CHAPTER 1 Introduction to Critical Respiratory Care

CHAPTER © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 1NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTIntroduction FOR SALE OR DISTRIBUTION to CriticalNOT FOR SALE OR DISTRIBUTION Respiratory Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORDavid DISTRIBUTION C. Shelledy and JayNOT I. PetersFOR SALE OR DISTRIBUTION © Thep © Thep Urai/Shutterstock © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

OUTLINE 7. Explain the importance of interprofessional practice (IPP) in the ICU. Overview © Jones & Bartlett Learning, LLC8. Contrast the design and activities© Jones associated & withBartlett each of Learning, LLC Critical Respiratory Care NOT FOR SALE OR DISTRIBUTIONthe four zones or areas foundNOT in the FORICU. SALE OR DISTRIBUTION Types of Intensive Care Units (ICUs) 9. Explain the differences between an acute care hospital ward, Patients step-down unit, and ICU. Personnel 10. Explain the term long-term acute care (LTAC) to include the Intensive Care Unit Design types of patients seen in an LTAC facility. Other Units 11. Explain the difference between a specialty hospital and a Assessment© Jones of the & Patient Bartlett in the ICU Learning, LLC skilled ©nursing Jones facility &(SNF). Bartlett Learning, LLC ReviewNOT of theFOR Medical SALE Record OR DISTRIBUTION 12. ExplainNOT the importance FOR SALEof assessment OR of DISTRIBUTION the respiratory care Patient History patient in the ICU to include types of assessment procedures Physical Examination and methods used. Laboratory Studies 13. Identify common admitting diagnoses seen in the ICU. Imaging in the ICU 14. Explain the significance of specific physician’s orders in Bronchoscopy and Thoracentesis the ICU to include medication orders for respiratory care, © Jones & BartlettCardiac Monitoring Learning, in the ICU LLC © Jones laboratory& Bartlett testing, Learning, imaging, and special LLC procedures. Types of Respiratory Care Provided in the ICU 15. Describe the elements of the history and physical NOT FOR SALESummary OR DISTRIBUTION NOT FORexamination SALE performedOR DISTRIBUTION in the ICU. 16. Recognize and contrast the signs and symptoms of OBJECTIVES hypoxia, hypercapnea, respiratory failure, and ventilatory failure. 1. Define respiratory care and critical care. 17. Describe the importance of specific laboratory tests and 2. Summarize the disease© Jones states or & conditions Bartlett that oftenLearning, LLC imaging procedures performed© Jonesin the ICU. & Bartlett Learning, LLC require ICU admission and mechanical ventilatory support. 18. Explain the purpose of bronchoscopy and thoracentesis 3. Contrast the typesNOT of patients FOR seen SALE in the medical OR intensiveDISTRIBUTION performed in the intensive careNOT unit. FOR SALE OR DISTRIBUTION care unit (MICU), surgical intensive care unit (SICU), coronary 19. Describe the types of cardiac and hemodynamic monitoring care unit (CCU), pediatric intensive care unit (PICU), and performed in the ICU. neonatal intensive care unit (NICU). 20. Contrast the terms acute respiratory failure and acute 4. Explain the differences between Level I, II, III, and IV neonatal ventilatory failure. levels of care. 21. Recognize the indications for mechanical ventilatory support. 5.© JonesDescribe the & types Bartlett of services Learning, provided in a LLCLevel I Trauma 22. Describe© theJones use of airway& Bartlett clearance therapiesLearning, (ACT) inLLC NOTCenter. FOR SALE OR DISTRIBUTION the ICU.NOT FOR SALE OR DISTRIBUTION 6. Explain the types of personnel and their qualifications needed 23. Summarize the types of care often provided by respiratory to staff the ICU. therapists in the ICU.

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© Jones &KEY Bartlett TERMS Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEacute respiratory OR DISTRIBUTION conduction disorders NOTlong-term FOR SALE acute care OR DISTRIBUTIONrenal failure distress syndrome congestive heart (LTAC) respiratory care (ARDS) failure (CHF) mechanical ventilation respiratory failure acute respiratory coronary artery mechanical ventilatory respiratory therapist failure (ARF) disease (CAD) support sepsis acute ventilatory coronary care unit (CCU) medical intensive shock failure (AVF) © Jonescritical & Bartlett care Learning, LLCcare unit (MICU) ©step-down Jones unit& Bartlett Learning, LLC atelectasis NOT FORendobronchial SALE OR DISTRIBUTIONmusculoskeletal NOTsurgical FOR intensive SALE OR DISTRIBUTION bronchoscopy ultrasound (EBUS) disease care unit (SICU) bronchoalveolar exudate myocardial infarction (MI) thoracentesis lavage (BAL) heart failure neonatal intensive tracheostomy cardiac arrhythmia intensive care unit (ICU) care unit (NICU) transudate cerebral infarction interprofessional neuromuscular disease trauma center chronic© Jones obstructive & Bartlett Learning,education (IPE)LLC pediatric intensive© Jones & Bartlett Learning, LLC pulmonary disease interprofessional care unit (PICU) (COPD)NOT FOR SALE OR DISTRIBUTIONpractice (IPP) pneumonia NOT FOR SALE OR DISTRIBUTION coma intracranial hemorrhage pulmonary edema

© Jones & OverviewBartlett Learning, LLC © JonesCritically & Bartlett ill patients Learning, are at high LLC risk for actual or potential life-threatening health problems.2 The purpose of this chapter is to introduce the reader NOT FOR SALE OR DISTRIBUTION NOTCritical FOR SALEcare is a OR term DISTRIBUTION used to refer to the care and to critical respiratory care and mechanical ventilation. management of critically ill patients who require so- We will review the definitions of respiratory care and phisticated support, careful and constant monitoring, critical care, discuss various types of intensive care and complex decision making to ensure that therapy units, and introduce patient assessment as applied to is adjusted as patients’ needs change. Critically ill the intensive care unit© (ICU)Jones patient. & Bartlett Types of respira-Learning, LLC © Jones & Bartlett Learning, LLC patients suffer from a wide range of diseases and dis- tory care provided in the ICU will also be reviewed, to NOT FOR SALE OR DISTRIBUTIONorders that often result in multiorganNOT FOR system SALE failure. OR DISTRIBUTION include ventilatory support, patient monitoring, care Examples include shock, trauma, cardiac disease, plans and protocols, and special procedures. hemodynamic instability, renal failure, neurologic Critical Respiratory Care disease, liver failure, and acute pulmonary disease. © Jones & Bartlett Learning, LLC Critically ill© patients Jones are & often Bartlett physiologically Learning, unstable, LLC Respiratory care may be defined as the healthcare dis- requiring comprehensive care and minute-to-minute ciplineNOT that FOR specializes SALE in ORthe promotion DISTRIBUTION of optimum adjustmentsNOT in the FOR support SALE provided. OR WhileDISTRIBUTION typically cardiopulmonary function and health.¹ Respiratory delivered in an ICU, critical care may be provided in care is specifically focused on the assessment, diag- the prehospital setting, emergency department, or nostic evaluation, treatment, and care of patients with other acute care settings. deficiencies and abnormalities of the cardiopulmonary Critical respiratory care refers to those respiratory © Jones & system.Bartlett Thus, Learning, the treatment LLC and support of patients in © Jonescare techniques & Bartlett and Learning, procedures used LLC in the assess- NOT FOR SALErespiratory OR failure DISTRIBUTION is a core respiratory care competency.NOTment, FOR diagnosis, SALE OR management, DISTRIBUTION support, monitoring, Respiratory care may be provided by physicians, and care of critically ill patients. While the types of nurses, physician assistants, or other healthcare provid- respiratory care provided in the ICU range from diag- ers. The respiratory therapist is specifically trained and nostic and monitoring procedures (e.g., blood gases, educated to deliver respiratory care to patients across © Jones & Bartlett Learning, LLCrespiratory monitoring), maintenance© Jones and & manage Bartlett- Learning, LLC multiple settings, including acute care hospitals and ment of artificial airways (e.g., suctioning and airway ICUs. Respiratory therapistsNOT FOR are trained SALE in ORcardiopul- DISTRIBUTIONcare), and basic respiratory careNOT techniques FOR SALE (e.g., OR DISTRIBUTION monary physiology and pathophysiology, the principles oxygen therapy, aerosolized medication delivery), an of biomedical engineering, and the application of tech- essential respiratory care function is the provision nology to assist in the provision of patient care services. of mechanical ventilatory support (also known as mechanical ventilation Respiratory© Jones therapists & Bartlett apply Learning,scientific principles LLC to © Jones )& to Bartlett patients suffering Learning, from LLCre- prevent, identify, and treat acute or chronic dysfunction spiratory failure. The role of the respiratory therapist in of theNOT cardiopulmonary FOR SALE system.OR DISTRIBUTION Thus, the respiratory the ICU includesNOT patientFOR SALEassessment OR and DISTRIBUTION monitoring, therapist must also attend to the prevention of cardio- performing basic and advanced respiratory care pro- pulmonary disease and the management of patients cedures and techniques, and providing care to patients with chronic disease. The practice of respiratory care receiving mechanical ventilatory support. Care often © Jones & extendsBartlett to theLearning, patient, the LLC patient’s family, and public © Jonesprovided & Bartlettby the respiratory Learning, therapist LLC in the ICU is sum- education. marized in Table 1-1. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & BartlettTABLE 1-1 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALETypes ofOR Respiratory DISTRIBUTION Care Provided in the ICU NOT FOR SALE OR DISTRIBUTION The role of the respiratory therapist in the ICU includes patient assessment, performance of basic and advanced respiratory care techniques and procedures, care of patients receiving mechanical ventilatory support, respiratory-related diagnostic testing, and performance or assistance with special procedures: Patient Assessment © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Obtain/review history and physical examination. • Obtain/review clinicalNOT laboratory FOR testing SALE (e.g., ORcomplete DISTRIBUTION blood count [CBC], cardiac markers, electrolytes,NOT oximetry, FOR blood SALE gases, OR DISTRIBUTION lactate level, coagulation studies, sputum Gram stain, culture and sensitivities, blood urea nitrogen [BUN] and creatinine, urinalysis, analysis of pleural fluid, and cerebrospinal fluid [CSF] analysis). • Obtain/review imaging studies (e.g., radiograph, computed tomography [CT scans], magnetic resonance imaging [MRI], ultrasound, and angiography). ©• AssessJones oxygenation, & Bartlett ventilation, Learning, and acid–base LLC balance. © Jones & Bartlett Learning, LLC • Assess for respiratory failure (e.g., acute respiratory distress syndrome [ARDS], pulmonary edema, pneumonia, exacerbation of NOTobstructive FOR disease, SALE neuromuscular OR DISTRIBUTION disease, and other restrictive pulmonary disease).NOT FOR SALE OR DISTRIBUTION • Assess patients’ airway and recognize difficult airways. • Assess patients for ventilator initiation. • Assess patients for adjustment in ventilatory support provided (e.g., ventilator mode, trigger effort, rates, volumes, pressures, flows, oxygen concentration, positive end-expiratory pressure/continuous positive airway pressure [PEEP/CPAP], patient–ventilator interaction, and alarm settings). © Jones & Bartlett• Perform Learning, ventilator waveform LLC analysis. © Jones & Bartlett Learning, LLC NOT FOR SALE• Assess OR for DISTRIBUTION patient–ventilator asynchrony. NOT FOR SALE OR DISTRIBUTION • Evaluate pulmonary mechanics (e.g., compliance and resistance) and work of breathing. • Assess patients for ventilator weaning and discontinuance. • Evaluate neurologic status (e.g., level of consciousness, neuromuscular function, respiratory drive, stroke, seizures, and brain death) • Evaluate cardiac/cardiovascular status (e.g., cardiac arrhythmias, heart failure, coronary artery disease [CAD], hypotension and hypertension [systemic, pulmonary]). • Assess hemodynamics© Jones (e.g., preload, & Bartlett afterload, contractility, Learning, and cardiac LLC output). © Jones & Bartlett Learning, LLC • Recognize and assessNOT different FOR types SALE of shock OR (e.g., DISTRIBUTION anaphylactic, cardiogenic, septic, hypovolemic, andNOT neurogenic FOR shock). SALE OR DISTRIBUTION • Assess nutritional status. • Recognize effects of drugs and medications (e.g., sedatives, hypnotics, analgesics, neuromuscular blocking agents, reversal agents, vasoactive drugs, inotropic agents, and diuretics). • Develop, implement, assess, and modify respiratory care plans.

©Basic Jones Respiratory & Bartlett Care Procedures Learning, in the ICU LLC © Jones & Bartlett Learning, LLC • Oxygen therapy NOT• Secretion FOR management SALE andOR airway DISTRIBUTION clearance therapy NOT FOR SALE OR DISTRIBUTION • Management of bronchospasm and mucosal edema (e.g., bronchodilators) • Lung expansion therapy • Airway care (humidification, suctioning, secretion management, tube position, cuff pressure, and tracheostomy care)

Critical Care and Ventilatory Support © Jones & Bartlett• Conventional Learning, (invasive) mechanical LLC ventilatory support: © Jones & Bartlett Learning, LLC NOT FOR SALE ORVentilator DISTRIBUTION initiation NOT FOR SALE OR DISTRIBUTION Patient stabilization Ventilator monitoring Weaning and ventilator discontinuance • Noninvasive mechanical ventilatory support (initiation, stabilization, monitoring, and discontinuance). • High-frequency ventilation (initiation, stabilization, monitoring, and discontinuance). • Differential/independent© Jones lung ventilation. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Recruitment maneuvers.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Prone positioning. • Physiologic monitoring. • Ventilator waveform analysis. • Cardiac and hemodynamic monitoring. • Monitor intracranial pressure (ICP). ©• JonesSuctioning &and Bartlett airway care. Learning, LLC © Jones & Bartlett Learning, LLC NOT• Administer FOR additional SALE aerosolized OR DISTRIBUTION agents (e.g., narcotics, antimicrobials, and vasodilators).NOT FOR SALE OR DISTRIBUTION • Administer airway installations (e.g., lidocaine, cold saline, and topical thrombin). • Advanced cardiovascular life support. • Administer specialty gas mixtures (e.g., helium-oxygen) and inhaled vasodilators (nitric oxide, prostacyclin).

• Metabolic studies and nutritional studies (V˙ o2, V˙ co2, and indirect calorimetry). • Extracorporeal membrane oxygenation (ECMO). © Jones & Bartlett• Mechanical Learning, circulatory assistance. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Manage OR specificDISTRIBUTION disease states and conditions (see also BoxNOT 1-2). FOR SALE OR DISTRIBUTION (Continues)

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© Jones & BartlettTABLE 1-1 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALETypes ofOR Respiratory DISTRIBUTION Care Provided in the ICU (ContinuedNOT) FOR SALE OR DISTRIBUTION Diagnostic Testing • Oximetry • Arterial blood gases • Bedside measures of pulmonary function • Cardiac testing (ECG)© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Ultrasound (thoracic,NOT cardiac, FOR abdominal, SALE and ORtransesophageal DISTRIBUTION sonography) NOT FOR SALE OR DISTRIBUTION Special Procedures • Patient transport. • Bedside bronchoscopy. • BAL (bronchoalveolar lavage). ©• InsertJones and manage& Bartlett arterial lines. Learning, LLC © Jones & Bartlett Learning, LLC • Insert and manage central lines. NOT• Thoracentesis. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Insert, manage, and remove chest tubes. • Perform airway intubation, to include use of advanced techniques (e.g., cricoid pressure, specialty visualization devices). • Exchange endotracheal tubes. • Airway extubation. • Percutaneous tracheostomy. © Jones & Bartlett• Change Learning, tracheostomy tubes. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Disaster OR response.DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Types of Intensive Care Units © Jones & Bartlett Learning, LLCICUs accepting a variety of ©patients Jones (e.g., & MICUBartlett Learning, LLC While types of ICUsNOT vary fromFOR hospital SALE to OR hospital, DISTRIBUTION and SICU).³ NOT FOR SALE OR DISTRIBUTION some of the more common types of ICUs are listed ICUs may be described by the level of care pro- in Box 1-1. These include medical intensive care vided.3 Level I ICUs are found in teaching hospitals units (MICU), surgical intensive care units (SICU), with an academic mission and provide comprehen- coronary care units (CCU), pediatric intensive care sive care for patients with a wide variety of disorders. units© (PICU)Jones, and & Bartlettneonatal intensive Learning, care LLCunits (NICU). Level II ICUs© mayJones be found & Bartlett in large community Learning, hospi LLC- SmallNOT hospitals FOR maySALE have OR only DISTRIBUTION one or two types of tals that provideNOT comprehensive FOR SALE care OR but DISTRIBUTION may not have the

© Jones & BartlettBOX 1-1 Learning, Types of Intensive LLC Care Units © Jones & Bartlett Learning, LLC NOT FOR SALEMedical OR DISTRIBUTION Intensive Care Unit (MICU). The MICU NOT FOR(MI), patientsSALE withOR unstableDISTRIBUTION angina, and those with generally accepts a wide variety of critically ill pa- other serious cardiac arrhythmias. The CCU typi- tients, excluding only those patients who can be cally incorporates telemetry or other continuous managed in another available ICU setting, such as cardiac monitoring system and is supported by the surgical intensive© careJones or pediatric & Bartlett intensive Learning, care. LLCcardiology service of the hospital.© Jones & Bartlett Learning, LLC In smaller hospitals,NOT where FOR no SALE other specialty OR DISTRIBUTION units Cardiovascular IntensiveNOT Care FORUnit (CVICU) SALE. OR DISTRIBUTION are available, pediatric patients and surgical pa- The types of patients seen in the CVICU vary, tients are sometimes placed in the MICU. depending on the hospital. In hospitals with Surgical Intensive Care Unit (SICU). An intensive separate CCU services (see above), the CVICU care unit that primarily serves critically ill post- tends to focus on postoperative care follow- © operativeJones &patients Bartlett and isLearning, staffed and LLCmanaged by ing cardiothoracic© Jones or & vascular Bartlett surgery Learning, including LLC NOTsurgeons FOR and SALE anesthesiologists OR DISTRIBUTION with training and coronaryNOT artery FOR bypass, SALE heart valveOR DISTRIBUTIONreplacement, specialization in critical care. and heart transplants. Other CVICUs may see Coronary Care Unit (CCU). The traditional coro- patients following cardiac arrest and/or MI, and nary care unit tends to focus on to providing care those with cardiac dysrhythmias, or heart failure; © Jones & Bartlettto patients Learning, following LLC acute myocardial infarction © Jonesinterventional & Bartlett cardiology Learning, procedures LLC (e.g., cardiac NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlettcatheterization) Learning, may LLC be followed by admission to© Jonesand &monitoring, Bartlett and Learning, providing mechanicalLLC ven- NOT FOR SALEthe OR CVICU. DISTRIBUTION Special procedures, such as hypotherNOT- FORtilatory SALE support. OR Some DISTRIBUTION units also provide ECMO, mia post–cardiac arrest (now the standard of care high-frequency ventilation, and inhaled nitric oxide in all ICUs for patients who remain unresponsive therapy (iNO). after return of spontaneous circulation [ROSC]), Neurologic Intensive Care Unit (Neuro ICU). The extracorporeal© membrane Jones & oxygenation Bartlett Learning,(ECMO), LLCNeuro-ICU focuses on the care© Jones of patients & Bartlett with Learning, LLC intra-aortic balloonNOT pump FOR (IABP), SALE and OR use DISTRIBUTION of ven- critical, life-threatening neurologicalNOT FOR disorders SALE OR DISTRIBUTION tricular assist devices (VADs) may be employed in such as stroke, cerebral aneurysm, head trauma, the CVICU. traumatic brain injury, intracranial or subarachnoid Respiratory Intensive Care Unit (RICU). hemorrhage, encephalitis, meningitis, and subdural Though less common in the United States, hematoma. Other conditions seen in the Neuro- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC RICUs specialize in the care of critically ill pa- ICU include status epilepticus, postoperative brain NOTtients FOR with pulmonarySALE OR problems. DISTRIBUTION Examples of surgery (e.g.,NOT tumor FOR removal), SALE spinal OR DISTRIBUTIONcord injury, patients that may be seen in the respiratory and neuromuscular disease (e.g., Guillain-Barre ICU include those with acute exacerbation of syndrome, myasthenia gravis). chronic obstructive pulmonary disease (COPD), Postanesthesia Care Unit (PACU). The PACU, also © Jones & Bartlettacute respiratoryLearning, distress LLC syndrome (ARDS), © Jonessometimes & Bartlett known Learning, as the recovery LLC room, receives NOT FOR SALEsevere OR pneumonia, DISTRIBUTION and patients with other chronicNOT FORpatients SALE immediately OR DISTRIBUTION following surgical opera- lung conditions suffering from acute respiratory tions and anesthesia. Patients generally remain in failure. the PACU for short periods of time until they are Neonatal Intensive Care Unit (NICU). The NICU stabilized. The PACU provides postoperative obser- provides care for© criticallyJones ill& newborns. Bartlett Disorders Learning, LLCvation, monitoring of vital ©signs, Jones medication & Bartlett ad- Learning, LLC seen in the NICU include respiratory distress syn- ministration, intravenous (IV) fluid administration, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION drome (RDS), transient tachypnea of the newborn airway care, oxygen therapy, and extubation in pa- (TTN), neonatal pneumonia, meconium aspiration, tients ready for removal of the endotracheal tube, persistent pulmonary hypertension of the neonate if not removed in the operating room. Recovery (PPHN), sepsis, and bronchopulmonary dysplasia room nurses also provide the initial management © (BPD).Jones Respiratory & Bartlett care Learning,provided in the LLC NICU may of postoperative© Jones pain, & treatment Bartlett for Learning, postoperative LLC NOTinclude FOR provision SALE of ORa neutral DISTRIBUTION thermal environ- nausea andNOT vomiting, FOR treatment SALE OR of postanesthetic DISTRIBUTION ment, monitoring, surfactant therapy, oxygen ther- shivering, and monitoring of surgical sites for apy, continuous positive airway pressure (CPAP), bleeding, swelling, discharge, or other complica- and ventilatory support. ECMO and inhaled nitric tions. Occasionally, patients in the PACU require oxide therapy (iNO) are also sometimes provided in mechanical ventilatory support, generally for brief © Jones & Bartlettthe NICU. Learning, LLC © Jonesperiods & Bartlett of time. Once Learning, stable, the LLC PACU patient is NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pediatric Intensive Care Unit (PICU). The PICU transferred back to the general hospital ward or focuses on the care of critically ill children, typically other care unit. In outpatient surgical settings, the ranging in age from infants to teenagers. Disease patient may be discharged to home. states or conditions seen in the PICU include acute Mobile Intensive Care Unit (Mobile ICU). The respiratory failure,© Jones shock, trauma, & Bartlett overwhelming Learning, LLCterm mobile intensive care ©unit Jones is used &to Bartlettde- Learning, LLC infection, multi-organNOT FORsystem SALE dysfunction, OR DISTRIBUTION acute scribe an emergency responseNOT unit, FOR ambulance, SALE or OR DISTRIBUTION neurologic disease, gastrointestinal disorders, liver transport vehicle that includes sophisticated life– failure, renal disease, blood disorders, and cardiac support and monitoring technology. Typically, the disease. Pneumonia, respiratory syncytial virus Mobile ICU is staffed by qualified paramedics who © (RSV),Jones bronchiolitis, & Bartlett epiglottitis, Learning, laryngeal LLC tracheo- are linked© to Jones a medical & center Bartlett via telecommunica- Learning, LLC bronchitis (i.e., croup), upper airway obstruction, tions technology. In addition, critical care transport NOTacute FOR pediatric SALE asthma, OR cystic DISTRIBUTION fibrosis, sepsis, ana- may be accomplishedNOT FOR usingSALE a ground OR DISTRIBUTION mobile ICU, phylaxis, poisoning, near drowning, and neurologic helicopter, or fixed-wing aircraft. Critical care trans- or neuromuscular disorders may lead to respira- port teams may include critical care nurses, critical tory failure in pediatric patients. PICU services care flight medics, respiratory therapists, and criti- © Jones & Bartlettinclude Learning, basic respiratory LLC care, patient assessment© Jonescal care& Bartlett physicians. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones &re Bartlettsources to Learning, care for specific LLC types of patients (e.g., mul-© Jonesbeen developed. & Bartlett Thus, Learning, we have medical,LLC surgical, car- tiple trauma). Level III ICUs may be found in smaller NOTdiac, FOR respiratory, SALE OR neurologic, DISTRIBUTION pediatric, and neonatal NOT FOR SALEhospitals OR and DISTRIBUTIONare able to stabilize critically ill patients, patients. Eighteen conditions have been associated with but unable to provide certain types of comprehensive the highest proportion of ICU utilization by patients care. Level III ICUs typically have transfer arrange- requiring hospitalization.6 Over 93% of hospitalized ments with more comprehensive units. patients requiring ventilatory support needed ICU ser- 6 Trauma centers are© oftenJones identified & Bartlett by level Learning, based on LLCvices. Common diagnoses that© Jonesoften require & Bartlett mechani- Learning, LLC acute respiratory failure (ARF) the kinds of resourcesNOT available FOR and SALE the types OR and DISTRIBUTION num- cal ventilation include NOT FOR SALE OR, DISTRIBUTION bers of patients admitted. For example, a Level I Trauma COPD exacerbation, neuromuscular disease, and Center provides total care for every aspect of injury coma. Cardiac conditions accounted for a large num- and is characterized by 24-hour in-house coverage by ber of hospitalizations requiring ICU services. For general surgeons, and the rapid availability of specialists example, over 70% of hospitalized patients with acute (e.g., anesthesiology, radiology, orthopedics, and neuro- myocardial infarction (MI) who survived required © Jones4 & Bartlett Learning, LLC © Jones6 & Bartlett Learning, LLC surgery).NOT FORA Level SALE I Trauma OR Center DISTRIBUTION serves as a compre- ICU admission.NOT Other FOR cardiac SALE or cardiovascularOR DISTRIBUTION hensive regional resource. A Level V Trauma Center, on conditions that often required ICU admission in- the other hand, provides basic emergency department cluded cardiogenic pulmonary edema, heart failure, services, and may only perform initial patient evalua- shock, cardiac arrhythmia, and conduction disorders. tion, stabilization, and transfer of patients to facilities Intracranial hemorrhage, cerebral infarction, severe 4 © Jones & providingBartlett more Learning, comprehensive LLC care, as needed. © Jonessepsis ,& and Bartlett toxic effects Learning, of drugs LLCwere also listed as fre- 6 Box 1-2 NOT FOR SALEUnlike OR adult DISTRIBUTION critical care units and trauma centers, NOTquent FOR causes SALE of ICUOR admission. DISTRIBUTION summarizes where Level I indicates the most comprehensive care, common conditions that often require ICU admission newborn infant care complexity goes from Level I, basic and mechanical ventilatory support. newborn care to Level IV, the highest level of regional neonatal intensive care unit (NICU).5 Level I nurseries Personnel (well newborn nursery)© Jones care for healthy& Bartlett babies, Learning, while LLCSpecially trained physicians, ©nurses, Jones and respiratory& Bartlett Learning, LLC Level II units provideNOT advanced FOR newborn SALE care OR (special DISTRIBUTION therapists are needed in orderNOT to staff FOR the ICU.SALE Physi- OR DISTRIBUTION care nursery). Level II nurseries may provide mechani- cians providing ICU patient care should hold medical cal ventilatory support until the infant improves or is staff privileges for the management of critically ill pa- transferred to a higher-level facility. Level III NICUs tients. They should also hold board certification in criti- provide comprehensive intensive care for very prema- cal care medicine and be available to see the patient as ture© infants Jones (i.e., & <32 Bartlett weeks’ gestationLearning, and weighingLLC often as necessary,© Jones but at& least Bartlett two times Learning, per day. In LLC ad- <1500NOT g), FORas well SALEas those ORwith DISTRIBUTIONother critical illnesses. dition, 24-hour,NOT in-house FOR SALEICU coverage OR DISTRIBUTION should be pro- Level III NICUs are sometimes further delineated as vided by intensivists or other experienced physicians. Level IIIA, Level IIIB and Level IIIC, with Level IIIC The ratio of physician intensivists to patients should 5 Level III NICUs providing the highest level of care. be based on the acuity and complexity of the patients provide conventional ventilatory support, and may pro- being cared for and sufficient to ensure patient safety. vide high-frequency ventilation, inhaled nitric oxide, © Jones & Bartlett Learning, LLC © JonesIn addition, & Bartlett physician Learning, specialists (e.g., LLC surgeons, anes- ECMO, and advanced imaging procedures. Level IV thesiologists, cardiologists, and neurologists) should NOT FOR SALEunits (i.e., OR regional DISTRIBUTION NICUs) provide the highest level of NOT FOR SALE OR DISTRIBUTION be available. One multicenter observational study sug- complex care, serving as regional referral centers.5 gested ICU physician-to-patient ratios exceeding 1:14 In addition to critical care units, larger hospitals may 7 step-down units were associated with increased mortality. The use of have of various kinds that provide inter- midlevel providers (e.g., physician assistants, advanced mediate care. Regardless of the type of ICU, specialized © Jones & Bartlett Learning, LLCpractice nurses [APNs]) with ©training Jones and & experience Bartlett in Learning, LLC nurses, physicians, and respiratory therapists with criti- the management of ICU patients has increased in recent cal care training are needed.NOT FOR Additional SALE services OR DISTRIBUTION typi- NOT FOR SALE OR DISTRIBUTION years. cally provided in the ICU include diagnostic services Nurses specifically trained in critical care should su- (e.g., laboratory and imaging), pharmacy, nutritional pervise all care carried out in the ICU. Nurse-to-patient 3 In addition, services, social services and pastoral care. ratios should be sufficient to safely deliver the care re- ICUs must be equipped to provide certain special- © Jones & Bartlett Learning, LLC quired, based© onJones patient & acuity Bartlett and complexity. Learning, Higher LLC ized procedures, such as thoracentesis, chest tube NOT FOR SALE OR DISTRIBUTION nurse-to-patientNOT ratios FOR (i.e., SALE 1:1 or OR 1:2) DISTRIBUTIONhave been associ- placement, percutaneous tracheostomy, and bedside 8 bronchoscopy ated with improved safety and better patient outcomes. . Others have suggested evidence-based thresholds of not 7 Patients more than five patients for every two nurses. The American Association of Critical-Care Nurses © Jones & PatientsBartlett requiring Learning, intensive LLC care can be broadly classi- © Jones(AACN) & offersBartlett specialty Learning, certification LLC in acute/critical NOT FOR SALEfied in-line OR withDISTRIBUTION the common types of ICUs that have NOTcare FOR nursing SALE for nursesOR DISTRIBUTION working in adult, pediatric, or

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 1-2 Learning, Patient Conditions LLC Requiring ICU Admission and Mechanical Ventilation NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The following disease states or conditions are often yyCoronary artery disease (CAD) seen in the ICU and sometimes require mechanical yyShock (anaphylactic, cardiac, hypovolemic, neu- ventilatory support: rogenic, septic) Respiratory disease © Jones & Bartlett Learning, LLCyyPulmonary edema (cardiac)© Jones & Bartlett Learning, LLC yyAcute respiratory failure NOT FOR SALE OR DISTRIBUTIONyyHypertensive emergenciesNOT FOR SALE OR DISTRIBUTION ARDS yyHematologic and coagulation disorders Pneumonia Neuromuscular or neurologic disease Trauma yyComa © JonesSepsis & Bartlett Learning, LLC Intracranial© Jones hemorrhage & Bartlett Learning, LLC NOT FORPostoperative SALE failureOR DISTRIBUTION CerebralNOT infarction FOR SALE OR DISTRIBUTION Aspiration Head trauma Sedative or narcotic drug overdose Sedative or narcotic drug overdose yyChronic respiratory disease yyNeuromuscular disease © Jones & Bartlett AcuteLearning, exacerbation LLC of COPD © Jones &Guillain-Barré Bartlett Learning, LLC NOT FOR SALE ORAcute, DISTRIBUTION severe asthma exacerbation NOT FOR MyastheniaSALE OR gravis DISTRIBUTION Restrictive lung disease (e.g., pulmonary Amyotrophic lateral sclerosis (ALS) fibrosis) Tetanus Upper or central airway obstruction yy Botulism Tumor © Jones & Bartlett Learning, LLCyyCervical spinal cord injury© Jones & Bartlett Learning, LLC LaryngealNOT edema FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Trauma (e.g., chest trauma, multiple trauma, Foreign body obstruction motor vehicle accident, near drowning, electrical yyPulmonary embolus shock Cardiac/cardiovascular/circulatory disease Multi-organ system failure © yJonesyHeart failure& Bartlett Learning, LLC Renal disorders© Jones and kidney & Bartlett failure Learning, LLC NOTyyCardiac FOR arrhythmiaSALE OR DISTRIBUTION AnaphylaxisNOT and FOR acute SALEallergic reactionsOR DISTRIBUTION

© Jones & neonatalBartlett critical-care Learning, settings. LLC9 The certified critical-care© Jonestherapists & Bartlett must also Learning,apply basic respiratory LLC care tech- NOT FOR SALEregistered OR nurse DISTRIBUTION CCRN credential is awarded to nurses NOTniques FOR (e.g.,SALE oxygen OR therapy, DISTRIBUTION management of broncho- (registered nurses [RNs] or APNs) who meet certain ex- spasm and mucosal edema, secretion management, perience requirements for providing direct, bedside care and lung expansion therapy) to critically ill patients. to acutely/critically ill patients and successfully pass the In addition, critical care respiratory therapists may be CCRN examination. The CCRN examination includes expected to administer specialty gases (e.g., nitric oxide, clinical judgment questions© Jones (about & 80%Bartlett of the test)Learning, cov- LLChelium–oxygen), intubate and© extubate Jones patients, & Bartlett insert Learning, LLC ering the care of patientsNOT in FORthe following SALE content OR DISTRIBUTION areas: and maintain arterial lines, assistNOT with FOR and/or SALE perform OR DISTRIBUTION cardiovascular, pulmonary, endocrine, hematology, hemodynamic monitoring, and assist with and/or pro- gastrointestinal, renal, integumentary, musculoskeletal, vide ECMO and mechanical circulatory support (e.g., neurology, psychological, and multisystem disease states intra-aortic balloon pump [IABP]). Respiratory thera- and conditions.9 Approximately 20% of the examination pists holding the Adult Critical Care Specialty (ACCS) is devoted© Jones to professional & Bartlett caring Learning, and ethical LLC practice. credential from© Jones the National & Bartlett Board for Learning, Respiratory LLC NOTRespiratory FOR therapists SALE ORwith DISTRIBUTIONtraining and experience Care are especiallyNOT FOR well qualified SALE ORto work DISTRIBUTION in the ICU.10 in critical care should be available at all times. Respira- ICU respiratory therapists should be especially skilled tory therapists in the ICU must be expert in the use in patient assessment, administration of protocols, care of mechanical ventilators, the application of specific plan development, and management of respiratory care ventilatory modes, patient monitoring, airway care, patients. Competencies needed for the respiratory ther- © Jones & techniquesBartlett forLearning, ventilator weaningLLC and discontinu- © Jonesapist work & Bartlett in adult critical Learning, care and LLC ACCS certification NOT FOR SALEance, and OR critical DISTRIBUTION care patient transport. Respiratory NOTare FOR described SALE in ORTable DISTRIBUTION 1-2.

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© Jones & BartlettTABLE 1-2 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAdult Critical OR DISTRIBUTION Care Specialty (ACCS) Examination ContentNOT FOR SALE OR DISTRIBUTION The National Board for Respiratory Care administers the Adult Critical Care Specialty (ACCS) examination to assess the knowledge and skills needed by the respiratory therapist to work in the adult critical care specialty. The examination includes 170 multiple-choice items that must be completed within 4 hours and covers the following content areas: I. Respiratory Critical Care© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC A. Manage airways (airway clearance techniques, difficult airway, advanced techniques during intubation, artificial airways, exchanging ET tubes, and specialtyNOT tracheostomy FOR SALE tubes). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION B. Administer specialty gases (nitric oxide, helium-oxygen). C. Manage ventilation/oxygenation. 1. Initial ventilator settings 2. Advanced ventilator modes © Jones3. Noninvasive & Bartlett ventilation Learning, LLC © Jones & Bartlett Learning, LLC 4. Waveform analysis NOT5. Rescue FOR techniques SALE (recruitment OR DISTRIBUTION maneuvers, inhaled vasodilators, high-frequencyNOT ventilation, FOR prone SALE positioning, OR and DISTRIBUTION ECMO) 6. Specific strategies during ventilatory support (ventilator liberation, prevention of lung injury, ARDS, trauma, exercise, and rehabilitation while receiving ventilatory support, and PEEP) 7. Differential/independent lung ventilation 8. Intrahospital transport of unstable and high-risk patients 9. Optimizing patient–ventilator interaction © Jones & Bartlett D. Deliver Learning, pharmacologic agentsLLC (aerosolized vasodilators and ©antimicrobials, Jones &airway Bartlett installations, Learning, and optimization LLC of aerosol delivery NOT FOR SALEduring OR ventilatory DISTRIBUTION support and with high-flow nasal cannula). NOT FOR SALE OR DISTRIBUTION II. General Critical Care A. Assess patient status and changes in status (airway issues, chest imaging, respiratory physiology and mechanics indices, neurologic assessment, cardiovascular assessment, hemodynamic assessment, differentiation among types of shock, recognition of respiratory failure mechanisms, assessment of renal function, metabolic measures, gastrointestinal assessment, coagulation, musculoskeletal issues, and therapeutic hypothermia). B. Anticipate care based© Jones on laboratory & Bartlettresults (albumin, Learning, CBC, cardiac LLCmarkers, lactate, D-dimer, procalcitonin,© Jones electrolytes, & acid–baseBartlett Learning, LLC status, anion gap,NOT ketones, FOR lactic level,SALE coagulation OR DISTRIBUTIONstudies, culture and sensitivities, sputum Gram stain,NOT hemoximetry FOR [co-oximetry], SALE OR DISTRIBUTION endocrine assessment, BUN and creatinine, liver function, and fluid analysis [plural, CSF, peritoneal, and urine]). C. Anticipate care based on imaging studies and/or reports of imaging (radiographs, CT scans, MRI, ultrasound, nuclear scans [V˙/Q˙ scan], and angiography). D. Anticipate effects of pharmacologic agents: sedatives/hypnotics, analgesics, reversal agents, drugs that may induce methemoglobinemia, prophylaxis for deep vein thrombosis (DVT), prophylaxis for gastric stress ulcers, diuretics, drug interactions, © Jonesdrugs which & may Bartlett contribute Learning,to delirium, and influenceLLC of comorbid conditions on ©drug Jones metabolism/excretion. & Bartlett Learning, LLC NOTE. Anticipate FOR care SALE based on OR nutritional DISTRIBUTION status (malnutrition, nutritional support, enteralNOT and parenteral FOR feeding,SALE morbid OR obesityDISTRIBUTION, and metabolic studies). F. Prevent ventilator-associated events (oral care, bed positioning, minimize intubation time, ventilator circuit care, specialty airways, and assessment of endotracheal/tracheostomy cuff integrity and pressure). G. Recognize and manage patients with infections and/or sepsis (clinical and laboratory signs, management of the infection, sepsis, and prevention). © Jones & Bartlett H. Manage Learning, end-of-life care LLC(types of end-of-life care, determination© ofJones brain death, & withdrawalBartlett of Learning,support, and car eLLC of organ donors). I. Prepare for disaster and mass casualty events. NOT FOR SALE J. Interact OR withDISTRIBUTION members of an interdisciplinary team. NOT FOR SALE OR DISTRIBUTION K. Perform procedures (arterial line insertion and monitoring, mini BAL, esophageal probe [NAVA, transpulmonary pressure monitor). L. Troubleshoot systems (chest tube drainage, bronchoscopy, hemodynamic monitoring, and inhaled vasodilators).

Data from: The National Board for Respiratory Care (NBRC). Adult Critical Care Specialty (ACCS): Scoring. Available at https://www.nbrc.org/examinations/ accs/#scoring. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Interprofessional Practice testing may be provided for certain laboratory stud- Care of patients in ICU requires interprofessional ies (e.g., blood gases/electrolytes, glucose, activated communication, cooperation, and teamwork. In ad- clotting time, and cardiac biomarkers). Portable chest dition© Jones to physicians, & Bartlett critical-care Learning, nurses, and LLC respira- radiographs,© CT Jones and CT & angiography, Bartlett Learning, ultrasound, LLC tory therapists, pharmacy, laboratory, and imaging MRI, echocardiography, and fluoroscopy should be NOT FOR SALE OR11 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION3 services must be provided. Pharmacists must be available for ICU patients 24 hours a day. Physical available to evaluate medication orders and possible therapists, occupational therapists, dietitians/clinical drug interactions, monitor drug dosing and admin- nutritionists, social service workers, mental health pro- istration, and make appropriate recommendations. viders, and hospital clergy should be available to pro- © Jones & Ideally,Bartlett a clinical Learning, pharmacist LLC dedicated to the ICU © Jonesvide services, & Bartlett as needed. Learning, Clinical Focus LLC 1-1 describes interprofessional education (IPE) NOT FOR SALEwill be provided. OR DISTRIBUTION Clinical laboratory services must be NOTthe FOR application SALE of OR DISTRIBUTION , available at all times and satellite or STAT labs may interprofessional practice (IPP), and interprofessional be located in or near the ICU. Point-of-care (POC) teamwork to the ICU.

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© Jones & Bartlett Learning, LLC © Jones & BartlettCLINICAL Learning, FOCUS 1-1 LLC Interprofessional Practice in the ICU NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Physicians, physician assistants, nurses (including Question 3. What interprofessional competencies advanced practice nurses [APNs]), respiratory thera- should members of the ICU team possess? pists, unit clerks, and other support service personnel Values and Ethics: The patient’s needs come first; must all work together in the ICU to ensure patients patients’ dignity, privacy, and confidentiality must are provided safe, ©effective, Jones and & Bartletthigh-quality Learning, care. Ef- LLCbe respected. Cultural diversity© Jones must be & embraced, Bartlett Learning, LLC fective interprofessionalNOT teamsFOR areSALE those OR that DISTRIBUTION foster a accounting for individual differences,NOT FOR including SALE OR DISTRIBUTION climate of mutual respect, adopt effective communi- patients, families, and healthcare team members. cation strategies, develop a sense of trust, and invite Respect the roles, responsibilities, and expertise of contributions from others.11 Organizational factors as- other team members; work in cooperation, honesty, sociated© Jones with & effective Bartlett interprofessional Learning, LLC teams include integrity and© Jones trust with & those Bartlett involved Learning, in the care LLC aNOT patient-centered FOR SALE focus OR that DISTRIBUTION promotes a culture of of patients,NOT including FOR patients SALE and OR their DISTRIBUTION families. safety (not blame), and that supports individual and Exhibit high ethical standards and professional com- team development.11 Core competencies and defin- petence and properly manage ethical dilemmas. itions for interprofessional collaborative practice have Roles and Responsibilities: ICU team members 12 been identified. should understand the roles and responsibilities of © Jones & Bartlett Learning, LLC © Joneseach & team Bartlett member Learning, and be able to LLC communicate NOT FOR SALEQuestion OR 1.DISTRIBUTION What is the difference between NOT FOR SALE OR DISTRIBUTION interprofessional education (IPE) and these clearly to patients, their families, and other interprofessional practice (IPP)? team members. Each team member should seek to integrate the knowledge, skills, professional attri- Interprofessional education (IPE): Circumstances in which two or more professionals learn with, butes, and full scope of practice of the entire team to from, and about© each Jones other & to Bartlett improve collabora- Learning, LLCoptimize care provided. Each© team Jones member & Bartlett should Learning, LLC tion and the qualityNOT of FOR care. SALE OR DISTRIBUTIONrecognize his or her own limitationsNOT FOR and seek SALE to com OR- DISTRIBUTION municate and clarify each member’s responsibilities in Interprofessional practice (IPP): Circumstances in providing care. Professional development to improve which multiple health workers from different pro- team and individual performance should be ongoing. fessional backgrounds work together with patients, : Recognize and © families,Jones careers, & Bartlett and communities Learning, to LLC deliver the Interprofessional© Jones Communication & Bartlett Learning, LLC highest quality of care. communicate the importance of teamwork; use NOT FOR SALE OR DISTRIBUTION effective NOTcommunication FOR SALE tools andOR communicate DISTRIBUTION Question 2. What is the difference between information clearly and understandably to other interprofessional teamwork and interprofessional team members, patients, and their families. Each team-based care? team member should respectfully communicate his © Jones & BartlettInterprofessional Learning, teamwork LLC : The levels of coop- © Jonesor her & knowledgeBartlett Learning,and opinions toLLC other members NOT FOR SALEeration, OR DISTRIBUTIONcoordination, and collaboration charac- NOT FORof the SALE team, actively OR DISTRIBUTION listen to and encourage the terizing the relationships between professions in ideas and opinions of other team members, and delivering patient-centered care. provide timely, respectful, and instructive feedback. Interprofessional team-based care: Care delivered Effectively participate in conflict resolution and de- by intentionally created work groups in health care, velop and maintain positive interprofessional work- which are usually© relativelyJones &small Bartlett and are Learning,recog- LLCing relationships with all team© Jones members. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nized by others as well as by themselves as having Teams and Teamwork: Integrate the knowledge, a collective identity and shared responsibility for skills, and professional attributes of each team a patient or group of patients, e.g., rapid response member and profession represented in order to team, palliative care team, primary care team, provide the best care possible. Engage in team de- © operatingJones & room Bartlett team. Learning, LLC velopment,© Jonesappropriate & Bartlettleadership Learning,practices, and LLC NOTBecause FOR the SALE ICU requires OR DISTRIBUTIONhigh levels of interprofes- process improvementNOT FOR toSALE improve OR team DISTRIBUTION effective- sional communication, coordination, and collabora- ness. Constructively manage disagreements, and tion involving a diverse team of healthcare workers, share accountability for patient outcomes. each member of the healthcare team should have A complete description of the core competencies the necessary interprofessional competencies © Jones & Bartlett Learning, LLC © Jonesfor interprofessional, & Bartlett Learning, collaborative LLC practice may be needed to provide team-based care and collaborative found at the Interprofessional Education Collaborative NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION practice. (IPEC) website.12

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© Jones &Intensive Bartlett CareLearning, Unit Design LLC © Jonesinclude & furniture Bartlett that Learning, allows family LLC members to com- fortably spend the night, if needed or desired. Clock, NOT FOR SALEThe design OR and DISTRIBUTION layout of the ICU should provide a heal-NOT FOR SALE OR DISTRIBUTION ing environment that allows for safe, efficient, and ef- calendar, whiteboard, television, and adequate surfaces fective care delivery. The ICU layout and design should so the patient’s personal items, such as greeting cards optimize the well-being of patients, staff, physicians, and photos, can be placed where the patient can see them should be provided. Room decor should include and visitors by use of pleasant decor and furnishings Figure 1-1 and attend to patient,© family, Jones and & staff Bartlett comfort. Learning, ICU LLCpleasant pictures and artwork.© Jones & provides Bartlett an Learning, LLC design and layout shouldNOT incorporate FOR SALE the use OR of DISTRIBUTIONnatural example of an adult intensiveNOT care room. FOR SALE OR DISTRIBUTION light and reduce noise levels.13 An effective ICU design Sufficient medical utility outlets (i.e., oxygen, electri- may help reduce medical errors and improve patient cal power, and vacuum) must be provided, often in a flat outcomes.13 headwall or column-mounted configuration. Outlets for The physical layout of the critical care unit consists oxygen, compressed air, vacuum, and electricity should of four© Jones zones or & areas. Bartlett The patient Learning, care zone LLC includes be easily accessible© Jones from & both Bartlett sides of Learning, the bed. Monitor- LLC theNOT patient FOR rooms SALE where directOR DISTRIBUTION patient care is pro- ing equipmentNOT must FOR be incorporated SALE OR into DISTRIBUTION the design vided.13 Rooms should have doorways that allow for and positioned so that medical staff can easily observe the fast and unobstructed movement of patients, beds, each monitor. Patient care rooms should include sinks, staff, and equipment. Lift equipment should be avail- alcohol gel dispensers, sharps disposal, toilet facilities, able to help in moving patients. Windows providing and waste and fluid disposal, and provide for privacy © Jones & naturalBartlett light, Learning, ideally with LLCa pleasant outside view, may © Jonesand the & use Bartlett of mobile Learning, commode stands LLC or bedpans. NOT FOR SALEimprove OR patients’ DISTRIBUTION sense of well-being. Single-bed roomsNOT Adjustable FOR SALE temperature OR DISTRIBUTION and lighting controls, as well are preferred, with adequate floor space to accommo- as a high-intensity light source for clinical procedures, date portable imaging equipment, dialysis equipment, should be provided. Isolation rooms for infectious pa- equipment for special procedures, and mechanical tients (e.g., negative-pressure rooms) and for patients ventilators. Rooms must also be able to accommodate who require protection from infection (e.g., positive- IV pumps, and mobile© orJones fixed computing& Bartlett equipment Learning, LLCpressure rooms) should be available.© Jones & Bartlett Learning, LLC for charting and maintainingNOT FOR medical SALE records. OR In-room DISTRIBUTION The clinical support zone inNOT the ICU FOR includes SALE staff OR DISTRIBUTION storage for supplies and separate storage for the pa- work areas, centralized monitoring stations, and work- space for order entry and medical record documenta- tient’s clothing and personal effects must be provided. 13 Furnishings should include a critical care hospital bed, a tion and review. The configuration of the ICU should chair for the patient, and a chair for visitors. Rooms may allow for clear sight lines so staff may visualize each © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

NOT FOR SALEFigure 1-1OR Typical DISTRIBUTION Adult Intensive Care Room. NOT FOR SALE OR DISTRIBUTION

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© Jones &patient’s Bartlett face Learning, and body position LLC from various loca- © Jones & Bartlett Learning, LLC tions within the ICU clinical support zone. Walking NOT FOR SALE OR DISTRIBUTION NOT FOR SALEdistances OR and DISTRIBUTION workflow should be optimized. Space and equipment for preparing and dispensing medications, emergency equipment and supplies, and an area for respiratory therapy equipment and supplies must be provided, as well as storage© Jones for nonemergency & Bartlett equipment Learning, LLC © Jones & Bartlett Learning, LLC such as wheelchairs,NOT stretchers FOR and SALE special ORprocedure DISTRIBUTION NOT FOR SALE OR DISTRIBUTION carts. An emergency eyewash station may be provided in case staff are exposed to hazardous fluids. The ICU also needs a dedicated space for patients’ food and bev- erages, including water, ice, a refrigerator, microwave oven,© andJones space & for Bartlett dietary carts. Learning, Figure 1-2 LLC provides an © Jones & Bartlett Learning, LLC exampleNOT of FOR a typical SALE clinical OR support DISTRIBUTION area of an ICU. Figure 1-3 ExampleNOT FORLayout ofSALE an ICU. OR DISTRIBUTION The unit support zone refers to the areas within the © Greg Benson Photography. ICU where administrative and staff support functions 13 occur. This area may include offices and conference monitoring but did not require other services typically spaces in or near the unit and often provides a location provided in the ICU.14 Step-down units are often used © Jones & forBartlett change ofLearning, shift reports. LLC A staff lounge, on-call room,© Jonesto care & for Bartlett patients whoLearning, had been LLCin the ICU, but are NOT FOR SALEand a workroom OR DISTRIBUTION for clean and sterile supplies, as well NOTnow FOR improved SALE to OR the pointDISTRIBUTION that they no longer need the as a soiled utility room may be included in this area. full array of intensive care services. Step-down units are Figure 1-3 provides an example of the layout of an ICU, also sometimes used to provide a higher level of care including the patient care, clinical support, and unit for patients who are getting worse on a general medical support zones. or surgical ward, but do not yet require intensive care – The family support© zone Jones refers & to Bartlett those areas Learning, in or LLCthis being a “step up” in the level© Jones of care provided.& Bartlett Learning, LLC near the ICU designedNOT to support FOR SALEfamilies ORand visitors. DISTRIBUTION Step-down units are sometimesNOT used FOR for lateral SALE trans- OR DISTRIBUTION This may include a family and visitors lounge, consulta- fers for patients such as those in postoperative recovery tion rooms, meditation spaces, and other facilities for rooms, when the recovery period is prolonged.14 families and visitors. Long Term Acute Care Other Units © Jones & Bartlett Learning, LLC Long-term acute© Jones care (LTAC)& Bartlett refers to Learning, care provided LLC to Specialized care may be delivered in other unit settings. NOT FOR SALE OR DISTRIBUTION patients withNOT serious FOR medical SALE conditions OR DISTRIBUTION requiring an Step-down units are common in larger hospitals to ac- extended hospital stay, but no longer requiring intensive commodate patients who do not need the level of care 15 care or extensive diagnostic procedures. Long-term provided in the ICU, but require a higher level of care acute care hospitals may be standalone units or colo- than typically provided on general medical and surgical cated within an existing acute care hospital. In order hospital wards. Step-down units, sometimes referred © Jones & Bartlett Learning, LLC © Jonesto qualify & Bartlett for admission Learning, to an LTAC, LLC patients generally to as progressive care units, intermediate care units, NOT FOR SALE OR DISTRIBUTION NOTmust FOR require SALE more OR than DISTRIBUTION 25 days of hospitalization; the or transitional care units, were introduced in 1968 as a average length of stay of LTAC patients is approximately care setting for post-MI patients who needed cardiac 15 30 days. Types of patients often seen in LTACs include ventilator-dependent patients who require long-term weaning, patients requiring intensive respiratory care, © Jones & Bartlett Learning, LLCpatients with chronic renal failure© Jones requiring & Bartlettongoing Learning, LLC NOT FOR SALE OR DISTRIBUTIONdialysis, and patients requiringNOT complex FOR wound SALE care. OR DISTRIBUTION

Specialty Hospitals Specialty hospitals focus on providing care for specific © Jones & Bartlett Learning, LLC types of patients© Jones and conditions. & Bartlett Children’s Learning, hospitals LLC NOT FOR SALE OR DISTRIBUTION are a well-establishedNOT FOR type SALE of specialty OR DISTRIBUTION hospital, often providing very high levels of specialized care and services, including intensive care for pediatric and neonatal patients. Children’s hospitals are often affiliated with medical schools, and typically have an important academic mission that includes training future clini- © Jones & FigureBartlett 1-2 ExampleLearning, of ICU Clinical LLC Support Area. © Jones & Bartlett Learning, LLC cians, and research. Children’s hospitals often provide NOT FOR SALECourtesy of TheOR University DISTRIBUTION fo Chicago. Photograph by Tom Rossiter.Retrieved from https://NOT FOR SALE OR DISTRIBUTION www.uchicago.edu/features/center_for_care_and_discovery/. sophisticated respiratory care services, with staff who

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© Jones &are Bartlett skilled in Learning, providing mechanical LLC ventilatory support © Jonesmedication & Bartlett dosages. Learning, For example, LLCelderly patients may to neonates, infants, and children. Hospitals focusing NOThave FOR slowed SALE medication OR DISTRIBUTION clearance by the kidney and a NOT FOR SALEon women’s OR health DISTRIBUTION have also existed for many years, and progressive loss of other organ function. these hospitals often have very active labor and delivery Theadmitting diagnosis and/or problem list often services. More recently, the development of specialty provides a good starting point for assessment of the hospitals that focus on cardiac care or orthopedics has patient. Common admitting diagnoses seen in the occurred. These hospitals© Jones may concentrate& Bartlett on Learning, perform- LLCICU include lung disease (e.g.,© pneumonia Jones &, respira Bartlett- Learning, LLC heart failure ing certain surgical proceduresNOT FOR (i.e., SALE cardiac OR or ortho- DISTRIBUTIONtory failure, ARDS), heart diseaseNOT (e.g., FOR SALE OR DISTRIBUTION pedic surgery), and may lack other highly developed [also known as congestive heart failure or CHF], services such as a full-service emergency department. coronary artery disease [CAD], acute MI), neuromuscular disease, musculoskeletal disease, shock Skilled Nursing Facilities (anaphylactic, cardiogenic, septic, hypovolemic, and renal failure Skilled© Jones nursing &facilities Bartlett (SNF) Learning, provide care LLC to patients neurogenic),© Jones &, andBartlett traumatic Learning, injury. Com LLC- monly encountered traumatic injuries include chest requiringNOT aFOR higher SALE level of OR care DISTRIBUTION than can be provided in NOT FOR SALE OR DISTRIBUTION trauma, rib fractures, sternal injury, lung contusions, and the home, often following hospitalization. SNF services traumatic pneumothorax. Other common traumatic in- may include patient assessment, skilled nursing care, injuries seen in the ICU include long bone fractures, head travenous injections, dietary counseling, physical ther- trauma, abdominal trauma, burns, and cervical spine apy, occupational therapy, respiratory therapy, speech and/or spinal cord injury. Near-drowning and sedative © Jones & therapy,Bartlett audiology, Learning, and medical LLC social services. Certain© Jones & Bartlett Learning, LLC or narcotic drug overdose often result in ICU admission. NOT FOR SALESNFs will OR accept DISTRIBUTION patients who are ventilator dependent.NOT FOR SALE OR DISTRIBUTION Respiratory failure is often seen in the ICU and may be caused or precipitated by a number of different disease Assessment of the Patient states or conditions (see Box 1-3). Other admitting in the ICU Assessment of the respiratory© Jones care & patientBartlett in the Learning, ICU LLC © Jones & Bartlett Learning, LLC is a core competencyNOT and must FOR include SALE evaluation OR DISTRIBUTION and BOX 1-3 Conditions AssociatedNOT FOR SALE OR DISTRIBUTION monitoring of the patient’s oxygenation, ventilation, and with the Development of Acute circulation. Respiratory care provided in the ICU is con- cerned with maintaining adequate tissue oxygenation, Respiratory Failure alveolar ventilation and carbon dioxide removal, acid– Aspiration © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC base balance, circulation, blood pressure, and cardiac Atelectasis output.NOT Assessment-based FOR SALE OR respiratory DISTRIBUTION care plans may NOT FOR SALE OR DISTRIBUTION Drug overdose (e.g., sedatives, narcotics) focus on improving oxygenation, ensuring adequate ventilation, providing cardiorespiratory support, and moni- Hypoventilation syndrome toring the patient’s condition. Respiratory care plans Morbid obesity may also be developed to provide secretion manage- © Jones & Bartlett Learning, LLC © JonesMusculoskeletal & Bartlett Learning, disease (e.g., LLC ICU myopathy, ment and airway care, treat bronchospasm and mucosal rhabdomyolysis [breakdown of muscle tis- edema, or deliver lung expansion therapy to treat or pre- NOT FOR SALE OR DISTRIBUTION NOT FORsue SALE leading ORto the DISTRIBUTION release of myoglobin in the vent atelectasis. Monitoring procedures can range from blood], and spinal cord injury) respiratory monitoring, to ventilator waveform analysis, to cardiac and hemodynamic monitoring.16 Neuromuscular disease (e.g., myasthenia gravis, Guillain-Barré syndrome) Review of the Medical© Jones Record & Bartlett Learning, LLCExacerbation of chronic ©lung Jones disease & (e.g., Bartlett COPD Learning, LLC A review of the medicalNOT record FOR often SALE provides OR the DISTRIBUTION clini- exacerbation, acute severeNOT asthma) FOR SALE OR DISTRIBUTION cian with a great deal of information needed to monitor, Pneumonia evaluate, and deliver patient care. The patient’s admis- Postoperative respiratory sion data, including name, age, sex, race/ethnicity, Pulmonary contusion height,© Jones weight, & admission Bartlett date Learning, and time, attending LLC phy- © Jones & Bartlett Learning, LLC Pulmonary edema (cardiogenic, noncardiogenic) sician,NOT and FOR other SALE demographic OR DISTRIBUTION information, provides NOT FOR SALE OR DISTRIBUTION an initial picture of the patient as well as information Pulmonary embolus needed to deliver patient care. For instance, the patient’s Restrictive lung disease height is used to calculate predicted body weight (some- Sleep apnea times called ideal body weight), which in turn is used © Jones & toBartlett estimate Learning,desired tidal volumeLLC range for ventilatory © JonesTransfusion-related & Bartlett Learning, acute lung LLC injury (TRALI) NOT FOR SALEsupport. OR The DISTRIBUTION patient’s age should be considered, espe- NOT FORUpper SALE airway OR obstruction DISTRIBUTION cially for the elderly, infants, and children, regarding

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© Jones &diagnoses or problems Bartlett Learning, often LLC see in hospitalized ICU © JonesOther & Bartlettimportant Learning,information found LLC in the patient’s patients include mental health issues, malignant neo- NOTmedical FOR SALErecord includes OR DISTRIBUTION physician’s orders, results of NOT FOR SALEplasms, acuteOR DISTRIBUTION cerebrovascular disease (stroke), diabetes history and physical examinations, vital signs and crit- mellitus, and postoperative surgical procedures (e.g., ical care monitoring flowsheets, progress notes and cardiac surgery, other thoracic surgery, abdominal sur- reports of procedures, results of imaging studies, and gery, and orthopedic surgery). Chronic diseases that reports and diagnostic studies related to respiratory sometimes require intensive© Jones care & include Bartlett heart Learning, failure, LLCcare. Box 1-4 summarizes the© information Jones & often Bartlett found Learning, LLC stroke, COPD exacerbation,NOT FOR cancer, SALE asthma OR exacerba DISTRIBUTION- in the patient’s admitting historyNOT and FOR physical SALE examina- OR DISTRIBUTION tion, and diabetic crisis. tion report.

BOX© Jones 1-4 Results & Bartlett of History Learning, and Physical LLC Examinations © Jones & Bartlett Learning, LLC ReportsNOT FOR of the SALEadmitting OR history DISTRIBUTION and physical Family historyNOT. The FOR family SALE history OR should DISTRIBUTION include examination(s) found in the patient’s medical record pulmonary or cardiac disease among family can be invaluable in the assessment of the ICU pa- members. tient. Items to note include: Review of symptoms. The review of symptoms Date of admission. The date the patient was admit- © Jones & Bartlett Learning, LLC © Jonesshould & Bartlettprovide a summary Learning, of the LLC symptoms, which ted to the hospital and to the ICU. NOT FOR SALE OR DISTRIBUTION NOT FORmay be SALE organized OR by DISTRIBUTION body system. An example of Chief complaint. The primary reason for seeking a review of symptoms organized by body system medical care. follows: History of the present illness. For the ICU patient, this yyGeneral symptoms – such as fever, chills, and may include a description of the course of events re- fatigue © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC lated to the patient’s primary diagnosis or problem. yySymptoms related to the skin – such as sweat- Past medical historyNOT. This FOR may SALE include ORsuch DISTRIBUTIONthings ing, rash, cyanosis, and coldNOT or FORclammy SALE skin OR DISTRIBUTION as previous hospitalizations for cardiac or pul- yyMusculoskeletal symptoms – such as muscle monary problems, prior heart or lung surgery, or weakness, aches and pain thoracic trauma, along with the relevant dates. yyHead-related symptoms – such as headache or © ChronicJones heart & Bartlett disease (such Learning, as CHF or LLC prior MI) or dizziness© Jones & Bartlett Learning, LLC lung problems (such as COPD or asthma) and other NOT FOR SALE OR DISTRIBUTION yyEyes – NOTsuch as FOR blurred SALE vision ORor other DISTRIBUTION vision chronic disease (cancer, diabetes, hypertension, and disturbances obesity) should be noted. Home use of oxygen or ventilatory assist devices (such as bilevel positive yyEars – such as pain, hearing loss, or discharge airway pressure [BiPAP] or CPAP) should also be yyNose – such as nasal discharge, postnasal drip, © Jones & Bartlettnoted. Learning, Any testing performed, LLC such as allergy test-© Jonessinus & Bartlett pain, sneezing, Learning, or nasal LLC obstruction NOT FOR SALEing, OR chest DISTRIBUTION or cardiac imaging studies, pulmonary NOT FORyyThroat SALE – pain, OR hoarseness, DISTRIBUTION or other symptoms function, or sleep studies may be reported. Skin yyEndocrine system – symptoms such as enlarged testing for tuberculosis or fungal disease should thyroid, diabetes, or pregnancy also be noted, along with any immunizations for yyRespiratory system – symptoms such as cough, influenza or pneumococcal© Jones & pneumonia. Bartlett Learning, LLCsputum production, and© dyspnea Jones & Bartlett Learning, LLC Medications. A descriptionNOT FOR of SALEmedications OR theDISTRIBUTION pa- yyCardiac – related symptomsNOT such FOR as chest SALE pain OR DISTRIBUTION tient had been using prior to admission. or palpitations Allergies. Any allergies (e.g., drugs, foods, insect and yyHematologic symptoms – related symptoms stings) should be noted. such as easy bruising or bleeding © PersonalJones and & Bartlettsocial history Learning,. This should LLC include yyLymph© nodes Jones – tender, & Bartlett enlarged Learning, LLC employment, home environment, exposure to in- NOT FOR SALE OR DISTRIBUTION yyGastrointestinalNOT FOR tract SALE – loss ORof appetite, DISTRIBUTION diet, fectious disease, and hobbies. The personal history digestion problems, heartburn, nausea, vomit- should also note the patient’s nutritional status, ing, diarrhea, weight loss, abdominal swelling fitness and exercise tolerance, tobacco use, use of or pain alcohol or recreational drugs, and HIV risk factors. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (Continues)

9781284139860_CH01_001_026.indd 13 21/02/19 3:47 PM 14 CHAPTER 1 Introduction to Critical Respiratory Care

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 1-4 Learning, Results of LLC History and Physical Examinations (Continued) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION yyGenitourinary system – urine output, pain on yyHeart and blood vessels urination (dysuria) yyThorax and lungs (inspection, palpation, percus- yyNeurologic symptoms – fainting, seizures, con- sion, and auscultation) vulsions, unconsciousness,© Jones & Bartlettcoma, paralysis, Learning, or LLCyyAbdomen/gastrointestinal© Jones (abdominal & Bartlett disten- Learning, LLC tremors NOT FOR SALE OR DISTRIBUTIONsion, ileus [bowel obstruction],NOT FOR GI bleeding, SALE and OR DISTRIBUTION yyPsychiatric – to include anxiety, depression, or feeding tube placement). confusion yyGenitourinary (breast, pelvis, genitalia, prostate) yyHematologic symptoms – anemia, easy bruising yyExtremities (swelling, pulses, and tenderness) or bleeding © Jones & Bartlett Learning, LLC yyMusculoskeletal© Jones & Bartlett Learning, LLC Previous patient education. This may include asthma NOT FOR SALE OR DISTRIBUTION yyNeurologicNOT (mental FOR status,SALE motor OR DISTRIBUTIONstrength, and education; smoking cessation instruction; educa- sensation) tion related to the chronic care and management yyOther (skin, hair, and nails; lymphatic system) of COPD, CHF, or diabetes; and weight loss or nutritional education. Assessment or impression. The medical history and physical report will generally conclude with a sec- © Jones & BartlettPhysical Learning, examination LLC. The typical report of the © Jones & Bartlett Learning, LLC tion entitled “Assessment” or “Impression” in which NOT FOR SALEphysical OR DISTRIBUTION examination found in the patient medicalNOT FOR SALE OR DISTRIBUTION the physician or other clinician describes what he or record or chart will include: she has established as the principal, initial, or work- yyGeneral appearance and orientation (aware of ing diagnosis or problem list. name, location, and date) Plan. The last section of the history and physical yyVital signs © Jones & Bartlett Learning, LLCreport describes what is to© be Jones done to complete& Bartlett the Learning, LLC yySkin NOT FOR SALE OR DISTRIBUTIONdifferential diagnosis and NOTto manage FOR the SALE patient’s OR DISTRIBUTION yyEvaluation of head, eyes, ears, nose, and throat problems. This may include further diagnostic tests (HEENT) to confirm or refute the leading diagnosis as well as yyNeck the therapy to be provided and any monitoring or © yJonesyBack and & spineBartlett Learning, LLC patient follow-up© Jones that & is Bartlett planned. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Physician’s orders include medications, IV fluid ad- manage ventilation, special modes (e.g., high-frequency © Jones & ministration,Bartlett Learning, respiratory careLLC orders, and orders for © Jonesventilation, & Bartlett independent Learning, lung ventilation), LLC recruitment laboratory and imaging tests and procedures. Do not re- maneuvers, use of inhaled vasodilators (e.g., nitric oxide, NOT FOR SALEsuscitate OR (DNR) DISTRIBUTION orders and other orders relating to the NOTprostacyclin), FOR SALE specialty OR DISTRIBUTION gas orders, and airway care to level of care (e.g., “comfort care”) should also be noted. include humidification, cuff maintenance, tube position Medication orders may include antimicrobials; car- monitoring, and tracheostomy care. The results of respi- diac and/or cardiovascular agents; systemic steroids; ratory care–related diagnostic studies may also be found sedatives, hypnotics,© narcotics, Jones and & Bartlettpain medications; Learning, LLCin the medical record. These ©include Jones the &results Bartlett of arte- Learning, LLC neuromuscular blocking agents; and respiratory care rial blood gas studies, oximetry, capnography, electro- medications. Box 1-5NOT provides FOR a list SALE of common OR DISTRIBUTIONdrugs cardiography [ECG] studies, pulmonaryNOT FOR function SALE tests, OR DISTRIBUTION and medications often ordered in the ICU. Orders for and sleep study results. IV fluid administration should be noted, including the Orders for laboratory and imaging tests or procedures solution to be used, the rate of infusion, and any medi- should be noted, as they alert the clinician to review the cations© Jones or electrolytes & Bartlett that may Learning, be included. LLC Nutritional medical record© Jones for laboratory & Bartlett reports andLearning, the results LLC of supportNOT orders FOR should SALE also OR be DISTRIBUTIONnoted, including orders imaging studies.NOT Laboratory FOR SALE testing OR results DISTRIBUTION found in the for parenteral nutrition. medical record may include hematology (e.g., complete Respiratory care orders may include orders for oxygen blood count [CBC], hemoglobin), blood chemistry (e.g., therapy, respiratory therapy “treatments,” respiratory electrolytes, magnesium, calcium, phosphate, and lactate diagnostic tests and procedures, and mechanical ventila- levels), coagulation studies (e.g., coagulation indices, © Jones & toryBartlett support Learning, orders (see Box LLC 1-6). Orders for mechani-© Jonesplatelet & count, Bartlett and hypercoagulable Learning, LLC assays), cardiac bio- NOT FOR SALEcal support OR may DISTRIBUTION include noninvasive ventilation, invasiveNOT markers FOR SALE(e.g., troponin, OR DISTRIBUTION brain natriuretic peptide, and ventilation, initial ventilator settings, protocols to creatine kinase-myocardial band [CK-MB]), microbiology

9781284139860_CH01_001_026.indd 14 21/02/19 3:47 PM Assessment of the Patient in the ICU 15

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 1-5 Learning, Medications LLC Ordered in the ICU NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Common medication orders that should be noted as (Medrol), dexamethasone (Decadron), and be- part of a respiratory care patient assessment in the tamethasone (Celestone). Systemic steroids are ICU include: sometimes prescribed in the treatment of acute, Antimicrobials to treat (or prevent) infection. These severe asthma and in exacerbations of COPD. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC may include antibiotics, antivirals, and/or antifun- Neuromuscular blocking agents. These include ve- gal agents usedNOT to treat FOR lung SALEinfection. OR DISTRIBUTIONcuronium (Norcuron), succinylcholineNOT FOR (Anectine), SALE OR DISTRIBUTION Cardiac/cardiovascular agents include vasopressors, rocuronium (Zemuron), and cisatracurium. Neu- inotropic agents, antiarrhythmic agents, antihy- romuscular blocking agents are sometimes used pertensives, antianginal agents, antiplatelet, anti- to immobilize/paralyze patients receiving invasive ©thrombotic Jones & drugs, Bartlett and diuretics. Learning, LLC mechanical© ventilation. Jones & Great Bartlett care must Learning, be taken LLC NOTSedatives, FOR hypnotics, SALE ORnarcotics, DISTRIBUTION and pain medications with the useNOT of neuromuscular FOR SALE blocking OR DISTRIBUTION agents dur- ordered should be noted. Remember that opioids ing mechanical ventilatory support as a ventilator (morphine, meperidine [Demerol], codeine, fen- malfunction or disconnect can be catastrophic in the tanyl [Duragesic, Actiq], oxycodone [Oxycontin], paralyzed patient who is unable to breathe on his or her own. © Jones & Bartlettand hydrocodone Learning, [Vicodin]) LLC act as sedatives and © Jones & Bartlett Learning, LLC may depress ventilation. NOT FOR SALE OR DISTRIBUTION NOT FORDrugs SALE that may OR cause DISTRIBUTION methemoglobinemia include Airway medication instillations. Drugs that may be lidocaine, benzocaine spray, dapsone (Aczone), instilled directly into the airway include cold saline, chloroquine, nitric oxide, and nitroprusside (Nitro- epinephrine, lidocaine (Xylocaine), and atropine press). An elevated level of methemoglobin may (Atropen). On rare occasions, topical thrombin may interfere with the blood’s oxygen-carrying capacity. be directly instilled© Jones into the &airway Bartlett during Learning, bron- LLCMethylene blue may be used© toJones treat severe & Bartlett Learning, LLC choscopy to stopNOT or help FOR control SALE airway OR bleeding DISTRIBUTION or methemoglobinemia. NOT FOR SALE OR DISTRIBUTION hemoptysis. Iced saline lavage via bronchoscopy has Reversal agents. Naloxone (Narcan) is used to reverse also been used in an attempt to control pulmonary the effects of opioid drugs or narcotics. Flumazenil bleeding, though this technique may not be effec- (Romazicon) may be used to reverse the effects of © tiveJones and evidence & Bartlett to support Learning, its use is LLClimited. Direct benzodiazepines,© Jones a class & Bartlettof tranquilizers Learning, also some LLC- NOTinstallation FOR SALEof epinephrine OR DISTRIBUTION (as a vasoconstrictor) times usedNOT to treat FOR insomnia. SALE Neostigmine OR DISTRIBUTION (Prostig- during bronchoscopy has also been suggested to min) is a reversal agent that can reverse the effects control pulmonary bleeding, though evidence for of nondepolarizing muscle relaxants such as ve- the effectiveness of this technique is also limited. curonium and rocuronium. Sugammadex (Bridion) is Systemic steroids. Steroids that may be given a newer agent that specifically reverses rocuronium. © Jones & Bartlettsystemically Learning, include LLCcortisone, hydrocortisone, © JonesEdrophonium & Bartlett (Enlon) Learning, is sometime LLC used in the “ten- NOT FOR SALEprednisone OR DISTRIBUTION (Deltasone), prednisolone (Orapred), NOT FORsilon test”SALE to differentiate OR DISTRIBUTION between a myasthenic vs. triamcinolone (Nasacort), methylprednisolone cholinergic crisis in myasthenia gravis.

BOX 1-6 Respiratory© Jones Care & inBartlett the ICU Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Patient assessment in the ICU should include review Oxygen therapy. O2 therapy to include device, and evaluation of specific orders for respiratory care. liter flow, desired Fio2 and associated oximetry This may include: (Spo2), and/or blood gas results should be noted. Respiratory care consults to assess and treat pa- Oxygen therapy may be ordered “per protocol” © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tients using established protocols or to generate to allow titration based on Spo2 and/or blood gas NOTa respiratory FOR SALE care plan OR may DISTRIBUTION be ordered in some results. ANOT pretherapy FOR blood SALE gas OR or Spo DISTRIBUTION2 measured institutions. Common protocols include those on room air is helpful to establish baseline values

for oxygen therapy, bronchodilator therapy, ven- for Pao2 and Sao2. As-needed or PRN (as opposed tilator adjustments, and ventilator weaning and to protocol-based) oxygen therapy orders should © Jones & Bartlettdiscontinuance. Learning, LLC © Jonesbe avoided, & Bartlett as intermittent Learning, O2 can LLC result in severe

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 1-6 Learning, Respiratory LLC Care in the ICU (Continued) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION hypoxemia if needed oxygen therapy is temporarily should be reviewed carefully to include whether stopped (e.g., during meals, bathroom visits, and protocols should be used for ventilator initia-

patient transport). CPAP devices may also be or- tion, patient stabilization, Fio2 and positive end- dered to improve oxygenation. expiratory pressure (PEEP) support titration, and/or © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Respiratory therapy Orders for inhaled aerosol weaning. The clinician should note the following: NOT. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION medications (bronchodilators, corticosteroids, non- yyNoninvasive ventilation and desired support steroidal anti-asthma medications, anti-infective levels. agents, and mucus-controlling agents), lung expan- yyInvasive ventilation to include mode of sion therapy (incentive spirometry, intermittent ventilation. ©positive Jones pressure & Bartlett breathing Learning, [IPPB]), airway LLC clear- yyInitial ventilator© Jones settings & Bartlett (patient Learning, trigger; tidal LLC NOTance FORtechniques SALE (cough OR and DISTRIBUTION deep breathing instruc- volume;NOT rate; FORinspiratory SALE pressure, OR DISTRIBUTION flow and tion, positive expiratory pressure [PEP] therapy, time; Fio2; PEEP/CPAP). and high-frequency chest wall oscillation), chest yyProtocols to manage ventilation (initial settings, physiotherapy (postural drainage, chest percussion, patient stabilization, weaning, PEEP titration, vibration, and use of chest percussors and/or vibra- © Jones & Bartlett Learning, LLC © Jonesand & Bartlettother). Learning, LLC tors), and other therapies aimed at improving re- NOT FOR SALEspiratory OR DISTRIBUTION function should be noted. HumidificationNOT FORyySpecial SALE modes OR (high-frequency DISTRIBUTION ventilation, in- and/or bland aerosol nebulizer therapy may also be verse ratio ventilation, independent lung ventila- ordered. tion, and other). Respiratory care diagnostic tests and assessment yyProcedures to improve oxygenation to include procedures. Diagnostic© Jones procedures & Bartlett include Learning, oximetry, LLCbronchial hygiene, recruitment© Jones maneuvers, & Bartlett and/ Learning, LLC blood gas studies,NOT and FOR bedside SALE pulmonary OR functionDISTRIBUTION or prone positioning. NOT FOR SALE OR DISTRIBUTION measures (e.g., vital capacity [VC], rapid shallow yyInhaled vasodilators (nitric oxide, prostacyclin). breathing index [RSBI], and maximum inspiratory yySpecialty gas orders (e.g., helium-oxygen pressure [MIP]). Airway care (see also below) and mixtures). © ventilatoryJones & and/or Bartlett hemodynamic Learning, monitoring LLC may yyAirway© care Jones to include & Bartlett humidification, Learning, suction- LLC be prescribed. Therapeutic and/or diagnostic bron- NOT FOR SALE OR DISTRIBUTION ing, cuffNOT maintenance, FOR SALE tube ORposition DISTRIBUTION monitoring, choscopy and insertion of chest tubes to treat pleu- and tracheostomy care. ral effusion and/or pneumothorax may be ordered. yySpecial life-support techniques such as ECMO Mechanical ventilatory support. Orders for invasive and mechanical circulatory assistance (cardiac or noninvasive mechanical ventilatory support balloon pump) may also be ordered. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

(e.g., sputum Gram stain, culture, and sensitivities), liver provided, critical care monitoring flowcharts, and res- functions (alanine aminotransferase, aspartate amino- piratory care notes. Box 1-7 provides an example of the transferase [AST], bilirubin,© Jones and albumin),& Bartlett tests Learning,of kidney LLCtype of information often derived© Jones from review & Bartlett of critical Learning, LLC function (e.g., BUN, creatinine), urinalysis, cytology, his- care monitoring flowcharts.16 tology, and the resultsNOT of molecular FOR SALEdiagnostic OR tests DISTRIBUTION (e.g., NOT FOR SALE OR DISTRIBUTION genetic tests, tests for specific microorganisms). Patient History Reports of imaging studies and procedures may include reports of medical radiography (e.g., chest ra- Obtaining a patient history in the ICU can be problem- diographs,© Jones upper & Bartlettairway radiograph), Learning, CT scans,LLC MRIs, atic. The patient© Jones may be& anxious,Bartlett confused, Learning, incoherent, LLC diagnosticNOT FOR ultrasound SALE studies, OR DISTRIBUTIONpositron emission test- unconscious,NOT or unresponsive, FOR SALE and OR intubated DISTRIBUTION patients ing (PET scans), V˙/Q˙ scans, and results of angiography cannot speak. Even if the patient is able to respond, (i.e., coronary, pulmonary, bronchial, or gastrointestinal the gravity of the clinical situation may preclude tak- angiography). ing a thorough history until the patient is stabilized. In Other valuable information found in the medical many cases, a prior history taken earlier and found in © Jones & recordBartlett includes Learning, the results LLC of prior history and physical© Jonesthe medical & Bartlett record canLearning, be very helpful. LLC In addition, the NOT FOR SALEexaminations, OR DISTRIBUTION progress notes, reports of consultations, NOTpatient’s FOR SALE family, caregiver,OR DISTRIBUTION or other close individuals may reports of procedures and operations, patient education be able to provide some details.

9781284139860_CH01_001_026.indd 16 21/02/19 3:47 PM Assessment of the Patient in the ICU 17

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 1-7 Learning, Critical Care LLC Monitoring NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Results of tests and studies found in the patient’s yyTranscutaneous O2/CO2

medical record directly related to cardiac, respiratory, yyO2 delivery, C(a-v)o2 difference, shunt fraction and hemodynamic function includes flowsheets and Cardiac and hemodynamic monitoring reports related to: yyECG monitoring (heart rate, rhythm, and pres- Respiratory monitoring© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONence of arrhythmias) NOT FOR SALE OR DISTRIBUTION yyPulse oximetry (Spo2) yyBlood pressure monitoring yyRespiratory rate and pattern (spontaneously yyFluid balance (intake and output – I&O) breathing patients), patient-to-ventilator syn- chrony (ventilator patients) yyCentral venous pressure (CVP) monitoring ©y JonesyMachine & and Bartlett patient Learning,spontaneous respiratoryLLC yyPulmonary© Jones artery pressure& Bartlett monitoring Learning, (PAP) and LLC NOTrate FOR for ventilator SALE OR patients, DISTRIBUTION tidal volume (ma- pulmonaryNOT capillary FOR SALEwedge pressure OR DISTRIBUTION (PCWP) chine and patient), minute volume, and I:E ratio yyNoninvasive hemodynamic monitors (uses arte- for ventilator patients rial or capillary waveform analysis or changes in thoracic bioreactance) yyCompliance, airway resistance, and work of © Jones & Bartlettbreathing Learning, (WOB) LLCfor ventilator patients © JonesyyLeft & Bartlettheart preload Learning, (often assessed LLC by estimates of left atrial end-diastolic pressure) NOT FOR SALEyy PulmonaryOR DISTRIBUTION mechanics (maximum inspiratory NOT FOR SALE OR DISTRIBUTION pressure [MIP], bedside vital capacity [VC]) yyLeft heart afterload (often assessed by arterial blood pressure) yyRapid shallow breathing index (RSBI) for ventilator discontinuance yyCardiac output/index yyCapnography,© end-tidal Jones carbon& Bartlett dioxide Learning, tension LLCyyIntracranial pressure monitoring© Jones (ICP) & Bartlett Learning, LLC (PETco2), deadNOT space FOR to tidal SALE volume OR ratio DISTRIBUTION (VD/ NOT FOR SALE OR DISTRIBUTION VT), and CO2 clearance

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTThe traditional FOR SALE patient OR history DISTRIBUTION will include demo- respiratory NOTdistress, FOR agitation, SALE impaired OR DISTRIBUTION judgment, graphic data, a patient profile, the chief complaint, confusion, decreased night vision, disorientation, history of the present illness, past medical history, listlessness, headache, tingling, and loss of coordina- personal and social history, and occupational and envi- tion. Severe hypoxia may be accompanied by severe ronmental history (see Box 1-4). Ideally, a pulmonary dyspnea, confusion, somnolence, severe headache, © Jones & historyBartlett provides Learning, information LLC regarding cough, sputum © Jonesvisual &disturbances Bartlett (e.g.,Learning, blurred or LLC tunnel vision), and production, hemoptysis, wheezing, stridor, chest tight- slowed reaction time. Symptoms associated with ven- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ness, chest pain, dyspnea, smoking history, and current tilatory disorders (e.g., altered Paco2) include anxiety, medications, and includes respiratory and/or cardiac/ restlessness, headache, drowsiness, dyspnea (conscious cardiovascular medications as well as current respira- sensation of difficult breathing), orthopnea (breathing tory care. Additional information gathered during an more comfortable in the upright position), trepopnea initial history and physical© Jones examination & Bartlett may include Learning, LLC(breathing more comfortable© in Jonesa specific & position),Bartlett and Learning, LLC nutritional status, the patient’s learning needs, exercise ponopnea (painful breathing). tolerance, and advanceNOT directives, FOR SALEif any. Items OR to DISTRIBUTION be NOT FOR SALE OR DISTRIBUTION included in the pulmonary history for assessment of the Physical Examination ICU patient are listed in Box 1-8. Of particular interest in assessing patients in the The traditional physical examination includes exam- ICU© areJones problems & Bartlett with oxygenation Learning, or ventilation. LLC Re- ination of the© skin;Jones head, & eyes, Bartlett ears, nose, Learning, and throat LLC callNOT that symptoms FOR SALE are subjective OR DISTRIBUTION findings reported to (HEENT); neck;NOT back FOR and SALE spine; heartOR andDISTRIBUTION blood ves- you by the patient, while signs are objective findings sels; thorax and lungs; abdomen (i.e., gastrointestinal); that you observe directly (or via laboratory or other musculoskeletal system, and extremities. The neurologic diagnostic testing). Symptoms of mild hypoxia may examination may include evaluation of the patient’s include shortness of breath, mild respiratory distress, mental status and assessment to identify cognitive, sen- © Jones & excitement,Bartlett Learning, overconfidence, LLC restlessness, anxiety, eu- © Jonessory, motor, & Bartlett or coordination Learning, deficits. LLC NOT FOR SALEphoria, lightheadedness,OR DISTRIBUTION nausea, dizziness, and fatigue.NOT FORThe SALErespiratory OR physical DISTRIBUTION assessment should be espe- Moderate hypoxia may be accompanied by increased cially attentive to signs of respiratory distress, hypoxia,

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 1-8 Learning, Pulmonary LLC History in the ICU NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ICU patients may be unable to provide a detailed his- yyColor: bright red, brown tory, due to the nature of their condition. Information, yyAmount: slight, blood-tinged sputum vs. frank however, may sometimes be obtained from the medi- hemoptysis cal record, a family member, or the patient regarding © Jones & Bartlett Learning, LLCWheezing, whistling, chest© tightness Jones – &presence Bartlett Learning, LLC important aspects of the pulmonary history. This and nature of wheezing or chest tightness includes evaluationNOT of cough, FOR sputum SALE production, OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION yyOnset, duration, frequency, associated events hemoptysis, wheezing or chest tightness, chest pain, and dyspnea. Knowledge of the patient’s smoking his- Chest pain – presence and nature of chest pain tory, current medications, and prior respiratory care yyNature, location, duration, associated activities received© Jones (if any) & Bartlettis also important. Learning, The patient’s LLC pul- or events© Jones & Bartlett Learning, LLC monaryNOT FORhistory SALE includes: OR DISTRIBUTION BreathlessnessNOT (dyspnea)FOR SALE – presence OR DISTRIBUTIONand nature of Cough – presence and characteristics dyspnea yyOnset: sudden, gradual; duration yyOnset, position, associated symptoms, level of yyNature: dry, moist, wet, hacking, hoarse, barking, activity associated with dyspnea (severe exer- tion, exercise, stairs, walking, at rest) © Jones & Bartlettwhooping, Learning, bubbling, LLC productive, nonproductive© Jones & Bartlett Learning, LLC Smoking history NOT FOR SALEyy Pattern:OR DISTRIBUTION occasional, regular, paroxysmal; relatedNOT FOR SALE OR DISTRIBUTION to time of day, weather, activities, talking, deep yyCigarettes, cigars, pipes, other breaths; change over time yyFrequency and amount (pack-years for yySeverity: tiring, sleep disruption, chest pain cigarettes) Associated symptoms: dyspnea, chest pain, yyAttempts to quit yy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC headache, and choking Current medications NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION yyEfforts to treat: medications, other yyRespiratory (bronchodilators, anti-inflammatory Sputum – presence, amount, and nature of sputum agents, other) production yyAntibiotics yyAmount: milliliters, tablespoons, teaspoons Cardiac drugs © Jones & Bartlett Learning, LLC yy © Jones & Bartlett Learning, LLC yyFrequency: daily, mornings, Mondays, etc. Other NOT FOR SALE OR DISTRIBUTION yy NOT FOR SALE OR DISTRIBUTION yyColor: green, yellow, brown, colorless, “red Current respiratory care brick,” frothy pink yyOxygen yyConsistency: purulent, viscous, tenacious, wa- yyVentilatory support tery, saliva yyBronchodilators and anti-asthmatic medications © Jones & BartlettyyOdor: Learning, foul smelling, LLC sweet smelling © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORyyBronchial SALE hygiene OR DISTRIBUTION and airway care (chest phys- yyOther: blood-tinged, bloody, mucus plugs iotherapy, PEP therapy, flutter, artificial airways, Hemoptysis – presence and nature of hemoptysis humidifiers, nebulizers, etc.)

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and hypercapnia (i.e., ventilatory failure). Signs of mild Irregular or asynchronous breathing, periods of hypoxia include increased respiratory rate, increased apnea, or rapid, shallow breathing all suggest prob- heart rate, mild hypertension, and peripheral vasocon- lems with ventilation. An increase in inspiratory work striction.© Jones Moderate & Bartlett hypoxia mayLearning, be accompanied LLC by of breathing© may Jones be accompanied & Bartlett by Learning,palpable sca- LLC tachycardia,NOT FOR tachypnea, SALE hyperventilationOR DISTRIBUTION (increased lene muscleNOT contraction FOR duringSALE inspiration. OR DISTRIBUTION Palpable minute volume), accessory muscle use, intercostal re- abdominal muscle contraction during expiration is tractions, hypertension, and cardiac arrhythmias. Se- associated with increased expiratory work due to air- vere hypoxia may be accompanied by slowed, irregular way obstruction. A serious problem seen in patients breathing, cyanosis, hypertension followed by hypoten- receiving mechanical ventilation is patient-ventilator © Jones & sion,Bartlett tachycardia Learning, followed LLC by bradycardia, unconscious-© Jonesbreathing & Bartlett asynchrony, Learning, which occurs LLC when a patient’s NOT FOR SALEness, and OR coma; DISTRIBUTION severe hypoxia may lead to respiratoryNOT breathing FOR SALE efforts OR are DISTRIBUTIONnot matched by the ventilator. and/or cardiac arrest. Signs associated with an elevated carbon dioxide level

9781284139860_CH01_001_026.indd 18 21/02/19 3:47 PM Assessment of the Patient in the ICU 19

© Jones &(i.e., Bartlett hypercapnia/hypoventilation) Learning, LLC are similar to those © Joneswith kidney & Bartlett disease, Learning, dehydration, LLCor a high-protein diet. found with hypoxia, though a red or flushed appear- NOTElevated FOR SALE BUN and OR serum DISTRIBUTION creatinine are associated spe- NOT FOR SALEance to theOR skin DISTRIBUTION may be present. Other signs of hyper- cifically with kidney disease. An elevated total bilirubin capnia may include alterations in respiratory rate or may be associated with liver disease, biliary obstruction, pattern, blood pressure elevation or depression, head- or a hemolytic disorder. Cardiac markers include the ache, dizziness, confusion, nausea, vomiting, abnormal cardiac troponins, CK-MB, myoglobin, lactate dehydro- mental state (e.g., hallucinations),© Jones & diaphoresis,Bartlett Learning, visual LLCgenase (LDH), and AST. Elevated© Jones troponin & levelsBartlett and Learning, LLC distortion, lethargy, NOTloss of FORconsciousness, SALE ORconvulsions, DISTRIBUTION CK-MB are used to confirm NOTa diagnosis FOR of SALE acute MI.OR DISTRIBUTION and coma. Elevated troponin levels with a negative CK-MB are as- Acute ventilatory failure (AVF) is defined as a sudden sociated with non-ST segment elevation MI (NSTEMI rise in arterial Paco2 with a corresponding decrease in type 1 or NSTEMI type 2, also called demand ischemia). pH. Clinical manifestations of AVF include alterations An elevated hemoglobin A1C, elevated fasting plasma in vital© Jones signs (e.g., & Bartletttachycardia, Learning, tachypnea), LLCsigns of glucose level,© orJones elevated & plasma Bartlett glucose Learning, level during LLC a respiratoryNOT FOR distress SALE (e.g., dyspnea)OR DISTRIBUTION and increased work 2-hour oral NOTglucose FOR tolerance SALE test ORare associated DISTRIBUTION with of breathing (e.g., accessory muscle use, intercostal re- diabetes. tractions, and diaphoresis), and oxygen desaturation. Rapid shallow breathing is common, though slowed or irregular respirations, reduced chest expansion, and hy- RC Insight © Jones & potensionBartlett are Learning, seen with severe LLC ventilatory failure. Rest-© Jones & Bartlett Learning, LLC NOT FOR SALElessness, OR anxiety, DISTRIBUTION headache, and altered mental status NOT FORElectrolyte SALE disturbances OR DISTRIBUTION can affect the body’s may be followed by confusion, somnolence, and coma acid–base balance. For example, low potassium as respiratory failure progresses. Nasal flaring is some- (↓K+) may cause metabolic alkalosis (i.e., hypoka- times seen in infants and children. lemic alkalosis). Laboratory Studies© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC A wide range of laboratoryNOT FORstudies SALE may be orderedOR DISTRIBUTION to NOT FOR SALE OR DISTRIBUTION assist in the assessment of the ICU patient. For example, Arterial blood gas studies include measurement of various hematology tests may be performed to assess pH, oxygen, and carbon dioxide tensions (Pao2 and for the presence of anemia (e.g., decreased red blood Paco2), and calculation of arterial oxygen saturation (Sao2) and metabolic acid–base parameters (e.g., plasma cell count [RBC], decreased hemoglobin [Hb], and de- − creased© Jones hematocrit & Bartlett [HCT]); impairedLearning, blood LLC coagulation bicarbonate© [HCO Jones3 ], base & Bartlett excess or deficit).Learning, The LLCarte- (e.g.,NOT decreased FOR plateletSALE count, OR DISTRIBUTIONincreased prothrombin rial blood gasNOT and FORpH analysis SALE provides OR DISTRIBUTION a method for time [PT/INR, expressed as the International Normal- rapid evaluation of a patient’s oxygenation, ventilation, ized Ratio]), and increased activated partial thrombo- and acid–base balance. Newer blood gas analyzers may incorporate measurement of many additional param- plastin time [aPTT], or polycythemia (e.g., increased + + 2+ − Hb and HCT). The white blood cell count (WBC) can eters including HCT, electrolytes (Na , K , Ca , Cl ), © Jones & helpBartlett assess forLearning, the presence LLC of infection (e.g., changes © Jonesglucose, & lactate,Bartlett and Learning,creatinine. The LLC addition of CO oximetry allows for the measurement of oxygen saturation NOT FOR SALEin neutrophil OR DISTRIBUTION count, lymphocyte count, or monocyte NOT FOR SALE OR DISTRIBUTION count), allergic reactions (e.g., elevated eosinophil (Sao2), total hemoglobin (Hb), oxyhemoglobin (HbO2), count, elevated basophil count), or leukemia. carboxyhemoglobin (HbCO), and methemoglobin (HbMet), Infectious agents can be isolated from blood, spu- RC Insight © Jones & Bartlett Learning, LLCtum, other body fluids (e.g., ©pleural Jones fluid), & Bartlettor wounds Learning, LLC and identified and tested for susceptibility to antimicro- Anemia or blood lossNOT may FOR decrease SALE hemoglobin OR DISTRIBUTION bial agents using various microbiologyNOT FOR laboratory SALE tech- OR DISTRIBUTION (Hb) and hematocrit (HCT) levels. Anemia reduces niques. Infectious agents so identified include bacteria, the blood’s oxygen-carrying capacity. mycobacteria, yeasts, molds, parasites, and viruses. Laboratory tests used to identify specific microorgan- © Jones & Bartlett Learning, LLC isms include© direct Jones examination & Bartlett using Learning, light microscopy, LLC Clinical chemistry includes measures of serum elec- various staining techniques (e.g., Gram stain, acid-fast NOT FOR +SALE+ −OR DISTRIBUTION− NOT FOR SALE OR DISTRIBUTION trolytes (e.g., Na , K , Cl , HCO3 ), glucose, calcium, stain, and fluorescent stains), traditional culture-based total protein, albumin, BUN, creatinine, bilirubin, and methods, techniques that incorporate laser ionization liver-associated enzymes. Electrolyte disorders may be and mass spectrometry, and analysis of nucleic acid caused by renal failure, acid–base disturbances (acidosis (i.e., DNA or RNA) in the microorganism using poly- or alkalosis), or dehydration, which may cause elevated merase chain reaction (PCR) or transcription-mediated © Jones & Bartlett+ Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALENa . An OR elevated DISTRIBUTION creatinine can be caused by kidney NOTamplification FOR SALE (TMA). OR DISTRIBUTION PCR panels are available that can disease or muscle tissue breakdown. BUN may increase rapidly identify multiple respiratory viruses and atypical

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© Jones &bac Bartlettteria (Mycoplasma Learning,, Chlamydia LLC , and Bordatella per-© Jonescardiac & tamponade. Bartlett Learning,Lung ultrasound LLC provides a method tussis). Urinary antigen assays may be helpful to identifyNOT for FOR rapid SALE diagnosis OR of DISTRIBUTIONpneumothorax, identification of NOT FOR SALEcertain infectiousOR DISTRIBUTION agents (e.g., Streptococcus pneu- pleural effusion, and differentiating between lung con- moniae, Legionella) that may cause pneumonia. solidation, interstitial syndrome, and distinguishing be- Urinalysis may include measurement of the urine’s tween atelectasis and pneumonia.17 The BLUE-protocol specific gravity, pH, glucose concentration, ketones, is an ultrasound technique for the rapid (< 3 minutes) 17 nitrate, leukocyte esterase,© Jones bilirubin, & Bartlett urobilinogen, Learning, LLCdiagnosis of ARF. The Fluid© AdministrationJones & Bartlett Limited Learning, LLC protein, and red blood cells. For example, a decrease in by Lung Sonography (FALLS) protocol adapts this pro- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR17 DISTRIBUTION urine pH may be associated with starvation, diabetes cedure for the assessment of acute circulatory failure. mellitus (e.g., diabetic ketoacidosis), or diarrhea. Severe Abdominal ultrasound techniques can be used to assess vomiting, hyperventilation, gastric suction, or kidney ICU patients with ascites, bladder distention, dimin- failure may cause urine pH to rise. Normally, glucose is ished renal blood flow, and kidney swelling (hydro- not© found Jones in the & urine; Bartlett however, Learning, an elevated LLC urine glu- nephrosis) due© Jones to urine &flow Bartlett obstruction Learning, (e.g., kidney LLC coseNOT level FORis associated SALE with OR diabetes DISTRIBUTION mellitus or Cush- stone, tumor,NOT or papillary FOR SALEnecrosis OR from DISTRIBUTION a urinary tract ing syndrome. In a similar fashion, starvation, diabetes infection or bladder obstruction). Ultrasound tech- mellitus, or very low carbohydrate diet can result in an niques may also be used to evaluate cerebral blood flow, increase in ketones in the urine. and to aid in thoracentesis and the placement of arterial Histological and cytological procedures may be em- or central venous lines. Ultrasound may also be used © Jones & ployedBartlett to identify Learning, abnormal LLC cells (e.g., tumor cells) in © Jonesduring & cardiac Bartlett resuscitation Learning, to assess LLC cardiac standstill NOT FOR SALEtissues, secretions,OR DISTRIBUTION or aspirates. Molecular diagnostic NOTand FOR fine SALE ventricular OR fibrillation.DISTRIBUTION techniques use DNA and RNA analysis to identify the cause of diseases or to refine the diagnosis. Examples include inherited diseases, cancer, or viral disease. Mul- RC Insight tiplex nucleic acid amplification assays can be used to detect a number of bacterial© Jones and & viral Bartlett respiratory Learning, patho- LLCThe BLUE-protocol uses lung© Jonesand venous & Bartlettultra- Learning, LLC sound to rapidly distinguish some of the main gens from a nasal aspirate,NOT nasopharyngealFOR SALE OR swab, DISTRIBUTION or NOT FOR SALE OR DISTRIBUTION bronchoalveolar lavage sample. Skin tests for tubercu- causes of respiratory failure: pneumonia, pulmo- losis or fungal lung disease may also be useful for some nary edema, pneumothorax, COPD, asthma, and patients. pulmonary embolism.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Bronchoscopy and Thoracentesis RCNOT Insight FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Diagnostic bronchoscopy can be especially help- Arterial blood gas analysis can quantify the de- ful in the evaluation of hemoptysis, certain types of gree of hypoxemia (↓Pao2, ↓Sao2) and identify pneumonia, interstitial lung disease, and evaluation hypoventilation (↑Paco2) or hyperventilation of masses and solitary pulmonary nodules. Bronchos- © Jones & Bartlett(↓Paco2). Learning, The degree of LLC an acidosis (↓pH) or alka- © Jonescopy can & Bartlettbe used therapeutically Learning, toLLC remove foreign NOT FOR SALElosis (↑pH)OR DISTRIBUTION can also be determined. NOTbodies FOR or SALE clear plugs OR andDISTRIBUTION secretions directly from the airway. Bronchoalveolar lavage (BAL) is sometimes performed during bronchoscopy to provide a fluid Imaging in the ICU sample for laboratory testing to diagnose infection, perform cytology, or to perform immunologic studies. Imaging studies available© Jones for the &assessment Bartlett of Learning, the ICU LLCEndobronchial ultrasound (EBUS)© Jones is a type & of Bartlett flexible Learning, LLC patient include portableNOT chest FOR radiographs, SALE OR various DISTRIBUTION bed- bronchoscopy that incorporatesNOT an ultrasoundFOR SALE probe. OR DISTRIBUTION side sonography (i.e., ultrasound) studies, and access to EBUS is especially useful for sampling mediastinal more sophisticated diagnostic imaging techniques such and hilar lymph nodes. While bronchoscopy nor- as CT scans, MRI, PET scans, diagnostic medical so- mally is performed in the bronchoscopy suite, bedside nography (abdominal ultrasound, vascular ultrasound, bronchoscopy can be performed in the ICU. Bedside and© echocardiography), Jones & Bartlett and otherLearning, imaging LLC studies that bronchoscopy© Jones in the ICU & mayBartlett be especially Learning, helpful LLC to mayNOT require FOR patient SALE transport OR DISTRIBUTIONto the radiology depart- evaluate theNOT airway, FOR clear SALE a mucus OR plug, DISTRIBUTION remove secre- ment or other central imaging center. tions, or differentiate causes of hemoptysis. In recent years, bedside ultrasonography has gained Thoracentesis allows the removal of pleural fluid widespread acceptance in the ICU. Cardiac ultrasound for both diagnostic and therapeutic purposes. Pleural may be employed in the ICU to assess hemodynamics fluid analysis generally includes the measurement of © Jones & andBartlett volume Learning, status, cardiac LLC output, myocardial con- © Jonespleural & fluid Bartlett pH, protein, Learning, lactate LLCdehydrogenase (LDH), NOT FOR SALEtractility, OR ventricular DISTRIBUTION function, pericardial effusion, andNOT cholesterol, FOR SALE and glucose,OR DISTRIBUTION and may include other tests

9781284139860_CH01_001_026.indd 20 21/02/19 3:47 PM Types of Respiratory Care Provided in the ICU 21

(e.g., cytology, bacterial culture). Pleural fluid analysis technique for hemodynamic monitoring that incorpo- © Jones & Bartlett Learning, LLCtransudates exudates © Jones & Bartlett Learning, LLC can differentiate between and . NOTrates FOR transpulmonary SALE OR DISTRIBUTIONthermodilution for calibration NOT FOR SALEExudative OR pleural DISTRIBUTION effusions can be caused by infection, and pulse contour analysis for continuous monitoring of cancer, or pulmonary embolus, while transudates may cardiac output. be caused by heart failure, renal failure, liver failure, or Patients receiving mechanical ventilation are con- cirrhosis. Whenever possible, thoracentesis should be tinuously monitored for ventilatory pressures, flows, 16 guided by ultrasound© to Jones ensure patient& Bartlett safety andLearning, opti- LLCvolumes and waveforms (see ©Clinical Jones Focus & Bartlett1-2). In Learning, LLC mize the success of theNOT procedure. FOR SALE OR DISTRIBUTIONaddition, certain patients (e.g.,NOT head FOR trauma, SALE postopera- OR DISTRIBUTION tive neurosurgery) may benefit from intracranial pres- Cardiac Monitoring in the ICU sure (ICP) monitoring. Patients in the ICU often receive continuous cardiac monitoring, which usually includes heart rate, blood Types of Respiratory Care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC pressure, electrocardiogram (ECG), and continuous Provided in the ICU monitoringNOT FOR of pulse SALE oximetry OR valuesDISTRIBUTION (Spo2). Newer NOT FOR SALE OR DISTRIBUTION cardiac monitors may allow for simultaneous monitor- Patients in ICU often have problems that affect oxygen- ing of multiple leads and have sophisticated algorithms ation and/or ventilation. Respiratory failure is a general to alert the clinician to the development of cardiac term indicating an inability of the heart and lungs to arrhythmias (e.g., changes in the ST segment, develop- maintain adequate tissue oxygenation and/or removal of © Jones & mentBartlett of atrial Learning, fibrillation). LLC The traditional 12-lead ECG© JonesCO2. ARF& Bartlett can be defined Learning, as a sudden LLC decrease in arte- NOT FOR SALEis also readily OR DISTRIBUTION available in the ICU. NOTrial FOR blood SALE oxygen OR levels DISTRIBUTION with or without carbon dioxide Invasive hemodynamic monitoring techniques us- retention. AVF can be defined as a sudden rise in Paco2 ing central lines to measure CVP, PAP, PCWP, cardiac with a corresponding decrease in pH. Clinical Focus 1-2 output, and mixed venous oxygen saturation are not discusses the use of mechanical ventilation in the ICU. as common in the ICU as in the past, and a number ICU patients may suffer from upper respiratory tract of noninvasive and less-invasive© Jones &measures Bartlett of hemo- Learning, LLCinfection, pneumonia, acute bronchitis,© Jones and & Bartlettasthma Learning, LLC dynamic function areNOT now available.FOR SALE Critical OR care DISTRIBUTION exacerbation, exacerbation ofNOT COPD, FOR pulmonary SALE hyper- OR DISTRIBUTION echocardiography (i.e., bedside cardiac ultrasound) is tension, CHF, pulmonary emboli, cardiac or noncardiac a noninvasive method that can be used in assessment pulmonary, or postoperative pulmonary complications. of ventricular preload, left ventricular function, and All of these conditions may lead to ARF, impair gas response to fluid administration. Pulse index continu- exchange, and require oxygen therapy, ventilatory sup- ous© cardiac Jones output & Bartlett (PiCCO) providesLearning, a less-invasive LLC port, and the© useJones of PEEP. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

CLINICAL FOCUS 1-2 Mechanical Ventilation Mechanical ventilatory support, also known as me- Question 2. What are the indications for © Jones & Bartlettchanical ventilation,Learning, is usedLLC to support oxygenation © Jonesmechanical & Bartlett ventilation? Learning, LLC NOT FOR SALEand ventilation OR DISTRIBUTION in patients with ARF. These patients NOTThe FOR most SALE common OR reason DISTRIBUTION for initiating mechanical

may be suffering from a wide range of disorders that ventilation is hypercapnic (↑Paco2) respiratory failure, can affect the heart and lungs ability to maintain tis- also known as ventilatory failure or pump failure. AVF sue oxygenation and removal of CO2. is an indication for mechanical ventilation. The other Question 1. What© are Jones the most & commonBartlett Learning, mainLLC indications for mechanical© Jonesventilation & areBartlett apnea Learning, LLC causes of ARF? NOT FOR SALE OR DISTRIBUTIONand impending ventilatory failure.NOT Patients FOR withSALE severe OR DISTRIBUTION Common causes of ARF include ARDS, pneumonia, oxygenation problems may also be placed on mechan- trauma, sepsis, heart failure, postoperative respiratory ical ventilatory support in order to ensure adequate failure, and aspiration. Other causes of ARF include ventilation and oxygenation and apply PEEP. acute© Jones exacerbation & Bartlett of COPD, Learning, acute, severe LLC asthma, Question 3.© How Jones can you & recognizeBartlett AVF?Learning, LLC upperNOT or FOR central SALE airway OR obstruction, DISTRIBUTION and pulmonary Clinical manifestationsNOT FOR (i.e., SALE signs andOR symptoms) DISTRIBUTION of embolus. Neuromuscular or neurologic disease may AVF include respiratory distress, abnormal breath- also predispose patients for the development of ARF. ing pattern (e.g., tachypnea, rapid-shallow breath- Respiratory failure may require ICU admission and me- ing, accessory muscle use, and slowed, irregular

chanical ventilatory support. breathing or apnea), oxygen desaturation (e.g., Spo2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (Continues)

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© Jones & Bartlett Learning, LLC © Jones & BartlettCLINICAL Learning, FOCUS 1-2 LLC Mechanical Ventilation (Continued) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION < 90%), cardiac arrhythmias (e.g., tachycardia, abnor- be considered for patients with an acute increase in

mal rhythm), and alterations in mental status (e.g., Paco2 (> 45 mmHg) resulting in a pH ≤ 7.25. Items to anxiety, confusion, somnolence, unconsciousness, or be monitored following the institution of mechanical

coma). AVF is confirmed by obtaining an arterial blood ventilation include oximetry values (i.e., Spo2), ventila- gas study that shows© Jones an elevated & Bartlett arterial carbon Learning, diox- LLCtory parameters (e.g., respiratory© Jones rate, tidal & volume, Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ide level (e.g., Paco2 > 45 mmHg) and a corresponding I:E ratio, ventilatory pattern, patient-ventilator in- decrease in arterial pH (e.g., pH < 7.35) due to respira- teraction, airway pressures, and ventilator graphics), tory acidosis/hypercapnia. cardiac monitoring (e.g., rate, rhythm, and ECG), and Question 4. What are some of the things hemodynamic monitoring (e.g., arterial blood pressure, that© Jones should be& Bartlettmonitored Learning, during mechanical LLC fluid intake ©and Jones output, ¢ral Bartlett line pressures, Learning, and LLC ventilation?NOT FOR SALE OR DISTRIBUTION measures of NOTcardiac FOR output). SALE OR DISTRIBUTION AVF is an important indication for the institution of mechanical ventilation and ventilatory support should

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALERespiratory OR DISTRIBUTION care provided in the ICU may include NOT(e.g., FOR incentive SALE spirometry OR DISTRIBUTION [IS]and various forms of therapy to improve oxygenation and/or ventilation, positive airway pressure) may also be of some value to provide secretion management and airway care, treat prevent or treat inadequate lung expansion and atelec- bronchospasm and mucosal edema, or deliver lung tasis. It must be noted however, that the evidence base expansion therapy to© treat Jones or prevent & Bartlett atelectasis. Learning, Inva- LLCfor the effectiveness of various© JonesACT and & lung Bartlett expan- Learning, LLC sive or noninvasive ventilatory support (i.e., mechani- sion therapy techniques does not provide a high level of cal ventilation) in theNOT ICU shouldFOR SALEaim to maintain OR DISTRIBUTION support for their use.18, 19 ClinicalNOT Focus FOR 1-3 SALE discusses OR DISTRIBUTION adequate tissue oxygenation, support ventilation and the use of airway clearance therapies in the ICU. carbon dioxide removal, and maintain a normal or To review, basic respiratory care techniques and near-normal acid–base balance. Respiratory care pro- procedures often used in the ICU setting include oxy- vided© Jonesin the ICU & alsoBartlett seeks toLearning, maintain adequate LLC circu- gen therapy,© secretion Jones management, & Bartlett managementLearning, ofLLC lation, blood pressure, and cardiac output. Monitoring bronchospasm and airway edema, and lung expansion of theNOT patient’s FOR oxygenation SALE OR status, DISTRIBUTION ventilatory status, therapy. ProceduresNOT FOR and techniquesSALE OR sometimes DISTRIBUTION clas- and cardiac and hemodynamic function is a central sified as critical respiratory care include invasive and concern. noninvasive mechanical ventilatory support, physiologic Specific respiratory problems seen in the ICU in- monitoring, cardiac and hemodynamic monitoring, clude bronchospasm and mucosal edema, retained suctioning and airway care, airway intubation, advanced © Jones & secretions,Bartlett andLearning, airway plugging. LLC These problems may © Jonescardiovascular & Bartlett life support, Learning, ECMO, LLC and mechanical NOT FOR SALErespond OR to various DISTRIBUTION forms of respiratory care, such as NOTcirculatory FOR SALE assistance. OR DISTRIBUTION Respiratory care diagnostic tests oxygen therapy, administration of aerosolized medica- performed in the ICU include oximetry, arterial blood tions and secretion clearance techniques (e.g., suction- gases, venous blood gases, and bedside pulmonary ing and airway care, and/or airway clearance therapy function testing. Table 1-1 lists the types of respiratory Clinical Focus 1-3 [ACT]; see © Jones). Lung & Bartlett expansion Learning, therapy LLCcare commonly provided in the© JonesICU. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

CLINICAL FOCUS 1-3 Airway Clearance Therapies in the ICU Concerns regarding secretion mobilization, ineffective intubation. Impaired cough is common in patients with cough,© Jones secretion & Bartlett retention, Learning,mucous plugging, LLC atel- neuromuscular© Jonesdisease, respiratory& Bartlett muscle Learning, weakness, LLC ectasis,NOT FORand the SALE possible OR development DISTRIBUTION of pneumonia and followingNOT abdominal FOR or SALE thoracic OR surgery. DISTRIBUTION Conse- secondary to retained secretions and infection are com- quently, airway clearance therapy (ACT) for secretion mon in the ICU patient. Excessive airway secretions may management has been widely used in the acute care set- be seen in ICU patients with COPD exacerbation, acute ting, including the ICU. © Jones & Bartlettand chronic Learning, bronchitis, acuteLLC asthma, bronchiectasis, © JonesACT techniques& Bartlett commonly Learning, used LLCinclude chest phys- NOT FOR SALEpneumonia, OR DISTRIBUTION and in patients following endotracheal NOTiotherapy FOR SALE (CPT), positiveOR DISTRIBUTION expiratory pressure (PEP),

9781284139860_CH01_001_026.indd 22 21/02/19 3:47 PM Key Points 23

© Jones & Bartlett Learning, LLC © Jones & Bartlettintrapulmonary Learning, percussive LLC ventilation (IPV), and in- 4. What would be the associated cost of NOT FOR SALEcentive OR spirometry DISTRIBUTION (IS) to prevent atelectasis. AirwayNOT FORproviding ACT? SALE OR DISTRIBUTION clearance therapies also include active cycle breath- 5. Does the patient have any preferences ing, forced exhalation technique (FET), high-frequency regarding ACT? chest wall compression (HFCWC), and mechanical If an individual patient has an inadequate cough and insufflation–exsufflation.© Jones & Administr Bartlettation of Learning,aerosol- LLCdifficulty clearing secretions, ©retained Jones secretions & Bartlett are Learning, LLC ized medications (e.g.,NOT bronchodilators, FOR SALE mucolytics)OR DISTRIBUTION affecting gas exchange or lungNOT mechanics FOR (e.g., SALE lung OR DISTRIBUTION and/or bland aerosols have also been routinely used in compliance and/or airway resistance), the potential for the ICU setting to aid in secretion mobilization. Cur- adverse effects are minimal, and the cost is acceptable, rent evidence suggests that ACT may be considered in ACT may be appropriate. Patient preferences should also 18 the following types of patients seen in the ICU: 18, 19 © Jones & Bartlett Learning, LLC be considered.© GoalsJones of ACT & Bartletttherapy may Learning, include : LLC COPD patients with secretion retention and associ- Changes in volume of expectorated sputum NOTated FORsymptoms SALE and ORan ineffective DISTRIBUTION cough. NOT FOR SALE OR DISTRIBUTION Improvements in gas exchange Patients with neuromuscular disease and ineffective Improvement in the chest radiograph cough (i.e., peak cough flow < 270 L/min) may benefit from cough-assist techniques such as mechani- Improvement in symptoms (e.g., dyspnea) © Jones & Bartlettcal insufflation-exsufflation. Learning, LLC (e.g., Cough-Assist). © JonesRemember: & Bartlett the routine Learning, use of ACT LLC techniques for NOT FOR SALEWhile OR the DISTRIBUTION lack of high-level evidence does not sup-NOTairway FOR clearance SALE ORin patients DISTRIBUTION without cystic fibrosis is port the routine use of ACT, according to the AARC not recommended; the routine use of IS also is not 18,19 recommended to prevent atelectasis. Further, there Clinical Practice Guidelines, it may be considered is currently no high-level evidence to support the use for certain individuals based on clinical judgment. An- of bronchodilators, mucolytics, or mucokinetics for swers to the following questions should be considered: © Jones & Bartlett Learning, airwayLLC clearance in hospitalized© patientsJones who& Bartlett do not Learning, LLC Does the patient have difficulty clearing airway 1. NOT FOR SALE OR DISTRIBUTIONhave cystic fibrosis.18,19 ClinicalNOT judgment, FOR however, SALE OR DISTRIBUTION secretions? may suggest that ACT and/or the use of aerosolized 2. Are retained secretions affecting gas exchange or bronchodilators is appropriate in individual patients lung mechanics? in the ICU in order to facilitate secretion management 3.© WhatJones is the & potentialBartlett for Learning, adverse effects LLC (vs. and prevent ©or Jonestreat bronchospasm. & Bartlett18,19 Learning, LLC NOTbenefits) FOR due SALE to ACT? OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Summary Key Points © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Critically ill patients are those at high risk for ■■ Respiratory care is defined as the healthcare disci- NOT FOR SALElife-threatening OR DISTRIBUTION health problems. Critically ill patients NOT FORpline SALEthat specializes OR DISTRIBUTION in the promotion of optimal are often unstable and require sophisticated support, cardiopulmonary function. careful monitoring and rapid adjustment of care based ■■ Critically ill patients are at high risk for life- on changes in their condition. Critical care is provided threatening health problems. ■■ in various types of ICUs© Jones using interprofessional & Bartlett Learning, teams LLCCritical care refers to the care© Jones and management & Bartlett of Learning, LLC consisting of specially trained physicians, nurses, respi- critically ill patients who require sophisticated sup- ratory therapists, andNOT other FOR healthcare SALE personnel. OR DISTRIBUTIONport and constant monitoring.NOT FOR SALE OR DISTRIBUTION Critical respiratory care refers to those respiratory ■■ Conditions sometimes requiring ICU admission and care techniques and procedures used in the assessment, mechanical ventilation include acute and chronic diagnosis, management, support, monitoring, and care respiratory disease; cardiac, cardiovascular, or circu- of critically© Jones ill patients. & Bartlett Respiratory Learning, care provided LLC in the latory disease;© Jones shock; & trauma; Bartlett sepsis; Learning, and neuromus- LLC ICUNOT includes FOR diagnostic SALE and OR monitoring DISTRIBUTION procedures, cular or NOTneurologic FOR disease. SALE OR DISTRIBUTION management of artificial airways, basic respiratory care ■■ Critical care requires complex decision making techniques (e.g., oxygen therapy, aerosolized medication to ensure therapy is adjusted as patients’ needs delivery), and the provision of mechanical ventilatory change. support. The treatment and support of patients in respi- ■■ Critically ill patients are often unstable and require ratory failure is a core respiratory care competency. This frequent adjustments in the support provided. © Jones & Bartlett Learning, LLC © Jones■■ & Bartlett Learning, LLC NOT FOR SALEincludes OR careful DISTRIBUTION assessment, monitoring, care, and man-NOT FORCritical SALE respiratory OR DISTRIBUTION care includes diagnostic and agement of patients requiring mechanical ventilation. monitoring procedures, management of artificial

9781284139860_CH01_001_026.indd 23 21/02/19 3:47 PM 24 CHAPTER 1 Introduction to Critical Respiratory Care

■■ © Jones & Bartlettairways, performingLearning, basic LLC and advanced respiratory © JonesSpecial & Bartlett procedures Learning, performed inLLC ICU include bed- care, and management of mechanical ventilation. NOT FORside bronchoscopySALE OR DISTRIBUTIONand thoracentesis. NOT FOR SALE■■ Types OR of ICUs DISTRIBUTION include medical intensive care units ■■ Respiratory care plans in the ICU may focus on im- (MICU), surgical intensive care units (SICU), coro- proving oxygenation, ensuring adequate ventilation, nary care units (CCU), pediatric intensive care units providing cardiorespiratory support, and monitoring (PICU), and neonatal intensive care units (NICU). the patient’s condition. ■■ ICUs may be classified© Jones by level. & BartlettA Level I TraumaLearning, LLC■■ Respiratory care plans in the© JonesICU may & also Bartlett provide Learning, LLC Center provides theNOT highest FOR level SALE of support OR forDISTRIBUTION for secretion management,NOT airway FOR care, SALEtreatment OR of DISTRIBUTION adults and children while a Level III NICU provides bronchospasm and airway edema, and/or delivery of the highest level of support for the newborn. lung expansion therapy. ■■ Acute care hospitals often have step-down units that ■■ Indications for mechanical ventilation include ap- provide a lower level of care than the ICU but a higher nea, acute ventilatory failure, impending ventilatory level© Jones of care than& Bartlett general medical Learning, and surgical LLC wards. failure, and© Jonessevere oxygenation & Bartlett problems Learning, (refractory LLC ■■ SpeciallyNOT FOR trained SALE physicians, OR DISTRIBUTION nurses, and respiratory hypoxemia).NOT FOR SALE OR DISTRIBUTION therapists are needed to staff the ICU. ■■ Specialty credentials are available for nurses and respiratory therapists who wish to work in the ICU. References ■■ Interprofessional practice (IPP) occurs when mul- 1. American Association for Respiratory Care (AARC). Position tiple health workers from different professional back- statement: Definition of Respiratory Care. July 2015. Available at © Jones & Bartlett Learning, LLC © Joneshttps://www.aarc.org/wp-content/uploads/2017/03/statement & Bartlett Learning, LLC NOT FOR SALEgrounds OR work DISTRIBUTION together with patients, families, and NOT FOR-of-definition-of-respiratory-care.pdf. SALE OR DISTRIBUTION communities to deliver the highest quality of care. 2. Robertson LC, Al-Haddad M. Recognizing the critically ill pa- ■■ Interprofessional practice (IPP) occurs when mul- tient. Anaesthesia & Intensive Care Medicine. 2013;14(1):11–14. tiple health workers from different professional 3. Haupt MT, Bekes CE, Brilli RJ, et al. Guidelines on critical care backgrounds work together with patients, families, services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med. careers, and communities© Jones to deliver& Bartlett the highest Learning, LLC2003;31:2677–2683. © Jones & Bartlett Learning, LLC quality of care. NOT FOR SALE OR DISTRIBUTION4. American Trauma Society. TraumaNOT center FOR levels SALEexplained. OR Avail -DISTRIBUTION ■■ Standards have been recommended for the design of able at http://www.amtrauma.org/?page=traumalevels. Accessed ICUs. April 5, 2016. ■■ Long-term acute care hospitals (LTACs) provide care 5. BarfieldWD. Policy statement: Levels of neonatal care. Pediat- rics 2012;130(3); a statement of reaffirmation for this policy was to patients with serious medical conditions that re- published in Pediatrics 2015;136(5):e1418. Available at http:// ©quire Jones an extended & Bartlett hospital Learning, stay but no longer LLC require pediatrics.aappublications.org/content/130/3/587.full.© Jones & Bartlett Learning, Accessed LLC NOTintensive FOR care. SALE OR DISTRIBUTION April 5, 2016.NOT FOR SALE OR DISTRIBUTION ■■ Children’s hospitals are specialty hospitals that provide 6. Barrett ML, Smith MW, Elixhauser A, et al. Utilization of Inten- high levels of care to pediatric and neonatal patients. sive Care Services, 2011. HCUP Statistical Brief #185. December ■■ 2014. Rockville, MD: Agency for Healthcare Research and Qual- Certain skilled nursing facilities (SNFs) will accept ity. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs patients who are ventilator dependent and may re- /sb185-Hospital-Intensive-Care-Units-2011.pdf. © Jones & Bartlettquire prolonged Learning, ventilator LLC weaning. © Jones7. Neuraz & Bartlett A, Guérin C, Learning, Payet C, et al. Patient LLC mortality is associated ■■ Assessment of the respiratory care patient in the with staff resources and workload in the ICU: A multicenter ob- NOT FOR SALEICU mustOR DISTRIBUTIONinclude evaluation and monitoring of the NOT FORservational SALE study. OR Crit DISTRIBUTION Care Med. 2015;43(8):1587–1594. 8. Kleinpell RM. ICU workforce. Crit Care Med. 2014;42(5):1291–1292. patient’s oxygenation, ventilation, and circulation. 9. American Association of Critical-Care Nurses (AACN). CCRN Exam ■■ ICU patient assessment should include review of the Handbook. Available at https://www.aacn.org/certification/preparation medical records, history and physical exam, review -tools-and-handbooks/~/media/aacn-website/certification/ get-certified/handbooks/ccrnexamhandbook.pdf?la=en. Accessed of laboratory studies,© Jones medical &imaging, Bartlett results Learning, of LLC © Jones & Bartlett Learning, LLC cardiac and hemodynamic tests, and monitoring and April 5, 2016. NOT FOR SALE OR DISTRIBUTION10. National Board for RespiratoryNOT Care FOR (NBRC). SALE Adult ORCriti -DISTRIBUTION review of critical care monitoring flowsheets. cal Care Specialty Examination Detailed Content Outline. ■■ Physical assessment should be especially attentive to June 2018. Available at https://www.nbrc.org/wp-content/ the signs of respiratory distress, hypoxia, and hyper- uploads/2017/08/ACCS-Detailed-Content-Outline-For-Public capnia (i.e., ventilatory failure). -Uses.pdf. Accessed August 25, 2018. ■■ A wide range of laboratory studies may be ordered to 11. Ekmekci O, Sheingold B, Plack M, et al. Assessing performance © Jones & Bartlett Learning, LLC and learning© Jones in interprofessional & Bartlett health Learning, care teams. J LLCAllied assist in the assessment of the ICU patient. Health. 2015;44(4):236–243. ■■ NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Arterial blood gas studies can quantify the degree of 12. Interprofessional Education Collaborative Expert Panel.Core hypoxemia, identify hypoventilation or hyperventila- Competencies for Interprofessional Collaborative Practice: Report tion, and assess acid–base balance. of an Expert Panel. 2011. Washington, DC: Interprofessional ■■ ICU bedside imaging includes portable chest radio- Education Collaborative. 13. Thompson DR, Hamilton DK, Cadenhead CD, et al. Guidelines for graphs and bedside sonography (i.e., ultrasound). intensive care unit design. Crit Care Med. 2012;40(5):1586–1600. © Jones & Bartlett■■ Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEMonitoring OR DISTRIBUTION procedures in the ICU include respira- NOT14. FOR Prin SALEM, Wunsc ORh H. TheDISTRIBUTION role of stepdown beds in hospital care. tory, cardiac, and hemodynamic monitoring. Am J Respir Crit Care Med. 2014;190(11):1210–1216.

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15. American Speech-Language-Hearing Association (ASHA). Long- 18. Strickland SL, Rubin BK, Drescher GS, et al. AARC Clinical © Jones & BartlettTerm Acute Learning, Care Hospitals LLC. Available at http://www.asha.org/slp/© JonesPractice & Bartlett Guideline: Learning, Effectiveness LLC of nonpharmacologic air- NOT FOR SALEhealthcare/ltac/. OR DISTRIBUTION Accessed April 5, 2016. NOT FORway SALEclearance ORtherapies DISTRIBUTION in hospitalized patients. Respir Care. 16. Brochard L, Martin GS, Blanch L, et al. Clinical review: Res- 2013;58(12):2187–2193. Available at http://rc.rcjournal.com piratory monitoring in the ICU – a consensus of 16. Crit Care. /content/58/12/2187.short. 2012;16:219. Available at http://ccforum.biomedcentral.com 19. Strickland SL, Rubin, BK, Haas, CF; et al. AARC Clinical Practice /articles/10.1186/cc11146. Accessed April 5, 2016. Guideline: Effectiveness of pharmacologic airway clearance thera- 17. Lichtenstein DA. Lung ultrasound in the critically ill. Ann In- pies in hospitalized patients. Respir Care. 2015;60(7):1071–1077. tens Care. 2014;4:1.© Available Jones at &http://annalsofintensivecare Bartlett Learning, LLC © Jones & Bartlett Learning, LLC .springeropen.com/articles/10.1186/2110-5820-4-1.NOT FOR SALE OR DISTRIBUTION Accessed NOT FOR SALE OR DISTRIBUTION April 5, 2016.

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