Critical Respiratory Care in the ICU

Intro To Mechanical Ventilation

• Respiratory therapists are trained in cardiopulmonary physiology and pathophysiology, and biomedical engineering principles
• They apply technology to assist in patient care services
• Physicians, nurses, physician assistants, or other healthcare providers may provide respiratory care
• They apply scientific principles to prevent, identify, and treat acute or chronic cardiopulmonary dysfunction

Critical Respiratory Care

• Refers to the management of critically ill patients needing sophisticated support, monitoring, and complex decision-making
• Therapy adjustments must occur with patient needs
• Critical respiratory care may be provided in prehospital, the emergency department, or other acute care settings
• Includes diagnostic/monitoring procedures such as blood gases and respiratory monitoring

Role of Respiratory Therapist

• Patient assessment and monitoring
• Performing basic and advanced respiratory care procedures
• Providing care to patients receiving mechanical ventilatory support

Types of Intensive Care Unit

• Common types include medical, surgical, coronary, pediatric, and neonatal
• Respiratory intensive care units care for COPD, ARDS, and severe pneumonia cases, but are less common in the U.S.
• Post-anesthesia care units are also known as recovery rooms
• There are mobile intensive care units
• They can be described by level of care provided:
  • Level 1 is found in teaching hospitals with academic missions that provide care for patients with a variety of disorders
  • Level II may not have the resources for specific types of patients
  • Level III is able to stabilize critically ill patients and has transfer agreements with more comprehensive units
• Level I Trauma Centers provide total care for every aspect of injury

Neonatal Intensive Care Unit

• Care complexity ranges from Level I, for basic newborn care, to Level IV, the highest level of regional NICU
• Level III NICUs provide conventional and high-frequency ventilation
• They also provide inhaled nitric oxide, ECMO, and advanced imaging procedures
• Level IV NICUs provide the highest level of complex care and serves as regional referral centers

Step-Down Units

• Step-down units provide intermediate care
• Specialized nurses, physicians, and respiratory therapists with critical care training are needed regardless of ICU type
• ICUs must be equipped to provide specialized procedures like thoracentesis, chest tube placement, percutaneous tracheostomy, and bedside bronchoscopy

Patients Requiring ICU Admission and Mechanical Ventilation

• Common diagnoses include acute respiratory failure, COPD exacerbation, neuromuscular disease, and coma
• Cardiac conditions, shock, cardiac arrhythmia, and conduction disorders account for many ICU hospitalizations
• More than 70% of hospitalized patients with acute myocardial infarction(MI) who survived had required ICU admission.
• Other causes of admission to the ICU include intracranial hemorrhage, cerebral infarction, severe sepsis, and toxic effects of drugs

Critical Care Personnel

• Specially trained physicians, nurses, and respiratory therapists are required
• Physicians must hold medical staff privileges and board certifications, and be available at least twice per day
• 24-hour in-house ICU coverage should be provided by intensivists or other experienced physicians
• Physician intensivist-to-patient ratios should be based on the acuity and complexity of the patients

Intensive Care Nurses

• The American Association of Critical Care Nurses has specialty certifications in acute/critical care nursing
• The nurses must work in adult, pediatric, or neonatal critical-care settings
• Nurses awarded with a CCRN or APN, must meet experience requirements, and pass the CCRN examination

Respiratory Therapists

• Must be expert in the use of mechanical ventilators, application of specific ventilatory modes, patient monitoring, and airway care
• They must understand techniques for ventilator weaning and discontinuance, and critical care patient transport
• Respiratory therapists apply basic respiratory techniques and might be expected to administer specialty gases such as nitric oxide, helium, and oxygen

Critical Care Specialty of Respiratory Therapists

• Respiratory therapists should must be skilled in patient assessment, care plan development, and respiratory care patient care management
• Respiratory therapists holding credentials from the National Board for Respiratory Care are well qualified to work in the ICU.

Interprofessional Practice

• Providing care to patients in the ICU requires communication and teamwork with physicians and critical-care nurses
• Care is supplemented with respiratory therapists, pharmacists, lab and imaging services
• Pharmacists evaluate medication use and monitor dosage
• Satellite or STAT labs must be near the ICU

Interprofessional Personnel Practices

• Portable chest radiographs, CT and CT angiography, and fluoroscopy are needed
• The ICU will need support by MRI, ultrasound, and echocardiography
• Physical therapists, occupational therapists, and dietitians are part of the full patient care team

Intensive Care Unit Designs

• The design and layout should provide a healing environment that allows for safe, efficient, and effective care delivery
• Optimize wellbeing of patients - Accommodate staff, physicians, and visitors with pleasant décor and furnishings
• The design should accommodate and attend to patient comfort

Four Zones or Areas

• The layout consists of four zones or areas
  • These areas include patient care, clinical support, unit support, and family support
• Patient care zones include patient rooms
  • Rooms should have doorways that allow the fast and unobstructed movement of patients, beds, staff, and equipment
  • Rooms should include windows to improve patients' wellbeing
  • Rooms should include single-bed rooms with adequate floor space to accommodate equipment and the patients' personal effects

Furnishings for Intensive Care Units

• Critical care hospital beds
• Chairs for family
• Furniture for family to spend overnight
• Adequate room lighting
• Room decor with pleasant pictures and artwork

Additional Services For Intensive Care Units

• Sinks and alcohol gel dispensers
• Sharps disposal
• Toilet facilities
• Adjustable temperature controls
• Privacy for use of commodes

Other Useful Areas of an Intensive Care Unit

• Clinical support provides centralized monitoring stations for staff work areas
• Unit support has administrative and staff support functions, and includes offices, change of shift reports, and soiled utility room
• A family support zone provides family and visitor lounges

Other Units: Step-down Units

• Step down units are used to care for patients who used to be in the ICU but no longer need intensive care
• Also used for patients getting worse on a general medical/surgical ward, or for lateral transfers for postoperative patients
• These units accommodate patients that do not require the level of care as an ICU

Long-Term Acute Care

• They provide care for patients with serious medical conditions requiring a hospital stay, but not intensive care
• They see ventilator dependent cases in long-term weaning
• Services including intensive respiratory care, chronic renal failure requiring ongoing dialysis, and requiring complex wound care

Skilled Nursing Facilities

• SNFs provide service to patients requiring a level of care that exceeds what can be taken care of in the home, often following a hospitalization
• Services at a SNF include nursing care, therapies (PT, OT, ST), dietary counseling, and social services
• Some SNFs will accept patients who are ventilator dependent

Defining the Hospital Type

• Specialty hospitals focus on care for specific patients/conditions
  • Children's hospitals with specialized care & services (including intensive care for pediatric/neonatal patients)
  • Specialty hospitals providing sophisticated respiratory service, with skilled staff in mechanical ventilation to neonates, infants, and children
• Women's hospitals offer active labor and delivery services
• Cardiac or orthopedic hospitals perform surgical procedures, but lack other services

Explore the vital role of respiratory therapists in intensive care units (ICUs). Learn about diagnostic procedures, airway management, and care for conditions like COPD. Understand the priorities and actions of respiratory therapists in critical situations.