Development and Implementation of Respiratory Care Plans

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC 9781284217155_CH02_025_068.indd 25

© Toria/Shutterstock CHAPTER OBJECTIVES Respiratory Care PlanFormat Diagnostic Testing Critical Care andMechanicalVentilation Provide LungExpansionTherapy Mobilize andRemoveSecretions Assessment andTreatment ofCOPD Treat and/orPrevent Bronchospasm andMucosalEdema Maintain AdequateTissueOxygenation Respiratory Care PlanDevelopment Common ConditionsRequiringCare PlanDevelopment Introduction toRespiratoryCare Plans Overview CHAPTER OUTLINE 10. Development andImplementation 9. 8. 7. 6. 5. 4. 3. 2. 1. NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

Describe thecare ofpatientswithasthmaandCOPD. prevention ofbronchospasm andmucosaledema. Create arespiratory care planforthetr oxygenation. Develop arespiratory care plantomaintainadequatetissue of arespiratory care plan. Outline thekeystepsindevelopmentandimplementation r Give examplesofappropriate outcomemeasures fora failur Define of respiratory failure. Define of ar Describe commonconditionsthatmayrequire development Identify thekeyelementsofarespiratory care plan. Describe thepurposeofarespiratory care plan. espiratory care plan. e andchronic ventilatoryfailure. espiratory care plan. ventilatory failure, andcontrastacuteventilatory respiratory failure, andgiveexamplesofseveraltypes of Respiratory CarePlans © Jones&Bartlett Learning LLC,anAscendCompany. NOTFORSALEORDISTRIBUTION. NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC David C.Shelledy,Jay I.Peters eatment and/or CHAPTER 2 NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

chronic ventilatory chronic obstructive chronic bronchitis chest physiotherapy(CPT) bronchospasm bronchodilator therapy bronchiectasis bronchial hygiene atelectasis asthma anti-inflammatory agent antiasthmatic medication clearanceairway acute ventilatory acute respiratory acute respiratory distress KEY TERMS 14. 13. 12. 11. failure (CVF) (COPD) pulmonary disease techniques (ACT) failure (AVF) failure (ARF) syndrome (ARDS)

prevention ofatelectasisandpneumonia. Propose arespiratory care planforthetr Design arespiratory care plantomobilizesecretions. respiratory car Explain therole ofdiagnostictestinginthedevelopment ofa intensive car Give examplesoftypesrespiratory care plansusedinthe NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC e unit. e plan. NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC treatment menu SOAP note six-minute walktest(6MWT) retained secretion respiratory care plan pulmonary edema protocol positive airway pneumonia physical oxygen therapy mucosal edema mechanical ventilation lung expansiontherapy intermittent positive inhaled corticosteroid incentive spirometry (IS) hypoxemia history pressure (PAP) (IPPB) pressure breathing (ICS) eatment and/or

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© Jones &Overview Bartlett Learning, LLC © JonesO (Objective). & Bartlett Refers Learning, to what the LLC clinician observes or objective test results. This chapter provides a guide to the development, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A (Assessment). Refers to the clinician’s assessment. implementation, and evaluation of respiratory care P (Plan). Refers to the plan of care. plans. The respiratory care plan provides a detailed description of the care to be provided based on the in- A modification known as SOAPIER adds care plan dividual needs of the patient. Care plans often include documentation of the following: assessment, diagnosis,© orJones problem & list;Bartlett goals and/or Learning, ob- LLC © Jones & Bartlett Learning, LLC I (Intervention). What was done. jectives; specific activitiesNOT FORor interventions SALE OR to be DISTRIBUTION taken; NOT FOR SALE OR DISTRIBUTION E (Evaluation). The clinician’s evaluation of the care outcomes of care provided; and evaluation. In order to provided. develop an appropriate respiratory care plan, the clini- R (Revision). Any changes in care provided based on cian must first perform a thorough patient assessment, the clinician’s evaluation. including a review of the patient’s existing medical record,© aJones patient interview,& Bartlett and Learning, a physical assessment. LLC The Further details© Jones of SOAPIER & Bartlett can be Learning, found in LLC bedsideNOT measurement FOR SALE of clinicalOR DISTRIBUTION parameters related to Chapter 3. TheNOT respiratory FOR SALE care planOR mayDISTRIBUTION also include oxygenation, ventilation, and pulmonary function may a statement of how the intensity and/or duration of be performed. Pulse oximetry (Spo2) is routinely used therapy will be adjusted and when the therapy will be to assess oxygenation status. Arterial blood gases should discontinued. Assessment of the outcomes of therapy be obtained if there is concern regarding the patient’s may also be included, as well as measurable objectives © Jones & ventilatoryBartlett status,Learning, acid–base LLC balance, or the reliability of© Jonesof the &care Bartlett delivered. Learning, LLC NOT FOR SALESpo2 values. OR Laboratory,DISTRIBUTION imaging, and other diagnostic NOT FOR SALE OR DISTRIBUTION studies may be needed to further define and clarify the RC Insight patient’s problem and diagnosis. Following establishment and clarification of the patient’s diagnosis and/or The respiratory care plan provides a written de- problem list (see Chapter 1), a respiratory care plan is scription of the care the patient is to receive, based developed, implemented,© Jones and evaluated. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONon a thorough assessmentNOT and determination FOR SALE of OR DISTRIBUTION Introduction to Respiratory the care needed. Care Plans In summary, the respiratory care plan provides the Therespiratory care plan provides a written descrip- © Jones & Bartlett Learning, LLC written plan© of Jones treatment & thatBartlett the patient Learning, will receive. LLC tion of the care the patient is to receive. The plan is based The plan may include goals, objectives, rationale, sig- on NOTa careful FOR patient SALE interview OR and DISTRIBUTION physical assessment, nificance, andNOT a description FOR SALE of how OR care DISTRIBUTION will be assessed. review of diagnostic test results, and consideration of Following a careful patient assessment, the respiratory the treatment modalities available, sometimes known care plan is developed, implemented, and evaluated. A treatment menu as the . The respiratory care plan may take summary of the types of care often included in the res- the form of physician’s orders, a detailed progress note piratory care plan is provided in Table 2-1. © Jones & in theBartlett medical Learning, record, an established LLC protocol, completion© Jones & Bartlett Learning, LLC NOT FOR SALEof a standardized OR DISTRIBUTION respiratory care consultation and treat- NOTCommon FOR SALE Conditions OR DISTRIBUTION Requiring ment plan template, or the use of problem-oriented medical records (e.g., SOAP notes). The respiratory care plan Respiratory Care Plan can be viewed as an individualized protocol for the patient. Development A basic respiratory care plan often includes the fol- Problems that affect oxygenation and/or ventila- lowing elements: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tion often require the development of a respiratory ■ Goals of therapyNOT FOR SALE OR DISTRIBUTIONcare plan. Other common respiratoryNOT FOR problems SALE in- OR DISTRIBUTION ■ Device or procedure to be used or medications to clude bronchospasm and mucosal edema, retained be given secretions, airway plugging, infection, consolidation, ■ Method or appliance to be used inadequate lung expansion, atelectasis, and pulmonary ■ Gas source or oxygen concentration edema. Common disease states or conditions en- © ■ Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTDevice FOR pressure, SALE volume, OR DISTRIBUTION and/or flow countered inNOT the physician’s FOR SALE office, OR clinic, DISTRIBUTION or acute ■ Frequency of administration and duration of care setting that may require respiratory care include therapy upper respiratory tract infection, pneumonia, acute bronchitis, asthma, chronic obstructive pulmonary SOAP notes are sometimes used to document patient disease (COPD) (including emphysema and chronic care plans: bronchitis © Jones & Bartlett Learning, LLC © Jones & Bartlett), pulmonary Learning, hypertension, LLC heart failure, lung NOT FOR SALES (Subjective). OR DISTRIBUTION Refers to what the patient says, or NOTcancer, pulmonary FOR SALE OR fibrosis, DISTRIBUTION pulmonary emboli, postop- subjective information obtained from the chart or erative pulmonary complications, and acute respiratory medical record. failure (see Chapter 1).

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Respiratory Failure © Jones & BartlettTABLE 2-1 Learning, LLC © Jones & Bartlett Learning, LLC Types of Care Provided in the Respiratory Care Plan NOT FOR SALE OR DISTRIBUTION NOTRespiration FOR SALE refers OR to the DISTRIBUTION exchange of oxygen (O2) and carbon dioxide (CO ) across the lung and pulmonary Basic Respiratory Care 2 • Oxygen and medical gas therapy capillaries (external respiration) and at the tissue level • Humidity therapy (internal respiration). Respiratory failure, broadly de- • Aerosol therapy fined, is an inability of the heart and lungs to provide • Secretion management© (airwayJones clearance & Bartlett therapy) Learning, LLCadequate tissue oxygenation and/or© Jones carbon & dioxide Bartlett re- Learning, LLC • Sputum induction moval.1,2 Acute respiratory failure (ARF) may be defined • Management of bronchospasmNOT FOR and mucosal SALE edema OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Lung expansion therapy as a sudden decrease in arterial blood oxygen levels with 1,2 • Follow-up assessment and care plan modification and/or or without carbon dioxide retention. Acute respiratory discontinuation distress syndrome (ARDS) is a form of respiratory failure that is characterized by oxygenation problems that gen- Critical© Jones Respiratory & Bartlett Care Learning, LLC © Jones & Bartlettoxygen Learning, therapy LLC • Invasive mechanical ventilatory support erally do not respond well to basic • NOTNoninvasive FOR mechanical SALE ventilatory OR DISTRIBUTION support (Pao2/Fio2 ≤NOT300 on FOR at least SALE 5 cm ofOR positive DISTRIBUTION end- • Physiologic monitoring expiratory pressure [PEEP]). The term hypoxemic respira- • Cardiac and hemodynamic support and monitoring tory failure (aka “lung failure”) is sometimes used when • Suctioning and airway care the primary problem is oxygenation.3 Chapter 6 describes • Airway intubation and management Box 2-1 • Arterial line insertion, management, and care the assessment of a patient’s oxygenation status. © Jones & Bartlett• Advanced Learning,cardiovascular life LLC support © Jonessummarizes & Bartlett the various Learning, types of respiratory LLC failure. NOT FOR SALE• Metabolic OR studies DISTRIBUTION NOT FORThe SALEmost common OR DISTRIBUTION reason for initiation of mech- • Extracorporeal life support (ECLS) anical ventilatory support is hypercapnic respiratory • Mechanical circulatory assistance failure (aka “ventilatory failure” or “pump failure”).3,5 • Basic care in the intensive care setting Acute ventilatory failure (AVF) can be defined as a sud- Diagnostic Testing den rise in arterial CO2 levels (as assessed by Paco2) • Oximetry © Jones & Bartlett Learning, LLCwith a corresponding decrease© inJones pH.6 Respiratory & Bartlett Learning, LLC • Arterial blood gases NOT FOR SALE OR DISTRIBUTIONmuscle fatigue and an increasedNOT work FOR of breathing SALE OR DISTRIBUTION • Pulmonary function testing may lead to AVF. Decreased ventilatory drive due to • Cardiac testing (e.g., electrocardiogram [ECG], invasive cardiol- ogy, cardiac catheterization laboratory) narcotic or sedative drug overdose, head trauma, or • Ultrasound (bedside ultrasound, echocardiography, other) stroke can also result in AVF. Common disease states • Sleep studies or conditions associated with the development of AVF • ©Exercise Jones testing & Bartlett Learning, LLC include severe© Jones pneumonia, & Bartlett ARDS, massive Learning, or sub-mas LLC- SpecialNOT Procedures FOR SALE OR DISTRIBUTION sive pulmonaryNOT emboli, FOR congestiveSALE OR heart DISTRIBUTION failure (CHF), • Patient land and air transport and pulmonary edema. More recently, coronavirus • Patient education disease 2019 (COVID-19) caused by the SARS-CoV-2 • Smoking cessation virus has been associated with the development of • Pulmonary rehabilitation severe viral pneumonia, respiratory failure, and ARDS • Cardiac rehabilitation © Jones & Bartlett• Acute and Learning, chronic disease LLCmanagement © Jonesin some & patients.Bartlett Shock, Learning, trauma, LLCsmoke or chemical NOT FOR SALE OR DISTRIBUTION NOTinhalation, FOR SALE aspiration, OR DISTRIBUTION and near drowning may also

BOX 2-1 Types of Respiratory Failure Respiratory Failure© Jones & Bartlett Learning, LLC Hypoxemic respiratory failure© (lung Jones failure) & Bartlett refers to Learning, LLC Respiratory failure isNOT a general FOR term SALE that indicatesOR DISTRIBUTION the a primary problem with oxygenation.NOT FOR SALE OR DISTRIBUTION inability of the heart and lungs to provide adequate Hypercapnic respiratory failure (pump failure) refers to tissue oxygenation and/or carbon dioxide removal. a primary problem with ventilation. Hypercapnic res- Acute Respiratory Failure piratory failure is also known as ventilatory failure. Acute© Jones respiratory & Bartlett failure may Learning, be defined LLCas a sud- Ventilatory© Failure Jones & Bartlett Learning, LLC denNOT decrease FOR inSALE arterial OR blood DISTRIBUTION oxygen levels (arterial Ventilatory failureNOT may FOR be SALEdefined ORas an DISTRIBUTION elevated partial pressure of oxygen [Pao2] <50 to 60 mm Hg; Paco2 (>45 to 50 mm Hg). An increased Paco2 may arterial oxygen saturation [Sao2] <88% to 90%), with also be called hypoventilation or hypercapnia: or without carbon dioxide retention (arterial partial Acute ventilatory failure is defined as a sudden pressure of carbon dioxide [Paco ] >45 mm Hg can be © Jones & Bartlett Learning, LLC 2 © Jonesincrease & Bartlett in arterial Learning, Paco2 with a LLCcorresponding de- defined as CO2 retention): NOT FOR SALE OR DISTRIBUTION NOT FORcrease SALE in pH. OR DISTRIBUTION (Continues)

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-1 Learning, Types of Respiratory LLC Failure (Continued) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chronic ventilatory failure is defined as a chronically imaging, and Pao2/Fio2 ratio while receiving at least elevated Paco2 with a normal or near-normal pH 5 cm H2O of PEEP or continuous positive airway pres- owing to metabolic compensation. sure (CPAP).4 This revised definition combines aspects of ALI and ARDS and requires (1) identification of res- Acute-on-chronic© ventilatoryJones & failure Bartlett is defined Learning, as LLC © Jones & Bartlett Learning, LLC a chronically elevated Paco followed by an acute piratory symptoms within 1 week of new or worsen- NOT FOR2 SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION increase in the Paco2 and a corresponding fall ing symptoms or a known clinical insult; (2) bilateral in pH. opacities upon chest imaging (chest x-ray or com- puted tomography [CT] scan); (3) opacities that can- Acute Respiratory Distress Syndrome not be due to lobar collapse, lung collapse, pulmonary Acute respiratory distress syndrome (ARDS) is a form of effusion, or pulmonary nodules; (4) pulmonary edema noncardiogenic© Jones & Bartletthypoxemic Learning, respiratory failure LLC as de- © Jones & Bartlett Learning, LLC that cannot be due to cardiac failure or fluid overload finedNOT (in FOR part) SALEby the Pao OR/Fio DISTRIBUTION ratio. Traditionally, the NOT FOR SALE OR DISTRIBUTION 2 2 as assessed by echocardiography or other measures to characteristics of ARDS were as follows: exclude hydrostatic edema (e.g., PCWP <18 mm Hg); Bilateral pulmonary infiltrates on chest x-ray. and (5) Pao2/Fio2 ≤300 mm Hg with PEEP or CPAP Pulmonary capillary wedge pressure <18 mm Hg ≥5 cm H2O where: © Jones & Bartlett(i.e., pulmonary Learning, edema LLC not due to cardiac failure or© Jones & Bartlett Learning, LLC Pao2/Fio2 ≤300 mm Hg but >200 mm Hg—mild NOT FOR SALEfluid OR overload). DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pao2/Fio2 ≤200 mm Hg but >100 mm Pao2/Fio2 <300 was considered the borderline Hg—moderate value for acute lung injury, or ALI. This is equivalent Pao2/Fio2 ≤100 mm Hg—severe to a Pao2 of less than 63 torr while breathing room Fio , fraction of inspired oxygen; PEEP, positive end-expiratory air (Fio2 = 0.21).© Today, Jones a Pao &2 /FioBartlett2 ≤300 Learning, but >200 LLC2 © Jones & Bartlett Learning, LLC is considered to be mild ARDS (see Berlin Definition pressure; PCWP, pulmonary capillary wedge pressure. If altitude is NOT FOR SALE OR DISTRIBUTIONhigher than 1000 m, then correctionNOT factor shouldFOR be SALE calculated OR DISTRIBUTION later). A Pao /Fio <200 is equivalent to a Pao of 2 2 2 as follows: [Pao2/Fio2 × (barometric pressure/760)]. less than about the 42 torr while breathing room air Data from: ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, (Fio2 = 0.21). Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky More recently, the Berlin Definition of ARDS was AS. Acute respiratory distress syndrome: the Berlin Definition. adopted,© Jones which & Bartlettis based on Learning, symptom timing, LLC chest JAMA. 2012;307(23):2526-2533.© Jones & doi: Bartlett 10.1001/jama.2012.5669. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

cause AVF. Acute exacerbation of COPD, acute severe Respiratory Care Plan Development asthma, severe burns, upper airway obstruction, obe- The process for respiratory care plan development sity, and thoracic deformity all predispose patients to © Jones & Bartlett Learning, LLC © Jonesgenerally & Bartlett includes the Learning, receipt of anLLC order for a spe- the development of AVF. Neuromuscular disease such cific type of respiratory care or for a respiratory care NOT FOR SALEas Guillain-Barré OR DISTRIBUTION syndrome, myasthenia gravis, and NOT FOR SALE OR DISTRIBUTION consult. The process for developing a respiratory care spinal cord injury may also precipitate AVF. plan may begin when a patient enters the healthcare Chronic ventilatory failure (CVF) (aka “chronic hy- setting with a problem or complaint. Sometimes the percapnia”) may be defined as a chronically elevated need for respiratory care is not immediately apparent Paco2 with a normal (compensated) or near-normal 6 © Jones & Bartlett Learning, LLCand, in the acute care setting,© patients Jones often & Bartlett require Learning, LLC pH. The most common cause is severe COPD, al- respiratory care at some point following admission to though not all COPDNOT patients FOR develop SALE CVF. OR Ventilatory DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the hospital. failure usually suggests that fewer than 25% of alveoli are functioning. Acute pneumonia in COPD patients often will result in AVF that resolves as the pneumonia RC Insight improves© Jones and inflammatory& Bartlett Learning, cells are cleared LLC from the © Jones & Bartlett Learning, LLC airway. Other chronic lung diseases, such as late-stage Developing a respiratory care plan requires a care- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cystic fibrosis, severe interstitial lung disease, and ful patient assessment obesity-hypoventilation syndrome, are associated with the development of CVF. Evaluation of ventilation is described in Chapter 7. Following initial assessment and verification of the © Jones & BartlettRespiratory Learning, failure requires LLC careful patient assess- © Jonespatient’s & problemBartlett or Learning, diagnosis by theLLC physician, nurse ment followed by the development and implementation practitioner, or physician assistant, an order for res- NOT FOR SALEof the respiratory OR DISTRIBUTION care plan. Common causes of respira-NOTpiratory FOR SALE care may OR be written.DISTRIBUTION Upon receipt of an order, tory failure are listed in Box 2-2. Clinical Focus 2-1 pro- the respiratory care clinician performs a medical rec- vides an example of a specific type of respiratory failure. ords review, patient interview, and physical assessment.

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-2 Learning, Common CausesLLC of Respiratory Failure NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Oxygenation Problems y Examples of conditions associated with AVF: Low ventilation/perfusion ratio (i.e., V/ Q <1 but >0) y ARDS, severe pneumonia y Underventilation with respect to pulmonary y Shock, chest trauma, pneumothorax, head perfusion trauma, stroke, spinal cord injury, smoke or y Examples: asthma,© Jones emphysema, & Bartlett COPD, Learning, cystic LLC chemical inhalation, aspiration,© Jones near & Bartlett drowning Learning, LLC fibrosis, bronchiectasisNOT FOR SALE OR DISTRIBUTIONy Sedative or narcotic drugNOT overdose, FOR SALE paralytic OR DISTRIBUTION Pulmonary shunt (V/ Q = 0) drugs, deep anesthesia y No ventilation with respect to pulmonary y Respiratory muscle fatigue and increased perfusion work of breathing due to acute exacerbation y Examples: ARDS, atelectasis, severe pneumonia of COPD, acute severe asthma, severe obesity, © Diffusion Jones &problems Bartlett Learning, LLC thoracic© Jones deformity & Bartlett Learning, LLC NOTy Impaired FOR SALE diffusion OR due DISTRIBUTION to increased diffusion y NeuromuscularNOT FOR disease SALE associated OR DISTRIBUTION with res- distance, diffusion block piratory failure, such as Guillain-Barré, amyo- y Example: early pulmonary fibrosis trophic lateral sclerosis (ALS), myasthenia Hypoventilation gravis, polio, critical illness/steroid myopathy, botulism, tetanus y Increases in Paco2 result in a corresponding © Jones & Bartlett Learning, LLC © Jonesy & Patients Bartlett recovering Learning, from abdominalLLC or tho- NOT FOR SALE decreaseOR DISTRIBUTION in Pao2 NOT FOR SALE OR DISTRIBUTION Low blood oxygen content racic surgery who may need mechanical ventilatory support y Low Pao2, Sao2, or hemoglobin Chronic ventilatory failure y Examples: y A chronically elevated Paco2 with normal or y Low Pao due to low V/ Q, shunt, diffusion 2 near-normal pH problems,© or Jones hypoventilation & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC y Examples: chronic bronchitis, severe COPD, y Low hemoglobinNOT FOR (anemia) SALE or abnormal OR DISTRIBUTION he- NOT FOR SALE OR DISTRIBUTION obesity-hypoventilation syndrome moglobin (e.g., elevated carboxyhemoglobin due to carbon monoxide poisoning) COPD, chronic obstructive pulmonary disease; ARDS, acute respiratory Increased pulmonary dead space distress syndrome; Paco2, arterial partial pressure of carbon dioxide; Pao , partial pressure of oxygen, arterial; Sao , oxygen saturation. y Examples: pulmonary embolus, obliteration of the 2 2 © Jonespulmonary & Bartlett capillaries Learning,(as in severe emphysema) LLC Data from West© JB. AcuteJones respiratory & Bartlett failure. In: West Learning, JB, editor. LLC NOT FOR SALE OR DISTRIBUTION Pulmonary physiologNOTy and FOR pathophysiology: SALE anOR integrated, DISTRIBUTION Ventilation Problems case-based approach, 2nd ed. Philadelphia: Lippincott, Williams & Acute ventilatory failure (AVF) Wilkins; 2007:116–133. y A sudden increase in Paco2 with a corresponding decrease in pH © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CLINICAL FOCUS 2-1 Respiratory Failure A 30-year-old male was admitted to the hospital with How would you describe the patient’s respiratory chest trauma following a motor vehicle accident. The condition? (Hint: Before describing the patient’s condi- patient’s increasing© respiratory Jones &distress, Bartlett tachypnea, Learning, and tion,LLC review the definitions and© Jonesdescriptions & Bartlettof respira- Learning, LLC hypoxemia while breathingNOT FOR room SALE air led to OR intubation DISTRIBUTION tory failure found in Box 2-1). NOT FOR SALE OR DISTRIBUTION and the initiation of mechanical ventilation. The chest The patient is in acute respiratory failure. The x-ray shows bilateral pulmonary infiltrates; however, patient has new bilateral pulmonary infiltrates, no there is no evidence of cardiogenic pulmonary edema or evidence of cardiogenic pulmonary edema or fluid fluid overload. Current arterial blood gases while being overload, and a Pao2/Fio2 ratio of 103, which is consis- supported© Jones in &the Bartlett assist-control Learning, mode of ventilation LLC with tent with a diagnosis© Jones of &moderate Bartlett ARDS. Learning, LLC anNOT Fio2 ofFOR 0.60 SALE and 5 cm OR H2O DISTRIBUTION PEEP are: NOT FOR SALE OR DISTRIBUTION Fio2, fractional concentration of inspired oxygen; PEEP, positive pH: 7.36 end-expiratory pressure; Paco2, arterial partial pressure of carbon dioxide; Pao2, partial pressure of oxygen, arterial; Sao2, oxygen satu- Paco2: 36 mm Hg – ration; HCO3 , bicarbonate; B.D., base deficit; ARDS, acute respira- Pao2: 62 mm Hg tory distress syndrome. © Jones & BartlettSao2: 90%Learning, LLC © JonesThe definition & Bartlett of ARDS wasLearning, first clarified LLC by a 1992 American- – European Consensus Conference. Rubenfeld GD, Herridge NOT FOR SALEHCO OR3 : 20DISTRIBUTION mEq/L NOT FOR SALE OR DISTRIBUTION B.D.: –5 mEq/L MS. Epidemiology and outcomes of acute lung injury. Chest 2007;131(2):554–562.

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© Jones &Bedside Bartlett measurement Learning, of oxygenLLC saturation (Spo2) and © Jonestreatment & Bartlett options that Learning, are available. LLC Basic respiratory basic pulmonary function parameters may be per- NOTcare FOR options SALE include OR techniquesDISTRIBUTION to improve oxygenation NOT FOR SALEformed. ORFollowing DISTRIBUTION this assessment, the respiratory care and manage secretions, treatment for bronchospasm clinician may then select the appropriate care based and mucosal edema, and lung expansion therapy. on the patient’s condition. The goal is to optimize the A typical basic respiratory care treatment menu match between the care needed and the care “menu,” or is provided in Table 2-2. Following selection of a © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TABLE 2-2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Respiratory Care Treatment Menu

Oxygenation Bronchospasm/Mucosal Edema • Nasal cannula • Bronchodilator therapy (SVN, MDI, DPI, SMI) • Oxygen masks (simple/partial/nonrebreather) • Short-acting beta-2 agonists (SABA, e.g., albuterol [Proventil HFA, • ©High-flow Jones systems & Bartlett (“Venturi” masks,Learning, large-volume LLC air- Ventolin HFA]; ©levalbuterol Jones [Xopenex]) & Bartlett Learning, LLC entrainment nebulizers, high-flow nasal cannula [HFNC]) • Short-acting muscarinic antagonist (SAMA, e.g., ipratropium [Atrovent]) • NOTCPAP by FOR mask SALE OR DISTRIBUTION • Long-acting beta-2NOT agonist FOR (LABA, SALE e.g., salmeterol OR DISTRIBUTION [Serevent], • PEEP (may require invasive mechanical ventilation) formoterol [Foradil], formoterol for nebulizers [Perforomist], arformoterol [Brovana], indacaterol [Arcapta], olodaterol [Striverdi]) • Long-acting muscarinic antagonist (LAMA; e.g., tiotropium [Spiriva], umeclidinium [Incruse Ellipta]) © Jones & Bartlett Learning, LLC © Jones• Revefenacin & Bartlett (Yupelri solution) Learning, LLC • Combination bronchodilators (e.g., SAMA/SABA combinations NOT FOR SALE OR DISTRIBUTION NOT suchFOR as ipratropium/albuterol SALE OR DISTRIBUTION [Combivent] and LAMA/LABA combinations, including umeclidinium/vilanterol [Anoro], tiotropium/ olodaterol [Stiolto], glycopyrrolate/formoterol [Bevespi], and glycopyrronium/indacaterol [Utibron]) • Inhaled corticosteroids (ICS) (fluticasone [Flovent], flunisolide [Aero- bid], budesonide [Pulmicort], beclomethasone [Qvar]) © Jones & Bartlett Learning,• Combination LLC bronchodilator/corticosteroid© Jones medications & (e.g.,Bartlett ICS/ Learning, LLC NOT FOR SALE OR DISTRIBUTIONLABA: fluticasone and salmeterol [Advair]);NOT fluticasone FOR SALEand vilanterol OR DISTRIBUTION (Breo); budesonide and formoterol (Symbicort); and ICS/LAMA/LABA: fluticasone, umeclidinium and vilanterol (Trelegy) • Antiasthmatic aerosol agents (cromolyn, etc.)

Ventilation Lung Expansion Therapy • ©Noninvasive Jones mechanical & Bartlett ventilation Learning, (NIV, BiPAP) LLC • Cough and deep-breathing© Jones techniques & Bartlett Learning, LLC • NOTInvasive FOR mechanical SALE ventilation OR DISTRIBUTION • Suctioning NOT FOR SALE OR DISTRIBUTION • Incentive spirometry • IPPB

Secretion Management (Airway Clearance/Bronchial Frequency of Treatment Options Hygiene) • Continuous • Directed cough and deep-breathing instruction • Every 1 to 2 hours © Jones & Bartlett• Inhaled agents Learning, for airway clearance LLC (e.g., DNase [dornase ©• JonesEvery 4 hours & Bartlett Learning, LLC NOT FOR SALEalpha], OR hypertonic DISTRIBUTION saline [3% to 7% NaCl], mannitol) NOT• Every FOR 6 hours SALE OR DISTRIBUTION • Suctioning (NT, ET, tracheostomy suctioning) • Four times per day • Chest physiotherapy (postural drainage, percussion, vibration) • Three times per day • Positive expiratory pressure (PEP) • Two times per day • Oscillatory PEP (e.g., acapella flutter valve) • Daily • High-frequency chest wall oscillation (percussion vest) • As needed • High-volume bland aerosol© Jones therapy (ultrasonic& Bartlett nebulizer, Learning, LLC © Jones & Bartlett Learning, LLC heated large-volume nebulizer)NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Mucus-controlling agents (mucolytics)

Sputum Induction/Obtain Specimen • Directed cough • Hypertonic saline aerosol • ©Suctioning Jones (NT, & ET, Bartlett tracheostomy Learning, suctioning) LLC © Jones & Bartlett Learning, LLC AerosolizedNOT FOR (Inhaled) SALE Antibiotics OR DISTRIBUTION (CF, Bronchiectasis) NOT FOR SALE OR DISTRIBUTION • Tobramycin • Aztreonam lysine • Colistin • Others (e.g., gentamicin, ciprofloxacin)

© Jones & BartlettCPAP, continuous Learning, positive airway pressure;LLC PEEP, positive end-expiratory pressure;© Jones NIV, noninvasive & Bartlett ventilation; BiPAP,Learning, bilevel positive LLC airway pressure; NT, nasotracheal; ET, endotracheal; CF, cystic fibrosis; SVN, small volume nebulizer; MDI, metered-dose inhaler; DPI, dry powder inhaler; SMI, soft mist inhaler; NOT FOR SALEIPPB, intermittent OR DISTRIBUTION positive pressure ventilation. NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning,Order for respiratory LLC care received © Jonesstabilization, & Bartlett mechanical Learning, circulatory LLC assistance, and ex- NOTtracorporeal FOR SALE membrane OR DISTRIBUTION oxygenation (ECMO). We will NOT FOR SALE OR DISTRIBUTION now turn to the development of specific respiratory care Perform assessment plans based on an assessment of the patient’s needs and Chart review the related goals of therapy. Patient interview Physical assessment © Jones & Bartlett Learning, LLCKey Elements of a Respiratory© Jones Care & BartlettPlan Learning, LLC NOT FOR SALE OR DISTRIBUTIONThe key elements of a basic respiratoryNOT FOR care SALE plan are OR DISTRIBUTION Establish desired treatment goals, Box 2-3 objectives, or outcomes listed in and include the goals of therapy, devices, medications, methods, gas source, and frequency of administration. Assessment of basic respiratory care Evaluate/select treatment should note improvement in oxygenation and ventila- © Jones & Bartlett Learning, LLC tion, work of© breathing, Jones &breath Bartlett sounds, Learning, and, in some LLC NOT FOR SALE OR DISTRIBUTION cases, pulmonaryNOT functionFOR SALE and blood OR gases. DISTRIBUTION Box 2-4 Physician notification/review lists the key elements of a respiratory care plan for mechanical ventilatory support.

Deliver respiratory care © Jones & Bartlett Learning, LLC © JonesMaintain & Bartlett Adequate Learning, Tissue LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chart in the medical record Oxygenation Oxygen therapy is indicated for documented or suspected hypoxemia, severe trauma, acute myocardial Monitor, modify, and reevaluate infarction (MI), and immediate postoperative recov- based on patient response 7 © Jones & Bartlett Learning, LLCery. It also may be indicated ©to Jonessupport the& Bartlettpatient Learning, LLC with chronic lung disease during exercise and to pre- FIGURE 2-1 Steps in theNOT development FOR and SALE implementation OR DISTRIBUTION of the NOT FOR SALE OR DISTRIBUTION vent or treat right heart failure (cor pulmonale) due to respiratory care plan. 7 chronic pulmonary hypertension. A Pao2 <60, Sao2 <90%, and/or an Spo2 <90% to 92% are considered clear indications for oxygen therapy in most patients.7 respiratory care treatment regimen, the patient’s physi- © Jones & Bartlett Learning, LLC Exceptions ©to thisJones rule include& Bartlett patients Learning, with chronic LLC cian should be notified and given the opportunity to carbon dioxide retention and the premature neonate. reviewNOT and/or FOR modify SALE the OR care DISTRIBUTION plan. The care is then NOT FOR SALE OR DISTRIBUTION A critical value in the COPD patient may be a Pao2 of delivered. The patient is monitored, and the care plan is ≤55 torr with an Spo2 of ≤88% while breathing room reevaluated based on the patient’s response to therapy. < Figure 2-1 air or a Pao2 of 56 to 59 and an Sao2 89% in the pres- summarizes the steps in respiratory care ence of cor pulmonale, pulmonary hypertension, CHF, plan development and implementation. > 8 © Jones & Bartlett Learning, LLC © Jonesor erythr & ocythemiaBartlett Learning,with a hematocrit LLC 56. A critical Pao2 for the newborn may be a Pao2 <50 torr and/or an NOT FOR SALEGoals ofOR Respiratory DISTRIBUTION Care Plans NOT FOR SALE OR DISTRIBUTION9 Spo2 <88% or a capillary Po2 <40 torr. Respiratory care plans may be developed for basic and Hypoxemia should be suspected whenever the pa- critical respiratory care, diagnostic testing, and special- tient is exhibiting the signs and symptoms of hypoxia. ized procedures (see Table 2-1). Goals of the respiratory Initial signs of hypoxia include tachycardia, increased care plan may include© maintaining Jones & orBartlett improving Learning, oxy- LLCblood pressure, tachypnea, hyperventilation,© Jones & Bartlett dyspnea, Learning, LLC genation and ventilation, managing secretions, treating and use of accessory muscles. Other early manifesta- or preventing bronchospasmNOT FOR and mucosalSALE edema,OR DISTRIBUTION treat- tions of hypoxia include restlessness,NOT FOR disorientation, SALE OR DISTRIBUTION ing infection and treating and/or preventing atelectasis dizziness, excitement, headache, blurred vision, im- and pneumonia. Basic respiratory care plans may in- paired judgment, and confusion. Clinical manifestations clude oxygen therapy, secretion management, treatment of severe hypoxia may include slow, irregular respira- of bronchospasm© Jones & Bartlettand mucosal Learning, edema, and LLC lung expan- tions; bradycardia;© Jones hypotension; & Bartlett dysrhythmias; Learning, loss LLC of sionNOT therapy. FOR SALE OR DISTRIBUTION consciousness;NOT somnolence; FOR SALE convulsions; OR DISTRIBUTION and coma. Diagnostic respiratory care procedures include tech- These later findings are more common when hypoxia niques to assess oxygenation, ventilation, acid–base and hypercapnia coexist. Severe hypoxia may lead to balance, and pulmonary function and to obtain spu- respiratory and/or cardiac arrest. The respiratory care tum samples (e.g., sputum induction) for Gram stain, clinician should obtain an Spo2 or arterial blood gas © Jones & culture,Bartlett and Learning, cytologic examination. LLC Critical respira- © Jonesstudy in& orderBartlett to confirm Learning, the presence LLC of hypoxemia. NOT FOR SALEtory care OR may DISTRIBUTION include mechanical ventilatory support, NOTThe FOR indications SALE ORfor oxygen DISTRIBUTION therapy in the acute care set- airway care, physiologic monitoring, cardiovascular ting are summarized in Box 2-5.

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-3 Learning, Key Elements LLC of a Basic Respiratory Care Plan NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Goals of Therapy Antiasthmatic agents (cromolyn sodium [Intal], Maintain adequate tissue oxygenation and/or nedocromil sodium [Tilade]) alveolar ventilation. Bland aerosol (normal saline [0.9% NaCl], one-half Treat/prevent bronchospasm and/or mucosal normal saline [0.45% NaCl], sterile distilled water) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC edema. Other inhaled airway clearance agents (hypertonic NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Deliver anti-inflammatory or antiasthmatic agents. saline [3% to 7% NaCl], mannitol) Manage secretions, promote secretion clearance. Method or Appliance Treat infection (e.g., Pseudomonas aeruginosa Mask, mouthpiece, mouth seal, tracheostomy infection in cystic fibrosis). mask, nose clips, holding chamber (e.g., Aero- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Induce sputum for testing (e.g., Gram stain, cul- Chamber), or spacer NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ture, cytology). Gas Source, Flow, and/or Pressure Prevent or treat atelectasis. Oxygen or compressed air

Device or Procedure Liter flow and/or Fio2 Oxygen therapy (nasal cannula, air-entrainment Pressure (IPPB, IPV) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mask, other masks or high-flow nasal cannula NOT FOR SALE OR DISTRIBUTION NOTFrequency FOR SALE and Duration OR DISTRIBUTION of Therapy [HFNC]) Twice daily, three times daily, four times daily, every Aerosol medication via SVN, MDI, DPI, or SMI 6 hours, every 4 hours, every 2 hours, every 1 hour, Incentive spirometry continuous, as needed, etc. IPPB Duration of therapy in minutes or continuous © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Directed cough NOT FOR SALE OR DISTRIBUTIONVolume Goals NOT FOR SALE OR DISTRIBUTION Suctioning Incentive spirometry minimum of one-third of Chest physiotherapy (postural drainage and chest predicted IC (1/3 × IBW in kg × 50 mL/kg) percussion) IPPB minimum of one-third predicted IC (or at least Positive expiratory pressure (PEP) 10 mL/kg) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTOscillatory FOR PEPSALE (e.g., OR acapella DISTRIBUTION flutter valve) AssessmentNOT FOR SALE OR DISTRIBUTION High-frequency chest wall oscillation (percussion Improvement and/or reversal of clinical signs and vest) symptoms of respiratory failure Intrapulmonary percussive ventilation (IPV, Reversal of the manifestations of hypoxia and/or Percussionaire) hypoventilation © Jones & BartlettHigh-volume Learning, bland aerosolLLC with or without supple-© JonesDecreased & Bartlett work of Learning, breathing LLC NOT FOR SALEmental OR oxygenDISTRIBUTION NOT FORDecreased SALE cardiac OR work DISTRIBUTION Mechanical ventilatory support (invasive and non- Improved breath sounds (air movement, wheezing, invasive ventilation; see also Box 2-4) rhonchi, crackles) Medications Pulse oximetry and arterial blood gases Bronchodilators© (e.g., Jones short-acting & Bartlett beta-2 Learning, ago- LLCBedside pulmonary function© (respiratory Jones & rate,Bartlett vol- Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nists [SABA], short-acting muscarinic antagonists umes, inspiratory force, PEF, IC, FVC, FEV1) [SAMA], long-acting beta-2 agonists [LABA], or Chest x-ray or other imaging techniques long-acting muscarinic antagonists [LAMA]) SVN, small volume nebulizer; MDI, metered-dose inhaler; DPI, dry Mucolytics (N-acetylcysteine [Mucomyst]; dornase powder inhaler; SMI, soft mist inhaler; IPPB, intermittent positive © alfa,Jones aka DNase& Bartlett [Pulmozyme]) Learning, LLC pressure breathing;© Jones Fio2, fractional & Bartlett concentration Learning, of inspired oxy- LLC gen; IC, inspiratory capacity; IBW, ideal body weight; PEF, peak expi- NOTAnti-inflammatory FOR SALE agentsOR DISTRIBUTION and decongestants NOT FOR SALE OR DISTRIBUTION ratory flow rate; FVC, forced vital capacity; FEV1, forced expiratory (inhaled corticosteroids [ICS], racemic epinephrine, volume in 1 second. others) Data from West JB. Acute respiratory failure. In: West JB. Pulmo- Combined medications (e.g., LABA and LAMA; nary physiology and pathophysiology: an integrated, case-based LABA and ICS; LABA, LAMA, and ICS) approach, 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; © Jones & Bartlett Learning, LLC © Jones2007: 116-133. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-4 Learning, Key Elements LLC of a Respiratory Care Plan for Mechanical Ventilatory Support NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Goals of Therapy Other modes and terminology (e.g., assist/control, Ensure adequate tissue oxygenation volume-limited ventilation, pressure-limited venti-

Provide adequate alveolar ventilation and CO2 lation, pressure support ventilation, SIMV, SIMV removal with pressure support, PRVC, VS, ASV, APRV, PAV, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Restore and maintain acid–base homeostasis NAVA, BiPAP, HFV) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Maintain adequate circulation, blood pressure, and Breath initiation (time or patient trigger) cardiac output Inspiratory termination (volume, time, pressure, or Treat bronchospasm/mucosal edema/excess flow) secretions Gas Source, Flow, and/or Pressure © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Maintain lung volumes/prevent or treat atelectasis Oxygen concentration NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Reduce the work of breathing Patient trigger (pressure or flow trigger) Ensure patient safety and comfort Inspiratory flow or time Minimize harmful side effects and complications Termination of inspiration (pressure, volume, or flow) © Jones & BartlettPromote Learning, liberation of LLC the patient from the © Jones & Bartlett Learning, LLC NOT FOR SALEventilator OR DISTRIBUTION NOTFrequency FOR SALE and Duration OR DISTRIBUTION of Therapy Device or Procedure Continuous mechanical ventilatory support Volume ventilators Intermittent support (ventilator weaning, night Pressure ventilators (includes NIV/BiPAP devices) only, or for acute distress) High-frequency© ventilators Jones & Bartlett Learning, VolumeLLC and Pressure © Jones & Bartlett Learning, LLC Volume ventilation (mL/kg IBW or mL) Humidifiers NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nebulizers Inspiratory pressure or pressure limit MDI and holding chamber Baseline pressure (PEEP or CPAP) Positive pressure masks (nasal/oral) Pressure support for “spontaneous” breaths © ArtificialJones airways& Bartlett (endotracheal Learning, and tracheostomy LLC Assessment© Jones & Bartlett Learning, LLC NOTtubes) FOR SALE OR DISTRIBUTION ImprovementNOT and/or FOR reversal SALE of OR clinical DISTRIBUTION signs and Suctioning equipment symptoms Reversal of the manifestations of hypoxia and/or Medications hypoventilation Bronchodilators, anti-inflammatory agents, decongestants, antiasthmatic drugs Cardiovascular/hemodynamics (pulse, blood pres- © Jones & Bartlett Learning, LLC © Jonessure, & cardiac Bartlett output, Learning, CVP, other) LLC NOT FOR SALEDrugs OR to DISTRIBUTION treat infection NOT FOR SALE OR DISTRIBUTION Work of breathing Drugs to support circulation, cardiac function, blood pressure Improved breath sounds (air movement, wheezing, rhonchi, crackles) Sedatives, tranquilizers, pain medications, paralytic Pulse oximetry and arterial blood gases agents © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Bedside pulmonary function (spontaneous respira- Method or Appliance NOT FOR SALE OR DISTRIBUTIONtory rate, volumes, RSBI, inspiratoryNOT FOR force, SALE IC, VC) OR DISTRIBUTION Mask (oral/nasal) Chest x-ray or other imaging techniques Endotracheal tube Tracheostomy tube BiPAP, bilevel positive airway pressure; MDI, metered-dose inhaler; SIMV, synchronized intermittent mandatory ventilation; PRVC, pres- Mode© Jones of Ventilation & Bartlett Learning, LLC sure regulated ©volume Jones control; & VS, Bartlett volume support; Learning, ASV, adaptive LLC NOTInvasive FOR or noninvasiveSALE OR ventilation DISTRIBUTION (NIV) support ventilation;NOT APRV, FOR airway SALE pressure ORrelease DISTRIBUTION ventilation; PAV, proportional assist ventilation; NAVA, neurally adjusted ventilatory Continuous mandatory ventilation (CMV)— assist; HFV, high-frequency ventilation; IBW, ideal body weight; pressure control or volume control PEEP, positive end-expiratory pressure; CPAP, continuous positive airway pressure; CVP, central venous pressure; RSBI, rapid shallow Intermittent mandatory ventilation (IMV)— breathing index; IC, inspiratory capacity; VC, vital capacity. © Jones & Bartlettpressure Learning, control or volumeLLC control © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© JonesOne & should Bartlett avoid Learning, high oxygen levelsLLC (>50% to 60%) © Jones & BartlettBOX 2-5 Learning, Indications LLC for Oxygen Therapy NOT FOR SALE OR DISTRIBUTION NOTfor FOR extended SALE periods OR ofDISTRIBUTION time because of the threat of Documented hypoxemia (Spo2 or arterial blood oxygen toxicity, absorption atelectasis, and depression 7,9 gases): of ciliary and/or leukocytic function. If high levels of oxygen are needed for more than short periods of time, y Adults and children: Pao2 <60 and/or alternative methods to improve oxygenation should be Spo <90 2 © Jones & Bartlett Learning, LLCconsidered. © Jones & Bartlett Learning, LLC Neonates (<28 days): Pao <50 and/or y NOT FOR SALE2 OR DISTRIBUTIONSome but not all COPD patientsNOT FORdevelop SALE chronic OR DISTRIBUTION Spo2 <88% or a capillary Po2 <40 torr CO2 retention, sometimes referred to as CVF or chronic Suspected hypoxemia based on patient condition hypercapnia. Excessive oxygen levels in patients who and/or clinical manifestations of hypoxia (follow are chronic CO2 retainers may lead to worsened hypercapnia in some, and this is thought to be largely due with Spo2 or arterial blood gas measurement)* to worsening mismatch and increased dead space ©y Jones Clinical & manifestations Bartlett Learning, of hypoxia include:LLC ©V/ JonesQ & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ventilation. NOTThe Pao FOR2 and SALESpo2 values OR which DISTRIBUTION may trig- y Tachycardia, increased blood pressure, ger this oxygen-induced hypercapnia are thought to be 7 dysrhythmias when Pao2 exceeds 60 torr and Spo2 >90%. The most y Dyspnea, tachypnea, hyperventilation, use recent Global Initiative for Chronic Obstructive Lung of accessory muscles Disease (GOLD) Report guidelines suggest that oxygen © Jones & Bartletty Restlessness,Learning, disorientation,LLC dizziness, © Jonestherapy & for Bartlett the COPD Learning, patient with LLC chronically elevated Paco levels should be targeted at maintaining a Pao NOT FOR SALE ORexcitement, DISTRIBUTION headache, blurred vision, im- NOT FOR2 SALE OR DISTRIBUTION 2 of 60 to 70 torr with an Sao2 of 88% to 92% in order to paired judgment, and confusion 10 avoid oxygen-induced hypercapnia. However, in hy- y Clinical manifestations of severe hypoxia may poxemic COPD patients with severe chronic hypercap- include: nic respiratory failure, consider titration to a Pao2 goal y Slowed, irregular© Jones respirations & Bartlett Learning, LLCof 55 to 60 mm Hg with an Spo© 2Jones of 88% to & 90% Bartlett to avoid Learning, LLC 11 y Bradycardia,NOT hypotension FOR SALE OR DISTRIBUTIONworsening hypercapnia. NOT FOR SALE OR DISTRIBUTION For long-term oxygen therapy (LTOT) in the COPD y Confusion, loss of consciousness, somno- patient at rest, a Pao2 goal of 60 to 65 mm Hg or Spo2 of lence, convulsions, or coma 90% to 92% has been suggested.12 Severe trauma Some patients with chronic lung disease experi- © AcuteJones myocardial & Bartlett infarction Learning, LLC ence hypoxemia© Jones with increased & Bartlett levels Learning, of activity, and LLC the six-minute walk test (6MWT; see Chapter 12) is NOTPostoperative FOR SALE recovery OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sometimes used to titrate oxygen requirements during Treat or prevent pulmonary hypertension second- exercise for these patients. For example, a patient who ary to chronic hypoxemia: does not require oxygen at rest begins walking vigor-

Pao2 ≤55 and/or Spo2 of ≤88% while breathing ously on a standard 30-m course while monitoring © Jones & Bartlettroom airLearning, in patients withLLC COPD © JonesSpo2. If& Spo Bartlett2 falls below Learning, an acceptable LLC level (e.g., Spo2 ≤ NOT FOR SALEor OR DISTRIBUTION NOT FOR88%), SALEO2 therapy OR by DISTRIBUTION nasal cannula is started at 2 L/ min and the test resumed. If Spo once again falls below COPD patients with cor pulmonale or hemato- 2 an acceptable level, O2 flow is increased and the test crit >56, Pao2 of 56 to 59, Sao2 <89%, and pre- resumed. This procedure is repeated until the 2O flow existing pulmonary hypertension needed to maintain an acceptable Spo2 during exercise *Hypoxemia should be ©suspected Jones in the & presence Bartlett of the Learning, clinical LLCis identified. © Jones & Bartlett Learning, LLC manifestations of hypoxia.NOT FOR SALE OR DISTRIBUTIONRetinopathy of prematurityNOT (ROP) FOR is a vascular SALE dis- OR DISTRIBUTION Spo2, arterial blood oxygen saturation; Pao2, partial pressure of order of the eye that may lead to visual impairment or oxygen, arterial; COPD, chronic obstructive pulmonary disease. blindness. ROP is thought to be caused by hypoxia, hy- peroxia, and/or hypotension in very premature infants. Providing high oxygen levels to premature infants has ©Once Jones it is established & Bartlett that Learning, oxygen therapy LLC is re- been associated© Jones with the & development Bartlett Learning, of ROP and LLCin quired,NOT the FOR respiratory SALE care OR clinician DISTRIBUTION must decide on the NOT FOR SALE OR DISTRIBUTION appropriate equipment, the correct oxygen flow and/ or Fio2, and how the therapy will be assessed. In gen- RC Insight eral, the lowest Fio2 needed to ensure adequate tissue oxygenation should be chosen. Generally, this means a High concentrations of oxygen (>50%–60%) for © Jones & targetBartlett Pao2 Learning,of 60 to 100 with LLC an Spo2 of 92% to 98% for© Jonesextended & Bartlett periods Learning,of time should LLC be avoided, unless NOT FOR SALEmost patients, OR DISTRIBUTION with the exception of the COPD patient NOT FORthey areSALE necessary OR toDISTRIBUTION correct severe hypoxemia. and the premature infant.

9781284217155_CH02_025_068.indd 34 28/11/20 5:25 PM Maintain Adequate Tissue Oxygenation 35

© Jones &the Bartlett past, maintenance Learning, of aLLC Pao2 in the range of 50 to 70© JonesPatients & Bartlett with hypoxemia Learning, due to LLC pulmonary shunting for these patients was thought to be acceptable.13 Cur- (e.g., ARDS or severe pneumonia) and patients suf- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION rent evidence suggests Spo2 be maintained in the range fering from cardiogenic shock (e.g., severe reduction of 90% to 95%, which corresponds to a Pao2 of about 60 in cardiac output) or trauma may require moderate to 75 mm Hg in preterm infants of less than 28 weeks’ to high concentrations of oxygen therapy. Short-term gestation.14–16 oxygen therapy for patients who need moderate to Other techniques© that Jones may improve & Bartlett the patient’s Learning, LLChigh concentrations of oxygen© can Jones be provided & Bartlett using a Learning, LLC airway oxygenation status includeNOT FORPEEP or SALE CPAP, OR DISTRIBUTIONsimple mask (35% to 50% O2 NOTat 5 to FOR10 L/min), SALE a partial OR DISTRIBUTION clearance techniques (sometimes referred to as rebreathing mask (40% to 70% O2 at 5 to 10 L/min), or a “bronchial hygiene”) to mobilize secretions, and bronchodilator therapy. Prone positioning has been Yes shown to improve oxygenation in patients with ARDS; Oxygen therapy by nasal No prone© Jonespositioning & Bartlettmay improve Learning, survival in LLCselected pa- © Jonescannula indicated?& Bartlett Learning, LLC tients with severe ARDS if applied early in the course of NOT FOR17–20 SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the disease. Rotational therapy (turning the patient) Begin therapy at 0.5 to may reduce the occurrence of atelectasis and ventilator- 6 L/min associated pneumonia, and thus improve oxygenation; however, improvements in length of stay have not been 21 © Jones & shown.Bartlett Rescue Learning, therapy usingLLC ECMO may be used to © Jones & BartlettMeasure Learning, SpO2 LLC NOT FOR SALEsupport ORoxygenation DISTRIBUTION in selected patients with acute, NOT FOR SALE OR DISTRIBUTION severe cardiac or respiratory failure.22 Attention to maintaining cardiac output and blood pressure is re- SpO2 $92%? quired to ensure adequate oxygen delivery to the tissues in patients with cardiovascular instability. Replacement

of blood in patients with© Jones severe anemia& Bartlett or blood Learning, loss LLC O2 flow to achieve Adjust© flowJones to maintain & Bartlett Learning, LLC (e.g., trauma or GI bleed)NOT may FOR also SALE be helpful. OR DISTRIBUTIONSpO2 $92%* SpONOT2 of 92% FOR to 98% SALE OR DISTRIBUTION The selection of an oxygen delivery method should be based on the desired Fio2, as well as patient-specific

factors such as disease state or condition, ventilatory Recheck SpO2 pattern, patient comfort, and patient acceptance of the oxygen© Jones appliance. & Bartlett Generally, Learning, hypoxemia LLC due to low © Jones & Bartlett Learning, LLC < > V/QNOT ( 1 butFOR 0) SALE or hypoventilation OR DISTRIBUTION responds well to NOT FORSpO2 $ 92%?SALE OR DISTRIBUTION low to moderate concentrations of oxygen. This includes patients with asthma, emphysema, chronic bronchitis, bronchiectasis, and cystic fibrosis. Often, patients with Continue to O2 flow; Does patient require O2 heart failure without acute pulmonary edema and pa- consider alternate to maintain SpO2 $92%? tients with coronary artery disease (CAD) also respond administration device* © Jones & Bartlett Learning, LLC © Jones (e.g.,& Bartlett O mask) Learning, LLC well to low to moderate concentrations of oxygen. 2 NOT FOR SALEThe ORdevice DISTRIBUTION of choice for most patients requiring lowNOT FOR SALE OR DISTRIBUTION Is SpO2 $92% Recheck on to moderate concentrations of oxygen is the nasal can- on room air? next shift nula. Setting the nasal cannula oxygen flow at 0.5 to (while awake) 6.0 L/min will deliver approximately 22% to 40% oxygen.7 The nasal cannula is well tolerated, easy to use, © Jones & Bartlett Learning, LLC Restart O2 © JonesDiscontinue & Bartlett Learning, LLC and effective for most patients and does not require hu- Recheck on next shift (D/C) O2 midification at flowsNOT ≤4 L/min. FOR The SALE only ORmajor DISTRIBUTIONproblem (while awake) NOT FOR SALE OR DISTRIBUTION associated with the cannula is that the delivered Fio2 will vary with the patient’s ventilatory pattern and tidal Is SpO2 $92% volume (amount of air moved with each breath). An on room air? air-entrainment© Jones & mask Bartlett should Learning, be considered LLC in patients © Jones & Bartlett Learning, LLC withNOT a variable FOR ventilatory SALE OR pattern DISTRIBUTION or those with rapid, NOT FOR SALE OR DISTRIBUTION shallow breathing. Air-entrainment (Venturi) masks will Restart O2 Discontinue deliver a stable Fio2 for most patients and are available Maintain SpO2 $92% (D/C) O2 to deliver percentages of 24%, 28%, 30%, 35%, and 40% Recheck oxygen.7 A sample respiratory care plan for providing *If flow is >6 L/min and SpO <92%, consider alternative device to deliver oxygen therapy by nasal cannula using the SOAP note 2 © Jones & Bartlett Learning, LLC © Jonesmoderate & to Bartletthigh FIO2. SpO2 , Learning,arterial blood oxygen LLC saturation. Clinical Focus 2-2 Figure 2-2 NOT FOR SALEformat isOR provided DISTRIBUTION in . NOT FOR SALE OR DISTRIBUTION presents a simple oxygen therapy protocol. FIGURE 2-2 Protocol for oxygen therapy by nasal cannula.

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© Jones & Bartlett Learning, LLC © Jones & BartlettCLINICAL Learning, FOCUS 2- LLC2 Oxygen Therapy Respiratory Care Plan NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A 65-year-old man with a history of COPD has come 60 due to the patient’s documented history of

to the emergency department with worsening short- CO2 retention (CVF, aka chronic hypercapnia). ness of breath, increased sputum production, and y Obtain arterial blood gases on oxygen to further production of thick, yellow sputum. The patient has access the patient’s ventilatory and acid-base © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a 50-pack-year history of smoking; however, he quit status for possible worsening hypercapnia (i.e., smoking 3 years ago.NOT The FORpatient SALE has been OR admitted DISTRIBUTION to acute-on-chronic ventilatoryNOT failure). FOR SALE OR DISTRIBUTION the hospital several times over the past 3 years, most y Begin albuterol and ipratropium bromide (Atro- recently 8 months ago due to acute exacerbation of vent) short-acting bronchodilator therapy per COPD with documented CO2 retention. On physical protocol to relieve airflow obstruction. assessment, the patient displays accessory muscle use © Jones & Bartlett Learning, LLC y Consider© administrationJones & Bartlett of systemic Learning, corticoste- LLC and tachypnea with an increased pulse and blood pres- NOT FOR SALE OR DISTRIBUTION roids (e.g.,NOT oral FOR prednisone SALE 40 OR mg/day DISTRIBUTION × 5 days sure. Oximetry on room air reveals an Spo of 85%. 2 [adults]) to improve outcomes and decrease On his previous admission, blood gas analysis dem- length of stay. onstrated chronic ventilatory failure (i.e., chronically y Consider antibiotics for pulmonary infection. elevated Paco2). © Jones & Bartlett Learning, LLC © Jonesy Obtain & Bartlett labs (complete Learning, blood LLC count and differ- Respiratory Care Plan NOT FOR SALE OR DISTRIBUTION NOT FORential, SALE serum OR electrolytes, DISTRIBUTION glucose) and chest S (Subjective): “I’m feeling really bad and can barely radiograph to identify/rule out comorbidities get my breath. I am so short of breath that I am (pneumonia, pneumothorax, pleural effusion, having trouble walking, and I have been coughing cardiovascular disease, pulmonary edema). up some awful-looking stuff.” y Continue to monitor patient (level of conscious- O (Objective): © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONness, dyspnea, vital signs,NOT Spo2 ,FOR blood gases,SALE fluid OR DISTRIBUTION y Vital signs: respiratory rate, 28; pulse, 116; BP, balance), and be alert to other possible comor- 142/92 mm Hg; temperature, 99.6°F bidities (heart failure, other cardiovascular dis-

y Spo2 = 85% while breathing room air ease, pulmonary embolism, lung cancer, diabetes, y Physical assessment: accessory muscle use, gastroesophageal reflux disease [GERD], etc.). © Jonesdiminished & Bartlett breath sounds Learning, bilaterally, LLC cough with y Consider© Jonesnon-invasive & Bartlett ventilation Learning, (NIV) if acute LLC NOTpurulent FOR SALE sputum ORproduction DISTRIBUTION respiratoryNOT acidosis FOR occursSALE (e.g., OR Paco DISTRIBUTION2 ≥45 mm A (Assessment): Acute exacerbation of COPD. Hg with pH ≤7.35), or severe dyspnea and signs P (Plan): of respiratory muscle fatigue or increased work of breathing persist. y Begin oxygen via nasal cannula at 1 to 2 L/min © Jones & Bartlettand Learning, titrate by oximetry. LLC © JonesCOPD, chronic & Bartlett obstructive Learning, pulmonary disease; LLC Spo2, arterial blood oxygen saturation; Paco , arterial partial pressure of carbon dioxide; NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR2 DISTRIBUTION y Titrate oxygen flow based on oximetry to main- BP, blood pressure; Pao2, partial pressure of oxygen, arterial; tain an Spo2 of 88% to 90% and a Pao2 of 55 to CVF, chronic ventilatory failure.

nonrebreathing mask© (60% Jones to 80% & OBartlett2 at 6 to 10 Learning, L/min). LLCHFNC may improve patient comfort,© Jones reduce & Bartlett the work Learning, LLC Air-entrainment nebulizers via aerosol mask, tracheos- of breathing, deliver a more stable Fio2 and provide tomy mask, or “T” pieceNOT can FOR be very SALE useful ORin providing DISTRIBUTION an alternative to NIV.24 HFNCNOT systems FOR deliver SALE up to OR DISTRIBUTION a stable oxygen concentration from 28% to 50%. Above 60 L/min of gas flow via an oxygen blender, humidifier, 50% oxygen, most air-entrainment nebulizers do not and heated tubing. The high gas flows employed result have an adequate total gas flow to deliver a dependable in a small amount of upper airway positive pressure Fio©2. TheJones Misty & BartlettOx high-flow, Learning, high-Fio2 nebulizer, LLC how- and the warm,© Jones humified & gasesBartlett may facilitate Learning, secretion LLC ever,NOT will deliverFOR SALE60% to 96% OR oxygen DISTRIBUTION with total gas flows clearance. TNOTypically, FOR the HFNCSALE is ORinitiated DISTRIBUTION at a flow of of 42 to 80 L/min. The Thera-Mist air-entrainment 20–25 L/min with an Fio2 of 0.40 to 0.60 (40% to 60% 24 nebulizer is designed to provide 36% to 96% oxygen at O2). The blended Fio2 and flow are adjusted to achieve 23 flows of 47 to 74 L/min. the desired Spo2 and/or Pao2. The HFNC can deliver a More recently, the administration of oxygen via relatively high concentration of oxygen and as flow and/ © Jones & HFNCBartlett has beenLearning, suggested LLC for patients with severe, hy-© Jonesor blended & Bartlett Fio2 increase, Learning, so do arterial LLC oxygen levels. poxemic respiratory failure (e.g., Pao2/Fio2 <300 mm When HFNC flows and Fio2 can be safely reduced to NOT FOR SALE24 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hg). When compared to other high-flow devices, the less than 20 L/min and Fio2 ≤0.50, the HFNC can be

9781284217155_CH02_025_068.indd 36 28/11/20 5:25 PM Treat and/or Prevent Bronchospasm and Mucosal Edema 37

© Jones &replaced Bartlett by Learning,conventional oxygenLLC therapy (e.g., nasal © Jones & Bartlett Learning, LLC cannula).24 HFNC use is often restricted to the intensive BOX 2-6 Indications for Bronchodilator NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION care or step-down units. Therapy Patients with conditions that are unresponsive to Asthma basic oxygen therapy may require the use of PEEP or CPAP. PEEP and CPAP may be applied through the use COPD (emphysema/chronic bronchitis) of specialized face masks.© Jones Often, & however, Bartlett administra- Learning, LLCCystic fibrosis © Jones & Bartlett Learning, LLC tion of PEEP or CPAPNOT will requireFOR SALEintubation OR and DISTRIBUTION the Wheezing NOT FOR SALE OR DISTRIBUTION use of mechanical ventilatory support. Documented response to a bronchodilator: To summarize, if the patient requires a low to moderate concentration of oxygen, the nasal cannula is the y Increase in FEV1 >12% following therapy and device of choice for oxygen delivery for most patients. at least 200 mL In patients© Jones with & unstable Bartlett ventilatory Learning, patterns LLC or rapid, © Jones & Bartlettor Learning, LLC shallowNOT breathing, FOR SALE an air-entrainment OR DISTRIBUTION (Venturi) mask y IncreaseNOT in FOR FVC > SALE12% following OR DISTRIBUTION therapy and may be considered. For moderate to high concentra- at least 200 mL tions of oxygen therapy for short-term use, consider or a simple, partial rebreathing or nonrebreathing mask. For stable oxygen concentration via aerosol mask, y Increase in PEF*: © Jones & tracheostomyBartlett Learning, mask, or “T” LLC piece, consider a standard © Jones &y Bartlett PEF >80% Learning, to 100% of personal LLC best = good NOT FOR SALEair-entrainment OR DISTRIBUTION nebulizer for an Fio2 of 0.28 to 0.50 andNOT FOR SALEresponse OR (Green DISTRIBUTION Zone) in asthma control a high-flow, high-Fio2 entrainment nebulizer for 60% y PEF 50% to 79% of personal best = caution, to 96% oxygen (e.g., Thera-Mist or Misty-Ox). As an al- airways somewhat obstructed (Yellow Zone) ternative in patients with acute, hypoxemic respiratory failure requiring higher oxygen concentrations, consider y PEF <50% of personal best = medical the use of the HFNC.© In Jones patients & who Bartlett do not respond Learning, to LLC alert (Red Zone) © Jones & Bartlett Learning, LLC conventional oxygenNOT therapy, FOR the useSALE of PEEP OR or DISTRIBUTION CPAP y Increased airway resistanceNOT FORin patients SALE receiv- OR DISTRIBUTION should be considered. ing mechanical ventilation

*Monitoring of lung function (e.g., PEF, spirometry for FEV1 and Treat and/or Prevent FVC) and symptoms is recommended for patients with moderate to severe asthma. A peak flow> 80% of predicted or per- Bronchospasm© Jones & Bartlett and Learning, Mucosal LLC sonal best suggests© Jones that asthma & Bartlett is in good control;Learning, 50% to 79% LLC Edema of predicted or personal best suggests that asthma is not well NOT FOR SALE OR DISTRIBUTION controlled; NOT<50% suggests FOR asthmaSALE is poorlyOR controlledDISTRIBUTION and rep- Bronchodilator Therapy resents a medical alert that requires immediate treatment and contact with the patient’s physician.25 The primary indication for bronchodilator therapy is to COPD, chronic obstructive pulmonary disease; FEV1, forced ex- treat or prevent bronchospasm. Bronchodilator therapy piratory volume in 1 second; FVC, forced vital capacity; PEF, peak © Jones & isBartlett indicated Learning,in the treatment LLC of acute asthma, COPD © Jonesexpiratory & Bartlett flow rate. Learning, LLC (to include chronic bronchitis and cystic fibrosis), and NOT FOR SALEwhenever OR wheezing DISTRIBUTION is due to reversible bronchocon- NOT FOR SALE OR DISTRIBUTION striction. A documented response to bronchodilator of administration must be determined. Bronchodila- therapy may be demonstrated by an improvement in tors are most commonly administered by inhalation via peak expiratory flow rate (PEF), forced expiratory vol- a metered-dose inhaler (MDI), a small-volume nebu- ume in 1 second (FEV©1 ),Jones or forced & vital Bartlett capacity Learning, (FVC) LLClizer (SVN), or a dry powder© inhaler Jones (DPI); & Bartlettthe soft Learning, LLC following therapy. An improvement in clinical findings mist inhaler (SMI) is a newer device available for deliv- such as decreased wheezingNOT FOR or improved SALE aeration OR DISTRIBUTION or a ery of certain medications (e.g.,NOT Combivent FOR SALE Respimat, OR DISTRIBUTION subjective improvement in the respiratory status of the Spiriva Respimat). Bronchodilators may be classified as patient are also important indicators of bronchodila- β2-agonists (beta-2 agonists, aka sympathomimetics) tor effectiveness. In mechanically ventilated patients, or muscarinic antagonists (sometimes referred to as bronchodilator© Jones & therapy Bartlett may Learning,be helpful with LLC increased anticholinergics© Jones or parasympatholytics) & Bartlett Learning, and as short LLC β airwayNOT resistance. FOR SALE An improvement OR DISTRIBUTION in peak inspiratory acting or longNOT acting. FOR Short-acting SALE OR 2-agonists DISTRIBUTION (SABA) pressures or expiratory gas flow curves may be useful in include albuterol, levalbuterol, and pirbuterol. All have documenting the effectiveness of the therapy in these a rapid onset and a duration of effect of approximately patients. Box 2-6 summarizes the indications for bron- 4 to 8 hours. Long-acting β2-agonists (LABA) include chodilator therapy. salmeterol, formoterol, arformoterol, indacaterol, and © Jones & BartlettOnce the Learning, respiratory careLLC clinician has determined © Jonesolodaterol. & Bartlett Muscarinic Learning, antagonists LLC (aka anticholin- NOT FOR SALEthat bronchodilator OR DISTRIBUTION therapy is indicated, the specific NOTergic FOR bronchodilators) SALE OR DISTRIBUTION include ipratropium bromide medication, dosage, method of delivery, and frequency (short-acting muscarinic antagonist, or SAMA) and

9781284217155_CH02_025_068.indd 37 28/11/20 5:25 PM 38 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones &tiotropium Bartlett bromideLearning, (long-acting LLC muscarinic antago- © Jonestherapy” & Bartlettrefers to medications Learning, that LLC combine a LABA, nist, or LAMA). Duration of action for long-acting NOTLAMA, FOR SALEand ICS. OR A list DISTRIBUTION of inhaled bronchodilator NOT FOR SALEbronchodilators OR DISTRIBUTION ranges from 12 to 24 hours. Addi- agents is found in Table 2-3. Asthma and COPD repre- tional formulations combine a LABA and LAMA, sent two conditions that often require bronchodilator and a LABA and inhaled corticosteroid (ICS). “Triple therapy.

Duration Medication Method of Onset of Effect Type© Jones &Generic Bartlett Name Learning, Trade Name LLC Administration (minutes)© Jones & Bartlett Peak Effect Learning,(hours) LLC Ultra-SABANOT FOR RacemicSALE OR DISTRIBUTIONAsthmanefrin, Pri- SVN, MDI 3–5NOT FOR SALE5–20 OR DISTRIBUTION0.5–2 epinephrine matene Mist

SABA Metaproterenol Alupent SVN 1–5 60 min 2–6

SABA Albuterol Proventil HFA, Ven- SVN, MDI, DPI 15 30–60 min 4–6 and 12 © Jones & Bartlett Learning, LLC tolin, other © Jones & Bartlett Learning, LLC (ext. release) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION SABA Levalbuterol Xopenex SVN, MDI 15 30–60 min 5–8

SABA Fenoterol Berotec MDI, SVN Rapid, within 30–90 min 3–6 5 min SABA Terbutaline© Jones & BricanylBartlett Learning,DPI LLC 5–30 1–2© h Jones & 3–6Bartlett Learning, LLC LABA SalmeterolNOT FOR SALE Serevent OR DISTRIBUTIONDPI, MDI 20 3–5NOT h FOR SALE12 OR DISTRIBUTION

LABA Formoterol Foradil, SVN, DPI 15 30–60 min 12 Perforomist

LABA© Jones &Arformoterol Bartlett Learning, Brovana LLC SVN 15© Jones & Bartlett30–60 min Learning, 12 LLC LABANOT FOR SALEIndacaterol OR DISTRIBUTION Arcapta DPI 5 NOT FOR SALE30 min OR DISTRIBUTION24

LABA Olodaterol Striverdi SMI 15 30–60 min 24 Respimat

SAMA Ipratropium Atrovent MDI, SVN 15 1–2 h 6 © Jones & Bartlett Learning,bromide LLC © Jones & Bartlett Learning, LLC NOT FOR SALESAMA OR DISTRIBUTIONOxitropium Oxivent, Tersigan MDINOT FOR SALE10–15 OR DISTRIBUTION2 h 6 bromide

LAMA Aclidinium bromide Bretaris Genuair, DPI, MDI 10 2 h 12 Eklira Genuair, © Jones & Tudorza Bartlett Pressair Learning, LLC © Jones & Bartlett Learning, LLC LAMA GlycopyrroniumNOT FOR SALE Seebri Breezhaler OR DISTRIBUTION DPI Rapid 5 minNOT FOR SALE12–24 OR DISTRIBUTION

LAMA Tiotropium Spiriva DPI, SMI 30 1–3 h 24

LAMA Umeclidinium Incruse Ellipta DPI 5–15 1–3 h 24 bromide © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC LAMANOT FOR SALERevefenacin OR DISTRIBUTION Yupelri SVN 14NOT to 41 minFOR SALE 2–3 h OR DISTRIBUTION24 SABA + SAMA Ipratropium + Combivent Respi- SVN, DPI 15 1–2 h 4–6 Albuterol mat, Duoneb

LAMA + LABA Umeclidinium + Anoro Ellipta DPI 5–15 1–3 h 24 © Jones & Bartlett Learning,Vilanterol LLC © Jones & Bartlett Learning, LLC NOT FOR SALELAMA + ORLABA DISTRIBUTION Tiotropium + Stiolto Respimat SMINOT FOR SALE15 OR DISTRIBUTION1–2 h 24 Olodaterol

9781284217155_CH02_025_068.indd 38 28/11/20 5:25 PM Treat and/or Prevent Bronchospasm and Mucosal Edema 39

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Duration Medication Method of Onset of Effect NOT FOR SALEType OR DISTRIBUTIONGeneric Name Trade Name AdministrationNOT FOR SALE(minutes) OR DISTRIBUTION Peak Effect (hours)

LAMA + LABA Glycopyrronium + Utibron DPI Rapid 5–15 min 12–24 Indacaterol

LAMA + LABA Glycopyrronium + Bevespi MDI 3 5–15 min 12 Formoterol© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION LABA + LAMA Formoterol + Duaklir Pressair DPI 5 5 min 24 Aclidinium

LABA + LAMA Formoterol + Bevespi Aerosphere MDI 5 5–60 min 12 Glycopyrronium © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC LABANOT + ICS FOR FormoterolSALE OR + DISTRIBUTIONFostair MDI 1–3NOT FOR SALE0.5–1 h OR DISTRIBUTION12 Beclometasone

LABA + ICS Formoterol + Symbicort MDI, DPI 15 3 h 12 Budesonide

© Jones & BartlettLABA + ICS Learning, Formoterol LLC + Dulera MDI© Jones & BartlettRapid Learning,0.5–2 h LLC 12 Mometasone NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION LABA + ICS Salmeterol + Advair HFA, Advair MDI, DPI 30–60 min 1–2 h 12 Fluticasone Diskus

LABA + ICS Vilanterol + Breo Ellipta DPI 15 min 10 min–1 h 24 Fluticasone © Jones furoate & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC LABA + FluticasoneNOT +FOR SALETrelegy Ellipta OR DISTRIBUTION DPI 5–15 min 5 min–1NOT h FOR SALE 24 OR DISTRIBUTION LAMA + ICS Umeclidinium + Vilanterol

LABA + Beclometasone + Trimbow MDI 1–3 0.5–1hr 12 LAMA + ICS Formoterol + © Jones &Glycopyrronium Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

SABA,NOT short-acting FOR beta-2 SALE agonist; OR SVN, smallDISTRIBUTION volume nebulizer; MDI, metered-dose inhaler; HFA, hydrofluoroalkaneNOT FOR MDI propellant;SALE DPI, OR dry powderDISTRIBUTION inhaler; LABA, long-acting beta-2 agonist; SMI, soft mist inhaler; SAMA, short-acting muscarinic antagonist; LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroid.

© Jones & RespiratoryBartlett Learning, Care Plans LLC for Asthma © Jones(rescue & medications) Bartlett Learning, and anti-inflammatory LLC agents NOT FOR SALEExcellent OR clinical DISTRIBUTION practice guidelines for the manage- NOT(controller FOR SALE medications). OR DISTRIBUTION ment of asthma have been developed by the National With poorly controlled asthma, acute asthma ex- Institutes of Health and the Global Initiative for Asthma acerbations often result in visits to the emergency (GINA).25,26 Inhaled asthma medications include department (ED). Patients with mild or moderate ex- quick-relief bronchodilators and long-term control acerbations are generally not agitated and are able to agents, usually inhaled© corticosteroidsJones & Bartlett (ICS). Patients Learning, LLCtalk in phrases, although they© prefer Jones sitting & toBartlett lying Learning, LLC with persistent asthmaNOT usually FOR require SALE both OR types DISTRIBUTION of down to reduce dyspnea. AlthoughNOT accessoryFOR SALE muscles OR DISTRIBUTION medications. Most patients with persistent asthma can are not in use, respiratory rate is increased, and pulse maintain good control of their asthma with proper pa- may be in the range of 100 to 120 bpm. With mild to moderate asthma exacerbations, PEF is greater than tient education (including symptom monitoring and a > written asthma action plan), avoidance of asthma trig- 50% predicted (or 50% of personal best) and Spo2 is gers,© andJones an appropriate & Bartlett regimen Learning, of bronchodilators LLC in the range© of Jones 90% to 95% & Bartlett while breathing Learning, room air. LLC NOT FOR SALE OR DISTRIBUTION With severeNOT asthma FOR exacerbations, SALE OR patients DISTRIBUTION are often agitated and so short of breath that they can only talk in RC Insight words (vs. phases or sentences). They often sit hunched forward, using their accessory muscles; respiratory rate Current guidelines suggest that inhaled corticoste- may be >30/min with pulse >120 bpm and Spo2 <90% © Jones & Bartlettroids (ICS) Learning, be initiated inLLC asthma patients as soon © Joneswhile breathing& Bartlett room Learning, air. Patients LLCwith life-threatening NOT FOR SALEas possible OR DISTRIBUTION following diagnosis in order to avoid NOTasthma FOR exacerbationsSALE OR DISTRIBUTIONmay be drowsy, lethargic, and severe exacerbations. confused and upon auscultation, limited air movement may be detected (i.e., silent chest).26

9781284217155_CH02_025_068.indd 39 28/11/20 5:25 PM 40 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettInitial ED Learning, treatment of LLC acute asthma exacerbation © JonesGroup & of Bartlettthe National Learning, Institutes of LLC Health (NIH) Na- in the adult includes administration of a short-acting NOTtional FOR Heart, SALE Lung, OR and DISTRIBUTION Blood Institute (NHLBI) allows NOT FOR SALEbeta-2 agonist OR DISTRIBUTION (SABA) bronchodilator administered via for the use of formoterol/ICS for both asthma quick- SVN or MDI and spacer. For example, 2.5 to 5 mg (per relief (rescue) and controller therapy. Formoterol is a dose) of aerosolized albuterol via SVN may be given long-acting beta-2 agonist (LABA). every 20 minutes for a total of three doses. Following As noted, inhaled medications may be given via MDI the initial bronchodilator© Jones administration & Bartlett of three Learning, doses, LLCand holding chamber or SVN© with Jones equal &effectiveness, Bartlett Learning, LLC 2.5 to 5 mg of albuterolNOT is then FOR administered SALE OR by DISTRIBUTIONSVN if the patient is able to coordinateNOT the FOR use ofSALE the MDI. OR DISTRIBUTION every 1 to 4 hours as needed (or 10 to 15 mg/hour nebu- The frequency of administration is then reduced based lized continuously). As an alternative, 4 to 10 puffs of al- on the patient’s response and measurement of PEF or buterol may be given via MDI with spacer and repeated FEV1. Oral corticosteroids (OCS) are typically started every 20 minutes for 1 hour. Ipratropium, a short-acting (e.g., prednisolone 40–50 mg [adults]; 1–2 mg/kg with muscarinic© Jones antagonist & Bartlett (SAMA) Learning, may be added LLC for pa- a maximum© of Jones 40 mg [children]). & Bartlett Oxygen Learning, is provided LLC tientsNOT with FOR moderate SALE to severe OR DISTRIBUTIONexacerbations, initially to maintainNOT Spo2 in FOR the range SALE of 93% OR to DISTRIBUTION 95% (adults) or beginning with 0.5 mg every 20 minutes by nebulization 94% to 98% (children). A single infusion of intravenous for three rounds, and then every 2 to 4 hours as needed; magnesium sulfate or inhalation of Heliox (70%–80% however, ipratropium may only be beneficial during the helium) may be helpful in patients with severe asthma initial treatment of acute asthma. It must also be noted exacerbations who are unresponsive to initial therapy. © Jones & thatBartlett the Update Learning, on Selected LLC Topics in Asthma Manage-© JonesTable 2-4& Bartlett lists the medication Learning, dosages LLC for treatment NOT FOR SALEment 2020: OR A DISTRIBUTION Report from the National Asthma Educa-NOTof FOR asthma SALE exacerbations. OR DISTRIBUTION An outline of a protocol for tion and Prevention Program Coordinating Committee management of acute asthma exacerbation is provided (NAEPPCC) Expert Panel Report 4 (EPR-4) Working in Figure 2-3.

TABLE 2-4 Medication Dosages© for Jones Treatment & Bartlett of Asthma Learning, Exacerbation LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Medication Child Dose ($12 years) Adult Dose Comments

Inhaled Short-Acting Selective a2-Agonists (SABA)

Albuterol © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Nebulizer solution 0.15 mg/kg (minimum dose 2.5–5 mg every 20 minutes for Dilute aerosols to minimum of (0.63NOT mg/3 FOR mL, SALE 2.5OR mg) DISTRIBUTION every 20 minutes for three doses in the firstNOT hour, FOR SALE3 mL at gasOR flow DISTRIBUTION of 6–8 L/min. 1.25 mg/3 mL, three doses in the first hour then then 2.5–5 mg every 1–4 hours Use large-volume nebulizers for 2.5 mg/3 mL, 0.15–0.3 mg/kg up to 10 mg as needed or 10–15 mg/hour continuous administration. May mix 5.0 mg/mL) every 1–4 hours as needed, or continuously. with ipratropium nebulizer solution. 0.5 mg/kg/hour by continuous nebulization. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEMDI (90 ORmcg/puff) DISTRIBUTION via 4–8 puffs every 20 minutes for NOT4–8 puffs FOR every SALE 20 minutes OR for theDISTRIBUTION In mild to moderate exacerbations, valved holding chamber three doses, then every 1–4 hours first hour, then every 1–4 hours as MDI plus valved holding chamber (VHC) inhalation maneuver as needed. needed. (VHC) is as effective as nebulized Use VHC; add mask in children therapy with appropriate adminis- <4 years. tration technique and coaching by trained personnel. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Levalbuterol (R-albuterol)NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Nebulizer solu- 0.075 mg/kg (minimum dose 1.25–2.5 mg every 20 minutes Levalbuterol administered in tion (0.31 mg/3 1.25 mg) every 20 minutes for three doses, then 1.25–5 mg one-half the mg dose of albuterol ml; 0.63 mg/3 mL; for three doses, then 0.075– every 1–4 hours as needed. provides comparable efficacy and 1.25 mg/0.5 mL; 0.15 mg/kg up to 5 mg every safety. Has not been evaluated by 1.25© Jonesmg/3 mL) & Bartlett1–4 Learning,hours as needed. LLC © Jones & Bartlettcontinuous nebulization. Learning, LLC MDINOT (45 mcg/puff) FOR SALE OR See albuterol DISTRIBUTION MDI dose. See albuterol MDI dose.NOT FOR SALE OR DISTRIBUTION

Systemic (Injected) a2-Agonists

Epinephrine

© Jones & Bartlett1:1000 (1 mg/mL) Learning, 0.01LLC mg/kg up to 0.3–0.5 mg SQ ©0.3–0.5 Jones mg SQ& everyBartlett 20 minutes Learning, No proven LLC advantage of systemic NOT FOR SALE OR DISTRIBUTIONevery 20 minutes for three doses. NOTfor three FOR doses. SALE OR DISTRIBUTIONtherapy over aerosol.

9781284217155_CH02_025_068.indd 40 28/11/20 5:25 PM Assessment and Treatment of COPD 41

(1 mg/mL) 0.01 mg/kg SQ every 20 min- 0.25 mg SQ every 20 minutes for No proven advantage of systemic utes for three doses then every three doses. therapy over aerosol. 2–6 hours as needed.

Muscarinic Antagonists© (akaJones anticholinergics) & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ipratropium bromide

Nebulizer solution 0.25–0.5 mg every 20 minutes for 0.5 mg every 20 minutes for three May mix in nebulizer with alb- (0.25 mg/mL) three doses, then as needed. doses, then as needed. uterol. Should not be used as first-line therapy; add to SABA © Jones & Bartlett Learning, LLC © Jones & Bartletttherapy for severe Learning, exacerba - LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALEtions. The OR addition DISTRIBUTION of ipratropium not shown to provide further benefit once the patient is hospitalized.

MDI (18 mcg/puff) 4–8 puffs every 20 minutes × 3 4–8 puffs every 20 minutes × 3 Use with VHC and face mask for © Jones & Bartlett Learning, thenLLC as needed up to 3 hours. ©then Jones as needed & upBartlett to 3 hours. Learning,children

NOT FOR SALEIpratropium OR withDISTRIBUTION albuterol (SAMA plus SABA) NOT FOR SALE OR DISTRIBUTION

Nebulizer solution (each 1.5–3 mL every 20 minutes for 3 mL every 20 minutes for three Used for up to 3 hours in initial 3 mL vial contains three doses, then as needed. doses, then as needed. management of severe exacerba- 0.5 mg ipratropium tions. Addition of ipratropium to bromide and 2.5 mg © Jones & Bartlett Learning, LLC albuterol© Jones not shown & to Bartlett provide Learning, LLC albuterol) further benefit once the patient is NOT FOR SALE OR DISTRIBUTION hospitalized.NOT FOR SALE OR DISTRIBUTION

MDI (each puff contains 4–8 puffs every 20 minutes as 8 puffs every 20 minutes as Use with HC and face mask for 18 mcg ipratropium needed up to 3 hours. needed up to 3 hours. children <4 years. bromide and 90 mcg of albuterol) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC SystemicNOT FORCorticosteroids SALE (appliesOR DISTRIBUTION to all three corticosteroids) NOT FOR SALE OR DISTRIBUTION Prednisone 1–2 mg/kg day in two divided 40–80 mg/day Prednisone Prednisone: short course “burst”: Methylprednisolone doses (maximum = 60 mg/day) (32–64 mg methyl-prednisolone) use 40–80 mg/day in one or two Prednisolone until PEF is 70% of predicted or in one or two divided doses until divided doses for total of personal best. PEF reaches 70% of predicted or 3–10 days in adults. Typical is © Jones & Bartlett Learning, LLC ©personal Jones best. & Bartlett Learning,40 mg/day LLC × 5 days. Methylprednisolone: 32 to NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION64 mg/day for 3 to 10 days. Typical is 32 mg/day × 5 days.

There is no advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired. Course of systemic corticosteroids for asthma exacerbation requiring emergency department visit or hospitalization may be 3–10 days. For less than 1 week, no need to taper dose. For courses up to 10 days, tapering may not be necessary, especially if patients are concurrently taking inhaled corticosteroids. Inhaled corticosteroids can© be startedJones at any & point Bartlett in the treatment Learning, of an asthma exacerbation. LLC © Jones & Bartlett Learning, LLC MDI, metered-dose inhaler;NOT SQ, subcutaneous; FOR SALE SAMA, short-acting OR DISTRIBUTION muscarinic antagonist; HC, holding chamber; PEF, peakNOT expiratory FOR flow. SALE OR DISTRIBUTION Reproduced from National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the diagnosis and management of asthma: Expert Panel 3 report. Bethesda, MD: U.S. Department of Health and Human Services, 2007. NIH Publication 08-5846.

27 Assessment© Jones & Bartlett and Treatment Learning, LLC noxious particles© Jones or gases.” & Bartlett Small airways Learning, disease LLCand of COPDNOT FOR SALE OR DISTRIBUTION parenchymalNOT destruction FOR SALE result in OR chronic DISTRIBUTION airflow obstruction as best assessed by measurement of FEV1 and According to the Global Initiative for Chronic FEV1/FVC. Types of COPD include chronic bronchi- Obstructive Lung Disease (GOLD): “COPD is a com- tis, emphysema, and chronic obstructive asthma, and mon, preventable, and treatable disease that is char- there is considerable overlap between COPD and other © Jones & acterizedBartlett by Learning, persistent respiratory LLC symptoms, and © Jonescauses & of Bartlettairway obstruction Learning, (e.g., LLCasthma, bronchiol- history NOT FOR SALEair flow OR limitation DISTRIBUTION due to airway and/or alveolar ab- NOTitis, FOR bronchiectasis). SALE OR The DISTRIBUTION patient should include normalities usually caused by significant exposure to documentation of current or past cigarette smoking,

9781284217155_CH02_025_068.indd 41 28/11/20 5:25 PM 42 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettPatient Assessment Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Review OR of DISTRIBUTION the patient record and patient interview: AssessNOT for severity FOR ofSALE exacerbation OR andDISTRIBUTION risk factors associated with death from asthma: Asthma history Level of dyspnea (mild, moderate, or severe?) Previous history of exacerbation? Previous emergency department visits ( 3 in the past year?) Previous hospitalizations© Jones ( &2 inBartlett the past year?) Learning, LLC © Jones & Bartlett Learning, LLC ICU admissionNOT and/or FOR intubation SALE for asthma? OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Use of MDI β2-adrenergic agonist canisters ( 2 per month?) Difficulty perceiving asthma symptoms or severity of exacerbations? Written action plan (in place and followed)? Sensitivity to Alternaria (a fungus associated with hay fever and allergic asthma)?

© JonesSocial history & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTLow FOR socioeconomic SALE OR status DISTRIBUTION or inner-city resident? NOT FOR SALE OR DISTRIBUTION Illicit drug use? Major psychological problems?

Comorbidities Cardiovascular disease? © Jones & BartlettOther Learning, chronic lung disease?LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORChronic DISTRIBUTION psychiatric disease? NOT FOR SALE OR DISTRIBUTION • Physical assessment: Observe for: Breathlessness at rest? Ability to talk in sentences, phrases, or only words due to dyspnea? Alertness (agitated, drowsy, confused)? Increased respiratory© Jones rate ( 30& is Bartlett severe)? Learning, LLC © Jones & Bartlett Learning, LLC Tachycardia ( 120 is severe)? Pulsus paradoxus? Accessory muscleNOT use? FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Wheezing? (Absence of wheeze may signal an imminent respiratory arrest.)

• Pulmonary function: PEF percent predicted or percent personal best (for asthma): Mild severity: 70% Moderate severity: 40% to 60% © JonesSevere: &40% Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Oximetry and arterial blood gases breathing room air:

Normal: SpO2 95% and/or PaO2 80 to 100 on room air Moderate severity: SpO2 90% to 95% and/or PaO2 60 but 80 Severe: SpO2 90% and/or PaO2 60 – severe Mild or normal: PaCO 42 mm Hg; 42 mm Hg may progress to ventilatory failure requiring mechanical ventilation © Jones & Bartlett Learning, 2LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Treatment OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Supply oxygen therapy to relieve hypoxemia and maintain SaO2 90%. Administer inhaled short-acting β2-agonist to relieve air ow obstruction, with addition of inhaled ipratropium bromide in severe exacerbations. Administer systemic corticosteroids to decrease airway in ammation in moderate or severe exacerbations or for patients who fail to respond promptly and completely to a short-acting β2-agonist. Monitor vital signs,© SaJonesO2. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Consider adjunctNOT therapy FOR in severe SALE exacerbations OR DISTRIBUTION unresponsive to the initial treatment: NOT FOR SALE OR DISTRIBUTION Intravenous magnesium sulfate Heliox Monitor response with serial measurements of lung function (FEV1 or PEF). Prevent recurrence: Refer to follow-up asthma care within 1 to 4 weeks of discharge. © JonesProvide & asthma Bartlett care plan Learning, with instructions LLC for medications prescribed at discharge© Jones and for& increasingBartlett medications Learning, or LLC seeking medical care if asthma worsens. NOT Review/teachFOR SALE inhaler OR use/techniques. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Consider initiating inhaled corticosteroids.

FIGURE 2-3 Management of acute asthma exacerbation.

ICU, intensive care unit; MDI, metered dose inhaler; PEF, peak expiratory flow; Spo2, arterial blood oxygen saturation; Pao2, partial pressure of oxygen, arterial; Paco2, arterial partial pressure of © Jones & carbonBartlett dioxide; Sa oLearning,2, oxygen saturation; FEVLLC1, forced expiratory volume in the first second© of expiration.Jones & Bartlett Learning, LLC Data from National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the diagnosis and management of asthma: Expert Panel 3 report. Bethesda, MD: U.S. NOT FOR SALEDepartment ofOR Health DISTRIBUTIONand Human Services, 2007. NIH Publication 08-5846. NOT FOR SALE OR DISTRIBUTION

9781284217155_CH02_025_068.indd 42 28/11/20 5:25 PM Assessment and Treatment of COPD 43

■ © Jones &exposure Bartlett to Learning,secondhand smoke,LLC and exposure to air © Jones Chest& Bartlett auscultation Learning, may reveal LLC prolonged expira- pollution, occupational dusts and fumes, or smoke NOT FORtion SALE or wheezes OR DISTRIBUTIONon forced expiration, decreased NOT FOR SALEfrom biomass OR DISTRIBUTION fuels (e.g., wood fires for cooking or heat- breath sounds, wheezes or crackles at lung bases, ing).27,28 Common symptoms include chronic cough, and/or distant heart sounds. sputum production, and dyspnea, especially on exer- ■ Chest percussion may identify increased reso- tion. Less common symptoms include chest tightness nance (hyperresonant percussion) due to lung and wheezing. Many© patients Jones are & overweight Bartlett or Learning, obese, LLC overinflation. © Jones & Bartlett Learning, LLC 28 ■ and this may worsenNOT the exertional FOR SALE dyspnea OR observed. DISTRIBUTION Palpation may detect inspiratoryNOT FOR accessory SALE mus- OR DISTRIBUTION Dyspnea can be assessed for severity using a standard- cle contraction, and abdominal–chest wall asyn- ized scoring system, such as the modified Medical Re- chrony (see-saw breathing) associated with severe search Council (mMRC) dyspnea scale where: 29 distress and increased work of breathing. Neck vein distention may be present due to increased ■ Dyspnea only with strenuous exercise; score = 0 intrathoracic pressures. © ■ DyspneaJones when& Bartlett hurrying Learning, or walking up LLC a slight hill; © Jones & Bartlett Learning, LLC = + NOTscore FOR 1 SALE OR DISTRIBUTION PulmonaryNOT function FOR testing SALE is requiredOR DISTRIBUTION for docu- ■ Walks slower than people of the same age because mentation of airflow obstruction. While GOLD has of dyspnea or has to stop for breath when walking defined airflow obstruction as a reduced FEV /FVC = + 1 at own pace; score 2 ratio (<0.70), others have suggested use of the lower ■ Stops for breath after walking 100 yards or after a limit of normal (LLN) for the FEV /FVC to identify © Jones & Bartlett Learning, =LLC+ © Jones & Bartlett Learning, LLC1 few minutes; score 3 the presence of obstruction (i.e., FEV1/FVC below fifth ■ NOT FOR SALEToo OR breathless DISTRIBUTION to leave house or when dressing; NOTpercentile FOR SALE LLN). OR27,28 Pulse DISTRIBUTION oximetry should always be = + score 4 performed due to ease and low cost of obtaining Spo2 In addition to assessment of dyspnea and smoking values to evaluate the degree of hypoxemia. Arterial history, additional risk factors should be reviewed in- blood gases should also be obtained if hypercapnia is cluding family history;© environmental,Jones & Bartlett geographic, Learning, and LLCsuspected and to evaluate acid–base© Jones abnormalities. & Bartlett Learning, LLC Carbon monoxide diffusion testing (Dlco) can be use- occupational history;NOT and any FOR history SALE of asthma. OR DISTRIBUTION The NOT FOR SALE OR DISTRIBUTION history should also include a thorough review of the ful to establish the presence of emphysema (vs. chronic patient’s symptoms (e.g., cough, sputum production, bronchitis) while body plethysmography may be used dyspnea, wheezing, acute chest illness), treatment and to measure lung residual volume (RV), functional re- medications (current and past), and any previous ED sidual capacity (FRC), and total lung capacity (TLC). visits,© Joneshospitalizations, & Bartlett admissions Learning, to the intensive LLC care These measures© Jones can help & Bartlettdiscriminate Learning, between causes LLC mechanical ventilation of reduced FVC (e.g., air trapping vs. lung hyperinfla- unitNOT (ICU), FOR or need SALE for OR DISTRIBUTION. NOT FOR SALE OR DISTRIBUTION Physical examination results associated with COPD tion vs. restrictive lung disease). For example, reduced often include characteristic findings upon inspection, FVC with increased FRC and normal TCL suggests air auscultation, palpation, and percussion:28 trapping, whereas reduced FVC with increased FRC and increased TLC is associated with hyperinflation.28 ■ Inspection may reveal increased anterior-posterior The GOLD has developed a grading system to guide © Jones & Bartlett(AP) chestLearning, diameter LLC (barrel chest), decreased © JonesCOPD & management Bartlett Learning, based on the LLCnumber of COPD NOT FOR SALEchest OR wall DISTRIBUTION motion, and/or increased space be- NOTexacerbations FOR SALE (with OR and DISTRIBUTION without hospitalization), scores tween ribs due to lung overinflation. Increased on the mMRC dyspnea scale (see Chapter 4, Box 4-8), respiratory rate, accessory muscle use, pursed-lip and scores using the standardized COPD Assessment breathing, inward movement of the lower rib cage Test (CAT).27–30 An “A” grade is assigned if there were upon inspiration (Hoover sign), or other signs no exacerbations requiring hospitalizations in the past that respiratory© distress Jones may & beBartlett present. Learning,The skin, LLCyear and one or no exacerbations© Jones without & hospitaliza- Bartlett Learning, LLC gums, or lips mayNOT be cyanotic,FOR SALE and skin OR redness DISTRIBUTION tion, and an mMRC score of 0NOT or 1 orFOR CAT SALEscore < 10.OR DISTRIBUTION and/or hand tremors (asterixis) associated with A grade of “B” would be assigned if there were one or severe hypercapnia may be noted. Sitting or lean- no exacerbations without hospitalization and an mMRC ing forward with arms braced is a characteristic score ≥2 or CAT score ≥10. A grade of “C” indicates patient position associated with dyspnea at rest two or more exacerbations or one or more exacerba- © Jonesand respiratory & Bartlett distress. Learning, Fingers may LLC be nicotine tions with hospitalization© Jones & andBartlett an mMRC Learning, score of 1 LLC or 0 NOTstained FOR (yellow SALE stains) OR in DISTRIBUTION heavy smokers. Finger or CAT <10.NOT A “D” FOR grade SALE indicates OR two DISTRIBUTION or more exacer- clubbing is uncommon with COPD, although it bations or one or more exacerbations with hospitaliza- may occur with lung cancer, bronchiectasis, or tion and an mMRC ≥2 or CAT ≥10. Box 2-7 describes interstitial lung disease. Peripheral edema (espe- the GOLD ABCD scoring system. cially swelling of the ankles and legs) with COPD GOLD also suggests the evaluation of airflow lim- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC is sometimes seen due to pulmonary hypertension itation based on measurement of FEV1 (Box 2-8) fol- NOT FOR SALEleading OR DISTRIBUTIONto right heart failure (cor pulmonale). NOTlowing FOR bronchodilatorSALE OR DISTRIBUTION administration in patients with

9781284217155_CH02_025_068.indd 43 28/11/20 5:25 PM 44 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-7 Learning, Assessment LLC of COPD Based on BOX 2-8 COPD Severity of Airflow NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Symptoms and Risk of Exacerbations Limitation Based on Postbronchodilator

COPD Spirometry Exacerbations Dyspnea Assessment GOLD An FEV1/FVC <0.70 defines airflow obstruction. (past year) Score* Test† Grade © Jones & Bartlett Learning, LLCIn patients with FEV1/FVC <©0.70, Jones the severity & Bartlett of Learning, LLC 10 airflow limitation post bronchodilation administra- 0 or 1, no NOT0 or 1 FOR< SALE ORA DISTRIBUTION NOT FOR SALE OR DISTRIBUTION hospitalizations tion may be classified as:

0 or 1, no ≥2 ≥10 B Severity FEV % Predicted GOLD Stage* hospitalizations 1 Mild >80% 1 ≥2 or ≥1 with 0 or 1 <10 C ©hospitalization Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ModerateNOT FOR50%–79% SALE OR DISTRIBUTION2 >2 or ≥1 with ≥2 ≥10 D Severe 30%–49% 3 hospitalization Very severe <30% 4 *Modified Medical Research Council dyspnea scale (mMRC); see also Chapter 4, Box 4-8. COPD, chronic obstructive pulmonary disease; FEV , forced © Jones & Bartlett† Learning, LLC © Jones & Bartlett Learning, LLC 1 COPD assessment test (CAT); see also Chapter 4. expiratory volume in the first second of expiration; FVC, forced NOT FOR SALECOPD, chronicOR DISTRIBUTION obstructive pulmonary disease; GOLD, Global NOT FORvital capacity; SALE GOLD, OR Global DISTRIBUTION Initiative for Chronic Obstructive Initiative for Chronic Obstructive Lung Disease. Lung Disease. Data from Global Initiative for Chronic Obstructive Lung Disease. Data from Global Initiative for Chronic Obstructive Lung Dis- Pocket guide to COPD diagnosis, management, and prevention: a ease. Global strategy for the diagnosis, management, and pre- guide for health care professionals. 2020. Available at https:// vention of COPD: 2019 report. Available at https://goldcopd goldcopd.org/wp-content/uploads/2020/03/GOLD-2020-POCKET© Jones & Bartlett Learning, LLC.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL© Jones & Bartlett Learning, LLC -GUIDE-ver1.0_FINAL-WMV.pdf.NOT AccessedFOR SALE August 25, OR 2020. DISTRIBUTION-14Nov2018-WMS.pdf. Accessed MarchNOT 25, FOR 2020. SALE OR DISTRIBUTION

documented obstructive disease (e.g., FEV1/FVC <0.70) where the following are present: sleep apnea, lung cancer, bronchiectasis, interstitial lung disease, and GERD, and these must be recognized and © ■ Jones &

9781284217155_CH02_025_068.indd 44 28/11/20 5:25 PM Assessment and Treatment of COPD 45

indicated for COPD patients with severe hypoxemia at © Jonespersistent & Bartlett dyspnea receiving Learning, LAMA LLC or LABA alone © Jones & Bartlett Learning,≤ LLC ≤ 27,30,33 rest (e.g., Pao2 55 mm Hg or Spo2 88%). NOTmay FOR be changedSALE ORto a LAMA-LABA DISTRIBUTION combination. For NOT FOR SALECOPD OR patients DISTRIBUTION who do not require oxygen therapy patients receiving an ICS-LABA combination, consider at lower altitudes may experience hypoxemia when triple therapy with a LAMA-LABA-ICS. Triple therapy traveling to higher altitudes and during air travel, as may be administered using a combination LAMA-LABA aircraft cabin pressures are maintained during flight at inhaler and a separate ICS inhaler or using a sin- levels corresponding to an altitude of about 8000 feet gle LAMA-LABA-ICS combination inhaler (e.g., 30 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC above sea level. SupplementalNOT FOR oxygen SALE therapy OR shouldDISTRIBUTION fluticasone-furoate/vilanterol/umeclidiniumNOT FOR SALE [Trelegy OR DISTRIBUTION be provided for patients expected to experience a Pao2 Ellipta—available in the United States], single inhaler be- 30 <50 mm Hg (Spo2 <85%) during air travel. clomethasone-dipropionate/formoterol/glycopyrronium Aerosol medication regimens for patients with stable [Trimbow—available in the European Union]; or single COPD should be based on disease severity and risk of inhaler budesonide/glycopyrronium/formoterol [Breztri exacerbation. GOLD standards suggest that patients’ Aerosphere—not yet available in the United States]).34 © Jones & Bartlett Learning, LLC27,34 © Jones & Bartlett Learning, LLC ABCDNOT scores FOR be usedSALE to guide OR initialDISTRIBUTION therapy. For For patientsNOT currently FOR receiving SALE aOR LAMA-LABA DISTRIBUTION com- example, patients who are less symptomatic and at low bination with persistent dyspnea, but low risk of exacerba- risk of exacerbation (GOLD grade “A”) may be provided a tion, an alternative inhaler or medication combination may short-acting bronchodilator for use as needed for symp- be tried. For patients currently receiving a LAMA-LABA- tom relief. This may be a SABA (e.g., albuterol [Proven- ICS combination with adverse effects of the ICS, consider 34 © Jones & til,Bartlett Ventolin], Learning, levalbuterol LLC[Xopenex], or pirbuterol © Joneschanging & Bartlettto a LAMA-LABA Learning, combination LLC alone. NOT FOR SALE[Maxair]), OR a SAMA DISTRIBUTION (e.g., ipratropium), or a combinationNOT FORFor patients SALE with OR persistent DISTRIBUTION exacerbations (with or SABA-SAMA (e.g., albuterol-ipratropium [Combivent]). without dyspnea) currently receiving LAMA or LABA Patients who are more symptomatic, but at low risk alone, consider a LAMA-LABA combination. For of exacerbation (GOLD grade “B”) may receive regu- those with persistent exacerbations already receiving lar treatment with a LABA (e.g., salmeterol [Serevent] LAMA-LABA therapy or LABA-ICS therapy, consider or formoterol [Foradil])© Jones or a LAMA & Bartlett (e.g., tiotropium Learning, LLCchanging to triple therapy (LAMA-LABA-ICS).© Jones & Bartlett For Learning, LLC [Spiriva] or umeclidiniumNOT [IncruseFOR SALE Ellipta]), OR depending DISTRIBUTION patients with persistent exacerbationsNOT FOR already SALE receiving OR DISTRIBUTION on patient preference.27,34 A short-acting bronchodilator triple therapy (LAMA-LABA-ICS), consider addition may also be provided for symptom relief, as needed. of a macrolide antibiotic (in nonsmoking patients) or Patients who are less symptomatic but at high risk of roflumilast (a long-acting phosphodiesterase-4 inhibi- exacerbation (i.e., ≥2 exacerbations per year, with ≥1 tor that acts as an anti-inflammatory agent). Alternative hospitalization—GOLD© Jones & Bartlett grade Learning, “C”) may receive LLC regular therapies may© Jonessometimes & beBartlett considered Learning, for these pa- LLC LAMANOT treatment FOR SALE and a SABA OR DISTRIBUTION for symptom relief, as tients, includingNOT lung FOR transplantation. SALE OR DISTRIBUTION needed.27,34 Patients who are more symptomatic and at high risk Respiratory Care Plans for COPD of exacerbation (GOLD grade “D”) would also receive regular LAMA treatment; however, if they are very short Inhaled bronchodilator therapy is central to the man- © Jones & ofBartlett breath, a LABALearning, may be LLC added (i.e., LAMA-LABA; e.g.,© Jonesagement & ofBartlett COPD, asLearning, described in LLC the GOLD stan- umeclidinium-vilanterol [Anoro Ellipta] or tiotropium- dards.27 Bronchodilators are prescribed on an as-needed NOT FOR SALEolodaterol OR [Stiolto DISTRIBUTION Respimat]).27,34 As an alternative, NOTbasis FOR to SALEprevent orOR reduce DISTRIBUTION symptoms, improve exercise COPD grade “D” patients may receive a combination ICS capacity, and reduce airflow limitation. Some evidence plus LABA (e.g., budesonide-formoterol [Symbicort], suggests that long-acting bronchodilators, such as mometasone-formoterol [Dulera], or fluticasone- tiotropium, may improve health status, reduce exacer- salmeterol [Advair]), ©especially Jones if &the Bartlett patient has Learning, asthma- LLCbations, decrease the number© of Jones hospitalizations, & Bartlett and Learning, LLC COPD overlap.27,34 Grade “D” patients also are provided improve the efficacy of pulmonary rehabilitation.27 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a SABA inhaler for symptom relief, as needed. See Combination of a β2-agonist and anticholinergic bron- Box 2-7 for a description of the GOLD grading scale chodilator (combination therapy) may result in greater based on symptoms and risk of exacerbations. bronchodilation than either drug when used alone. Medications are then reviewed and adjusted based on Inhaled triple therapy, which combines a β2-agonist, an- severity© Jones of symptoms & Bartlett and occurrence Learning, of exacerbations. LLC ticholinergic© agent, Jones and & inhaled Bartlett corticosteroid, Learning, has LLCbeen If patientsNOT FOR have good SALE symptom OR DISTRIBUTION control and exacerbation advocated forNOT use FORwith severe SALE COPD. OR AsDISTRIBUTION noted, cur- risk is low, they are generally continued on their current rent GOLD standards suggest that COPD treatment be therapy. If ICSs are in use, they may be tapered or dis- constructed using the ABCD grading system based on continued, although care must be taken, especially with the patient’s symptoms and likelihood of exacerbations. patients with eosinophil counts >300 cells/mcL.27,34 Long-term oxygen therapy should be provided to those © Jones & BartlettFor patients Learning, with persistent LLC dyspnea, but low risk of © Jonespatients & whoBartlett meet LTOT Learning, criteria, LLCand supplemental NOT FOR SALEexacerbation, OR DISTRIBUTION treatment adjustment may vary, depend- NOToxygen FOR duringSALE exercise OR DISTRIBUTION may be indicated in certain pa- ing on the current therapy. For example, those with tients. Table 2-5 lists common COPD medications and

9781284217155_CH02_025_068.indd 45 28/11/20 5:25 PM 46 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettTABLE 2-5 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECOPD MedicationsOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION DPI/MDI/ SMI Solution for Duration of Drug Trade Names Inhaler (mcg) Dose Nebulizer Nebulizer Dose Action (hours)

a2-agonists © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Short Acting a2-agonists (SABA) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Albuterol Proventil HFA; 90 mcg/puff 2 puffs three to 0.5% solution— 2.5 mg in 3-mL 4–6 Ventolin HFA; (MDI) four times per 0.5 mL (2.5 mg), normal saline ProAir HFA; Ac- day or 0.63 mg, three to four cuNeb; VoSpire 1.25 mg, and times per day ER 2.5-mg unit dose © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC LevalbuterolNOT FOR SALE Xopenex; OR DISTRIBUTION45 mcg/puff 2 puffs every 0.31NOT mg, FOR SALE3 mL three OR times DISTRIBUTION 5–8 Xopenex HFA (MDI) 4–6 hours 0.63 mg, 1.25 mg per day in 3-mL solution

Pirbuterol Maxair Autohaler 200 mcg/puff 2 puffs every NA NA 5–8 (MDI) 4–6 hours © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALELong-Acting OR Beta-2DISTRIBUTION Agonists (LABA) NOT FOR SALE OR DISTRIBUTION Arformoterol Brovana NA NA 15 mcg/2-mL unit 2 mL every 12 dose vial 12 hours

Formoterol Perforomist; 12 mcg/inhala- 1 inhalation 20 mcg/2-mL unit 2 mL every 12 Foradil© Jones & tionBartlett (DPI) Learning,every 12 hoursLLC dose vial 12 hours© Jones & Bartlett Learning, LLC Olodaterol StriverdiNOT FOR SALE2.5 mcg/ OR DISTRIBUTION2 inhalations NA NA NOT FOR 24SALE OR DISTRIBUTION Respimat actuation once daily (SMI)

Indacaterol Arcapta 75 mcg/inhala- 1 inhalation NA NA 24 Neohaler tion (DPI) every day © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC SalmeterolNOT FOR SALE Serevent OR Diskus DISTRIBUTION 50 mcg/inhala- 1 inhalation NA NOT FOR SALENA OR DISTRIBUTION12 tion (DPI) every 12 hours

Muscarinic Antagonists (aka Anticholinergics)

Short-Acting Muscarinic Antagonists (SAMA)

© Jones & BartlettIpratropium Learning,Atrovent LLCHFA 17 mcg/puff 2 puffs© Jonesfour &0.2 Bartlett mg/mL Learning,2.5-mL unit LLC 6 NOT FOR SALEbromide OR DISTRIBUTION (MDI) timesNOT daily FOR (0.02%SALE solution) OR DISTRIBUTIONdose/500 mcg in a 2.5-mL unit three to four dose times daily

Oxitropium bro- Oxivent; Tersi- 100 mcg (MDI) 2 puffs two to NA NA 6 mide (available gan; Tersigat; three times daily outside U.S.) Ventilat;© Jones Ventox & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Long-Acting Muscarinic Antagonists (LAMA)

Tiotropium Spiriva 18 mcg/inhala- 1 inhalation NA NA 24 tion (DPI) every day Aclidinium© Jones & BartlettBretaris Genuair; Learning, 400 mcg/inhala- LLC 1 inhalation 2 NA © Jones & NABartlett Learning,12 LLC bromide Ekira Genuair; tion (DPI) times per day NOT FOR SALETudorza ORPressair DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Glycopyrronium Seebri DPI Contents of NA NA 24 bromide Breezhaler 50-mcg glyco- one 50-mcg pyrronium as capsule per day glycopyrronium using Seebri © Jones & Bartlett Learning, LLC bromide per Breezhaler© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION capsule NOT FOR SALE OR DISTRIBUTION

9781284217155_CH02_025_068.indd 46 28/11/20 5:25 PM Assessment and Treatment of COPD 47

© Jones & Bartlett Learning, LLC DPI/MDI/© Jones SMI &Solution Bartlett for Learning, LLC Duration of Drug Trade Names Inhaler (mcg) Dose Nebulizer Nebulizer Dose Action (hours) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Umeclidinium Incruse Ellipta 62.5 mcg/inhala- 1 inhalation per NA NA 24 tion (DPI) day

Combination Short-Acting a2-Agonists Plus Muscarinic Antagonist (SABA plus SAMA)

Albuterol/ Combivent;© Jones & Albuterol:Bartlett Learning,2 puffs four LLC Albuterol: 2.5 mg 3 mL© four Jones times &4–6 Bartlett Learning, LLC Ipratropium DuoNebNOT FOR SALE90-mcg OR DISTRIBUTIONtimes per day Ipratropium: per dayNOT FOR SALE OR DISTRIBUTION Ipratropium: 18 of 18 mcg/puff 0.5 mg in 3 mL mcg/puff ipratropium and 90 mcg/puff albuterol

Fenoterol/© Jones & BartlettDuovent UDV Learning, NA LLC NA Fenoterol:© Jones &4 BartlettmL every Learning,6–8 LLC IpratropiumNOT FOR SALE OR DISTRIBUTION 1.25NOT mg Ipratro- FOR SALE6 hours OR DISTRIBUTION (available in pium: 0.5 mg in Canada) 4 mL

Combination Long-Acting a2-Agonists Plus Long-Acting Muscarinic Antagonist (LABA plus LAMA) © Jones & BartlettFormoterol plusLearning, Duaklir Pressair LLC 12 mcg/400 One ©inhalation Jones &NA Bartlett Learning,NA LLC 12 aclidinium mcg per breath two times per NOT FOR SALE OR DISTRIBUTION (DPI) day NOT FOR SALE OR DISTRIBUTION

Formoterol plus Bevespi 4.8 mcg/9 mcg Two inhalations NA NA 12 glycopyrronium Aerosphere (MDI) two times per day

Indacaterol plus Utibron© Jones Neohaler & 27.5Bartlett mcg/15.6 Learning, Contents ofLLC one NA NA © Jones &12 Bartlett Learning, LLC glycopyrronium NOT FOR SALEmcg (DPI) OR DISTRIBUTIONcapsule twice NOT FOR SALE OR DISTRIBUTION daily

Vilanterol plus Anoro Ellipta 25 mcg/62.5 One inhalation NA NA 24 umeclidinium mcg (DPI) one time per day

Olodaterol© Jones plus & BartlettStiolto Respimat Learning, 2.5 mcg/12.5 LLC Two inhalations NA © Jones &NA Bartlett Learning,24 LLC tiotropiumNOT FOR SALE OR DISTRIBUTIONmcg (SMI) one time per day NOT FOR SALE OR DISTRIBUTION Methylxanthines

Duration of Drug Trade Names Dosage and Administration Action (hours)

© Jones & BartlettAminophylline Learning, Phyllocontin; LLC Tru- • IV 5.7 mg/kg loading dose© Jones in patients & not Bartlett currently receiving Learning, LLC Variable, up NOT FOR SALE OR DISTRIBUTIONphylline (Canada) • IV maintenance dose inNOT adults 16–60FOR years: SALE 0.51 ORmg/kg/h; DISTRIBUTION maximum to 24 400 mg/day to achieve a serum theophylline level of 5–10 mcg/mL • IV maintenance dose in adults >60 years: 0.38 mg/kg/h; maximum 400 mg/day • Dose should be adjusted for shock, sepsis, cardiac decompensation, cor pulmonale, or liver dysfunction to 0.25 mg/kg/h; maximum 400 mg/day

Theophylline Theochron;© Jones Elixo- & •Bartlett Initial dose (oral):Learning, 300–400 mgLLC once daily © Jones &Variable, Bartlett up Learning, LLC phyllin;NOT Theo-24 FOR SALE• Maintenance: OR DISTRIBUTION400–600 mg once daily (maximum 600 mg/day) NOT FOR toSALE 24 OR DISTRIBUTION Phosphodiesterase-4 inhibitors

Duration of Drug Trade Names Dosage and Administration Action (hours)

Roflumilast© Jones & BartlettDaliresp Learning,500-mcg LLCoral tablet once daily © Jones & Bartlett Learning,24 LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Inhaled Corticosteroids

Beclomethasone Qvar 40 mcg/puff and 40–80 mcg NA NA NA diproprionate 80 mcg/puff twice daily or HFA (MDI) 40–160 mcg © Jones & Bartlett Learning, LLC twice© daily* Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (Continues)

9781284217155_CH02_025_068.indd 47 28/11/20 5:25 PM 48 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettTABLE 2-5 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECOPD MedicationsOR DISTRIBUTION (Continued) NOT FOR SALE OR DISTRIBUTION DPI/MDI/ SMI Solution for Duration of Drug Trade Names Inhaler (mcg) Dose Nebulizer Nebulizer Dose Action (hours)

Budesonide Pulmicort; Pulmi- 90 mcg/ac- 180–360 mcg NA NA NA cort© Respules Jones & tuationBartlett and 180 Learning, twice daily LLC or © Jones & Bartlett Learning, LLC mcg/actuation 360–720 mcg NOT FOR SALE(DPI) OR DISTRIBUTIONtwice daily† NOT FOR SALE OR DISTRIBUTION

Fluticasone Flovent HFA; 44 mcg/puff, 88 mcg twice NA NA NA propionate Flovent Diskus 110 mcg/puff, daily‡ and 220 mcg/ © Jones & Bartlett Learning,puff (MDI) LLC © Jones & Bartlett Learning, LLC CombinationNOT FOR Long-Acting SALE aOR2-Agonists DISTRIBUTION Plus Corticosteroids (LABA plus ICS) NOT FOR SALE OR DISTRIBUTION Formoterol/ Symbicort 160 mcg 2 puffs twice NA NA 12 Budesonide budesonide/4.5 daily mcg formoterol per puff (MDI) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Salmeterol/ Advair Diskus, 100, 250, or 1 inhalation NA NA 12 NOT FOR SALEFluticasone OR DISTRIBUTIONAdvair HFA 500 mcg fluti- everyNOT 12 hours FOR SALE OR DISTRIBUTION casone/50 mcg (DPI) salmeterol (DPI) 2 puffs every 45, 115, or 12 hours (MDI) 230 mcg fluti- © Jones & casone/21Bartlett mcg Learning, LLC © Jones & Bartlett Learning, LLC salmeterol (MDI) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Formoterol plus Fostair 100 mcg/6 mcg Two inhalations NA NA 12 beclometasone twice daily (MDI)

Formoterol plus Dulera 200 mcg/5 mcg Two inhalations NA NA 12 mometasone twice daily (MDI) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Vilanterol plus Breo Ellipta 25 mcg/100 One inhalation NA NA 24 fluticasoneNOT FOR SALE OR DISTRIBUTIONmcg once per day NOT FOR SALE OR DISTRIBUTION furoate (DPI)

Triple Therapy (LABA plus LAMA plus ICS)

Fluticasone plus Trelegy Ellipta 100 mcg/62.5 One inhalation NA NA 24 © Jones & Bartlettumeclidinium Learning, LLC mcg/25 mcg once© per Jones day & Bartlett Learning, LLC NOT FOR SALEplus vilanterol OR DISTRIBUTION (DPI)NOT FOR SALE OR DISTRIBUTION Beclometa- Trimbow 87 mcg/5 Two inhalations NA NA 12 sone plus mcg/9 mcg twice per day formoterol plus (MDI) glycopyrronium © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Systemic Corticosteroids May Improve Outcomes When Used in the Treatment of Acute Exacerbation of COPD NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Drug Trade Names Dosage and Administration

Methyl-prednis- Medrol; Methylprednisolone suggested dosage for severe COPD exacerbation with impending respiratory olone Meprolone failure is 60 to 125 mg IV, every 6 to 12 hours.

Prednisone© Jones & Bartlett Prednisone Learning,Oral prednisone LLC dose of 40–60 mg/day for 5 days© Jones has been suggested& Bartlett for patients Learning, not requiring LLC ICU NOT FOR SALEIntensol OR DISTRIBUTIONadmission. GOLD guidelines suggest 40 mg, onceNOT daily FOR for the majoritySALE of COPDOR DISTRIBUTIONexacerbations. *Beclomethasone recommended starting dose if previously taking inhaled corticosteroids. †Budesonide starting dose if only taking bronchodilators and/or inhaled corticosteroids previously. Starting dose should be higher (360 to 720 mcg twice daily) if previously taking oral corticosteroids. ‡Fluticasone starting dose if only taking bronchodilators previously. Starting dose should be 88 to 220 mcg twice daily if previously taking inhaled corticosteroids and 880 mcg twice daily if previously taking oral corticosteroids. © Jones & BartlettCOPD, chronic Learning, obstructive pulmonary LLC disease; DPI, dry powder inhaler; MDI,© metered-dose Jones inhaler; & Bartlett SMI, soft mist Learning, inhaler; HFA, hydrofluoroalkane LLC MDI propellant; NOT FOR SALENA, not applicable;OR DISTRIBUTION IV, intravenous; ICS, inhaled corticosteroids. NOT FOR SALE OR DISTRIBUTION Data from Gardenhire D. Rau’s respiratory care pharmacology. 9th ed. St. Louis: Elsevier Health; 2016; Global Initiative for Chronic Obstructive Lung Disease. Pocket guide to COPD diagnosis, management, and prevention: a guide for health care professionals. 2020. Available at https://goldcopd.org/wp-content/uploads /2020/03/GOLD-2020-POCKET-GUIDE-ver1.0_FINAL-WMV.pdf. Accessed August 25, 2020.

9781284217155_CH02_025_068.indd 48 28/11/20 5:25 PM Assessment and Treatment of COPD 49

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-9 Learning, Management LLC of Stable COPD NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Spirometric assessment and classification using y Mucolytics/antioxidant therapy (oral GOLD grade (A, B, C, D) based on symptoms and N-acetylcysteine)

risk of exacerbation y α-Trypsin augmentation therapy (identifiedα 1- Consider testing for alpha-1 antitrypsin (ATT) defi- antitrypsin deficiency) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ciency (if not done previously) Vaccination (influenza, pneumococcal disease, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Smoking cessation pertussis per guidelines) COPD education Oxygen therapy (as indicated) Pharmacologic therapy based on symptoms and Long-term oxygen therapy for chronic, resting hypox- risk of exacerbations: emia (Pao ≤55 mm Hg, Spo ≤88% on room air) © Jones & Bartlett Learning, LLC ©2 Jones & Bartlett2 Learning, LLC y Short-acting β2-agonists (SABA; e.g., albuterol) Nutrition (to include weight loss for obesity) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION y Short-acting anticholinergic bronchodilator Exercise (SAMA; e.g., ipratropium) Pulmonary rehabilitation y Combined short-acting β2-agonists and Lung resection or volume reduction surgery for short-acting muscarinic antagonist bronchodila- COPD (based on recommended criteria) © Jones & Bartletttors Learning, (SABA plus SAMA) LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORSleep SALE(assess forOR sleep DISTRIBUTION issues and/or sleep y Long-acting inhaled β2-agonists (LABA; e.g., sal- disorders) meterol, formoterol) Air travel considerations (evaluate the need for y Long-acting anticholinergic bronchodilator in-flight oxygen) (LAMA; e.g., tiotropium) © Jones & Bartlett Learning, *ForLLC chronic bronchitis with frequent© exacerbations. Jones & Bartlett Learning, LLC y Combined long-acting β2-agonists and long-acting muscarinicNOT FOR antagonist SALE ORbronchodila- DISTRIBUTIONGOLD, Global Initiative for Chronic ObstructiveNOT FOR Lung Disease;SALE OR DISTRIBUTION COPD, chronic obstructive pulmonary disease; Pao2, partial pressure tors (LABA plus LAMA) of oxygen, arterial; Spo2, arterial blood oxygen saturation. y Phosphodiesterase-4 inhibitor (roflumilast)* Data from American Thoracic Society. Prevention of COPD Exacer- y Inhaled corticosteroids (ICS; e.g., beclometha- bations: a European Respiratory Society/American Thoracic Society © Jonessone, budesonide, & Bartlett triamcinolone, Learning, fluticasone,LLC Guideline. 2017.© Available Jones at https://www.thoracic.org/statements & Bartlett Learning, LLC /resources/copd/prevention-copd-exacerbations.pdf. Accessed NOTflunisolide) FOR SALE OR DISTRIBUTION August 23, 2020;NOT and Global FOR Initiative SALE for Chronic OR DISTRIBUTION Obstructive Lung y Combined long-acting inhaled β-agonists and in- Disease (GOLD). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: 2019 report. haled corticosteroids in one inhaler (LABA plus ICS) Available at www.goldcopd.org. Accessed July 31, 2020.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEdosages. OR Box DISTRIBUTION2-9 outlines the management of patients NOTpharmacologic FOR SALE management OR DISTRIBUTION of stable COPD; Figure 2-5 with stable COPD. See Box 2-7 for a description of the describes the treatment of COPD exacerbation. GOLD ABCD grading system. As noted, low-risk COPD patients with intermit- Bronchodilator Therapy for Other Conditions tent symptoms (e.g., ©GOLD Jones “A”) are& Bartlett treated with Learning, two LLC © Jones & Bartlett Learning, LLC For other disease states or conditions where broncho- puffs of an inhaled SAMANOT FORor SABA SALE via MDI, OR as DISTRIBUTION needed. NOT FOR SALE OR DISTRIBUTION Low-risk patients with regular or daily symptoms (e.g., spasm is suspected, the frequency of administration of a GOLD “B”) may be treated with a LAMA or LABA short-acting bronchodilator generally ranges from every bronchodilator. High-risk patients with moderate to 4 hours to four times per day, depending on the patient’s severe symptoms (GOLD “D”) and severe airflow lim- response and the duration of effect of the medication. < < itation© Jones (FEV1/FVC & Bartlett 0.70 and Learning, FEV1 50% LLCpredicted) For example,© theJones recommended & Bartlett dosage Learning, of albuterol LLC mayNOT be treated FOR with SALE a combined OR DISTRIBUTION LABA plus LAMA by SVN is 2.5NOT mg threeFOR or SALE four times OR per DISTRIBUTION day, with the plus SABA for symptom relief, as needed. Patients with onset of action occurring in about 15 minutes, a peak features of COPD–asthma overlap may benefit from effect in 30 to 60 minutes, and a duration of action of a combination ICS and long-acting bronchodilator. 4 to 6 hours. Salmeterol, a LABA, has an onset within A severe exacerbation of COPD may require a SABA 20 minutes, a peak effect in 180 to 300 minutes, and a via MDI or SVN every 0.5 to 2 hours and/or increas- duration of action of 12 hours.35 The normal dose for © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 35 NOT FOR SALEing the doseOR ofDISTRIBUTION ipratropium. Hospitalized patients with NOTsalmeterol FOR SALE via DPI OR is oneDISTRIBUTION inhalation every 12 hours. acute exacerbation of COPD are also treated with oral Formoterol also has a duration of 12 hours but an onset corticosteroids and antibiotics, in addition to receiv- of action similar to albuterol. The usual dose for for- ing bronchodilator therapy. Figure 2-4 outlines the moterol via MDI is two puffs every 12 hours.35

9781284217155_CH02_025_068.indd 49 28/11/20 5:25 PM 50 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettPATIENTS WITHLearning, LOW RISK, LLC LESS SYMPTOMS © Jones & Bartlett Learning, LLC NOT FOR SALESABA, SAMAOR orDISTRIBUTION combination SABA-SAMA for symptom relief, as needed.NOT FOR SALE OR DISTRIBUTION PATIENTS WITH LOW RISK, MORE SYMPTOMS Regular treatment with LAMA or LABA; SABA for symptom relief, as needed. PATIENTS WITH HIGH RISK, LESS SYMPTOMS Regular treatment with© LAMA; Jones SABA for& symptomBartlett relief, Learning, as needed. LLC © Jones & Bartlett Learning, LLC PATIENTS WITH HIGHNOT RISK, FORMORE SYMPTOMSSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Regular treatment with LAMA; SABA for symptom relief, as needed. OR With severe dyspnea: combination LABA plus LAMA; SABA for symptom relief, as needed. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC OR NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION With severe dyspnea: combination ICS plus LABA if asthma–COPD overlap present; SABA for symptom relief, as needed. Following initial therapy, the patient is revaluated and therapy is adjusted in the presence of persistent dyspnea (mMRC ≤2) or high COPD Assessment Test scores (CAT ≥10, see: https://www.catestonline.org/hcp-homepage.html). Low risk: one or no exacerbations in the past year, no hospitalizations. © Jones & BartlettHigh risk: twoLearning, or more exacerbations LLC per year with one or more ©leading Jones to hospitalization. & Bartlett Learning, LLC NOT FOR SALELess symptomatic: OR DISTRIBUTION mild or infrequent symptoms or COPD AssessmentNOT TestFOR Scores SALE (CAT) < OR10 DISTRIBUTION More symptomatic: moderate to severe symptoms or CAT ≥10

FIGURE 2-4 Pharmacologic treatment for stable COPD. SABA, short-acting beta agonist; SAMA, short-acting muscarinic antagonist; LAMA, long-acting muscarinic antagonist; LABA, long-acting beta agonist; ICS, inhaled corticosteroid; mMRC, Modified Medical Research Council, dyspnea scale, see also Chapter 4, Box 4-8; COPD, chronic obstructive pulmonary disease; CAT, COPD assessment test. Data from Global Initiative for Chronic© ObstructiveJones Lung & Disease. Bartlett Global strategy Learning, for the diagnosis, management,LLC and prevention of COPD: 2019 report.© AvailableJones at https://goldcopd.org & Bartlett Learning, LLC /wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf.NOT FOR SALE OR AccessedDISTRIBUTION March 25, 2020. NOT FOR SALE OR DISTRIBUTION

• Interview: Question patient regarding increased dyspnea, orthopnea; increased cough frequency or severity; increased volume and/ © Jones & Bartlettor change Learning, in character of sputumLLC production (e.g., purulence), ©and Jones time course & of Bartlett current symptoms Learning, (e.g., hours LLC to days). Assess for the presence of fever, chills, night sweats, chest pain or pressure, peripheral edema, and symptoms associated with viral respiratory NOT FOR SALEinfection. OR History DISTRIBUTION of prior exacerbations and any associated hospitalizationsNOT FOR to includeSALE use ORof systemic DISTRIBUTION glucocorticoids and need for ventilatory support (e.g., NIV and/or intubation and mechanical ventilation) should also be assessed; symptoms and history of hospitalizations for exacerbations are highly predictive of exacerbation risk. • Physical assessment: Observe for signs of respiratory distress, which may include increased respiratory rate, tachycardia, accessory muscle use, and or paradoxical chest wall to abdominal movement. Level of consciousness (oriented, anxious, sleepy, decreased mental status, lethargic, somnolent); color (cyanosis, pale, skin flushed/red); presence of pursed lip breathing; and chest configuration (overinflation; barrel© chest) Jones should &be Bartlettnoted. Breath Learning,sounds should be LLC assessed (diminished, crackles, gurgles,© Jones wheezing), & andBartlett cough Learning, LLC and presence of purulentNOT sputum FOR should SALE be noted. OR Fever, DISTRIBUTION hypotension, basilar crackles, or peripheral edemaNOT may suggestFOR comorbiditiesSALE OR DISTRIBUTION (e.g., respiratory tract infection, heart failure).

• Oximetry and arterial blood gases and associated Fio2 (e.g., room air or supplemental oxygen) • Spo2 <88% to 90% is consistent with a Pao2 <55 to 58 (Spo2 <85% is consistent with a Pao2 <50). • Pao2 <60 on Fio2 = .21 (with or without CO2 elevation) indicates respiratory failure. • Arterial blood gases should be obtained if hypercapnia (e.g., acute-on-chronic respiratory acidosis), other acid–base disorders or the © Jonesneed for ventilatory & Bartlett support Learning, are suspected. LLC © Jones & Bartlett Learning, LLC •NOT Chest FORradiograph: SALE Review OR for infiltrates,DISTRIBUTION pneumonia, pneumothorax, pulmonary edema,NOT or FORpleural effusionSALE and OR to exclude DISTRIBUTION other alternative diagnoses.

FIGURE 2-5 Outline of the management of COPD exacerbation.

NIV, noninvasive ventilation; Fio2, fractional concentration of inspired oxygen; Spo2, arterial blood oxygen saturation; Pao2, partial pressure of oxygen, arterial; WBC, white blood cell; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; CHF, congestive heart failure. © Jones &Data Bartlett from Global Initiative Learning, for Chronic Obstructive LLC Lung Disease. Global strategy for the diagnosis,© Jones management, & and Bartlett prevention of COPD: Learning, 2019 report. Available LLC at https://goldcopd.org /wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. Accessed March 25, 2020; Stoller JK. Management of exacerbations of chronic obstructive pulmonary disease. NOT FOR SALEIn: UpToDate. ORBarnes PJ,DISTRIBUTION Hollingsworth H, (eds.). UpToDate, Waltham, MA. February 2020. NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett• Laboratory Learning, studies LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Complete OR DISTRIBUTION blood count and differential (polycythemia, anemia,NOT elevated FOR WBC) SALE OR DISTRIBUTION • Glucose • Electrolytes • Renal function • Evaluation for respiratory virus infection (e.g., influenza) if respiratory tract infection is suspected • Electrocardiogram and cardiac troponins to evaluate tachycardia or suspected myocardial ischemia; plasma brain natriuretic peptide (BNP) to assess for© possibleJones heart & failureBartlett Learning, LLC © Jones & Bartlett Learning, LLC • If pulmonary embolusNOT is suspected, FOR SALE consider OR D-dimer DISTRIBUTION measurement NOT FOR SALE OR DISTRIBUTION Treatment

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC •NOT Oxygen FOR therapy SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Low-flow cannula (0.5 to 4 L/min) to achieve Spo2 of 88% to 92% and Pao2 of 60 to 70 mm Hg • High-flow air-entrainment mask (24% to 28%) may be considered in the presence of an irregular ventilatory pattern or rapid shallow breathing

• Bronchodilators: Short-acting β2-agonist (SABA) every 1 to 4 hours, as needed with or without short-acting muscarinic antagonist (SAMA) for treatment of an exacerbation © Jones & Bartlett• Systemic Learning, corticosteroids LLC © Jones & Bartlett Learning, LLC • Corticosteroids may improve patient outcomes and reduce length of stay NOT FOR SALE• Oral OR prednisone DISTRIBUTION 40 to 60 mg, once daily for 5 to 14 days NOT FOR SALE OR DISTRIBUTION • As an alternative, methylprednisolone, 60 to 125 mg every 6 to 12 hours for severe COPD exacerbation may be prescribed • Prednisolone dose suggested by the GOLD standards is 40 mg given once daily day for five days (oral route preferred) • Antibiotics: Antibiotics should be given in the presence of moderate to severe COPD exacerbation requiring hospitalization • Ventilatory support • Noninvasive ventilation© Jones (NIV) may& Bartlettbe helpful in theLearning, presence of actualLLC or impending ventilatory failure ©in anJones attempt to& avoid Bartlett the Learning, LLC need for intubation and invasive mechanical ventilation • Invasive mechanicalNOT ventilation FOR SALE may be necessary OR DISTRIBUTION in patients who will not tolerate NIV or in whom NIVNOT is unsuccessful FOR SALE OR DISTRIBUTION • Other therapy: Attention should be paid to: • Fluid balance (consider diuretics for fluid overload) • Nutrition • Treatment of comorbidities such as pneumonia, cardiovascular disease (ischemic heart disease, CHF, hypertension, atrial fibrillation), lung cancer, renal failure, liver failure, osteoporosis, diabetes, anxiety and depression ©• JonesSupportive & care Bartlett to include smokingLearning, cessation, LLC prevention of deep vein thrombosis© (DVT), Jones pulmonary & Bartlett embolus, and Learning, nutritional support LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-5 (Continued)

Anti-inflammatory Agents and © Jones & AntiasthmaticBartlett Learning, Medications LLC © JonesBOX & 2-Bartlett10 Indications Learning, for Anti-LLC NOT FOR SALEAnti-inflammatory OR DISTRIBUTION aerosol agents andantiasthmatic NOT FORinflammatory SALE OR and DISTRIBUTION Antiasthmatic Agents medications include inhaled corticosteroids; cromolyn Anti-inflammatory aerosol agents (inhaled sodium (a mast cell stabilizer); and antileukotrienes, steroids) such as zafirlukast (Accolate), montelukast (Singulair), Asthma and zileuton (Zyflo), the latter three medications be- © Jones & Bartlett Learning, LLC COPD (emphysema, chronic© Jones bronchitis, & Bartlett cystic Learning, LLC ing administered in tablet form. The indications for anti-inflammatory aerosolNOT FORagents SALEand antiasthmatic OR DISTRIBUTION fibrosis) NOT FOR SALE OR DISTRIBUTION agents are listed in Box 2-10. Upper airway edema (post-extubation, croup) Corticosteroids are the strongest and most effective Antiasthmatic aerosol agents (cromolyn, anti-inflammatory agents currently available and are antileukotrienes) more effective in asthma control than any other single © Jones & Bartlett25 Learning, LLC Asthma© Jones & Bartlett Learning, LLC long-termNOT FOR medication. SALE TheOR DISTRIBUTIONappropriate use of cortico- NOT FOR SALE OR DISTRIBUTION steroids in the treatment of asthma is well described in COPD, chronic obstructive pulmonary disease. the NIH Guidelines and the recommendations from the Global Initiative for Asthma (GINA) 2019.25,26 Inhaled corticosteroids may be taken daily on a long-term basis that even patients with mild asthma begin low-dose © Jones & toBartlett control persistent Learning, asthma; LLC short courses of oral cor- © JonesICS treatment & Bartlett as soon Learning, as possible LLCafter the diagnosis ticosteroids are often used to gain rapid control during of asthma is made in order to control symptoms and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION26 asthma exacerbations. GINA recommendations suggest prevent severe exacerbations. Treatment may be in

9781284217155_CH02_025_068.indd 51 28/11/20 5:25 PM 52 CHAPTER 2 Development and Implementation of Respiratory Care Plans

combination with a LABA (e.g., ICS and LABA such management of asthma and as a preventive measure © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 25 as formoterol) adjusted in steps, based on the patient’s NOTprior FOR to SALEexercise ORor exposure DISTRIBUTION to known allergens. NOT FOR SALEneeds. For OR example, DISTRIBUTION initial asthma therapy (Step 1) may Leukotriene modifiers that reduce or block inflam- begin with a low-dose ICS with formoterol used as mation include montelukast (Singulair), zafirlukast needed.26 Step 2 may be a daily low-dose ICS with an (Accolate), and zileuton (Zyflo). Montelukast, zafirlu- ICS-formoterol combination, used as needed for symp- kast and pranlukast are leukotriene receptor antago- tom relief. Step 3 may© be Jones a daily combined& Bartlett ICS-LABA, Learning, LLCnists (LTRAs) and may be useful© Jones as alternatives & Bartlett in the Learning, LLC whereas Steps 4 and 5 may incorporate medium- and treatment of mild to moderate asthma.25 LTRAs may NOT FOR SALE OR DISTRIBUTION26 NOT FOR SALE OR DISTRIBUTION high-dose ICS, respectively, combined with a LABA. be used in combination with inhaled corticosteroids, Table 2-6 lists commonly available ICS medications. although in adults the addition of long-acting bron- Cromolyn sodium, administered by inhalation, chodilators should be considered first.25 Zileuton is stabilizes the mast cells in the lungs and may prevent a 5-lipoxygenase pathway inhibitor that may also be or reduce© Jones the inflammatory & Bartlett Learning,response in asthma. LLC As a considered for© Jonesasthma prophylaxis.& Bartlett Zileuton Learning, requires LLC prophylactic agent, cromolyn sodium may be added assessment of liver enzymes prior to initiation and on- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE35 OR DISTRIBUTION to the care regimen as an alternative in the long-term going liver function monitoring. Box 2-11 describes nonsteroidal and antiasthmatic TABLE 2-6 anti-inflammatory agents. Inhaled Corticosteroids (ICS) © Jones & Bartlett Learning, LLC © JonesTreatment & Bartlett of Upper Learning, Airway Inflammation LLC Single Agents NOT FOR SALE OR DISTRIBUTION NOTA FOR cool, blandSALE aerosol OR DISTRIBUTIONis sometimes used in the treat- Generic Name Trade Name ment of upper airway edema, including laryngotracheobronchitis and subglottic edema, and for postoperative Beclomethasone dipropionate HFA Qvar management of the upper airway.36 Upper airway edema Budesonide DPI Pulmicort Flexihaler (DPI) is common following extubation, and the use of a cool, © Jones &Pulmicort Bartlett Respules Learning, (SVN) LLCbland aerosol with supplemental© Jones oxygen may& Bartlett be use- Learning, LLC Ciclesonide NOT FORAlvesco SALE OR DISTRIBUTIONful for these patients. NebulizedNOT racemic FOR epinephrine SALE OR DISTRIBUTION (0.5 mL of 2.25% in 3 mL of diluent) or dexamethasone Flunisolide hemihydrate HFA Aerospan (1 mg in 4 mL of diluent) by nebulizer have also been Fluticasone propionate Flovent HFA suggested for the treatment of post-extubation laryngeal Flovent Diskus edema; however, the evidence to support this recom- © Jones & Bartlett Learning, LLC mendation ©is weak.Jones Helium–oxygen & Bartlett mixturesLearning, (60% LLCHe Fluticasone furoate Arnuity Ellipta NOT FOR SALE OR DISTRIBUTION and 40% O2NOT) by nonrebreathing FOR SALE mask OR may DISTRIBUTION be helpful Budesonide Pulmicort Flexhaler in decreasing the severity of stridor and reducing the Pulmicort Respules need for reintubation. Helium–oxygen therapy (60% to 80% helium) may also be of value in treatment of acute Mometasone furoate Asmanex Twisthaler Asmanex HFA severe asthma exacerbation and has been used in an at- © Jones & Bartlett Learning, LLC © Jonestempt &to Bartlettreduce the Learning,need for intubation LLC and mechanical NOT FOR SALETriamcinolone OR DISTRIBUTIONacetonide Azmacort NOTventilation FOR SALE in these OR patients. DISTRIBUTION For pediatric patients suffering from croup (laryngo- Combination Agents tracheobronchitis), treatment typically consists of cool Generic Name Trade Name mist therapy, although its effectiveness may largely be due to providing a sense of comfort to the patient and Fluticasone propionate/salmeterol Advair Diskus 36,37 © Jones &Advair Bartlett HFA Learning, LLCfamily. Aerosolized racemic© epinephrineJones & (0.05Bartlett mL/ Learning, LLC NOT FOR SALE OR DISTRIBUTIONkg of a 2.25% solution not to exceedNOT 0.5FOR mL SALEper dose OR di- DISTRIBUTION Budesonide/formoterol Symbicort luted to 3 mL) may provide rapid improvement in upper fumarate HFA airway obstruction in moderate to severe croup. Aerosol- Mometasone furoate/formoterol Dulera ized dexamethasone or budesonide may also be effective fumarate HFA in reducing severity of symptoms in patients suffering © Jones & Bartlett Learning, LLC from croup,© although Jones dexamethasone & Bartlett Learning,is most commonly LLC Fluticasone furoate/vilanterol Breo Ellipta NOT FOR SALE OR DISTRIBUTION administeredNOT intravenously, FOR SALE intramuscularly, OR DISTRIBUTION or orally.37 Fluticasone/umeclidinium/ Trelegy Ellipta vilanterol Mobilize and Remove Secretions Beclometasone/formoterol/ Trimbow Disease states or conditions in which mucus clearance glycopyrronium © Jones & Bartlett Learning, LLC © Jonesmay be & a Bartlettproblem include Learning, chronic LLC bronchitis, bron- NOT FOR SALEDPI, dry powderOR DISTRIBUTIONinhaler; SVN, small-volume nebulizer; HFA, hydrofluoroalkaneNOT chiectasis, FOR SALE and cystic OR fibrosis.DISTRIBUTION Mucus hypersecretion, MDI propellant. inflammation, and bronchospasm are sometimes seen

9781284217155_CH02_025_068.indd 52 28/11/20 5:25 PM Mobilize and Remove Secretions 53

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-11 Learning, Antiasthmatic LLC and Nonsteroidal Anti-inflammatory Agents NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Mast Cell Stabilizers

Generic Name Trade Name Dosage and Administration

Cromolyn sodium NA Small volume nebulizer (SVN): 20 mg/ampule or 20 mg/2 mL (1%) © Jones & BartlettAdults and Learning, children ≥2 yr: LLC 20 mg inhaled 4 times daily © Jones & Bartlett Learning, LLC NOT FOR SALESpray: OR 5.2 DISTRIBUTIONmg per actuation; available over the counter (OTC) NOT FOR SALE OR DISTRIBUTION Adults and children ≥2 yr: One spray in each nostril, three to six times daily, every 4–6 h Oral concentration: 100 mg/5 mL Adults and children ≥13 yr: Two ampules four times daily, 30 min before meals and at bedtime Children 2–12 yr: One ampule four times daily, 30 min before meals and at bedtime © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTAntileukotrienes FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Generic Name Trade Name Dosage and Administration

Zafirlukast Accolate Tablets: 10 and 20 mg Adults and children ≥12 yr: 20 mg twice daily, without food © Jones & Bartlett Learning, LLC Children 5–11 yr: 10© mg Jones twice daily & Bartlett Learning, LLC NOT FOR SALEMontelukast OR DISTRIBUTION Singulair Tablets: 10 mg and NOT4- and 5-mg FOR cherry-flavored SALE OR chewable; DISTRIBUTION 4-mg packet of granules Adults and children ≥15 yr: One 10-mg tablet daily Children 6–14 yr: One 5-mg chewable tablet daily Children 2–5 yr: One 4-mg chewable tablet or one 4-mg packet of granules daily Children 6–23 mo: One 4-mg packet of granules daily

Zileuton ©Zyflo; Jones Zyflo & BartlettCR Tablets: Learning, 600 mg LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAdults OR and DISTRIBUTIONchildren ≥12 yr: One 600-mg tablet four times per day;NOT CR, FORtwo tablets SALE twice OR DISTRIBUTION daily within 1 hour of morning and evening meals

Monoclonal Antibody

Generic Name Trade Name Dosage and Administration © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Omalizumab Xolair Adults and children ≥12 yr: Subcutaneous injection every 4 wk; dose depends on weight NOT FOR SALE OR DISTRIBUTIONand serum IgE level NOT FOR SALE OR DISTRIBUTION

Phosphodiesterase-4 Inhibitors

Generic Name Trade Name Dosage and Administration © Jones & BartlettRoflumilast Learning, Daliresp LLC Tablets: 500 mg once© eachJones day & Bartlett Learning, LLC NOT FOR SALEData fromOR Gardenhire DISTRIBUTION D. Rau’s respiratory care pharmacology. 9th ed. St.NOT Louis: Elsevier FOR Health; SALE 2016. OR DISTRIBUTION

38 in asthma, acute bronchitis,© Jones and ´ Bartlett pulmonary Learning, infec- LLCand positive expiratory pressure© Jones (PEP). Indications& Bartlett Learning, LLC tions. Mucus plugging can cause atelectasis, and copi- for airway clearance techniques (ACT) include dif- ous secretions are sometimesNOT FOR seen SALE with atelectasis OR DISTRIBUTION and ficulty with secretion clearance,NOT evidence FOR SALEof retained OR DISTRIBUTION pneumonia. secretions, the presence of copious secretions (generally expectorated sputum production greater than 25 Techniques to Mobilize Secretions to 30 mL/day in the adult), atelectasis associated with © Jones & Bartlett Learning, LLC mucus plugging,© Jones and the & presence Bartlett of Learning,a foreign body LLC in AirwayNOT clearance FOR SALE techniques OR (alsoDISTRIBUTION known as bronchial the airway. NOTACT recommended FOR SALE in OR the treatmentDISTRIBUTION of pa- hygiene) to mobilize or remove secretions include dir- tients with cystic fibrosis include the use of inhaled air- ected cough, suctioning, chest physiotherapy (CPT) way clearance agents (e.g., hypertonic saline [7% NaCl], (postural drainage, percussion, and vibration), kinetic DNase, N-acetylcysteine) and chest physiotherapy. therapy (turning), active cycle breathing, forced exhala- Bronchial hygiene therapy is probably not helpful in © Jones & tionBartlett technique Learning, (FET), high-frequency LLC chest wall com- © Jonesacute exacerbation& Bartlett ofLearning, COPD, pneumonia LLC without excess NOT FOR SALEpression OR (percussive DISTRIBUTION vest), intrapulmonary percussive NOTsecretion FOR SALE production, OR DISTRIBUTIONand acute asthma exacerbation. ventilation (IPV), mechanical insufflation-exsufflation, Mucus clearance for COPD patients should focus on

9781284217155_CH02_025_068.indd 53 28/11/20 5:25 PM 54 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-12 Learning, Airway Clearance LLC Techniques NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Directed cough: A cough technique taught and su- pressure (PEP), or expiratory positive airway pres- pervised by a healthcare professional. sure (EPAP). Postural drainage: The use of gravity and position Flutter valve: A mechanical device that combines to mobilize secretions. EPAP and high-frequency airway oscillations at the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chest percussion (aka clapping or cupping) and airway as the patient exhales through the device. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION vibration: Manual or mechanical percussion and Intrapulmonary percussive ventilation (IPV): An IPV vibration of the chest wall in order to mobilize device is used to produce high-frequency oscillation secretions. of the inspired gas in combination with PAP. Kinetic therapy (turning): Rotation of the body to Forced expiratory technique (FET): A modified ver- ©improve Jones lung & Bartlett expansion, Learning, oxygenation, LLC and secre- sion of the© directed Jones cough, & Bartlett also known Learning, as a “huff” LLC NOTtion mobilization.FOR SALE OR DISTRIBUTION cough. NOT FOR SALE OR DISTRIBUTION High-frequency chest wall oscillation (HFCWO): A Active cycle breathing (ACB): A breathing exercise technique that uses a mechanical device attached cycle that incorporates FET. to an inflatable vest worn by the patient. Air is Autogenic drainage: A modification of the directed © Jones & Bartlettpulsed Learning, into the vest LLCat a high frequency to vibrate © Jonescough & thatBartlett incorporates Learning, diaphragmatic LLC breathing NOT FOR SALEthe OR chest DISTRIBUTION and lungs and thus improve mucus NOT FORat varied SALE lung volumes.OR DISTRIBUTION clearance. Mechanical insufflation–exsufflation: The use of a Positive airway pressure (PAP): Adjunct techniques mechanical device that uses positive pressure on infor secretion mobilization that incorporates the spiration to produce a deep breath followed by neg- use of a mechanical device to generate continuous © Jones & Bartlett Learning, LLCative pressure on exhalation© toJones simulate & aBartlett cough. Learning, LLC positive airway pressure (CPAP), positive expiratory NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

smoking cessation and appropriate use of bronchodila- airways and thus help maintain mucociliary clearance. tors and inhaled corticosteroids. A list of techniques Heated bland aerosols are used routinely to provide hu- sometimes© Jones used & to Bartlett facilitate airwayLearning, clearance LLC is pro- midification© in Jones patients & withBartlett artificial Learning, airways for LLC which videdNOT in Box FOR 2-12 SALE. Specific OR indications DISTRIBUTION for therapy to there is evidenceNOT or FOR potential SALE for secretionOR DISTRIBUTION problems. mobilize secretions are listed in Box 2-13. High-volume bland aerosols may be useful for mobilization of secretions and induction of sputum specimens; Directed Cough however, the efficacy of using bland aerosols to reduce mucus has not been established.42,43 Most pneumatic Directed cough to clear secretions may be employed cool mist aerosol generators do not deliver a substantial © Jones & inBartlett patients withLearning, an inadequate LLC spontaneous cough and © Jones & Bartlett Learning, LLC amount of water to the airway and have little potential NOT FOR SALEshould beOR included DISTRIBUTION as an integral part of other bron- NOT FOR SALE OR DISTRIBUTION for mobilizing secretions. Heated pneumatic nebulizers chial hygiene therapies to mobilize and remove secre- 39–41 and ultrasonic nebulizers may deliver sufficient volumes tions. The indications for a directed cough include of water to the airway to assist in mobilizing secre- retained secretions, atelectasis, and lung disease with tions; however, the physical properties of mucus are excess secretions (chronic bronchitis, bronchiecta- only minimally affected by the use of bland aerosols.42,43 sis, cystic fibrosis, and© Jonesnecrotizing & Bartlettpulmonary Learning, infec- LLC © Jones & Bartlett Learning, LLC 39–41 Heated aerosols and ultrasonic nebulizers are some- tion). Directed coughNOT is FOR also indicated SALE inOR patients DISTRIBUTION NOT FOR SALE OR DISTRIBUTION times used to administer either sterile distilled water or at risk of developing postoperative complications and a hypertonic saline solution (3% to 7% NaCl) for sputum to obtain sputum specimens for diagnostic analysis, induction.44 and it has been suggested for patients with spinal cord injury.39–41 A mechanically provided artificial cough, using© Jonesan insufflation–exsufflation & Bartlett Learning, device LLC (also known RC Insight© Jones & Bartlett Learning, LLC as cough-assistNOT FOR device) SALE may OR be DISTRIBUTION especially helpful in pa- NOT FOR SALE OR DISTRIBUTION tients with spinal cord injury or neuromuscular disease. Techniques to improve secretion clearance in COPD patients should focus on smoking cessation, High-Volume Bland Aerosol Therapy management of airway obstruction, and appropri- © Jones & High-volumeBartlett Learning, heated, bland LLC aerosols (normal saline, half© Jonesate use& Bartlett of bronchodilator Learning, and inhaled LLC corticoste- NOT FOR SALEnormal saline,OR DISTRIBUTION and sterile distilled water) may minimizeNOT FORroid therapy. SALE OR DISTRIBUTION or eliminate humidity deficits in patients with artificial

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-13 Learning, Indications LLC for Therapy to Mobilize Secretions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Directed cough Chest physiotherapy (postural drainage and y Retained secretions percussion) y Atelectasis y Suggestion/evidence of problems with secretion clearance y At risk for postoperative© Jones & pulmonary Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Difficulty clearing secretions with volume> 25 to complicationsNOT FOR SALE OR DISTRIBUTIONy NOT FOR SALE OR DISTRIBUTION y Cystic fibrosis, bronchiectasis, chronic bronchi- 30 mL/day (adult) tis, necrotizing pulmonary infection, or spinal y Retained secretions in presence of an artificial cord injury airway y Atelectasis caused/suspected to be due to mu- ©y Jones During/following & Bartlett other Learning, bronchial hygiene LLC © Jones & Bartlett Learning, LLC therapies cus plugging NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION y To obtain sputum specimens y Cystic fibrosis, bronchiectasis, cavitating lung Suctioning disease y Presence of endotracheal or tracheostomy tube y Presence of a foreign body in airway Mucolytic therapy © Jones & Bartletty Inability Learning, to clear secretionsLLC in spite of best © Jones & Bartlett Learning, LLC y Evidence of viscous/retained secretions that are NOT FOR SALE coughOR DISTRIBUTION effort (secretions audible in large/centralNOT FOR SALE OR DISTRIBUTION airways) not easily removed via other therapy y Need to remove accumulated pulmonary secre- y Chronic bronchitis, cystic fibrosis, bronchiectasis tions in presence of an artificial airway High-volume bland aerosol y Coarse or noisy breath sounds (rhonchi, gurgles) y Cool large-volume nebulizer with bland solution © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC y Increased PIP during mechanical ventilation y Following extubation NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION or decreased Vt during pressure-controlled y Delivery of precise Fio2 via aerosol mask and ventilation humidity y Ineffective spontaneous cough y Upper airway edema: y Visible secretions in airway © Jones & Bartlett Learning, LLC Laryngotracheobronchitis© Jones & Bartlett Learning,(croup) LLC y Suspected aspiration NOT FOR SALE OR DISTRIBUTION SubglotticNOT FOR edema SALE OR DISTRIBUTION y Increased work of breathing y Heated large-volume nebulizer with bland solution y Deterioration of arterial blood gases y Evidence/potential for secretion clearance y Chest radiograph changes consistent with re- problem tained secretions y Delivery of precise Fio via aerosol mask and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,2 LLC y To obtain sputum specimen high humidity NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION y To maintain artificial airway patency y Mobilization of secretions y To stimulate cough Hypertonic saline administration y Presence of atelectasis or consolidation y Need to induce sputum specimens presumed to be associated with secretion © Jones & Bartlett Learning, PIP,LLC peak inspiratory pressure; Vt, tidal© volume; Jones Fio2 , &fractional Bartlett Learning, LLC retention concentration of inspired oxygen. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Mucolytic Therapy There is little evidence to support the use of aerosolized Mucolytic© Jones agents & Bartlettmay promote Learning, secretion clearance LLC by acetylcysteine© Jonesin COPD & or Bartlett bronchiectasis Learning, patients, LLCal- reducingNOT mucusFOR SALEviscosity. OR Aerosolized DISTRIBUTION dornase alfa (Pul- though the NOTuse of aerosolizedFOR SALE N-acetylcysteine OR DISTRIBUTION has been mozyme) is indicated for clearance of purulent secre- suggested for use as an adjunct, along with chest phys- tions in cystic fibrosis.35,45 Acetylcysteine (Mucomyst) iotherapy and directed cough to promote airway secre- thins mucus by breaking down mucoprotein disulfide tion clearance following inhalational injury due to heat, bonds. Acetylcysteine may be given orally, by inhaled smoke, or chemical irritants.46 © Jones & aerosol,Bartlett or directlyLearning, instilled LLC into the airway. Aerosol- © JonesOral & acetylcysteine Bartlett Learning, (e.g., 600 mg LLC three times daily) NOT FOR SALEized acetylcysteine OR DISTRIBUTION should always be accompanied by NOTmay FOR be helpfulSALE in OR COPD DISTRIBUTION patients with viscid secretions a bronchodilator to avoid inducing bronchospasm. and has been included as a mucolytic treatment option,

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© Jones &along Bartlett with erdosteineLearning, and LLC carbocysteine in the current © JonesDirected & Bartlett cough should Learning, follow anyLLC therapy used GOLD recommendations for COPD patients not receiv- to mobilize secretions and may be useful in obtain- 10 NOT FOR SALE OR DISTRIBUTION NOT FOR SALEing inhaled OR corticosteroids. DISTRIBUTION Agents to mobilize and ing a sputum specimen. Suctioning should be applied remove secretions are listed in Box 2-14. to patients with artificial airways on an as-needed The least expensive and most effective method for basis. Routine suction schedules (every 2 hours, every mobilization of secretions should be selected. For ex- 4 hours, etc.) should be avoided. Box 2-15 describes ample, a well-hydrated© patientJones with & Bartlettchronic bronchitis Learning, LLCcurrent thinking regarding the© effectivenessJones & Bartlett of phar- Learning, LLC who is able to easily expectorateNOT FOR secretions SALE ORusing DISTRIBUTION a macologic and nonpharmacologicNOT techniquesFOR SALE for airOR- DISTRIBUTION directed cough probably has no need for chest phys- way clearance. iotherapy or use of an oral mucolytic. A cystic fibrosis patient with abundant secretions that are not easily cleared by directed cough might require vigorous chest physiotherapy© Jones or& useBartlett of alternative Learning, techniques LLC for secre- RC Insight© Jones & Bartlett Learning, LLC tionNOT management, FOR SALE such as OR administration DISTRIBUTION of aerosolized NOT FOR SALE OR DISTRIBUTION dornase alfa. Airway clearance techniques recommended in Frequency of therapy will vary with the respiratory the treatment of cystic fibrosis include inhaled care modality selected and the patient’s condition. For airway clearance agents (e.g., hypertonic sa- example, aerosolized dornase alfa is indicated specific- line [7% NaCl], DNase, mannitol) and chest © Jones & allyBartlett in the management Learning, of LLC cystic fibrosis using 2.5 mg in© Jonesphysiotherapy. & Bartlett Learning, LLC NOT FOR SALEa 2.5-mL OR solution DISTRIBUTION administered once daily. NOT FOR SALE OR DISTRIBUTION

BOX 2-14 Agents to Mobilize and Remove Secretions

Inhalation Agents © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Generic Name NOT FORTrade SALE Name OR DISTRIBUTIONAdult Dosage NOT FOR SALE OR DISTRIBUTION

N-Acetylcysteine 10% Mucomyst SVN: 3–5 mL two to four times per day (give with or following (NAC) 20% Mucomyst bronchodilator)

Dornase alfa* Pulmozyme SVN: 2.5 mg/ampule, one ampule daily © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Sterile distilled water NA SVN: 3–5 mL; NOTNormal FORsaline SALE OR DISTRIBUTIONNA Heated aerosol by maskNOT or mouthpiece FOR SALEthree to four OR times DISTRIBUTION per day for (0.9% NaCl) 20 minutes; Hypertonic saline NA Ultrasonic nebulizer by mask or mouthpiece three to four times per day (7% NaCl) for 20 minutes SVN: 3–5 mL; Heated aerosol by mask or mouthpiece three to four times per day for © Jones & Bartlett Learning, LLC 20© minutes; Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION UltrasonicNOT FOR nebulizer SALE by mask ORor mouthpiece DISTRIBUTION three to four times per day for 20 minutes

Mannitol (inhaled dry powder) Bronchitol Inhaled twice daily

Oral Agents © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Generic Name NOT FORTrade SALE Name OR DISTRIBUTIONAdult Dosage NOT FOR SALE OR DISTRIBUTION Erdosteine† Erdotin (UK) 300-mg tablets two times per day Not available in the U.S.

Carbocysteine† Mucodyne (Canada) 375-mg capsules © Jones & Bartlett Learning,Not available inLLC the U.S. Initial dose: two capsules© threeJones times &per Bartlett day reducing Learning, to one capsule, LLC four times per day NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Mucomyst† N-Acetylcysteine (NAC) 200 mg two to three times per day or 300 mg two times per day or 600 mg one time per day or three times per week or 600 mg twice daily (1200 mg/day)

*Indicated for mucopurulent secretions in cystic fibrosis. © Jones & Bartlett†May reduce Learning, the frequency and LLC severity of exacerbations in COPD in patients© Jones not receiving & inhaled Bartlett corticosteroids. Learning, LLC NOT FOR SALESVN, smallOR volume DISTRIBUTION nebulizer. NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-15 Learning, Effectiveness LLC of Pharmacologic and Nonpharmacologic Airway Clearance NOT FOR SALE OR DISTRIBUTION 38,39,47 NOT FOR SALE OR DISTRIBUTION Therapies in Hospitalized Patients Pharmacologic techniques have been used to promote COPD airway clearance, improve oxygenation and respiratory y ACT should not be routinely used in patients mechanics, reduce ventilator time and ICU stay, and © Jones & Bartlett Learning, LLCwith COPD. © Jones & Bartlett Learning, LLC resolve atelectasis/consolidation. These techniques NOT FOR SALE OR DISTRIBUTIONy ACT may be considered NOTin COPD FOR patients SALE with OR DISTRIBUTION include administration of bronchodilators, mucolytics, symptomatic secretion retention, guided by and aerosols to alter the properties of mucus. Recom- patient preference, toleration, and effectiveness mendations for hospitalized adults and children are of therapy. summarized as follows: Effective cough. ACT is not recommended if the © Recombinant Jones & Bartlett human dornase Learning, alfa (DNase) LLC should patient is ©able Jones to mobilize & Bartlett secretions Learning, with cough, LLC NOTnot be FOR used SALEto facilitate OR airway DISTRIBUTION clearance in hos- but instructionNOT inFOR effective SALE cough OR technique DISTRIBUTION may be pitalized adult and pediatric patients, except those useful. with cystic fibrosis (CF). DNase is recommended for Neuromuscular disease most patients with cystic fibrosis. y Cough assist techniques may be used in patients Routine use of bronchodilators to aid in secretion © Jones & Bartlett Learning, LLC © Joneswith & Bartlett neuromuscular Learning, disease, LLCparticularly when clearance is not recommended. NOT FOR SALE OR DISTRIBUTION NOT FORpeak SALE cough OR flow DISTRIBUTION is< 270 L/min. Routine use of aerosolized N-acetylcysteine to im- y CPT, PEP, IPV, and HFCWC are not recommended prove airway clearance is not recommended. for patients with neuromuscular disease due to Aerosolized agents to change mucus biophysical insufficient evidence. properties or promote airway clearance are not © Jones & Bartlett Learning, LLC Postoperative patients © Jones & Bartlett Learning, LLC recommended for patients with neuromuscular disease, respiratoryNOT muscle FOR weakness, SALE OR or impaired DISTRIBUTION y Incentive spirometry is notNOT recommended FOR SALE OR DISTRIBUTION cough. Aerosolized hypertonic saline (7% NaCl) or for routine, prophylactic use in postoperative aerosolized mannitol are recommended as aids to patients. airway clearance in the treatment of CF. y ACT is not recommended for routine postoperative care. © MucolyticsJones & are Bartlett not recommended Learning, to treatLLC atelecta- © Jones & Bartlett Learning, LLC NOTsis in FOR postoperative SALE patients.OR DISTRIBUTION y Early mobilityNOT FOR and ambulation SALE OR are DISTRIBUTION recommended The routine administration of bronchodilators to to reduce postoperative complications and pro- postoperative patients is not recommended. mote airway clearance. Nonpharmacologic ACT include chest physiotherapy *Recommended airway clearance techniques (ACT) often used in (CPT), cough assist, techniques, positive expiratory pres- the care of adults and children with cystic fibrosis include bron- © Jones & Bartlett Learning, LLC © Joneschodilators & (e.g.,Bartlett albuterol) Learning, by metered-dose LLC inhaler; nebulized NOT FOR SALEsure (PEP), OR intrapulmonaryDISTRIBUTION percussive ventilation (IPV),NOT hypertonic FOR SALEsaline (7% OR NaCl) DISTRIBUTION or nebulized mannitol for mobiliza- and high-frequency chest wall compression (HFCWC). tion of secretions; inhaled DNase (dornase alpha); chest phys- American Association for Respiratory Care clinical prac- iotherapy; aerobic exercise; aerosolized antibiotics; and inhaled antiasthmatics. tice guideline recommendations for hospitalized adults and children without cystic fibrosis* follow: ICU, intensive care unit; ACT, airway clearance techniques; COPD, chronic obstructive pulmonary disease. Pneumonia. CPT© isJones not recommended & Bartlett for Learning, routine LLC © Jones & Bartlett Learning, LLC treatment of uncomplicatedNOT FOR pneumonia.SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Chest Physiotherapy © Jones & Bartlett Learning, LLC should be based© Jones on the &patient’s Bartlett ability Learning, to tolerate the LLC ChestNOT physiotherapy FOR SALE may OR include DISTRIBUTION postural drainage, procedure andNOT the FOR effectiveness SALE ofOR the DISTRIBUTIONprocedure in percussion, and vibration accompanied by directed mobilizing secretions. Generally, postural drainage and cough. Postural drainage positions are generally applied chest percussion in the acute care setting are applied for 3 to 15 minutes per position for a total treatment every 4 to 6 hours. time of 30 to 40 minutes, as tolerated by the patient. Other techniques sometimes used as an aid to © Jones & ChestBartlett percussion Learning, or vibration LLC may be applied for each © Jonesmobilizing & Bartlett secretions Learning, include the useLLC of the huff NOT FOR SALEpostural OR drainage DISTRIBUTION position for 3 to 5 minutes per pos- NOTcough FOR (FET), SALE active-cycle OR DISTRIBUTION breathing, autogenic drain- ition. Frequency of performance of chest physiotherapy age, mechanical insufflation–exsufflation, PEP, and

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© Jones & Bartlett Learning, LLC © Jones & BartlettCLINICAL Learning, FOCUS 2- LLC3 Respiratory Care Plan to Mobilize Secretions in a Hospitalized NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Patient with Bronchiectasis A 68-year-old man with a history of bronchiectasis Follow aerosol therapy with postural drainage is admitted to the hospital for acute exacerbation. and chest percussion to right lower lobe and left The patient has been coughing up more than approxi- lower lobe and anterior, posterior, and lateral © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mately 25 mL/day of thick, dark yellow muco-purulent segments. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sputum and has some difficulty clearing secretions. Directed cough following aerosol therapy and chest The patient is short of breath, has some pleuritic physiotherapy. chest pain, and is receiving oxygen by nasal cannula at Continue nasal cannula at 1 to 4 L/min to main- 2 L/min with a resultant Spo2 of 92%. tain Spo2 >90% to 92% with a Pao2 of 60 to 70. ©Treatment Jones &of Bartlettacute exacerbation Learning, of bronchiectasis LLC is © Jones & Bartlett Learning, LLC Monitor Spo2 during chest physiotherapy. aimed at treating infection, providing supportive care, NOT FOR SALE OR DISTRIBUTION AssessmentNOT includes FOR monitoring SALE OR breath DISTRIBUTION sounds, and delivering bronchial hygiene therapy. The follow- cough, sputum production (color, volume, consist- ing is the care plan for this patient: ency), shortness of breath, Spo2, and vital signs. The goals of therapy are to treat infection, provide Review results of sputum culture and sensitivity to © Jones & Bartlettbronchial Learning, hygiene, manage LLC secretions, maintain © Jonestailor & antibiotic Bartlett therapy. Learning, LLC oxygenation, and treat/prevent bronchospasm as- NOT FOR SALE OR DISTRIBUTION NOT FORNote that SALE inhaled OR corticosteroids DISTRIBUTION may improve sociated with inflammation. lung function and dyspnea and reduce cough in bron- Obtain a sputum sample for culture and sensitivity chiectasis and may be added. Bronchiectasis may be followed by antibiotics to treat acute infection. accompanied by gastroesophageal reflux, requiring Ensure adequate patient hydration via oral liquids. medication to suppress gastric acid. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Provide 2.5 mg of albuterol in 3 mL of 0.9% NaCl NOT FOR SALE OR DISTRIBUTIONSpo2, arterial blood oxygen saturation;NOT SVN, small-volumeFOR SALE nebu- OR DISTRIBUTION by SVN every 4 hours while awake and as needed at lizer; Pao2, partial pressure of oxygen, arterial. night powered by compressed air (keep cannula in use during therapy; see later).

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC high-frequencyNOT FOR compression/oscillationSALE OR DISTRIBUTION (high- ProvideNOT Lung FOR Expansion SALE OR TherapyDISTRIBUTION frequency chest wall compression, flutter valve, and 39–41 The primary indications for lung expansion therapy are intrapulmonary percussive ventilation). in the treatment and/or prevention of atelectasis and An example of a respiratory care plan designed to the prevention of the development of respiratory failure, assist in mobilizing secretions in a patient with bronchi- particularly in postoperative patients.41,49,50 Patients ectasis is found in Clinical Focus 2-3. © Jones & Bartlett Learning, LLC © Joneswho are & bedridden,Bartlett immobilized,Learning, orLLC prone to shallow NOT FOR SALE OR DISTRIBUTION NOTbreathing FOR SALE with a ORweak DISTRIBUTION cough may also be candidates for Nasotracheal Suctioning lung expansion therapy. The two primary techniques Nasotracheal (NT) suctioning is indicated in cases for applying lung expansion therapy are incentive where the patient’s spontaneous or directed cough is spirometry (IS) and intermittent positive pressure ineffective. Specifically, NT suctioning may be required breathing (IPPB). In addition, positive airway pressure to maintain a patent ©airway Jones in the & presence Bartlett of excessLearning, LLC(PAP) is sometimes used to mobilize© Jones secretions & Bartlett and Learning, LLC pulmonary secretions,NOT blood, FOR saliva, SALE vomitus, OR or DISTRIBUTION foreign treat atelectasis.51 NOT FOR SALE OR DISTRIBUTION material in the trachea or central airways.48 NT suction- Incentive spirometry should be considered in pa- ing may also be useful to stimulate a cough or to obtain tients who are able to perform the maneuver every 1 to a sputum sample for microbiologic or cytologic analysis. 2 hours while awake and are able to achieve an inspired NT suctioning is contraindicated with nasal bleeding, volume of at least one-third of the predicted inspiratory epiglottitis,© Jones croup, & Bartlett laryngospasm, Learning, bronchospasm, LLC or an capacity (IC).© InspiratoryJones & capacityBartlett may Learning, be estimated LLC by irritableNOT airway. FOR ItSALE also is ORcontraindicated DISTRIBUTION in the pres- multiplyingNOT the patient’s FOR calculatedSALE OR ideal DISTRIBUTION body weight ence of coagulopathy or bleeding disorders; acute head, (IBW) in kilograms by 50 mL (i.e., IBW kg × 50 mL/kg). facial, or neck injury; gastric surgery with high anasto- Clinical Focus 2-4 provides an example of the applica- mosis; and myocardial infarction.48 tion of incentive spirometry. Recommended frequency © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & BartlettCLINICAL Learning, FOCUS 2- LLC4 Application of Incentive Spirometry NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A preoperative 54-year-old coronary artery bypass Calculated ideal body weight (IBW) for this patient graft patient is seen by the respiratory care clinician 172 pounds, or 78 kg: for assessment and patient education. The patient is IBW (lb) = 106 + 6(H – 60) = 106 + 6(71 – 60) = 172 lb alert, awake, and cooperative, and has no history of pulmonary disease.© Vitals Jones signs, & breathBartlett sounds, Learning, and LLC kg = lb/2.2 = 172/2.2© Jones = 78 kg & Bartlett Learning, LLC oximetry are normal,NOT and FOR the patient SALE is inOR no distress.DISTRIBUTION Predicted inspiratory capacityNOT (IC) FOR for this SALE patient OR is DISTRIBUTION The patient’s spontaneous inspiratory capacity prior to approximately 3900 mL: surgery is 3000 mL. The patient is 5 feet 11 inches and Predicted IC = 50 mL/IBW (kg) = 50 × 78 = 3900 mL weighs 200 pounds. Volume goal should be at least one-third predicted ©In Jones order to &prevent Bartlett postoperative Learning, atelectasis LLC IC, or about© 1200Jones mL per& Bartlett breath: Learning, LLC and related respiratory problems, a respiratory care NOT FOR SALE OR DISTRIBUTION NOT1/3 × FOR 3900 SALEmL = 1287 OR mL DISTRIBUTION plan for this patient may include lung expansion therapy: Assessment includes monitoring volumes and com- pliance with IS and watching patient for develop- Goal of therapy is to prevent postoperative atelec- ment of signs and symptoms of atelectasis and tasis and respiratory failure. © Jones & Bartlett Learning, LLC © Jonespostoperative & Bartlett respiratory Learning, failure: LLC Device or procedure is incentive spirometry every NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION hour while awake for 10 to 15 breaths followed by Minimum volume for incentive spirometry = directed cough. IBW × 50 mL/kg × 1/3

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and duration of an incentiveNOT FOR spirometry SALE session OR DISTRIBUTIONshould to take a deep breath is compromised.NOT FOR IPPB SALE as a form OR of DISTRIBUTION be every hour while awake for 10 to 15 breaths of at lung expansion therapy usually includes the administra- least one-third predicted IC each (or >10 mL/kg). Also tion of an aerosolized bronchodilator, and therapy is see the RC Insight. usually given three times per day, four times per day, or every 2 to 4 hours for approximately 10 to 20 minutes. © Jones & Bartlett Learning, LLC The indications© Jones for lung & expansionBartlett therapy Learning, are listed LLC in RCNOT Insight FOR SALE OR DISTRIBUTION Box 2-16. ANOT sample FOR protocol SALE for delivery OR DISTRIBUTION of lung expansion therapy is found in Figure 2-6. Inspiratory capacity (IC) in adults can be estimated as follows: Critical Care and Mechanical IC = 50 mL/kg of ideal body weight (IBW) © Jones & Bartlett Learning, LLC © JonesVentilation & Bartlett Learning, LLC where IBW in kg is: NOT FOR SALE OR DISTRIBUTION NOTRespiratory FOR SALE care ORplans DISTRIBUTION for patients in the ICU may IBW men = [106 + 6(H – 60)]/2.2 include therapy to improve oxygenation and/or venti- IBW women = [105 + 5(H – 60)]/2.2 lation, provide secretion management and airway care, treat bronchospasm and mucosal edema, or deliver lung expansion therapy to treat or prevent atelectasis. IPPB should generally© Jones be reserved & Bartlett for patients Learning, who LLCThe goals of invasive and noninvasive© Jones ventilatory & Bartlett sup- Learning, LLC have clinically importantNOT atelectasis FOR SALE in which OR other DISTRIBUTION port in the ICU include maintainingNOT FOR adequate SALE tissue OR DISTRIBUTION therapy has been unsuccessful.41,49 When used as a form oxygenation, ventilation, carbon dioxide removal, and of lung expansion therapy, minimum delivered tidal vol- acid–base balance. Respiratory care in the ICU is also umes during IPPB therapy should probably be at least concerned with maintaining adequate circulation, blood one-third of predicted IC, or about 1200 mL in a typical pressure, and cardiac output and monitoring ventilatory adult.© Jones49 IPPB may & Bartlettalso be considered Learning, for patients LLC at risk and hemodynamic© Jones function. & Bartlett Chapters Learning, 6 and 7 describe LLC forNOT developing FOR atelectasis SALE OR who DISTRIBUTION cannot or will not take assessmentNOT of oxygenation FOR SALE and ventilation. OR DISTRIBUTION Chapter 8 a deep breath on their own. IPPB may also be useful in reviews arterial blood gases and acid–base balance. The a few patients for delivery of bronchodilators or other focus of Chapter 14 is acute and critical care patient as- medications where patient coordination and the ability sessment and monitoring. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & BartlettBOX 2-16 Learning, Indications LLC for Lung Expansion Therapy NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Incentive Spirometry Neuromuscular disease or spinal cord injury Patient is able to achieve an inspired volume of at Intermittent Positive Pressure Breathing (IPPB) least one-third of predicted IC (or VC ≥10 mL/kg). Other therapy has been unsuccessful (incentive spi- and © Jones & Bartlett Learning, LLCrometry, chest physical therapy,© Jonesdeep breathing & Bartlett exer- Learning, LLC Patient is able to perform the maneuver every 1 to cises, positive airway pressure) and at least one of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2 hours while awake. following: and one or more of the following: Clinically important atelectasis Patient predisposed to development of atelectasis: At risk for postoperative pulmonary complications upper/lower abdominal, cardiac, or thoracic sur- (e.g., atelectasis, pneumonia, respiratory failure) ©gery; Jones surgery & Bartlettin COPD; patient Learning, debilitated/bedrid- LLC Inability to© spontaneously Jones & Bartlett deep breathe Learning, with inad- LLC NOTden; acuteFOR chestSALE syndrome OR DISTRIBUTION in patients with sickle equate coughNOT and/or FOR secretion SALE clearanceOR DISTRIBUTION (inspired cell disease volumes less than one-third predicted IC or VC Preoperative screening/instruction for surgical pa- <10 mL/kg) tients to obtain baseline volume or flow To deliver aerosol medication in patients unable to © Jones & Bartlett Presence Learning, of atelectasis LLC © Jonesadequately & Bartlett deep breathe Learning, and/or LLC unable to coordi- NOT FOR SALE Quadriplegic OR DISTRIBUTION and/or dysfunctional diaphragm NOT FORnate theSALE use of OR other DISTRIBUTION aerosol devices Lack of inadequate pain control For short-term ventilatory support in an attempt to avoid intubation and continuous mechanical venti- Thoracic or abdominal binders lation, a noninvasive positive pressure ventilation Restrictive lung defect with a dysfunctional dia- device should be considered phragm or involving© Jones the respiratory & Bartlett musculature Learning, LLC © Jones & Bartlett Learning, LLC IC <2.5 L NOT FOR SALE OR DISTRIBUTIONIC, inspiratory capacity; VC, vital capacity;NOT COPD, FOR chronic SALE obstructive OR DISTRIBUTION pulmonary disease.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC DiagnosticNOT FOR SALETesting OR DISTRIBUTION care plan usingNOT the FOR SOAP SALE technique. OR Another DISTRIBUTION format Patient assessment and care plan development may re- may include problems or complaints, possible sources quire measurement of clinical parameters related to ox- of problems or complaints, actions taken to relieve ygenation, ventilation, and cardiopulmonary function. problems or complaints, short- and long-term goals, Chapters 6 and 7 describe assessment of oxygenation and evaluation and documentation. © Jones & andBartlett ventilation; Learning, Chapter 8LLC reviews arterial blood gases © JonesA third & Bartlett possible formatLearning, for the LLCrespiratory care plan NOT FOR SALEand acid–base OR DISTRIBUTION balance. Laboratory, imaging, and other NOTis FOR found SALE in Figure OR 2-8 DISTRIBUTION. This format includes patient diagnostic studies may be needed to further define and demographic data, indications for specific respiratory clarify the patient’s problem and diagnosis. Chapter 9 care, and a care plan oriented toward maintaining oxy- reviews laboratory studies, Chapter 10 describes the genation, treating and preventing bronchospasm and/or use of the electrocardiogram (ECG), and Chapter 11 mucosal edema, delivering anti-inflammatory and an- describes medical imaging.© Jones Chapter & Bartlett 13 reviews Learning, pulmo- LLCtiasthmatic medications, initiating© Jones therapy & to Bartlett mobilize Learning, LLC nary function testing.NOT Following FOR establishment SALE OR ofDISTRIBUTION the and remove secretions, and providingNOT FOR lung SALEexpansion OR DISTRIBUTION patient’s diagnosis, a respiratory care plan is developed, therapy. implemented, and evaluated. Summary Respiratory© Jones & Bartlett Care PlanLearning, Format LLC The respiratory© Jones care plan & Bartlettis simply a Learning,written explanation LLC ManyNOT institutions FOR SALE have developed OR DISTRIBUTION various forms and of the respiratoryNOT careFOR that SALE the patient OR DISTRIBUTIONis to receive. The formats for use in writing and organizing the respira- respiratory care plan may take the form of physician’s tory care plan. One common format uses problem-ori- orders, a detailed progress note in the medical record, ented charting, including the use of a SOAP note for the an established protocol, completion of a standardized respiratory care plan, as described earlier. Figure 2-7 respiratory care plan form, or the use of POMRs us- © Jones & containsBartlett a suggested Learning, format LLC for organizing a respiratory© Jonesing SOAP & Bartlett notes. In theLearning, clinical setting, LLC respiratory care NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284217155_CH02_025_068.indd 60 28/11/20 5:25 PM Summary 61

© Jones & Bartlett Learning,As sessLLC Patient © Jones & Bartlett Learning, LLC • Chart review NOT FOR SALE OR DISTRIBUTION • Patient interview NOT FOR SALE OR DISTRIBUTION • Physical assessment • Measure inspiratory capacity

Is ©Lung Jones Expansion & TherapBartletty Indicated Learning,? LLC © Jones & Bartlett Learning, LLC NOT• Pa tiFORent pred SALEisposed toOR developm DISTRIBUTIONent of NOT FOR SALE OR DISTRIBUTION atelectasis • Upper abdominal surgery • Thoracic surgery • Coronary artery bypass graft • Lower abdominal surgery © Jones & Bartlett • Surger Learning,y in patients wi LLCth COPD © Jones & Bartlett Learning, LLC • Patient debilitated/bedridden NOT FOR SALE • PrOResence DISTRIBUTION of atelectasis NOT FOR SALE OR DISTRIBUTION • Quadriplegic and/or dysfunctional diaphragm/spinal cord injury • Presence of thoracic or abdominal binders • Lack of pain control © Jones & Bartlett Learning, • ICLLC <2.5L © Jones & Bartlett Learning, LLC • Neuromuscular disease NOT FOR SALE OR DISTRIBUTION • Acute chest syndrome (sickle cell NOT FOR SALE OR DISTRIBUTION disease)

Yes

Is the patient’s spontaneous IC ≥1/3 ©(or Jones VC ≥10 mL/kg)& Bartlett predicte dLearning,*? No LLCConsider IPPB © Jones & Bartlett Learning, LLC Is patient able to perform incentive (see next page) NOTspirom FORetry ev erSALEy hour wh ORile aw DISTRIBUTIONake? NOT FOR SALE OR DISTRIBUTION Yes

Can patient self-administer No Supervised incentive incentive spirometry? spirometry © Jones & Bartlett Learning,Yes LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Instruct patient on proper use, target volumes (≥1/3 predicted IC), and frequency (every hour while awake)

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Assess Outcomes: NOT FOR SALE OR DISTRIBUTION• Adequate volumes achieved? NOT FOR SALE OR DISTRIBUTION • Improved cough effectiveness/secretion clearance? • Improved breath sounds? • Improved chest radiograph? © Jones• Patient’s & subjective Bartlett comments? Learning, PredictedLLC IC = 50 mL/kg IBW © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-6 Protocol for lung expansion therapy. COPD, chronic obstructive pulmonary disease; IC, inspiratory capacity; VC, vital capacity; IPPB, intermittent positive pressure breathing; IBW, ideal body weight; FEV1, forced expiratory volume in the first second of expiration. Modified from American Association for Respiratory Care. Clinical practice guideline: intermittent positive pressure breathing—2003 revision and update. Respir Care 2003;48(5):540–546. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC planNOT development FOR SALE requires OR an DISTRIBUTIONinitial physician’s order, the patient NOTassessment, FOR the SALE respiratory OR DISTRIBUTIONcare clinician a well-designed protocol or policy, and careful patient selects the appropriate care based on the patient’s con- assessment. The physician’s order may be specific, or it dition and the indications for each type of therapy. The may simply state “respiratory care per protocol.” respiratory care plan may include the goals of therapy, Developing and implementing the respiratory care the device or procedure that will be used, medications © Jones & planBartlett requires Learning, a careful patient LLC assessment. Following © Jonesgiven, &method Bartlett or appliance Learning, used, gasLLC source and/or NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284217155_CH02_025_068.indd 61 28/11/20 5:25 PM 62 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettIs IPPB Learning, indicated? LLC © Jones & BartlettIs IPPB contraindicated?Learning, LLC NOT FOR SALE• PrOResence DISTRIBUTION of clinical significant atelectasis when NOT FOR SALEAbsolute OR contraiDISTRIBUTIONndication: untreated tension other therapy (incentive spirometry, chest pneumothorax physiotherapy, deep breath exercises, positive Relative contraindications: airway pressure) has been unsuccessful. • Inability to spontaneously deep breathe (inspired • Intracranial pressure (ICP) >15 mm Hg • Hemodynamic instability volumes less ©than Jones 1/3 predicted & Bartlett IC or VC Learning, <10 LLCYes © Jones & Bartlett Learning, LLC mL/kg) in patients with inadequate cough and/or • Recent facial, oral, or skull surgery secretion clearanceNOT FORand other SALE therap ORy has DISTRIBUTION been • TracheoesophagealNOT fistula FOR SALE OR DISTRIBUTION unsuccessful. • Recent esophageal surgery • Patient at risk for postoperative pulmonary • Active hemoptysis complications (e.g., atelectasis, pneumonia, • Nausea respiratory failure) AND other lung-expansion • Air swallowing © Jonestherapy &has Bartlett been unsu Learning,ccessful. LLC ©• AcJonestive untreated & Bartlett tuberculosis Learning, LLC NOT• To FOR deliver SALE aerosol ORmedication DISTRIBUTION in patients who are NOT• Radiographic FOR SALE evidence OR of DISTRIBUTIONpulmonary bleb unable to adequately deep breathe and/or • Singulation (hiccups) coordinate the use of other aerosol devices and No therapy (metered-dose inhaler [MDI], small- volume nebulizer) has been unsuccessful. • Patients with ventilatory muscle fatigue, Determine volume goals, medications, and © Jones & Bartlett neurom Learning,uscular disease, LLC kyphoscoliosis, spinal © Jones & Bartlettfrequenc yLearning, of administration LLC NOT FOR SALE injurORy, DISTRIBUTION or chronic conditions requiring intermittent NOT FOR SALE • OR ≥1/3 DISTRIBUTIONpredicted IC or ≥10 mL/kg or ventilatory support may also benefit from IPPB to ≥1200 mL in most adults deliver aerosol therapy. • Frequency for critical care: every 1–6 • Provide short-term ventilatory support as an hours alternative to tracheal intubation and continuous • Frequency for acute care or home care: mechanical ventilatio© Jonesn. De &vices Bartlett specificall Learning,y for LLC two to four ti©me Joness daily & Bartlett Learning, LLC noninvasive positiveNOT FORpressure SALE ventilation OR (NDISTRIBUTIONPPV) • BronchodilatorsNOT are FOR normal SALEly OR DISTRIBUTION should be considered. administered with IPPB • Decrease dyspnea and discomfort during nebulized therapy in patients with severe hyperinflation.

Apply Therapy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Reassess Patient: • Adequate volumes achieved? • Improved cough effectiveness? © Jones & Bartlett Learning, LLC © Jones & Bartlett • Learning,Secretion clearance/sput LLC um production? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR • ChestDISTRIBUTION radiograph improved? • Breath sounds improved? • Patient’s subjective comments? • Improved FEV1 or peak flow following bronchodilator © Jones & Bartlett Learning, LLC administration?© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-6 (Continued)

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC flow,NOT volume FOR goals, SALE frequency OR DISTRIBUTION of therapy, and duration FEV1), improvementNOT FOR in oxygenation SALE OR (e.g., DISTRIBUTION Spo2, Pao2) or of therapy. The care plan may also include a statement ventilation, or improvement in health-related quality of of how the intensity and/or duration of therapy will be life and absence of adverse side effects. adjusted and when the therapy will be discontinued. In summary, the respiratory care plan is the writ- Assessment of the outcomes of therapy may also be ten plan of treatment that the patient will receive. The © Jones & included.Bartlett These Learning, may include LLC evidence of clinical im- © Jonesrespiratory & Bartlett care plan Learning, may include LLC goals, rationale and NOT FOR SALEprovement, OR patient DISTRIBUTION subjective improvement, bedside NOTsignificance, FOR SALE and OR a description DISTRIBUTION of how care will be pulmonary function data improvement (e.g., PEF or assessed.

9781284217155_CH02_025_068.indd 62 28/11/20 5:25 PM Summary 63

© Jones & BartlettS: TheLearning, patient’s subjective LLC expression of the symptoms© thatJones have brought & Bartlett him or her Learning, before the clinician. LLC • The chief complaint is the leading statement reported by the patient. NOT FOR SALE OR DISTRIBUTION• The history of present illness and past medicalNOT history FOR are also SALE subjective. OR DISTRIBUTION

O: The objective signs that are exhibited by the patient. • Includes physical assessment, vital signs, inspection, palpation, percussion, and auscultation. • Diagnostic data such as the results of arterial blood gas analysis, chest radiography, pulmonary function, and other© laboratory Jones tests & Bartlettmay also be Learning,recorded. LLC © Jones & Bartlett Learning, LLC A: The clinician’sNOT assessment FOR SALE of the findings OR DISTRIBUTIONnoted in the S & O sections of the clinical note. NOT FOR SALE OR DISTRIBUTION • Commonly an assessment of the clinical signs and symptoms followed by the disease or disorder that is suggested by the findings. • For example, the symptoms, physical findings, and diagnostic data noted during examination of the asthmatic patient present a very characteristic disease pattern.

©P :Jones Describes & Bartlett the care plan Learning, that has been LLC formulated based on the assessment© Jones findings. & Bartlett Learning, LLC NOT FOR • SALEThe plan shouldOR DISTRIBUTION address the treatment and/or monitoring of the patient’sNOT diseaseFOR SALEstate, conditions, OR DISTRIBUTION or complaint. SOAP Note Format

Patient Name: ______Age: ______Physician(s): ______Height: ______Hospital ID No.: ______Weight: ______© Jones & Bartlett Learning, LLC © JonesSex: & Bartlett ______Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Admitting Diagnosis: ______

Problems or Complaints: 1. ______4. ______2. ______5. ______3. ______© Jones & Bartlett Learning, 6. LLC ______© Jones & Bartlett Learning, LLC

Subjective Findings:NOT ______FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ______

Objective Findings: ______©______Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT______FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Assessment: ______

Plan: ______© Jones & Bartlett______Learning, LLC © Jones & Bartlett Learning, LLC ______NOT FOR SALE______OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 2-7 SOAP format for organizing a respiratory care plan. The problem-oriented medical record (POMR) may be used to collect and document data, assess the patient, and develop an appropriate treatment plan. The most common POMR technique is the SOAP note. The SOAP note allows the clinician to report a patient assessment and treatment plan. The four letters of the acronym are described in the figure.© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284217155_CH02_025_068.indd 63 28/11/20 5:25 PM 64 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettCHART REVIEW Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEPatient OR Name: DISTRIBUTION ______NOT FOR Age: SALE ______OR DISTRIBUTION Physician(s): ______Height: ______Hospital ID No.: ______Weight: ______Floor/Unit: ______Sex: ______Admitting Diagnosis: ______

Other Problems from© Problem Jones List & or BartlettPatient History Learning, and Physical: LLC © Jones & Bartlett Learning, LLC 1. ______NOT FOR SALE OR 4.DISTRIBUTION ______NOT FOR SALE OR DISTRIBUTION 2. ______5. ______3. ______6. ______Current Physician Orders for Respiratory Care: ______Most Recent ABGs and/or SpO2: ______©______Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Most Recent Chest X-ray Reports: ______NOT______FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Most Recent Pulmonary Function Testing: ______

PATIENT INTERVIEW

Cough: ______Sputum Production: ______© Jones & BartlettHemoptysis: Learning, ______LLC Wheezing, Whistling,© Jones or Chest & Tightness: Bartlett ______Learning, LLC NOT FOR SALEBreathlessness: OR DISTRIBUTION ______NOT FOR SALE OR DISTRIBUTION Chest Illness: ______Smoking: ______Occupational History: ______Hobby and Leisure History: ______Medicines or Respiratory Care Used: ______Response to Current© Respiratory Jones Care:& Bartlett ______Learning, LLC © Jones & Bartlett Learning, LLC

PHYSICAL ASSESSMENTNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

General Appearance: ______Pulse: ______Respirations: ______Blood Pressure: ______Level of Consciousness: ______Chest Inspection: ______©Auscultation: Jones & ______Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTPercussion: FOR ______SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Palpation: ______Bedside Spirometry: IC: ______PEFR: ______VC: ______FEV1: ______

ASSESSMENT FOR THERAPY © Jones & BartlettEvaluate whetherLearning, each specific LLC therapy listed is indicated and/or© Jones appropriate & for Bartlett this patient Learning, based on your chartLLC review, patient interview, and physical assessment data. NOTE: Check all indications present REGARDLESS of whether the patient is currently NOT FOR SALEreceiving OR a DISTRIBUTIONparticular therapy or not. NOT FOR SALE OR DISTRIBUTION

Assessment for Oxygen Therapy (check all indications present for oxygen therapy; see Box 2-5)

Yes No Documented hypoxemia © Corrected Jones hypoxemia & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT Suspected FOR hypoxemia SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Severe trauma Acute M.I. Immediate post-op recovery (recovery room or ICU)

Assessment for Bronchodilator Therapy (check all indications present for bronchodilator therapy; see Box 2-6) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Yes No NOT FOR SALE Asthma OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION COPD Wheezing Documented response to a bronchodilator

© Jones & BartlettFIGURE 2-8 Learning, Detailed respiratory LLC care plan format. Format includes© patientJones demographic & Bartlett data, indications Learning, for specific LLC respiratory care, NOT FOR SALEand a care OR plan DISTRIBUTION oriented toward maintenance of oxygenation, treatmentNOT and FOR prevention SALE of bronchospasm OR DISTRIBUTION and/or mucosal edema, delivery of anti-inflammatory and antiasthmatic medications, therapy to mobilize and remove secretions, and lung expansion therapy.

9781284217155_CH02_025_068.indd 64 28/11/20 5:25 PM Summary 65

© Jones & BartlettAssessment Learning, for Anti-inammatory LLC Aerosol Agents (inhaled© Jones steroids) & (check Bartlett all of the Learning, indications present; LLC see Box 2-10) NOT FOR SALE Yes OR DISTRIBUTION No NOT FOR SALE OR DISTRIBUTION Asthma COPD Upper airway edema

Assessment for Antiasthmatic© Jones &Aerosol Bartlett Agents Learning, (cromolyn, etc.) LLC (check all of the indications present;© Jones see Box 2-10)& Bartlett Learning, LLC Yes No NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Asthma

Assessment for Directed Cough (check all of the indications present for this patient; see Box 2-13)

Yes No © Jones .. & .. Bartlett Retained Learning, secretions, excess LLC secretion production © Jones & Bartlett Learning, LLC .. .. Following bronchial hygiene therapy NOT .. FOR SALE.. At risk OR for atelectasis/post-opDISTRIBUTION pulmonary complications NOT FOR SALE OR DISTRIBUTION .. .. To obtain sputum specimen

Assessment for Suctioning (check all of the indications present for this patient; see Box 2-13)

Yes No © Jones & Bartlett .. Learning, .. Inability LLC to clear secretions with cough © Jones & Bartlett Learning, LLC NOT FOR SALE .. OR DISTRIBUTION .. Need to remove secretions with articialNOT airway FOR SALE OR DISTRIBUTION .. .. Need to stimulate cough .. .. To obtain sputum specimen

Assessment for Mucolytic Therapy (check the indications present for this patient; see Box 2-13)

Yes No © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Evidence of viscous/retained secretions that are not easily removed via other therapy CNOThronic FOR bronchitis, SALE cystic OR brosis, DISTRIBUTION bronchiectasis NOT FOR SALE OR DISTRIBUTION

Assessment for Chest Physiotherapy (check all of the indications present for this patient; see Box 2-13)

Postural Drainage and Percussion

© JonesYes & No Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE Suggestion/evidence OR DISTRIBUTION of problems with secretion clearance NOT FOR SALE OR DISTRIBUTION Difficulty clearing secretions with volume 25–30 mL/day (adult) Retained secretions in presence of an articial airway Atelectasis caused/suspected to be due to mucus plugging Cystic brosis, bronchiectasis, cavitating lung disease Presence of a foreign body in airway © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Assessment for High-Volume Bland Aerosol (see Box 2-13) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Cool Mist Bland Solution

Yes No Post extubation Deliver precise FIO2 via air-entrainment nebulizer U© pperJones airway & edema Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT To obtain FOR sputum SALE specimen OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Heated Large-Volume Nebulizer

Yes No Evidence/potential for secretion clearance problem © Jones & BartlettDeliver preciseLearning, FIO2 with LLC high humidity © Jones & Bartlett Learning, LLC Mobilize secretions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hypertonic Saline Administration

Yes No Induce sputum © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEFIGURE OR 2-8 DISTRIBUTION (Continued) NOT FOR SALE OR DISTRIBUTION

9781284217155_CH02_025_068.indd 65 28/11/20 5:25 PM 66 CHAPTER 2 Development and Implementation of Respiratory Care Plans

© Jones & BartlettAssessment Learning, for Lung LLC Expansion Therapy (see Box© 2-16) Jones & Bartlett Learning, LLC NOT FOR SALE OR Incentive DISTRIBUTION Spirometry (check all of the indications presentNOT for FOR this patient) SALE OR DISTRIBUTION Yes No Patient is able to perform the maneuver q1–2 hours while awake and is able to achieve adequate inspired volume. AND: Check as many© Jones as apply: & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Yes No Patient is predisposed to development of atelectasis (surgery, debilitated, bedridden, ventilatory impairment/restrictive/neuromuscular defect). Presence of atelectasis. Preoperative screening/education of patients at risk. © Jones & Bartlett Patient Learning, has reduced LLC inspiratory capacity (,2.5 L). © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION IPPB (check all the indications present for this patient)

Yes No Presence of clinically important atelectasis AND other therapy has been unsuccessful. Patient cannot or will not spontaneously deep breathe and is at risk for atelectasis. © Jones & Bartlett Learning, LLC To deliver aerosol medication with© coordination Jones &or cooperationBartlett issues.Learning, LLC NOT FOR SALE OR DISTRIBUTION NPPV to provide short-term ventilatoryNOT support FOR in SALEan attempt OR to avoid DISTRIBUTION intubation and continuous mechanical ventilation.

ABG, arterial blood gas; SpO2, arterial blood oxygen saturation; IC, inspiratory capacity; PEFR, peak expiratory flow rate; VC, vital capacity; FEV1, forced expiratory volume in the first second of expiration; M.I., myocardial ischemia; ICU, intensive care unit; COPD, chronic obstructive pulmonary disease; FIO2, fractional concentration of inspired oxygen.© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-8 (Continued)

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Key Points ■ For delivery of a low to moderate concentration of ■ NOTThe respiratory FOR SALE care planOR providesDISTRIBUTION a written descrip- oxygen, theNOT nasal FOR cannula SALE is the OR device DISTRIBUTION of choice for tion of the care the patient is to receive. most patients. ■ Respiratory care plans include the goals of therapy, ■ With unstable ventilatory patterns or rapid, shal- the device or procedure to be used, medications to low breathing, an air-entrainment mask may be be given, frequency of administration, and duration considered. © Jones & Bartlettof therapy. Learning, LLC © Jones ■ For & moderate Bartlett to highLearning, concentrations LLC of oxygen NOT FOR SALE ■ SOAP OR notes DISTRIBUTION refers to Subjective, Objective, Assess- NOT FORtherapy SALE for short-term OR DISTRIBUTION use, consider a simple ment, and Plan. partial-rebreathing or nonrebreathing mask. ■ SOAPIER notes add Intervention, Evaluation, and ■ A high-flow nasal cannula may be considered for Revision of care provided. patients with severe hypoxemic respiratory failure; it ■ Acute respiratory failure (ARF) is defined as a sud- can deliver up to 60 L/min of gas flow via an oxygen den decrease in arterial© Jones oxygen & levels Bartlett with orLearning, without LLCblender, humidifier, and heated© Jones tubing. & Bartlett Learning, LLC carbon dioxide retention.NOT FOR SALE OR DISTRIBUTION ■ The primary indication forNOT bronchodilator FOR SALE therapy OR is DISTRIBUTION ■ Acute ventilatory failure (AVF) is defined as a sudden to treat or prevent bronchospasm. ■ rise in Paco2 with a corresponding decrease in pH. Bronchodilator therapy is indicated in acute asthma, ■ Chronic ventilatory failure is defined as a chroni- COPD, and whenever wheezing is due to reversible cally elevated Paco2 with a normal (compensated) or bronchoconstriction. ©near-normal Jones & pH. Bartlett Learning, LLC ■ Anti-inflammatory© Jones &aerosol Bartlett agents Learning, and antiasthmatic LLC ■ NOTRespiratory FOR care SALE plans OR may DISTRIBUTIONbe developed for basic drugs includeNOT inhaled FOR SALEcorticosteroids, OR DISTRIBUTION cromolyn so- and critical respiratory care, diagnostic testing, or dium, and antileukotrienes. specialized procedures. ■ Techniques to mobilize or remove secretions include ■ Oxygen therapy is indicated for documented or directed cough, suctioning, use of high-volume aero- suspected hypoxemia, severe trauma, acute myo- sol therapy, and bronchial hygiene. © Jones & Bartlettcardial infarction, Learning, and LLC immediate postoperative © Jones ■ Directed & Bartlett cough should Learning, be included LLC as an integral NOT FOR SALErecovery. OR DISTRIBUTION NOT FORpart ofSALE bronchial OR hygiene DISTRIBUTION therapy.

9781284217155_CH02_025_068.indd 66 28/11/20 5:25 PM References 67

■ syndrome: the Berlin Definition. JAMA 2012;307(23):2526–2533. © Jones & BartlettForced expiratory Learning, technique, LLC also known as a “huff”© Jones & Bartlett Learning, LLC cough, is a modified version of the directed cough. doi: 10.1001/jama.2012.5669. NOT FOR SALE ■ OR DISTRIBUTION NOT 5.FOR Esteb SALEan A, Anzueto OR A,DISTRIBUTION Alia I, Gordo F, Apezteguia C, Palizas F, A cool, bland aerosol is indicated in the treatment of et al. How is mechanical ventilation employed in the intensive upper airway edema and for postoperative manage- care unit? An international utilization review. Am J Respir Crit ment of the upper airway. Care Med 2000;161:1450–1458. ■ Airway clearance techniques include chest physio- 6. Shapiro BA, Peruzzi WT, Kozelowski-Templin R. Clinical appli- therapy, kinetic therapy, high-frequency chest wall cation of blood gases. 5th ed. St. Louis: Mosby; 1994. © Jones & Bartlett Learning, LLC7. American Association for Respiratory© Jones Care. & Clinical Bartlett practice Learning, LLC oscillation, positive airway pressure (PAP), the flutter NOT FOR SALE OR DISTRIBUTIONguideline: oxygen therapy in theNOT acute FOR care hospital—2002 SALE OR re -DISTRIBUTION valve, intrapulmonary percussive ventilation, and vision and update. Respir Care 2002;47:717–720. mechanical insufflation–exsufflation. 8. American Association for Respiratory Care. Clinical practice ■ Nasotracheal suctioning is indicated in cases where guideline: oxygen therapy in the home or alternate site health the patient’s spontaneous or directed cough is care—2007 revision and update. Respir Care 2007;52:1063–1068. 9. Boatright J, Ward JJ. Therapeutic gases: management and admin- ineffective.© Jones & Bartlett Learning, LLC istration. ©In: JonesHess DR, MacIntyre& Bartlett NR, MishoeLearning, SC, Galvin LLC WF, ■ AirwayNOT FOR clearance SALE techniques OR DISTRIBUTION recommended in the Adams AB,NOT editors. FOR Respiratory SALE care ORprinciples DISTRIBUTION and practice. 2nd treatment of cystic fibrosis include inhaled airway ed. Burlington, MA: Jones & Bartlett Learning; 2012:271–302. clearance agents such as hypertonic saline [7% NaCl], 10. Global Initiative for Chronic Obstructive Lung Disease (GOLD). DNase, and mannitol and chest physiotherapy. Global strategy for the diagnosis, management and prevention of ■ chronic obstructive pulmonary disease: 2019 report. Available at The primary indications for lung expansion https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019 © Jones & Bartletttherapy areLearning, in the treatment LLC and/or prevention of © Jones-v1.7-FINAL-14Nov2018-WMS.pdf?. & Bartlett Learning, LLC Accessed February 4, 2019. NOT FOR SALEatelectasis. OR DISTRIBUTION NOT11. FOR Feller-K SALEopmna ORDJ, Schwartzstein DISTRIBUTION RM. The evaluation, diagno- ■ Lung expansion therapy may be used in an attempt sis, and treatment of the adult patient with acute hypercapnic to prevent the development of postoperative compli- respiratory failure. In: Stoller JK, Finlay G, editors. UpToDate. Waltham, MA: UpToDate Inc. Available at https://www.uptodate cations such as atelectasis, pneumonia, and respira- .com. Accessed January 2, 2020. tory failure, particularly in abdominal and thoracic 12. Tiep BL, Carter RC. Long term supplemental oxygen therapy. In: surgery patients. © Jones & Bartlett Learning, LLCStoller JK, Hollingsworth H, editors.© Jones UpToDate. & BartlettWaltham, MA: Learning, LLC ■ UpToDate Inc. Available at https://www.uptodate.com. Accessed The two primary NOTtechniques FOR for SALE applying OR lung DISTRIBUTION expan- NOT FOR SALE OR DISTRIBUTION sion therapy are incentive spirometry and intermit- January 2, 2020. 13. American Association for Respiratory Care. Clinical practice tent positive pressure breathing (IPPB). guideline: selection of an oxygen delivery device for neonatal ■ Incentive spirometry should be considered in pa- and pediatric patients—2002 Revision and Update. Respir Care tients who are able to perform the maneuver every 1 2002;47:707–716. ©to 2Jones hours while & Bartlett awake and Learning, are able to achieve LLC an ad- 14. Martin R.© Neona Jonestal target & oxygenBartlett levels Learning,for preterm infants. LLC In: equate inspired volume. Weisman LE, Kim MS, editors. UpToDate. Waltham, MA: UpTo- ■ NOT FOR SALE OR DISTRIBUTION Date Inc.NOT Available FOR at https://www.uptodate.com. SALE OR DISTRIBUTION Accessed Janu- IPPB should generally be reserved for patients who ary 2, 2020. have clinically important atelectasis in which other 15. Manja V, Lakshminrusimha S, Cook DJ. Oxygen saturation tar- therapy has been unsuccessful. get range for extremely preterm infants: a systematic review and ■ PAP is sometimes used to mobilize secretions and meta-analysis. JAMA Pediatr 2015;169:332. treat atelectasis. 16. Heuer A. Medical gas therapy. In: Kacmarek RM, Stoller JK, Heuer AJ, © Jones & Bartlett Learning, LLC © Joneseditors. & Bartlett Egan’s fundamentals Learning, of respiratory LLC care. 11th ed. St. Louis: ■ The goals of ventilatory support in the ICU include NOT FOR SALE OR DISTRIBUTION NOT FORMosby; SALE 2017:905–936. OR DISTRIBUTION maintaining adequate tissue oxygenation, ventilation, 17. Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of and acid–base balance. ARDS with prone positioning. Chest 2017;151:215–224. doi:10 ■ Patient assessment and care plan development may .1016/j.chest.2016.06.032. require measurement of clinical parameters related 18. Curley MA. Prone positioning in patients with acute respiratory distress syndrome: a systematic review. Am J Crit Care to oxygenation, ventilation, and cardiopulmonary © Jones & Bartlett Learning, LLC1999;8:397–405. © Jones & Bartlett Learning, LLC function. NOT FOR SALE OR DISTRIBUTION19. Gattinoni L, Tognoni G, PesentiNOT A, Taccone FOR P,SALE Mascheroni OR D, DISTRIBUTION Labarta V. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 2001;345:568–573. References 20. Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, 1. Aboussouan L. Respiratory failure and the need for ventilatory et al. Effects of systematic prone positioning in hypoxic acute support. In: Kacmarek RM, Stoller JK, Heuer AJ, editors. Egan’s respiratory failure: a randomized controlled trial. JAMA ©fundamentals Jones & of Bartlett respiratory Learning,care. 11th ed. St. LLC Louis: Mosby; 2004;292(19):2379–2387.© Jones & Bartlett Learning, LLC 2017:972–986. 21. Ahrens T, Kollef M, Stewart J, Shannon W. Effect of kinetic 2. NOTWest JB.FOR Acute SALE respiratory OR failure. DISTRIBUTION In: West JB, editor. Pulmo- therapy onNOT pulmonary FOR complications. SALE OR Am DISTRIBUTION J Crit Care 2004;13: nary physiology and pathophysiology: an integrated, case-based 376–383. doi:10.1001/jama.292.19.2379. approach. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 22. Bartlett R. Extracorporeal membrane oxygenation (ECMO) in 2007:116–133. adults. In: Parsons PE, Finlay G, editors. UpToDate. Waltham, 3. Weinberger SE, Cockrill B, Manel J. Principles of pulmonary MA: UpToDate Inc. Available at https://www.uptodate.com. Ac- © Jones & Bartlettmedicine. Learning, 3rd ed. Philadelphia: LLC W.B. Saunders; 1998. © Jonescessed & Bartlett January 14, 2020.Learning, LLC 4. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thomp- 23. Gardner DD, Vines DL, Wettstein RB, Garcia J, Peters JI. 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(Fio2)–high-flow nebulizer and the Theramist air entrainment 36. American Association for Respiratory Care. Clinical practice © Jones & Bartlettnebulizer Learning, in delivering LLChigh oxygen concentrations. Chest© Jonesguideline: & Bartlett bland aerosolLearning, administration—2003 LLC revision and NOT FOR SALE2005;128:305S. OR DISTRIBUTION NOT FORupdat SALEe. Respir CareOR 2003;48 DISTRIBUTION (5):529–533. 24. Hyzy RC. Heated and humidified high-flow nasal oxygen in adults: 37. Word CR. Management of croup. In: Kaplan SL, Messner AH, practical consideration and potential applications. In: Manaker S, Armsby C, editors. UpToDate. Waltham MA: UpToDate Inc. Finlay G, editors. UpToDate. Waltham, MA: UpToDate Inc. Avail- Available at https://www.uptodate.com. Accessed Jan 26, 2020. able at https://www.uptodate.com. Accessed January 2, 2020. 38. Strickland SL, Rubin BK, Drescher GS, Haas CF, O’Malley CA, 25. National Institutes of Health, National Heart, Lung, and Blood In- American Association for Respiratory Care, et al. AARC clini- stitute. Guidelines for© theJones diagnosis & and Bartlett management Learning, of asthma: LLCcal practice guideline: effectiveness© Jones of nonpharmacologic & Bartlett airLearning,- LLC Expert Panel 3 report.NOT Bethesda, FOR MD: SALE U.S. Department OR DISTRIBUTION of Health way clearance therapies in hospitalizedNOT FOR patients. SALE Respir OR Care DISTRIBUTION and Human Services, 2007. NIH Publication 08-5846. 2013:58:2187–2193. doi:10.4187/respcare.02925. 26. Global Initiative for Asthma. Asthma management and pre- 39. Vines DL, Gardiner DD. Airway clearance therapy (ACT). In: vention (for adults and children older than five years): a pocket Kacmarek RM, Stoller JK, Heuer AJ, editors. Egan’s fundamentals guide for health professionals. Updated 2019. Available at https:// of respiratory care. 11th ed. St. Louis: Mosby; 2017:951–971. ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main 40. American Association for Respiratory Care. Clinical practice ©-Pocket-Guide-wms.pdf. Jones & Bartlett Accessed Learning, May 20, 2020. LLC guideline:© directed Jones cough. & Respir Bartlett Care 1993;38:495–499. Learning, LLC 27. NOTGlobal FORInitiative SALE for Chronic OR Obstructive DISTRIBUTION Lung Disease (GOLD). 41. Hess, DRNOT. Airway FOR clearance SALE and lung OR expansion DISTRIBUTION therapy. In: Hess Global strategy for the diagnosis, management and prevention of DR, MacIntyre NR, Galvin B, Mishoe SC, editors. Respiratory chronic obstructive pulmonary disease: 2019 report. Available at care principles and practice. 3rd ed. Burlington, MA: Jones & https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019 Bartlett Learning; 2016:352–379. -v1.7-FINAL-14Nov2018-WMS.pdf?. Accessed December 23, 42. Hess DR. Humidity and aerosol therapy. In: Hess DR, MacIntyre 2019. NR, Galvin B, Mishoe SC, editors. Respiratory care principles © Jones & 28.Bartlett Han MK, Learning, Dransfield MT, LLCMartinez FJ. Chronic obstructive pul©- Jonesand & practice. Bartlett 3rd ed. Learning, Burlington, MA: LLC Jones & Bartlett Learning; monary disease: definition, clinical manifestations, diagnosis, 2016:307–351 NOT FOR SALEand staging.OR DISTRIBUTION In: Stoller JK, Hollingsworth H, editors. UpToDate.NOT 43. FOR Fink SALEJB, Arzu OR A. Humidity DISTRIBUTION and bland aerosol therapy. In: Waltham, MA: UpToDate Inc. Available at https://www.uptodate Kacmarek RM, Stoller JK, Heuer AJ, editors. Egan’s fundamentals .com. Accessed December 23, 2019. of respiratory care. 11th ed. St. Louis: Mosby; 2017:820–842. 29. Munari AB, Gulart AA, Dos Santos K, Venâncio RS, Karloh M, 44. Thomas KW, Gould MK. Procedures for tissue biopsy in patients Mayer AF. Modified medical research council dyspnea scale in with suspected non-small cell lung cancer. In: Colt HG, Finlay G, GOLD classification© betterJones reflects & Bartlett physical activities Learning, of daily LLCeditors. UpToDate. Waltham, ©MA: Jones UpToDate & Inc. Bartlett Available Learning,at LLC living. Respir Care 2018;63:77–85. doi:10.4187/respcare.05636. https://www.uptodate.com. Accessed January 2, 2020. 30. Ferguson GT, MakeNOT B. Stable FOR COPD: SALE overview ORof management. DISTRIBUTION 45. Simon RH. Cystic fibrosis: overviewNOT of FORthe treatment SALE of lung OR dis -DISTRIBUTION In: Stoller JK, Hollingsworth H, editors. UpToDate. Waltham, ease. In: Mallory GB, Hoppin AG, editors. UpToDate. Waltham, MA: UpToDate Inc. Available at https://www.uptodate.com. Ac- MA: UpToDate Inc. Available at https://www.uptodate.com. Ac- cessed December 23, 2019. cessed January 3, 2020. 31. Stoller JK. Clinical manifestations, diagnosis, and natural history 46. Micak RP. Inhalation injury from heat, smoke, or chemical irri- ©of Jones alpha-1 antitrypsin & Bartlett deficiency. Learning, In: Barnes PJ, LLCHollingsworth H, tants. In:© Bulger Jones EM, Jeschke & Bartlett MG, Colline Learning, KA, Finlay G, editors.LLC editors. UpToDate. Waltham, MA: UpToDate Inc. Available at UpToDate. Waltham, MA: UpToDate Inc. Available at https:// NOThttps://www.uptodate.com. FOR SALE OR Accessed DISTRIBUTION December 26, 2019. www.uptodate.com.NOT FOR Accessed SALE January OR 20, 2020.DISTRIBUTION 32. Jarosch I, Gloeckl R, Damm E, Schwedhelm AL, Buhrow D, 47. Strickland SL, Rubin BR, Haas CF, Volsko TA, Drescher GS, Jerrentrup A, et al. Short-term effects of supplemental oxygen O’Malley CA. AARC clinical practice guideline: effective- on 6-min walk test outcomes in patients with COPD: a random- ness of pharmacologic airway clearance therapies in hospitalized, placebo-controlled, single-blind, crossover trial. Chest ized patients. 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Clinical practice 34. Ferguson GT, Make© B. JonesStable COPD: & Bartlettfollow-up pharmacologic Learning, LLCguideline: incentive spirometry.© Respir Jones Care 2011;56:1600–1604. & Bartlett Learning, LLC management. In: StollerNOT JK, HollingsworthFOR SALE H, editors. OR UpToDate.DISTRIBUTION 51. American Association for RespiratoryNOT FOR Care. ClinicalSALE practice OR DISTRIBUTION Waltham, MA: UpToDate Inc. Available at https://www.uptodate guideline: use of positive airway pressure adjuncts to bronchial .com. Accessed December 23, 2019. hygiene therapy. Respir Care 1993;38:516–521. 35. Gardenhire D. Rau’s respiratory care pharmacology. 8th ed. St. Louis: Elsevier Health; 2012. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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