Introduction

Therapist-driven protocols (TDPs) are an integral part of respiratory care health services. According to the American Association for Respiratory Care (AARC), the purposes of respiratory TDPs are to:

To further support the AARC’s purpose statement on TDPs, the American College of Chest Physicians (ACCP) defines respiratory therapy protocols as follows:

Respiratory TDPs provide the respiratory care practitioner with a wide-ranging flexibility to both assess and treat the patient—but only within preapproved and clearly defined boundaries outlined by the physician and/or the medical staff. In addition, respiratory TDPs give the practitioner specific authority to (1) gather clinical information related to the patient’s respiratory status, (2) make an assessment of the clinical data collected, and (3) start, increase, decrease, or discontinue certain respiratory therapies on a moment-to-moment, hour-to-hour, shift-by-shift, or day-to-day basis. The innate beauty of respiratory TDPs is that (1) the physician is always in the “information loop” regarding patient care and (2) therapy can be quickly modified in response to the specific and immediate needs of the patient. Numerous clinical research studies have verified these facts: Respiratory TDPs (1) significantly improve respiratory therapy outcomes and (2) appreciably lower therapy costs.

Unfortunately, the implementation of TDPs throughout the United States has been slow. In 2008 the AARC Protocol Implementation Committee conducted a survey to evaluate the barriers to protocol implementation. Over 450 respiratory managers responded to the survey. Despite the overwhelming evidence that protocols clearly improve outcomes and reduce cost, the survey showed that less than 50% of respiratory care was provided by protocols. About 75% of the respondents had at least one protocol in operation. The majority of the hospitals did not have a comprehensive program in place. According to the managers, the medical directors, managers of the department, nurses, and administrators were not perceived as barriers. The biggest barrier to the implementation of protocols was perceived to be the medical staff. The primary reason for the medical staff’s resistance was perceived to be that “staff therapists did not have the skills (e.g., assessment skills) to function under protocols.” The AARC Protocol Implementation Committee states that “[this] perception must change… .”*

The essential components of a good TDP program do not come easy. This is because a strong TDP program promises that the respiratory care practitioner, who is identified as “TDP safe and ready,” be qualified to (1) systematically collect the appropriate clinical data, (2) formulate a uniform and accurate assessment, and (3) select a uniform and optimal treatment within the limits set by the protocol (Figure 9-1). The converse, however, is also true: When the respiratory care practitioner is not “TDP safe and ready,” the collection of clinical data is not done at all or is incomplete. As a result, nonuniform or inaccurate assessments are made, resulting in nonuniform or inaccurate treatment selections (Figure 9-2). This inappropriate and ineffective type of respiratory therapy leads to the misallocation of care, the administration of unneeded care, and—most important—the nonprovision of needed patient care. The bottom line is poor-quality patient care and unnecessary costs. To be sure, the development and implementation of a strong TDP program require some fundamental knowledge, training, and practice, but the benefits are worth the price. The essential components of a good TDP program are discussed in the following paragraphs.

The “Knowledge Base” Required for a Successful Therapist-Driven Protocol Program

As shown in Figure 9-3, the essential knowledge base for a successful TDP program includes (1) the anatomic alterations of the lungs caused by common respiratory disorders, (2) the major pathophysiologic mechanisms activated throughout the respiratory and cardiac systems as a result of the anatomic alterations, (3) the common clinical manifestations that develop as a result of the activated pathophysiologic mechanisms, and (4) the treatment modalities used to correct them. In other words, the clinical manifestations demonstrated by the patient do not arbitrarily appear but are the result of anatomic lung alterations and pathophysiologic events.

Hence, it is essential that the respiratory practitioner know and understand that certain anatomic alterations of the lung will lead to specific—and often predictable—clinical manifestations. Each respiratory disease chapter presented in this textbook describes these four essential knowledge components necessary for TDP work. In the clinical setting this knowledge base enhances the assessment process essential to a good TDP program.

The “Assessment Process Skills” Required for a Successful Therapist-Driven Protocol Program

Using the knowledge base described above, the respiratory care practitioner must also be competent in performing the actual assessment process. This means that the practitioner can (1) quickly and systematically gather the clinical information demonstrated by the patient, (2) formulate an accurate assessment of the clinical data (i.e., identify the cause and severity of the problem), (3) select an optimal treatment modality, and (4) document this process quickly, clearly, and precisely. In the clinical setting, the practice—and mastery—of the assessment process is absolutely central and essential to the success of a good TDP program (Figure 9-4). In other words, immediately after the respiratory care practitioner identifies the appropriate clinical manifestations (clinical indicators), an assessment of the data must be performed, and a treatment plan must be formulated. For the most part the assessment is primarily directed at the anatomic alterations of the lungs that are causing the clinical indicators (e.g., bronchospasm) and the severity of the clinical indicators.

For example, an appropriate assessment for the clinical indicator of wheezing might be bronchospasm—the anatomic alteration of the lungs. If the practitioner assesses the cause of the wheezing correctly as bronchospasm, then the correct treatment selection would be a bronchodilator treatment from the Aerosolized Medication Therapy Protocol (see Protocol 9-4, page 122). If, however, the cause of the wheezing is correctly assessed to be excessive airway secretions, then the appropriate treatment plan would entail a specific treatment modality under the Bronchopulmonary Hygiene Therapy Protocol, such as cough and deep breathing or chest physical therapy (see Protocol 9-2, page 120).

Table 9-1 illustrates common clinical manifestations (i.e., clinical indicators), assessments, and treatment selections routinely made by the respiratory care practitioner.

Abnormal Lung Parenchyma Indicators Bronchial breath sounds Atelectasis Hyperinflation treatment, oxygen treatment Dull percussion note Infiltrates or effusion Treat underlying cause Opacity on chest X-ray Fibrosis No specific treatment Restrictive pulmonary function test values Consolidation No specific, effective respiratory care treatment Depressed diaphragm on X-ray Air trapping and hyperinflation Treat underlying cause Abnormal Pleural Space Indicators Hyperresonant percussion note Pneumothorax Evacuate air* and hyperinflation treatment Dull percussion note Pleural effusion Evacuate fluid* and hyperinflation treatment Abnormalities of the Chest Shape and Motion Paradoxical movement of the chest wall Flail chest Mechanical ventilation* Barrel chest Air trapping (hyperinflation) Treat underlying cause—e.g., asthma Posterior and lateral curvature of spine Kyphoscoliosis Bronchial hygiene treatment Arterial Blood Gases—Ventilatory pH↑, Paco₂↓, ↓ Acute alveolar hyperventilation Treat underlying cause pH N, Paco₂↓, ↓↓ Chronic alveolar hyperventilation Generally none pH↓, Paco₂↑, ↑ Acute ventilatory failure Mechanical ventilation* pH N, Paco₂↑, ↑↑ Chronic ventilatory failure Low-flow oxygen, bronchial hygiene Sudden Ventilatory Changes on Chronic Ventilatory Failure (CVF) pH↑, Paco₂↑, ↑↑, Pao₂↓ Acute alveolar hyperventilation on CVF Treat underlying cause pH↓, Paco₂↑↑, ↑ Pao₂↓ Acute ventilatory failure on CVF Mechanical ventilation* Metabolic pH↑, Paco₂ N, or ↑, ↑, Pao₂ N Metabolic alkalosis Give potassium*—Hypokalemia     Give chloride*—Hypochloremia pH↓, Paco₂ N or ↓, ↓, Pao₂↓ Metabolic acidosis Give oxygen—Lactic acidosis pH↓, Paco₂ N or ↓, ↓, Pao₂ N Metabolic acidosis Give insulin*—Ketoacidosis pH↓, Paco₂ N or ↓, ↓, Pao₂ N Metabolic acidosis Renal therapy* Indication for Mechanical Ventilation pH↑, Paco₂↓, ↓, Pao₂↓ Impending ventilatory failure Mechanical ventilation pH↓, Paco₂↑, ↑, Pao₂↓ Ventilatory failure   pH↓, Paco₂↑, ↑, Pao₂↓ Apnea   Oxygenation Status Pao₂ < 80 mm Hg Mild hypoxemia Oxygen treatment and treat underlying cause Pao₂ < 60 mm Hg Moderate hypoxemia   Pao₂ < 40 mm Hg Severe hypoxemia   Oxygen Transport Status ↓Pao₂, anemia, ↓cardiac output Inadequate oxygen transport Oxygen treatment and treat underlying cause

Severity Assessment

The frequency at which a respiratory therapy modality is to be administered is just as important as the correct selection of a respiratory therapy treatment. Often the frequency of treatment must be up-regulated or down-regulated on a shift-by-shift, hour-to-hour, minute-to-minute, or even (in life-threatening situations) second-to-second basis. Such frequency changes must be made in response to a severity assessment. In a good TDP program, the well-seasoned respiratory care practitioner routinely and systematically documents many severity assessments throughout each working day. For the new practitioner, however, a predesigned Severity Assessment Rating Form may be used to enhance this important part of the assessment process. One excellent, semiquantitative method of accomplishing this is illustrated in Table 9-2. The clinical application of this severity assessment is provided in the following case example.