RESPIRATORY HOME CARE

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CHAPTER 15 RESPIRATORY HOME CARE

PRETEST QUESTIONS

Answer the pretest questions before studying the chapter. This will help you determine your strong and weak areas in the material covered.

1. Which of the following O2 systems would be indicated for a very active home care patient?

A. O2 concentrator
B. Liquid O2
C. “H” cylinder
D. “E” cylinder

2. Which of the following is the LEAST important area for the respiratory therapist to discuss with the home care patient?

A. Pathology of the disease process
B. Cleaning of equipment
C. Side effects of prescribed therapy
D. Importance of proper therapy techniques

3. Which of the following IPPB machines is most convenient for use in the home?

A. Bird Mark 7
B. Bird Mark 8
C. Bennett PR-2
D. Bennett AP-5

4. Diaphragmatic breathing exercises should result in which of the following?

1. Increased VT
2. Less dependence on the diaphragm during quiet breathing
3. Increased FRC
4. Decreased respiratory rate
A. 1 and 2 only
B. 1 and 4 only
C. 2, 3, and 4 only
D. 1, 2, and 4 only

See answers and rationales at the back of the text.

REVIEW

I. HOME REHABILITATION

CRT Exam Content Matrix: IIIH1-8

RRT Exam Content Matrix: IIIH1-8

A. Goals of Rehabilitation
1. Help the patient become independent.
2. Help the patient improve the ability to cope with the disease.
3. Help the patient gain an understanding of the disease and the limitations that result from it.
4. Help the patient to set realistic goals for life and then help him or her attain those goals.
B. Conditions Requiring Pulmonary Rehabilitation
1. Chronic lung diseases
a. Emphysema
b. Asthma
c. Chronic bronchitis
d. Cystic fibrosis
e. Bronchiectasis
f. Pulmonary fibrosis
2. Neuromuscular diseases
a. Myasthenia gravis
b. Guillain-Barré syndrome
c. Poliomyelitis
d. Muscular dystrophy
3. Central respiratory center disorders
a. CNS injury
b. Hypoventilation syndrome (nonobese or pickwickian syndrome, sleep apnea)
c. Ondine curse (primary alveolar hypoventilation)

II. CARE OF THE REHABILITATION PATIENT

CRT Exam Content Matrix: IIA9b-c, IIB1, IIIF2d3, IIIK1,2,5,7

RRT Exam Content Matrix: IIA4a-c, IIIK2,5,7

A. Patient Care Plan
1. Humidity therapy
2. Aerosol therapy
3. O2 therapy: the use of reservoir cannulas and pulse dose O2 delivery systems aid in conserving O2.
4. Bronchodilator therapy
5. ABG sampling and analysis or pulse oximeter (SpO2) monitoring
6. Oropharyngeal and tracheal suctioning
7. Determination of breath sounds by chest auscultation
8. Chest physical therapy
9. Breathing exercises
10. Sputum induction
11. IPPB therapy: The Bennett AP-5 unit is commonly used because it operates on electricity rather than compressed gas.
B. Periodic Evaluations
1. Pulmonary function testing
2. Sputum collection and analysis
3. ABG collection and analysis
4. Exercise tolerance testing (6 to 12 min walk)
5. Chest x-ray films
C. Breathing Exercises
1. Pursed-lip breathing
a. Teach to patients who experience premature airway closure.
b. Instruct the patient to inhale through the nose and exhale through pursed lips.
c. Aids in the patient gaining control of dyspnea.
d. Provides improved ventilation before a cough effort.
e. Teaches the patient how to better control the rate and depth of breathing.
f. Prevents premature airway collapse by generating a back pressure into the airways.
g. Has psychological benefits.
2. Diaphragmatic breathing
a. Teaches the COPD patient to use the diaphragm during breathing rather than accessory muscles.
b. The patient or respiratory therapist places a hand over the abdomen as the patient, while lying on his or her back, concentrates on moving the hand upward on inspiration. (A book or weight may be used rather than a hand.)
c. Increasing the use of the diaphragm results in a decreased respiratory rate, increased tidal volume, decreased FRC, and increased alveolar ventilation.
3. Segmental breathing
a. This is similar to diaphragmatic breathing exercises, except a hand is placed over a specific lung area in which there is atelectasis, secretions, or decreased airflow.
b. The patient should concentrate on moving the hand outward on inspiration.

D. Cough Instruction
1. A VC of less than 10 to 15 mL/kg of ideal body weight indicates inadequate volume for an effective cough.
2. Proper cough instruction: tell the patient to
a. Inhale slowly and deeply through the nose and hold breath for 3 to 5 s (in a sitting position).
b. Clasp arms across his or her abdomen and give three sharp coughs without taking a breath while pressing arms into the abdomen.
c. Use a pillow to “splint” incision sites (e.g., thorax, abdomen)
E. Home O2 Administration
1. O2 cylinders
a. Probably the least expensive O2 setup in the home at the present time depending on usage.
b. Disadvantages of O2 cylinders in the home
(1) Heavy and difficult to move
(2) High pressure hazard
(3) Difficult for older or debilitated patients to change cylinder or attach a regulator
(4) Small cylinders are difficult to walk with
(5) The respiratory therapist should discuss the safety measures and handling of the cylinders with the patient and family members. After instruction, the RT should document the caregivers ability to operate and handle the equipment safely
(6) Cylinders are a good supply system for patients using a small volume of oxygen
2. Liquid O2 system
a. More O2 in liquid form may be stored than in gaseous form (860 times more).
b. Liquid is safer than gas stored in high-pressure cylinders.
c. Portable liquid walkers are more convenient and easier for the patient to handle.
d. Calculating the duration of flow for a liquid O2 system. (See Chapter 1 on oxygen and medical gas therapy.)
e. A good supply system for the patients who use high volumes of oxygen.
3. O2 concentrator
image

FIGURE 15-1 O2 concentrator. A., Stationary oxygen concentrator for home care patients B., Light weight portable oxygen concentrator

Courtney Airsep, Buffalo, NY.

a. Uses O2 in the surrounding room air by drawing it into the concentrator and filtering out most of the gases except O2
b. Two types of concentrators
(1) Membrane: produces only about 40% O2 from the unit
(2) Molecular sieve: much more commonly used and produces 90% to 95% O2 from the unit. The nitrogen, carbon dioxide, and water vapor is removed as the air passes through sieves containing sodium-aluminum silicate pellets.
c. The concentrator should be placed in the home where air can freely be drawn into it.
d. The concentrator should not be placed near heat vents.
e. The respiratory therapist, on a routine visit, should analyze the delivered O2 from the concentrator and check all alarms, the flow rate, filters, and batteries. Air inlet filters should be cleaned weekly by the patient or caregiver. If the oxygen concentrator analyzes less than the manufacturers specifications, the pellets need to be replaced.
f. A backup O2 system with 1 to 3 days’ supply should be available in case of a power outage because concentrators are powered by electricity. Cylinders should be used for the back-up system, not liquid, which evaporates over time.
g. The higher the flow rate used on a concentrator, the less the delivered O2 percentage. With most concentrators, 1 to 2 L/min will provide 92% to 95% oxygen. Flows of 3 to 5 L/min provide approximately 85% to 92%.
h. Portable concentrators are now available that allow for more patient activity. Most models weigh less than 10 lbs and have a battery life of 2 to 5 h. The flow range is generally 1 to 5 L/min and provides oxygen percentages of up to 93%. The flow can be set on a continuous or pulse setting (inspiration only). Some concentrators have been approved for air transportation.

image The patient and family should be instructed in all aspects of the proper care and safety of equipment used in the home.

F. Cleaning Equipment in the Home
1. All equipment designated “single use only” should be considered disposable and discarded after one use.
2. Nondisposable equipment, such as nebulizers and humidifiers, may be cleaned as follows
a. Clean first with mild soap.
b. Rinse.
c. Disinfect with a solution recommended by the manufacturer.
d. Rinse again.
e. Dry the equipment.
f. Repeat the process every 1 to 3 days.

image Exam Note

Nebulizing 10 mL of 0.25% acetic acid (vinegar) through nebulizers and room humidifiers is an appropriate cleaning technique. Allowing the equipment to soak in a vinegar solution overnight is also an acceptable method of disinfecting equipment.

3. Cannulas should be cleaned with mild soap that does not leave a soap film and then rinsed before a disinfectant is used. They should be replaced every 2 to 4 wk.
4. Humidifiers and nebulizers should be filled with sterile water, and safety relief devices should be incorporated.
5. If heated moisture is delivered, a thermometer should be placed in the line, close to the patient, to monitor inspired gas temperature.
6. Medication nebulizers should be rinsed with water and dried after each treatment. They should be cleaned every day in a mild soap solution, rinsed, disinfected, rinsed again, dried on a paper towel, and placed in a plastic bag until used again.
7. IPPB circuits (nondisposable) may be cleaned in mild soap, rinsed, disinfected, rinsed again, and dried every 1 to 2 days.
8. IPPB machines may be wiped down with a liquid disinfectant every few days.
G. Respiratory Therapist Responsibilities in Home Care of Pulmonary Patients
1. Help set up and maintain equipment.
2. Instruct the patient and family on the use, care, and safety of all equipment used in the home setting.
3. Instruct the patient and family in all therapy to be done in the home, including the indications, contraindications, side effects, and hazards of the specific therapy.
4. Assist in the delivery of therapy to the patient.
5. Perform simple spirometry tests.
6. Assess the patient’s present cardiopulmonary status and general well-being.
7. Report to the physician to discuss the present therapy and possible changes needed in current therapy.

III. HOME APNEA MONITORING

CRT Exam Content Matrix: IB9n, IB10n,

RRT Exam Content Matrix: IB9o, IB10p, IIIK1

A. Apnea monitoring is most commonly used for infants or pediatric patients who have conditions that cause apnea or bradycardia. Also, infants experiencing apnea from unknown causes and siblings of infants who have died of SIDS should be monitored for apnea.
B. Other patients who may require apnea monitoring are those with BPD, neuromuscular diseases, and tracheostomies and those receiving mechanical ventilation.
C. A soft foam belt with electrodes is fastened around the chest of the infant. The wires of the electrodes send signals of the heartbeat and breathing back to the monitor via a patient cable. These are referred to as impedance monitors.
D. Apnea monitors have audible and visual alarms that detect not only apnea and bradycardia but also malfunctions that occur with the patient cable, electrodes, wires, and battery.
E. Caregivers in the home must be trained thoroughly in the use of and troubleshooting for the monitor.
F. Caregivers must be trained in CPR.

POSTCHAPTER STUDY QUESTIONS

1. List four goals of rehabilitation.

2. List five periodic evaluations of the home care patient that should be conducted by the respiratory therapist.

3. How does pursed-lip breathing benefit patients with emphysema?

4. List two types of O2 concentrators and the O2 percentage available with each.

5. What type of evaluations should be made by the respiratory therapist regarding the O2 concentrators during routine visits?

6. Calculate how long 3 lb of liquid oxygen running through a 2 L/min nasal cannula will last.

See answers at the back of the text.

BIBLIOGRAPHY

Hess D, Respiratory care principles and practice, ed 1, Philadelphia, Saunders, 2002.

Wilkins RL, Stoller JK, Kacmarek R. Egan’s fundamentals of respiratory care, ed 9. St Louis: Mosby; 2009.

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