Guide To Respiratory

Care
Camille A. Matthew RRT, MPH
September 22, 2017
Table of Contents

 Oxygen Devices
 Aerosol Devices
 Respiratory Medications
 Miscellaneous Orders
 Invasive Ventilation
 Non-Invasive Ventilation
All Respiratory Interventions
Needs an Order!
Oxygen Devices
Oxymask

 Range from 1 - ≥15 L/min (25-90% FIO2)

 Does not provide a precise oxygen
concentration
 Order as a Simple Mask but must include
Goal SpO2 (see below)
 Keep O2 Sat: Above(Specify) or Below
(Specify)
Venturi Mask

 Range from 24-50% FIO2

 Precise FIO2 concentration
 Order as a Venturi Mask and must include
FIO2
Non-Rebreathing Mask

 Range from ≥10 L/min (60-80% FIO2)

 Oxygen concentration will depend on
minute ventilation
 Order as a Non-rebreather mask and must
include liter flow or Goal Spo2
Purpose of High Flow Nasal Cannula

 Ensure delivery of high inspired warm

humidified gas
 Provides higher delivered flow that can reduce
dead space, therefore decreasing WOB
 Ability to flush upper airway dead space of
CO2, therefore decreasing minute ventilation
Purpose of High Flow Nasal Cannula

 Meet or exceed the patient’s inspiratory

demand
 Alternative delivery for patients who may
not tolerate other devices
 Has the ability to deliver a precise oxygen
concentration in addition to liter flow
High Flow Nasal Cannula

Indications of HFNC Advantages of HFNC

 Patients with moderate  Increased patient comfort
levels of hypoxemic  Patient is able to eat, drink,
respiratory failure and speak
Delivery of High Flow Nasal Cannula

 Provides an adjustable range of FiO2 (0.21-

0.95)
 Delivers flow of 10-60 L/min
 Humidification via high-efficiency heated
humidifiers
 Prevent mucosal drying effects of the high gas flow
 Order as High Flow Nasal Cannula and
indicate FIO2 and Liter Flow
Aerosol Devices
Tracheostomy Mask (“Trach Collar”)

 Range from 24-100% FIO2

 Used for spontaneously breathing
tracheostomy patients
 Provides humidification
 Order as a tracheostomy mask and must
include FIO2
Aerosol Mask

 Range from 24-100% FIO2

 Recommended device for post extubation
patients but can also be used to provide
oxygen with additional humidification*
 Order as a aerosol mask and must include
FIO2
* Recommend using high flow nasal cannula at this point
Respiratory Medications
Frequently Ordered Respiratory Medications

 Nebulized Treatments  MDI via ventilator

 Atrovent  Atrovent
 Albuterol  Albuterol
 Xopenex (requires approval)  Symbicort
 Duoneb  Budesonide
 Mucomyst
 Budesonide
Respiratory Medications Frequency
Order of
Frequency
ADMINISTRATION TIMES
Q4 10:00 AM 2:00 PM 6:00 PM 10:00 PM 2:00 AM 6:00 AM

Q6 12:00 PM 6:00 PM 12:00 AM 6:00 AM

Q8 6:00 AM 2:00 PM 10:00 PM 6:00 AM

BID 10:00 AM 10:00 PM

TID 10:00 AM 2:00 PM 6:00 PM

QID 10:00 AM 2:00 PM 6:00 PM 10:00 PM

*Start of the treatment should be based on this timetable and not the current time*
Medication Orders

 Orders must include:

 Correct Dosage
 Route: Nebulization vs. Inline nebulization
(vent)
 Frequency
 First Dose: Include Now vs. As Scheduled
 Q4 – enter the time to start according to the
respiration medication frequency
Miscellaneous Orders
Peak Flow

 Asthmatic patients require a Peak Flow

order unless the patient is physically unable
to perform the task
 Order as PFT and select Peak Flow
 Peak flows should be ordered at least once
daily before and after their treatment
Bedside PFT

 In addition to peak flow, we have the

capability to perform the following:
 Vital Capacity (VC)
 Negative Inspiratory Force (NIF)
 Order as PFT and select either VC or NIF
Sputum Induction

 DOH recommends sputum induction to be

completed by 3 samples
 First one – early morning sample and then 8 hours
apart
 Patient must be on airborne isolation
 Order should only be for AFB culture
 Two orders are required
 AFB (lab)
 Sputum Induction (resp)
Arterial Blood Gas

 Respiratory draws only routine ABGs

 Two orders are required:
 Blood Gas (lab)
 ABG Draw (resp)
Mechanical Ventilation
Purpose of Mechanical Ventilation

 Ventilation
 to bring in fresh air for gas exchange into the
lungs and to allow the exhalation of air that
contains carbon dioxide
 Mechanical Ventilation
 Used for patients who are unable to sustain the
level of ventilation needed to maintain gas
exchange
Types of Ventilation

 Noninvasive Ventilation
 Provided through a mask or other type of non-invasive
interface
 Full face mask, nasal mask, nasal pillows, total face
mask
 BIPAP, CPAP
 Invasive Ventilation
 Provided through an artificial airway
 Oral or nasal endotracheal tubes, tracheostomy tubes
Noninvasive Positive Pressure
Ventilation (NIPPV)
Purpose of NIPPV

 Provides ventilation without the use of an artificial

airway
 Used to assist patients with obstructive sleep apnea
 Provides positive pressure through the upper
airway by various interfaces
 Nasal mask
 Full face mask
 Total face mask
 Nasal pillows
Clinical Benefits of NIPPV

 Acute care
 Reduces need for intubation
 Shortens hospital stay and in the ICU
 Reduces mortality
 Improves patient comfort
 Reduces incidence of nosocomial pneumonia
Clinical Benefits of NIPPV

 Chronic care
 Alleviates symptoms of chronic hypoventilation
(ex. COPD)
 Improves quality of sleep in OSA patients
 Prolongs survival
Indications of NIPPV

 Acute respiratory failure

 Acute or chronic respiratory insufficiency
 Acute hypercapnic exacerbations of COPD
 Difficulty weaning
 Sleep apnea syndrome
Contraindications of NIPPV

 Incapability of maintaining life-sustaining

ventilation/Apnea
 Unable to maintain a patent airway/clearance of
secretions
 At risk of aspiration
 History of allergy of hypersensitivity to mask material
 Facial trauma
 Epistaxis causing pulmonary aspiration of blood
 Hypotension
 Claustrophobia
Interfaces used for NIPPV
 Nasal Mask  Total Face Mask

 Full Face Mask

Modes of NIPPV

 Bi-level Positive Airway Pressure (BIPAP or S/T)

 Patient triggered, pressure targeted and flow or
time cycled
 Inspiratory Positive Airway Pressure (IPAP)
 Expiratory Positive Airway Pressure (EPAP)
 Note: IPAP – EPAP = Pressure Support (P/S)
 Continuous Positive Airway Pressure (CPAP)
Modes of NIPPV

 Average volume-assured pressure support

(AVAPS)
 Delivers target tidal volume by regulating the
pressure applied
 Time-cycled mandatory breaths and pressure-
supported spontaneous breaths
Order/Settings for NIPPV

 Bi-level Positive Airway Pressure (BIPAP or S/T)

 IPAP
 EPAP
 RR
 FIO2
 Continuous Positive Airway Pressure (CPAP)
 CPAP
 FIO2
Order/Settings for NIPPV

 Average volume-assured pressure support

(AVAPS)
 IPAP
 EPAP
 FIO2
 RR
 Tidal Volume
Monitoring of NIPPV

 Patients vitals signs

 HR, RR, B/P, SpO2
 Respiratory status
 ABG may be taken 1-2 hours after initiation
 Note: PaCO2 may take longer to decrease in patients with chronic
hypercapnia
 Monitor oxygenation and decrease in respiratory distress
 Improvement of patient comfort
 Decrease in RR
 Reduced inspiratory muscle activity
 Ventilator synchrony
Terminating NIPPV

 Criteria for switching to invasive ventilation

 Worsening pH and PaCO2
 Tachypnea
 Hemodynamic stability
 SpO2 <90%
 Decreased level of consciousness
 Inability to clear secretions
 Inability to tolerate interface
Weaning and Discontinuation of
NIPPV
 Patients condition has stabilized
 Acceptable vital signs
 Effective gas exchange
 No signs of respiratory distress
 Vitals: HR, RR, SpO2
 Reversal of the disease process that caused
acute respiratory failure
 Patient refusal and/or tolerance
Invasive Ventilation
Invasive Ventilation

 Full ventilatory support

 Commonly provided by using a ventilator mode that
gives a set volume or pressure whenever a breath is
delivered
 Patient is not required to assume any of the work of
breathing
 Partial ventilatory support
 Patient is required to assume some work of breathing
to maintain effective alveolar ventilation
Types of Breath Delivery

 Mandatory breaths
 Ventilator controls the timing or tidal volume
 Spontaneous breaths
 Patient controls the timing and the tidal volume
 Assisted breaths
 Characteristics of both mandatory and
spontaneous breaths
Modes of Ventilation
 Continuous Mandatory Ventilation (CMV)
 Provides mandatory breaths
 Can be patient triggered or time triggered
 Volume Control: volume is set therefore pressure will vary
 Pressure Control: pressure is set therefore volume will vary
 Synchronized Intermittent Mandatory Ventilation (SIMV) w/
Pressure Support
 Provides mandatory and spontaneous breaths
 Can be patient triggered or time triggered
 Between mandatory breaths, the patient breathes spontaneously
with the assistance of pressure support if provided.
 Volume Control or Pressure Control
Modes of Ventilation
 Continuous Positive Airway Pressure (CPAP)
 Used to assess patients readiness to wean off the
ventilator
 Patients breathe spontaneously with a set pressure
support
 Airway Pressure Release Ventilation (APRV)/Bi-level
 Intended for patients with ARDS
 Provides two levels of PEEP/CPAP and to allow
spontaneous breathing at both levels when the effort is
present
Main Ventilator Settings
 Respiratory Rate (f)
 Tidal Volume (VT)
 Variable during pressure control ventilation
 Usually set 6 to 12ml/kg of IBW
 Peak Inspiratory Flow (Vmax)
 Peak flow during inspiratory phase; determines how fast the tidal
volume is delivered to the patient
 Inspiratory Pressure (PI)
 Variable during volume control ventilation
 Inspiratory time (TI)
 Length of the inspiratory breath
Main Ventilator Settings
 Oxygen Concentration (FIO2)
 Positive End Expiratory Pressure (PEEP)
 Positive pressure at the end of exhalation
during either spontaneous breathing or
mechanical ventilation
 Pressure Support (PS or ∆Psupp)
 Used to overcome the work of breathing for
spontaneously breathing patients while on
CPAP or SIMV
Monitoring of Patient Data
 Respiratory Rate (f)
 Exhaled Tidal Volume (Vexh)
 Minute Ventilation (MV)
 Peak Inspiratory Pressure (PIP)
 Mean Airway Pressure
 I:E Ratio
 Oxygen Concentration (FIO2)
 Rapid Shallow Breathing Index (RSBI)
Orders/Settings for Mechanical Ventilation

 Volume AC (CMV)
 Tidal Volume, RR, FIO2, PEEP
 Pressure AC (PCV+ Assist)
 Pressure, PEEP, FIO2, RR
 SIMV (SIMV/PSupp)
 Tidal Volume, RR, FIO2, PEEP, Pressure Support
Orders/Settings for Mechanical Ventilation

 CPAP/PSupp (CPAP/Spont)
 Pressure Support, PEEP, FIO2
 Airway Pressure Release Ventilation
(APRV)
 Pressure High, Pressure Low, Time High, Time
Low, FIO2