Respiratory Therapist in Critical Care: Key Roles

Intro to Mechanical Ventilation: Chapter 1 Part 1

• Respiratory therapists are trained in cardiopulmonary physiology, pathophysiology, biomedical engineering principles, and the application of technology to aid patient care.
• Respiratory care can be provided by physicians, nurses, physician assistants, and other healthcare providers.
• Scientific principles are applied to prevent, identify, and treat acute or chronic cardiopulmonary dysfunction.
• Critical care encompasses managing critically ill patients who need sophisticated support, monitoring, and complex decision-making.
• Common critical care examples include shock, trauma, cardiac disease, renal failure, neurologic disease, liver failure, and acute pulmonary disease
• Critical care can be provided in prehospital settings, emergency departments, or other acute care settings.
• Respiratory care in the ICU includes diagnostic and monitoring procedures, artificial airway management, and basic respiratory care techniques.
• An essential respiratory care function is providing mechanical ventilatory support to patients with respiratory failure.
• Respiratory therapists in the ICU perform patient assessments, basic and advanced respiratory care procedures, and care for patients receiving mechanical ventilation.

Types of Intensive Care Units

• Medical (MICU), Surgical (SICU), Coronary (CCU), Pediatric (PICU), and Neonatal (NICU) intensive care units are common ICU types.
• RICU (Respiratory Intensive Care Units) is less common.
• Medical ICUs attend to general issues, while surgical ones provide post-operative care.
• Coronary care units treat acute myocardial infarctions (MI).
• Neonatal units care for premature infants and infants needing specialized support.
• ICUs are classified by care level: Level I hospitals are teaching hospitals with an academic mission.
• Level III ICUs can stabilize critically ill patients and have transfer agreements with more comprehensive units.
• Neonatal ICU levels range from Level I (basic newborn care) to Level IV (highest level of regional NICU).
• Level I Trauma Centers provide total care for injuries with 24-hour in-house coverage by general surgeons and rapid specialist availability.
• Level V Trauma Centers offer basic emergency services and may only perform initial patient evaluations and stabilization, before transfer.
• Eighteen conditions are associated with the highest proportion of intensive care unit utilization by patients requiring hospitalization.
• Over 93% of hospitalized patients who need ventilatory support need ICU services.
• Common diagnoses that require mechanical ventilation include acute respiratory failure, COPD exacerbation, neuromuscular disease, and coma.
• Cardiac conditions account for a large number of hospitalizations requiring ICU services.
• Over 70% of hospitalized acute myocardial infarction (MI) survivors require ICU admission

Critical Care Personnel

• Specially trained physicians, nurses, and respiratory therapists are needed to staff the ICU.
• Physicians who manage critically ill patients should hold medical staff privileges.
• Physicians should have board certification in critical care medicine available as often as necessary, but at least two times per day.
• Physician intensivist to patient ratios should be based on patient acuity and complexity. Patient ratios exceeding 1:14 correlate with increased mortality.
• Mid-level providers must have training and experience in ICU patient management.
• Nurses should be specifically trained in critical care and supervise all care carried out in the ICU
• A 1:1 or 1:2 nurse-to-patient ratio has been associated with better patient outcomes. Evidence-based thresholds suggest no more than five patients for every two nurses.
• The American Association of Critical Care Nurses (AACN) offers critical care certifications.
• Respiratory therapists must be skilled in mechanical ventilators, specific ventilatory modes, patient monitoring, and airway care.
• Respiratory therapists apply basic techniques such as oxygen therapy, and secretion management
• Respiratory therapists may intubate and extubate patients, insert arterial lines, perform hemodynamic monitoring; and assist with ECMO and other circulatory supports.
• The NBRC (National Board for Respiratory Care) offers an ACCS (Adult Critical Care Specialty exam) credential.
• ICU respiratory therapists should be skilled in patient assessment, administration of protocols, care plan development and respiratory care patient care management.

Interprofessional Practice and ICU Design

• Patient care in the ICU requires interprofessional communication and teamwork.
• Pharmacists evaluate medication orders and monitor drug dosing, dedicated solely to the ICU.
• Clinical labs must be available at all times, offering satellite or STAT labs near the ICU.
• Essential imaging services include portable chest radiographs, ultrasounds, MRIs, 25/7.
• Physical, occupational, and speech therapists, dietitians, social workers, mental health providers, and clergy provide needed services.
• The ICU design should provide a safe, efficient, healing, and comfortable environment.
• Effective ICU design may reduce medical errors and improve patient outcomes.
• The ICU layout consists of four zones or areas.
• The patient care zone focuses on direct patient care, featuring single-bed rooms. Rooms must have doorways for easy movement, lift equipment, natural light, and in-room storage.
• Critical care beds, chairs for visitors, and surfaces for personal items belong in care rooms.
• Sinks, sharps disposal, and adjustable temperature regulation are required in patient rooms.
• Clinical support zones include staff work areas, monitoring stations, and order entry workspaces.
• The configuration will all staff to visualize each patient.
• Unit support zones facilitate administrative and staff functions with offices, lounges, and supply areas.
• Family supports include family lounges, consultation rooms, and meditation spaces.

Other Units

• Step-down units care for patients transitioning out of the ICU or worsening patients on general medical or surgical floors.
• LTACs (Long-Term Acute Care) serve patients dependent on long-term weaning.
• LTAC patients require intensive respiratory care for conditions such as chronic renal failure.
• Specialty children's hospitals offer specialized care for pediatric and neonatal patients.
• Skilled nursing facilities provide care for many patients, offering ventilator support for those who are ventilator dependent
• Women's Health centers focus on labor and delivery services.
• Cardiac or orthopedics units focus on surgical procedures.

Patient Assessment

• Respiratory care in the ICU focuses on maintaining adequate tissue oxygenation, alveolar ventilation, acid-base balance, circulation, blood pressure and cardiac output.
• Respiratory care plans focus on oxygenation, ensuring ventilation, providing cardiopulmonary support, and monitoring the patient's condition.
• Oxygenation, adequate ventilation and monitoring is important.
• Airway care, treating bronchospasms, and lung expansion therapies is needed.
• Patient history from the medical record are vital.
• Important elements: The date of admission, Chief complaint and Past medical history
• Social history should Include employment, home environment, exposure to infectious disease, and hobbies.
• General, skin Cardiovascular review of systems
• The physician's plan states how to handle problems and perform diagnostics.
• Important physician's orders medication orders, orders for IV fluids, and orders for respiratory care, labs, imaging, or special procedures.
• The review of physician orders may include orders for medications, IV fluids, respiratory care, laboratory tests, and imaging procedures.
• Common medications include antibiotics, vasopressors, and cardiac medications.
• Potential test include ABGs, diagnostic test, ECG
• A patient's history in the intensive care unit can be difficult. Obtaining information from family, caregiver, or other individuals often substitutes for traditional patient reports.
• Pulmonary history includes current medication, lung function, and respiratory health.
• Particular attention should be focused on problem with oxygenation and ventilation
• Symptoms are subjective findings reported from the patient, while signs are objective findings that can b observed directly or through diagnostic testing.
• Physical assessment will assess respiratory distress, hypoxia, and hypercapnia
• Key symptoms of hypoxia are mild to severe shortness of breath (SOB)
• Irregular or rapid shallow breathing suggests a problem with ventilation
• Lab test look at Anemia and impaired blood coagulation
• WBC (White blood cell) presence of infection
• Review chemistry panel and look for Serum electrolytes and blood sugars
• Review troponin
• A1c, check Bili
• Analyze a arterial blood gas results
• Measure the O2 and CO2 in the blood
• Measure the oxygen saturation of the body
• Newer blood gas analyzes: -HCT -electrolytes -glucose -lactate -creatinine
• Imaging in the ICU -Chest xrays -bedside sonography
• The ventilator will be more helpful in applying and managing care.
• Can be used to identify lesions
• Hemoptysis
• Can be used to evaluate for infections
• Bronchoalveolar lavage can be used to identify lesions
• Endrobronchial lavage uses ultrasound with the camera Thoracentesis: a removal of fluid from the plural space will determine what needs removing
• Exudative due to the inflammatory process and the patient gets sick Transudtes: due to a pressure problem causing leaks
• Monitor Blood pressure, Heart rate etc
• Continuously monitor V and CO2
• Arterial catheter will measure BP in real time Types of respiratory provided the ICUs:
• Upper resp inf = pnuemonia bronchitis asthma
• Congestive heart failure plum emboli - cardio or noncardio

Key points to remember for Critical Care: Chapter 1

• Respiratory care discipline that the healthcare that specialices in the promotion of optimal cardiopulmonary function
• Critically ill patients are at high risk of life threatening health problems
• Adjust patient need change for the support
• Look for medical Medical. surgical, coronary, cardiac, and neonatal ICUs are classified by level
• 1 traume centers provide the hospital level of support for
• Step down provides a lower level of care
• Traint physician nurses therapists there
• There are specialty credentials in a ICUs
• IPE: multiple professions must be use to coordinate with the patient with multiple health background with the patient to liver the best support
• Assessment: Evaluate the the patient's Oxygenation ventilation and circulation Review lab test for Check ABG Monitor rate , volume oxygenation Invasive and noninvasive Apena is a indication. acute ventilatory failure and oxygenation Ate a is primary reason Aped is the highest level of care

Explore the role of respiratory therapists in critical care, including diagnostic procedures, airway management, and interventions for conditions such as acute respiratory failure and COPD. Understand hemodynamic instability and the decision-making involved in complex respiratory scenarios within the ICU.