Respiratory Therapy

Definition

Respiratory therapy is a therapeutic treatment for respiratory diseases and conditions. A respiratory therapist (RT) is a healthcare professional who usually provides these treatments and evaluates the patient's response to the treatments.

Purpose

The purpose of respiratory therapy is to maintain an open airway for trauma, intensive care, and surgical patients, assist in cardiopulmonary resuscitation and support, provide life support for patients who cannot breathe on their own, provide assistance to the anesthesiologist in the operating room, provide inhaled drugs and medical gases, provide results from the testing of measuring lung function, and assist with patient education.

Description

Respiratory therapy is performed in hospitals, in neonatal, emergency, intensive care, surgical and cardiac units, and various other health care facilities. Respiratory therapy treats many kinds of patients, and provides temporary relief to patients suffering from respiratory ailments. The therapies most commonly administered are oxygen and aerosol medications, and ventilator support after intubation. RTs are assigned to patients during their shift and continuously monitor those patients and respiratory equipment.

It is essential to assess a patient's respiratory function if he/she has a known or suspected pulmonary condition. Therapists perform procedures that are both diagnostic and therapeutic.

Diagnostic therapy includes:

• Obtaining and analyzing sputum and breath specimens. Blood specimens are also obtained and analyzed for levels of oxygen, carbon dioxide, and other gases.
• Interpreting data obtained from these specimens.
• Measuring the capacity of a patient's lungs to determine if there is impaired function.
• Performing other studies of the cardiopulmonary system.
• Studying disorders of people with disruptive sleep patterns.

Treatment therapy includes:

• Operating and maintaining various types of highly sophisticated equipment to administer oxygen or assist with breathing.
• Employing mechanical ventilation for treating patients who cannot breathe adequately on their own.
• Monitoring and managing therapy that will help a patient recover lung function.
• Administering medications in aerosol form to help alleviate breathing problems and to help prevent respiratory infections.
• Monitoring equipment and patient response to therapy.
• Maintaining the patient's artificial airway.

The following are the most commonly performed procedures in respiratory therapy:

• Oxygen therapy—Oxygen therapy involves the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. Indications include documented hypoxemia, severe trauma, acute myocardial infarction, and short-term therapy as in post-anesthesia recovery. The need for oxygen therapy is determined by measurement of inadequate oxygen saturations, by invasive or noninvasive means or the presence of clinical indicators. Low-flow oxygen therapy systems deliver 100% oxygen at flows lower than the patient's inspiratory flow rate. The concentration inhaled may be low or high, depending on the specific device and the patient's inspiratory flow rate. Nasal cannulas can provide 24-40% oxygen with flow rates up to 6 L/min in adults. In infants and newborns, flow should be limited to a maximum of 2 L/min. If the oxygen supplied to adults via nasal cannula is at a flow rate lower than or equal to 4 L/min, it does not have to be humidified. Simple oxygen masks can provide 35-50% oxygen at flow rates of 5-10 L/min. Rates should be maintained at 5 L/min or more to avoid rebreathing exhaled CO₂ that may be retained in the mask. Masks with reservoir bags(partial and non-rebreathers) provide FIO₂ (fraction-inspired oxygen, or the concentration of oxygen as delivered to the patient) of 0.5 or greater. Highflow systems deliver a prescribed gas mixture—either high or low FDO₂—at flow rates that exceed patient demand. Aerosol masks, tracheostomy collars, T-tube adaptors and face tents can be used with high-flow supplemental oxygen systems. O₂ therapy should be administered continuously unless needed only in specific situations, as with exercise or sleep.
• Pulse oximetry—Indications for pulse oximetry include the need to monitor the adequacy of arterial oxyhemoglobin saturation, gauge the response of O₂ saturation to therapeutic interventions, and complying with regulations. SpO₂ (a measure of oxygen saturation) is used for continuous and prolonged monitoring as in during sleep, exercise or surgical procedures. Results of SpO₂ tests validate the basis for ordering the test by reflecting the patient's clinical condition. Documentation of results should be noted in the patient's chart.
• Incentive spirometry—I.S. encourages patients to take long, slow, deep breaths. It is a device that provides patients with positive feedback during inhalation at a predetermined flow rate or volume and sustains the inflations for a minimum of three seconds. I.S. is used to increase transpulmonary pressure and inspiratory volumes, improve inspiratory muscle performance, and reestablish or simulate the normal pattern of pulmonary hyperinflation. Airway patency is maintained and atelectasis prevented and/or reversed if the procedure is performed on a repeat basis. It is not effective unless performed as ordered, so proper teaching is mandatory. I.S. is used in postsurgical procedures, especially those involving the thorax or upper abdomen; or conditions that portend atelectasis, as in immobility, abdominal binders, and less than optimal pain control.
• Selection of aerosol delivery devices—for delivery of aerosol to the lower airways. Devices include metered dose inhalers (MDIs), dry powder inhalers, and nebulizers. Drugs used in delivery include beta-adrenergic agents, anticholinergics, anti-inflammatory agents, and mucokinetics. For maximum success, the technique is important—for instance, coordination, breathing pattern, and inspiratory hold. Patient compliance may be a limiting factor in the procedure.
• Arterial blood gases (ABGs)—for arterial blood gas analysis. Blood is drawn from a peripheral artery (radial, brachial, femoral) via a single percutaneous needle puncture or from an indwelling arterial cannula, for a direct measurement of partial pressures of carbon dioxide (PaCO₂) and oxygen (PaO₂), hydrogen ion activity (pH), total hemoglobin (Hbtotal), and oxyhemoglobin saturation (HbO₂). The procedure is performed by trained health care personnel (usually the RT). ABGs are utilized to quantify the patient's response to therapeutic interventions and/or diagnostic evaluation and to monitor disease severity or progression. The sampling of arterial blood must be done according to protocol or test results may be rendered invalid.
• Nasotracheal suctioning (NTS)—to remove secretions, blood or vomitus from the trachea, especially if the patient is unable to cough spontaneously, to maintain a patent airway. To accomplish NTS, a suction catheter is inserted through the nasal passage and pharynx into the trachea to aspiration secretions or foreign material.
• Patient-ventilator system checks—documented evaluation of a mechanical ventilator and of the patient's response to ventilatory support. Objectives of ventilator checks include: evaluating the patient's response to mechanical ventilation; assuring proper operation of the ventilator, that it is functioning properly and alarms are activated; and verifying that inspired oxygen concentration is measured with every change in FIO₂ and that ventilator settings comply with physician orders. All of the above are documented in the patient's chart. Clinical observations of the patient's response to ventilation are also charted in narrative form.

In order for respiratory therapy to be effective, RTs have to evaluate, document, and report all of the above procedures so that appropriate action can be taken by other members of the health care team.

Aftercare

Another important part of respiratory therapy is planning and implementing safe and effective care after discharge from the medical institution. The patient must be successfully transferred from the health care facility to another care site. Patient evaluation involves assessing the patient's current medical condition and ascertaining the type of respiratory care and support needed. The patient's physical, functional, and psychological ability is assessed, as well as the family's psychosocial condition. The goals of care for the patient and family are also evaluated.

KEY TERMS

Artificial airway— A passage for respiration that is created and maintained by a device, such as tubing. Artificial airways are usually established for patients who are at risk of having their own natural airways collapse because of trauma or another medical condition.

Mechanical ventilation— The process of maintaining respiration in a patient who cannot breathe naturally by means of a respiratory device.

Complications

• Pulse oximetry is usually considered a safe procedure. Device limitations and false-negative results for hypoxemia, though, may lead to inappropriate treatment of the patient. At times, tissue injury at the monitoring site may occur due to misuse of the probe.
• Incentive spirometry. Unless closely supervised, pulse oximetry may be ineffective. It is also inappropriate as a sole treatment for major lung collapse. There may be discomfort secondary to inadequate pain control. Hyperventilation and fatigue may also occur.
• Aerosol delivery devices. Malfunction of the device or improper technique may result in underdosing or overdosing. There may be complications of specific pharmacologic agents and repeated aerosol exposure may produce asthmatic symptoms in caregivers.
• Arterial blood gases. Dangers encountered during this procedure include air or clotted-blood emboli, introduction of contagion at sampling site and infection, hemorrhage, trauma to the vessel, arterial occlusion, and pain.

• Nasotracheal suctioning. Mechanical trauma (laceration of nasal turbinates, perforation of pharynx, nasal irritation, mucosal hemorrhage) are hazards of this procedure. Other complications of NTS include hypoxia, cardiac dysrhythmias, hyperor hypotension, respiratory arrest, coughing, gagging or vomiting, bronchoconstriction, atelectasis, misdirection of catheter, and increased intracranial pressure.
• Patient-ventilator system checks. Disconnecting the patient from the ventilator during system checks may result in hypoventilation, hypoxemia, bradycardia, and hypotension.

Health care team roles

Physicians, registered nurses, respiratory therapists, and pulmonologists all work to maintain respiratory health in the patient. Physicians diagnose respiratory illnesses and determine which kinds of therapy will be most effective in alleviating them. Registered nurses monitor the effects of the therapy on the patient, administer tests, and make recommendations for any needed changes to the therapy program. Respiratory therapists are trained in the use of therapy equipment and are responsible for maintaining the welfare of patients while they are undergoing therapy. Pulmonologists specialize in the study of the heart-lung system and may also recommend or adjust therapy.

Resources

PERIODICALS

Hess, D. "Respiratory Care in a Managed Care Environment." Critical Care Alert 8, no. 12 (March 2001):138.

Myers, C. "Facility Profile: Expanding the Reach of Respiratory Therapists." RT Magazine (December 2000).

Woodruff, D. "How to Ward Off Complications of Mechanical Ventilation." Nursing 29, no. 11 (November 1999): 34.

ORGANIZATIONS

American Association for Respiratory Care. 11030 Ables Lane, Dallas, TX 75229-4593. (972) 243-2272. 〈http://www.rcjournal.com/online_resources/cpgs/pcgtcpg.html〉.

Canadian Society of Respiratory Therapy. 1785 Alta Vista Drive, Suite 102, Ottawa, Ontario K1G3Y6. (800) 267-3422. 〈http://www.csrt.com〉.

OTHER

Bureau of Labor Statistics, United States Department of Labor Occupational Outlook Handbook (December 2000). 〈http://stats.bis.gov/oco/ocos/084.htm〉.