Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Independently Modify Therapeutic Procedures Based on Patient’s Response

2. Generally, therapy should be terminated when the patient’s safety is in question, the therapeutic objectives have been fully met, the therapy is clearly not achieving the intended goals, or in certain end-of-life situations. • During therapy, all patients must be monitored for adverse effects – once therapy is initiated, periodically during therapy, and after therapy is completed. • When a serious adverse effect is suspected • Stop the therapy • Stay with and monitor the patient • Stabilize the patient, by providing oxygen therapy, if necessary. • If in a health care facility, notify the nurse and physician immediately • If in an alternate site such as home care, call for help and dial 911. • If the adverse effect appears life threatening and occurs in a health care facility, call for either “code blue” or the rapid response team (RRT) as indicated

3. Modifying Treatment Techniques Modifying Incentive Spirometry • Assess cooperation, effectiveness of instruction • Troubleshoot equipment • Appropriateness of therapy in relation to patient condition / abilities Modifying IPPB • Selection of appropriate patient interface (mask, mouthpiece, etc) • Control and modify gas source, FiO2, sensitivity, inspiratory/expiratory flow, and peak pressure. • Troubleshoot equipment • Appropriateness of therapy in relation to patient diagnosis Modify Bland Aerosol Therapy • Make adjustments to assure adequate flows at FiO2 higher than 40%. • Adjust equipment appropriately for adequate aerosol production • Ensure infection control

4. Modifying Aerosol Drug Therapy • Optimize drug delivery by changing delivery device or modifying patient’s breathing pattern. Modifying Oxygen Therapy • Followed approved protocols for adjusting delivery • Troubleshoot equipment • Ensure delivery device is appropriate for patient condition Modifying Specialty Gas Therapy • NBRC expects you to have a basic understanding of the indications, setup and equipment, troubleshooting, and common modifications involved in administering helium-oxygen (heliox) and nitric oxide gases. Modifying Bronchial Hygiene Therapy • Appropriately apply various techniques used to help mobilize and remove secretions • Manual and mechanical chest percussion and vibration • Postural drainage • Directed coughing • Positive Expiratory Pressure (PEP) • Intrapulmonary percussive ventilation • Mechanical insufflation-exsufflation • Whenever several techniques are employed to clear secretions the recommended sequence should be • Open them up (bronchodilators • Thin them out (bland aerosol and/or mucolytic agents) • Clear them out (by bronchial hygiene techniques)

5. Modifications Relating to the Management of Artificial Airways • Make appropriate changes in order to achieve goals of the care plan and/or to minimize the likelihood of unwanted hazards and side effects. Modifying Suctioning Technique • Assess secretions for signs of inadequate humidification and correct • Appropriately care for tracheostomy stoma • Take corrective action for obstruction of artificial airway Modifications in Mechanical Ventilation • Suggest appropriate “primary” setting changes to ordering physician (tidal volume, rate, FiO2 and PEEP) • Make appropriate “secondary” setting changes in inspiratory flow, sensitivity, I:E ratio, and alarms. • Make only one parameter change at a time • Troubleshoot patient-ventilator asynchrony • Be able to apply concepts to specific clinical situations

6. Common Errors to Avoid on the Exam • Never continue therapy on a patient who exhibits severe adverse reactions. Instead, if you note adverse reactions, stop the therapy, monitor the patient closely, and notify the physician and nurse. • Never apply percussion or vibration too close to surgical incisions or chest injury or trauma. Instead, apply the therapy a safe distance (6-12 inches) from incision or injuries. • Never use incentive spirometry on an uncooperative patient or one who can not follow commands. Instead, consider recommending IPPB, which can be used to treat or prevent atelectasis regardless of mental status. • In general, do not use a standard air-entrainment device to deliver a high FiO2 (greater than 45-50%) to a spontaneously breathing patient. Instead, consider (1) a nonrebreathing mask, (2) a high-flow cannula, (3) two large-volume nebulizers connected in parallel, or (4) high-output nebulizer.

7. More Common Errors to Avoid on the Exam • Never use an electronically powered (air compressor) device to deliver IPPB therapy to a patient requiring high FiO2s. Instead, consider pneumatically powered devices like the Bird Mark 7 or Bennett PR-II, which can deliver high FiO2. • Never drain tubing condensate back into a nebulizer. Rather, place a water trap in line to capture condensate. • Never use an MDI or DPI on a patient who is tachypneic or in severe respiratory distress. Instead, use a small-volume nebulizer. • Never use a standard nasal cannula on a patient requiring a low FiO2 but who has a high or unstable minute ventilation. Instead, use a high-flow device such as an air-entrainment (venturi) mask or high-flow cannula.

8. More Common Errors to Avoid on the Exam • During postural drainage, never keep a nauseous patient or one coughing violently in a head-down position. Instead, sit the patient up, monitor closely, and notify the physician and nurse. • Never keep a nasopharyngeal airway in place (in the same naris) for more than one day. • Never use low-flow systems, like nasal cannula, to administer heliox therapy to spontaneously breathing patients. Instead, administer heliox using a tight-fitting nonrebreathing mask at a minimum flow of 10 – 15 LPM (you also might consider a high-flow cannula). • Avoid tracheal damage by never inflating endotracheal tube cuffs to pressures above 25 cm H2O. Instead, aim for lower pressures or use either the minimal occluding volume (MOV) or minimal leak technique (MLT).

9. More Common Errors to Avoid on the Exam • Never use oropharyngeal airways in fully conscious patients. • To avoid the potential for tracheal tissue damage or an airway leak, never keep an undersized ET tube in place for a long time period. Instead, recommend that an appropriate-size tube be put in place via either reintubation or a tube exchanger. • Never use excessive suctioning pressure or application time. Instead, suction adult patients with the lowest effective negative pressure for no longer than 10 – 15 seconds. • When making changes to primary ventilator settings, never make more than one change at a time that affects either oxygen (e.g. FiO2 or PEEP) or ventilation (e.g. tidal volume or respiratory rate).

10. More Common Errors to Avoid on the Exam • Never continue using a heat and moisture exchanger (HME) for a patient who develops thick, bloody, or copious secretions. In these cases, switch to a heated humidifier. • Never set the low minute ventilation alarm on adults receiving ventilator support below 4.0 – 5.0 L/min. • When using a CPAP or BiPAP mask, minimize tissue damage by avoiding too tight a fit.

11. Exam Sure Bets • When you suspect a serious adverse effect, always follow these steps: • Stop or pause the therapy • Stay with the patient and monitor him or her • Notify the nurse and physician, if the patient is at a health care facility • If the adverse effect appears life threatening, initiate a “code blue” if the patient is in a health care facility, or activate the EMS if the patient is in an alternate site such as home care. • Always ensure a good lip seal during IS or IPPB hyperinflation therapy. If a good lip seal is not possible (neuromuscular weakness) but patient is at risk for atelectasis, consider IPPB via mask. • When administering heliox therapy, always use an oxygen analyzer with active alarms to continuously measure the FiO2.

12. More Exam Sure Bets • Always remember to use the appropriate conversion factor (1.8 for 80/20 and 1.6 for 70/30 mixtures) when using a standard flow meter to administer heliox therapy. • If you suspect insufficient drug delivery with an MDI, always review the technique and consider adding a holding chamber or spacer or adding an actuator assist device for patients unable to activate the device. • Always consider adding humidity for patients on a nasal cannula with flows greater than 4 L/min or for those who may be at risk for retained secretions (e.g. patients with bronchitis or pneumonia) but who need moderate- to high-flow O2 therapy • If the tubing is correctly set up to a nonrebreathing mask and the bag fails to remain at least partially inflated during inspiration, always increase the flow.

13. More Exam Sure Bets • Always preoxygenate and hyperinflate patients with 100% O2 before suctioning and ensure that the appropriate-size catheter is used. • Always consider using a Coude` suction catheter when attempting to target the left lung in suctioning. • Always ensure that the tracheal stoma is cleaned and the inner cannula and dressing are changed at least every 8 hours to minimize the chance of infection. • To avoid ventilator self-cycling or imposing excessive work on the patient, always ensure that the triggering sensitivity is properly set at -0.5 to -2.0 cm H2O (pressure trigger) or -1.0 to -3.0 L/min (flow trigger). • If the ventilator pressure manometer fluctuates widely during inspiration or if the inspiratory flow waveform is “scalloped”, always consider increasing the inspiratory flow.

14. More Exam Sure Bets • When administering nitric oxide (NO) to a mechanically ventilated patient, always ensure that NO, nitrogen dioxide(NO2), and FiO2 levels are continuously analyzed and are at acceptable levels.. • Always consider increasing the flow if you observe an unintended inverse I:E ratio during flow-limited ventilation. • To maximize patient safety and avoid unnecessary alarm activation, always set, check, and adjust ventilator alarms several times during each shift. Pay special attention to low pressure (disconnect) and low minute ventilation alarms. • Always check and appropriately adjust ventilator alarms when making major ventilator settings changes, such as switching to pressure support to begin weaning.

15. Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers