Respiratory ServicesRespiratory Services

RT DepartmentRT Department

RT resources = 82 therapistsRT resources = 82 therapists

In-house skeleton crew = 12 patient careIn-house skeleton crew = 12 patient care

Work: 12 hour shifts; 7a-7p & 7p-7a.Work: 12 hour shifts; 7a-7p & 7p-7a.

RT Supervisor 24/7. In-house pager: 2103-RT Supervisor 24/7. In-house pager: 2103-1041810418

Other: Director, Clinical Educator, Patient Other: Director, Clinical Educator, Patient Educator, PF therapist, ABG therapist, Pedi Educator, PF therapist, ABG therapist, Pedi Clinic RT(respiratory therapy)Clinic RT(respiratory therapy)

Respiratory ServicesRespiratory Services

CContinuous PPressure RRespirasi Oxygen TherapyOxygen TherapyAerosol TherapyAerosol TherapyNasotracheal SuctioningNasotracheal SuctioningInduced SputumInduced SputumHand-held Nebulizer Hand-held Nebulizer

TreatmentsTreatmentsMetered Dose InhalersMetered Dose InhalersChest PhysiotherapyChest PhysiotherapyArterial Blood GasesArterial Blood GasesCapillary Blood GasesCapillary Blood GasesUmbilical Cord GasesUmbilical Cord Gases

Cont Mechanical VentilationHFOVInhaled Nitric OxideBIPAP/CPAPPulse Oximetry/TrendingPulmonary Function StudiesBronchoscopyPatient Education*Infant Pulmonary Fungsion Test. (PFTs)*Pediatric Sleep Studies

CPAP (Continuous Positive Airway Pressure)CPAP (Continuous Positive Airway Pressure)BIPAP( Bilevel positive airway pressure)

HFOV (High Frequency Oscillatory Ventilation)HFOV (High Frequency Oscillatory Ventilation)

Today’s Topics:Today’s Topics: Oxygen delivery devicesOxygen delivery devices Nebulizer therapyNebulizer therapy Asthma ProtocolAsthma Protocol Airway Clearance devicesAirway Clearance devices Assisting with Intubation/ExtubationAssisting with Intubation/Extubation Mechanical VentilationMechanical Ventilation Arterial Blood GasArterial Blood Gas Pulmonary Functional Test (PFTs) / BronchoscopiesPulmonary Functional Test (PFTs) / Bronchoscopies

Patient EducationPatient Education

Oxygen delivery devicesOxygen delivery devices

Nasal CannulaNasal Cannula Simple Oxygen MaskSimple Oxygen Mask Venti-MaskVenti-Mask Non-rebreatherNon-rebreather Aerosol MaskAerosol Mask Trache CollarTrache Collar OxyhoodOxyhood

Nasal cannula: Lightweight, flexible plastic tubing with two curved prongs that fit just inside patient’s nostrils.

Delivers 24-44% FIO2 at 1-6 L/min flow Delivers 4% Oxygen per liter flow

Flow 1 liters per minute: 24% Flow 2 liters per minute: 28% Flow 3 liters per minute: 32% Flow 4 liters per minute: 36% Flow 5 liters per minute: 40% Flow 6 liters per minute: 44%

Flow rates >3 lpm irritates nasopharynx

Venti-maskVenti-mask

Mask poorly tolerated by infants/todlers.Mask poorly tolerated by infants/todlers.Venturi adapters:Venturi adapters:

Blue= 24% at 2 lpmBlue= 24% at 2 lpm

Yellow=28% at 4 lpmYellow=28% at 4 lpm

White= 31% at 6 lpmWhite= 31% at 6 lpm

Green= 35% at 8 lpmGreen= 35% at 8 lpm

Pink= 40% at 8 lpmPink= 40% at 8 lpm

Orange= 50% at 12 lpmOrange= 50% at 12 lpm

Trache CollarTrache Collar

Aerosol MaskAerosol Mask

both deliver aerosol at both deliver aerosol at 28% - 100% FiO2.28% - 100% FiO2.

Simple O2 MaskSimple O2 Mask

6 lpm to 10 lpm6 lpm to 10 lpm

24% to 44% FiO224% to 44% FiO2

Non-Rebreather MaskNon-Rebreather Mask

Delivers 90%-95% O2Delivers 90%-95% O2

Oxygen Hood Used in NICU

Clear plastic shell encompasses the baby's head Size of hood limits use to younger than age 1 year Allows easy access to chest, trunk, and extremities

Inspired oxygen temperature and humidity Delivers 80-90% oxygen at 10-15 liter per minute

Nicu = neonatus intensive care unit

Oxygen ordersOxygen orders

Things to take into consideration:Things to take into consideration:1. Oxygen saturation on Room Air1. Oxygen saturation on Room Air2. Age2. Age3. Mouth-breathing3. Mouth-breathing4. Sats will drop when asleep!4. Sats will drop when asleep!

Order example: “O2 by NC to keep sats Order example: “O2 by NC to keep sats >90%” or “FiO2 to keep sats >90%.”>90%” or “FiO2 to keep sats >90%.”

HHN TherapyHHN Therapy

Order example:Order example:

““Albuterol sulfat: 2.5mg/ Albuterol sulfat: 2.5mg/ 3 ml NS3 ml NS Q4” Q4”

1.1. Albuterol SulfateAlbuterol Sulfate

2.2. Ipratroprium BromideIpratroprium Bromide

3.3. LevalbuterolLevalbuterol

4.4. BudesonideBudesonide

5.5. Hypertonic SalineHypertonic Saline

6. 6. TOBITOBI

7. Pulmozyme7. Pulmozyme

8. Pentamidine8. Pentamidine

9. Racemic Epinephrine9. Racemic Epinephrine

Hand-held Nebulizer (HHN) TreatmentsHand-held Nebulizer (HHN) Treatments

Hypertonic SalineHypertonic Saline Used to induce sputum Used to induce sputum 4-5 mls 3%, 7% & 10% solution.4-5 mls 3%, 7% & 10% solution. Delivered by Delivered by Hand Held NebulizerHand Held Nebulizer.. Albuterol is administered before.Albuterol is administered before. Side effect: bronchospasm.Side effect: bronchospasm. Used as a routine airway clearance Rx for Used as a routine airway clearance Rx for

patients with CF.patients with CF. Order: “3% Hypertonic Saline by HHN 4 ml Order: “3% Hypertonic Saline by HHN 4 ml

Q4”Q4”

MDI therapyMDI therapy(Metered Dose Inhalers)(Metered Dose Inhalers)

Advair DiskusAdvair DiskusDRY POWDER INHALER

Patient must be able to self administer.

Pulmicort TurbohalerPulmicort Turbohaler

DRY POWDER INHALER

Patient must be able to self administer.

Asthma ProtocolAsthma Protocol

TherapiesTherapies

SUCTIONINGSUCTIONING Chest Physical TherapyChest Physical Therapy EzpapEzpap AcapellaAcapella IPVIPV ThairapyThairapy®® VestVest

SuctioningSuctioning

Respiratory Therapys Respiratory Therapys LOVE to suction!!!LOVE to suction!!!

DO NOT need an DO NOT need an order to suction.order to suction.

(jangan diberikan (jangan diberikan

bila tidak indikasi)bila tidak indikasi)

RTs= respiratory terapis.

SuctioningSuctioning

Time = (dewasa) 5 -10 detik.Time = (dewasa) 5 -10 detik. Time = (anak) 3 - 5 detikTime = (anak) 3 - 5 detik Dapat diulang 5-10 ulangan.Dapat diulang 5-10 ulangan. Dengan intermetten rest 5-10 detik.Dengan intermetten rest 5-10 detik. Kekutan suction = 60-120 mmHg dewasaKekutan suction = 60-120 mmHg dewasa Anak = 40 – 60 mmHgAnak = 40 – 60 mmHg Bayi = 20-40 mmHg.Bayi = 20-40 mmHg.

Chest Physical Therapy (CPT)Chest Physical Therapy (CPT)

Chest wall percussionChest wall percussion Mobilizing secretionsMobilizing secretions CPT and AsthmaCPT and Asthma CPT and pneumoniaCPT and pneumonia CPT and post-op patientsCPT and post-op patients CPT and CFCPT and CF Order: “CPT Q3”Order: “CPT Q3”

EZPAPEZPAP1.1. Presence of atelectasis or patients at riskPresence of atelectasis or patients at risk

for developing atelectasisfor developing atelectasis

2.2. Restrictive lung defectRestrictive lung defect

3.3. Impending or worsening hypercapniaImpending or worsening hypercapnia

4.4. To optimize delivery ofTo optimize delivery of

bronchodilatorbronchodilator

Order: “Ezpap Q4”Order: “Ezpap Q4”

AcapellaAcapella

To aid in mobilizing retained secretions. To aid in mobilizing retained secretions. To prevent or reverse atelectasis.To prevent or reverse atelectasis. To optimize delivery of bronchodilators.To optimize delivery of bronchodilators. Order: Acapella BID or QID.Order: Acapella BID or QID. Need patient’s cooperation.Need patient’s cooperation.

ThairapyThairapy®® Vest Vest

High frequency chest High frequency chest wall oscillationwall oscillation

Used in CF, patient’s Used in CF, patient’s with retained with retained secretions: Muscular secretions: Muscular dystrophy, cerebral dystrophy, cerebral palsypalsy

Order: Vest therapy Order: Vest therapy Q3-Q4 while awakeQ3-Q4 while awake

Intrapulmonary Percussive Intrapulmonary Percussive VentilationVentilation

Provides percussive Provides percussive oscillatory vibration to oscillatory vibration to improve the improve the mobilization of mobilization of secretions, treat and secretions, treat and prevent atelectasisprevent atelectasis

Order: IPV with 10 or Order: IPV with 10 or 15 ml NS ~Alb. 2.5mg15 ml NS ~Alb. 2.5mg

Non-Invasive VentilationNon-Invasive Ventilation

Nasal CPAP & Nasal CPAP & VapothermVapotherm

BiPAPBiPAP NPVNPV

Sleep Apnea,

Shallow breathing/↑ CO2

Neuromuscular Disease

Assisting with Intubation/ExtubationAssisting with Intubation/Extubation

ET tubesET tubes

<1000g = 2.5<1000g = 2.5 1000 to 2000 g = 3.01000 to 2000 g = 3.0 2000 to 3000 g = 3.52000 to 3000 g = 3.5 > 3000 g = 4.0> 3000 g = 4.0 Newborn = 3.5 – 4.0Newborn = 3.5 – 4.0 6 months = 4.06 months = 4.0 18 mo. = 4.018 mo. = 4.0 3 yrs = 4.53 yrs = 4.5 5 yrs = 5.05 yrs = 5.0 6 yrs = 5.56 yrs = 5.5

8 yrs = 6.08 yrs = 6.0 12 yrs = 6.512 yrs = 6.5 16 yrs = 7.016 yrs = 7.0 Note: tube selection should Note: tube selection should

be based on child’s size not be based on child’s size not age. Good idea to have age. Good idea to have one size larger and one size one size larger and one size smaller.smaller.

Formulas:Formulas: age + 16age + 16 or or ht. (cm)ht. (cm) 4 204 20

Mechanical VentilationMechanical Ventilation AveaAvea

Sensormedics HFOV

Drager Evita 4

Modes of VentilationModes of Ventilation

CPAP- Continuous Positive Airway CPAP- Continuous Positive Airway PressurePressure

SIMV- sychronized intermittent mandatory SIMV- sychronized intermittent mandatory ventilationventilation

AC-Assist ControlAC-Assist Control PC-Pressure ControlPC-Pressure Control HFOV- High Frequency Oscillatory HFOV- High Frequency Oscillatory

VentilationVentilation

Ventilator SettingsVentilator Settings

Vt : 6-8 ml/kgVt : 6-8 ml/kg PIP: peak inspiratory pressure 12PIP: peak inspiratory pressure 12 RR : Respiratory rate 12-14RR : Respiratory rate 12-14 PEEP: Positive end expiratory pressurePEEP: Positive end expiratory pressure Ti : Ti : FiO2 : FiO2 : Frational inspired oxygen concentration.Frational inspired oxygen concentration.

PS : PS :

Arterial Blood GasArterial Blood Gas Normal valuesNormal values

pH 7.35 - 7.45 pH 7.35 - 7.45

PCO2 35-45 mmHgPCO2 35-45 mmHg

PO2 80-100 mmHgPO2 80-100 mmHg

HCO3 22-26 HCO3 22-26

BE -2 to +2BE -2 to +2

AcidosisAcidosis

pH < 7.35pH < 7.35

PCO2 > 55 mmHgPCO2 > 55 mmHg

(HCO3 < 22)(HCO3 < 22) AlkalosisAlkalosis

pH > 7.45 mmHgpH > 7.45 mmHg

HCO3 > 26 mmol/lHCO3 > 26 mmol/l

(PCO2 < 35)(PCO2 < 35)

PaCO2 = 35-45 mmHg= 4,7-6.0 kPa Base excess (BE)= +/- 2pH = 7.31 – 7.41 (H+) = 46-38 n mol/l (H+) = hydrogen ion concentration

Conversion tablesConversion tables

0,133kPa = 1.0 mmHg pH=9-log(H+) 0,133kPa = 1.0 mmHg pH=9-log(H+) where (H+) is in nmol/lwhere (H+) is in nmol/l

kPa mmHg pH (H+)kPa mmHg pH (H+)1 7,5 7.52 301 7,5 7.52 302 15.0 7.45 35 2 15.0 7.45 35 4 30 7.40 404 30 7.40 406 45 7.35 45 6 45 7.35 45 8 60 7.30 508 60 7.30 5010 75 7.26 5510 75 7.26 5512 90 7.22 60 12 90 7.22 60 14 105 7.19 6514 105 7.19 65

PRESURESPRESURESmmHg kPa

Right atrial (RA) pressureRight atrial (RA) pressure

Right ventrikular (RV) Right ventrikular (RV) pressurepressure

Pulmonary artery (PA) Pulmonary artery (PA) pressurepressure

Pulmonary capillary wedg Pulmonary capillary wedg pressure (PCWP)pressure (PCWP)

Central venus pressure Central venus pressure (CVP)(CVP)

Intracranial pressure (ICP)Intracranial pressure (ICP)

Peak inspiratory mouth Peak inspiratory mouth pressure (Pi Max)pressure (Pi Max)

Peak expiratory mouth Peak expiratory mouth pressure ( Pe Max)pressure ( Pe Max)

MeanMeanSystolicSystolic

DiastolicDiastolic

SystolicSystolic

DiastolicDiastolic

MeanMean

Mean Mean

--

--

MaleMale

FemaleFemale

MaleMale

FamaleFamale

-1 s/d -7-1 s/d -7

15-2515-25

0-80-8

15-2515-25

8-158-15

10-2010-20

6-156-15

3-15 cm H2O3-15 cm H2O

<10 mmHg / <10 mmHg / <1.3 kPa)<1.3 kPa)

-0.13 s/d 0.93-0.13 s/d 0.93

Pulmonary Function TestsPulmonary Function Tests

Indications:Indications:– to aid in diagnosis of lung disorders, to aid in diagnosis of lung disorders, – to follow the natural history of lung growth, or to follow the natural history of lung growth, or

diseases presenting in infancy (eg, cystic diseases presenting in infancy (eg, cystic fibrosis, thoracic insufficiency),fibrosis, thoracic insufficiency),

– to evaluate therapeutic responses; (eg, to to evaluate therapeutic responses; (eg, to medication or physical or respiratory medication or physical or respiratory interventions),interventions),

– Estimate prognosis Estimate prognosis

Pulmonary Function Tests (PFT)Pulmonary Function Tests (PFT) Full studies: in hospital & CCF Pulmonary Full studies: in hospital & CCF Pulmonary

ClinicClinic Dr Henschel-Franks-RT Pedi Medical Dr Henschel-Franks-RT Pedi Medical

DirectorDirector Developing stress testing & exercise testing Developing stress testing & exercise testing

induced protocol. induced protocol. NOTENOTE: Cannot do full studies on IV access or : Cannot do full studies on IV access or

wheelchair bound patients in clinic. wheelchair bound patients in clinic. Shouldn’t be ordered for < 5 yrs of age.Shouldn’t be ordered for < 5 yrs of age.New infant PFT machine New infant PFT machine

BronchoscopyBronchoscopy Presence of lesions of unknown etiology on the chest x-ray Presence of lesions of unknown etiology on the chest x-ray

film, need to evaluate recurrent or persistent atelectasis or film, need to evaluate recurrent or persistent atelectasis or pulmonary infiltrates; pulmonary infiltrates;

assess patency or mechanical properties of the upper airwayassess patency or mechanical properties of the upper airway investigate hemoptysis, persistent unexplained cough, investigate hemoptysis, persistent unexplained cough,

localized wheeze, or strider;localized wheeze, or strider; Suspicious or positive sputum cytology results; to obtain Suspicious or positive sputum cytology results; to obtain

lower respiratory tract secretions, cell washings, and biopsies lower respiratory tract secretions, cell washings, and biopsies for cytologic, histologic, and microbiologic evaluation; for cytologic, histologic, and microbiologic evaluation;

determine the location and extent of injury from toxic determine the location and extent of injury from toxic inhalation or aspiration;inhalation or aspiration;

evaluate problems associated with endotracheal or evaluate problems associated with endotracheal or tracheostomy tubes (tracheal damage, airway obstruction, tracheostomy tubes (tracheal damage, airway obstruction,

aid in performing difficult intubations;aid in performing difficult intubations; suspicion that secretions or mucus plugs are responsible for suspicion that secretions or mucus plugs are responsible for

lobar or segmental atelectasis; lobar or segmental atelectasis; remove abnormal endobronchial tissue or foreign materialremove abnormal endobronchial tissue or foreign material

Patient EducationPatient Education

Asthma Education, (on Asthma Orders)Asthma Education, (on Asthma Orders) Trach educationTrach education Home Ventilator EducationHome Ventilator Education Oxygen TherapyOxygen Therapy Airway Clearance devicesAirway Clearance devices BiPAPBiPAP CPR (control pressure respirasi)CPR (control pressure respirasi)