspiratory
airway pressures and barotrauma (e.g. decrease or eliminate
PEEP, decrease flow, or lower Vt)
Recommending Adjustment in Fluid Balance
 Maintaining balance between intake and output is essential to
maintain proper metabolic functions.
 Recognize signs of and suggest strategies to treat dehydration
(negative I/O) and overhydration (positive I/O)
Recommending Adjustment of Electrolyte Therapy
 Know the normal electrolyte values for sodium, potassium, and
chloride.
 Recognize common causes of low (hypo) and high (hyper)
serum levels and be able to suggest actions for treatment
Recommending Initiation and Modification of Pharmacologic Therapy
 Know indications for use of respiratory medications
 Suggest initiation, modification, or discontinuation of respiratory
medications based on patient situation.
 Bronchodilators – short and long acting
 Beta adrenergics
 anticholinergics
 Inhaled steroids, systemic inflammatory mediators
 Mucolytics
 Inhaled alpha adrenergics
 Airway anesthetizers
 Sedation for patient-ventilator asynchrony, intubation
Recommending Sedation and Neuromuscular Blockade
 Know indications for common sedatives, neuroleptics/antipsychotics,
analgesics, and paralytics
Recommending Changes in Oxygen Therapy
 Changes in input flow, delivery device, or FiO2 to meet patient’s need.
Recommending Changes in Mechanical Ventilation
 To improve patient-ventilator synchrony
 Identify patient-related causes
 Identify ventilator-related causes
 Enhancing Oxygenation
 During mechanical ventilation
 If hyperoxia is present (usually PaO2>100 torr), you should lower
the parameter (FiO2 or PEEP) that is potentially most dangerous to
the patient at the moment.
 If the PaO2 or SaO2 is low (<60 torr or <90%), hypoxemia is present,
and either the FiO2, or the PEEP level should be increased.
 Determining which parameter to change.
 If the PO2 is greater than 60 torr on an FiO2 less than 0.6, the
problem is mainly a V/Q imbalance that will respond to a simple
increased in FiO2.
 If the PO2 is less than 60 torr on an FiO2 greater than 0.6, the
problem is shunting and PEEP/CPAP must be added or increased
Recommending Changes in Mechanical Ventilation (cont.)
 To improve alveolar ventilation
 Estimate changes in minute volume
 Current VE x Current PaCO2 = new VE x Desired PaCO2
 Rate changes are preferred method to alter minute
volume, as long as the patient’s tidal volume is
properly set.
 Adjusting the Inspiratory to Expiratory Time Ratio Settings
 Recognize signs of expiratory airflow obstruction and
relationship to auto-peep
 To treat severe conditions recommend
 Administering bronchodilator therapy
 Keeping the airway clear/removing secretions
 Increasing the ET/trach tube size (if too small)
 Decreasing the I:E rato (decrease rate, increase
flow, etc.)
 Decreasing tidal volume/minute volume, within safe
limits
 Allowing the patient to breath spontaneously
 Applying extrinsic PEEP, pressures up to 80% of autoPEEP level
Recommending Changes in Mechanical Ventilation (cont.)
 Modify Ventilator Techniques
 Appropriate changes of mode of ventilation based on
changes in patient’s condition.
 Monitoring and Adjusting Alarm Settings
 Ensure patient safety
 Remove the patient from the ventilator
 Manually ventilate the patient
 Ask for help if necessary
 Assess and monitor the patient
 If patient-related problem, treat and/or recommend
treatment:
 Suction airway
 Administer bronchodilators
 Check artificial airway and recommend reintubation if
necessary
 Troubleshoot ventilator-related problems
 Fix circuit leak
 Readjust alarm parameters to correct level
 Once patient is stabilized and/or ventilator problem fixed,
reconnect patient
 Monitor patient-ventilator interface to ensure no repeat of
episode.
Recommending Changes in Mechanical Ventilation (cont.)
 Adjusting ventilator settings based on graphics
 Recognize clinical situation as seen on waveform (patient-ventilator
asynchrony, auto-PEEP, overdistention, airway leaks)
 Independently initiate or recommend changes to physician
 Changing type of ventilator and breathing circuit
 Selecting and changing ventilators should be based on patient
variables, application settings, and needed capabilities.
 Selecting and changing ventilator circuits appropriate to
compatibility with ventilator, soiled or malfunctioning circuit, meeting
patient care objectives.
 Use low-compliance circuit for neonates and young pediatric
patients to minimize volume loss.
 Changing or modifying a single-limb circuit by adding PEEP
capabilities to the exhalation valve
 Adding an additional exhalation port to a bi-level pressure
ventilator circuit (e.g. whisper swivel valve) for patients at risk for
CO2 retention.
 Adding 50-100 mL mechanical deadspace between the
ventilator circuit’s Y-connector and the patient’s airway to raise
the PaCO2 and manage acute respiratory alkalosis(generally
limited to ventilator modes that do not include spontaneous
breaths)
Recommending Changes in Mechanical Ventilation (cont.)
 Other recommendations related to ventilator settings
 Minimize ventilator-induced lung injury
 Volume-targeted ventilation with low tidal volumes (4-6
mL/kg of IBW)
 Volume-targeted ventilation with low plateau pressures
(< 30 cm H2O)
 Pressure controlled ventilation with PIP less than 30 cm
H2O
 “Dual-mode” ventilation (e.g. pressure-regulated
volume control)
 Airway pressure release ventilation (APRV)
 Permissive hypercapnea
 Appropriate clinical situations for high-frequency
oscillation or jet ventilation
 Lung recruitment maneuvers
Recommending Weaning From Mechanical Ventilation and Extubation
 Assess patient readiness
 Evidence for some reversal of the underlying cause of respiratory failure
 Adequate oxygenation, e.g.
1. PaO2/FiO2 > 150 – 200
2. PEEP </= 5 – 8 cm H2O
3. FIO2 </= 0.4 – 0.5
 pH >/= 7.25
 Hemodynamic stability (no myocardial ischemia or significant hypotension)
 The capability to initiate an inspiratory effort
 Interpret weaning parameters
 Assess parameters collectively; if most or all of them are favorable, weaning
should be recommended
 A variety of weaning methods have been deemed effective in a clinical setting
 One of the most widely accepted methods involves using pressure support
ventilation (PSV) to obtain a VT, as tolerated by the patient, decreased to a
minimum level of 5-6 cm H2O
 Unwanted physiological changes, such as a respiratory rate greater than 30 or a
heart rate greater than 120-140, may signal that the patient is not tolerating the
weaning process and should be returned to full ventilatory support
 If the patient tolerates a “T-piece trial” and has good airway protective reflexes,
you should recommend that the patient also be extubated
 Once a patient is extubated, you should recommend that the patient be
placed on an oxygen-delivery device with an FiO2 slightly higher (10% increase
in FiO2) than that which he or she was on during mechanical ventilation.
Recommending Weaning From Mechanical Ventilation and
Extubation
 Post-extubation monitoring for need for reintubation /
mechanical ventilation
 Unstable vital signs (significant increase in respiratory rate
and/or heart rate, hypo/hypertension)
 Stridor
 Decrease in SpO2
 PaO2 less than 60 torr or PCO2 greater than 50 torr
 Prolonged accessory muscle use or paradoxical
breathing
 Altered mental status
 Hemodynamic instability
Common Errors to Avoid on the Exam
 When performing postural drainage, avoid recommending a
head-down position for patients with increased ICP and
instead rotate the patient laterally to approximate the desired
position.
 Never recommend sedatives, such as benzodiazepines, to
relieve pain. These drugs are often helpful in decreasing
anxiety but don’t alleviate pain.
 Never recommend weaning a patient from mechancal
ventilation who is hemodynamically compromised, has
unstable vital signs, or requires FiO2s in excess of 0.50. – 0.60 or
PEEP level greater than 10 cm H2O
 Never attempt to perform CPR on a patient who is in a bed
unless a “compression board” is placed under their back or
the bed is in “CPR” mode
More Common Errors to Avoid on the
Exam
 Never recommend prophylactic or maintenance medications
such as chromolyn sodium or long acting beta-agonist
bronchodilators such as salmeterol for patients experiencing a
severe asthmatic episode or in status asthmaticus.
 To prevent oxygen-induced hypoventilation, never
recommend FiO2 much above 0.28 for COPD patients
suspected of also being CO2 retainers.
 Never recommend PEEP levels in excess of 5 cm H2O for
ventilator patients who are hemodynamically unstable or at
risk for developing a pneumothorax.
 Never recommend 1:1 or inverse I:E ratios for mechanically
ventilated patients who are not sedated or who are
hemodynamically unstable.
More Common Errors to Avoid on the
Exam
 Never initiate low inspiratory flows or short expiratory times on
ventilator patients who are at risk for air trapping and auto-PEEP.
 Never recommend a conventional ventilator with iron-based
metals and microprocessors for use in an MRI room. Instead,
recommend a pneumatically powered and controlled ventilator.
 Never simply recommend sedation for patient-ventilator
asynchrony before ruling out other patient causes such as
bronchospasm, airway obstruction and pneumothorax, or
ventilator-related causes such as insufficient inspiratory air flow or
inappropriate pressure support.
 Never set a low-pressure (disconnect) alarm much below 5-8 cm
H2O.
 Never use a standard high-compliance circuit for neonates or
young pediatric patients.
Exam Sure Bets
 Always stop postural drainage in the head-down position
if the patient begins to cough vigorously. Sit up and
stabilize the patient before continuing with therapy.
 To facilitate a difficult intubation, always consider
recommending a depolarizing paralyzing agent such as
succinylcholine (Anectine), which has a rapid onset and
short duration.
 Always recommend rapid-sequence intubation for
patients with clinical signs of impending respiratory
failure or inadequate airway protection.
 Always consider a laryngeal mask airway (LMA) when an
immediate intubation is indicated but not easily
achievable or in the presence of a difficult airway.
More Exam Sure Bets
 Always recommend the use of the correct-size ET tube
when assisting with intubation. In general, recommend
the following tube sizes: average adult male: 8.0 – 9.0;
average 16-year-old: 7.0; 3-year-old: 4.5 mm (uncuffed).
 Always recommend placing a spontaneous-breathing
patient who is dyspneic in a Fowler’s or high-Fowler’s
position, to help promote chest excursion and lung
expansion.
 Always recommend a fast-acting adrenergic
bronchodilator for a patient with severe bronchospasm
associated with asthma or a similar condition.
 For patients with unstable or high minute ventilation who
need a low to moderate FiO2 (0.24 – 0.50), always
recommend a high-flow device such as an airentrainment mask.
More Exam Sure Bets
 For patient-ventilator asynchrony, always consider and
recommend measures to address both patient-related
causes, such as airway obstruction and anxiety, as well as
machine-related causes, such as inappropriate trigger
sensitivity or inspiratory flow.
 Always recommend increasing PEEP above 5-10 cm H2O for
ventilator patients who are hemodynamically stable but
hypoxemic despite an FiO2 in excess of 0.50 – 0.60.
 Always recommend increasing either the P (IPAP-EPAP) or
the respiratory rate when seeking to increase the minute
ventilation for a patient on BiPAP.
 Always ensure that there is appropriate full ventilatory support
backup before recommending that a patient be placed on a
weaning mode, such as SIMV with pressure support, CPAP or
pressure support alone.
More Exam Sure Bets
 Always consider recommending pressure-targeted mode or
dual mode of ventilation when attempting to reduce a
ventilator patient’s peak and/or mean airway pressure.
 When a patient with ARDS does not respond well to
conventional volume and pressure modes of ventilation,
consider recommending high-frequency oscillation or jet
ventilation.
 When responding to a ventilator alarm, always start by
checking patient causes such as disconnect or airway leak
(low pressure) or bronchospasm or secretions (high pressure).
 Always disconnect a patient from the ventilator and manually
ventilate him or her with 100% oxygen if a ventilator alarm can
not be fixed within 15 – 30 seconds, especially if the patient is
in distress.
 Always insert an oropharyngeal airway if you are unable to
ventilate a patient with any bag-valve-mask device.
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig Scanlon,
Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers