Initiation and Modification of Initiation and Modification of Therapeutic ProceduresTherapeutic Procedures

Act As an Assistant to the Physician Performing Special Procedures

NBRC expects you to be

Especially familiar with the therapist’s role when assisting with intubation and bronchoscopy.

Have a basic understanding of how the therapist assists with thoracentesis, tracheostomy, chest tube insertion, and cardioversion.

Know how moderate sedation and ultrasound can facilitate some of these procedures.

Endotracheal IntubationIndications: conditions that include impending or actual1.Airway compromise2.Respiratory failure3.The need to protect the airway

Contraindications:1.Lack of adequate facilities or trained personnel2.DNR order or other properly documented evidence of the patient’s desire not to be resuscitated.

Required Equipment (typically included in intubation tray)1.Local anesthetic spray2.Lubricating jelly3.Laryngoscopes (2) with assorted blades, batteries, and bulbs4.Endotracheal tubes (at least 3 different sizes)5.Stylets6.Magill forceps7.Syringes8.Tape and/or ET tube holders9.Oropharyngeal airways and/or bite blocks

Endotracheal Intubation

Selecting and Testing the Equipment1.Laryngoscope

1. Select blade size appropriate to age1. Large adult: size 42. Small adult: size 33. Pediatric: size 2

2. Connect to handle and confirm illumination

2.ET tube1. Select appropriate size

1. Adult male: 8.0 – 9.0 mm2. Adult female: 7.0 – 8.0 mm3. Average 16 -year-old: 7.0 mm4. 3-year-old: 4.5 mm

2. Check cuff for leaks then fully deflate

3.Ensure functioning vacuum source and properly set up suction device(s)

Endotracheal Intubation

Preparing and Monitoring the Patient1.Properly position patient2.Clear airway of secretions if necessary with Yankauer tip3.Apply local anesthetic spray to posterior oropharynx, or nasal passages4.Preoxygenate patient with BVM with oxygen reservoir5.Monitor vital signs before, during and immediately following intubation.

Assisting with Insertion1.Clarify and assist in the use of intubation aides (stylet for oral intubation, Magill forceps for nasal intubation)2.Lubricate proper-sized tube3.Apply moderate cricoid pressure4.Communicate elapsed time, vital signs, and SpO2 during intubation5.Be prepare to manually ventilate the patient, suction airway6.Inflate cuff and temporarily secure tube

Endotracheal Intubation

Assessing tube placement:1.Auscultate2.Esophageal detection device (EDD)3.Colorimetric CO2 detector4.Tape tube in position and note centimeter depth at the incisors5.Confirm with chest x-ray and re-secure tube with appropriate device.

Bronchoscopy Assisting

Indications for fiberoptic bronchoscopy include conditions that require: 1.Secretion and foreign body removal2.Collection of fluid / tissue specimens for microbiologic or cytologic assessment3.Tube position, airway injuries4.Difficult intubation

Contraindications:1.Lack of adequate facilities or trained personnel2.Absence of documented patient consent or physician’s order.3.Inability to adequately oxygenate the patient4.Coagulopathy or uncontrolled bleedng5.Severe obstructive airway disease6.Severe refractory hypoxemia7.Unstable hemodynamic status including dysrhythmias.

Bronchoscopy Assisting

Patient preparation1.NPO 2.Evaluate lab studies for contraindications3.Evaluate PFT / ABG if available4.Be aware of preparatory medications to be administered (narcotic, anxiolytic/sedativeEquipment1.Bronchoscope2.Suction3.Specimen containers, wash solutionsProcedure1.Patient positioned either supine or sitting2.Anesthetize pharynx with 2% centacaine spray or 4% lidocaine aerosol3.Local anesthetic instilled through bronchoscope to anesthetize vocal cords and tracheobronchial tree.4.Administer supplemental oxygen (a 20 torr drop in PaO2 is common during bronchoscopy)

TracheotomyIndications1.To bypass a partial or complete upper airway obstruction2.To provide access for secretion removal3.To facilitate prolonged mechanical ventilation

Contraindications:1.No absolute contraindications 2.Severe coagulopathies should be corrected first, and patients stabilized as much as possible

Required Equipment 1.Necessary surgical equipment to perform the procedure2.Extra tracheostomy tube one size smaller than tube being inserted3.10 ml syringe for ET tube cuff deflation / tracheostomy tube cuff inflation4.Scissors for removing ET tube securing device5.BVM, flow meter and O2 source6.Intubation equipment on standby7.Hazardous waste receptacle

Hazards and Complications1.Procedural

Adverse reaction to sedationTissue trauma at incision siteAirway compromise or loss of patent airwayExcessive bleedingHypoxemiaAspiration

2.Post-ProceduralInfection BleedingPain or discomfortTracheal stenosis

ThoracentesisIndications1.Diagnostically, to help determine presence of underlying conditions such as infection, malignancy, CHR, or cirrhosis2.Therapeutically, to remove excess pleural fluid that interferes with lung expansion and impairs oxygenation and/or ventilation

Contraindications:1.Absence of properly signed physician’s order or informed consent2.Absence of an experienced clinician to perform or supervise the procedure3.Inadequate facilities or personnel to handle hazards such as pneumothorax or bleeding4.An uncooperative patient5.Inability to identify the top to the rib6.Severe coagulopathy (platelet count < 50,000/mm3.7.Severe bullous lung disease8.Mechanical ventilation with PEEP9.Status post pneumonectomy10.Markedly elevated hemidiaphragm

Role of the Respiratory Therapist1.Prior to the procedure: bedside assessment may identify need for thoracentesis (dull percussion, decreased breath sounds in the presence of predisposing factors)2.During the procedure: assist with the equipment, monitoring, stabilizing and positioning patient3.After the procedure: monitor the patient, assist with preparing samples for lab

Hazards and Procedural Considerations1.Hypoxemia2.Pneumothorax and hemothorax3.Hemorrhage/bleeding4.Puncture of the liver or spleen5.Infections

Chest Tube InsertionIndications1.Pneumothorax, hemothorax, empyema, chylothorax, and pleural effusion2.Administration of drugs / chemicals into pleural space

Contraindications:1.Absence of significant air or fluid in the pleural space

Role of the Respiratory Therapist1.Monitor patient and equipment2.Identify and respond to adverse reactions

Hazards and Procedural Considerations1.Bleeding2.Tissue trauma3.Secondary pneumothorax4.Post tube removal: recurrence of pneumothorax

CardioversionIndications1.Immediate cardioversion is needed if a ventricular rate greater than 150 persists despite efforts to control it with applicable drugs2.Arrhythmias:

1. Atrial fibrillation2. Atrial flutter3. Other supraventricular tachycardia4. Monomorphic ventricular tachycardia (if stable)5. Polymorphic ventricular tachycardia (irregular form and rate) and

unstable

Contraindications:1.Lack of properly trained personnel2.Patient’s desire not to be treated

Role of Respiratory Therapist1.Monitor and respond to any adverse reactions2.Have suction, intubation, O2 equipment and BVM ready

Moderate (Conscious Sedation)Indications1.Helps minimize patient discomfort during procedures while maintaining respiratory drive

Contraindications:1.Known adverse reaction to sedating agents

Role of the Therapist1.Assess vital signs, cardiopulmonary and airway status, pulse oximetry, and any adverse side effects from the procedure or medications2.Must be familiar with common medications and their major side effects and hazards3.Know proper reversing agents for sedating drugs

Common Errors to Avoid on the Common Errors to Avoid on the ExamExam

To minimize tissue trauma during intubation, never permit the tip of the stylet to extend beyond the end of the endotracheal tube

Never perform bronchoscopy in the presence of absolute contraindications such as refractory hypoxemia, unstable hemodynamic status, or inability to oxygenate patient.

Never attempt potentially uncomfortable procedures such as cardioversion, chest tube insertion, or bronchoscopy unless the patient has been premedicated with a medication such as Versed to achieve moderate sedation

When assisting with a tracheostomy procedure, never remove the endotracheal tube until just before the insertion of the tracheostomy tube.

More Common Errors to Avoid on More Common Errors to Avoid on the Examthe Exam

Never attempt to assist with an intubation unless you have a complete intubation tray that includes a fully functional laryngoscope with multiple blades, several different-size endotracheal tubes, a stylet, suction source and catheter(s), and a device to confirm tube placement

Never rely on only one means of verifying successful intubation. Instead, confirm success with at least two methods, including auscultation of the lungs and epigastric region, end-tidal capnography, colorimetry, esophageal detector device, and chest x-ray.

Never place patients with neck trauma in a “sniffing position” for intubation

Never use a stylet for nasal intubation

Never use more than 100 joules for initial attempts at synchronized cardioversion, initial energy levels of 50 joules are appropriate for A-flutter and supraventricular tachycardia (SVT)

Exam Sure Bets Exam Sure Bets Always announce “clear” several times and verify that

no on is in contact with the patient before attempting cardioversion

When positioning patients for a thoracentesis procedure, always ensure that they are adequately supported in front to help prevent them from falling and being injured

Always confirm proper functioning of endotracheal tube cuff, pilot balloon, and valve by first inflating the cuff with a syringe prior to intubation

After each attempt of cardioversion, always activate “sync” mode again, in addition to selecting the appropriate change in energy level

More Exam Sure Bets More Exam Sure Bets Always recommend a tracheostomy for an orally

intubated patient who is expected to remain mechanically ventilated for some time

Always recommend an immediate chest tube insertion (or needle decompression) for a patient with a tension pneumothorax

Always recommend the use of the correct-size endotracheal tube when assisting with intubation

Always suggest diagnostic ultrasound prior to a thoracentesis to determine the specific location of the fluid and to identify the ideal insertion site for the needle or catheter

Always closely monitor patient’s vital signs, pulse oximetry, and ECG before, during, and immediately following cardioversion or bronchoscopy

More Exam Sure Bets More Exam Sure Bets Always monitor a patient’s vitals signs, pulse oximetry, and

other clinical indicators during procedures such as tracheostomy, chest tube insertion, bronchoscopy, and cardioversion. If necessary, administer supplemental oxygen to address or prevent hypoxemia during or immediately following such procedures.

Always ensure that a manual resuscitator bag-valve-mask and oxygen source are nearby in case a patient experiences severe adverse effects of procedures such as bronchoscopy, chest tube insertion, thoracentesis, or cardioversion

Always make sure that the patient is NPO for at least 8-12 hours prior to bronchoscopy to minimize aspiration risk.

Always recommend that an X-ray be ordered after certain special procedures such as intubation and chest tube insertion.

Reference:Reference:

Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis SinopoliJones and Bartlett Publishers