Introduction

Therapist-driven protocols (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:

To further support the AARC’s purpose statement on TDPs, the American College of Chest Physicians (ACCP) defines respiratory therapy protocols as follows:

Respiratory TDPs provide the respiratory care practitioner with a wide-ranging flexibility to both assess and treat the patient—but only within preapproved and clearly defined boundaries outlined by the physician and/or the medical staff. In addition, respiratory TDPs give the practitioner specific authority to (1) gather clinical information related to the patient’s respiratory status, (2) make an assessment of the clinical data collected, and (3) start, increase, decrease, or discontinue certain respiratory therapies on a moment-to-moment, hour-to-hour, shift-by-shift, or day-to-day basis. The innate beauty of respiratory TDPs is that (1) the physician is always in the “information loop” regarding patient care and (2) therapy can be quickly modified in response to the specific and immediate needs of the patient. Numerous clinical research studies have verified these facts: Respiratory TDPs (1) significantly improve respiratory therapy outcomes and (2) appreciably lower therapy costs.

Unfortunately, the implementation of TDPs throughout the United States has been slow. In 2008 the AARC Protocol Implementation Committee conducted a survey to evaluate the barriers to protocol implementation. Over 450 respiratory managers responded to the survey. Despite the overwhelming evidence that protocols clearly improve outcomes and reduce cost, the survey showed that less than 50% of respiratory care was provided by protocols. About 75% of the respondents had at least one protocol in operation. The majority of the hospitals did not have a comprehensive program in place. According to the managers, the medical directors, managers of the department, nurses, and administrators were not perceived as barriers. The biggest barrier to the implementation of protocols was perceived to be the medical staff. The primary reason for the medical staff’s resistance was perceived to be that “staff therapists did not have the skills (e.g., assessment skills) to function under protocols.” The AARC Protocol Implementation Committee states that “[this] perception must change… .”*

The essential components of a good TDP program do not come easy. This is because a strong TDP program promises that the respiratory care practitioner, who is identified as “TDP safe and ready,” be qualified to (1) systematically collect the appropriate clinical data, (2) formulate a uniform and accurate assessment, and (3) select a uniform and optimal treatment within the limits set by the protocol (Figure 9-1). The converse, however, is also true: When the respiratory care practitioner is not “TDP safe and ready,” the collection of clinical data is not done at all or is incomplete. As a result, nonuniform or inaccurate assessments are made, resulting in nonuniform or inaccurate treatment selections (Figure 9-2). This inappropriate and ineffective type of respiratory therapy leads to the misallocation of care, the administration of unneeded care, and—most important—the nonprovision of needed patient care. The bottom line is poor-quality patient care and unnecessary costs. To be sure, the development and implementation of a strong TDP program require some fundamental knowledge, training, and practice, but the benefits are worth the price. The essential components of a good TDP program are discussed in the following paragraphs.

The “Knowledge Base” Required for a Successful Therapist-Driven Protocol Program

As shown in Figure 9-3, the essential knowledge base for a successful TDP program includes (1) the anatomic alterations of the lungs caused by common respiratory disorders, (2) the major pathophysiologic mechanisms activated throughout the respiratory and cardiac systems as a result of the anatomic alterations, (3) the common clinical manifestations that develop as a result of the activated pathophysiologic mechanisms, and (4) the treatment modalities used to correct them. In other words, the clinical manifestations demonstrated by the patient do not arbitrarily appear but are the result of anatomic lung alterations and pathophysiologic events.

Hence, it is essential that the respiratory practitioner know and understand that certain anatomic alterations of the lung will lead to specific—and often predictable—clinical manifestations. Each respiratory disease chapter presented in this textbook describes these four essential knowledge components necessary for TDP work. In the clinical setting this knowledge base enhances the assessment process essential to a good TDP program.

The “Assessment Process Skills” Required for a Successful Therapist-Driven Protocol Program

Using the knowledge base described above, the respiratory care practitioner must also be competent in performing the actual assessment process. This means that the practitioner can (1) quickly and systematically gather the clinical information demonstrated by the patient, (2) formulate an accurate assessment of the clinical data (i.e., identify the cause and severity of the problem), (3) select an optimal treatment modality, and (4) document this process quickly, clearly, and precisely. In the clinical setting, the practice—and mastery—of the assessment process is absolutely central and essential to the success of a good TDP program (Figure 9-4). In other words, immediately after the respiratory care practitioner identifies the appropriate clinical manifestations (clinical indicators), an assessment of the data must be performed, and a treatment plan must be formulated. For the most part the assessment is primarily directed at the anatomic alterations of the lungs that are causing the clinical indicators (e.g., bronchospasm) and the severity of the clinical indicators.

For example, an appropriate assessment for the clinical indicator of wheezing might be bronchospasm—the anatomic alteration of the lungs. If the practitioner assesses the cause of the wheezing correctly as bronchospasm, then the correct treatment selection would be a bronchodilator treatment from the Aerosolized Medication Therapy Protocol (see Protocol 9-4, page 122). If, however, the cause of the wheezing is correctly assessed to be excessive airway secretions, then the appropriate treatment plan would entail a specific treatment modality under the Bronchopulmonary Hygiene Therapy Protocol, such as cough and deep breathing or chest physical therapy (see Protocol 9-2, page 120).

Table 9-1 illustrates common clinical manifestations (i.e., clinical indicators), assessments, and treatment selections routinely made by the respiratory care practitioner.

TABLE 9-1

Clinical Manifestations, Assessments, and Treatment Selections Commonly Made by the Respiratory Care Practitioner

Clinical Data (indicators)	Assessments	Treatment Selections
Vital Signs
↑Breathing rate, ↑blood pressure, ↑pulse	Respiratory distress	Treat underlying cause
Abnormal Airway Indicators
Wheezing	Bronchospasm	Bronchodilator treatment
Inspiratory stridor	Laryngeal edema	Cool mist
Rhonchi	Secretions in large airways	Bronchial hygiene treatment
Crackles	Secretions in distal airways	Treat underlying cause—e.g., congestive heart failure (CHF)
		Hyperinflation treatment
Cough Effectiveness Indicators
Strong cough	Good ability to mobilize secretions	None
Weak cough	Poor ability to mobilize secretions	Bronchial hygiene treatment
Abnormal Secretion Indicators
Amount: >30 ml/24 hrs White and translucent sputum Yellow or opaque sputum Green sputum Brown sputum Red sputum Frothy secretions	Excessive bronchial secretions Normal sputum Acute airway infection Old, retained secretions and infections Old blood Fresh blood Pulmonary edema	Bronchial hygiene treatment None Treat underlying cause Bronchial hygiene treatment Bronchial hygiene treatment Notify physician Treat underlying cause—e.g., congestive heart failure (CHF) Hyperinflation treatment
Abnormal Lung Parenchyma Indicators
Bronchial breath sounds	Atelectasis	Hyperinflation treatment, oxygen treatment
Dull percussion note	Infiltrates or effusion	Treat underlying cause
Opacity on chest X-ray	Fibrosis	No specific treatment
Restrictive pulmonary function test values	Consolidation	No specific, effective respiratory care treatment
Depressed diaphragm on X-ray	Air trapping and hyperinflation	Treat underlying cause
Abnormal Pleural Space Indicators
Hyperresonant percussion note	Pneumothorax	Evacuate air* and hyperinflation treatment
Dull percussion note	Pleural effusion	Evacuate fluid* and hyperinflation treatment
Abnormalities of the Chest Shape and Motion
Paradoxical movement of the chest wall	Flail chest	Mechanical ventilation*
Barrel chest	Air trapping (hyperinflation)	Treat underlying cause—e.g., asthma
Posterior and lateral curvature of spine	Kyphoscoliosis	Bronchial hygiene treatment
Arterial Blood Gases—Ventilatory
pH↑, Paco2↓, ↓	Acute alveolar hyperventilation	Treat underlying cause
pH N, Paco2↓, ↓↓	Chronic alveolar hyperventilation	Generally none
pH↓, Paco2↑, ↑	Acute ventilatory failure	Mechanical ventilation*
pH N, Paco2↑, ↑↑	Chronic ventilatory failure	Low-flow oxygen, bronchial hygiene
Sudden Ventilatory Changes on Chronic Ventilatory Failure (CVF)
pH↑, Paco2↑, ↑↑, Pao2↓	Acute alveolar hyperventilation on CVF	Treat underlying cause
pH↓, Paco2↑↑, ↑ Pao2↓	Acute ventilatory failure on CVF	Mechanical ventilation*
Metabolic
pH↑, Paco2 N, or ↑, ↑, Pao2 N	Metabolic alkalosis	Give potassium*—Hypokalemia
		Give chloride*—Hypochloremia
pH↓, Paco2 N or ↓, ↓, Pao2↓	Metabolic acidosis	Give oxygen—Lactic acidosis
pH↓, Paco2 N or ↓, ↓, Pao2 N	Metabolic acidosis	Give insulin*—Ketoacidosis
pH↓, Paco2 N or ↓, ↓, Pao2 N	Metabolic acidosis	Renal therapy*
Indication for Mechanical Ventilation
pH↑, Paco2↓, ↓, Pao2↓	Impending ventilatory failure	Mechanical ventilation
pH↓, Paco2↑, ↑, Pao2↓	Ventilatory failure
pH↓, Paco2↑, ↑, Pao2↓	Apnea
Oxygenation Status
Pao2 < 80 mm Hg	Mild hypoxemia	Oxygen treatment and treat underlying cause
Pao2 < 60 mm Hg	Moderate hypoxemia
Pao2 < 40 mm Hg	Severe hypoxemia
Oxygen Transport Status
↓Pao2, anemia, ↓cardiac output	Inadequate oxygen transport	Oxygen treatment and treat underlying cause

^*These procedures should be performed only as ordered by the physician.

The Essential Cornerstone Respiratory Protocols for a Successful Therapist-Driven Protocol Program

Although there are many “assess and treat” respiratory care protocols used throughout the health-care industry today, the following respiratory protocol examples provide the “essential foundation” of a successful TDP program:

• Oxygen Therapy Protocol (Protocol 9-1)

• Bronchopulmonary Hygiene Therapy Protocol (Protocol 9-2)

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