How do you recommend, delegate, coordinate, and provide safe, therapeutic respiratory care to patients with respiratory conditions such as COPD and pneumonia?

Respiratory Care Process for COPD and Pneumonia Management

Assessment Phase

Begin with arterial blood gas measurement to quantify respiratory failure severity before initiating treatment, targeting identification of pH <7.35, PaCO₂ ≥6.5 kPa, and hypoxemia. 1, 2, 3

Critical Assessment Parameters

• Arterial Blood Gases: Measure pH, PaCO₂, PaO₂ within 30 minutes of presentation, then repeat at 30-60 minute intervals during acute management 2, 4, 3
• Respiratory Rate: Document rate >23 breaths/min as indicator for escalated care; >35 breaths/min signals potential intubation need 1, 2, 3
• Oxygen Saturation: Monitor continuously with target SpO₂ 88-92% to prevent oxygen-induced hypercapnia 1, 4, 3
• Mental Status: Assess for confusion, somnolence, or inability to cooperate—these contraindicate non-invasive ventilation 1, 2
• Sputum Characteristics: Document increased volume, purulence, or viscosity as these indicate antibiotic need and affect NIV suitability 1, 3
• Hemodynamic Stability: Check for peripheral edema, jugular venous pressure elevation, hypotension, or arrhythmias 1

Infection Assessment

• Temperature and Neutrophil Count: Elevated temperature and blood neutrophils are single best markers of respiratory infection 5
• Cardinal Symptoms: Prescribe antibiotics when two or more are present: increased dyspnea, increased sputum volume, or purulent sputum 3

Planning Phase

Oxygen Therapy Algorithm

Start controlled oxygen at 24% Venturi mask (2-3 L/min) or 28% Venturi mask (4 L/min), never delay oxygen for fear of hypercapnia—hypoxemia causes immediate cardiovascular collapse while hypercapnia develops gradually. 4, 3

• Recheck ABGs at 30-60 minutes to ensure PaCO₂ has not risen >1.3 kPa or pH fallen to <7.25 3
• Adjust oxygen to maintain SpO₂ 88-92% 1, 4, 3

Non-Invasive Ventilation Decision Tree

Initiate NIV immediately when pH ≤7.35 with elevated PaCO₂ and respiratory rate >23 breaths/min persists after one hour of optimal medical therapy. 2, 4, 3

• Initial BiPAP Settings: IPAP 12-20 cm H₂O, EPAP 4-5 cm H₂O, backup rate 12-15 breaths/min 2, 4
• Contraindications to NIV: Respiratory arrest, cardiovascular instability, impaired mental status, copious/viscous secretions, recent facial surgery, extreme obesity 1, 2
• Success Criteria: Improvement in pH and PaCO₂ within 1-2 hours, reduced respiratory rate, improved mental status 1, 2

Intubation Criteria

Proceed to intubation when pH <7.26 with rising PaCO₂ despite NIV, or when NIV shows worsening ABGs within 1-2 hours or lack of improvement after 4 hours. 1, 2, 4

Additional intubation indications: 1, 2

• Life-threatening hypoxemia (PaO₂/FiO₂ <200 mmHg)
• Severe tachypnea (>35 breaths/min)
• Respiratory arrest
• Cardiovascular instability

Implementation Phase

Pharmacological Management

Administer nebulized bronchodilators via air-driven nebulizer: salbutamol 2.5-5 mg or ipratropium 500 mcg, with supplemental oxygen monitoring to maintain SpO₂ 88-92%. 1, 4, 6

• Combination Therapy: Use both β-agonist and anticholinergic for severe exacerbations or poor single-agent response 1, 3
• Corticosteroids: Prednisolone 30 mg daily for 7-14 days (or hydrocortisone 100 mg IV if oral route unavailable), then stop abruptly unless specific indication for continuation 1, 3
• Antibiotics: Amoxicillin/clavulanate, macrolides, or tetracyclines for 5-7 days when two cardinal symptoms present 3

Respiratory Support Delivery

For NIV implementation, use bilevel positive pressure with continuous oxygen via NIV circuit, reassess ABGs at 1-2 hours, and monitor for failure signs: worsening acidosis, rising respiratory rate, altered mental status. 1, 2, 4

• Continue nebulized bronchodilators for 24-48 hours or until clinical improvement, then transition to metered-dose inhalers at least 24 hours before discharge 1, 3
• Document individualized escalation plan at NIV initiation regarding measures if NIV fails 3

Delegation and Coordination

Respiratory therapists should perform initial patient assessment, initiate therapist-driven protocols for bronchodilator delivery, monitor ventilator parameters (plateau pressure, tidal volume 4-8 mL/kg predicted body weight, PEEP, auto-PEEP), and assess artificial airway cuff pressure using manometer. 7, 8

• Home Care Coordination: For early discharge candidates, arrange respiratory specialist nurse follow-up through frequent telephone contact and home visits as needed 1
• Pulmonary Rehabilitation Referral: Recommend participation for all stable COPD patients and those post-hospitalization to reduce dyspnea, increase exercise capacity, and decrease readmission risk 1

Evaluation Phase

Monitoring Protocol

Reassess ABGs every 30-60 minutes until stable, then every 4-6 hours; monitor for NIV failure indicators: worsening pH/PaCO₂ after 1-2 hours or lack of improvement after 4-6 hours. 1, 2, 4

• Ventilator Parameters: Document plateau pressure, tidal volume as mL/kg predicted body weight, driving pressure, FiO₂, PEEP, and auto-PEEP 7
• Skin Assessment: Inspect skin surrounding artificial airways and NIV interfaces regularly 7
• Cuff Pressure: Assess using manometer (continuous monitoring not recommended for VAP prevention) 7

Discharge Planning

Before discharge, assess for long-term oxygen therapy by checking ABGs on room air; LTOT criteria include PaO₂ ≤7.3 kPa or SaO₂ ≤88% despite optimal therapy, confirmed twice over 3 weeks. 3

• Transition nebulized bronchodilators to usual inhaler at least 24-48 hours before discharge 3
• Arrange early follow-up (<30 days) to reduce exacerbation-related readmissions 2
• Stop oral corticosteroids abruptly after 7 days unless specific reasons for long-term use 3

Home Care Services

For patients requiring ongoing support, coordinate home health services including skilled nursing for medication management, respiratory therapist consultation for equipment needs, and physical therapy for pulmonary rehabilitation continuation. 1

• Home mechanical ventilation patients should receive routine outpatient palliative care with regular assessment of continued ventilation indication considering prognosis and quality of life 1
• Hospice referral appropriate for terminal respiratory disease with life expectancy ≤6 months who elect palliative care 1

Critical Pitfalls to Avoid

• Never delay intubation when NIV is clearly failing—this increases mortality 2
• Never over-oxygenate COPD patients—target SpO₂ 88-92% to prevent worsening hypercapnia and respiratory acidosis 2, 4
• Never rely solely on PaCO₂ levels for intubation decisions—pH is a better predictor of survival 2
• Never continue chest physiotherapy in acute COPD exacerbations—there are insufficient data supporting benefit 1
• Never use continuous cuff pressure monitoring to prevent VAP—it does not reduce infection risk 7