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Protocol Directed Respiratory Care

The use of protocols in Respiratory Care

Section 1 ­ Protocol Concepts Protocol Definition

Respiratory therapy protocols are guidelines, usually written in algorithmic form, for providing respiratory therapy services. Protocols are based on scientific evidence and include guidelines and options at decision points, along with clearly stated outcome objectives. Current medical literature supports the use of respiratory therapy protocols as an effective tool for producing improved patient outcomes and appropriate allocation of services. American Association for Respiratory Care, Position Statement on Respiratory Therapy Protocols, May 16, 2001

Understanding the protocol process

· At the completion of this program the learner will:

­ Understand the steps involved in delivering patient care by protocols ­ Understand the advantages of using protocols ­ Be familiar with the use of oxygen therapy protocols ­ Be familiar with the use of protocols to wean patients from mechanical ventilation

Outline

· Section 1- Protocol Concepts · Section 2- Oxygen therapy protocol · Section 3- Ventilator weaning protocol

Protocol Definition Continued

· Protocol is from the Greek "prot + kollan" to glue together.* · Protocols are rigid codes of procedure in which medical treatment results in: assessment, then intervention, then assessment.

* Scheinhorn, DJ, et al, Outcomes in Post ICU Mechanical Ventilation, Chest. 2001;119:236-242.

Protocol Process

· Protocol therapy is ordered by the physician as "evaluate and treat" or "Respiratory Care by protocol". · The physician's order must be verified. · The Respiratory Therapist evaluates the patient and determines the most appropriate therapy.

Protocol Process Continued

· The therapy decision is made by the Respiratory Therapist based on indications and outcome criteria such as the AARC Clinical Practice Guidelines that have been approved by the medical staff at each facility. · There are guidelines within the protocols that indicate when the physician should be contacted; for example, if the patient's condition determinates. · There are also guidelines for situations in which therapy can be reduced or discontinued. · The Respiratory Therapist will treat the patient and reevaluate on a routine basis usually every 24 hours, for continuation, modification and discontinuation of therapy.

Protocol Process Continued

· This initial evaluation involves a physical examination and review of the patient's medical record to include:

­ ­ ­ ­ ­ lab data radiographs medical history PFT tests oxygen saturation by pulse oximetry (SpO2) or arterial blood gas results and FIO2

Protocol Advantages

· Protocols are institution specific. ­ Patient population is taken into consideration as well as staff competencies · Improve allocation of services ­ Since therapy is specific to the patient's condition, there is less chance of unnecessary therapy · Improve triage of services ­ Acuity scores can be assigned to each patient based on assessment findings · Decrease cost of care while improving outcomes. ­ More appropriate care is given · Unburdens physicians from tasks respiratory therapist can assume

Additional Reading and Viewing

· Hess DR, et al, Respiratory care: principle & practice. W.B. Saunders Co., 2002, pg 102-104. · UCSD Respiratory Services, Respiratory Care Patient Driven Protocols, 2nd ed, Daedalus Enterprises Inc., Dallas, TX, 2002. · Kester L, Tietsort J, Moving toward 100% protocols. AARC web cast, http:// www.aarc.org/education/webcast/#archives, October 9, 2003. · American Association for Respiratory Care, Respiratory Care Protocols: Benefits for Patients, Therapists and Hospitals. Symposium Proceedings, 2005.

Learning Slide

You receive an order to provide Respiratory Care by protocol for Mr. Big. He is a 50 year old pre-operative patient with stable COPD. Which of the following will you do prior to initialing any therapy? a. listen to his breath sounds b. check for recent arterial blood gas values c. verify the order d. review his past medical history Press enter for answer: All of the above

Section 2 - Oxygen Therapy Protocol

Purpose - To administer oxygen at concentrations greater than

ambient air to treat or prevent symptoms and manifestations of hypoxia.

Definitions - Hypoxemia is a decreased PaO2 in the blood below

normal range. PaO2 of < 60 torr or oxygen saturation obtained by pulse oximetry (SpO2) < 90% in room air. It can also be an SpO2 below desirable range for specific clinical conditions. - Prevention of hypoxemia is important in acute myocardial infarction, during certain diagnostic or surgical procedures (i.e. Bronchoscopy).

O2 Protocol

Procedure - Verify the physician's order - Assess the patient and the patient's medical record - Select a high or low flow system oxygen administration device - Adjust the FIO2 to keep the SpO2 92% - Notify the physician if the patient demonstrates an increased need for oxygen ( 3 LMP or two sequential increases in the past 24 hours). - Reevaluate and decrease FIO2 or liter flow at intervals of 8 ­ 24 hours - The goal is to discontinue oxygen when it is no longer required

Oxygen Delivery

· Low - flow systems

­ Nasal cannula, simple oxygen mask, partial rebreathing mask ­ Deliver 100% oxygen at flows less than the patient's inspiratory flow. Room air is mixed, reducing the FIO2.

Low Flow Devices

· Nasal Cannula

­ Can provide up to 44% Oxygen ­ Appropriate flow rates are 1 ­ 6 LMP · Masks with reservoir ­ partial rebreathers or non ­ rebreathers ­ Provide FIO2 of .5 or greater ­ Should be run on liter flows high enough to keep the reservoir bag inflated during inspiration ­ Should only be used as temporary or short term oxygen therapy

High ­ flow Devices

· Nebulizers ­ Air entrainment mask, aerosol mask, tracheostomy mask, face tents and T-tube adaptor ­ Deliver a prescribed gas mixture that exceed the patient's inspiratory flow demand - Can provide from 28 ­ 96% oxygen · Air-entrainment systems ­ Venturi ­masks provide precise FIO2 up to .4

Exemptions

· Patients with certain clinical conditions should be exempt for oxygen protocols · These are clinical conditions in which it is acceptable to have SaO2 greater than 92% · Patients who cannot obtain "normal" SaO2 should also be exempt. · Such conditions are: pulmonary hypertension, sickle cell anemia, respiratory failure, trauma, and unstable cardiac conditions

Selection of High or Low Flow Systems

Physician Order for Oxygen per Protocol Assess the patient Review medical history and lab values Respiratory Rate < 25 Normal Respiratory Pattern Tidal Volume between300 ­ 700 ml SaO2 < 92 YES

NO

Respiratory Rate 25 SaO2 < 88

YES

Place the patient on a Nasal cannula at 2 LPM Titrate liter flow to maintain SaO2 92%

Place on a High Flow System Titrate FIO2 to maintain SaO2 92%

Reevaluate in 24 hours

Reevaluate in 8 hours

When to notify the physician

· Using Low Flow Systems

­ When the SaO2 is 92 on 6 LPM ­ The patient has an increase in O2 requirements of 3 LMP or two sequential increases in 24 hours

· Using High Flow Systems

­ The patient has an increase in O2 requirements of > 10 % ­ Cannot maintain a SaO2 of 92 %

Learning Slide #1

You receive an order for oxygen therapy by protocol. In order to assure that the most appropriate therapy is provided how many of the following must be completed? a. listen to his breath sounds b. check for recent arterial blood gas values c. verify the order d. review his past medical history Press enter for answer: All of the above

Learning Slide #2

You receive a physician order for oxygen by protocol for a post-operative patient. The patient's SaO2 is 88%, respiratory rate is 16 breaths per minute, with regular breathing pattern. The medical history reveals no previous pulmonary problems and no smoking history. Which of the following is the most appropriate therapy:

a. Place the patient on 2 LPM nasal cannula and obtain a pulse oximetry measurement b. Call the physician for further orders c. Place the patient on 6 LPM nasal cannula and obtain a pulse oximetry measurement d. Place the patient on a high flow aerosol mask at 24% oxygen.

See the next slide for the answer.

Learning Slide #3

Answer: Place the patient on 2 LPM nasal cannula and obtain a pulse oximetry measurement A high flow device is not indicated because the patient's respiratory rate is normal.

The oximetry measurement reveals an O2 saturation of 92% on 2 L/min.

Learning Slide #4

The following day you are doing rounds. The patient is still on 2 LPM but his SpO2 (oxygen saturation by pulse oximetry) is 88%, respiratory rate is 18 BPM. Which of the following is the best coarse of action?

a. Place the patient on a high flow device at a higher FIO2. b. Increase the liter flow on the cannula to 4 LPM. c. Take no action at this time d. Recommend that an arterial blood gas is ordered Press enter for answer: b. Increase the liter flow and obtain a pulse oximetry measurement.

Learning Slide #5

You are asked to initiate O2 by protocol for a patient who was recently admitted to the medical floor. The patient is being admitted for evaluation of possible pneumonia. A chest x- ray has been ordered. The SpO2 = 87%, RR = 28 breaths per minute and the respiratory pattern indicates an increased work of breathing. Which of the following is the most appropriate action? a. Place the patient on a 4 liter nasal cannula and obtain an oxygen saturation. b. Place the patient on an aerosol mask with an FIO2 of .40 and obtain an oxygen saturation. c. Call your supervisor for advice. d. Place the patient on 100% oxygen by non ­ rebreathing mask. See next slide for answer.

Press enter for answer: All of the above

Learning Slide #6

a. Place the patient on nasal cannula at 4 L/min and obtain an oxygen saturation. Since the patient has an elevated respiratory rate he needs a high flow device. b. Place the patient on an aerosol mask with an FIO2 of .40 and obtain an oxygen saturation. This is the correct choice! c. Call your supervisor for advice. This should not be necessary if a protocol is being used. d. Place the patient on 100% oxygen by non ­ rebreathing mask. This high of an FIO2 is not indicated at this time.

Section 3- Ventilator Weaning Protocols

Respiratory therapist directed Ventilator Weaning Protocols (VWP) have been shown to be an effective and safe method to wean patients from mechanical ventilation.* Some are based on the length of time or duration of ventilation. Other VWPs are specific to the reason mechanical ventilation was necessary. Most VWPs include the results of a spontaneous breathing trial (SBT) as criteria for discontinuing or liberating the ventilator. Patients are placed on mechanical ventilators when they are unable to maintain adequate ventilation or gas exchange. As the conditions that warranted the ventilator stabilize and begin to resolve, attention should be placed on weaning and discontinuing the ventilator as soon as possible. The use of VWPs has been shown to decrease the duration of ventilation. * MacIntyre NR, et al. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory

Support. Chest 2001 supplement;120:375s-395s

Ventilator Weaning Protocol

Purpose, Goal and Procedure

Purpose - To provide protocol driven respiratory care to wean or liberate adult patients from mechanical ventilation. Goal - To discontinue the ventilator as soon as it is safe to do so. Delays in discontinuation increase the complication rate as well as the cost. Procedure - Mechanically ventilated patients should be evaluated for readiness to wean once or twice each day. Weaning is accomplished through successful spontaneous breathing trials.

Designing a Weaning Protocol

· Many details must be addressed when developing a VWP. · Many VWPs exist that are specific to:

­ the reason the patient required ventilation to begin with ­ the duration the ventilator was required ­ the institution in which the protocol was developed

· The following slides contain one example of a VWP.

Ventilator Weaning Protocol

Does the patient meet the criteria for readiness to wean ? YES Is there an order for Ventilator Weaning by Protocol ?

YES

Explain procedure to the patient and begin Spontaneous Breathing trial (SBT )

SBT settings : FIO 2 . 5 PEEP 5 cm H 20 PSV 1-5 or Flow By 10/ 3 For 30 minutes to 2 hours

Stable respiratory and hemodynamic parameters ?

NO

Return to previous settings

YES Extubate patient , place on appropriate oxygen device or place on trach collar

Repeat SBT in 6 - 24 hours if Readiness criteria is met

Obtain an ABG in 30 minutes

Wean oxygen maintaining SaO 2 92%

Readiness for Weaning

· Before weaning can begin readiness must be established. The following are parameters that indicate a patient is ready to begin weaning:

The condition which caused the respiratory failure is improving or has stabilized ­ Sedation and analgesia medications should be minimized or temporarily discontinued to allow the patient to breath spontaneously ­ Hemodynamic stability

· HR 140 · Stable blood pressure with minimum or no pressors (Levophed or Dopamine)

Readiness for Weaning continued...

­ Capacity to initiate an inspiratory effort ­ No significant Respiratory acidosis

· pH 7.25 or greater*

­ Adequate arterial oxygenation

· PaO2 60 mmHg with an FIO2 .5 · PEEP 5 cm H2 O · PaO2 /FIO2 150 -300

* MacIntyre NR, et al. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. Chest 2001 supplement;120:375s-395s.

Weaning Technique

· If readiness criteria are met, a Spontaneous Breathing Trial (SBT) should be completed for 30 ­ 120 minutes. SBT can be conducted while the patient is attached to the ventilator using the following settings: * 5cm H2O CPAP or less

* Optional Pressure Support Ventilation (PSV) of 5 ­ 8 cm H2 O * FIO2 equal to the ventilator setting prior to SBT (.5 or less).

Parameters during SBT

· Parameters that suggest that the SBT is successful are

­ Spontaneous Vt > 5 ml/kg body weight ­ Respiratory rate < 30 breaths/minute ­ Rapid Shallow Breathing Index (RSBI)* 105

* spontaneous respiratory rate /Vt (in liters)

Unsuccessful Weaning

· Discontinue the SBT if any of the following occur: ­ Respiratory rate 30 breaths/minute ­ Hypoxemia (SaO2 < 90%) ­ Tachycardia ( heart rate > 140 beats/minute or a sustained increase of 20 % ­ Hypertension (systolic blood pressure > 180 mm Hg) or hypotension (systolic blood pressure < 90 mm Hg) ­ Agitation, diaphoresis, or anxiety

VWP Learning Slide #1

Mr. Crasher has been on a ventilator for 36 hours following an automobile accident. You are responsible for determining if he is ready for weaning. You notice that he is alert and stable. His vial signs are normal and stable. His PaO2 is 87 mmHg on an FIO2 of .45. His pH is 7.35. Calculate his PaO2 /FIO2 and determine if he is he ready to begin weaning. See the next slide for the answers.

VWP Learning Slide #2

PaO2 /FIO2 = 87/.45 = 193 PaO2 /FIO2 is acceptable for weaning as well as his pH, vital signs and level of consciousness. Based on this information he is ready to begin weaning.

VWP Learning Slide #3

· Ten minutes into Mr. Crasher's spontaneous breathing trial his Vt = 510 ml, his respiratory rate is 22. His vital signs continue to be stable. His last weight was 80 kg. · Calculate his RSBI and determine if the weaning trail can safely be continued.

­ See next slide for answer

VWP Learning Slide #4

· RSBI = 22/.510 = 43 · Vt = 6.4 ml/kg · Vital signs are stable · Respiratory rate of 22 meets the criteria · Yes it is save to continue with the SBT.

VWP Learning Slide #5

· Which of the following information is needed to determine if a patient is ready for weaning?

a. b. c. d. Date of birth ABG The medications that have been given Vital signs

­ See next slide for answer

VWP Learning Slide #6

a. Date of birth - this is unnecessary b. ABG ­ this is necessary to determine if oxygenation and pH are acceptable c. The medications that have been given ­ this is necessary to determine is the patient is on pressors and /or sedation d. Vital signs ­ this is necessary to determine hemodynamic stability. Answer: b, c, and d

VWP Learning Slide #7

You are on morning "weaning rounds". Ms. Amigood has been on a ventilator for 48 hours. Her ventilator settings are: PEEP = 5 cmH20 Pressure Support = 5 cmH20 FIO2 = .5 Based on these settings should you evaluate her for weaning readiness? Click Enter for answer. Yes, these same settings can be used during a SBT.

Additional Reading and Viewing

Congratulations you have completed this learning module! Here are some additional references. · Chadburn,RL, Fundamentals of Mechanical Ventilation, Mandu Press Ltd.,Clevland OH, 2003. · Hess DR, Ventilator Care Patr II:Weaning protocols that work. AARC web cast, http:// www.aarc.org/education/webcast/#archives, February 5, 2004. · UCSD Respiratory Services, Respiratory Care Patient Driven Protocols, 2nd ed, Daedalus Enterprises Inc., Dallas, TX, 2002.

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