Chapter 11: Respiratory orders

respiratory care orders:

________rESPIRATORY tHERAPY protocol

________oxygen protocol

I.                   Respiratory Therapy Protocol

     A.         Initial assessment

1.                           heart rate, respiratory rate

2.                           hemoglobin/hematocrit

3.                           height/weight

4.                           blood pressure

5.                           albumin

6.                           FIO₂

7.                           breath sounds, sputum quality

8.                           x-ray findings. 

A.      Therapy

1.        Coughing - encouraged to promote airway clearance of mucus and fibrin

2.        Chest physiotherapy -  via percussion and vibrations, assists with bronchial drainage

3.        Positioning - patients are shaken and turned side to side every two hours to aid in secretion mobilization

4.        Early ambulation - allows adequate air exchange in lung regions that are normally hyperventilated while the patient is recumbent

5.        Airway suctioning- removes accumulated secretions that cannot be removed by spontaneous cough.  Patients should be hyperoxygenated with 100% oxygen prior to suctioning. This should not be continued for more than 15 seconds without further oxygenation.  Vagal stimulation and bradycardia are possible complications.

6.        Other methods to remove mucus include: bronchodilators, hypertonic saline, and aerosolized acetylcysteine (Mucomyst).  Mucomyst contains a thiol group that ruptures the disulfide bonds of mucus.  A standard 7 days Mucomyst regimen includes 5,000 to 10,000  U heparin with 3cc of normal saline nebulized every 4 hours, alternating with 5cc of 20% Mucomyst.  Baseline and daily PT/PTT values should be monitored for these patients.

II.   Oxygen protocol

This is used for patients who are not necessarily intubated, but who are receiving oxygen either via nasal canula or facemask. The patient is weaned as tolerated.   

III.  Mechanical Ventilation

              A.  Burned patients fall into two categories

 a.  Patients unlikely to be weaned, use Assist Control mode (AC)

i.                               A method of ventilation in which the ventilator delivers a preset number of breaths of a preset tidal volume.  Between these machine-initiated breaths, the patient may trigger spontaneous breaths.  When the ventilator senses the patient’s spontaneous respiratory effort, it delivers a breath of the preset tidal volume.  The patient cannot vary the volume of spontaneously initiated breaths.  The only work that the patient must perform is the negative inspiratory effort required to trigger the ventilator on the patient-initiated breathes.  The ventilator performs the rest of the work.[i]

ii.                            Used in patients with inhalational injuries, major burns with airway edema

b.     Patients likely to be weaned, use Synchronized Intermittent Mandatory Ventilation (SIMV)

i.                    A method of ventilation in which the ventilator delivers a preset number of breaths of a preset tidal volume.  Between these mandatory breaths, the patient may initiate spontaneous breaths.  The volume of the spontaneous breaths is dependent on the muscular respiratory effort that the patient is able to generate.   In SIMV, the ventilator delivers the mandatory breath simultaneously as it senses the patient’s negative inspiratory effort.  If the patient does not make a negative inspiratory effort within the timing window, the mandatory breath is delivered at the scheduled time.  The ventilator then resets to respond to the next inspiratory effort.

            B.    Initial Ventilator settings (Table I)

Table I:  Guidelines for Full Ventilatory Support

         C.  Extubation criteria

            There are a vide variety of extubation criteria:

A.    PaO₂/FIO₂ ratio greater than 250

B.    Negative inspiratory pressure greater than 30 cmH₂O[ii]

C.    Tidal volume at least 5-7 mg/kg

D.    Minute ventilation less than 10 l/min[iii]

E.    Vital capacity at least 15-20 ml/kg[iv]