1. The Therapist-Driven Protocol Program—The Essentials
Section III
The Therapist-Driven Protocol Program—The Essentials

2. Chapter 9
The Therapist-Driven Protocol Program and the Role of the Respiratory Care Practitioner

3. The days when a respiratory care practitioner was told what to do, and was expected to do it, almost irrespective of the outcomes, have long since past.

4. Today, in every accredited respiratory care program, students are routinely challenged with the following types of questions:
What signs and symptoms are manifested by the patient?
What respiratory care diagnostic procedures should be implemented?
What treatment modalities might be helpful?
How is the effectiveness of the therapy evaluated?
What should be done if the selected procedures and treatments do not work?

5. In fact, these types of questions are the very foundation of the modern day respiratory care education system—and, important—the very basis of the “case-based scenarios” tested in the NBRC advanced practitioner examination.

6. Fortunately, this fundamental therapeutic paradigm is readily transferable to the modern respiratory care practice in the form of therapist-driven protocols (TDPs).

7. The Purpose of TDPs
TDPs are an integral part of respiratory care health services. According to the American Association for Respiratory Care (AARC), the purposes of respiratory TDPs are to:
Deliver individualized diagnostic and therapeutic respiratory care to patients
Assist the physician with evaluating patients’ respiratory care needs and optimizing the allocation of respiratory care services

8. The Purpose of TDPs (Cont’d)
Determine the indications for respiratory therapy and the appropriate modalities for providing high-quality, cost-effective care that improves patient outcomes and decreases length of stay
Empower respiratory care practitioners to allocate care using sign- and symptom-based algorithms for respiratory treatment

9. Respiratory TDPs Give practitioner authority to:
Gather clinical information related to the patient’s respiratory status
Make an assessment of the clinical data collected
Start, increase, decrease, or discontinue certain respiratory therapies on a moment-to-moment basis

10. The Innate Beauty of Respiratory TDPs Is That:
The physician is always in the “information loop” regarding patient care
Therapy can be quickly modified in response to the specific and immediate needs of the patient

11. Clinical Research Verifies These Facts
Respiratory TDPs:
Significantly improve respiratory therapy outcomes
Appreciably lower therapy costs

12. Figure 9-1. The promise of a good TDP program.

13. Figure 9-2. No assessment program in place.
Figure 9-2. No assessment program in place.

14. The Knowledge Base Required for a Successful TDP Program
The essential knowledge base includes the:
Anatomic alterations of the lungs
Pathophysiologic mechanisms activated
Clinical manifestations that develop
Treatment modalities used to correct the problem

15. Figure 9-3. Foundations for a strong TDP program
Figure 9-3. Foundations for a strong TDP program. Overview of the essential knowledge base for assessment of respiratory diseases.

16. The Assessment Process Skills Required for a Successful TDP Program
The practitioner must:
Systematically gather clinical information
Formulate an assessment
Select an optimal treatment
Document in a clear and precise manner

17. Figure 9-4. The way knowledge, assessment, and a TDP program interface.

18. Common Respiratory Assessments— (see Table 9-1)
Clinical Data Assessment
Wheezing Bronchospasm
Rhonchi Secretions in large airways
Weak cough Poor ability to mobilize secretions
ABGs Acute ventilatory failure
pH 7.24
PaCO2 73
HCO3 27
PaO2 53

19. Common Respiratory Assessments and Treatment Plans—(see Table 9-1)
Clinical Data Assessment Tx Plan
Wheezing Bronchospasm beta2 agent
Rhonchi and Secretions in large airways weak cough Poor ability to mobilize secretions CPT
ABGs Acute ventilatory failure Mechanical ventilation
pH 7.24
PaCO2 73
HCO3 27
PaO2 53

20. Severity Assessment

21. Respiratory Care Protocol Severity Assessment—(see Table 9-2)
Item 0 point 1 point 2 points 3 points 4 points Total Points
Breath sounds Clear Bilateral Bilateral Bilateral Absent and/or —
crackles crackles wheezing, diminished
and rhonchi crackles and bilateral and/or
rhonchi severe wheezing,
crackles, or
rhonchi
Cough Strong, Excessive Excessive Thick Thick —
spontaneous, bronchial bronchial bronchial bronchial
nonproductive secretions and secretions but secretions and secretions but
strong cough weak cough weak cough no cough

22. Severity Assessment Case Example
A 67-YEAR-OLD MAN ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS WELL KNOWN TO THE 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 (0 POINTS). HE COMPLAINED OF DYSPNEA AND WAS USING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS). AUSCULTATION REVEALED BILATERAL RHONCHI OVER BOTH LUNG FIELDS (3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK GRAY SECRETIONS (3 POINTS). A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE LEFT LOWER LUNG LOBE (3 POINTS). ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, PaCO2 54, HCO3− 41, AND PaO2 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY FAILURE (3 POINTS).
ACCORDING TO THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE:
TOTAL SCORE: 17
TREATMENT SELECTION: CHEST PHYSICAL THERAPY
FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDED

23. The Essential Cornerstone Respiratory Protocols for a Successful TDP Program
Oxygen Therapy Protocol
Bronchial Hygiene Therapy Protocol
Lung Expansion Therapy Protocol
Aerosolized Medication Therapy Protocol
Ventilator Management Protocol
Mechanical Ventilation Weaning Protocol

24. Unnumbered Figure 9-1.

25. Unnumbered Figure 9-2.

26. Unnumbered Figure 9-3.

27. Unnumbered Figure 9-4.

28. Unnumbered Figure 9-5.

29. Unnumbered Figure 9-6P1.

30. Unnumbered Figure 9-6P2. 30

31. Unnumbered Figure 9-6P3. 31

32. Unnumbered Figure 9-6P4. 32

33. Unnumbered Figure 9-6P5. 33

34. Unnumbered Figure 9-6P6. 34

35. Unnumbered Figure 9-6P7. 35

36. Unnumbered Figure 9-7P1.

37. Unnumbered Figure 9-7P2. 37

38. Unnumbered Figure 9-7P3. 38

39. Unnumbered Figure 9-7P4. 39

40. Disorder: Normal Lung Mechanics but Patient Has Apnea
(see Table 9-3. Common Ventilatory Management Strategies)
Disorder: Normal Lung Mechanics but Patient Has Apnea
Disease characteristics
Normal compliance and airway resistance
Ventilator mode
Volume ventilation in the AC or SIMV mode
Or pressure ventilation—either PRVC or PC
Tidal volume and respiratory rate
10 to 12 mL/kg
10 to 12 breaths/min
6 to 10 breaths/min when SIMV mode is used

41. (see Table 9-3. Common Ventilatory Management Strategies)
Normal Lung Mechanics
Flow rate
60 to 80 L/min
I:E ratio
1:2
FIO2
Low to moderate
General goals and/or concerns
Care to ensure plateau pressure of 30 cm H2O or less
Smaller tidal volumes (<7 mL/kg) should be avoided because atelectasis can develop

42. Disorder: Chronic Obstructive Pulmonary Disease (COPD)
(see Table 9-3. Common Ventilatory Management Strategies)
Disorder: Chronic Obstructive Pulmonary Disease (COPD)
Disease characteristics
High lung compliance and high airway resistance
Ventilator mode
Volume ventilation in the AC or SIMV mode
Or pressure ventilation—either PRVC or PC
Noninvasive positive pressure ventilation (NPPV) is good alternative
Tidal volume and respiratory rate
Good starting point: 10 mL/kg and 10 to 12 breaths/min
A small tidal volume (8 to 10 mL/kg) and 8 to 10 breaths/min with increased flow rates to allow adequate expiratory time

43. (see Table 9-3. Common Ventilatory Management Strategies)
COPD (Cont’d)
Flow rate
60 L/min
I:E ratio
1:2 or 1:3
FIO2
Low to moderate
General goals and/or concerns
Air trapping and auto-PEEP can occur when expiratory time is too short
↑ Expiratory time to offset auto-PEEP
May ↑ inspiratory flow up to 100 L/min to ↑ expiratory time
May ↓ VT or rate to ↑ expiratory time
Do not overventilate COPD patients with chronically high PaCO2 levels

44. Disorder: Acute Asthmatic Episode
(see Table 9-3. Common Ventilatory Management Strategies)
Disorder: Acute Asthmatic Episode
Disease characteristics
High airway resistance
Ventilator mode
SIMV mode is recommended to offset air trapping
Tidal volume and respiratory rate
Good starting point: 8 to 10 mL/kg
Rate of 10 to 12 breaths/min
When air trapping is extensive, a lower tidal volume (5 to 6 mL/kg) and slower rate may be required

45. Acute Asthmatic Episode (Cont’d)
(see Table 9-3. Common Ventilatory Management Strategies)
Acute Asthmatic Episode (Cont’d)
Flow rate
60 L/min
I:E ratio
1:2 or 1:3
FIO2
Start at 100% and titrate downward per SpO2 and ABGs
General goals and/or concerns
In severe cases, the development of auto-PEEP may be inevitable.
With controlled ventilation, a small amount of PEEP to offset auto-PEEP may be cautiously applied.

46. Disorder: Acute Respiratory Distress Syndrome
(see Table 9-3. Common Ventilatory Management Strategies)
Disorder: Acute Respiratory Distress Syndrome
Disease characteristics
Diffuse, uneven alveolar injury
Ventilator mode
Volume ventilation in the AC or SIMV mode
Or pressure ventilation—PRVC or PC
Tidal volume and respiratory rate
Typically, started at low tidal volumes and higher rates
8 mL/kg and adjusted downward to 6 mL/kg; or 4 mL/kg
Respiratory rate as high as 35 breaths/min

47. Acute Respiratory Distress Syndrome (Cont’d)
(see Table 9-3. Common Ventilatory Management Strategies)
Acute Respiratory Distress Syndrome (Cont’d)
Flow rate
60 to 80 L/min
I:E ratio
1:1 or 1:2
Do what is necessary to meet a rapid respiratory rate
Fio2
Less than 0.6 if possible
General goals and/or concerns
Goal is to limit transpulmonary pressures
30 cm H2O or less if possible
PEEP is usually needed to prevent atelectasis
Permissive hypercapnia may be allowed

48. Disorder: Postoperative Ventilatory Support
(see Table 9-3. Common Ventilatory Management Strategies)
Disorder: Postoperative Ventilatory Support
Disease characteristics
Often normal compliance and airway resistance
Ventilator mode
SIMV with pressure support
Or AC volume ventilation
Or pressure ventilation—either PRVC or PC
Tidal volume and respiratory rate
Good starting point: 10 to 12 mL/kg
Rate of 10 to 12 breaths/min
However, larger tidal volumes (12 to 15 mL/kg) and slower rates (6 to 10 breaths/min) may be used to maintain lung volume.

49. Postoperative Ventilatory Support (Cont’d)
(see Table 9-3. Common Ventilatory Management Strategies)
Postoperative Ventilatory Support (Cont’d)
Flow rate
60 L/min
I:E ratio
1:2
FIO2
Low to moderate
General goals and/or concerns
PEEP or CPAP of 3 to 5 cm H2O may be applied to offset atelectasis.

50. Disorder: Neuromuscular Disorder
(see Table 9-3. Common Ventilatory Management Strategies)
Disorder: Neuromuscular Disorder
Disease characteristics
Normal compliance and airway resistance
Ventilator mode
Volume ventilation in the AC or SIMV mode
Or pressure ventilation—either PRVC or PC
Tidal volume and respiratory rate
Good starting point: 12 to 15 mL/kg
Rate of 10 to 12 breaths/min

51. Neuromuscular Disorder (Cont’d)
(see Table 9-3. Common Ventilatory Management Strategies)
Neuromuscular Disorder (Cont’d)
Flow rate
60 L/min
I:E ratio
1:2
FIO2
Low to moderate
General goals and/or concerns
PEEP of 3 to 5 cm H2O may be applied to offset atelectasis.

52. Ventilatory Management in Catastrophes

53. Figure 9-5. Iron lungs in gym
Figure 9-5. Iron lungs in gym. Iron lungs were in high demand during the polio epidemic of 1951 to 1953.

54. Three Tiers of Criteria—Excerpts
(See Box 9-2)
Tier 1: Do not offer AND withdraw ventilatory support for patients with any one of the following:
Respiratory failure requiring intubation with persistent hypotension
Failure to respond to mechanical ventilation and antibiotics after 72 hours
Laboratory or clinical evidence of four or more organ systems failing

55. Three Tiers of Criteria—Excerpts
(See Box 9-2) (Cont’d)
Tier 2: Do not offer AND withdraw ventilatory support from patients with respiratory failure requiring intubation with following conditions (in addition to those in tier 1):
Patients with pre-existing system compromise or failure, including:
Known congestive heart failure with ejection fraction <25%
Acute renal failure requiring hemodialysis
Severe chronic lung disease
Acquired immunodeficiency syndrome
Active malignancy with poor potential for survival

56. Three Tiers of Criteria—Excerpts
(See Box 9-2) (Cont’d)
Tier 3: Specific protocols to be agreed on by guideline development committee. Possibilities include:
Restriction of treatment based on disease-specific epidemiology and survival data for patient subgroups
Expansion of preexisting disease classes that will not be offered ventilatory support
Applying Sequential Organ Failure Assessment scoring to the triage process and establishing a cutoff score above which mechanical ventilation will not be offered

57. Overview Summary of a Good TDP Program

58. Figure 9-6. Overview of the essential components of a good therapist-driven protocol program.

59. Figure 9-7. Respiratory care protocol program assessment form.

60. Common Anatomic Alterations of the Lungs
Atelectasis
Alveolar consolidation
Increased alveolar-capillary membrane thickness
Bronchospasm
Excessive bronchial secretions
Distal airway and alveolar weakening

61. Clinical Scenarios Activated by the Common Anatomic Alterations of the Lungs

62. Figure 9-8. Atelectasis clinical scenario.

63. Figure 9-9. Alveolar consolidation clinical scenario
Figure 9-9. Alveolar consolidation clinical scenario. *Or increased when a fever is present.

64. Figure 9-10. Increased alveolar-capillary membrane thickness clinical scenario.

65. Figure 9-11. Bronchospasm clinical scenario.

66. Figure 9-12. Excessive bronchial secretions clinical scenario.

67. Rehabilitation Protocol is not covered in the text.
Figure Distal airway and alveolar weakening clinical scenario. The Pulmonary
Rehabilitation Protocol is not covered in the text.

68. Figure A three-component model of a prototype airway. A, Airway lumen; B, airway wall; C, supporting structure.