What information should I discuss during ICU rounds as a respiratory therapist?

ICU Rounds: Essential Respiratory Therapy Discussion Points

As a respiratory therapist, your ICU rounds discussion must prioritize airway patency and oxygenation status first, followed by ventilator settings and hemodynamic stability, as this ABC-focused approach prevents the majority of critical incidents and deaths in the ICU. 1

Immediate Priority Assessment: Airway-Breathing-Circulation

Airway Status

• Report endotracheal tube position and depth at every shift, documenting on bedside charts, as tube displacement contributes significantly to ICU airway-related deaths 1
• Confirm cuff pressure is maintained at 20-30 cm H₂O to prevent aspiration and tracheal injury 1
• Verify continuous waveform capnography is functioning, as failure to use capnography contributes to >70% of ICU airway-related deaths 1
• Identify any signs of airway obstruction, including secretion accumulation, tube kinking, or patient biting on the tube 1

Oxygenation and Ventilation Status

• Present current oxygen saturation, respiratory rate, and work of breathing, noting any severe hypoxemia (SpO₂ <80%) which occurs in up to 25% of ICU intubations 1
• Report arterial blood gas results, specifically addressing PaO₂/FiO₂ ratio, PaCO₂ levels, and pH to identify hypoxemia or hypercapnia 2
• Monitor for hypercapnia (>45 mm Hg/6 kPa) which requires urgent reassessment and consideration of ventilatory support adjustments 2
• For hypoxemic patients, target oxygen saturation of 88-92% in adults or above 92% in children, recognizing that saturations below 95% indicate high risk of deterioration even without supplemental oxygen 2

Ventilator Settings and Compliance

• Review and report current ventilator mode, tidal volume (should be 6 mL/kg predicted body weight), plateau pressure (should be ≤30 cm H₂O), and PEEP level (minimum 5 cm H₂O for hypoxemic patients) 2, 3
• Confirm alarm parameters are appropriately set and active to detect disconnections, high pressures, or apnea 1
• Assess patient-ventilator synchrony and report any signs of fighting the ventilator or increased work of breathing 1

Patient-Specific Respiratory Considerations

High-Risk Patient Identification

• Flag patients with known difficult airways to the entire team, including specific details and patient-specific strategies for preventing airway emergencies 1
• Identify patients requiring Level III care (highest acuity) who need 1:1 nurse-to-patient ratios and most experienced staff 1
• Communicate any history of failed intubation attempts, as four or more attempts dramatically increase cardiac arrest risk 1

Disease-Specific Monitoring

• For patients with neuromuscular disease (e.g., Duchenne muscular dystrophy), emphasize CO₂ monitoring and maintain low threshold for capillary/arterial blood gas analysis to rule out hypercapnia 2
• For ARDS patients, report use of rescue therapies including high PEEP, prone positioning, neuromuscular blockade, or inhaled nitric oxide 2
• For patients with cardiac dysfunction, note that uncorrected nocturnal hypoventilation can lead to adrenergic surges and worsen cardiac function 2

Therapeutic Interventions and Adjustments

Positioning Strategies

• Confirm head of bed elevation at 45° for all ventilated patients to prevent ventilator-associated pneumonia 1
• Report any patients in prone position and duration of proning, as this provides beneficial impact on respiratory mechanics compared to supine position 4
• For obese patients, ensure proper ramping technique with external auditory meatus at level of sternal manubrium 5

Recruitment Maneuvers

• Report if post-intubation recruitment maneuver was performed (40 cm H₂O CPAP for at least 30 seconds in hypoxemic patients), as this significantly improves oxygenation without cardiovascular compromise when properly executed 2, 3
• Recommend recruitment maneuver if SpO₂ is consistently ≤94% or after ventilator disconnection 3
• Ensure hemodynamic stability before any recruitment maneuver, as hypotension requiring vasopressor support can occur 3

Oxygen Therapy Considerations

• Emphasize that oxygen therapy alone should not be provided without checking for hypercapnia, as supplemental oxygen without ventilatory support can mask respiratory failure 2
• Report high or increasing oxygen requirements that should prompt urgent reassessment and consideration of non-invasive ventilation 2
• Avoid empirical high-flow oxygen administration; instead, target saturations appropriately 2

Hemodynamic-Respiratory Interface

Cardiovascular Monitoring During Respiratory Interventions

• Report any hemodynamic instability, which occurs in up to 25% of ICU intubations with cardiac arrest in approximately 2% 1
• Confirm vasopressors are prepared and immediately available before any high-risk respiratory procedure 5
• Monitor for hypotension from positive pressure ventilation reducing venous return 1

Medication Considerations

• For patients on corticosteroids (e.g., prednisolone, deflazacort), assume adrenal suppression and ensure stress dosing is provided during physiological stress 2
• For patients with tachycardia and respiratory failure, note that beta-blocker doses should be increased if heart rate remains high after starting non-invasive ventilation 2

Communication and Documentation Priorities

Team Communication

• Present information in ABC priority order (airway, breathing, circulation) to ensure critical issues are addressed first 1
• Highlight any patients requiring immediate escalation, including those with four or more intubation attempts, severe hypoxemia unresponsive to standard therapy, or hemodynamic instability 1
• Ensure bedhead signage is visible for tracheostomy, laryngectomy, or identified airway difficulty 1

Prognostic Information

• Discuss key domains of prognosis with the team, including risks of short and long-term mortality, ventilator dependence, functional impairment, and cognitive impairment 2
• For patients with prolonged ventilation, report median ventilatory durations and likelihood of weaning success 2

Goals of Care Discussions

• Identify patients requiring goals of care discussions, particularly when mechanical ventilation is no longer meeting patient goals or has become more burdensome than beneficial 2
• Report any advance directives or patient wishes regarding mechanical ventilation and life-sustaining therapy 2

Equipment and Resource Management

Essential Equipment Status

• Confirm availability of rescue equipment including second-generation supraglottic airway devices and surgical cricothyroidotomy supplies 5
• Report ventilator inventory and capacity, especially during surge situations 2
• Ensure adequate supplies of sedatives, analgesics, vasopressors, bronchodilators, and neuromuscular blocking agents 2

Respiratory Therapy Staffing

• Communicate respiratory therapist workload and capacity to ensure appropriate staffing for patient acuity 2
• Coordinate with pharmacy regarding neuraminidase inhibitors, antibiotics, and other essential medications during infectious disease outbreaks 2