Job of Respiratory Therapy * I. Select, Review, Obtain and Interpret Data SETTING: In any patient care setting, the respiratory care practitioner reviews existing clinical data and collects or recommends obtaining additional pertinent clinical data. The practitioner interprets all data to determine the appropriateness of the prescribed respiratory care plan, and participates in the development of the respiratory care plan. 8 11 8 27 A. Review existing data in the patient record: 1 1 1 3 1. Patient history [e.g., present illness, admission notes, respiratory care orders, progress notes] 2. Physical examination [e.g., vital signs, physical findings] 3. Pulmonary function and blood gas results 4. Radiological studies [e.g., x-rays of chest/upper airway, CT, MRI] 5. Monitoring data a. pulmonary mechanics [e.g., maximum inspiratory pressure, negative inspiratory force] b. respiratory monitoring [e.g., rate, tidal volume, minute volume, I:E ratio, inspiratory and expiratory pressure, flow, volume and pressure wave forms] c. lung compliance, airway resistance, work of breathing d. dead space to tidal volume ratio (V D /V T ) non-invasive monitoring [e.g., Capnography, pulse oximetry, transcutaneous O 2 /CO 2 ] 6. Results of cardiovascular monitoring, ECG, blood pressure, heart rate B. Collect and evaluate additional pertinent clinical information: 4 5 3 12 1. Assess patient s overall cardiopulmonary status by inspection to determine: a. general appearance, muscle wasting, venous distention, peripheral edema, diaphoresis, digital clubbing, cyanosis, capillary refill b. chest configuration, evidence of diaphragmatic movement, breathing pattern, accessory muscle activity, asymmetrical chest movement, intercostal and/or sternal retractions, nasal flaring, character of cough, amount and character of sputum 2. Assess patient s overall cardiopulmonary status by palpation to determine: a. heart rate, rhythm, force b. asymmetrical chest movements, tactile fremitus, crepitus, tenderness, secretions in the airway, tracheal deviation, endotracheal tube placement - 1 -
Job of Respiratory Therapy * 3. Assess patient s overall cardiopulmonary status by auscultation to determine presence of: a. breath sounds [e.g., normal, bilateral, increased, decreased, absent, unequal, rhonchi or crackles, wheezing, stridor, friction rub] b. heart sounds, dysrhythmias, murmurs, bruits c. blood pressure 4. Interview patient to determine: a. level of consciousness, orientation to time, place and person, emotional state, ability to cooperate b. presence of dyspnea and/or orthopnea, work of breathing, sputum production, exercise tolerance and activities of daily living 5. Review chest x-ray to determine: a. position of endotracheal or tracheostomy tube, evidence of endotracheal or tracheostomy tube cuff hyperinflation b. presence of, or changes in, pneumothorax or subcutaneous emphysema, other extra pulmonary air, consolidation and/or atelectasis, pulmonary infiltrates c. presence and position of foreign bodies d. position of, or changes in, hemidiaphragms, hyperinflation, pleural fluid, pulmonary edema, mediastinal shift, patency and size of major airways. 6. Review lateral neck x-ray to determine: a. presence or position of foreign bodies b. airway narrowing 7. Perform bedside procedures to determine: a. ECG, pulse oximetry, transcutaneous O 2 /CO 2 monitoring, capnography, mass spectrometry b. tidal volume, minute volume, I:E ratio c. blood gas analysis, P(A-a)O 2, alveolar ventilation, V D /V T, mixed venous sampling d. peak flow, maximum inspiratory pressure, maximum expiratory pressure, forced vital capacity, timed forced expiratory volumes [e.g., FEV 1 ], lung compliance, lung mechanics e. tracheal tube cuff pressure, volume 8. Interpret results of bedside procedures to determine: a. ECG, pulse oximetry, transcutaneous O 2 /CO 2 monitoring, capnography, mass spectrometry b. tidal volume, minute volume, I:E ratio c. blood gas analysis, P(A-a)O 2, alveolar ventilation, V D /V T,, mixed venous sampling - 2 -
Job of Respiratory Therapy * d. peak flow, maximum inspiratory pressure, maximum expiratory pressure, forced vital capacity, timed forced expiratory volumes [e.g., FEV 1 ], lung compliance, lung mechanics e. tracheal tube cuff pressure, volume C. Recommend the following procedures to obtain additional data: 0 1 1 2 1. -ray of chest and upper airway, CT scan, bronchoscopy, ventilation/perfusion lung scan, barium swallow 2. Spirometry before and/or after bronchodilator, maximum voluntary ventilation, diffusing capacity, functional residual capacity, flowvolume loops, body plethysmography, nitrogen washout distribution test, total lung capacity, CO 2 response curve, closing volume, airway resistance, bronchoprovocation, MIP/MEP 3. Blood gas analysis, insertion of arterial, umbilical and/or central venous, pulmonary artery monitoring lines 4. Lung compliance, airway resistance, lung mechanics, work of breathing 5. ECG, echocardiography, pulse oximetry, transcutaneous O 2 /CO 2 monitoring D. Perform and/or measure the following: 1 1 0 2 1. Pulmonary function tests 2. Pulse oximetry, transcutaneous O 2 /CO 2 monitoring 3. Arterial sampling and blood gas analysis, co-oximetry P(A-a)O 2 4. Ventilator pressure-volume and flow-volume loops, lung compliance E. Interpret results of the following: 0 1 1 2 1. Spirometry before and/or after bronchodilator, maximum voluntary ventilation, diffusing capacity, functional residual capacity, flowvolume loops, body plethysmography, nitrogen washout distribution test, total lung capacity, CO 2 response curve, closing volume, airway resistance, bronchoprovocation. 2. ECG, pulse oximetry, transcutaneous O 2 /CO 2 monitoring 3. Arterial sampling and blood gas analysis, P(A-a)O 2 4. Blood pressure and pulse 5. Ventilator pressure-volume and flow-volume loops, lung compliance F. Determine the appropriateness of the prescribed respiratory care plan and recommend modifications where indicated: 1 1 1 3 1. Analyze available data to determine pathophysiological state 2. Review planned therapy to establish therapeutic plan 3. Determine appropriateness of prescribed therapy and goals for identified pathophysiological state 4. Recommend changes in therapeutic plan (based on data) if indicated 5. Perform respiratory care quality assurance 6. Review interdisciplinary patient and family plan - 3 -
Job of Respiratory Therapy * II. G. Participate in development of respiratory care plans: 1 1 1 3 1. Case management 2. Protocol application 3. Disease management education 4. Programs to improve quality Select, Assemble and Check Equipment for Proper Function, Operation and Cleanliness SETTING: In any patient care setting, the respiratory care practitioner selects and assembles all equipment used in providing respiratory care. The practitioner checks all equipment and corrects malfunctions. 8 10 0 18 A. Selects and assembles the equipment to use; checks the equipment for proper functioning, identifies malfunctioning and does what necessary to correct it: 7 8 0 15 1. Oxygen administration devices: a. nasal cannula, mask, reservoir mask (partial rebreathing, nonrebreathing), face tents b. air entrainment devices, tracheostomy collar and T-piece, oxygen hoods and tents c. CPAP devices (mask and nasal) 2. Humidifiers [e.g., bubble, passover, cascade, wick, heat moisture exchanger] 3. Aerosol generators [e.g., pneumatic nebulizer, ultrasonic nebulizer, termal nebulizer] 4. Resuscitation devices [e.g., manual resuscitator (bag-valve), pneumatic (demand-valve), mouth-to-valve mask resuscitator] 5. Ventilators: a. pneumatic, electric, microprocessor b. high frequency c. non-invasive positive pressure 6. Artificial airways: a. airways: 1) oro- and nasopharyngeal airways 2) other airways [e.g., laryngeal mask airway (LMA) b. tubes: 1) oral, nasal 2) tracheostomy tubes 3) fenestrated cannula for tracheostomy c. intubation equipment [e.g., laryngoscope and blades] 7. Suctioning devices [e.g., suction catheters, specimen collectors, oropharyngeal suction devices] - 4 -
Job of Respiratory Therapy * 8. Gas delivery, metering, and clinical analyzing devices: a. regulators, reducing valves, connectors and flowmeters, air/oxygen blenders b. oxygen concentrators, air compressors c. gas cylinders, oxygen bulks 9. Devices for clinical gas analysis: a. capnograph, blood gas analyzer, and sampling devices b. transcutaneous O 2 /CO 2 monitor c. pulse oximetry 10. Incentive breathing devices 11. Environmental devices: a. Aerosol tent (croupete) b. halo 12. Positive expiratory pressure (PEP) devices 13. Ventilator circuits: a. IPPB b. Continuous mechanical ventilation c. Assemble of valves for: 1) CPAP, PEEP 2) H (IMV) 3) percutors and vibrators 14. Gauges and regulators 15. Cuff pressure manometers (ET/tracheal) 16. Flowmeters [e.g., Flow sensing devices (pneumotachometer), Wright respirometer] 17. Vacuum systems [e.g., pumps, regulators, collection bottles, pleural drainage devices] 18. Metered-dose inhalers (MDI), MDI spacers 19. Cleaning, disinfection and sterilization (autoclave, pasteurizator, washing and dryer machines) equipment B. Assure selected equipment cleanliness [e.g., select or determine appropriate agent and technique for disinfection and/or sterilization, perform procedures for disinfection and/or sterilization, monitor effectiveness of sterilization procedures] 0 1 0 1 C. Perform quality control procedures for: 1 1 0 2 1. Pulmonary function equipment 2. Ventilator volume/flow/pressure calibration 3. Gas delivery devices 4. Noninvasive monitors [e.g., transcutaneous] - 5 -
Job of Respiratory Therapy * III. Initiate, Conduct, and Modify Prescribed Therapeutic Procedures SETTING: In any patient care setting, the respiratory care practitioner initiates, conducts, and modifies prescribed therapeutic procedures to achieve the desired objectives. 16 22 17 55 A. Maintain records and communication: 1 2 2 5 1. Record therapy and results using conventional terminology as required in the health care setting and/or by regulatory agencies: a. specify therapy administered, date, time, frequency of therapy, medication, and ventilatory data b. note and interpret patient s response to therapy: 1) effects of therapy, adverse reactions, patient s subjective and attitudinal response to therapy 2) verify erroneous data 3) auscultatory findings, cough and sputum production, and characteristics 4) vital signs [e.g., heart rate, respiratory rate, blood pressure, body temperature] 5) pulse oximetry, heart rhythm, capnography 2. Communicate information regarding patient s clinical status to appropriate members of the health care team 3. Communicate information relevant to coordinating patient care and discharge planning [e.g., scheduling, avoiding conflicts, sequencing of therapies] 4. Communicate results of therapy and alter therapy per protocol(s) B. Explain planned therapy and goals to patient in understandable terms to achieve optimal therapeutic outcome and protect patient from nosocomial infection: 1 1 0 2 1. Counsel patient and family concerning smoking cessation, disease management education 2. Protect patient from nosocomial infection by adherence to infection control policies and procedures [e.g., universal/standard precautions, blood and body fluid precautions] C. Conduct therapeutic procedures to achieve maintenance of a patent airway including the care of artificial airways: 2 2 0 4 1. Insert oropharyngeal airways 2. Insert nasopharyngeal airways 3. Prepare endotracheal or tracheostomy tubes 4. Maintain proper cuff inflation, position of endotracheal or tracheostomy tube 5. Maintain adequate humidification 6. Extubate the patient 7. Properly position patient 8. Identify tube placement by available means [e.g., chest auscultation] - 6 -
Job of Respiratory Therapy * D. Conduct therapeutic procedures to achieve removal of bronchopulmonary secretions: 1 2 0 3 1. Administer postural drainage, perform percussion and/or vibration 2. Suction endotracheal and tracheostomy tubes, perform nasotracheal or orotracheal suctioning 3. Insert closed system suction catheter 4. Administer aerosol therapy, administer prescribed agents [e.g., bronchodilators, corticosteroids, saline, mucolytics] 5. Instruct and encourage bronchopulmonary hygiene techniques [e.g., coughing techniques, autogenic drainage, positive expiratory pressure device (PEP)] E. Conduct therapeutic procedures to achieve adequate spontaneous and artificial ventilation: 1 1 3 5 1. Instruct in proper breathing technique, instruct in inspiratory muscle training techniques, encourage deep breathing, instruct and monitor techniques of incentive spirometry 2. Select appropriate ventilator 3. Initiate and select the appropriate settings for high frequency ventilation 4. Initiate noninvasive mechanical ventilation (BIPAP-CPAP) 5. Initiate and adjust: a. continuous mechanical ventilation when parameters have not been specified and when parameters have been specified [e.g., select proper tidal volume and/or minute ventilation] b. IPPB therapy c. ventilator modes [e.g., A/C, SIMV, pressure support ventilation (PSV), pressure control ventilation (PCV)] 6. Administer prescribed bronchoactive agents [e.g., bronchodilators, corticosteriods, mucolytics] 7. Institute and modify weaning procedures F. Conduct therapeutic procedures to achieve adequate arterial and tissue oxygenation: 1 1 1 3 1. Initiate and adjust: a. CPAP, PEEP and noninvasive positive pressure b. combinations of ventilatory techniques [e.g., SIMV, PEEP, PS, PCV] 2. Position patient to minimize hyperemia 3. Administer oxygen (on or off ventilator) 4. Prevent procedure-associated hypoxemia [e.g., oxygenate before and after suctioning and equipment changes] - 7 -
Job of Respiratory Therapy * G. Evaluate and monitor patient s response to respiratory care: 1 4 2 7 1. Recommend and review chest x-ray 2. Recommend: a. electrolytes, total hematology, and/or blood chemistry analysis b. sputum culture 3. Perform: a. arterial puncture b. pulse oximetry c. perform spirometry/determine vital capacity, measure lung compliance and airway resistance, interpret airway graphics, measure peak flow 4. Calculate and interpret P(A-a)O 2, 5. Interpret arterial, capillary, and mixed venous blood gas analysis results 6. Obtain capillary blood gas sampling, and venipuncture 7. Obtain blood from arterial or pulmonary artery lines 8. Monitor pressure: a. monitor mean airway pressure, adjust and check alarm systems, measure tidal volume, respiratory rate, airway pressures, I:E ratio, and maximum inspiratory pressure b. monitor endotracheal or tracheostomy tube cuff pressure 9. Observe changes in sputum production and consistency, note patient s subjective response to therapy and mechanical ventilation 10. Measure F I O 2 and/or oxygen flow in liters 11. Auscultate chest and interpret changes in respiratory sounds H. Make necessary modifications in therapeutic procedures based on patient response: 3 3 4 10 1. Terminate treatment based on patient s response to therapy being administered 2. Modify treatment techniques: a. IPPB: 1) adjust sensitivity, flow, volume, pressure, F I O 2 2) adjust expiratory retard 3) change patient machine interface [e.g., mouthpiece, mask] b. incentive breathing devices [e.g., increase or decrease incentive goals] c. aerosol therapy: 1) instruct the patient on breathing patterns 2) change type of equipment, change aerosol output 3) change dilution of medication, adjust temperature of the aerosol - 8 -
Job of Respiratory Therapy * d. oxygen therapy: 1) change mode of administration, adjust flow, and F I O 2 2) set up or change an O 2 blender 3) set up an O 2 concentrator e. bronchial hygiene therapy [e.g., alter position of patient, alter duration of treatment and techniques, coordinate sequence of therapies, alter equipment used and PEP therapy] f. management of artificial airways: 1) verify endotracheal or tracheostomy tube position 2) change type of humidification equipment 3) initiate suctioning 4) inflate and deflate the cuff g. suctioning of bronchial fluids: 1) alter frequency and duration of suctioning 2) change size and type of catheter 3) regulate negative pressure 4) instill irrigating solutions h. mechanical ventilation: 1) adjust ventilator settings [e.g., tidal volume, F I O 2, inspiratory plateau, PEEP and CPAP levels, pressure support and pressure control levels, noninvasive positive pressure, alarm settings] 2) change patient breathing circuit, change type of ventilator 3) measure volume loss through thoracic tube (s) 4) change mechanical dead space i. weaning procedures I. Recommend modifications in the respiratory care plan based on the patient response: 1 2 2 5 1. Participate in respiratory functional rehabilitation in post-operative patients with thoracic deformities and chronic pathologies [e.g., asthma, COPD] 2. Change: a. F I O 2 and peak flow b. mechanical dead space c. ventilatory techniques [e.g., tidal volume, respiratory rate, ventilatory mode, inspiratory effort (sensitivity), PEEP/CPAP, main airway pressure, support pressure, inverse ratio ventilation, positive noninvasive pressure] d. weaning and extubation procedures e. medication for aerosol dose or concentration 3. Use or change artificial airway [e.g., endotracheal, tracheostomy tube] 4. Sedation and/or use of muscular relaxants - 9 -
Job of Respiratory Therapy * 5. Bronchopulmonary hygiene procedures [e.g., PEP, incentive spirometry, intrapulmonar ventilation-percussion, thorax physiotherapy] 6. Modify therapies based on patient response [e.g., duration of therapy and body position] J. Recommend the utilization of pharmacologic agents: 1 1 1 3 1. Bronchodilators [e.g., agonist Beta 2, anticholinergics, xantines, adrenergics] 2. Anti-inflammatory [e.g., steroids, disodic chromoglicate, sodic neodocromile] 3. Surfactants [e.g., survanta, exosurf] 4. Mucolytics [e.g., acetiycisteyne] K. Initiate, conduct, or modify respiratory care techniques in an emergency setting: 1 1 1 3 1. Participate with the cardiopulmonary team according to protocols: a. BCLS (Basic Cardiac Life Support) b. ACLS (Advances Cardiac Life Support) c. PALS (Pediatric Advanced Life Support) d. NRP (Neonatal Resuscitation Program) 2. Participate in patient transport: a. land b. intra-hospital L. Act as an assistant to the physician performing special procedures including: 1 1 0 2 1. Bronchoscopy 2. Transtracheal aspiration 3. Tracheostomy 4. Intubation M. Initiate and conduct pulmonary rehabilitation and home care within the prescription: equipment controls 1 1 1 3 1. Monitor patient care 2. Revise apnea monitors 3. Explain planned therapy and goals to patient in understandable terms to achieve optimal therapeutic outcome, counsel patient and family concerning smoking cessation and disease management 4. Use safety and infection control measurements 5. Modify respiratory care procedures for use in the home 6. Implement and monitor graded exercise program 7. Conduct patient education and disease management programs s 32 43 25 100 * Each new test form will include one 15-item pretest (e.g., 1A, 2A). - 10 -