tdp review and application

Copyright © 2006 by Mosby, Inc.Slide 1

TDPTDPREVIEW and APPLICATIONREVIEW and APPLICATION


Therapist-Driven Protocols Therapist-Driven Protocols (TDPs) Are an Integral Part of (TDPs) Are an Integral Part of

Respiratory Care Health ServicesRespiratory Care Health Services


The Purpose of TDPsThe Purpose of TDPs

Deliver individualized diagnostic and Deliver individualized diagnostic and therapeutic respiratory to patientstherapeutic respiratory to patients

Assist the physician with evaluating patients’ Assist the physician with evaluating patients’ respiratory care needs and to optimize the respiratory care needs and to optimize the allocation of respiratory care servicesallocation of respiratory care services


The Purpose of TDPsThe Purpose of TDPs

Determine the indications for respiratory Determine the indications for respiratory therapy and the appropriate modalities for therapy and the appropriate modalities for providing quality, cost-effective care that providing quality, cost-effective care that improves patient outcomes and decreases improves patient outcomes and decreases length of staylength of stay

Empower respiratory care practitioners to Empower respiratory care practitioners to allocate care using sign- and symptom-based allocate care using sign- and symptom-based algorithms for respiratory treatmentalgorithms for respiratory treatment


Respiratory TDPsRespiratory TDPs

Give practitioner authority to:Give practitioner authority to:

Gather clinical information related to the Gather clinical information related to the patient’s respiratory statuspatient’s respiratory status

Make an assessment of the clinical data Make an assessment of the clinical data collectedcollected

Start, increase, decrease, or discontinue Start, increase, decrease, or discontinue certain respiratory therapies on a moment-certain respiratory therapies on a moment-to-moment basisto-moment basis


The Innate Beauty of Respiratory The Innate Beauty of Respiratory TDPs Is That:TDPs Is That:

1.1. The physician is always in the “information The physician is always in the “information loop” regarding patient careloop” regarding patient care

2.2. Therapy can be quickly modified in response Therapy can be quickly modified in response to the specific and immediate needs of the to the specific and immediate needs of the patientpatient


Clinical Research VerifiesClinical Research VerifiesThese FactsThese Facts

Respiratory TDPsRespiratory TDPs

1.1. Significantly improve respiratory therapy Significantly improve respiratory therapy outcomes, andoutcomes, and

2.2. Appreciably lower therapy costsAppreciably lower therapy costs


The Knowledge Base Required for a The Knowledge Base Required for a Successful TDP ProgramSuccessful TDP Program

The essential knowledge base includes the:The essential knowledge base includes the:

Anatomic alterations of the lungsAnatomic alterations of the lungs

Pathophysiologic mechanisms activatedPathophysiologic mechanisms activated

Clinical manifestations that developClinical manifestations that develop

Treatment modalities used to correct the Treatment modalities used to correct the problemproblem


The Assessment Process Skills Required The Assessment Process Skills Required for a Successful TDP Programfor a Successful TDP Program

The practitioner must: The practitioner must:

Systematically gather clinical informationSystematically gather clinical information

Formulate an assessmentFormulate an assessment

Select an optimal treatmentSelect an optimal treatment

Document in a clear and precise mannerDocument in a clear and precise manner


Figure 9-4. Figure 9-4. The way knowledge, assessment, and a TDP program interface.The way knowledge, assessment, and a TDP program interface.


Overview Summary of a Good Overview Summary of a Good TDP ProgramTDP Program


Figure 9-5. Figure 9-5. Overview of the essential components of a good TDP program.Overview of the essential components of a good TDP program.


Figure 9-5. Close-up.Figure 9-5. Close-up.


Figure 9-6Figure 9-6Respiratory Care Protocol Respiratory Care Protocol

Program Assessment Form— Program Assessment Form— ExcerptsExcerpts


Oxygen TherapyOxygen Therapy

Clinical IndicatorsClinical Indicators

HistoryHistory

SpSpOO22 <80% <80%

PaPaOO22 <60 mm Hg <60 mm Hg

Acute hypoxemiaAcute hypoxemia ↑ ↑ Respiratory rateRespiratory rate

↑ ↑ PulsePulse

CyanosisCyanosis

ConfusionConfusion

Figure 9-6. Respiratory care protocol program assessment formFigure 9-6. Respiratory care protocol program assessment form—Example Excerpts—Example Excerpts


Respiratory AssessmentRespiratory Assessment

ExamplesExamples

Mild hypoxemiaMild hypoxemia

Moderate hypoxemiaModerate hypoxemia

Severe hypoxemiaSevere hypoxemia

Severity score: __________Severity score: __________

Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.


Treatment PlanTreatment Plan

Oxygen TherapyOxygen Therapy

Examples:Examples:

Nasal cannulaNasal cannula

Oxygen maskOxygen mask

28% Venturi mask28% Venturi mask

Frequency: _______________Frequency: _______________

Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.


Common Anatomic AlterationsCommon Anatomic Alterationsof the Lungsof the Lungs

AtelectasisAtelectasis

Alveolar consolidationAlveolar consolidation

↑ ↑ Alveolar-capillary membrane thicknessAlveolar-capillary membrane thickness

BronchospasmBronchospasm

Excessive bronchial secretionsExcessive bronchial secretions

Distal airway and alveolar weakeningDistal airway and alveolar weakening


Box 9-2. PathophysiologicBox 9-2. PathophysiologicMechanisms Commonly Mechanisms Commonly

ActivatedActivatedin Respiratory Disordersin Respiratory Disorders

Decreased V/Q ratioDecreased V/Q ratio

Alveolar diffusion blockAlveolar diffusion block

Decreased lung complianceDecreased lung compliance

Stimulation of oxygen receptorsStimulation of oxygen receptors

Deflation reflexDeflation reflex

Irritant reflexIrritant reflex

Pulmonary reflexPulmonary reflex

Increased airway resistanceIncreased airway resistance

Air-trapping and alveolar hyperinflationAir-trapping and alveolar hyperinflation(See clinical scenarios.)(See clinical scenarios.)


Severity AssessmentSeverity Assessment


Table 9-2. Respiratory Care Protocol Table 9-2. Respiratory Care Protocol Severity Assessment—Severity Assessment—ExcerptsExcerpts

ItemItem 0 point0 point 1 point1 point 2 points2 points 3 points3 points 4 points4 points Total PointsTotal Points

Breath soundsBreath sounds ClearClear BilateralBilateral BilateralBilateral BilateralBilateral Absent and/orAbsent and/or ____________

cracklescrackles cracklescrackles wheezing,wheezing, diminishdiminish

& rhonchi& rhonchi crackles &crackles & bilateral and/orbilateral and/or

rhonchirhonchi severe wheezing,severe wheezing,

crackles, orcrackles, or

rhonchirhonchi

CoughCough Strong,Strong, ExcessiveExcessive ExcessiveExcessive ThickThick ThickThick ____________

spontaneous,spontaneous, bronchialbronchial bronchialbronchial bronchialbronchial bronchialbronchial

nonproductivenonproductive secretions &secretions & secretions butsecretions but secretions &secretions & secretions butsecretions but

strong coughstrong cough weak coughweak cough weak coughweak cough no coughno cough


Severity Assessment Case ExampleSeverity Assessment Case ExampleSEVERITY ASSESSMENT CASE EXAMPLESEVERITY ASSESSMENT CASE EXAMPLE

A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS 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 WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL

YEARS BEFORE THIS ADMISSIONYEARS BEFORE THIS ADMISSION (3 POINTS)(3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE . THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE

WAS AMBULATORY, ALERT, AND COOPERATIVEWAS AMBULATORY, ALERT, AND COOPERATIVE (0 POINTS)(0 POINTS).. HE COMPLAINED OF DYSPNEA AND WAS HE COMPLAINED OF DYSPNEA AND WAS

USING HIS ACCESSORY MUSCLES OF INSPIRATIONUSING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS).(3 POINTS). AUSCULTATION REVEALED BILATERAL AUSCULTATION REVEALED BILATERAL

RHONCHI OVER BOTH LUNG FIELDSRHONCHI OVER BOTH LUNG FIELDS (3 POINTS)(3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK . HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK

GRAY SECRETIONSGRAY SECRETIONS (3 POINTS)(3 POINTS).. A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE

LEFT LOWER LUNG LOBELEFT LOWER LUNG LOBE (3 POINTS)(3 POINTS).. ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52,

PaPaCOCO22 54, HCO 54, HCO33-- 41, AND Pa 41, AND PaOO22 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY

FAILUREFAILURE (3 POINTS)(3 POINTS)..

USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION

AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE:

TOTAL SCORE:TOTAL SCORE: 1717

TREATMENT SELECTION:TREATMENT SELECTION: CHEST PHYSICAL THERAPYCHEST PHYSICAL THERAPY

FREQUENCY OF ADMINISTRATION:FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDEDFOUR TIMES A DAY; AS NEEDED


The Top Four Respiratory ProtocolsThe Top Four Respiratory Protocols

Oxygen therapy protocolOxygen therapy protocol

Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol

Hyperinflation therapy protocolHyperinflation therapy protocol

Aerosolized medication therapy protocolAerosolized medication therapy protocol


Common Respiratory Assessments—Common Respiratory Assessments—Excerpts (see Table 9-1)Excerpts (see Table 9-1)

Clinical DataClinical Data AssessmentAssessment

WheezingWheezing BronchospasmBronchospasm

RhonchiRhonchi Secretions in large airwaysSecretions in large airways

Weak coughWeak cough Poor ability to mobilize Poor ability to mobilize secretionssecretions

ABGsABGs Acute ventilatory failureAcute ventilatory failure pHpH 7.24 7.24 PaPaCOCO22 73 73

HCOHCO33-- 27 27

PaPaOO22 5353


Common Respiratory Assessments Common Respiratory Assessments and Treatment Plans—Excerpts (see and Treatment Plans—Excerpts (see

Table 9-1)Table 9-1)

Clinical DataClinical Data AssessmentAssessment Tx PlanTx Plan

WheezingWheezing BronchospasmBronchospasm betabeta22 agent agent

Rhonchi &Rhonchi & Secretions in large airwaysSecretions in large airwaysWeak coughWeak cough Poor ability to mobilize secretionsPoor ability to mobilize secretions CPTCPT

ABGsABGs Acute ventilatory failureAcute ventilatory failure Mechanical ventilationMechanical ventilation

pHpH7.24 7.24

PaPaCOCO22 73 73

HCOHCO33-- 27 27

PaPaOO22 5353

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