Section III
The
Therapist-Driven Protocol Program—
The Essentials
Slide 1
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Chapter 9
The Therapist-Driven Protocol
Program and the Role of the
Respiratory Care Practitioner
Slide 2
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Therapist-Driven Protocols
(TDPs) Are an Integral Part of
Respiratory Care Health Services
Slide 3
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The Purpose of TDPs


Slide 4
Deliver individualized diagnostic and
therapeutic respiratory to patients
Assist the physician with evaluating patients’
respiratory care needs and to optimize the
allocation of respiratory care services
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The Purpose of TDPs
Slide 5

Determine the indications for respiratory
therapy and the appropriate modalities for
providing 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
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Respiratory TDPs
Give practitioner authority to:
Slide 6

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 momentto-moment basis
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The Innate Beauty of Respiratory
TDPs Is That:
1. The physician is always in the “information
loop” regarding patient care
2. Therapy can be quickly modified in response
to the specific and immediate needs of the
patient
Slide 7
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Clinical Research Verifies
These Facts
Respiratory TDPs
1. Significantly improve respiratory therapy
outcomes, and
2. Appreciably lower therapy costs
Slide 8
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Figure 9-1. The promise of a good TDP program.
Slide 9
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Figure 9-2. No Assessment Program in Place.
Slide 10
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The Knowledge Base Required for a
Successful TDP Program
The essential knowledge base includes the:
Slide 11

Anatomic alterations of the lungs

Pathophysiologic mechanisms activated

Clinical manifestations that develop

Treatment modalities used to correct the
problem
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Figure 9-3. Foundations for a strong TDP program. Overview of the
essential knowledge base for assessment of respiratory diseases.
Slide 12
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The Assessment Process Skills Required
for a Successful TDP Program
The practitioner must:
Slide 13

Systematically gather clinical information

Formulate an assessment

Select an optimal treatment

Document in a clear and precise manner
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Figure 9-4. The way knowledge, assessment, and a TDP program interface.
Slide 14
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Common Respiratory Assessments—
Excerpts (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
PaCO2
HCO3PaO2
Slide 15
7.24
73
27
53
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Severity Assessment
Slide 16
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Table 9-2. Respiratory Care Protocol
Severity Assessment—Excerpts
Item
0 point
1 point
2 points
3 points
4 points
Total Points
Breath sounds
Clear
Bilateral
crackles
Bilateral
crackles
& rhonchi
Bilateral
wheezing,
crackles &
rhonchi
Absent and/or
diminish
bilateral and/or
severe wheezing,
______
crackles, or
rhonchi
Cough
Slide 17
Strong,
spontaneous,
nonproductive
Excessive
bronchial
secretions &
strong cough
Excessive
bronchial
secretions but
weak cough
Thick
bronchial
secretions &
weak cough
Thick
bronchial
secretions but
no cough
______
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Severity Assessment Case Example
SEVERITY ASSESSMENT CASE EXAMPLE
A 67-YEAR-OLD-MALE 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).
USING 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
Slide 18
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The Top Four Respiratory Protocols
Slide 19

Oxygen therapy protocol

Bronchopulmonary hygiene therapy protocol

Hyperinflation therapy protocol

Aerosolized medication therapy protocol
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Common Respiratory Assessments
and Treatment Plans—Excerpts (see
Table 9-1)
Clinical Data
Assessment
Tx Plan
Wheezing
Bronchospasm
beta2 agent
Rhonchi &
Weak cough
Secretions in large airways
Poor ability to mobilize secretions
CPT
ABGs
Acute ventilatory failure
Mechanical ventilation
pH
Slide 20
7.24
PaCO2
73
HCO3-
27
PaO2
53
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Oxygen Therapy
Protocol 9-1
Slide 21
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Slide 22
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Slide 23
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Oxygen Therapy
Protocol 9-1—
Close-ups
Slide 24
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Slide 25
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Slide 26
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Slide 27
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Slide 28
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Common
Oxygen Therapy Selections
Slide 29

Nasal cannula

Oxygen mask

Venturi mask

Partial rebreathing mask

Nonrebreathing mask
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Bronchopulmonary
Hygiene Therapy
Protocol 9-2
Slide 30
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Slide 31
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Slide 32
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Bronchopulmonary Hygiene
Therapy Protocol 9-2—
Close-ups
Slide 33
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Slide 34
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Slide 35
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Slide 36
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Common Bronchopulmonary
Hygiene Therapy Selections
Slide 37

Increased fluid intake

Cough and deep breathe

Chest physical therapy

Suctioning

Bronchoscopy assist

Mucolytic aerosol
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Hyperinflation Therapy
Protocol 9-3
(Lung Expansion Protocol)
Slide 38
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Slide 39
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Slide 40
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Hyperinflation Therapy
Protocol 9-3
(Lung Expansion Protocol)—
Close-ups
Slide 41
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Slide 42
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Slide 43
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Slide 44
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Slide 45
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Common
Hyperinflation Therapy Selections
Slide 46

Cough and deep breathe

Incentive spirometry

IPPB

CPAP

PEEP
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Aerosolized Medication Therapy
Protocol 9-4
Slide 47
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Slide 48
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Slide 49
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Aerosolized Medication Therapy
Protocol 9-4—
Close-ups
Slide 50
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Slide 51
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Slide 52
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Slide 53
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Common Aerosolized Medication
Selections

Slide 54
Bronchodilator agents

Sympathomimetics

Parasympatholytics

Mucolytic agents

Antiinflammatory agents

Antibiotic agents
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Mechanical Ventilation
Protocol 9-5
Slide 55
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Slide 56
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Slide 57
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Mechanical Ventilation
Protocol 9-5—
Close-ups
Slide 58
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Slide 59
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Slide 60
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Slide 61
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Slide 62
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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

6 to 10 bpm
• to 10 bpm when SIMV mode is used
Slide 63
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Table 9-3. Common Ventilatory Management Strategies, cont.
Normal Lung Mechanics, cont.

Flow rate


I:E ratio


Slide 64
1:2
FIO2


60 to 80 L/min
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
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Table 9-3. Common Ventilatory Management Strategies, cont.
Disorder: Chronic Obstructive
Pulmonary Disease (COPD)

Disease characteristics



Slide 65
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 to12 bpm

A small tidal volume (8-10 ml/kg) and 8 to 10 bpm with
increased flow rates to allow adequate expiratory time
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Table 9-3. Common Ventilatory Management Strategies, cont.
COPD, cont.

Flow rate


I:E ratio


Low to moderate
General goals and/or concerns





Slide 66
1:2 or 1:3
FIO2


60 L/min
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
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Table 9-3. Common Ventilatory Management Strategies, cont.
Disorder: Acute Asthmatic Episode

Disease characteristics


Ventilator mode


Slide 67
High airway resistance
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 bpm

When air-trapping is extensive, a lower tidal volume
(5-6 ml/kg) and slower rate may be required
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Table 9-3. Common Ventilatory Management Strategies, cont.
Acute Asthmatic Episode, cont.

Flow rate


I:E ratio


Slide 68
1:2 or 1:3
FIO2


60 L/min
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
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Table 9-3. Common Ventilatory Management Strategies, cont.
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 bpm
Slide 69
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Table 9-3. Common Ventilatory Management Strategies, cont.
Acute Respiratory Distress
Syndrome, cont.

Flow rate


I:E ratio



Less than 0.6 if possible
General goals and/or concerns




Slide 70
1:1 or 1:2
Do what is necessary to meet a rapid respiratory rate
FIO2


60 to 80 L/min
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
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Table 9-3. Common Ventilatory Management Strategies, cont.
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 for PC
Tidal volume and respiratory rate

Good starting point: 10 to 12 ml/kg

Rate of 10 to 12 bpm
• However, larger tidal volumes (12-15 ml/kg) and slower rates
(6-10 bpm) may be used to maintain lung volume
Slide 71
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Table 9-3. Common Ventilatory Management Strategies, cont.
Postoperative Ventilatory Support,
cont.

Flow rate


I:E ratio


Low to moderate
General goals and/or concerns

Slide 72
1:2
FIO2


60 L/min
PEEP or CPAP of 3 to 5 cm H2O may be applied
to offset atelectasis
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Table 9-3. Common Ventilatory Management Strategies, cont.
Disorder: Neuromuscular Disorder

Disease characteristics



Slide 73
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 bpm
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Table 9-3. Common Ventilatory Management Strategies, cont.
Neuromuscular Disorder, cont.

Flow rate


I:E ratio


Low to moderate
General goals and/or concerns

Slide 74
1:2
FIO2


60 L/min
PEEP of 3 to 5 cm H2O may be applied to
offset atelectasis
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Overview Summary of a Good
TDP Program
Slide 75
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Figure 9-5. Overview of the essential components of a good TDP program.
Slide 76
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Figure 9-5. Close-up.
Slide 77
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Figure 9-5. Close-up.
Slide 78
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Figure 9-5. Overview of the essential components of a good TDP program.
Slide 79
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Figure 9-6
Respiratory Care Protocol
Program Assessment Form—
Excerpts
Slide 80
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Oxygen Therapy
Clinical Indicators

History

SpO2 <80%

PaO2 <60 mm Hg

Acute hypoxemia

↑ Respiratory rate

↑ Pulse

Cyanosis

Confusion
Figure 9-6. Respiratory care protocol program assessment form—Example Excerpts
Slide 81
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Respiratory Assessment
Examples

Mild hypoxemia

Moderate hypoxemia

Severe hypoxemia

Severity score: __________
Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.
Slide 82
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Treatment Plan
Oxygen Therapy
Examples:

Nasal cannula

Oxygen mask

28% Venturi mask
Frequency: _______________
Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.
Slide 83
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Common Anatomic Alterations
of the Lungs
Slide 84

Atelectasis

Alveolar consolidation

↑ Alveolar-capillary membrane thickness

Bronchospasm

Excessive bronchial secretions

Distal airway and alveolar weakening
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Box 9-2. Pathophysiologic
Mechanisms Commonly Activated
in Respiratory Disorders

Decreased V/Q ratio

Alveolar diffusion block

Decreased lung compliance

Stimulation of oxygen receptors

Deflation reflex

Irritant reflex

Pulmonary reflex

Increased airway resistance

Air-trapping and alveolar hyperinflation
(See clinical scenarios.)
Slide 85
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Clinical Scenarios
Activated by the Common Anatomic
Alterations of the Lungs
Slide 86
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Atelectasis
Clinical Scenario
Slide 87
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Figure 9-7. Atelectasis clinical scenario.
Slide 88
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Figure 9-7. Atelectasis—close-ups.
Slide 89
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Figure 9-7. Atelectasis clinical scenario—close-ups.
Slide 90
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Figure 9-7. Atelectasis clinical scenario—close-ups.
Slide 91
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Figure 9-7. Atelectasis clinical scenario—close-ups.
Slide 92
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Figure 9-7. Atelectasis clinical scenario—close-ups.
Slide 93
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Figure 9-7. Atelectasis clinical scenario.
Slide 94
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Alveolar Consolidation
Clinical Scenario
Slide 95
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Figure 9-8. Alveolar consolidation clinical scenario.
Slide 96
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Figure 9-8. Alveolar consolidation clinical scenario (e.g., pneumonia)—close-ups.
Slide 97
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Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
Slide 98
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Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
Slide 99
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Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
Slide 100
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Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
Slide 101
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Figure 9-8. Alveolar consolidation clinical scenario.
Slide 102
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Increased Alveolar-Capillary
Membrane Thickness
Clinical Scenario
Slide 103
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
Slide 104
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario (e.g., ARDS)—close-ups.
Slide 105
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
Slide 106
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
Slide 107
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
Slide 108
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
Slide 109
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
Slide 110
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Bronchospasm
Clinical Scenario
Slide 111
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
Slide 112
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
Slide 113
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
Slide 114
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
Slide 115
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
Slide 116
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
Slide 117
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
Slide 118
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Excessive Bronchial Secretions
Clinical Scenario
Slide 119
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Figure 9-11. Excessive bronchial secretions clinical scenario.
Slide 120
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Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
Slide 121
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Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
Slide 122
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Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
Slide 123
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Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
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Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
Slide 125
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Figure 9-11. Excessive bronchial secretions clinical scenario.
Slide 126
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Distal Airway and
Alveolar Weakening
Clinical Scenario
Slide 127
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Fig. 9-12 Distal airway and alveolar weakening clinical scenario.
Slide 128
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Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
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Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
Slide 130
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Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
Slide 131
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Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
Slide 132
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Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
Slide 133
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Figure 9-12. Distal airway and alveolar weakening clinical scenario.
Slide 134
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Figure 9-13. A three-component model of a prototype airway.
A, Airway lumen; B, airway wall; C, supporting structure.
Slide 135
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