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Ростовский Государственный Медицинский Университет

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Clinical_Manifestations_and_Assessment_of_Respiratory

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The AARC has developed protocols that are pertinent to the topic of Aerosolized Medication Therapy: IPPB Protocol, Secretion Clearance Protocol, Metered Dose Inhaler (MDI) Protocol, Small Volume Nebulizer (SVN) Protocol, Therapeutic Effective Dosage Protocol, DNA-ase Protocol, Inhaled Antibiotics Protocol, MDI Protocol for Ventilated

Patients, and several protocols for infants and pediatric patients (see Part XIII).

Also see Strickland, S. L., et al. (2015). AARC clinical practice guideline: Effectiveness of pharmacologic airway clearance therapies in hospitalized patients. Respiratory Care 60, 7, 1071-1077.

NOTE: Standard algorithmic protocol format is such that boxes = start, mandated action and/or end points and diamonds = a yes or no decision is required.

Table 10.1 illustrates common clinical manifestations (i.e., clinical indicators), initial assessments, and treatment selections routinely made by the TDP-practicing respiratory therapist.

TABLE 10.1

Clinical Manifestations, Assessments, and Treatment Selections Commonly Made by the Respiratory Therapist

Clinical Data (Indicators)			Assessments	Treatment Selections
Vital Signs
↑ Breathing rate, blood pressure,			Respiratory distress and dyspnea	Treat underlying cause
pulse
Abnormal Airway Indicators
Wheezing			Bronchospasm	Bronchodilator treatment
Inspiratory stridor			Laryngeal edema	Racemic epinephrine
Coarse crackles			Secretions in large airways	Airway clearance therapy
Fine and medium crackles			Secretions in distal airways	Treat underlying cause, such as congestive heart
				failure
				Hyperinflation therapy
Cough Effectiveness Indicators
Strong cough			Good ability to mobilize secretions	None
Weak cough			Poor ability to mobilize secretions	Airway clearance therapy
Abnormal Secretion Indicators
Amount: >25 mL/24 h			Excessive bronchial secretions	Airway clearance therapy
White and translucent sputum			Normal sputum	None
Yellow or opaque sputum			Acute airway infection	Treat underlying cause
Green sputum			Old, retained secretions and	Airway clearance therapy
Brown sputum			infections	Airway clearance therapy
Red sputum			Old blood	Notify physician
Frothy secretions			Fresh blood	Treat underlying cause, such as congestive
			Pulmonary edema	heart failure
				Hyperinflation therapy
Abnormal Lung Parenchyma Indicators
Bronchial breath sounds			Atelectasis	Hyperinflation therapy, oxygen treatment
Dull percussion note			Infiltrates or effusion	Treat underlying cause
Opacity on chest radiograph			Fibrosis	No specific treatment
Restrictive pulmonary function			Consolidation	No specific, effective respiratory care treatment
test values
Depressed diaphragm on			Air trapping and hyperinflation	Treat underlying cause
radiograph
Abnormal Pleural Space Indicators
Hyperresonant percussion note			Pneumothorax	Evacuate air* and hyperinflation treatment
Dull percussion note			Pleural effusion	Evacuate fluid* and hyperinflation treatment
Abnormalities of Chest Shape and Motion
Paradoxical movement of the chest			Flail chest	Mechanical ventilation†
wall
Barrel chest			Air trapping (hyperinflation)	Treat underlying cause, such as asthma
Posterior and lateral curvature of			Kyphoscoliosis	Airway clearance therapy
spine
Arterial Blood Gases—Ventilatory
pH ↑, PaCO	↓,	↓	Acute alveolar hyperventilation	Treat underlying cause
2
pH N, PaCO	↓,	↓↓†	Chronic alveolar hyperventilation	Generally none
2

pH ↓, PaCO	↑,	↑	Acute ventilatory failure	Mechanical ventilation*
2

pH N, PaCO	↑,	↑↑	Chronic ventilatory failure	Low-flow oxygen, bronchial hygiene
2

Sudden Ventilatory Changes on Chronic Ventilatory Failure (CVF)
pH ↑, PaCO	↑,	↑↑, PaO ↓	Acute alveolar hyperventilation on	Treat underlying cause
2		2	CVF
pH ↓, PaCO ↑↑,		↑ PaO ↓	Acute ventilatory failure on CVF	Mechanical ventilation*
pH ↓, PaCO ↑↑,		↑ PaO ↓

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Metabolic

pH ↑, PaCO	N or ↑,	↑,		Metabolic alkalosis	Give potassium†—Hypokalemia
PaO2 N	2
PaO2 N

					Give chloride†—Hypochloremia
pH ↓, PaCO	N or ↓,	↓,		Metabolic acidosis	Give oxygen—Lactic acidosis
PaO2 ↓	2
PaO2 ↓
pH ↓, PaCO	N or ↓,	↓,		Metabolic acidosis	Give insulin*—Ketoacidosis
PaO2 N	2
PaO2 N
pH ↓, PaCO	N or ↓,	↓,		Metabolic acidosis	Renal therapy
PaO2 N	2
PaO2 N
Indication for Mechanical Ventilation
pH ↑, PaCO	↓,	↓, PaO	↓	Impending ventilatory failure	Mechanical ventilation
	2	2

pH ↓, PaCO	↑,	↑, PaO	↓	Ventilatory failure	Mechanical ventilation
	2	2

pH ↓, PaCO	↑,	↑, PaO	↓	Apnea	Mechanical ventilation
	2	2

Oxygenation Status
PaO2 <80 mm Hg				Mild hypoxemia	Oxygen therapy and treat underlying cause
PaO2 <60 mm Hg				Moderate hypoxemia
PaO2 <40 mm Hg				Severe hypoxemia
Oxygen Transport Status
↓ PaO2, anemia, ↓ cardiac output				Inadequate oxygen transport	Oxygen therapy and treat underlying cause

*These procedures should be performed only as ordered by the physician. It should be noted that some of the treatment options are not included in respiratory protocols and may not necessarily be administered by respiratory therapists.

†Significant.

Severity Assessment

The frequency at which a respiratory therapy modality is to be administered is just as important to quality cost-efficient care as the current selection of the respiratory therapy modality itself. Often the frequency of treatment must be upregulated or down-regulated on a shift-by-shift, hour-to-hour, minute-to-minute, or even (in life-threatening situations) second-to-second basis. Such frequency changes must be made in response to a severity assessment.

In a good TDP program, the well-seasoned respiratory therapist routinely and systematically documents many severity assessments throughout each working day. For the new practitioner, however, a predesigned Severity Assessment Rating Form may be used to enhance this important part of the assessment process. One excellent, semiquantitative method of accomplishing this is illustrated in Table 10.2. The clinical application of severity assessment using this scale is provided in the following case example:

TABLE 10.2

Respiratory Care Protocol Severity Assessment

Item	0 Points	1 Point	2 Points	3 Points	4 Points
Respiratory history	Negative for	Smoking history	Smoking history	Pulmonary	Severe or
	smoking or	<1 pack a	>1 pack a day	disease	exacerbation
	history not	day
	available
Surgery history	No surgery	General surgery	Lower abdominal	Thoracic or upper	Thoracic with lung
				abdominal	disease
Level of	Alert, oriented,	Disoriented,	Obtunded,	Obtunded	Comatose
consciousness	cooperative	follows	uncooperative
		commands
Level of activity	Ambulatory	Ambulatory with	Nonambulatory	Paraplegic	Quadriplegic
		assistance
Respiratory pattern	Normal rate 8–	Respiratory rate	Patient complains	Dyspnea, use of	Severe dyspnea, use
	20/min	20–25/min	of dyspnea	accessory	of accessory
				muscles,	muscles,
				prolonged	respiratory rate
				expiration	>25, and/or
					swallow
Breath sounds	Clear	Bilateral	Bilateral fine,	Bilateral	Absent and/or
		crackles	medium, or	wheezing; fine,	diminished
			coarse	medium, or	bilaterally and/or
			crackles	coarse crackles	severe wheezing;
					fine, medium, or
					coarse crackles
Cough	Strong,	Excessive	Excessive	Thick bronchial	Thick bronchial
	spontaneous,	bronchial	bronchial	secretions and	secretions but no
	nonproductive	secretions	secretions but	weak cough	cough
		and strong	weak cough
		cough
Chest radiograph	Clear	One lobe:	Same lung, two	One lobe in both	Both lungs, more than
		Infiltrates,	lobes:	lungs:	one lobe:
		atelectasis,	Infiltrates,	Infiltrates,	Infiltrates,
		consolidation,	atelectasis,	atelectasis,	atelectasis,
		or pleural	consolidation,	consolidation,	consolidation, or
		effusion	or pleural	or pleural	pleural effusion
			effusion	effusion
Arterial blood gases	Normal	Normal pH and	Normal pH and	Acute respiratory	Acute respiratory
and/or oxygen		PaCO2 but	PaCO2 but	alkalosis, PaO2	failure, PaO2 <80
saturation		PaO2 60–80	PaO2 40–60	<40 and/or	and/or SpO2 <80%
measured by		and/or SpO2	and/or SpO2	SpO2 80%–84%
pulse oximeter		91%–96%	85%–90%
(SpO2)		91%–96%	85%–90%
(SpO2)
Severity Index
Total Score		Severity		Treatment Frequency
		Assessment
1–5		Unremarkable		As needed
6–15		Mild		Two or three times a day
16–25		Moderate		Four times a day or as needed
>26		Severe		Two to four times a day and as needed;
				alert attending physician

Severity Assessment Case Example

A 67-year-old man arrived in the emergency department in respiratory distress. The patient was well known to the therapist-driven protocol (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 at the time of admission (0 points). He complained of dyspnea and was using his accessory muscles of inspiration (3 points). Auscultation revealed bilateral coarse crackles over both lung fields (3 points). His cough was weak and productive of thick gray sputum (3 points). A chest radiograph revealed pneumonia (consolidation) in the left lower lobe (3 points).

On room air his arterial blood gas values were pH 7.52, PaCO2 54, 41, and PaO2 52, suggesting an ABG-based

diagnosis of acute alveolar hyperventilation superimposed on chronic ventilatory failure (3 points).

Using the Severity Assessment Form shown in Table 10.2, the following treatment selection and administration frequency would be appropriate:

Total score: 17 (moderate)

Treatment selection: Chest physical therapy

Frequency of administration: Four times a day; and as needed

The Essential Cornerstones of a Successful Therapist-Driven Protocol Program

Although there are many “assess and treat” respiratory care protocols (now more appropriately called Assess, Treat, and Teach Protocols) used throughout the health care industry today, the following respiratory protocols provide the essential

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foundation of a successful TDP program3:

• Oxygen Therapy Protocol (Protocol 10.1, page 138)

Protocol 10.1

Oxygen Therapy Protocol1

1The AARC has developed protocols pertinent to the topic of Oxygen Therapy. These include: Oxygen Protocol, Oxygen Protocol Addendum for Pulmonary Thromboendarterectomy (PET), Oxygen Delivery Device Protocol, Oxygen to Treat Pneumothorax Protocol, and Oximetry Protocol.

• Airway Clearance Therapy Protocol (Protocol 10.2, page 140)

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Protocol 10.2

Airway Clearance Therapy Protocol2

2The AARC has developed protocols that are pertinent to the topic of Airway Clearance Therapy. These include Secretion Clearance Protocol, Secretion Clearance Device Selection Protocol, Cough Assist Protocol, and Airway Management Protocol for Artificial Airways. Other KHN Protocols cross-referenced here include Suctioning Protocol (not shown) and Aerosolized Medication Protocol (see Protocol 10.4).

• Lung Expansion Therapy Protocol (Protocol 10.3, page 142)

Protocol 10.3

Lung Expansion Therapy Protocol3 (Hyperinﬂation Therapy)

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3The AARC has developed protocols that are pertinent to the topic of Lung Expansion Therapy. These include Secretion Clearance Protocols Atelectasis Prophylaxis, Prophylactic Protocol Addendum for Post-Operative Laparotomy, Chest Trauma, and Rib Fracture, IPPB Protocol, Cough Assist Protocol, and Airway Management

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