ICU Patient Management & Respiratory Care

Intro to Mechanical Ventilation: Chapter 1 Part 1

Objectives

• This chapter aims to define respiratory and critical care.
• It summarizes disease states requiring ICU admission and mechanical ventilation.
• Aims to highlight the different types of patients seen in specialized intensive care units.
  • MICU (Medical Intensive Care Unit)
  • SICU (Surgical Intensive Care Unit)
  • CCU (Coronary Care Unit)
  • PICU (Pediatric Intensive Care Unit)
  • NICU (Neonatal Intensive Care Unit)
• NICU levels are compared with other levels
• Services in a Level I Trauma Center
• Outlines the personnel needed to staff an ICU and their qualifications.
• It explains the importance of interprofessional practice (IPP) in the ICU
• Contrasts design and activities of the four ICU zones.
• Differentiates between acute care wards, step-down units, and ICUs.
• Explains long-term acute care (LTAC) facilities.
• Details specialty hospitals vs skilled nursing facilities (SNF).
• Emphasizes respiratory assessment in the ICU.
• Identifies common ICU admitting diagnoses.
• Explains physician's orders significance in the ICU
• This includes medication, respiratory care, lab tests, imaging, and special procedures.
• Describes elements of history and physical ICU exams.
• One objective is to recognize hypoxia, hypercapnea, respiratory failure, and ventilatory failure signs.
• Outlines the importance of lab tests and imaging in the ICU.
• Explain the purpose of bronchoscopy and thoracentesis
• Cardiac and hemodynamic monitoring types in the ICU
• Acute and acute ventilatory failure defined and compared
• Indications for mechanical ventilatory support
• Discusses using airway clearance therapies (ACT) in the ICU.
• Summarizes respiratory therapists' care in the ICU

Key Terms

• Acute Respiratory Distress Syndrome (ARDS)
• Acute Respiratory Failure (ARF)
• Acute Ventilatory Failure (AVF)
• Arrhythmia
• Atelectasis
• Bronchoscopy
• Cerebral Infarction
• Coma
• Congestive Heart Failure (CHF)
• Chronic Obstructive Pulmonary Disease (COPD)
• Coronary Artery Disease (CAD)
• Critical Care
• Endobronchial
• Exudate
• Intensive Care Unit (ICU)
• Interprofessional Education (IPE)
• Interprofessional Practice
• Long-Term Acute Care (LTAC)
• Mechanical Ventilation
• Mechanical Ventilatory Support
• Musculoskeletal DIsease
• Myocardial Infarction (MI)
• Neonatal Intensive Care Unit (NICU)
• Neuromuscular Disease
• Pneumonia
• Pulmonary Edema
• Renal Failure
• Respiratory Care
• Respiratory Therapist
• Sepsis
• Shock
• Step-Down Unit
• Thoracentesis
• Tracheostomy
• Transudate
• Trauma Center

Critical Respiratory Care

• Respiratory therapists train in cardiopulmonary physiology, biomedical engineering, and technology application for patient care.
• Physicians, nurses, physician assistants, and healthcare providers can provide respiratory care.
• Scientific principles are used to prevent, identify, and treat cardiopulmonary dysfunction.
• Critical care manages critically ill patients with sophisticated support, monitoring, and complex decision-making.
• Shock, trauma, cardiac and neurologic disease, renal and liver failure, and acute pulmonary disease are examples
• This care can be provided in prehospital settings, emergency rooms, or other acute care locations.
• Respiratory care in the ICU includes diagnostic procedures, respiratory monitoring and artificial airway management.
• Basic respiratory care techniques like oxygen therapy and aerosolized medication delivery are included.
• Essential respiratory care includes mechanical ventilatory support for patients experiencing respiratory failure.
• The respiratory therapist's ICU role includes patient assessment, basic and advanced procedures, and mechanical ventilation care.

Types of Intensive Care Units

• MICU (Medical Intensive Care Units): General care
• SICU (Surgical Intensive Care Units): Post-operative care
• CCU (Coronary Care Units): Acute myocardial infarction (MI)
• CVICU (Cardiovascular Intensive Care Unit): ECMO, VADs, heart failure, dysrhythmias
• PICU (Pediatric Intensive Care Units): Infants to teens
• RICU (Respiratory Intensive Care Unit): COPD, ARDS, severe pneumonia; less common in the US
• NICU (Neonatal Intensive Care Units): RDS, TTN, PPHN, ECMO, Premature infants
• PACU (Post-Anesthesia Care Unit): AKA Recovery room
• Mobile ICU (Mobile Intensive Care Unit)
• ICUs are described by care level:
  • Level I: Teaching hospitals with academic missions, comprehensive care.
  • Level II: Some facilities may lack resources for specific patient types (e.g., multiple trauma).
  • Level III: stabilizes critical patients before transferring to more comprehensive units.
• Level I Trauma Centers:
  • Provides total care for every aspect of injury and is characterized by:
    • 24-hour in-house coverage by general surgeons
    • Rapid availability of specialists: anesthesiology, radiology, orthopedics, neurosurgery
    • Serves as a comprehensive regional resource
• Level V Trauma Centers:
  • Provides basic emergency care services.
  • May only perform:
    • Initial patient evaluation
    • Stabilization
    • Transfer patients to facilities providing more comprehensive care, as needed.
• Neonatal intensive care units (NICU) are different from adult units.
• Level I indicates basic newborn, while Level IV is the highest level regional NICU.
  • Level I: well newborn nursery for healthy babies
  • Level II: advanced newborn care, possible mechanical ventilation
  • Level III: comprehensive care for premature infants (<32 weeks, <1500 grams) and critically ill babies.
    • Conventional and high-frequency ventilation.
    • Inhaled nitric oxide, ECMO, and advanced imaging.
  • Level IV: highest level of complex care, regional referral center

Intensive Care and Other Units

• Step-down units provide intermediate care
• Regardless of the ICU type, specialized nurses, physicians, and respiratory therapists with critical care training are required.
• Additional services in the ICU include diagnostic, pharmacy, nutritional, social, and pastoral care.
• ICUs must have equipment for thoracentesis, chest tube placement, percutaneous tracheostomy, and bedside bronchoscopy.
• Eighteen conditions are associated with the highest proportion of intensive care unit utilization by patients requiring hospitalization.
• Over 93% of hospitalized patients requiring ventilatory support needed ICU services.
• Acute respiratory failure, COPD exacerbation, neuromuscular diseases, and coma are common diagnoses requiring mechanical ventilation.
• Cardiac conditions accounted for a large number of hospitalizations requiring ICU services.
  • Over 70% of hospitalized patients with acute myocardial infarction who survived required ICU admission.
• Shock, cardiac arrhythmia and conduction disorders also frequent causes.

Critical Care Personnel

• Specially trained physicians, nurses, and respiratory therapists are essential for staffing the ICU.
• Physicians:
  • Should have medical staff privileges.
  • Are board-certified in critical care medicine.
  • Should be available to see the patient at least two times a day.
  • Around-the-clock in-house coverage.
• The ratio of intensivist physicians to patients is based on patient acuity and complexity
  • Physician specialists (surgeons, anesthesiologists, cardiologists, neurologists, etc.) should be available.
  • Increased patient mortality if the Patient ratios exceed 1:14.
• Mid-level providers
  • Physician assistants, advanced practice nurses (APNs) can support the care of ICU patients

Nurses

• Specifically trained in criitical care
• Should supervise all care carried out in the ICU
• Nurse-to-patient ratios should be sufficient to safely deliver the care required, based on patient acuity and complexity.
• Higher ratios, (i.e., 1:1 or 1:2), associated with improved safety and better patient outcomes.
• Thresholds of no more than five patients for every two nurses.
• American Association of Critical-Care Nurses (AACN) is a specialty certification in acute/critical care nursing
• RNs or APNs granted CCRNs must meet experience requirements to ensure they are providing direct, bedside care to acutely/critically ill patients and succesfully pass the CCRN examination.

Respiratory Therapists

• With training and experience in critical care should be available at all times
• Must be expert in the use of:
  • Mechanical ventilators
  • Application of specific ventilatory modes
  • Patient monitoring, airway care
  • Techniques for ventilator weaning and discontinuance
  • Critical care patient transport
• Apply basic respiratory care techniques
  • Oxygen therapy, management of bronchospasm and mucosal edema, secretion management, lung expansion therapy
• May be expected to:
  • Intubate and extubate patients
  • Insert and maintain arterial lines
  • Assist with and/or perform hemodynamic monitoring
  • Assist with and/or provide extracorporeal membrane oxygenation (ECMO) and mechanical circulatory support (e.g., intra-aortic balloon pump [IABP])
• ICU respiratory therapists should be especially skilled in:
  • Patient assessment, protocols administration and care plan development
• Respiratory Therapists with a Critical Care Specialty (ACCS) from the National Board for Respiratory Care are espeically well qualified

Interprofessional Practice

• Requires interprofessional communication, cooperation and teamwork.
• The care of patients in the ICU requires:
  • Physicians
  • Critical care nurses
  • Respiratory therapists
  • Pharmacy
  • Laboratory
  • Imaging services
• Pharmacists:
  • Evaluate medication orders, monitor drug dosing and administration, and provide recommendations.
  • Dedicated to the intensive care unit
• Clinical laboratory services:
  • Must be available at all times.
  • Satellite or STAT labs may be located in or near the ICU.
• Point-of-care (POC) testing:
  • May be provided for certain laboratory such as:
    • Blood gases/electrolytes
    • Glucose
    • Activated clotting time
    • Cardiac biomarkers
• Portable chest radiographs, CT and CT angiography, ultrasound, MRI, echocardiography, and fluoroscopy
  • Should be available 24 hours a day
• Other professions such as Physical and occupational therapist, dieticians, mental health providers are available as needed

Intensive Care Unit Design

• The design and layout should: -provide a healing environment for safe, efficient care.
  • optimize well-being for patients, staff, and visitors.
  • attend to comfort and natural light and reduce noise.
• The ICU layout consists of four zones:
  • Patient care: rooms with direct patient care.
    • Should have doorways for fast movement, lift equipment, windows, single-bed rooms with supplies and clothing storage.
    • Furnishings should include hospital bed, chairs, furniture for the night, clock, calendar, whiteboard, television, adequate surfaces, and artwork.
    • Also should have medical utility outlets (oxygen, power, vacuum) on headwalls/columns, monitoring equipment.
    • Include sinks, gel dispensers, sharps disposal, fluids disposal, privacy, adjustable temperature/lighting, and high-intensity light
  • Clinical support: staff areas, monitoring stations and workspace/chart review and order entries - It enables good sightlines. optimized workflows, medication areas, emergency equipment, non-emergency storage. - Emergency eyewash station and food/beverage should be availabl
  • Unit support: administrative functions.
  • May have offices, conference spaces, shift report, staff lounge, on-call room, workroom, and soiled utility room.
  • Family support: areas for families/visitors.
  • A family lounge, consultation rooms, meditation spaces.

Additional Units

• Step-down units: Are used to care for patients who were in the ICU yet do not need assidous support
• Long-term acute care (LTAC): For serious conditions requiring extended stay, roughly around 30 days and no longer needing intesive care.
  • This includes ventilator dependent patient, requiring itensive care, renal failure and complexed wound car
• A specialty hospital, can include Children, Women and Cardiac or orthopedis hospitals
• Skilled nursing facilities (SNF): higher level of patient care like occupational, respiratory and speech therapy. Certain SNFs will accept patients who are ventilator dependent.

Patient Assessment

• Assessment is a core respiratory care competency.
• It includes evaluation/monitoring of:
  • Oxygenation
  • Ventilation
  • Circulation
• Respiratory care in the ICU is aimed at adequate tissue oxygenation, alveolar ventilation, acid-base balance, circulation as well as blood pressure and cardiac output
• Assessment based respitory care plan can be developed to cover oxygenaion and adequete ventilation, cardio-respiritory suport and patient monitoring

Review of Medical Records

• They provide important insight needed to provide adqueate patient care
• Admision data can include : weight, admission time and attending doctors and demographic information
• Heigh is used to caluate body weight
• Age is used to determine potential of ventialatry failure
• Asses the patients problem with medical record list
• Common problems can be the respitory failure, cardiac fialuer and schok

Information In Past and Present

• Reports can be helpful for ICU patients, as they give insightes into that patient
• The report is the physicians, doctor or clinican describes their thought progress with the patient to help other doctors to do the same
• Also, it must have past medical history, allergies, and what they would do with diagnosis
• The doctor is to keep tracking vital information while patients stay at the ICU
• Physicians are to keep logging the procedures or tests the patient takes as well as respiratory or notes

Respiratory Care in the ICU

• In ICU, they follow the patients oxygen
• In an average basis, patient can get a lung therapy with many breathing techneiques to the patient to ensure the safe level of oxygen usage
• The doctor is too is to keep monitoring the patients care, if it includes the ventilator then they are to set it to follow the safety protocal
• Doctor can perfomr bronchal hgiene, and other stuff

Laboratory Study

• Need to include the alerting
• Can test blood: Hematoogy(platelet), Chemistry, Coagulation
• Also test is the cardiac biomarker
• There are also scans and other tests

Explore critical aspects of patient care in Intensive Care Units (ICUs). Focus on respiratory therapist roles, ARDS management, and trauma center levels. Scenarios and interventions in RICU and CVICU environments are addressed.