PULMO FINALS REVIEWER

GENERAL EXERCISE TESTING SCHEMES ○ Men= 108.5 – (0.1636 x weight in

Kg) – (1.438 x exercise time in
❖ Constant Time Tests mins.) – (0.1928 x HR)
❖ Single Stage Tests Note: It is important to compute the client’s
❖ Discontinuous Tests VO2max to track the client’s improvement in
❖ Continuous Incremental Tests terms of Oxygen demands in the body and
Cardiac sufficiency. So we may be able to know if
WHAT IS VO2 MAX? we will maintain the pace of the exercise or bring
● It is the highest rate of whole-body it up to another level.
oxygen uptake achievable during exercise
SINGLE STAGE TEST CONSTANT TIME
that utilizes a large muscle mass.
TESTS
● Best overall measurement of
cardiovascular fitness and sets the upper ● Exercise at a ● Exercise at

limit to production of energy (ATP). constant work the highest

● The higher the result the better. rate for as long possible

● HRmax formula is HRmax = 205.8 – as possible work rate

(0.685 x client’s age) must round off to ● Careful for a given

the nearest whole number. selection of period of

steady state time.
● Sub-maximum
exercise level is
important to
allow test
completion in
approximately
8-12 mins

DISCONTINUOUS CONTINUOUS
TESTS INCREMENTAL
TESTS

● Exercise at ● Most
increasing commonly
work rates for used
constant time ● Employ stages
periods with that are 1-3
HOW TO DETERMINE VO2 MAX OF YOUR rests of 15 minutes long
CLIENT mins to 24 ● The increase
● Formulas: hours in workload
○ Women= 100.5 – (0.1636 x between between each
weight in Kg) – (1.438 x exercise exercise stage may
time in mins.) – (0.1928 x HR)
PULMO FINALS REVIEWER

periods vary, and a test can be

3-min stage is stopped at any Every three minutes,
required for time. keeps the speed steady
steady-state ● Commonly but increases the
measurement used in stress incline of the
s testing for treadmill by 3.5
cardiac percent.
diseases.
FORMULAS:
● HRmax formula is HRmax = 205.8 –
(0.685 x duration of exercise)
12-min walking test 2- or 6- min
variation of the
● HR= ((FinalHR-RestHR) X (50% or 70%
12-min walking test
of your desired target)) + RestHR.
● Requires that Less aggressive test

SPECIFIC PROTOCOLS the patient than 12 min. walking

● STANDARD BRUCE PROTOCOLS cover as much

● LOWER-LEVEL NAUGHTON distance as Should be done at the

PROTOCOL possible in a first few days of the

● 12-min walking test measured rehab program to

● 2- or 6- min variation of the 12-min level corridor, gauge if the patient

walking test resting only if can proceed in the

necessary succeeding tests.
STANDARD BRUCE LOWER-LEVEL
● If unable to
PROTOCOLS NAUGHTON
complete.
PROTOCOL

● Consists of Used for patients who

five 3-min require less physically
PROGRAM IMPLEMENTATION
stages demanding stress
● Staffing
beginning at testing.
○ Pulmonary rehabilitation is a
1.7 miles/hr
multidisciplinary endeavor
at 10% Shorter, lasting only
○ Team care is enhanced by
inclination. 12 minutes, and less
involving various health care
● Every three demanding of the
professionals in the planning,
minutes, heart muscle.
implementation, and evaluation
increases the
components of the program
incline by 2% An ECG machine is
○ Should be certified in BLS &
and the speed attached.
ACLS
by a set
● Facilities
amount, Begin by walking for
○ Must be wheelchair accessible
about 0.7 or four minutes at 2 mph
○ Should provide two separate
0.5 mph. The and no incline.
rooms for the program – one
PULMO FINALS REVIEWER

room for educational activities ○ Depending on available space,

and one room for physical equipment, and staff
reconditioning ○ To foster group identity,
○ Rooms should be spacious and interaction and support, small
comfortable with adequate group discussions are encouraged
lighting, ventilation and ○ Ideal: 3-10
temperature control ○ Comfortable class size,
○ Chair should be comfortable economically feasible
with good back support ● Equipment
○ Restrooms should be readily ○ Emergency oxygen
accessible ○ Bronchodilators
○ Preferably have PFT and ABG ○ Educational needs:
analysis capabilities ■ Blackboard or flipchart
○ Room for individualized ■ Powerpoint projector,
counseling is helpful screen, OHP
● Scheduling ■ Cassette or CD players
○ Open – ended ■ Videotape or DVD
■ Patient can attend player with monitor
rehabilitation at a ■ Slides, tapes, videos and
convenient time as long formal learning packages
as the facility is open and ○ Physical reconditioning needs:
staffed accordingly ■ Stationary bicycles
○ Closed format ■ Treadmills
■ 1-3 times hours/ day ■ Rowing machines
■ 1-3 days per week for ■ Upper extremity
8-16 weeks ergometers
○ Length of program often ■ Weights
depends on insurance coverage ■ Pulse oximeters
and expected reimbursement for ■ Inspiratory resistance
sessions attended breathing devices
○ Class times need to be scheduled EXERCISE TRAINING
when the largest number of ● Components of exercise prescription:
patients can attend ○ Type of exercise
○ Proper scheduling helps to ○ Frequency
encourage participation and ○ Intensity
removes potential stumbling ○ Duration
blocks, which could undermine TYPES OF EXERCISE
the rehabilitation process
Strengthening Aerobic Exercise
● Class Size
Exercise
○ Theoretically, 1 participant or 15
or more ● Aims to ● Aims to
improve the improve
PULMO FINALS REVIEWER

● Patients are taught 10- or 15- second

tone and cardiopulmon
pulse taking
function of ary fitness
● Each session begins with stretching and
select muscle through
warm- up or cool-down exercises
groups sustained
● The following are monitored:
● Isolated activity of
○ HR, BP, RR at rest, at the end of
muscle large muscle
exercise and 3 in after
movements groups;
○ Oxygen saturation as needed
are repeated intensity
● Main exercise should be continuous and
10 – 30 times, raising the
should involve large muscle groups (level
often against HR to a safe
walking, treadmill, cycle ergometer, stair
a resistance target range
climbing, swimming)
● Supplement O2 is given during exercise
EQUIPMENT & EXERCISES COMMONLY
USED
RESPIRATORY MUSCLE TRAINING
● Treadmill
● TYPES OF TRAINING:
● Cycle ergometer
○ INSPIRATORY RESISTIVE
● Stair climbing
BREATHING (IRB)
● Rowing
○ ISOCAPNIC HYPERPNEA
● Pulleys
■ Rapid deep breathing
● Swimming
into a circuit
● Light weights
maintaining end- tidal
● Arm ergometer
carbon dioxide level
within normal limits
INTENSITY
● RESPIRATORY MUSCLE
● Traditionally prescribed based on the HR
ENDURANCE TRAINING
or workload achieved by the baseline
■ Subject performs near-
exercise test
maximal breathing (rate
● Karvonen method:
and rhythm) for 15-30
○ An alternative means for
mins. 3-5 days/ week
calculating exercised target heart
rate
PROGRAM RESULTS
○ MHR- RHR = HRR
● Must be evaluated at the conclusion of
○ MHR – maximum heart rate
the program and periodically thereafter
achieved on the exercise test
● Must compare pre program to current
○ RHR – resting heart rate
patient status
○ HRR – heart rate range
● Outcome measures include:
● May also be selected based on the exercise
○ Exercise tolerance
test workload
○ Levels of dyspnea at rest & with
exertion
EXERCISE TRAINING IMPLEMENTATION
○ Quality of life
PULMO FINALS REVIEWER

EVALUATION OF REHABILITATION ○ Diaphragmatic fatigue and

PROGRAM OUTCOMES failure
● Patient’s achievement of goals ○ Exercise-induced muscle
● Patient satisfaction assessment contracture
● Hospitalization days ● Miscellaneous
● Comparative scores on pre-program and ○ Exercise- induced asthma
post-program tests of educational content ○ Hypoglycemia
presented ○ Dehydration
● Frequency and duration of respiratory BENEFITS
exacerbations ● Increased physical energy and endurance
● Frequency of ER visits ○ Increased exercise capacity
● Return to productive employment ○ Increased ability to do ADLs
● Changes in exercise tolerance ● Decreased anxiety and depression
● Before and after 6- or 12- minute walking ● Improved quality of life
distance ● Decreased respiratory symptoms
● Before and after pulmonary exercise ● Decreased hospital days
stress test ● Decreased mortality
● Review of patient home exercise logs
● Strength measurements PATIENT & FAMILY EDUCATION
● Flexibility and posture ● FACTORS INFLUENCING LEARNING
● Performance on specific exercises ○ Acceptance of diagnosis
● Changes in symptoms ○ Motivation and perceived need
● Dyspnea measurement comparison to learn
● Frequency of cough, sputum production ○ Physical energy level
or wheezing ○ Patient- professional relationship
● Weight loss or gain ○ Cognitive functional level
● Psychological test instruments ○ Health benefits and values
● ADL changes ○ Level of emotional stability
● Postprogram follow-up questionnaires ● TEACHING TECHNIQUES USED
○ Lecture or panel presentation to
POTENTIAL HAZARDS group
● Cardiovascular abnormalities ○ Individualized family-patient
○ Cardiac arrhythmias education sessions
○ Systemic hypotension and ○ Demonstration of skills, practice
hypertension and RD
● Blood gas abnormalities ○ Group/ family discussion
○ Arterial desaturation ○ Reading or written assignments
○ Hypercapnia ● CONTENT OF PULMO REHAB
○ Acidosis EDUCATION
● Muscular abnormalities ○ Respiratory anatomy and
○ Functional or structural physiology
abnormalities ○ Pathophysiology of COPD
PULMO FINALS REVIEWER

○ Breathing retraining:
○ Diaphragmatic breathing
○ Pursed lip breathing with
prolonged controlled exhalation
○ Relaxation of accessory muscles
○ Stress and relaxation
● CONTENT OF PULMO REHAB
EDUCATION
○ Medications
○ Energy conservation in ADLs
○ Bronchial hygiene measures
○ Smoking cessation
○ Nutrition
○ Oxygen therapy
○ Fluid management
○ Sexuality and Lund Disease
PULMO FINALS REVIEWER

CHEST TUBE THORACOSTOMY

the
CHEST TUBE INSERTION
hemithorax,
● Involves the surgical placement of a
or upon
hollow, flexible drainage tube into the
patient
chest.
refusal.
● Tube is placed between the ribs and into
the space between the inner lining and
HAZARDS AND COMPLICATIONS
the outer lining of the lung (pleural
● Malposition of tube
space).
● Re-expansion pulmonary edema
● Substances that may accumulate in the
● Infection
pleural spaces:
● Pneumonia
○ Air = pneumothorax
○ Pus = pyothorax/ empyema
SITES OF TUBE INSERTION
○ Blood = hemothorax
● Air (Pneumothorax) - 2nd or 3rd
○ Lymph = chylothorax
intercostal space
○ Serous fluid = pleural effusion
● Fluid, blood, pus (both air and fluid)- 4th
*Mentioned substances are also indications
to 7th intercostal space

REASONS FOR CTT

3 BASIC PRINCIPLES OF CTT
● Allow drainage of the problem substance
● Gravity - Causes air to flow from higher
● Restore normal intrapleural pressure
to lower level
● Permit lung expansion
● Positive Pressure - Positive pressure
● Promote adequate gas exchange
created by the air or fluid (>762 atm)will
seek to relieve itself to a lower pressure
CONTRAINDICATIONS
under the water (761 atm)
ABSOLUTE RELATIVE
● Suction - Subatmospheric pressure is

● Published ● Risk of bleeding reduced promoting air or fluid to move

guidelines due to from higher to lower pressure rapidly

state there are coagulopathies

no absolute or CHEST TUBE BOTTLE COMPONENTS

contraindicati anticoagulation ● Drainage collection chamber

ons for medications. ○ Receives fluid and air from chest

drainage via ● Multiple pleural cavity

tube adhesions ● Dry Suction

thoracostomy ● Emphysematous ○ A valve controls the amount of

except when a blebs negative pressure-no need for

lung is ● Scarring water in the suction control

completely chamber

adherent to ● Water Seal

the chest wall ○ Acts as one way valve

throughout ● Suction Control Chamber

PULMO FINALS REVIEWER
○ Amount of suction is regulated
by the depth of the water not the
amount of suction applied to the
system
TYPES OF UNDERWATER SEAL DRAINAGE
● 1 Bottle System Chest Drainage
○ Should be kept under the patient
○ The tube coming from the
patient must be kept under water
seal or else air will go inside the
thorax.
○ Can be also used as a waste
container for patients having
hemothorax, pleural effusion
and pyothorax.
○ For air removal (pneumothorax)
the water must be monitored
closely as it evaporates including
the air.
○ Disadvantage: Excessive
accumulation of fluid can cause
decreased function of the unit.
● 2 Bottle System
○ Same as your 1 bottle system
except that a trap bottle is
interposed between the drain
tube and the underwater seal
bottle.
○ Liquid or pus drains in the first
bottle while the 2nd bottle is
added to collect air exiting the
pleural space.
● 3 Bottle System
○ The 3rd bottle is called the
manometer bottle.
○ Added after your water seal
bottle.
○ Rarely used due to bulkiness.
IMPORTANT POINTS CONCERNING CHEST
TUBE DRAINAGE
● The water seal in the water seal bottle
fluctuates with changes in the pleural
pressure that occur in normal breathing
○ If no fluctuation is occurring in
the water – seal bottle,
obstruction of the tube is
suspected
● Chest tubes may become obstructed as a
result of blood clots or kinks in the tube
itself
○ Obstructed chest tubes may
result in a TENSION
PNEUMOTHORAX
● CHEST tube should be “stripped” or
“milked” every 1-2 hours accompanied
by compressing & releasing the tube
○ To ensure adequate drainage and
tube patency
○ Creates a sudden gush of suction
○ Keeps the tube clear of
obstruction caused by a blood
clot
● Occasional bubbling
○ Normal as it enters from the
pleural space
● Excessive or persistent bubbling
○ air leaks in the system
● Absence of bubbling
○ No air is being removed from
pleural space
○ Sign of patient’s improvement
○ Obstruction of the tube
● If an air leak is suspected, the chest
should be clamped to identify the source
of leak
● The drainage and collection bottles must
be kept at a level below the chest to
prevent backflow
● The glass tube MUST ALWAYS be
kept submerged under the water
PULMO FINALS REVIEWER

● Clamping of tube is required when ○ Increased amount of air entering

changing drainage bottles; must be done the patient’s pleural space from
with caution in patients with air leaks; a within the thorax.
tension pneumothorax may result ● Check if his vital signs are stable and act
● The whole system must be kept accordingly
AIRTIGHT with NO LEAKS round the ● Signs of respiratory distress,
connection subcutaneous emphysema, and vital signs
● If a suction source is connected to the are unstable. Therefore it is an
vent tube in the suction bottle, a negative EMERGENCY!
pressure (not to exceed -15cmH2o) is ○ Call for experienced help.
usually necessary ○ Offer the patient 100% oxygen
● After the lung re-expands, the chest tube and be prepared to give
should remain in place for another 1-2 respiratory support (positive
days. pressure ventilation) if necessary.
● After the tube is removed, the wound ○ Monitor his oxygenation by
should be covered with a sterile pulse oximetry and his blood
petroleum jelly dressing to prevent air pressure
from entering the pleural space.
WHAT TO DO IF A SUDDEN GUSH OF
MANAGEMENT AFTER INSERTION BLOOD APPEARS IN THE BOTTLE?
● A chest X-ray should be obtained after ● Check VS
insertion of a chest drain to ascertain its ○ If it is tachypneic, tachycardic,
position. and hypotensive (Bleeding and
○ Ideally the tip of the drain should must demand immediate action;
point toward the apex of the call physician and initiate oxygen
pleural space when draining therapy) the patient is on the
air from a pneumothorax and brink of shock.
toward the base when draining CRITERIA FOR CTT REMOVAL
liquid contents from the ● Vary according to the reason why the
pleural space. Previous concern chest drain was inserted in the first place:
of a drain lodged in a pulmonary ○ No air leak in the last 24 hours in
fissure is unfounded. pneumothorax.
● All connections should be secured with ○ No fresh bleeding in the last 24
adhesive tapes to prevent inadvertent hours in the hemothorax.
disconnection. ○ Fluid loss is <200 ml/day in
WHAT TO DO WHEN WATER-SEAL effusion.
BOTTLE UNDER SUCTION SUDDENLY ○ Clinical and radiological
BUBBLES FURIOUSLY? evidence of resolution of the
● Causes infection in empyema.
○ Disconnection of collecting
tubings or dislodgement of the
drain tube
PULMO FINALS REVIEWER
OXYGEN THERAPY
❖ For Home and Extended Care Facility
OXYGEN THERAPY
● Is the administration of oxygen at
concentrations greater than that in
ambient air (20.9%) with the intent of
treating or preventing the symptoms and
manifestations of hypoxia. Oxygen is a
medical gas and should only be dispensed
in accordance with all federal, state, and
local laws and regulations.
INDICATIONS
● Long-term oxygen therapy in the home
or alternate site health care facility is
normally indicated for the treatment of
hypoxemia.
● Laboratory Findings:
○ Documented hypoxemia
○ Adults, children, and infants >28
days old:
■ PaO2 ^55 torr or Sa02
<88% (room air)
● Pa02 of 56-59 torr or Sao2 <89% in
association with specific clinical
conditions
● Patients who do not qualify for O2
therapy at rest may qualify during
ambulation, sleep, or exercise if their
Sa02 falls below 89% during these specific
activities
● Oxygen therapy may be prescribed by the
attending physician for indications
outside of those noted above or in cases
where strong evidence may be lacking
(eg, cluster headaches) on the order and
discretion of the attending physician.
● Patients who are approaching the end of
life frequently exhibit dyspnea with or
without hypoxemia. Dyspnea in the
absence of hypoxemia can be treated with
techniques and drugs other than oxygen.
Oxygen may be tried in these patients at
1-3 liters per minute, to obtain subjective
relief of dyspnea.
CONTRAINDICATIONS
● No absolute contraindications to O2
therapy exist when indications are
present
PRECAUTIONS AND POSSIBLE
COMPLICATIONS
● In spontaneously breathing hypoxemic
patients with COPD, O2 therapy may
increase the PaCO2 (hypoventilation
caused by resp muscle fatigue)
● Problems may occur if the patient fails to
comply with the doctor's orders or
receives inadequate instruction
● Complications may result from use of
nasal cannula or transtracheal catheters
● Fire hazard
● Bacterial contamination associated with
certain nebulizers and humidifiers may
occur
● Physical hazards include unsecured
cylinders, ungrounded equipment, and
liquid oxygen burns
● Power or equipment failure can lead to an
inadequate oxygen supply
LIMITATION
● Oxygen therapy has only limited benefit
for the treatment of hypoxia due to
anemia and benefit may be limited when
circulatory disturbances (bradycardia and
hypovolemia) are present. Oxygen
therapy should not be used in lieu of but
in addition to mechanical ventilation
when ventilator support is indicated.
PULMO FINALS REVIEWER

ASSESSMENT OF NEED ○ Flow rate in liters/minute and/or

concentration
Initial assessment: Ongoing evaluation or
○ Frequency of use in hours/day
Need is determined by reassessment:
and minutes/hour (if applicable)
measurement of Additional measurements
○ Duration of need (up to a
inadequate blood of arterial blood gas
maximum of 12 months in the
oxygen tensions tensions and/or
home)
and/or saturations by saturations by invasive or
○ Diagnosis (severe primary lung
invasive or noninvasive methods may
disease, secondary conditions
noninvasive methods, be indicated whenever
related to lung disease and
and/or the presence of there is a change in
hypoxia, related conditions or
clinical indicators as clinical status that may be
symptoms that may improve
previously described. cardiopulmonary related.
with 02)
Once the need for Long
○ Laboratory evidence (arterial
term O2 therapy has been
blood gas [ABG] analysis or
documented, repeat
oximetry under the appropriate
arterial blood gasses or
testing conditions). Home care
oxygen saturation
companies cannot provide this
measurements are
testing.
unnecessary other than to
○ Additional medical
follow the course of the
documentation (no acceptable
disease, to assess changes
alternatives to home 0 2
in clinical status, or to
therapy).
facilitate changes in the
● Arterial blood 02 should be repeated after
oxygen prescription.
1 to 3 months to determine the need for
long-term 02 therapy
ASSESSMENT OUTCOME
● Supply Methods
● Outcome is determined by clinical and
○ Compressed O2 cylinders
physiologic assessment to establish
■ For either ambulation
adequacy of patient response to therapy.
(small cylinders)
OXYGEN THERAPY PRESCRIPTION
■ Backup to liquid or
● O2 therapy is by far the most common
concentrator supply
mode of respiratory care in post-acute
systems (H/K cylinders).
care settings.
○ Liquid O2 systems
● This high usage is based on the fact that
○ O2 concentrators
O2 therapy improves both survival and
● Delivery Methods
quality of life in selected patient groups,
○ Low flow device such as Nasal
especially those with advanced COPD.
cannula is most common for
● Must be based on documented
long term care
hypoxemia, as determined by either blood
○ High-flow device such as air
gas analysis or oximetry.
entrainment mask/venturi is
● Must include the following elements
PULMO FINALS REVIEWER

often used only when acute

exacerbation
○ O2 conserving devices that
decrease O2 use and costs such as
transtracheal catheter, reservoir
cannula, pulse-flow O2 delivery ● Thorpe Tube
system (detects inhalation and ○ Best Used in Bedside
gives O2).

VENTURI MASK
● Venturi Valves: O2% Delivery
● Blue- 24%
● White- 28%
● Orange- 31% TYPES OF THORPE TUBE FLOWMETER
● Yellow- 35% ● Uncompensated
● Red- 40% ○ Not recommended for medical
● Green- 60% (peak maximum) use as it delivers inaccurate flow
and increases risk for hypoxic
drive in COPD patients

TRANSTRACHEAL CATHETER
● Compensated
○ Most recommended for medical
use because of its accuracy.

RESERVOIR CANNULAS

COMMONLY USED O2 CYLINDER

● H Cylinder
○ Usually seen at bedside
accompanied with Thorpe tube

TYPES OF FLOWMETER flowmeter

● Bourdon Gauge ○ 3.14 L/psig Cylinder factor

○ Best Used for Transport ● E Cylinder

PULMO FINALS REVIEWER

○ Used during transport ○ Pa02 and/or S02 measurement

accompanied with Bourdon should be repeated when
Gauge Flowmeter indicated or to follow the disease
○ 0.28 L/psig Cylinder Factor course
○ Sa02 measurements also may
EXAMPLE: used to determine appropriate 02
● An E cylinder of O2 contains 1800 psig. If flow for ambulation, exercise, or
the respiratory therapist runs the cylinder sleep
at 4 L/min through a nasal cannula, how ● Equipment
long will it take for the cylinder? ○ All 02 equipment should be
checked at least daily by the
Formula: Min. Remaining in Cylinder = patient or caregiver for proper
Cylinder pressure x Cylinder factor/Flow function, prescribed flow, FI02,
Rate remaining liquid or gas content,
1800 x 0.28/4 = 126 min = 2.1 Hours and backup supply
○ During visits, the RRT should
reinforce proper
patient/caregiver practices and
ensure that equipment is being
maintained as per manufacturer's
recommendations
○ Liquid systems need to be
checked to ensure adequate
delivery
COMPRESSED O2 CYLINDERS
○ O2 concentrators should be
checked regularly to ensure at
least 85% 02 at 4 L/min

INFECTION CONTROL
● Under normal circumstances low-flow
oxygen systems without humidifiers do
not present a clinically important risk of
MONITORING
infection and need not be routinely
● Patient
replaced.
○ The patient/caregiver should
● High-flow systems that employ heated
routinely assess for changes in
humidifiers or aerosol generators,
status (Ex: use of dyspnea
particularly when applied to patients with
scales/diaries)
artificial airways, can be important
○ Patients should be
sources of infection and should be
visited/monitored at least
cleaned and disinfected on a regular basis,
monthly by credentialed
although there are no definitive studies
personnel
PULMO FINALS REVIEWER

regarding the frequency of tube changes

at home or in long-term care facilities
PULMO FINALS REVIEWER

DISCHARGE PLANNING FOR RESPIRATORY HAZARDS/COMPLICATIONS

CARE PATIENT ● Undesirable and/or unexpected outcomes
may occur if the patient is discharged
❖ From AARC Clinical Practice Guidelines prior to the full implementation of the
discharge plan. An undesirable and
PROCEDURE unexpected patient outcome may be a
● Development and implementation of a hazard or complication of the discharge
comprehensive plan for the safe discharge plan; however, not all undesirable
of the respiratory care patient from a outcomes can be attributed to the
health care facility and for continuing safe discharge planning process but may be a
and effective care at an alternate site. result of the natural course of the disease
● The discharge plan is the mechanism that or other factors beyond the control of the
guides a multidisciplinary effort to discharge planning process.
achieve the successful transfer of the
respiratory care patient from the health METHODS
care facility to an alternate site of care. 1) Discharge planning and implementation
Implementation of the discharge plan is should begin as early as possible.
used to assure the safety and efficacy of 2) The complexity of the plan is determined
the continuing care of the respiratory by the patient's medical condition, needs,
care patient and goals. Members of the discharge
● The discharge plan includes: planning team and their responsibilities
○ Evaluation of the patient for the should be identified and a coordinator
appropriateness of the discharge. specified. The steps in the planning
○ Determination of the optimal process are:
site of care and of patient-care a) Patient evaluation
resources. b) Other respiratory care and
○ Determination that financial equipment
resources are adequate. 3) The patient's physical and functional
ability and ADL
INDICATIONS CONTRAINDICATION
4) The patient and family's psychosocial
Discharge planning is There are no condition
indicated for all contraindications to the 5) The patient and family's desires for
respiratory care development of a medical and ventilator care
patients being discharge plan. 6) The goals of care from the perspective of
considered for the patient and family, the patient's
discharge or transfer physician, the health-care professionals
to alternative sites. who have and will be involved in the
The plan should be patient's care, and the bedside caregivers.
developed/implement ● Treatment of acute medical
ed as early as possible conditions
prior to transfer. ● Weaning
● Rehabilitation
PULMO FINALS REVIEWER

● assurance of optimal quality of goals and needs should be met in an

life optimal and cost-effective manner using
EVALUATION the resources available at the alternate
● The patient's medical condition site.
● The respiratory and ventilatory support ● Possible sites for the respiratory care
required patient include acute, intermediate, and
○ Mechanical ventilation (Type, long term care facilities, such as
method of application, and long-term acute, sub-acute,
duration) rehabilitation, skilled nursing facilities,
■ Positive-pressure, and home. The respiratory care patient
negative-pressure, or may transition among the sites according
other (eg, pneumatic to changing medical conditions.
belt, rocking bed, ● The site must be evaluated for available
diaphragm pacer) resources.
■ Invasive (via ● The chosen site must be capable of
tracheostomy) or operating, maintaining, and supporting
noninvasive (all methods the equipment required by the patient's
that do not include medical condition. This should include
tracheostomy) both respiratory and ancillary equipment
■ Continuous-requiring > and supplies as needed, such as the
or = 20 hours of ventilator, suction, oxygen, intravenous
ventilator assistance per therapy, nutritional therapy, and adaptive
day or non-continuous, equipment
which may be nocturnal PERSONNEL
only (requiring
THE STAFF OF THE FOR DISCHARGE
assistance only during
SELECTED TO THE HOME
hours of sleep)
HEALTH-CARE
FACILITY
OTHER RESPIRATORY CARE AND
EQUIPMENT Must clearly The ability of the

● Oxygen therapy (O2 cylinders, demonstrate and have caregivers to learn and

concentrators) documented (by the perform the required

● Aerosol therapy time of discharge) the care must be

● Airway clearance therapy competencies required evaluated.

● Monitoring and diagnostic procedures for the patient's The caregivers must

● Treatment for sleep-disordered breathing ventilator and clearly demonstrate

respiratory needs. and have documented

SITE EVALUATION FOR CONTINUING (by the time of

CARE Must be able to discharge) the

● The primary factors to be considered in provide other competencies required

site determination are the goals and needs health-care services as for caring for the

of the respiratory care patient. These may be indicated (eg; specific patient.
PULMO FINALS REVIEWER

5. Alternative emergency and contingency

occupational and Availability of
plans
physical therapy). caregivers (lay and
6. Plan for use, maintenance, and
professional) for each
troubleshooting of equipment
Must be adequate for 24- hour period must
7. Medication administration
24-hour coverage. be assured.
8. Method for ongoing assessment of
outcomes
9. Method to assess growth and
PHYSICAL ENVIRONMENT
development of pediatric patients
● Must be evaluated for safety and
10. Mechanism for communication among all
suitability. It should be free of fire, health,
members of healthcare team
and safety hazards; provide adequate
11. Follow-up (e.g., medical, respiratory care)
heating, cooling, and ventilation; provide
12. Plan for monitoring and appropriately
adequate electrical service; provide for
responding to changes in the patient's
patient access and mobility with adequate
medical condition
patient space (room to house medical and
13. Time frame for implementation
adaptive equipment) and storage
facilities.
RULE OF THUMB
● Education and training with clear
FINANCIAL RESOURCES
demonstration and documentation of
● Financial resources must be identified at
competencies must occur prior to
the beginning of the discharge process.
discharge and address key elements of
Lack of funding or inadequate funding
the plan of care
impacts the entire discharge plan and can
LIMITATIONS OF METHOD
determine the care site. It is essential to
● Patient's medical condition
determine sources and adequacy of funds
● Lack of availability of appropriate site
for alternate-site care, medical equipment
● Lack of financial and patient care
and supplies, the required medical
resources
personnel, any modifications necessary to
● Patient/family desires and cooperation
the environment, and ongoing medical
● Failure to identify all pertinent problems
care.
or needs (including problems stemming
from language or other barriers to
DEVELOPMENT OF THE
communication).
MULTIDISCIPLINARY PLAN OF CARE
BASED ON THE PATIENT'S NEEDS AND
ASSESSMENT OF NEED
GOALS
● All patients with a primary respiratory
1. Plan for integration into the community
diagnosis should be assessed for the need
2. Plan for patient self-care as appropriate
for a discharge plan.
3. Roles and responsibilities of team
members for daily care management
ASSESSMENT OUTCOMES
4. Documented mechanism for securing and
● No readmission due to discharge plan
training additional caregivers
failure
PULMO FINALS REVIEWER

● Satisfactory performance of all treatments ○ Case manager

and modalities by caregivers as instructed ○ Nutritionist
● The treatment's meeting the patient's ○ Representative of the alternate
needs/goals site
● The site's providing the necessary FREQUENCY
services ● The discharge planning process should be
● The equipment's meeting the patient's developed, reviewed, modified, and
needs implemented whenever the patient is
● Caregivers' ability to assess the patient, considered for transfer to an alternate
troubleshoot, and solve problems as they site.
arise
● The patient and family's satisfaction INFECTION CONTROL
● The presence of transmissible infection
REQUIREMENTS OF DISCHARGE and the presence of compromised
PLANNING immunity in the patient should be taken
● A written discharge plan that clearly into consideration when discharge
delineates planning is undertaken.
○ Educational materials, training ● Appropriate steps to protect patients,
aids and assessment tools caregiver, and family should be
○ Amount of time anticipated to incorporated into the plan of care,
complete the process and including provision for age-and
discharge the patient condition-specific immunizations.
○ Team member access to patient
and family for information
gathering and training
● Physical and financial support adequate to
implement the discharge plan
● Personnel - One member of the team
with particular expertise in respiratory
care should be designated to coordinate
the efforts of all team members.
○ Patient
○ Family and/or caregiver (lay or
professional)
○ Physician
○ Nurse
○ Respiratory care practitioner
○ Medical equipment provider
○ Social worker
○ Physical, occupational, and
speech therapist, as indicated by
patient condition
PULMO FINALS REVIEWER

RESPIRATORY HOMECARE PROGRAM ● Improve overall physiologic and

psychological function
RESPIRATORY CARE IN ALTERNATIVE ● Provides cost-effective medical care
SETTING ● Provides environment to enhance
● Includes home care, which is the most individual potential
common alternative site for providing
healthcare, as well as post-acute care Why is it Important?
settings such as sub-acute, rehabilitation, ● Supports and maintains life
and skilled nursing facilities (SNFs). ● Improving patient’s physical, emotional,
and social well-being
SUB-ACUTE CARE ● Promotes patient and family
● Is a comprehensive level of inpatient self-sufficiency
care for stable patients who have ● Ensuring cost-effective delivery of care
experienced an acute event resulting from ● Maximizing patient comfort near the end
injury, illness, or exacerbation of a disease of life
process; have a determined course of HOMECARE PATIENTS
treatment, and require diagnostics or ● Acute and Chronic Bronchitis,
invasive procedures but not those Bronchiolitis
requiring acute care. It aims to restore the ● Stable and Unstable Asthma
whole patient back to the highest ● Acute and Resolving Pneumonia
practical level of function, ideally that of ● Restrictive Lung Disease
self- care. ● Sleep-disordered Breathing
● Requires goal-oriented ● COPD
interdisciplinary team care, with frequent ● Cystic Fibrosis
assessment of progress and a time-limited ● Lung Carcinoma
plan of care Respiratory Home Care has ● Acute Upper Respiratory Infections
been defined by AARC as those specific ● Airway Clearance Problems
forms of respiratory care provided in the ● Neuromuscular and other Ventilatory
patient ‘s place of residence by personnel insufficiency disorders
trained in respiratory care working under ● Infant Apnea and Apnea of Prematurity
medical supervision. BENEFITS
What is their Goal? ● Increased longevity
● Primary goal of home care is to ● Improved quality of life
provide quality healthcare services to ● Increased functional performance
clients in their home setting, thus ● Reduction in the individual and societal
minimizing their dependence on costs associated with hospitalization
institutional care. RULE OF THUMB
● Extend life ● Effective discharge planning provides the
● Enhance quality of life foundation for quality post acute care. A
● Reduce morbidity associated with the properly designed and implemented
disease discharge plan guides the
multidisciplinary team in successfully
PULMO FINALS REVIEWER

transferring the respiratory care patient ○ Evaluates patient and

from the healthcare facility to an recommends appropriate
alternative site of care. Effective respiratory care
implementation of the discharge plan also ○ provides care and follow-up
ensures the safety and efficacy of the accordingly
patient‘s continuing care. ● Nurse
○ Writes/implements nursing care
SERVICES RENDERED IN ALTERNATIVE plan for patient
SETTING ○ Assesses patient's status and
● Supplemental Oxygen provides necessary follow-up
● Assisted Ventilation ● Dietary/nutritionist
● Aerosol Therapy ○ Assesses the patient's nutritional
● Respiratory Monitoring needs and writes dietary plans
● Pulmonary Rehabilitation with for the patient.
patient/caregiver education ○ Make arrangements for meals as
may be necessary.
POST CARE TEAM ● Physical/Occupational Therapist
● Utilization reviewer ○ Provides necessary physical
○ Advises and/or recommends therapy and recommends any
consideration of patient additional modalities or
discharge. procedures.
○ Documents patient's in-hospital ● Psychiatrist/psychologist
care. ○ Assesses a patient's emotional
● Discharge planner (social service or status and provides any needed
community/public health) counseling or support.
○ Brings all the needed elements ● Supplier/home care company
together and ensures that a ○ Provides needed equipment and
patient can be discharged to a supplies and handles any
post acute care setting. emergency situations involving
○ Makes contacts with outside delivery or equipment operation
agencies that may assist with
patient care. SITE AND SUPPORT SERVICE EVALUATION
● Physician ● Goals and needs of the patient
○ Writes order for patient ○ Primary factors determining the
discharge. appropriate site for discharge
○ Evaluates the patient's condition ○ Should be met in an optimal and
and prescribes needed care. cost-effective manner using the
○ Establishes therapeutic resources available at the
objectives. proposed site
● Respiratory Therapist ● Caregivers
○ Learn and perform the required
care before transfer.
PULMO FINALS REVIEWER

○ Must clearly demonstrate and ○ Kitchen

have documented the ○ Carpeting
competencies required to care for ● EQUIPMENT
the specific patient and, in ○ Available space
combination, provide 24-hour ○ Electrical power supply
coverage ○ Amperage
● Durable Medical Equipment (DME) ○ Grounded outlets
Supplier ○ Presence of hazardous appliances
○ Provide equipment support and ● ENVIRONMENT
selected clinical from ○ Heating/ventilation
multimillion dollar national ○ Humidity
corporations offering a broad ○ Lighting
range of services, to small local ○ Living space
companies.
○ Usually provide the following
services:
■ 24-hour, 7 days-a-week
service
■ Third-party insurance
processing
■ Home instruction and
follow-up by an RRT
■ Most forms of
respiratory care
● The following should be considered:
○ company's accreditation status
○ Cost and scope of services
○ Dependability
○ Location
○ Personnel
○ Past track record
○ Availability

ASSESSING THE HOME ENVIRONMENT

● ACCESSIBILITY
○ In and out of home/apartment
○ Accessibility between rooms
○ Doorway width/threshold
heights
○ Stairways
○ Wheelchair mobility
○ Bathroom
PULMO FINALS REVIEWER

VENTILATORY SUPPORT IN ALTERNATIVE ● Profile 2

SETTING ○ Requires continuous mechanical
ventilatory support associated
KEY FACTORS with long-term survival rates
● Interdisciplinary team approach ○ Diseases:
● Effective caregiver and family education ■ Apneic encephalopathies
● Thorough assessment and preparation of ■ Severe COPD
the environment ■ Late-Stage muscular
● Careful selection of needed equipment dystrophy
and supplies ■ High spinal cord injuries
● Profile 3
PATIENT SELECTION ○ Usually returns home at request
● Patients unable to maintain adequate of patient and family
ventilation over prolonged periods ○ Patient's condition is terminal,
(noninvasive nocturnal or intermittent life expectancy is short, and
use in particular) patient and family wish to spend
● Patients requiring continuous mechanical remaining time at home
ventilation for long-term survival ○ Diseases:
● Patients who are terminally ill with short ■ Lung Cancer
life expectancies ■ End-stage COPD
■ Cystic Fibrosis
Profiles of Patient Groups Requiring
Ventilatory Support in Alternative Settings Criteria to Determine Patient Stability for
● Profile 1 Ventilatory Support in Alternative Settings
○ Mainly composed of 1. Absence of severe dyspnea while on a
neuromuscular and thoracic wall ventilator
disorder; particular stage of 2. Acceptable arterial blood gas results
disease process allows patient 3. Inspired oxygen concentrations that are
certain periods of spontaneous relatively low
breathing time during day; 4. Psychological stability
generally requires only nocturnal 5. Evidence of developmental progress (for
mechanical support pediatric /adolescent candidates)
○ Diseases: 6. Absence of life-limiting cardiac
■ Amyotrophic lateral dysfunction and arrhythmias
sclerosis 7. If possible, no PEEP or if needed, PEEP
■ Diaphragmatic paralysis should not exceed 10 cm H2O
■ Myasthenia gravis 8. Ability to clear airway secretions either
■ Multiple sclerosis by cough or suction
■ Kyphoscoliosis and 9. A tracheostomy tube as opposed to an
related chest wall endotracheal tube
deformities 10. No readmissions expected for more than
1 month
PULMO FINALS REVIEWER

2 MAJOR APPROACHES ● Standard 5

○ There shall be established
INVASIVE NON-INVASIVE
recording and reporting
SUPPORT SUPPORT
mechanisms for the program
Application of Positive and negative ● Standard 6
positive pressure pressure ventilation via ○ The quality and appropriateness
ventilation by an intact upper airway of care provided under the
tracheotomy or abdominal auspices of the program must be
displacement method. monitored and evaluated by the
program's medical director and

STANDARDS AND GUIDELINES: AARC identified problems must be

STUDENTS FOR THE PROVISION OF CARE resolved

TO VENTILATOR-ASSISTED PATIENTS IN
AN ALTERNATIVE SITE LONG-TERM INVASIVE MECHANICAL

● Standard 1 VENTILATION IN THE HOME

○ The provision of care to a (AARC Clinical Practice Guideline)

ventilator-assisted patient ● Goals of HIMV (Home Invasive Mech

located in an alternative site shall Vent)

be defined and guided by ○ To sustain and extend life

established written policies and ○ To enhance the quality of life

procedures accepted by both the ○ To reduce morbidity

discharging institution and the ○ To improve or sustain physical

alternative care site. and psychological function of all

● Standard 2 Ventilator Assisted Individuals

○ The services provided to and to enhance growth and

ventilator-assisted patients shall development in pediatric

be dispensed in accordance with ○ To provide cost-effective care

a prescription written by the

physician responsible for the care INDICATIONS

of that particular patient. ● Patients requiring invasive long-term

● Standard 3 ventilatory support have demonstrated:

○ Participants shall be prepared for ○ An inability to be completely

their responsibilities in the weaned from invasive ventilatory

provision of services through support

appropriate training and ○ A progression of disease etiology

education. that requires increasing

● Standard 4 ventilatory support

○ The ventilator-assisted patient ● Conditions that meet these criteria may

shall be provided with safe and include but are not limited to:

effective equipment appropriate ○ Ventilatory muscle disorders

for that patient's physiological ○ Alveolar hypoventilation

needs. syndrome
PULMO FINALS REVIEWER

○ Primary respiratory disorders ○ Natural course of the disease

○ Obstructive diseases ● Equipment-related
○ Restrictive diseases ○ Ventilator Failure/Machine
○ Cardiac disorders including failure
congenital anomalies ○ Inadequate warming, and
humidification of the inspired
CONTRAINDICATIONS gasses
● An unstable condition that requires a ○ Inadvertent changes in ventilator
level of care or resources not available in settings
the home, as indicated by (FIO2 ○ Accidental disconnection from
requirement > 40%, PEEP >10cmH2O, ventilator
Lack of mature tracheostomy, need for ○ Accidental decannulation
continuous invasive monitoring) ● Psychosocial
● Patient's choice not to receive home ○ Depression
mechanical ventilation ○ Anxiety
● Lack of an appropriate discharge plan ○ Loss of resources
● Unsafe physical environment as (financial/caregiver)
determined by the patient's discharge ○ Detrimental change in family
planning team structure or coping capacity
○ Presence of fire, health, or safety
hazards, including unsanitary ASSESSMENT OF OUTCOME
conditions ● Implementation and adherence to the
○ Inadequate basic utilities (such as plan of care
heat, air conditioning, electricity) ● Quality of Life
● Inadequate resources for care in the ● Patient satisfaction
home: ● Resource Utilization
○ Financial ● Growth and development in the pediatric
○ Personnel patient
● Change in Prognosis
HAZARDS AND COMPLICATIONS ● Unanticipated morbidity, including need
● Medical for higher level site of care
○ Respiratory Alkalosis ● Unanticipated mortality
○ Respiratory Acidosis
○ Hypoxemia Special Challenges in Providing Home
○ Barotrauma Ventilatory Support
○ Seizures ● Prerequisites
○ Hemodynamic Instability ○ Willingness of family to accept
○ Airway Complications responsibility
○ Respiratory Infection ○ Adequacy of family and
○ Bronchospasm professional support
○ Exacerbation of underlying ○ Overall viability of the home care
disease plan
PULMO FINALS REVIEWER

○ Stability of patient ● Chest physical therapy techniques,

○ Adequacy of home setting including percussion, vibration, coughing
○ Plus, assessment of home setting ● Medication administration, including
requisites oral and aerosol
● Planning ● Patient movement and ambulation
○ Basic steps in the discharge ● Equipment operation and maintenance
process for a ● Equipment troubleshooting
ventilator-dependent patient ● Cleaning and disinfection
include the following: ● Emergency procedures (ventilator power
1. Family is consulted regarding feasibility. failure/circuit problems, airway
2. Physician writes appropriate orders. emergencies and cardiac arrest)
3. Discharge planner coordinates efforts of ● All caregivers should successfully
team members and discharge plan is complete this educational process.
formulated. ● Training generally requires a minimum
4. Physicians and other team members of 1 to 2 weeks over which time several
discuss plans with family and/or education sessions can take place and
caregivers. cover instruction, demonstration,
5. Education and training are initiated and caregiver practice, and evaluation.
completed.
6. Patients and family are prepared for
INVASIVE NON-INVASIVE
discharge.
SUPPORT SUPPORT
7. Home layout is assessed with necessary
changes made. Long-term Involves any method

8. Equipment and supplies are readied. tracheostomy is designed to augment

9. Discharge planner meets with team and associated with many alveolar ventilation

makes final preparations serious complications without an

10. Patient is discharged (with a trial period, endotracheal airway.

if necessary). Permanent

11. Local power companies are notified tracheostomy poses Usually the first

regarding the presence of life support significant choice.

equipment; appropriate backup power communication

(battery or compressed gas source) is problems between

made available. caregivers and

12. Ongoing and follow-up care provided by patients.

visiting nurses, RRT, and other

healthcare professionals (as necessary). Many long-term care

CAREGIVER EDUCATION facilities treat a

● Simple patient assessment tracheostomy as an

● Airway management, including open wound, patient

tracheostomy and stoma care, cuff care, placement at certain

suctioning, changing tubes/ties sites is prohibited

PULMO FINALS REVIEWER

○ Patient’s condition and

Invasive ventilation
therapeutic needs
by tracheostomy
○ Level of family or caregiver
poses significant
support available
limits on the quality of
○ Type and complexity of home
life patients can
care equipments
experience
○ Overall home environment
○ Ability of patient to provide
OTHER MODES OF RESPIRATORY CARE IN
self-care
ALTERNATIVE SITES
○ Third-party reimbursement
● Bland Aerosol Therapy
● RT Functions During Visits
○ Includes the delivery of sterile
○ Patient Assessment (objective
water or various concentrations
and subjective data; pretreatment
of saline solutions in aerosol
and post treatment clinical
form
assessment)
○ Aerosol can be produced by USN
○ Patient’s compliance with
or LVN
prescribed respiratory home care
○ If using a jet nebulizer, a 50-psi
○ Equipment assessment
air compressor is also required
(operation, cleanliness, need for
○ May be intermittent or
related supplies)
continuous
○ Identification of any problem
○ Useful as an adjunct to airway
areas or patient concerns
clearance procedures in patients
○ Statement related to patient goals
who regularly produce large
and therapeutic plans.
amounts of sputum
○ Potential problem (Infection
from contaminated equipment)
● Aerosol Drug Administration
○ The aerosol route is popular for
drug administration to patients
in alternative cares settings
○ Drug categories commonly
administered through aerosol
route (beta-adrenergic,
anticholinergic, anti-inflammatory)
● AIRWAY CARE & CLEARANCE
METHODS
○ Daily stoma care
○ Tracheobronchial secretion
clearance
● Factors Relevant to the Frequency of
Home Visits