Patient Data Evaluation and Recommendations

1. Patient Data Evaluation and Recommendations Recommend Procedures to Obtain Additional Data

2. The respiratory therapist often will make recommendations to others in order to improve the outcomes of care • You should demonstrate knowledge needed to recommend the following diagnostic procedures: • Radiographic and other imaging studies • Diagnostic bronchoscopy • Sputum Gram stain, culture, and sensitivities • Bronchoalveolar lavage • PFT • Lung Mechanics • ABG, pulse oximetry, transcutaneous monitoring • Capnography • Electrocardiogram • Hemodynamic monitoring • Sleep studies

3. NBRC Expectations • You have the knowledge to recommend needed diagnostic procedures for your patients.

4. Diagnostic Bronchoscopy Recommend whenever the need exists to: • Assess lesions of unknown etiology that appear on the chest X-ray film • Evaluate recurrent atelectasis or pulmonary infiltrates • Assess the patency of the upper airway • Investigate the source of hemoptysis • Evaluate unexplained cough, localized wheeze, or stridor • Follow up on suspicious or positive sputum cytology results • Obtain lower respiratory tract secretions, cell washings, or biopsies for cytologic or microbiologic assessment • Determine the location and extent of injury form toxic inhalation or aspiration • Evaluate problems associated with artificial airways – e.g., tube placement or tracheal damage • Facilitate endotracheal tube insertion during difficult intubations • Locate / clear mucus plugs causing lobar or segmental atelectasis • Remove abnormal endobronchial tissue by forceps, basket, or laser • Remove foreign bodies from the airway (although rigid bronchoscopy is preferred)

5. Recommend against performing diagnostic bronchoscopy in patients who: • Cannot be adequately oxygenated during the procedure due to severe refractory hypoxemia • Have a bleeding disorder that cannot be corrected • Have severe obstructive airway disease • Are hemodynamically unstable

6. Bronchoalveolar lavage • Indicated in patients with the following problems: • Nonresolving pneumonia • Unexplained lung infiltrates (interstitial and/or alveolar • Suspected alveolar hemorrhage • One of the best tools to diagnose bacterial ventilator-associated pneumonia (VAP) • Can be helpful in confirming a diagnosis of various lung cancers. • Only contraindication is predisposition for bleeding.

7. Sputum Gram Stain, Culture, And Sensitivity Recommend on any patient suspected of having a respiratory tract infection and for whom focused antibiotic therapy might be needed.

8. Pulmonary Function Testing • Monitor response to therapy • Screen for lung dysfunction • Quantify severity and prognosis associated with lung or chest wall disease • Assess potential pulmonary effects of environmental or occupational exposures • Assess the degree of pulmonary impairment for rehabilitation placement or disability claims • Evaluate and follow course of obstructive and restrictive lung disorders

9. Lung Mechanics (compliance / airway resistance) • Monitor patients during patient-ventilator system check • Detect trends in patients subject to rapid changes in lung “stiffness” • Detect trends in patients subject to rapid changes in airway caliber • Detect suspected overinflation (“beaking” on pressure-volume curve) • Determine optimum PEEP level • Assess response to bronchodilator therapy • Detect auto-PEEP

10. ABG If the goal is the most accurate evaluation of oxygenation, ventilation, and acid-base status, always recommend ABG analysis • ABG limitations: • Does not measure actual hemoglobin content and saturation • Does not reveal the presence of abnormal hemoglobins • Recommend hemoximetry (CO-oximetry) when • Patient scenario is smoke inhalation/CO poisoning • Need to calibrate pulse oximetry reading against actual arterial saturation

11. Pulse Oximetry • Pulse oximetry should never be substituted for ABG or hemoximetry when the clinical situation demands accurate assessment of blood oxygenation. • Recommend AGAINST reliance on pulse ox data: • for patients with poor peripheral perfusion • when there is a need to monitor for or warn of hyperoxemia (premature infant)

12. Transcutaneous monitoring • Traditionally reserved for infants and small children, however PtCO2 may be used on hemodynamically stable adults for continuous monitoring of ventilation when capnography is not available or impractical • Should never be recommended to assess oxygenation in emergencies due to long calibration and warm-up times.

13. Capnography Recommend when the need exists to: • Noninvasively monitor the effectiveness (PETCO2) and efficiency (PaCO2 - PETCO2) of ventilation, usually during mechanical ventilation • Monitor the severity of pulmonary disease and assess the response to therapies intended to lower physiologic deadspace and/or better match ventilation to perfusion (V/Q) • Determine endotracheal tube placement (tracheal vs. esophageal intubation) • Monitor levels of therapeutically administered CO2 gas • Measure CO2 production (to assess metabolic rate) • Provide graphic data useful in evaluating the ventilator-patient interface • AARC recommends against using capnography on all patients receiving mechanical ventilation • Simple colorimetric CO2 detectors are sufficient to help determine tube placement • End-tidal CO2 analysis should be confirmed with ABG

14. Electrocardiography Recommend obtaining a 12-lead ECG to: • Screen for heart disease (e.g. CAD, left ventricular hypertrophy) • Rule out heart disease in surgical patients • Evaluate patients with chest pain • Follow the progression of patients with CAD • Evaluate heart rhythm disorders (using rhythm strips)

15. Hemodynamic Monitoring • Noninvasive BP measurement • Monitor routinely on all patients • Invasive Hemodynamic Monitoring • Arterial Lines • To continuously monitor arterial pressure in unstable / hypotensive patients • To continuously monitor patients receiving vasoactive drugs • To obtain frequent ABGs to assess patients in respiratory failure or receiving mechanical ventilation • CVP • To monitor central venous pressure/right ventricular function in unstable or hypotensive patients • To provide volume resuscitation • To infuse drugs that can cause peripheral phlebitis • To provide a route for total parenteral nutrition (TPN) • To provide venous access in patients with poor peripheral veins

16. Pulmonary Artery Line (Swan-Ganz) • To identify the cause of various shock states • To identify the cause of pulmonary edema • To diagnose pulmonary hypertension • To diagnose valvular heart disease, intracardiac shunts, cardiac tomponade, and pulmonary embolus • To monitor and manage complicated myocardial infarction • To assess the hemodynamic response to therapies • To manage multiple organ failure and/or severe cardiac surgery • To manage hemodynamic instability after cardiac surgery • To optimize fluid and inotropic therapy • To measure tissue oxygenation and selected hemodynamic indices, including cardiac output • To perform arterial and ventricular pacing

17. Sleep Studies Recommend overnight oximetry to • Help identify patients with obstructive sleep apnea-hypopnea syndrome (SAHS) • Help assess SAHS patients’ response to therapy, such as CPAP • Identify whether serious desaturation occurs in COPD patients during sleep • Focus on patients with hypercapnia, erythrocytosis, and/or evidence of pulmonary hypertension

18. Recommend Polysomnography • For patients who complain of or exhibit signs or symptoms associated with sleep-disordered breathing. • Daytime somnolence and fatigue • Morning headaches • Pulmonary hypertension • Polycythemia • To help diagnose certain neurologic and movement disorders. • To assess the adequacy of sleep-related interventions • Titrating CPAP levels • Determining BiPAP levels

19. Specifically indicated in patients with: • COPD whose daytime PaO2 exceeds 55 torr and whose condition includes one or more of the following complications: • Pulmonary hypertension • Right heart failure • Polycythemia • Excessive daytime sleepiness • Chest wall or neuromuscular restrictive disorders and whose condition includes one or more of the following complications: • Chronic hypoventilation • Polycythemia • Pulmonary hypertension • Disturbed sleep • Morning headaches • Daytime somnolence • Fatigue • Disorders of respiratory control with chronic hypoventilation (datime PaCO2 >45 torr) or whose illness is complicated by: • Pulmonary hypertension • Disturbed sleep • Morning headaches • Daytime somnolence • Fatigue • Nocturnal cyclic brady or tachyarrthythmias, nocturnal AV conduction abnormalities, or ventricular ectopic beats that increase during sleep • Excessive daytime sleepiness or sleep maintenance insomnia • Snoring associated with observed apneas and/or excessive daytime sleepiness

20. Common Errors to Avoid on the Exam • Never recommend diagnostic bronchoscopy in patients who are hemodynamically unstable or cannot be adequately oxygenated during the procedure due to severe refractory hypoxemia • Never let pulse oximetry substitute for ABG analysis or hemoximetry when the clinical situation demands accurate assessment of blood oxygenation • Never use a capnograph to verify endotracheal tube placement when simpler methods (such as colorimetric CO2 detectors) are available • Never recommend or insert a radial arterial line when the Allen test indicates inadequate collateral circulation on that side

21. Exam Sure Bets • Always recommend a sputum Gram stain and culture and sensitivity on any patient suspected of having a respiratory tract infection. • To determine if a change in the dose or frequency of administration of an aerosolized bronchodilator is needed, always recommend pre-/post-bronchodilator spirometry • To assess the presence and severity of restrictive abnormalities, always recommend both TLC/FRC measurement and the diffusing capacity test (DLCO).

22. More Exam Sure Bets • Always recommend ABG analysis whenever the need exists to evaluate ventilation, acid-base balance, and/or oxygenation status. • Always recommend CO-oximetry for patients suspected of suffering smoke inhalation • Always recommend polysomnography for patients who complain of or exhibit signs or symptoms associated with sleep-disordered breathing, such as daytime somnolence, and fatigue.

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