Content Outline and Competencies:

I. Lung Structure and Function

A. Review terms and symbols pertinent to respiratory physiology.

B. Classify the fetal lung developmental stages of viability.

C. Attribute specific facts about the anatomy of the tracheobronchial tree to include:

1. Tracheal length

2. Tracheal structure

3. Tracheal bifurcation

D. Distinguish the anatomy and physiology of the alveolocapillary region including:

1. Pores of Kohn

2. Alveolar cells

3. Canals of Lambert

4. Sphingomyelin

5. Phospholipids

6. Alveolar cells

a. Type I

b. Type II

c. Macrophages

E. Relate the physiological humidification of inspired gas.

F. Describe internal and external gas exchanges.

G. Explain how the lung clears itself of foreign particles via the mucociliary apparatus.

H. Define metabolism and Basal Metabolic Rate.

I. Identify metabolic functions of the lung.

J. Articulate the respiratory quotient and its normal value.

II. Ventilation and Diffusion

A. Describe diffusion of gas across the alveolar-capillary membrane.

B. Identify factors affecting diffusion to include:

1. Time of exposure

2. Membrane integrity

3. Solubility of the gas

4. Temperature

5. Pressure gradients

C. Compare the rate of diffusion across the alveolocapillary membrane for carbon dioxide (CO2) and oxygen (O2.)

D. Describe the measurement of lung diffusion (DL).

E. Interpret lung diffusion measurements in lung disease.

F. Calculate the respiratory quotient (RQ).

G. Interpret normal values for O2 consumption (VO2) and CO2 production (VCO2).

H. Define internal and external respiration.

I. Determine normal lung volume and capacity factors.

J. Determine normal lung volumes and the relationship with lung capacities.

K. Explain the significance of functional residual capacity (FRC) and increased or decreased FRC.

L. Describe the changes in lung volumes and capacities with restrictive or obstructive lung disease.

M. Define anatomical and physiological deadspace.

N. Calculate minute ventilation, alveolar tidal volume and alveolar minute ventilation.

O. Compare normal and abnormal breathing patterns.

III. Lung Mechanics

A. Characterize the mechanics of normal inspiration and expiration of gas flow into and out of the thorax.

B. Classify the maximal inspiratory pressure created with negative inspiratory force (NIF) or maximal inspiratory pressure (MIP), and the MIP created with the Valsalva maneuver or maximal expiratory pressure (MEP).

C. Identify normal values of lung compliance (CL) and elastance.

D. Calculate lung compliance when changing pressures and volumes.

E. Identify normal values of airway resistance (Raw).

F. Define time constants.

G. Describe the relationship of surfactant and surface tension to lung compliance.

H. Describe the changes in lung compliance for respiratory diseases.

I. Define Laplace’s law.

J. Discuss the following factors as they relate to airway pressure:

1. Transairway pressure

2. Transpulmonary pressure

3. Time constants

4. CL and Raw

K. Describe the significance of work of breathing in disease states.

L. Compare CL and Raw in adult and infant lungs.

M. Apply each of the following gas laws to ventilation and lung mechanics.

1. Graham’s law

2. Boyle’s law

3. Henry’s law

4. Dalton’s law

5. Avogadro’s law

6. Poiseuille’s law

7. Fick’s law

IV. Blood Flow

A. Trace blood flow through the heart.

B. Identify pressure at various points in the systemic and pulmonary circulation to include:

1. Right Atrium Pressure

2. Right Ventricle Pressure

3. Pulmonary Artery Pressure (PAP)

4. Pulmonary Artery Wedge Pressure (PAWP)

C. Define systolic, diastolic and pulse pressures.

D. Identify the normal Central Venous Pressure (CVP).

E. Describe the balance of forces affecting fluid volumes within blood capillaries.

F. Describe causes of systemic and pulmonary edema.

G. Identify the effects of O2 and CO2 on pulmonary and systemic vasculature.

V. Hemodynamics

A. Describe values obtained with a pulmonary artery catheter and the clinical significance of increases or decreases in their values to:

1. CVP

2. PAP

3. PAWP

4. Cardiac Output (CO)

B. Review the pulmonary artery pressure tracing and wedging of a balloon in the pulmonary artery.

C. Identify methods for determining cardiac output.

D. Identify factors which influence cardiac output including:

1. Preload/afterload

2. Intrathoracic pressure

3. Inotropism

E. Describe the pressure differences between pulmonary vessels in the apex versus the base of the lung in an upright individual (zones 1-3).

F. Identify the relationship between alveolar pressure and pulmonary blood flow.

G. Explain how systemic and pulmonary blood flow can be changed by variations in mean intrathoracic pressure.

H. Identify the Fick Principle.

VI. Ventilation Perfusion Relationships

A. Define shunt and deadspace.

B. Review the normal distribution of blood in the upright lung.

C. Review the normal distribution of ventilation in the upright lung.

D. Explain pathological causes for uneven distribution of ventilation or perfusion within the lung.

E. Define normal ventilation to perfusion ratios.

F. Review tests used to identify regional ventilation and perfusion in the lung.

G. Identify bronchiolar and vascular responses to mismatch.

H. Compare the effect of inequality on arterial and alveolar oxygenation.

I. Describe the effects of an inequality on arterial and alveolar CO2 levels.

J. Describe pulmonary and systemic responses to hypoxia, hypocapnia and hypercapnia.

K. Describe the factors that can affect oxygen uptake by the tissues.

L. Describe performance of a shunt study.

VII. Oxygen Transport

A. Explain causes of hypoxemia.

B. Articulate the four types of hypoxia.

C. Describe normal binding of oxygen to hemoglobin.

D. List the two components of oxygen transport.

E. List abnormal types of hemoglobin.

F. Calculate oxygen content.

G. Describe cyanosis in terms of oxygen content.

H. Discuss the significant differences in arterial-venous content.

I. State the normal value for the partial pressure of oxygen in venous blood (PvO2.)

J. Calculate predicted alveolar oxygen levels.

K. Compare the partial pressure of oxygen in arterial blood (PaO2) and partial pressure of carbon dioxide in arterial blood (CaO2) to their roles in oxygen delivery.

L. Identify the importance of given points on the oxyhemoglobin dissociation curve (OHDC.)

M. List factors causing OHDC to shift left or right.

N. Identify the changes in O2 and hemoglobin (Hb) affinity occurring with an OHDC shift to the left or right.

O. Describe the effect of 2,3-Diphosphoglycerate (2,3-DPG) on the OHDC.

P. Describe the effect of carbon monoxide (CO) on the OHDC.

Q. Define P50 and state its clinical significance.

R. Describe the Bohr effect.

VIII. Carbon Dioxide Transport

A. Identify CO2 transport from the cells to the lungs.

B. Describe the process of CO2 uptake at the cell level and CO2 release at the lungs.

C. Describe the conversion of CO2 to bicarbonate (HCO3).

D. Describe the Haldane effect.

E. Describe the Bohr effect.

F. Compare the CO2 and O2 dissociation curves.

G. Define and calculate total CO2.

IX. Acid-Base Balance

A. Define acid and base.

B. Define buffers and their physiological role.

C. Recall the four body buffers.

D. Define pH and its relationship to hydrogen ion concentration measured in nanomoles.

E. Define acidosis and alkalosis.

F. Perform calculations using the Henderson-Hasselbalch equation.

G. Review basic kidney function.

H. Describe how hydrogen (H+) and HCO3 are regulated by the kidney in acid-base states.

I. Demonstrate the ability to identify the types and causes of acid-base disturbances.

J. Contrast how the lungs and kidneys compensate for imbalances in the acidity or alkalinity (pH).

K. Interpret arterial blood gas studies.

L. Contrast buffer base and base excess.

M. Calculate the anion gap and total CO2.

X. Control of Ventilation

A. Describe the role of the Gamma-efferent system in modifying breathing patterns:

1. Obstructive disease pattern

2. Restrictive disease pattern

B. Demonstrate the ability to define state the effect on breathing:

1. Hering-Breuer reflex

2. Paradoxic reflex of the head

3. Deflation reflex

4. J receptors

5. Irritant receptors

C. Identify the physiological responses to hyperventilation.

D. Contrast Biot’s and Cheyne-Stokes Breathing.

XI. Chemical regulation of ventilation

A. Identify the chemoreceptor area of the medulla.

B. Describe the effects of carbon dioxide on the central chemoreceptors.

C. Explain the role of the blood-brain barrier in chronic hyperventilation.

D. State the response of peripheral chemoreceptors to carbon dioxide.

E. State the effect of free H+ on respiration.

F. Identify the locations of the peripheral chemoreceptors.

G. Describe the effect of low oxygen levels on peripheral chemoreceptors.

H. Describe the mechanisms involved with oxygen-induced hypoventilation.

I. Calculate the partial pressure of inspired oxygen (PIO2) and the partial pressure of alveolar oxygen (PAO2) under various barometric conditions.

XII. Cardiac Conduction and Blood Components

A. Describe the function of the following specialized cells of plasma:

1. Erythrocytes

2. Leukocytes

3. Thrombocytes

B. Identify chemical components of the plasma.

C. Describe the effect of blood volume on cardiac output.

D. Compare the components of the pulmonary and systemic vascular systems.

E. Trace blood flow from the superior and inferior vena cava through the valves and chambers of the heart.

F. Explain systole and diastole in relation to the cardiac cycle.

G. Contrast the sympathetic and parasympathetic effects on the heart.

H. Explain the relationship between coronary circulation and the cardiac cycle.

I. Describe the electrical forces involved in membrane potentials of the heart.

J. Describe the relationship of ECG impulses and electrical conduction within the heart.

K. Describe ECG changes in disease states.

XIII. Unusual Atmospheres and Environments

A. Calculate expected PaO2 and PAO2 at different altitudes.

B. Describe the following physiologic responses to living at high altitude:

1. Hyperventilation

2. Pulmonary hypertension

3. Increased red blood cells (RBCs)

4. Increased 2,3-DPG

5. Increase in pulmonary vascularity

C. Demonstrate the ability to review the pressure changes and physiologic events involved with hyperbaric conditions:

1. Quantity of gas in the lung under pressure

2. Increase in gas dissolved in tissue

3. Explanation of “the bends”

4. Explanation of nitrogen narcosis

D. Review the pathophysiological effects of oxygen toxicity.

E. Describe the normal ventilatory response to increased inspired concentrations of CO2.

F. Describe the effects of tobacco smoke and pollution on the respiratory system.

G. Explain absorption atelectasis.

Content Outline and Competencies:

I. Recordkeeping

A. Review records

1. Patient demographics

2. Chief complaint/diagnosis

3. History of present illness

4. Past medical history

5. Social history

6. Occupational history

7. Current medications

8. Results of diagnostic procedures

9. Recent progress notes

10. Physician orders

B. Review documentation

1. Procedure for verbal and telephone orders.

2. Process for charting errors.

3. Methods of written recordkeeping.

4. Electronic applications of recordkeeping.

II. General Safety and Patient Comfort Considerations

A. Demonstrate the ability to apply proper body mechanics in the following:

1. Lifting and carrying an object

2. Moving a patient to the head of the bed with and without aid

3. Moving a patient from bed to stretcher with assistance

4. Assisting a patient from bed to chair

5. Assisting a patient walking

6. Assisting a falling patient

7. Turning a patient

B. Demonstrate the ability to position a patient for therapeutic procedures and patient comfort:

1. Supine

2. Prone

3. Fowler's

4. Semi-Fowler's

5. Trendelenburg

C. Describe methods of eliminating safety hazards in the patient care setting.

D. Explain the general rules for responding to emergencies in the patient care setting.

E. Demonstrate the appropriate measures to treat cardiopulmonary collapse according to Basic Life Support (BLS) protocols.

III. Infection Control and Standard Precautions

A. Identify sources of common nosocomial or iatrogenic infections.

B. Identify respiratory pathogens by their morphology, colony structure and characteristics.

C. Demonstrate the ability to perform appropriate infection control and standard precaution measures including:

1. Appropriate hand washing

2. Use of personal protective equipment

3. Handling of non-disposable and disposable equipment.

D. Describe the potential risks to healthcare workers in caring for patients with blood borne infectious diseases.

E. Describe the measures taken if a healthcare worker is exposed to blood or other body fluids.

F. Describe infection control measures used to minimize airborne contamination, and wound and skin infections.

III. Gas Physics

A. Demonstrate the ability to calculate and define:

1. Density of a gas or gas mixture based on its molecular weight

2. Critical temperature and critical pressure

3. Molecular weight, mass, density, boiling point, critical temperature and critical pressure for frequently used medical gases

4. Basic gas laws

a. Boyle's

b. Charles'

c. Dalton's

B. Describe the behaviors of gases.

1. Kinetic activity

2. Flow of gas

a. Laminar flow

b. Turbulent flow

c. Tracheobronchial flow

d. The Reynolds Number

IV. Gas Production and Storage

A. Describe and identify:

1. Gas production for frequently used medical gases

2. Purity requirements for medical gases

3. Agencies which regulate medical gas production

B. Recognize and describe:

1. Bulk storage as it applies to medical gases

2. Bulk systems found in hospitals.

3. Hospital piping systems with zone valves and alarms

4. Gas cylinder identification and safety issues for:

a. U.S. and international color coding

b. Proper labeling of contents

c. Cylinder construction

d. Cylinder testing

e. Cylinder maintenance codes

f. Safety systems

5. Agencies which regulate medical gas storage and transport

C. Compute the possible duration for liquid or gas cylinders based on the liter flow to be used.

D. Review the medical gas systems used in the home environment.

1. Oxygen concentrators

2. Liquid systems

3. Cylinder options

V. Reducing Valves, Regulators and Flowmeters

A. Describe the function of a reducing valve.

1. Preset versus adjustable

2. Single stage versus multi-stage

3. Working pressures

B. Describe and identify safety systems used in conjunction with reducing valves.

C. Define a regulator and describe its function.

1. Preset (Thorpe tube) versus adjustable (Bourdon gauge)

2. Single stage versus multi-stage

3. Working pressures

4. Differences between regulators and reducing valves.

5. Safety systems used in conjunction with regulators.

D. Describe:

1. Function of a flowmeter

2. Presence of pressure compensation in flowmeters.

3. Types of flow metering devices

a. Bourdon gauges

b. Thorpe tubes

c. Kinetic tubes

E. Describe the safety systems used in conjunction with flowmeters.

VI. Assessment of Overall Patient Cardiopulmonary Status

A. Recommend additional cardiopulmonary information needed to complete a patient assessment.

B. Recognize signs and symptoms in a patient interview indicating a cardiopulmonary disorder.

C. Apply appropriate medical terminology in describing a patient's:

1. Level of consciousness

2. Level of cooperation

3. Orientation to time, place, and person

4. Irregular breathing patterns

5. Cough and sputum characteristics

6. Education level

7. Knowledge of past medical history

8. Age and language

D. Demonstrate the ability of effective communication when obtaining a patient's medical history.

E. Locate the following structures on a patient model or diagram:

1. Suprasternal notch

2. Manubrium of sternum

3. Body of sternum

4. Xiphoid process

5. Sternal angle

6. Costal margin

7. Costal angle

8. Costochondral junctions

9. Ribs 1-12

10. Intercostal spaces 1-8

11. C7; T1; T6 vertebrae

12. Clavicles

13. Scapulae

14. Carina

15. Transverse fissure

16. Oblique fissure

F. Locate the following topographical marks on a patient model or diagram:

1. Mid-clavicular lines

2. Anterior, mid-, and posterior axillary lines

3. Mid-scapular lines

4. Vertebral line

5. Mid-sternal line

G. Demonstrate the ability to locate the lung lobes, transverse fissure, and oblique fissure on a patient model or diagram using appropriate thorax anatomy and terminology.

H. Identify the use of accessory muscles during inspiration and expiration.

I. Demonstrate the ability to obtain the following measures:

1. Respiratory rate

2. Pulse

3. Blood pressure

4. Pulse Oximetry

J. Demonstrate the ability to apply the normal ranges, units of measure, related abbreviations, and the medical terms indicating abnormal results for:

1. Temperature

2. Blood pressure

3. Pulse

4. Respiratory rate

5. Pulse Oximetry

K. Convert temperatures to alternate units.

L. Demonstrate a complete chest inspection on a patient model

M. Describe each of the following terms relating to inspection of the patient:

1. General appearance

2. Muscle wasting

3. Venous distention

4. Peripheral edema

5. Diaphoresis

6. Clubbing

7. Cyanosis

8. Capillary refill

9. Chest configuration

10. Diaphragmatic movement

11. Breathing pattern

12. Accessory muscle use

13. Asymmetrical chest movement

14. Retractions

15. Nasal flaring

16. Quality of cough

17. Sputum characteristics

18. Chronic obstructive pulmonary disease (COPD) posturing

19. Room observation

N. Describe the appropriate palpation technique and outcomes in pulmonary disorders including:

1. Tracheal location

2. Chest wall excursion

3. Fremitus

4. Apical pulse

5. Peripheral pulses

6. Airway secretions

7. Crepitus

8. Areas of tenderness

O. Describe the appropriate percussion techniques and percussion notes for identified pulmonary disorders.

P. Demonstrate the appropriate auscultation technique used to determine:

1. Vesicular sounds

2. Bronchial sounds

3. Bronchovesicular sounds

4. Blood pressure

Q. Recognize the causes for the adventitious (abnormal) chest sounds for:

1. Crackles

2. Coarse (previously termed Rhonchi)

3. Wheezes

4. Stridor

5. Pleural rub

6. Bronchophony

7. Egophony

8. Whispered pectoriloquy

R. Apply the various abnormal breathing patterns to specific patient scenarios:

1. Hypoventilation

2. Hyperventilation

3. Kussmaul's breathing

4. Biot's breathing

5. Cheyne-Stoke's breathing

6. Tachypnea

7. Bradypnea

8. Orthopnea

9. Dyspnea

10. Eupnea

11. Apnea

S. Apply appropriate terms and abbreviations relating to patient interview and assessment.

VII. Pulmonary Lab Assessment

A. Demonstrate the ability to recall the basic anatomy and function of the following structures:

1. Nose

2. Conducting airways

3. Alveolocapillary membrane

4. Heart

5. Arterial and venous vessels

B. Describe the mechanical movement of air on inspiration and expiration.

C. Diagram blood flow through the heart and lungs.

D. Explain the process of internal and external gas exchange.

E. Identify normal arterial blood gas values with correct units of measurement.

F. Interpret arterial blood gas examples.

G. Relate pulse oximetry to patient oxygenation status.

H. Recall normal lung volumes and capacities.

I. Appropriately label lung volumes and capacities on a diagram.

J. Identify normal and abnormal findings on pulmonary function tests.

K. Demonstrate the ability to obtain the following measures:

1. Bedside pulmonary function measurements

2. Pulse oximetry

L. Demonstrate bedside pulmonary function measurements.

M. Identify terms and abbreviations for bedside pulmonary function measurements.

N. Apply terms and abbreviations related to pulmonary lab assessment.

VIII. Introduction to Cardiopulmonary Pathophysiological States

A. Differentiate between the pathophysiological states

1. Hypoxia and hypoxemia

2. Types of hypoxia and hypoxemia

3. Clinical manifestations of hypoxia

4. List shunt and deadspace disorders.

5. Apply appropriate terms relating to patient interview and assessment.

B. Demonstrate the ability to spell, describe, and apply descriptions of the following pulmonary disorders:

1. Asthma

2. Bronchitis

3. Emphysema

4. Tuberculosis

5. Bronchiectasis

6. Pneumonia

7. Atelectasis

8. Cor pulmonale

9. Croup

10. Bronchiolitis

11. Epiglottitis

12. Cystic fibrosis

13. Acute Respiratory Distress Syndrome (ARDS)

14. Pulmonary edema

15. Pulmonary embolism

16. Flail chest

17. Pneumothorax

18. Pleural effusion

19. Hemothorax

20. Empyema

IX. Gas and Humidity Therapy

A. Demonstrate the ability to identify the rationale, clinical indications, contraindications, possible hazards, and complications for:

1. Oxygen therapy

2. Humidity therapy

3. Gas mixture therapy

B. Determine therapeutic plans for given patient scenarios including goals and modifications.

C. Interpret terminology relating to gas and humidity therapy.

X. Instruction and Application Techniques

A. Select the appropriate gas and humidity equipment for the implementation of the respiratory care plan.

B. Assemble functioning equipment forthe following axygen administration devices:

1. Nasal cannula

2. Simple mask

3. Non-rebreathing masks (NRB)

4. Face shield or tent

5. Air entrainment devices

6. Aerosol masks, trach masks or collars, and t-pieces

7. Titration accessories

8. Oxygen tents

9. Oxygen hoods

10. Transtracheal oxygen

11. Oxygen conserving devices including reservoir and demand systems

12. Continuous Positive Airway Pressure (CPAP)

C. Assemble functioning equipment for the following humidification devices:

1. Bubble

2. Passover

3. Cascade

4. Wick

5. Heat moisture exchange

D. Describe and operate gas delivery systems including:

1. Cylinders or bulk systems

2. Oxygen concentrator

3. Air compressors

4. Liquid oxygen system

5. Regulators and reducing valves

6. Flowmeter

7. Blenders

8. Oxygen analyzer

9. Pulse oximeter

E. Describe concentrations available for all oxygen and gas mixture administration devices.

F. Identify the oxygen administration devices for aerosol generators.

G. Compute total flow and ratios delivered by air entrainment devices.

H. Demonstrate the ability to explain planned therapy and goals to patient in understandable terms.

I. Demonstrate the ability to appropriately deliver gas and humidity therapy.

J. Adjust equipment following patient's responses to therapy.

K. Record therapy results in the patient record.

L. Communicate clinical status information to members of the healthcare team.

XI. Humidity Equipment

A. Define the terms related to humidity equipment:

1. Humidity

2. Humidifier

3. Absolute humidity

4. Relative humidity

5. Body humidity

6. Percent body humidity

7. Humidity deficit

8. Dew point

9. Saturation

10. Super saturation

11. Vapor pressure

B. Describe each of the following used to provide humidity:

1. Bubblers

2. Passover humidifiers

3. Large reservoir heated humidifiers

4. Heat moisture exchangers

C. Identify oxygen and gas mixture administration devices used with humidifiers.

D. Demonstrate the ability to assemble and adjust humidifiers.

XII. Aerosol Equipment and Therapy

A. Define the terms related to aerosol equipment:

1. Aerosol

2. Atomizer

3. Nebulizer

4. Baffle

5. Output

6. Total flow

7. Bernoulli effect

8. Venturi principle

9. Piezoelectric

B. Describe and adjust aerosol generators for particle size, output, and total flow.

1. Jet capillary nebulizers

a. Large reservoir airway hydration nebulizers

b. Small reservoir medication nebulizers

c. Large reservoir medication nebulizers

d. Tents

2. Ultrasonic nebulizers

3. Small particle aerosol generator (SPAG) nebulizers

C. Compute air entrainment ratios and total patient flow for large reservoir nebulizers.

D. List factors which determine aerosol deposition, stability, and particle size production.

E. Demonstrate the ability to assemble and adjust aerosol generators.

F. Identify oxygen and gas mixture administration devices used with the nebulizers.

G. Identify the rationale, clinical indications, contraindications, and complications for aerosol therapy.

H. Demonstrate the ability to determine therapeutic goals and modifications in the therapeutic plan.

I. Define terms and abbreviations related to aerosol therapy.

J. Select the appropriate aerosol equipment for the respiratory care plan.

K. Assemble equipment to include:

1. Small and large volume medication nebulizers

2. Metered Dose Inhalers (MDI) with spacer

3. Large reservoir nebulizers

4. Ultrasonic nebulizers

5. Oxygen mist tents

L. Explain planned therapy and goals to patient in understandable terms.

M. Demonstrate the ability to appropriately deliver aerosol therapy.

N. Demonstrate the ability to evaluate patient's responses, equipment operation, and modifications of delivered therapy.

O. Record therapy in the patient record using conventional terminology.

P. Communicate information regarding clinical status to appropriate members of the healthcare team.

XIII. Analyzers, Pulse Oximeters, and Blenders

A. Discuss the rationale for the use of analyzers.

B. Demonstrate the ability to assemble, calibrate, and troubleshoot analyzers.

C. Describe the appropriate use of oxygen analyzers for:

1. Placement of analyzers in patient circuits

2. Effect of humidity on analyzer accuracy

3. Appropriate alarm settings on analyzers for all patient populations

D. Describe the blender indications and operation.

E. Demonstrate the ability to identify pulse oximeters and their principles of operation.

F. Demonstrate the ability to set up and troubleshoot pulse oximeters.

XIV. Titration

A. Demonstrate the ability to assemble the appropriate equipment for the required fractional inspired oxygen (FiO2.)

B. Demonstrate the ability to calculate the liter flow requirements of air and oxygen required for a given FiO2 with adequate patient flow.

C. Demonstrate the ability to assemble equipment at a specified FiO2 to ensure adequate patient flow.

XV. Airway Clearance Techniques

A. Demonstrate the ability to identify the rationale, clinical indications, contraindications, possible hazards, and complications for airway clearance techniques.

B. Determine therapeutic goals and modifications to the therapeutic plan.

C. Discuss the requirements of an effective cough.

D. Demonstrate obtaining a sputum sample.

E. Describe possible macroscopic and microscopic findings of sputum examination.

F. Identify terms and abbreviations related to airway clearance techniques.

G. Demonstrate the ability to select the appropriate airway clearance equipment to implement the respiratory care plan.

H. Assemble the equipment for:

1. Vacuum systems

2. Open and in-line suction catheters

3. Mechanical vibrators/percussors

4. Flutter valves

5. High frequency chest wall oscillation (HFCWO)

6. Specimen collectors or traps

7. Oral suction devices

8. Intrapulmonary percussive ventilation (IPV)

9. Positive expiratory pressure (PEP) or other positive airway pressure (PAP) therapy

I. Explain planned therapy and goals to patients in understandable terms.

J. Demonstrate the ability to appropriately deliver the various therapies for airway clearance including:

1. Splinting

2. Deep breathing and coughing

3. Oropharyngeal, nasotracheal, endotracheal, and tracheal suction

4. Chest physiotherapy

5. Flutter

6. High Frequency Chest Wall Oscillation (HFCWO)

7. Autogenic drainage

8. Intrapulmonary Percussive Ventilation (IPV)

9. PEP or other PAP therapy

K. Demonstrate the ability to evaluate the patient's response and modifications to the operation of equipment for delivered therapy.

L. Record therapy in the patient record using appropriate medical terminology.

M. Communicate a patient's clinical status to appropriate members of the healthcare team.

XVI. Hyperinflation Equipment

A. Contrast the function of flow and volume oriented IS devices.

B. Identify the parts of basic continuous PAP and Bilevel PAP setups.

C. List the components checked on CPAP and Bilevel PAP equipment used with oxygen administration devices.

D. Demonstrate the ability to assemble and modify CPAP and Bilevel PAP devices.

XVII. Intermittent Positive Pressure Breathing (IPPB)

A. List the indications, hazards, and complications that may occur with IPPB

B. Demonstrate the ability to summarize the most common situations warranting modification of treatment techniques with recommended actions.

C. Demonstrate the ability to select appropriate lung expansion equipment used to implement the respiratory care plan.

D. Assemble equipment with modifications for:

1. IPPB

2. CPAP/BiLevel PAP

3. Incentive Spirometry (IS)

4. Intermittent positive pressure breathing (IPPB) and CPAP/BiLevel PAP breathing circuits

E. Explain planned therapy and goals to patients in understandable terms.

F. Demonstrate the ability to appropriately deliver the various therapies for lung expansion.

G. Demonstrate the ability to evaluate the patient's responses and modifications to equipment and respiratory care therapies.

H. Record therapy and results in the patient record.

I. Communicate clinical status to appropriate members of the healthcare team.

XVIII. Cleaning and Sterilization

A. Describe physical and chemical methods of disinfection or sterilization.

B. Identify procedures and agents used in sterilization and disinfection including:

1. Mode of action

2. Time requirements

3. Temperature requirements

4. Organisms disinfected or sterilized

5. Concentrations

6. Advantages and disadvantages of use

7. Precautions of use

C. Demonstrate the ability to outline equipment cleaning, disinfecting, and sterilizing procedures.

D. Contrast the sampling techniques used to determine equipment cleanliness or sterility.

E. Demonstrate the ability to describe the appropriate cleaning, disinfecting, and sterilization procedures for:

1. Flowmeters

2. Pulse oximeters

3. Resuscitation bags

4. Main flow filters

5. Peak flow meters

6. Large bore tubing

7. Respirometers/pneumotachs

8. Bronchoscopes

XIX. Hospital Safety Measures for Quality Improvement and Equipment Performance

A. Demonstrate the ability to discuss the selection and purchase of respiratory care equipment.

B. Identify the Respiratory Care Services' responsibilities for preventive maintenance and quality control of equipment.

C. List the current agencies monitoring equipment defects.

D. List compliance standards for equipment safety.

E. Demonstrate the ability to discuss evaluation methods for assessing respiratory care practitioner competencies, and the requirements for recordkeeping.

XX. Respiratory Care and the Healthcare System

A. Contrast ethical and legal behavior.

B. Discuss ways to address possible ethical and legal situations.

C. State the role of ethics in the delivery of respiratory care.

D. Demonstrate the ability to describe ethics committees and role of the respiratory therapist.

E. Discuss the way that technology has increased the incidence of confidentiality violations.

F. Interpret an ethical dilemma.

G. Describe the role of various members of the healthcare team.

H. Recognize the respiratory care practitioner's role in advancing the individual, institutional, and the profession's perceptions.

I. Discuss the skills necessary for effective communication with all customers.

J. Demonstrate the ability to identify stress factors that may be part of a Respiratory Care Practitioner's (RCP's) work, and possible mechanisms for relief.

K. Demonstrate appropriate nonverbal, verbal, and written communication with all customers.

L. Describe a typical hospital organization chart from student through administration.

M. Identify the role of each of the following members of a respiratory department:

1. Medical director

2. Department director or manager

3. Staff Supervisor

4. Staff therapist

5. Student

N. Describe the scheduling process that may be used in respiratory services.

O. Define the following terms:

1. Full-time Employee (FTE)

2. Job description

3. Triage

4. Patient evaluation system

5. Protocols

6. Outcome measures

P. Describe how respiratory employers are typically evaluated.

Q. Demonstrate the ability to describe how workloads may be assigned, and how productivity is determined.

R. Identify the scope of services that may be offered in large, medium, and small patient care arenas.

XXI. Introduction to the Healthcare Delivery System

A. Define the following terms:

1. Preferred provider organization (PPO)

2. Health Maintenance Organization (HMO)

3. Medicare/Medicaid

4. Diagnostic related groupings (DRGs)

5. Capitation

6. Gatekeeping

B. Describe the evolution of healthcare in the United States.

C. Evaluate today's healthcare picture.

D. Discuss the Respiratory Care Practitioner's status and responsibilities in today's healthcare delivery system.

Content Outline and Competencies:

I. Non-invasive oxygen and carbon dioxide monitoring

A. Demonstrate the ability to determine the indications, equipment, and normal parameters for the following non-invasive oxygen and carbon dioxide monitors:

1. Pulse oximeter

2. End-Tidal carbon dioxide (CO2) monitor

3. Transcutaneous CO2 monitor

B. Demonstrate the ability to calculate and interpret noninvasive blood oxygen and carbon dioxide measurements.

II. Arterial Blood Gas Procurement, Analysis, and Interpretation

A. Demonstrate the ability to identify anatomy of the wrist, groin and antecubital fossa in terms of nerve, artery and vein locations.

B. Describe a detailed procedure for obtaining arterial blood samples from:

1. Adult arterial blood gas (ABG) sites

a. Radial artery

b. Femoral artery

c. Brachial artery

d. Arterial lines

2. Infant

3. Neonates

C. Demonstrate the ability to state the indications, contraindications and hazards associated with arterial blood gas acquisition.

D. Discuss the importance of extracting data from a patient’s chart prior to obtaining arterial blood samples.

E. Briefly describe how each of the following function in the analysis of blood samples:

1. PO2 electrode

2. PCO2 electrode

3. pH electrode

4. Co-oximeter

F. Identify normal values for arterial and venous blood gases for adults and children.

G. State the mechanisms that cause the following conditions:

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

H. Interpret blood gas values with clinical impressions.

I. Demonstrate the ability to describe levels and methods of compensation that occur with respiratory acidosis, respiratory alkalosis, metabolic acidosis, metabolic alkalosis, and combined states of respiratory and metabolic acidosis and alkalosis.

J. Recognize erroneous blood gas results and possible causes for the errors.

K. Estimate the bicarbonate (HCO3) value when given the pH and PCO2.

L. Estimate the oxygen saturation on the hemoglobin when given the PO2 and HbO2 values.

M. Demonstrate the ability to identify the following abbreviations, normal values, units of measure and calculations for:

1. Alveolar-arterial gradient (P(A-a)O2)

2. Capillary oxygen content (CcO2)

3. Arterial oxygen content (CaO2)

4. Oxygen content of mixed venous blood (CvO2)

5. Shunt (Qs/Qt)

6. Dead space (Vd)

7. Minute Ventilation (VE)

8. Tidal Volume (Vt)

9. Deadspace to tidal volume ratio (Vd/Vt)

III. Pulmonary Function Testing

A. Define respiratory obstruction and restriction in pulmonary disease states.

B. Identify the criteria used to establish patient normal values for pulmonary function testing.

C. Identify the pulmonary function tests available to assist in the diagnosis of pulmonary disorders to include:

1. Spirometry (lung mechanics)

2. Lung volumes

3. Diffusing capacity

D. Describe the maneuvers utilized to obtain lung flow rates, lung volume, and diffusing capacity.

E. Relate the American Thoracic Society (ATS) criteria for pulmonary function reproducibility.

F. Define the following expiratory flow rate measurements:

1. Forced expiratory volume 1 second (FEV1)

2. Forced expiratory flow 25%-75% (FEF25-75)

3. Peak expiratory flow rate (PEFR)

4. Maximum voluntary ventilation (MVV)

G. Define the following Lung volumes and capacities

1. Total lung capacity

2. Vital Capacity

3. Inspiratory capacity

4. Functional residual capacity

5. Tidal volume

6. Inspiratory reserve volume

7. Expiratory reserve volume

8. Residual volume

H. Demonstrate the ability to define abbreviations used for pulmonary function testing to include:

1. Forced vital capacity (FVC)

2. Forced expiratory volume in one second (FEV1)

3. Forced expiratory flow from 25% to 75% of vital capacity (FEF 25-75)

4. Peak expiratory flow rate (PEFR)

5. Ratio of your forced expiratory volume in one second (FEV1) to your forced vital capacity (FVC). (FEV1/FVC)

6. Total Lung Capacity (TLC)

7. Residual volume (RV)

8. Functional Residual Capacity (FRC)

9. Diffusing Capacity (DLCO)

I. Demonstrate the ability to perform and interpret pulmonary function studies.

IV. Introduction to Radiology

A. Locate the following on normal and abnormal chest X-rays:

1. Position

2. Translucency

3. Soft tissue and thoracic cage

4. Diaphragm

5. Lung fields

6. Mediastinum

7. Hilum

8. Tracheal bifurcation

9. Heart and vasculature

10. Shadows

11. Fissures

12. Costophrenic angle

B. Describe the purpose of the following radiologic procedures:

1. Lordotic/oblique views

2. Inspiratory/expiratory views

3. Decubitus views

4. Tomograms

5. Fluoroscopy

6. Bronchograms

7. Angiograms

8. Lung scans

9. V/Q scans

10. Magnetic Resonance Imaging (MRI)

11. Computerized tomography (CT) scan

C. Demonstrate the ability to contrast normal radiologic findings for interpretation of the following disorders or conditions:

1. Atelectasis

2. Infectious diseases

3. Chronic Obstructive Pulmonary Disease (COPD)

4. Pleural effusion

5. Pneumothorax

6. Pneumonectomy

7. Pulmonary edema

8. Pulmonary embolism

9. Tumors

10. Tuberculosis

11. Chest tube placement

12. Endotracheal tube placement

13. Fractured ribs

D. Describe the impact of acute and chronic radiation exposures.

V. Introduction to Clinical Laboratory Medicine

A. Describe the clinical implications for each of the following hematological assessments:

1. Hemoglobin (Hb)

2. Red Blood Cell (RBC)

3. Hematocrit (Hct)

4. Indices

5. Reticulocyte count

6. White blood cell (WBC) differential

7. Platelet count

8. Bleeding time assessments

a. Prothrombin Time (PT)

b. Partial Thromboplastin Time (PTT)

c. International Normalized Ratio (INR)

9. Blood groups

B. Describe the clinical implications for each of the following tests:

1. Renal

a. Urea and Creatinine clearance

b. Blood, Urea, Nitrogen (BUN)

c. Urinalysis

2. Liver

a. Bilirubin

b. Alkaline phosphate

c. Cholesterol

d. Serum glutamic oxaloacetic transaminase (SGOT)

e. Serum glutamic pyruvic transaminase (SGPT)

f. Lactic acid dehydrogenase (LDH)

3. Endocrine

a. Glucose

b. Glucose Tolerance Test (GTT)

c. Thyroid

d. Parathyroid

e. Adrenal

4. Cardiac

a. SGOT

b. Lactate Dehydrogenase (LDH)

c. Creatine phosphokinase (CPK)

d. Erythrocyte sedimentation rate (ESR)

e. Troponin

5. Cerebral fluid

a. Pressures

b. Appearance

c. Analysis (sugar, protein, cell count)

C. Describe the clinical implications of the following analysis of serum electrolytes and proteins:

1. Electrolytes

a. Sodium (Na+)

b. Potassium (K+)

c. Calcium (Ca++)

d. Chloride (Cl-)

e. Carbon dioxide (CO2)

f. Phosphorus (PO4)

2. Proteins

a. Albumin

b. Alpha 1 and alpha 2

c. Gamma globulins

d. Immunoglobulins

VI. Introduction to Electrocardiography

A. Review the anatomy and physiology of the heart and electrophysiology.

B. Demonstrate the ability to deduce the proper lead placement for monitoring 12 lead electrocardiogram (ECG) evaluations.

C. Identify the normal components of an ECG tracing.

D. Determine the heart rate when provided an ECG tracing.

E. Identify the following ECG rhythms:

1. Normal sinus rhythm

2. Sinus arrhythmia

3. Sinus tachycardia

4. Sinus bradycardia

5. Pacemaker

6. Premature ventricular contractions

7. Ventricular tachycardia

8. Ventricular fibrillation

9. Paroxysmal atrial tachycardia

10. Premature atrial contractions

11. Atrial flutter

12. Atrial fibrillation

13. 1, 2, 3 degree heart blocks

14. Bundle branch blocks

15. Asystole

16. Pacemaker

17. Changes associated with the following conditions:

a. Pulmonary disease

b. Heart hypertrophy

c. K+ or Ca++ electrolyte changes

d. Myocardial ischemia

e. Myocardial injury

f. Myocardial infarction

VII. Bronchoscopy and Thoracentesis

A. Identify the indications for bronchoscopy.

B. Describe the potential complications and hazards of bronchoscopy.

C. Identify the need for rigid scope bronchoscopy.

D. List the steps for preparing a patient for a bronchoscopy.

E. List the steps for preparing a bronchoscope and specimen acquiring tools for a bronchoscopy.

F. Describe the therapist’s responsibilities during a bronchoscopy to include:

1. Bronchial washings and lavage

2. Bronchial tissue biopsy

3. Transbronchial biopsy

4. Brush biopsy

5. Needle biopsy

6. Patient monitoring and comfort

G. Discuss bronchoscopy sample preparation for laboratory analysis.

H. Describe the procedure for cleanup after a bronchoscopy.

I. List typical post bronchoscopy physician orders to include:

1. Respiratory Therapy (RT) orders

2. Nursing orders

J. Identify reasons for performing a thoracentesis.

K. Define transudate and exudate as they apply to thoracentesis fluids.

VIII. Cardiopulmonary Stress Testing

A. Describe the indications for a pulmonary exercise stress test.

B. Describe the parameters measured during a pulmonary exercise test.

C. Demonstrate the ability to define terminology or equations associated with pulmonary exercise testing:

1. Aerobic and anaerobic metabolism

2. Anaerobic threshold

3. Carbon dioxide production

4. Minute ventilation

5. Ergometer

6. Heart and breathing reserves

7. Oxygen consumption

8. Oxygen pulse

9. Respiratory exchange ratio

10. Respiratory quotient

D. Relate cardiac (heart rate) and respiratory response (O2 consumption) to exercise.

E. Identify the pulmonary response to exercise with regard to ventilation and O2 consumption.

F. Identify cardiac response to exercise in heart disease in terms of heart rate and O2 consumption.

G. Identify the use of pulmonary exercise testing in a pulmonary rehabilitation program.

IX. Sleep Studies

A. Demonstrate the ability to identify the types of sleep studies to rule out, diagnose, and treat sleep related breathing disorders.

B. Demonstrate the ability to list the indications and performance protocols for the following types of sleep studies:

1. Nocturnal oximetry

2. Baseline polysomnogram

3. Positive airway pressure (PAP) titration study

4. Split night polysomnogram

C. Identify the diagnostic criteria for the following sleep related breathing disorders:

1. Obstructive sleep apnea

2. Primary Central sleep apnea

3. Cheyne stokes

4. Sleep related hypoventilation

a. Caused by pulmonary disease

b. Obesity related

c. Caused by neuromuscular disease

D. Discuss the PAP desensitization procedure

1. State the types of masks available

2. Relate the modalities of pressure delivery and the settings associated with each.

E. Define the values related to sleep architecture including:

1. Total Study Time (TST)

2. Autonomic Arousal Index (AAI)

3. Sleep Latency

F. Using the sleep study results categorize the severity of the sleep related breathing disorder.

G. Demonstrate the ability to determine the optimal pressure and modality for treatment of sleep related breathing disorders using PAP titration results.

Content Outline and Competencies:

I. Introduction to Disease

A. Describe the potential contributing factors in developing a disease.

B. Explain the physiological response to disease to include:

1. Inflammation

2. The healing process

3. Retrograde changes

4. Circulation changes

5. Growth disturbances

C. Compare the infective process of the following:

1. Host-parasite relationship

2. Defense mechanisms

3. Infectivity of organisms

4. Natural and acquired immunity

5. Immunizations

6. Use of antibiotics

7. Role of bacteria, viruses, fungi and parasites in the infective process

II. Pulmonary Diseases and Other Disorders with Respiratory Implications

A. Explore the etiology, pathology, diagnosis, management and prognosis for the following pulmonary diseases and other disorders with respiratory implications.

1. Chronic Obstructive Pulmonary Disease (COPD)

a. Bronchitis

b. Emphysema

c. Asthma

d. Other obstructive disorders

2. Respiratory Failure

a. Acute respiratory failure

b. Chronic respiratory failure

3. Respiratory diseases due to infection

a. Common cold/other viral infections

b. Influenza

c. Pneumonia

d. Bronchiectasis

e. Tuberculosis

f. Fungal infections

g. Abscess

h. Parasitic infections

i. Granulomatous disease

j. Autoimmune diseases

4. Occupational/environmental pulmonary disorders

a. Pneumoconiosis

b. Organic lung disease

c. Noxious gases

d. Interstitial lung disease

5. Tumors of the lung

a. Neoplasia

b. Role of tobacco products

c. Benign and malignant pulmonary disorders

6. Cardiac Patients

a. Define and differentiate between High-Density Lipoprotein (HDL) and Low-Density Lipoprotein (LDL.)

b. Define angina and be able to differentiate among the three types of angina.

c. Identify diagnostic tests performed to detect myocardial infarction.

d. Describe the treatment of angina.

e. Identify diagnostic tests for chest pain.

f. List signs and symptoms of a myocardial infarction.

g. Classify cardiac disease.

h. Name cardiac enzymes and be able to discuss their significance.

i. Identify the coronary arteries.

j. Describe the pathophysiology and signs and symptoms of the following disease states:

1) Congestive heart failure

a) Right heart failure

b) Left heart failure

2) Cardiomyopathy

a) Hypertrophic

b) Congestive

c) Restrictive

3) Pulmonary edema

4) Valvular disease

a) Mitral

b) Tricuspid

5) Shock

a) Cardiogenic

b) Hemorrhage

c) Hypovolemic

d) Neurogenic

e) Anaphylactic

f) Traumatic

g) Septic

6) Heredity and congenital disorders

a) Alpha 1 antitrypsin

b) Cystic fibrosis

c) Immunoglobulin deficiencies

7) Pleural disorders

a) Effusion

b) Pleurisy

c) Pneumothorax

8) Neurological and neuromuscular disorders resulting in hypoventilation:

a) Guilliane-Barre' Syndrome

b) MyastheniaGravis

c) Trauma of the spinal cord

d) Amyotrophic lateral sclerosis (ALS)

B. Develop a treatment plan for obstructive lung disease to include:

1. Oxygen therapy

2. Therapeutic procedures

3. Mechanical Ventilation

4. Rehabilitation

5. Sub-acute/home care

C. Identify interventions for failing hearts including:

1. Heart transplants

2. Pacemakers

3. Automatic/artificial implantable cardioverter defibrillators (AICD)

4. Intra-aortic balloon pumps

5. Ventricular assist devices

III. Chest X-Ray Interpretation

A. Interpret presented chest X-rays using a systematic examination.

B. Demonstrate the ability to interpret the presented chest X-rays of the above respiratory diseases and disorders using a systematic examination.

Content Outline and Competencies:

I. General Principles of Pharmacology

A. Define the following terms:

1. Drug

2. Pharmacology

3. Therapeutic index

4. Tachyphylaxis

5. Side effect

6. Agonist

7. Antagonist

8. Synergism

9. Placebo

10. Affinity

11. Efficacy

12. Median lethal dose (LD50)

13. Principal effect

14. Half-life

B. Define the following abbreviations:

1. a.c. and p.c.

2. bid, qid, tid

4. gtt

3. g or gm

5. p.o.

6. prn

7. stat

8. MDI

9. noc

10. cc

11. mL

12. hs

13. IM

14. IV

15. I and O

16. DPI

17. mg

18. NPO

19. q2, q3, q4

20. OTC

21. SQ and SC

22. WA

23. SPAG

24. SVN and HHN

C. Differentiate between a generic and trade name.

D. Use the following resources to gain drug information:

1. Digital Physician’s Desk Reference (EPDR)

2. Hospital formulary

3. Product inserts

4. Pharmacist

5. Other reputable websites

E. Describe the pharmaceutical phase of drug action in terms of dosage forms and routes of administration.

F. Explain the pharmacokinetic phase of drug action to include:

1. Mechanisms of absorption

2. Distribution

3. Metabolism

4. Elimination

5. Application to inhaled aerosols

G. Explain the drug receptor model relating to the pharmacodynamics phase of drug action that leads to a drug effect.

H. Review metric to English measurement conversions.

I. Calculate doses from prepared-strength liquids, tablets and capsules.

J. Calculate doses from percentage-strength solutions.

K. Calculate intravenous infusion rates.

II. Administration of Aerosolized Agents

A. Select the equipment appropriate to the respiratory care plan in delivering pharmacological agents.

1. Small- and large-volume medication nebulizers

2. Metered dose inhaler with and without spacers and holding chambers

3. Dry powder inhaler

4. Large-volume bland nebulizers

5. Ultrasonic nebulizers

B. Describe proper aerosolized medication administration to include:

1. Assembling functioning equipment with modifications as needed

2. Drawing medication and diluent with a syringe or dropper

3. Patient instruction for the selected equipment

4. In-line therapy administration for the ventilated patient

5. Documentation

C. Compare the devices used for aerosol delivery and the factors that affect medication delivery to targeted areas of the airways and lung periphery.

III. Sympathomimetic (Adrenergic) Agents

A. Review the sympathetic branch of the autonomic nervous system to include:

1. Anatomy

2. Preganglionic and postganglionic neurotransmitters

3. Receptors

B. Describe the sympathetic response on the following organs/sites:

1. Heart

2. Bronchi smooth muscle

3. Bronchial mucus glands

4. Vascular smooth muscle

C. Describe the effects of alpha, beta 1 and beta 2 receptor stimulation.

D. Differentiate between sympathomimetic and sympatholytic agents.

E. Explain how the chemical structure of a drug may affect bronchodilation.

F. Evaluate clinical scenarios to determine the following for sympathomimetic bronchodilators:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects

5. Assessment of expected outcomes

G. Determine the most appropriate sympathomimetic bronchodilator for a patient respiratory care plan considering the following factors:

1. Onset and duration of action

2. Dosage form

3. Dosage amounts

4. Recommended frequency of administration

5. Signs and symptoms of the patient

H. Recognize the drug class, generic name and trade name for the currently used short and long acting sympathomimetic bronchodilator agents.

I. Review the pathophysiology of Chronic Obstructive Pulmonary Disease (COPD) and asthma, and relate this drug class to the management of COPD and asthma.

IV. Cholinergic and Anticholinergic

A. Review the parasympathetic branch of the autonomic nervous system to include:

1. Anatomy

2. Preganglionic and postganglionic neurotransmitters

3. Receptors

B. Describe the parasympathetic response on the following organs/sites:

1. Heart

2. Bronchi smooth muscle

3. Bronchial mucus glands

4. Vascular smooth muscle

C. Describe the effects of muscarinic receptor stimulation.

D. Differentiate between parasympathomimetic and parasympatholytic agents.

E. Evaluate clinical scenarios to determine the following or parasympathomimetic (e.g., methacholine) and parasympatholytic (e.g., atropine and ipratropium) agents:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects

5. Assessment of expected outcomes

F. Determine the most appropriate parasympatholytic bronchodilator for a patient respiratory care plan considering the following factors:

1. Onset and duration of action

2. Dosage form

3. Dosage amounts

4. Recommended frequency of administration

5. Signs and symptoms of the patient

G. Recognize the drug class, generic name, and trade name for the currently used short and long acting parasympatholytic bronchodilator agents.

H. Review the pathophysiology of COPD and asthma and the relationship of this drug class to the management of COPD and asthma.

V. Methylxanthine Agents

A. Critique clinical scenarios to determine the following for xanthine agents:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects and other physiological effects

5. Assessment of expected outcomes

B. Determine the most appropriate xanthine agent for a patient respiratory care plan considering the following factors:

1. Onset and duration of action

2. Dosage form

3. Dosage amounts

4. Recommended frequency of administration

5. Signs and symptoms of the patient

C. Recognize the drug class, generic name, and trade name for the currently used methylxanthine agents.

D. Discuss the use and role of caffeine in respiratory care practice.

E. Evaluate serum theophylline levels for determination of the anticipated effects of these levels.

F. Recognize factors that affect theophylline effectiveness and clearance for determination of possible therapeutic dosing or frequency adjustments..

G. Review the pathophysiology of COPD and asthma and the relationship of this drug class to the management of COPD and asthma.

VI. Mediator Antagonists (Anti-Asthmatic) Agents

A. Evaluate clinical scenarios to determine the following for mediator antagonist agents:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects and other physiological effects

5. Assessment of expected outcomes

B. Determine the most appropriate mediator antagonist agent for a patient respiratory care plan considering the following factors:

1. Onset and duration of action

2. Dosage form

3. Dosage amounts

4. Recommended frequency of administration

5. Signs and symptoms of the patient

C. Recognize the drug class, generic name and trade name for the currently used anti-asthmatic agents.

D. Review the pathophysiology of COPD and asthma and the relationship of this drug class to the management of COPD and asthma.

VII. Corticosteroids

A. Evaluate clinical scenarios to determine the following for steroidal agents:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects and other physiological effects

5. Assessment of expected outcomes

B. Determine the most appropriate steroidal agent for a patient respiratory care plan considering the following factors:

1. Onset and duration of action

2. Dosage form

3. Dosage amounts

4. Recommended frequency of administration

5. Signs and symptoms of the patient

C. Recognize the drug class, generic name and trade name for the currently used corticosteroid agents.

D. Review the pathophysiology of COPD and asthma and the relationship of this drug class to the management of COPD and asthma.

VIII. Mucokinetic, Surface Active and Cough-and-Cold Agents

A. Describe mucociliary transport in the lung and factors that affect this transport.

B. Describe the nature and physical properties of mucus.

C. Evaluate clinical scenarios to determine the following for mucokinetic, surface active and cough-and-cold agents:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects and other physiological effects

5. Assessment of expected outcomes

D. Determine the most appropriate mucokinetic, surface active and cough-and-cold agent for a patient respiratory care plan considering the following factors:

1. Onset and duration of action

2. Dosage form

3. Dosage amounts

4. Recommended frequency of administration

5. Signs and symptoms of the patient

E. Recognize the drug class, generic name and trade name for the currently used mucokinetic, surfactant and expectorant agents.

F. Discuss the role of bland aerosols and other mucolytic and expectorant agents that may be used in mucus control.

G. Relate these drug classes to respiratory clinical applications.

IX. Anti-Infective Agents

A. Define the following terms:

1. Antibiotic

2. Broad spectrum

3. Narrow spectrum

4. Bacteriocidal

5. Bacteriostatic

6. Anti-fungal

7. Anti-tuberculosis

8. Anti-viral

9. Vancomycin-resistant enterococcus (VRE)

10. Methicillin-resistant staphylococcus aureus (MRSA)

11. Pneumocystis Carinii Pneumonia (PCP)

B. Evaluate clinical scenarios to determine the following anti-infective agents:

1. Mode of action

2. Indication for use

3. Routes of administration

4. Associated adverse effects and other physiological effects

5. Assessment of expected outcomes

C. Determine the most appropriate inhaled anti-infective agent for a patient respiratory care plan considering the following factors:

1. Dosage form

2. Dosage amounts

3. Recommended frequency of administration

4. Signs and symptoms of the patient

5. Infective organism

D. Recognize the drug class, generic name and trade name for the currently used inhaled anti-infective agents.

E. Provide examples, mode of action, clinical indication, general contraindications, precautions and adverse reactions associated with following classes of antibiotics:

1. Penicillins

2. Cephalosporins

3. Carbapenems

4. Aminoglycosides

5. Tetracyclines

6. Quinolones

7. Polymixins

8. Erythromycins

9. Sulfonamides

10. Misc. antibiotics

11. Anti-tuberculosis

12. Anti-fungal

13. Anti-viral

14. Interferons

X. Cardiovascular and Diuretic Agents

A. Define the following terms:

1. Chronotropic

2. Inotropic

3. Cardiotonic

4. Preload

5. Afterload

B. Describe factors that affect blood pressure and cardiac function.

C. Provide examples, drug class, mode of action and general clinical indications for the following agents:

1. Cardiac glycosides

2. Phosphodiesterase inhibitors

3. Beta adrenergic stimulants

4. Anti-arrhythmics

5. Vasodilators/anti-hypertensive agents

6. Antianginal agents

7. Vasopressors

8. Antithrombotics

9. Diuretics

D. Manage common cardiac emergencies according to ACLS protocol.

E. Apply the appropriate class of agent to the cardiac patient scenario and recommendations of a drug or drugs in each class.

XI. Skeletal Muscle Relaxants

A. Describe the physiology of the neuromuscular junction and the nondepolarizing and depolarizing neuromuscular blocking agents.

B. Provide examples, mode of action, clinical indication, general contraindications, precautions, adverse reactions and possible reversal agents associated with the use of nondepolarizing and depolarizing neuromuscular blocking agents.

C. Relate these agents to respiratory clinical applications.

XII. Agents Affecting the Central Nervous System

A. Describe the clinical uses, principal effects and adverse effects associated with the following drug classes:

1. Sedatives and hypnotics

2. Barbiturates

3. Nonbarbiturate hypnotics

4. General anesthetics

5. Local anesthetics

6. Psychotherapeutic agents

7. Narcotic and non-narcotic analgesics

8. Respiratory stimulants

B. Provide examples, mode of action, clinical indication, precautions, adverse reactions and possible reversal agents associated with the drug classes identified.

C. Relate these agents to respiratory clinical applications.

D. Describe the clinical manifestations and management of barbiturate and narcotic overdoses.

E. Briefly describe malignant hyperthermia.

F. Briefly describe conscious sedation and the respiratory clinical applications.

Content Outline and Competencies:

I. Respiratory Failure

A. Define respiratory failure.

B. Describe the etiologies of respiratory failure.

C. Differentiate between acute hypoxemic respiratory failure, acute hypercapnic respiratory failure and chronic respiratory failure.

D. Analyze patient assessment, radiological, pulmonary function and laboratory findings associated with respiratory failure.

E. Develop a treatment plan for acute or chronic respiratory failure to include:

1. Oxygen therapy

2. Therapeutic procedures

3. Need for mechanical ventilation

II. Noninvasive Positive Pressure Ventilation

A. Identify the indications and contraindications for noninvasive positive-pressure ventilation (NPPV).

B. Describe the management of patients receiving NPPV including invasive/noninvasive blood gas monitoring, patient positioning, and other systemic precautions.

C. Initiate the use of NPPV including machine set up, machine/circuit testing, mode selection, entry of initial settings, and entry of alarm settings.

D. Demonstrate the application of the patient-ventilator interface.

E. Manage the use of NPPV including manipulation of modes/settings to achieve optimal ventilation/oxygenation and troubleshooting complications.

F. Assess the patient’s response to treatment.

G. Articulate the NPPV weaning procedure.

III. Airway Care

A. Identify the following types of manual resuscitators:

1. Flow-inflating

2. Self-inflating

3. T-piece

B. Determine the average minute volume delivered to the patient with a manual resuscitator as it relates to the patient ventilatory needs during resuscitation situations.

C. Identify factors that affect fraction of inspired oxygen (FIO2) delivery when using manual resuscitators.

D. Demonstrate effective techniques of bag/mask and bag/endotracheal or tracheal tube ventilation.

E. Describe corrective action for potential problems that may arise with manual resuscitators.

F. Discuss the advantages and disadvantages that may be encountered with different types of manual resuscitators.

G. Review the anatomy of the airway.

H. Identify the features, indications, applications, advantages, disadvantages and possible complications of each of the following:

1. Oropharyngeal airways

2. Nasopharyngeal airways

3. Orotracheal airways

4. Nasotracheal airways

5. Double lumen endotracheal (ET) tubes

6. Trach tubes and buttons

7. Cricothyroidotomy

8. Supraglottic airway devices

9. Esophageal/tracheal tubes

10. Esophageal obturator

11. Specialty tubes

I. Review airway management techniques to include:

1. Patient positioning

2. Foreign body removal

3. Artificial oral airways

4. Artificial endotracheal airways

5. Artificial tracheal airways

6. Oropharyngeal, endotracheal and tracheal suctioning

7. Endotracheal intubation and extubation

8. Laryngeal mask airways

9. Combitube airways

10. Esophageal obturator

J. Describe the features and applications of each of the following that may be used in inserting and assessing artificial airways:

1. Laryngoscope blades

2. Laryngoscope handles

3. Stylets

4. Fiber optic laryngoscopes

5. Exhaled carbon dioxide (CO2) detection devices

6. Cuff pressure manometers

K. Determine appropriate techniques for disinfection and/or sterilization of non-disposable airway care items to include:

1. Resuscitation bags

2. Laryngoscope blades

3. Laryngoscope handles

4. Stylets

L. Describe for each of the airways identified above:

1. Proper head position

2. Appropriate type and size of airway

3. Proper artificial airway insertion

4. Assessment techniques verifying airway placement

5. Stabilization of the artificial airway, as indicated

6. Removal of the artificial airway

M. Describe the proper procedure for trach care.

N. Articulate the appropriate application of oxygen, aerosol and humidity to the patient with the artificial airways identified above.

O. Demonstrate proper airway cuff assessments and maintenance.

P. Compare endotracheal tube sizes and the appropriate suction catheter size.

Q. Recognize the indications and complications of suctioning the airway.

R. Describe design characteristics and application of different types of suction catheters.

S. Demonstrate proper equipment selection and preparation for suctioning a patient.

IV. Arterial Blood Gas Procurement and Analysis

A. Identify anatomy of the wrist, groin & antecubital fossa in terms of nerve, artery& vein location.

B. Describe a detailed procedure for obtaining arterial blood samples from the following sites:

1. Radial/femoral/brachial artery puncture

2. Arterial and umbilical arterial lines

C. State the indications, contraindications and hazards associated with arterial blood gas acquisition.

D. Discuss the importance of extracting data re: diagnosis, clinical lab tests, medications, etc., from a patient’s chart prior to obtaining arterial blood samples.

E. Identify the normal values for arterial and venous blood gases for adults.

V. Critical Care Monitoring

A. State the indications and possible complications associated with pulmonary artery catheters, central venous pressure (CVP) catheters and arterial catheters.

B. Describe the insertion procedure and anatomic placement of each of the catheters listed above.

C. Describe the information that may be obtained from the blood samples and pressure tracings from pulmonary artery, CVP and arterial catheters.

D. Define (pulmonary artery pressure) PAP, (pulmonary artery wedge pressure) PAWP, CVP and cardiac output (CO), with normal values for each.

E. Describe the set-up for arterial lines including transducer calibration, pulmonary artery catheters and CVP lines.

F. Identify pressure tracings for each of the above monitoring lines.

G. Describe the different methods of obtaining cardiac output.

H. Describe the use of pulmonary artery, CVP and arterial catheters in patient/ventilator management.

I. Describe the use and function of the ear/pulse oximeters, transcutaneous monitoring and end-tidal CO2 monitoring.

J. Describe the procedures and anatomical placement of each item listed above.

K. Identify abnormal capnography tracings and the potential causes.

L. State advantages and disadvantages for each of the above monitoring techniques.

M. Describe factors that may cause errors in the information from each of these monitoring devices with recommendations for correcting malfunctions.

N. Identify patient conditions needing treatment based on information from these assessment sources.

VI. Introduction to Mechanical Ventilation

A. Differentiate different types of ventilators using a classification system.

B. Describe ventilator breathing circuits and related equipment.

C. Determine the implications of compliance and resistance of the patient on a ventilator.

D. Describe the mechanics of normal breathing.

E. Describe the modes of ventilation that may be available on mechanical ventilators.

F. Determine the clinical indications for mechanical ventilation.

G. Describe clinical conditions that may require mechanical ventilation.

H. Perform pre-application system and safety checks.

I. Set up a ventilator with initial parameters.

J. Establish initial alarm settings with appropriate adjustments upon patient application.

K. Adjust the ventilator parameters as indicated by ABGs and other clinical data.

L. Describe methods to maintain adequate humidification of the airway for mechanically ventilated patients.

M. Assemble additional equipment that may be associated with the mechanically ventilated patient.

N. Describe hemodynamic changes with Positive Pressure Ventilation (PPV) to include estimation of pulmonary artery wedge pressure (PAWP) with PPV.

O. Calculate volume delivered for alveolar exchange in a patient being mechanically ventilated based on tubing and anatomical deadspace loss.

P. Review monitoring techniques and devices used when ventilating a patient to include:

1. Arterial Blood Gases (ABGs)

2. Vital signs

3. Lab values

4. Urine output

5. Pulmonary artery pressure monitoring

6. Routine ventilator checks

7. External alarms

8. Cuff pressure monitoring

Q. Identify total ventilatory and partial ventilatory support modes.

R. Calculate the following in SIMV mode:

1. Spontaneous tidal volume

2. Spontaneous minute volume

3. Spontaneous respiratory rate

4. Machine minute volume

VII. Chest Trauma and Emergency Care

A. Produce appropriate priority action and emergency life support techniques for management of emergency situations.

B. Discuss hazards associated with cardiac compressions and ventilation during cardiopulmonary resuscitation (CPR) with measures taken to minimize the hazards.

C. Discuss methods to achieve maximum fraction of inspired oxygen (FIO2) delivered with a manual resuscitator.

D. Describe the indications, effectiveness factors and techniques of:

1. Closed chest massage

2. Open chest massage

3. Defibrillation

4. Cardioversion

E. Discuss the initial and secondary assessment of the trauma patient for application to real and simulated patient scenarios.

F. Identify abnormal findings associated with each of the following using physical exam and topographical and anatomical landmarks:

1. Simple rib fractures or flail chest

2. Pulmonary contusion

3. Pleural effusion

4. Fat emboli

5. Sucking chest wounds

6. Simple pneumothorax

7. Tension pneumothorax

8. Hemothorax

9. Cardiac contusion

10. Cardiac tamponade 

11. Rupture or laceration of:

a) Airways

b) Major vessels

c) Diaphragm

G. Determine the etiology, pathology, clinical findings and management for the identified conditions above.

H. Determine causes for respiratory failure after resuscitation or chest trauma.

I. Compare the etiology, pathology, clinical findings and management for three types of shock:

1. Hypovolemic

2. Cardiogenic

3. Distributive

Content Outline and Competencies:

I. Embryology and Fetal/Neonatal Transition

A. Compare the blood gas values of umbilical arteries and the umbilical veins.

B. Describe the development of the lung and when the development is compatible with maintaining life outside the uterus.

C. Describe the development of the heart and when the heart is fully formed.

D. Describe the development of lung fluids and surfactant in relationship to the following:

1. Sources

2. Composition

3. Time appearance in the developmental stage

4. Physiological importance

E. Describe the methods that may be used to stimulate surfactant development in utero.

F. Describe fetal circulation in relation to the following:

1. Placental role in fetal blood flow and gas exchange

2. Pathway of blood flow and limited circulation to the lungs in utero

3. Oxygen levels

4. Anatomical differences between fetal and adult circulation

5. Physiological changes in the cardiovascular system at birth

6. Anatomical changes in the cardiovascular system at birth

G. Interpret arterial blood gas levels at the following stages:

1. Fetal

2. At birth

3. 24 hours after birth

H. Describe the physiologic events that must occur with the first breath, to include:

1. Inflation pressures

2. Stimulus to breathe

3. Role of the lung fluids

I. Describe the compliance and resistance of the newborn lung.

J. Compare the OHDC (Oxygen-Hemoglobin Dissociation Curve) relationship of the newborn with that of the adult.

K. Compare fetal hemoglobin to adult hemoglobin and the implications for oxygenation.

II. Maternal and Fetal Assessment

A. Describe factors relating to high-risk pregnancies and deliveries that may result in an increased potential for respiratory distress of the neonate.

B. Describe the following assessment techniques used to determine fetal status:

1. Amniocentesis

2. Ultrasound

3. Fetal heart monitoring

C. Compare and contrast studies that assess lung maturity.

D. Describe early, late, and variable decelerations, and the implications for delivery.

E. Apply the Apgar scoring system to clinical descriptions of a newborn.

F. Describe the methods used to determine gestational age.

G. Analyze the respiratory rate, heart rate and blood pressure for presented scenarios.

H. Differentiate between periodic breathing and apnea.

I. Describe thermoregulation for newborns and the implications of heat loss or cold stress of the newborn.

J. Identify factors that will contribute to newborn heat loss or cold stress, given presented scenarios.

K. Describe the causes and basic management of hyperbilirubinemia.

L. Analyze clinical lab findings and radiologic findings for presented scenarios.

M. Describe why and how aseptic conditions are maintained in the nursery.

N. Differentiate between Level I, Level II and Level III nurseries.

III. Neonatology

A. Describe the assessments made in the physical and neurological exam of the neonate.

B. Describe the etiology, pathophysiology, signs, symptoms and clinical findings for the following neonatal disorders:

1. Respiratory distress syndrome (RDS)/Hyaline Membrane Disease (HMD)

2. Transient Tachypnea of Newborn (TTN or TTNB)

3. Bronchopulmonary Dysplasia (BPD)/Chronic Lung Disease (CLD)

4. Meconium Aspiration Syndrome (MAS)

5. Air leaks (Pneumothorax, Pneumomediastinum, and Pulmonary Interstitial Emphysema (PIE))

6. Pneumonia/Infection/Sepsis

7. Asphyxia

8. Intraventricular Hemorrhage (IVH)

9. Apnea of prematurity (AOP)

10. Persistent Pulmonary Hypertension (PPHN)/Persistent Fetal Circulation (PFC)

11. Retinopathy of Prematurity (ROP)

C. Analyze the available clinical data to determine the disease or pathophysiological state for presented neonatal scenarios.

D. Develop a respiratory care plan for the neonatal disorders identified in presented neonatal disorders.

E. Describe the technique(s), equipment selection and characteristics, and patient applications necessary to conduct pediatric resuscitation efforts according to established protocols.

F. Describe the potential developmental outcomes that are associated with the care of infants with early respiratory difficulties.

IV. Congenital Defects

A. Describe the defect, the primary means of diagnosis, and general and respiratory treatment management for the following defects:

1. Congenital pulmonary anomalies

a. Choanal atresia

b. Tracheoesophageal anomalies

c. Pierre Robin Syndrome

d. Congenital Diaphragmatic Hernia (CDH)

2. Congenital cardiac anomalies

a. Transposition of the great vessels (TGV)

b. Tetralogy of Fallot (TOF or TET)

c. Atrial Septal Defect (ASD)

d. Ventricular Septal Defect (VSD)

e. Patent Ductus Arteriosus (PDA)

f. Coarctation of the aorta (Coarc)

g. Tricuspid/pulmonary atresia

h. Total Anomalous Pulmonary Venous Return (TAPVR)

i. Truncus Arteriosus

j. Hypoplastic left heart

k. Subaortic stenosis

3. Miscellaneous conditions

a. Necrotizing enterocolitis (NEC)

b. Gastroschisis

c. Omphalocele

d. Myelomeningocele

B. Analyze the available clinical data to determine the disease or pathophysiological state for presented congenital defect scenarios.

C. Develop a respiratory care plan for the neonatal disorders identified in presented congenital defect scenarios.

V. Care of the Pediatric Patient

A. Determine normal physical characteristics, psychosocial skills, and motor development for infants, toddlers, preschool, school-age and adolescent patients.

B. Describe appropriate communication and teaching techniques for the five age groups.

C. Describe the etiology, pathophysiology, signs, symptoms and clinical findings for the following pediatric disorders:

1. Asthma

2. Bronchiolitis/Respiratory Syncytial Virus (RSV)

3. Croup/Laryngotracheobronchitis (LTB)

4. Epiglottis

5. Cystic Fibrosis (CF)

6. Sudden Infant Death Syndrome (SIDS)

7. Aspiration/Inhalation

8. Near drowning

9. Head trauma

10. Neuromuscular disorders

11. RDS

D. Analyze the available clinical data to determine the disease or pathophysiologic state for presented neonatal scenarios.

E. Develop a respiratory care plan for the neonatal disorders identified in presented neonatal disorders.

F. Describe the technique(s), equipment selection, and patient applications necessary to conduct pediatric resuscitation efforts according to established protocols.

VI. Transport

A. Compare and contrast the modes of transport.

B. Relate the effects of altitude with air transport to include patient problems, equipment problems and the effects on transport team members.

C. Describe stabilization techniques that may be performed by the transport therapist.

D. Discuss the appropriate support measures for a patient with marginally acceptable blood gas values prior to leaving on transport.

E. Describe the considerations that should be made when selecting equipment for transport.

F. Describe the considerations that should be made when determining if a patient should be transported to a major care center.

G. Calculate the length of gas service for given patient transport scenarios.

VII. Home Care

A. Describe the roles and responsibilities of a discharge planning team member.

B. Determine the considerations that should be made when selecting equipment for home care.

C. Describe tracheostomy home care for patients.

D. Compare gas systems used for home care to include gas cylinders, liquid systems and concentrators, and determine the most appropriate system for selected home care situations.

E. Contrast patient oxygen delivery devices and respiratory therapy equipment used for the home care and determine the most appropriate equipment for selected home care situations.

F. Describe the patient/family/caregiver education that should be provided for respiratory home care situations.

VIII. Assessment and Management of Oxygenation and Ventilation

A. Describe the assessment and monitoring techniques used for the neonatal/pediatric patients and to patient scenarios.

B. Describe the principles and goals of neonatal/pediatric mechanical ventilation.

C. Describe the indications and complications associated with neonatal/pediatric mechanical ventilation.

D. Determine the appropriate airway type and size for given neonatal/pediatric patients.

E. Determine the initial mechanical ventilator settings for various patient sizes.

F. Describe clinical indications and delivery techniques for surfactant replacement therapy.

G. Describe the effects of Continuous Positive Airway Pressure (CPAP) therapy on the following:

1. Functional Residual Capacity (FRC)

2. Lung compliance

3. Airway resistance

4. Respiratory rate

5. Cardiac output

6. Pulmonary blood flow

7. Cerebral blood flow

8. Arterial blood gases

H. Describe the indications, equipment and delivery techniques, potential complications and adverse effects relating to CPAP therapy and apply to given patient scenarios.

I. Compare and contrast the various CPAP system setups for advantages and disadvantages.

Content Outline and Competencies:

I. Effects of Positive-Pressure Ventilation on body systems

A. Recognize the presence of barotrauma or extra-alveolar air based on patient assessment.

B. Recommend an appropriate intervention in patients with barotrauma.

C. Identify situations in which chest-wall rigidity can alter transpulmonary pressures and acceptable plateau pressures (Pplateau).

D. Name the types of ventilator-induced lung injuries (VILI) caused by the opening and closing and over distention of the alveoli.

E. Compare the clinical findings associated with hyperventilation and hypoventilation.

F. Recommend ventilator settings in patients with hyperventilation and hypoventilation.

G. Identify a patient with air trapping.

H. Provide strategies to reduce auto-PEEP.

I. Suggest methods to reduce the work of breathing (WOB) during mechanical ventilation (MV).

J. List the possible responses to an increase in mean airway pressure in a patient who is receiving ventilation.

K. Describe the effects of positive-pressure ventilation (PPV) on pulmonary gas distribution and pulmonary perfusion in relation to normal spontaneous breathing.

L. Explain the effects of positive-pressure ventilation (PPV) on cardiac output and venous return to the heart.

M. Discuss the three factors that can influence cardiac output during PPV.

N. Explain the effects of PPV on gas distribution and pulmonary blood flow in the lungs.

O . Describe how PPV increases intracranial pressure.

P. Summarize the effects of PPV on renal and endocrine function.

Q. Describe the effects of abnormal arterial blood gases on renal function.

R. Name five ways of assessing a patient’s nutritional status.

S. Describe techniques that can be used to reduce some of the complications associated with mechanical ventilation.

II. Patient-Ventilator System Checks

A. Explain the purpose of patient-ventilator system checks.

B. Describe the essential elements of the patient-ventilator system check.

C. Describe the timing and frequency of patient-ventilator system checks.

D. List the typical components of a ventilator flow sheet.

E. Relate the purpose of advanced airway cuffs.

F. Demonstrate the procedure for obtaining optimal cuff pressure via auscultation and manometry.

G. Describe the hazards associated with inappropriate cuff pressures.

H. Recognize inappropriate endotracheal tube (ET) cuff pressures and an inappropriate tube size, and recommend measures to correct these problems.

I. Demonstrate the proper use of an endotracheal tube exchanger.

J. Describe methods that can be used to remedy a cut pilot tube (pilot balloon line) without changing the ET.

K. Calculate the appropriate suction catheter size for a specific size endotracheal tube (ET) and patient.

L. State appropriate suction pressures used during endotracheal suctioning of adults, children, and infants.

M. Compare the benefits of closed-suction catheters with the open-suction technique.

N. List the pros and cons of instilling normal saline to loosen secretions before suctioning.

O. Describe the appropriate conditions and placement of chest tubes for air and fluid evacuation.

P. Identify when a chest tube is indicated in the treatment of a pleural effusion.

Q. Contrast the features, function and precautions associated with the chest drainage systems:

1. Three-bottle

2. Pleur-Evac or other disposable systems

R. Recognize improper function of chest drainage systems with identification of appropriate troubleshooting measures to correct the improper function.

III. Assessment of Respiratory Function in the Mechanically Ventilated Patient

A. Calculate mean airway pressure (Paw), dynamic compliance (CD), static compliance (Cs), and airway resistance (Raw).

B. Identify various pathophysiologic conditions that alter a patient’s:

1. Transairway pressure (PTA)

2. Peak pressure

3. Plateau pressure (Pplateau)

C. Determine whether a lung compliance (CL) problem or an airway resistance (Raw) problem is present using the ventilator flow sheet and time, volume, peak inspiratory pressure (PIP), and Pplateau data.

D. Evaluate a static pressure–volume curve for static compliance (Cs) and dynamic compliance (CD) to determine changes in compliance or resistance.

E. Describe how changes in Raw and respiratory system compliance will affect the results of measurements of the work of breathing.

IV. Ventilator Graphics

A. Classify scalars based on morphology.

B. Describe the relationship between scalars and delivered flow, pressure and volume during the respiratory cycle.

C. Explain how changing ventilator parameters will affect scalars in various modes of mechanical ventilation.

D. Identify ventilator variables and ventilator parameters and their values from flow-volume and pressure-volume (P-V) loops.

E. Use ventilator scalars and loops to detect changes in lung compliance (CL) and airway resistance (Raw), inappropriate sensitivity settings, inadequate inspiratory flow, unintended positive end-expiratory pressure (auto-PEEP), leaks in the ventilator circuit, active exhalation during pressure support ventilation, and an inspiratory pressure overshoot during pressure support ventilation (PSV).

F. Use pressure-time and flow-time curves obtained during pressure-controlled continuous mandatory ventilation (PC-CMV) to determine the Pplateau.

G. Describe how changes in airway resistance and lung compliance affect scalars and loops during volume-targeted and pressure-targeted ventilation when airway resistance (Raw) increases and lung compliance (CL) decreases.

H. Recognize periods of patient-ventilator asynchrony using scalars and loops.

V. Methods to Improve Ventilation

A. Estimate a patient’s alveolar ventilation based on:

1. Ideal body weight

2. Tidal volume (VT)

3. Respiratory rate (f)

B. Recommend ventilator adjustments to reduce the work of breathing and to improve ventilation based on patient diagnosis, arterial blood gas (ABG) results, and ventilator parameters.

C. List the clinical findings that are used to establish the presence of a respiratory infection.

D. Compare the protocols for using metered-dose inhalers (MDIs) and small-volume nebulizers (SVNs) during mechanical ventilation.

E. Describe complications associated with using SVNs powered by external flowmeters during mechanical ventilation.

VI. Improving Oxygenation and Management of Acute Respiratory Distress Syndrome

A. Calculate the desired fractional inspired oxygen (FIO2) needed to achieve the desired partial pressure of oxygen in the arteries (PaO2), based on current ventilator settings and blood gases.

B. Calculate a patient’s pulmonary shunt fraction.

C. Identify indications and contraindications for CPAP and PEEP.

D. List the primary goal of PEEP and the conditions in which high levels of PEEP are most often used.

E. Describe the most appropriate method establishing an optimum level of PEEP for a patient with acute respiratory distress syndrome (ARDS) using a recruitment-derecruitment maneuver and the deflection point (lower inflection point during deflation or derecruitment). (This is repeated in O)

F. Explain the effects of PEEP/CPAP therapy on a patient with a unilateral lung disease.

G. Describe the problems associated with initiating PEEP in a patient with an untreated pneumothorax.

H. Recommend adjustments in PEEP and ventilator settings based on the physical assessment of the patient, ABGs, and ventilator parameters.

I. Compare static compliance, hemodynamic data, and ABGs as indicators of an optimum PEEP.

J. Identify from patient assessment and the ABGs when it is appropriate to change from CPAP to mechanical ventilation with PEEP.

K. Identify the severity of ARDS using the PaO2/FIO2 ratio.

L. Recommend an appropriate tidal volume (VT) setting for a patient with ARDS.

M. Identify the maximum Pplateau value to use for patients with ARDS.

N. Identify the criteria that should be used to liberate a patient from PEEP or CPAP.

O. Recommend a PEEP setting based on the inflection point on the deflation curve using the pressure-volume loop for a patient with ARDS.

P. Describe the procedure for prone positioning in ventilated patients with adult respiratory distress syndrome.

Q. List potential problems associated with placing the patient in a prone position during mechanical ventilation.

R. Discuss several theories that describe how prone positioning improves ventilation-perfusion in adult respiratory distress syndrome.

VII. Ventilator Associated Pneumonia

A. Define ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP).

B. Differentiate between early onset VAP and late onset VAP, and describe the overall incidence of VAP.

C. Discuss the prognosis, including morbidity and mortality rates, for patients diagnosed with VAP.

D. Identify the most common pathogenic microorganisms associated with VAP.

E. List non-pharmacologic and pharmacologic therapeutic interventions that have been shown to increase the risk of developing VAP.

F. Describe the sequence of events that are typically associated with VAP.

G. Discuss the advantages and disadvantages of using clinical findings versus quantitative diagnostic techniques to identify patients with VAP.

H. Briefly describe the criteria for starting empiric antibiotic therapy for patients without evidence of multidrug-resistant (MDR) infections and for those patients at risk of developing MDR infections.

I. Define de-escalation of antibiotic therapy and how it can be used to reduce the emergence of MDR pathogens.

J. Discuss how ventilator bundles can be used to prevent VAP and the emergence of MDR pathogens in the clinical setting.

VIII. Ventilator management for patient specific conditions.

A. Identify disease specific problems associated with mechanical ventilation for the following disease states:

1. COPD

2. Asthma

3. Neuromuscular Disorders

4. Closed Head Injury

5. ARDS

6. Acute Cardiogenic Pulmonary Edema and Congestive Heart Failure

B. Adjust mechanical ventilator parameters to achieve optimal oxygenation and ventilation for disease-specific scenarios.

IX. Weaning and Discontinuation from Mechanical Ventilation

A. List the weaning parameters and acceptable values for ventilator discontinuation.

B. Compare the three standard modes of weaning in relation to their success in discontinuing ventilation.

C. Define the closed loop modes of weaning described in this chapter.

D. Recognize appropriate clinical use of closed loop modes of weaning from a description of a clinical setting.

E. Identify assessment criteria for discontinuing a spontaneous breathing trial (SBT) in a clinical situation.

F. Describe criteria used to determine whether a patient is ready for extubation.

G. Recognize post-extubation difficulties from a clinical case description.

H. Recommend appropriate treatment for post-extubation difficulties.

I. State the first recommendation for weaning a patient from mechanical ventilation established by the task force formed by the American College of Chest Physicians (ACCP), the Society of Critical Care Medicine (SCCM), and the American Association for Respiratory Care (AARC).

J. Describe an appropriate treatment for a patient with an irreversible respiratory disorder that requires long-term ventilation.

K. Name the parameter used as the primary index of the drive to breathe.

L. Suggest adjustments to the ventilator settings during the use of a standard weaning mode based on patient assessment.

M. Explain the appropriate procedure for the management of a patient for whom an SBT has failed.

N. Defend the use of therapist-driven protocols as key components of efficient and effective patient weaning.

O. Explain the function of long-term care facilities in the management of patients who are dependent on ventilation.

P. Assess data used to establish the probable cause of a failure to wean.

X. Neonatal and Pediatric Mechanical Ventilation

A. Discuss the clinical manifestations of respiratory distress in neonatal and pediatric patients.

B. Identify differences in the level of noninvasive ventilatory (NIV) support.

C. Describe device function and settings for different mechanical respiratory support strategies.

D. Identify the primary and secondary goals of ventilatory support of newborn and pediatric patients.

E. Explain some key areas of assessment that influence the decision on whether to initiate ventilatory support.

F. Recognize the indications, goals, limitations, and potentially harmful effects of continuous positive airway pressure (CPAP) in a clinical case.

G. From patient data, recognize the need for mechanical ventilatory support in newborn and pediatric patients.

H. Identify the essential features of a neonatal and pediatric mechanical ventilator.

I. Explain how the advanced features of a ventilator enhance its usefulness over a wide range of clinical settings.

J. Select appropriate ventilator settings based on the patient’s weight, diagnosis, and clinical history; in addition, discuss the strategies and rationale for ventilator settings.

K. Discuss newborn and pediatric applications, technical aspects, patient management, and cautions for the following ventilatory modes:

1. Pressure-control ventilation

2. Volume-control ventilation

3. Dual-controlled ventilation

4. Pressure-support ventilation

5. Airway pressure release ventilation

6. Neurally adjusted ventilatory assist

L. Discuss the rationale and indications for high-frequency ventilation (HFV) in newborn and pediatric patients.

M. Compare the characteristics and basic delivery systems of the following HFV techniques:

1. High-frequency positive-pressure ventilation (HFPPV)

2. High-frequency jet ventilation (HFJV)

3. High-frequency flow interrupter (HFFI)

4. High-frequency percussive ventilation (HFPV)

5. High-frequency oscillatory ventilation (HFOV)

N. Explain the physiologic and theoretic mechanisms of gas exchange that govern HFV, and defend the mechanism believed to be most correct.

O. Explain how settings of a given high-frequency technique are initially adjusted, the effect of individual controls on gas exchange, and the strategies of patient management.

P. Discuss the physiologic benefits of inhaled nitric oxide (NO) therapy, and suggest recommended treatment.

XI. Special Techniques in Ventilatory Support

A. Discuss the benefits and disadvantages of airway pressure-release ventilation (APRV).

B. Recommend the initial settings for initiating APRV in patients with acute respiratory distress syndrome (ARDS).

C. Explain how to operate the controls of the high frequency oscillator.

D. Recommend initial ventilator settings for an adult with the oscillator unit.

E. List the types of medications that may be used in transitioning from volume control–continuous mandatory ventilation (VC-CMV) to high-frequency oscillatory ventilation (HFOV) for an adult.

F. Explain how the chest wiggle factor (CWF) is influenced by HFOV settings.

G. Name the pulmonary pathologic conditions in which heliox therapy may be beneficial.

H. Compare the differences among set tidal volume (VT), monitored VT, and actual VT delivery during heliox therapy.

I. Describe how heliox used with a mechanical ventilator may affect pressures and fractional inspired oxygen (FIO2) concentration monitoring and delivery.

J. Explain the procedure for using heliox cylinders with a mechanical ventilator.

K. Name at least four techniques that may help determine the correct placement of the esophageal electrical activity of the diaphragm (Edi) catheter.

L. Provide examples of how the Edi waveform can be of value in monitoring patients who are critically ill.

M. Discuss the various factors that can cause a low Edi signal and a high Edi signal.

N. Describe the safety back-up features and alarms available with neurally adjusted ventilatory assist (NAVA).

O. Calculate the estimated pressure delivery when given the NAVA level, Edi peak, Edi minimum, and positive end-expiratory pressure (PEEP).

P. Explain what parameters (pressure, flow, volume, neural signal, time) are used to deliver a breath during NAVA ventilation.

Q. Identify clinical situations in which NAVA should be used.

XII. Troubleshooting and Problem Solving

A. Identify various types of technical problems encountered during mechanical ventilation of patients who are critically ill.

B. Describe the steps that can be used to protect a patient when problems occur.

C. Name at least two possible causes for each of the following alarm situations:

1. High-pressure alarm

2. Apnea alarm

3. Low- or high-tidal volume alarm

4. Low- or high-minute volume alarm

5. Low- or high-respiratory rate alarm

6. Low- or high-fractional inspired oxygen (FIO2) alarm

7. Low-source gas pressure or power input alarm

8. Ventilator inoperative alarm

9. Technical error message

10. Low-pressure alarm

11. Low positive end-expiratory pressure (PEEP)/continuous positive airway pressure (CPAP) alarms

D. Determine the cause of a problem using a graphic from a patient-ventilator system.

E. Assess a patient situation, and recommend a solution.

F. Describe the signs and symptoms associated with patient-ventilator asynchrony.

G. Explain the correct procedure for determining whether a problem originates with the patient or with the ventilator in patient-ventilator asynchrony.

H. Recognize abnormalities in ventilator graphics and the patient response in the event of inadequate gas flow delivery to a patient.

I. Identify a problem associated with an artificial airway or a mask used for noninvasive positive-pressure ventilation.

J. Recognize the presence of unintended positive end-expiratory pressure (auto-PEEP) using ventilator graphics.

K. Suggest appropriate interventions for a patient who has experienced a right mainstem intubation and for a patient with a pneumothorax using physical assessment data.

L. Describe the potential problems associated with using a heated humidification system during mechanical ventilation.

M. Use a ventilator flow-volume loop to assess a patient’s response to bronchodilator therapy.

Content Outline and Competencies:

I. Respiratory Therapy Credential Exam Knowledge, Skills and Technical Proficiency Content

A. Evaluate patient data and make recommendations.

1. Patient record

2. Clinical information

3. Procedures

4. Procedure results

5. Diagnostic procedures

B. Troubleshoot and perform quality control of equipment and infection control.

1. Equipment

2. Infection control procedures

3. Quality control procedures

C. Initiate and modify interventions.

1. Airways

2. Airway clearance and lung expansion techniques

3. Oxygenation and ventilation measures

4. Medications and specialty gases

5. Respiratory care plan

6. Evidence-based medicine principles

7. Respiratory care techniques in high-risk situations

8. Special procedures

9. Patient and family education

10. Patient safety

II. Respiratory Care Subspecialties

A. Demonstrate the ability to administer pulmonary home care.

1. Oxygen therapy systems

2. Home O2 equipment

3. Role of the respiratory practitioner in home care

4. Living conditions and family acceptance

5. Ventilator selection

6. Apnea monitors

7. Home care provider company:

a. Proper setup procedures

b. Verbal and written instructions to patient/family

c. Visual demonstration and practice of equipment

d. Provision of round-the-clock service

e. Billing process

B. Demonstrate ability to administer pulmonary rehabilitation services.

1. Patient program goals

2. Guidelines and basic designs

3. Plan implementation

4. Rehabilitation plan selection

5. Patient compliance

6. Patient instructions for:

a. Graded exercise breathing pattern

b. Home respiratory equipment cleaning procedures

c. Breathing patterns to accommodate activities of daily living (ADL)

1) Breathing exercises

2) Multidisciplinary roles

3) Ambulation and body mechanics

4) Range of motion

5) Disease management

C. Respiratory Care Management

1. Describe the manager’s responsibilities to patients in relation to institutional mission statements.

2. Relate how payment and reimbursement systems affect the practice of respiratory care.

3. Discuss common personnel issues that arise in the respiratory care department (e. g. staffing, conflicts, nonproductivity, etc. ) and strategies for mitigating these issues.

4. Describe the impact of current healthcare delivery trends on respiratory care practice to include:

a. Specialty work teams

b. Consensus teams

c. Patient-focused care

d. Protocols

e. Disease management

f. Re-engineering

g. Collaborative care

h. Clinical care pathways

i. Long-term care, rehab units, etc.

j. Multi-skilling

5. Identify the impact of The Joint Commission (TJC) and other regulatory bodies on the respiratory therapist (RT) to include:

a. Competency profiles

b. License/registration requirements

6. Identify the procedures and expectations of the respiratory care graduate hiring process to include:

a. The employer’s desired applicant qualities

b. Procedures for applicant position inquiries

c. The interview process

d. The orientation process

e. One- and five-year goal setting

III. Capstone Project

A. Develop a Capstone project on a respiratory therapy topic that will facilitate future career development and build scholarship experience.

B. Synthesize project topic information including the background, history, best practices, and latest research from peer reviewed sources.

C. Conduct project topic field research to glean real world data.

D. Disseminate knowledge among colleagues and peers through a capstone project presentation

Content Outline and Competencies:

I. General Respiratory Care Implementation Objectives

A. Demonstrate the ability to gather appropriate data from the patient record in a timely manner.

B. Gather additional data from other appropriate resources.

C. Demonstrate the ability to perform, measure, interpret and analyze results for:

1. Vital signs (VS)

2. Pulse oximetry

3. ABGs, co-oximetry and other oxygenation and ventilation assessments

4. Electrocardiogram (ECG)

5. Artificial airway pressures

6. Other diagnostic tests (nutrition, sleep, stress, metabolic)

D. Demonstrate the ability to determine the appropriateness of the respiratory care plan and make modifications.

E. Demonstrate the ability to determine the disease or pathophysiological state through evaluating data and clinical evidence.

F. Demonstrate the ability to administer assigned therapeutic procedures according to established procedures or protocols with appropriate safety, dexterity and timing.

1. Obtain equipment appropriate to the respiratory care plan.

2. Assemble equipment prior to patient use with appropriate attention to safety, dexterity and timing.

3. Correct malfunctions of equipment identified, demonstrating appropriate dexterity, timing and attention to patient safety.

4. Maintain equipment cleanliness through the use of standard precautions and institution policies and procedures.

5. Demonstrate the ability to adhere to infection control procedures, proper body kinetics and patient safety at the bedside.

6. Explain planned therapy and goals to the patient and family members in understandable terms.

7. Assess patient responses to respiratory care therapies throughout the interaction with patients.

8. Modify therapeutic procedures based on patient responses and established protocols.

9. Record complete and accurate entries for therapies, procedures and diagnostic test results in patient and departmental records as required in the healthcare setting and by regulating agencies.

G. Recognize indications, contraindications and adverse effects related to administered therapies and pharmacological agents.

H. Demonstrate the ability to assist physicians in performing special procedures.

I. Demonstrate the ability to work well with peers by sharing opportunities, offering assistance and appropriately participating in discussions in a positive manner.

J. Demonstrate the ability to collaborate professionally with clinical instructors for assistance with patients and to clarify patient care practices.

K. Demonstrate the ability to practice courteous, concise and timely communication between respiratory care practitioners and all members of the healthcare team relating to:

1. Patient assessment

2. Benefits and responses of therapy

3. Clinical indications for therapy

4. Recommendations for modification or diagnostic testing

5. Clarification of orders

L. Demonstrate the use of computer technology in patient management.

M. Demonstrate the ability to develop and practice program and professional standards for appearance and promptness in performance of assigned responsibilities.

N. Demonstrate the ability to execute patient care following clinical directions with appropriate clarifications and action.

O. Perform care in a safe manner avoiding any risk to patient, self or other healthcare team members.

P. Demonstrate the ability to practice acquired clinical skills in all patient care areas showing competency, autonomy and professionalism.

Q. Integrate logistical approaches to improve timing, efficiency and decision making without compromising patient care.

R. Demonstrate flexibility through handling interruptions or abrupt changes in assignments with composure and professionalism.

II. Airway Care

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Adhere to infection control policies and procedures relating to airway care.

C. Review X-rays for endotracheal tube (ET) or tracheal (trach) tube positioning while noting the presence of possible supra or subglottic edema, or airway narrowing.

D. Perform cuff pressures of ET or trach tubes to assure optimal respiratory care practices.

E. Demonstrate the ability to describe the function, principles of operation, characteristics and advantages and disadvantages of the equipment used in airway care and secretion clearance for:

1. Vacuum systems

2. Open and in-line suction catheters

3. Specimen collectors/traps

4. Oral suction devices

5. Oro/nasal pharyngeal airways

6. Trach tubes and buttons

F. Discuss therapeutic procedures to maintain a patent airway including:

1. Proper patient position

2. Adequate humidification

3. Proper cuff inflation

4. Proper tube placement

5. Trach insertion and care

6. Insertion of oro/nasal pharyngeal airways

7. Proper tube stabilization

G. Discuss therapeutic procedures assigned to remove bronchopulmonary secretions, specifically:

1. Nasotracheal suctioning

2. Open and closed system ETT suctioning

3. Open and closed system tracheal suctioning

H. Demonstrate the ability to evaluate, monitor and make recommendations based on the patient’s response as it applies to airway care and airway patency through:

1. Chest X-rays

2. ABGs and pulse-oximetry

3. Sputum production and consistency

4. Patient’s subjective responses

5. VS and cardiac rhythms

6. Oxygen and liter flow requirements

7. Breath sounds

8. ETT or trach cuff pressures

I. Recognize indications, contraindications and possible adverse effects related to airway care procedures.

1. Therapy-induced hypoxemia

2. Therapy-induced vagal response

3. Mucus plugging from inadequate humidification

4. Improper artificial airway placement

III. Subacute Care Areas

A. Demonstrate the ability to apply the general respiratory care implementation objectives to all assigned therapies and activities with specific applications in the subacute area.

B. Select appropriate equipment to change humidification, breathing circuit and related supplies for ventilators.

C. Assemble functioning equipment.

IV. Hyperinflation Therapy

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Review X-rays for changes including presence of air, consolidation or fluid in chest fields.

C. Demonstrate the ability to review planned hyperinflation therapy to establish therapeutic goals and appropriateness of prescribed therapy.

D. Demonstrate the ability to describe the function, principles of operation, characteristics and advantages and disadvantages of the following equipment used for hyperinflation therapy:

1. Intermittent Positive Pressure Breathing (IPPB)

2. Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP)

3. Incentive spirometry (IS)

4. Intrapulmonary Percussive Ventilation (IPV)and Positive Expiratory Pressure (PEP)

E. Discuss therapeutic procedures to achieve adequate hyperinflation.

1. Proper breathing techniques

2. Incentive spirometry

3. IPPB, CPAP or BiPAP

F. Demonstrate the ability to evaluate, monitor and make recommendations based on the patient’s response as it applies to hyperinflation therapy.

1. Chest X-rays

2. ABGs and/or pulse-oximetry

3. Changes in sputum production and consistency

4. Patient’s subjective responses

5. VS and cardiac rhythms

6. Oxygen and liter flow requirements

7. Auscultation

8. Patient’s therapeutic lung volumes

G. Demonstrate the ability to recognize indications, contraindications and possible adverse effects related to hyperinflation procedures.

V. Critical Care Areas

A. Apply the general respiratory care implementation objectives to all assigned therapies and activities within the critical care areas.

B. Identify the differences in the sights, smells, pace, activity, communication and acuity of care in the critical care area.

C. Select appropriate equipment to change humidification, breathing circuits for mechanical ventilation.

D. Assemble equipment.

VI. Aerosol and Bronchial Hygiene Therapies

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Review X-ray for presence of air, consolidation and fluid in chest fields.

C. Review the therapeutic plan for aerosol therapy assuring therapeutic goals and modifications.

D. Review the therapeutic plan for bronchial hygiene therapy assuring therapeutic goals and modifications.

E. Demonstrate the ability to describe the function, principles of operation, characteristics and the advantages and disadvantages of the equipment used to deliver aerosol therapies:

1. Medication nebulizers

2. Metered Dose Inhaler (MDI) with spacers

3. Large reservoir nebulizers

4. Ultrasonic nebulizers

F. Demonstrate the ability to describe the function, principles of operation, characteristics and the advantages and disadvantages of the equipment used to deliver bronchial hygiene therapies:

1. Vibrators and percussors

2. Kinetic or similar beds

3. Flutter valves

4. High Frequency Chest Wall Oscillation (HFCWO)

5. IPV, PEP and other multipurpose therapies

G. Discuss therapeutic procedures specific to aerosol therapy:

1. Prescribed pharmacological agents delivery via medication nebulizers, MDI and MDI with spacer.

2. Large reservoir nebulizers

3. Ultrasonic nebulizers

H. Demonstrate therapeutic procedures specific to bronchial hygiene therapy:

1. Postural drainage, including proper positioning for the areas of involvement

2. Vibration and percussion

3. Flutter valve

4. HFCWO

5. IPV, PEP and other multipurpose therapies

6. Autogenic drainage

I. Demonstrate the ability to evaluate, monitor and make recommendations, based on patient’s response to aerosol and bronchial hygiene therapies.

1. Chest X-ray

2. ABG and pulse-ox

3. Changes in sputum production and consistency

4. Patient’s subjective response

5. VS and cardiac rhythm

6. Oxygen and liter flow requirements

7. Breath sounds

8. Fluid balance

J. Demonstrate the ability to recognize indications, contraindications and possible adverse effects related to aerosol and bronchial hygiene therapy.

VII. Clinic Time Management

A. Demonstrate the ability to apply the general respiratory care implementation objectives to all assigned therapies and activities with specific applications in the critical care area.

B. Demonstrate the ability to organize, prioritize and safely administer a workload that would be at least 50% of that assigned to a staff member.

C. Demonstrate the ability to identify, organize, prioritize and complete other responsibilities of a staff member in the course of a shift to include:

1. Stat oxygen setups

2. Stat blood gas and oximetry

3. Code blue or emergency calls

4. Stat therapies

5. Physician assistance

6. Patient transport

VIII. Cardiac Patient Care

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Demonstrate the ability to identify the differences in the sights, smells, pace, communication and acuity of care that occur in the cardiac critical care area.

C. Obtain appropriate equipment for changes in humidification and the mechanical ventilator breathing circuit.

D. Review the blood flow through the heart and cardiac circulation to the heart.

E. State the pathophysiology with the appropriate care plan for each of the following disease processes:

1. Hypertension

2. Myocardial infarction

3. Cardiac valve disorders

4. Congestive heart failure

5. Cardiomyopathy

F. Assess overall patient cardiopulmonary status by:

1. Inspection for venous distention, peripheral edema that may be significant for the cardiac patient.

2. Palpation for heart rate, rhythm and force.

3. Auscultation for verification of heart sounds, dysrhythmias, murmurs, bruits.

G. Discuss diagnostic testing procedures for cardiac disease, to include:

1. Cardiac catheterization

2. Exercise stress testing

3. Thallium stress testing

4. Echocardiograms

5. Holter monitoring

6. Lab data

H. Discuss therapy interventions for cardiac abnormalities, to include:

1. Pacemakers

2. Cardiac rehab

3. Thrombolitic therapy

4. Cardioversion

5. Defibrillation

6. Fluid balance

I. Demonstrate the ability to discuss indications, contraindications and possible adverse effects related to interventions and pharmacological agents used in cardiac patient care:

1. Angiotensin Converting Enzyme (ACE)  inhibitors

2. Beta blockers

3. Calcium antagonists

4. Diuretics

5. Anti-arrhythmic

6. Oxygen

7. Anti-thrombolytics

J. Demonstrate the ability to practice basic ECG interpretations with descriptions of therapeutic interventions for identified rhythms, including the application of BLS and ACLS protocols for cardiopulmonary collapse.

K. Determine cylinder length of service for patients being transported for various procedures.

IX. Pediatric Management

A. Apply general respiratory care implementation objectives to the pediatric population.

B. Demonstrate the ability to assess cardiopulmonary patient learning needs, vital signs and clinical signs and symptoms that are manifested in a child with respiratory distress.

C. Demonstrate the ability to describe the function, principles of operation, characteristics, advantages and disadvantages and applications to the pediatric population of:

1. Oxygen administration devices, including oxygen tents and hoods

2. Humidifiers

3. Aerosol generators, including oxygen tents

4. Hyperinflation devices

5. Secretion clearance devices

6. Resuscitation devices

7. Artificial airways

D. Explain planned therapy and goals to patient and family members in understandable terms.

E. Discuss therapeutic procedure applications for the pediatric population in:

1. Maintenance of a patent airway

2. Removal of bronchopulmonary secretions

3. Achievement of adequate ventilation

4. Achievement of adequate oxygenation

F. Describe the pathophysiology and the appropriate care plan for each of the following disease processes:

1. Croup

2. Epiglottitis

3. Cystic fibrosis

4. Asthma

5. Bronchiolitis

6. Respiratory Syncytial Virus

G. Discuss treatment of pediatric cardiopulmonary collapse according to Pediatric Advanced Life Support protocols.

X. Blood Gas Procurement, Analysis and Interpretation

A. Demonstrate the ability to appropriately contact the instructor, staff and others for assistance.

B. Demonstrate the ability to safely perform arterial puncture for blood gas analysis.

C. Demonstrate the ability to review existing data in the patient record and recommend procedures to obtain additional data assuring  a safe arterial puncture and correlated interpretations for:

1. Pulse oximetry

2. Clinical lab data

3. Previous ABGs

4. Medications

D. Demonstrate the ability to perform, measure, calculate and interpret results for:

1. ABGs acid base and oxygenation status

2. Co-oximetry

3. Alveolar-arterial gradient (P(A-a)O2)

4. Oxygen content

5. Bicarbonate (HCO3) estimation

6. HCO3 administration

7. Hydrogen (H+) ion content

8. Venous results

9. Mixed venous results

E. Demonstrate the ability to identify potential causes for a given acid/base state with recommended changes to the therapeutic plan.

F. Demonstrate the ability to perform blood gas quality control procedures on analyzing equipment and discuss implications of the results.

G. Demonstrate the ability to describe the function, principles of operation, characteristics and advantages and disadvantages of the equipment used for obtaining and analyzing the sample.

1. PO2 electrode

2. PCO2 electrode

3. pH electrode

4. Co-oximeter

5. Specialty gas mixtures

6. Arterial line equipment

7. Pulmonary artery equipment

H. Contrast the use of tonometry for quality control of analyzing equipment with other quality control measures.

I. Demonstrate the ability to handle blood samples to avoid erroneous results.

J. Describe the changes imposed on the blood sample if:

1. Iced/Not iced

2. Large air bubble is present

3. Diluted with liquid heparin

4. Patient is hyper/hypothermic

5. Patient has abnormal electrolytes

6. Patient has leukocytosis

K. Demonstrate the ability to recognize indications, contraindications and possible adverse effects related to arterial puncture or line draw.

L. Record results in patient and department records using conventional terminology as required by the healthcare institution and regulatory agencies including:

1. Specify sample site, date, time

2. Patient’s adverse or subjective response

3. Correlating oxygen and/or ventilator management

4. Verify computations and note erroneous data

M. Apply computer technology to patient management.

N. Demonstrate the ability to communicate information regarding patient’s clinical status to appropriate members of the healthcare team.

XI. Fluid and Electrolyte Balance

A. Identify the four most common and two other electrolytes measured noting the accepted normal ranges and usual units of measurement.

B. Demonstrate the ability to identify the appropriate cations and anions and determine the anion gap and its implications.

C. Describe the following:

1. Where electrolytes are stored

2. Mechanisms for fluid loss by the body

3. How imbalances in fluid status may occur

4. Possible implications of imbalances in fluid status

5. Possible implications of electrolyte imbalances

XII. Physician Rounds

A. Review data in the patient record determining the need for additional data.

B. Assess overall patient cardiopulmonary status by inspection and auscultation.

C. Assess overall patient cardiopulmonary status by percussion and palpation.

D. Observe taking a patient history.

E. Review findings of X-ray.

F. Demonstrate the ability to review planned therapy, ,establish therapeutic goals and recommend modifications to the therapeutic plan.

G. Discuss how the respiratory care practitioner may assist the physician in performing special procedures including:

1. Cardioversion

2. Intubation

3. Bronchoscopy

4. Thoracentesis

5. Insertion of chest tubes

6. Conscious sedation

H. Demonstrate the ability to communicate with the physician regarding patient assessment, benefits and responses to therapy, continuing clinical indications for therapy and recommendations for modification in therapy or diagnostic testing.

XIII. Diagnostic Bronchoscopy

A. Discuss the indications for a diagnostic bronchoscopy.

B. Discuss the potential complications for a bronchoscopy and strategies for minimizing complications.

C. Demonstrate the ability to observe, participate and identify the role of the respiratory care practitioner in assisting the physician with diagnostic bronchoscopy, to include:

1. Procedure setup

2. Patient preparation

3. Biopsy and specimen sample procurement and preparation

a. Needle biopsy

b. Retrieval baskets

c. Forceps

d. Blind and fluoroscopy assisted techniques

e. Brushings, washings

f. Specimen preparation for lab

4. Cleaning and disinfection of a bronchoscope

5. Physician technique for the procedure

Content Outline and Competencies:

I. General Respiratory Care Implementation Objectives

A. Demonstrate the ability to gather appropriate data from existing patient record in a timely fashion.

B. Gather additional needed data from other appropriate resources.

C. Demonstrate the ability to perform and measure, interpret and analyze results for:

1. Vital signs

2. Pulse oximetry

3. Arterial blood gases (ABGs), co-oximetry and other oxygenation and ventilation assessments

4. Electrocardiogram (ECG)

5. Artificial airway pressures

6. Respiratory mechanics and critical care indices

7. Other diagnostic tests (nutrition, sleep, stress, metabolic)

D. Demonstrate the ability to determine the appropriateness of the respiratory care plan and apply modifications.

E. Determine the disease or pathophysiological state through evaluating data and clinical evidence.

F. Administer assigned therapeutic procedures according to established procedures or protocols with appropriate safety, dexterity and timing.

1. Obtain equipment appropriate to the respiratory care plan

2. Assemble equipment prior to patient use with appropriate attention to safety, dexterity and timing

3. Correct malfunctions of equipment identified, demonstrating appropriate dexterity, timing and attention to patient safety

4. Maintain equipment cleanliness through the use of standard precautions and institutional policies and procedures

5. Demonstrate infection control procedures, proper body kinetics and patient safety at the bedside

6. Demonstrate the ability to explain planned therapy and goals to the patient and family members and confirm understanding of the information delivered

7. Assess patient responses to respiratory care throughout therapy

8. Modify therapeutic procedures based on patient responses and established protocols

9. Demonstrate the ability to record complete and accurate entries for therapies, procedures and diagnostic test results in patient and departmental records as required in the healthcare setting and by regulating agencies

G. Recognize indications, contraindications and adverse effects related to administered therapies and pharmacological agents.

H. Demonstrate the ability to assist physicians in performing special procedures.

I. Participate in physician’s rounds in the critical care units.

J. Demonstrate the ability to work well with peers in sharing opportunities, offering assistance and appropriately participating in discussions in a positive and timely manner.

K. Demonstrate the ability to collaborate professionally with clinical instructors for needed assistance with patients and to clarify questions about patient care.

L. Practice professional, concise and timely communication with all members of the healthcare team with regards to:

1. Patient assessment

2. Benefits/response of therapy

3. Continuing clinical indications for therapy

4. Recommendations for modification or diagnostic testing

5. Clarification of orders

M. Demonstrate the use of computer technology in patient management.

N. Project program and professional standards for appearance and promptness in performance of assigned responsibilities.

O. Execute patient care following clinical directions with appropriate clarifications and action.

P. Demonstrate the ability to perform care in a safe manner to avoid any risk to patient, self or other healthcare team members.

Q. Demonstrate acquired clinical skills in all patient care areas showing competency, autonomy and professionalism.

R. Integrate logistical approaches to improve timing, efficiency and decision making without compromising patient care.

S. Demonstrate flexibility through handling interruptions or abrupt changes in assignments with composure and professionalism.

II. Open Heart Surgical Management and Critical Care Monitoring

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Demonstrate the ability to conduct therapeutic procedures to achieve adequate ventilation and oxygenation, including:

1. Selecting the appropriate ventilator and equipment

2. Initiating the various ventilator modes with modifications

3. Initiating weaning procedures with modifications

4. Implement Continuous Positive Airway Pressure (CPAP) and Positive End Expiratory Pressure (PEEP) with modifications

5. Position patients appropriately to minimize hypoxemia

6. Prevent procedure associated hypoxemia

C. Demonstrate the ability to evaluate and monitor patient’s responses to respiratory care, to include:

1. Lung compliance and airway resistance

2. Ventilator waveforms

3. Ventilator mean airway pressure

4. Ventilator alarms

5. Ventilator parameters

6. Hemodynamic calculations

7. Critical care indices

8. Clinical indicators of oxygenation and ventilation

9. Other patient monitoring measures including chest X-ray, clinical lab and electrocardiogram (ECG)

D. Demonstrate the ability to review existing data in the patient record and recommend procedures to obtain additional data for open heart surgical management and critical care monitoring.

1. Vital signs

2. Fluid balance

3. Respiratory monitoring

4. Hemodynamic monitoring

5. Other diagnostic studies as ordered

E. Assess overall patient cardiopulmonary status by:

1. Auscultation of heart sounds, dysrhythmias, murmurs, bruits

2. Bedside cardiopulmonary monitoring and weaning procedures

3. Review of X-ray

a. Endotracheal (ET) and tracheal tube positions

b. Position of chest tubes and hemodynamic catheters

4. Recognition of clinical signs of hypoxia and hypercapnia

F. Demonstrate the ability to perform, monitor and interpret results, as indicated:

1. Hemodynamic monitoring

a. Central venous pressure (CVP)

b. Cardiac output/cardiac index

c. Pulmonary artery wedge pressure (PAWP)

d. Pulmonary artery pressure (PAP)

e. Mixed venous sampling

f. Arterial-mixed venous oxygen content difference C(a-v) O2

g. Pulmonary vascular resistance (PVR)

h. Stroke volume resistance (SVR)

i. Stroke volume (SV)

2. Critical care indices

a. ABG profile

b. Arterial oxygen content (CaO2)

c. Saturation of oxygen in mixed venous blood (SvO2)

d. Weaning parameters

e. Partial pressure of arterial oxygen/ fraction of inspired oxygen (PaO2/FIO2)

f. Alveolar-arterial oxygen partial pressure difference (P(A-a)O2)

g. Rapid shallow breathing index (RSBI)

G. Establish therapeutic goals with modifications to prescribed therapy.

1. Pre-op evaluation and clinical indications for surgery

2. Surgical management or alternatives

3. Post-op clinical lab, ECG, ABG

H. Demonstrate the ability to discuss the function, principle(s) of operation, characteristics, advantages/disadvantages of the equipment and methods used to manage and monitor the open heart surgical or other critical patient.

1. Blood pressure monitoring via sphygmomanometer, Doppler and arterial catheter

2. Pulmonary artery catheter equipment

3. Chest tubes

4. Intra-aortic balloon pump

5. Left ventricular assist device

6. Ventilator and respiratory adjuncts

I. Demonstrate the ability to recommend therapeutic procedures and make necessary modifications to therapy based on patient responses.

J. Apply computer technology to patient management.

1. Charting

2. Ventilator waveform analysis

3. Patient care protocols/algorithms

III. Ventilator Management and Weaning

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Demonstrate the ability to conduct therapeutic procedures to achieve adequate ventilation and oxygenation, to include:

1. Select the appropriate ventilator and equipment

2. Initiate ventilator modes with modifications

3. Weaning procedures

4. Initiate Continuous Positive Airway Pressure (CPAP) and Positive End Expiratory Pressure (PEEP) with modifications

5. Position the patient to minimize procedure induced hypoxemia

C. Demonstrate the ability to evaluate and monitor patient’s responses to respiratory care, to include:

1. Lung compliance and airway resistance

2. Ventilator waveforms

3. Ventilator mean airway pressure

4. Ventilator alarms

5. Ventilator parameters

6. Hemodynamic calculations

7. Critical care indices

8. Clinical indicators of oxygenation and ventilation

9. Other patient monitoring measures including chest X-ray, clinical lab and ECG.

D. Demonstrate the ability to review planned therapy to establish therapeutic goals and appropriateness of prescribed therapy and recommend changes in therapeutic plan, as indicated.

1. Contrast the following weaning methods:

a. T-tube trials

b. Synchronized intermittent mechanical ventilation (SIMV)

c. CPAP

d. Pressure support

e. Flow-by

2. Perform the following parameters for weaning:

a. Ventilation and FIO2 requirements

b. ABGs and pulse oximetry

c. Weaning parameters

d. Vital signs

e. Capnography

f. Sensorium and mentation

g. Deadspace volume/ tidal volume ratio (VD/VT)

E. Demonstrate the ability to discuss the function, principles of operation, characteristics, advantages and disadvantages, and indications of the equipment used to manage and monitor the weaning process.

1. Oxygen administration devices

2. Aerosol generators

3. Monitoring devices

F. Demonstrate the ability to appropriately measure parameters of the weaning process:

1. Respiratory monitoring

a. Frequency

b. VT

c. Minute ventilation (VE)

d. Inspiratory: Expiratory ratio (I:E ratio)

e. Inspiratory/Expiratory (I/E) pressures

f. Vital Capacity(VC)

g. Flow/volume/pressure waveforms

h. Lung compliance

i. Airway resistance

j. Work of breathing indices (RSBI)

k. Maximum inspiratory pressure (MIP)

G. Evaluate and monitor patient’s response to the weaning process.

IV. Airway Management

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Demonstrate the ability to conduct therapeutic procedures to achieve adequate ventilation and oxygenation, to include:

1. Selecting the appropriate ventilator and adjunct equipment

2. Initiating and adjusting assist/control (A/C), SIMV, pressure support ventilation (PSV), pressure control ventilation (PCV) and flow-by

3. Initiating and modifying weaning procedures

4. Initiating and adjusting CPAP and PEEP

5. Positioning the patient to minimize hypoxemia

6. Preventing procedure associated hypoxemia

C. Demonstrate the ability to evaluate and monitor patient’s response to respiratory care, to include:

1. Lung compliance and airway resistance

2. Ventilator waveforms

3. Ventilator mean airway pressure

4. Ventilator alarms

5. Ventilator parameters

6. Hemodynamic measurements/calculation

7. Critical care indices

8. Clinical indicators of oxygenation and ventilation

9. Other patient evaluation/monitoring measures (chest X-ray, clinical lab, ECG, etc.)

D. Demonstrate the ability to perform the correct procedures to insert, secure and remove the following airways:

1. Oro /nasopharyngeal

2. Oro/nasotracheal

3. Tracheostomy

4. Trach button

E. Demonstrate the correct procedure for:

1. Minimum leak technique

2. Cuff pressure monitoring

3. Trach dressing changes

4. Trach inner cannula replacement

F. Demonstrate appropriate suctioning technique of the patient airway, including the use of demand valves, self-inflating resuscitation bags and flow inflating resuscitation bag.

G. Describe indications and possible complications associated with the use of airway equipment.

H. Discuss the concerns for maintaining a stable airway and ventilation during patient transport.

I. Compare the role of respiratory care in a subacute healthcare environment with that of the acute care environment.

V. Adult Critical Care Management and Capnography

A. Apply general respiratory care implementation objectives to all assigned therapies and activities.

B. Demonstrate the ability to conduct therapeutic procedures to achieve adequate ventilation and oxygenation, to include:

1. Selecting the appropriate ventilator and adjunct equipment

2. Initiating and adjusting A/C, SIMV, PSV, PCV and flow-by

3. Initiating and modifying weaning procedures

4. Initiating and adjusting CPAP and PEEP

5. Positioning the patient to minimize hypoxemia

6. Preventing procedure associated hypoxemia

C. Demonstrate the ability to evaluate and monitor patient’s response to respiratory care, to include:

1. Lung compliance and airway resistance

2. Ventilator waveforms

3. Ventilator mean airway pressure

4. Ventilator alarms

5. Ventilator parameters

6. Hemodynamic measurements/calculation

7. Critical care indices

8. Clinical indicators of oxygenation and ventilation

9. Other patient evaluation/monitoring measures (chest X-ray, clinical lab, ECG, etc.)

D. Demonstrate the ability to perform, measure and interpret results of capnography.

E. Discuss the function, principles of operation, characteristics and advantages and disadvantages of the capnography.

F. Demonstrate the ability to determine the amount of auto-PEEP present and discuss the significance and alternatives for relieving it.

VI. Neonatal/Pediatric Critical Care

A. Apply general respiratory care implementation objectives to all assigned therapies and activities of the neonatal and pediatric patient.

B. Demonstrate the ability to review existing data in the patient record and recommend procedures to obtain additional data, as indicated.

1. Physical exam/ Vital signs (VS)

2. Pulse oximetry and/or transcutaneous monitoring of carbon dioxide (TcCO2), transcutaneous monitoring of oxygen (TcO2) and ABGs

3. Lab data

4. Chest/upper airway X-ray

5. ECG and echocardiography

6. Fluid balance

7. Respiratory monitoring

8. Hemodynamic monitoring

9. Medications

10. Maternal and perinatal/neonatal history and data

C. Demonstrate the ability to review the differences between the child and an adult anatomy and physiology and describe how the following may influence therapy administration:

1. Size/position/characteristics of the tongue, larynx, epiglottis and trachea

2. Tidal volume and respiratory rate

3. Alveolar size and number

4. Rib cage shape and structure

D. Assess overall patient cardiopulmonary status by:

1. Inspection, including transillumination of infant chest, Apgar scoring and gestational age assessment

2. Auscultation

3. Assessment of family and patient learning needs with age appropriate interactions

4. Review of X-ray

E. Demonstrate the ability to perform, measure and interpret results:

1. Basic vital signs

2. Pulse oximetry

3. Transcutaneous monitoring for oxygen (O2)and carbon dioxide (CO2)

4. Apnea monitoring

F. Demonstrate the ability to analyze available data and discuss factors that determine pathophysiological state of neonatal and pediatric disorders.

1. Neonatal

a. Hyaline membrane disease (HMD)

b. Transient tachypnea of newborn (TTN)

c. Bronchopulmonary Dysplasia/Chronic Lung Disease (BPD/CLD)

d. Meconium aspiration syndrome (MAS)

e. Pulmonary interstitial emphysema (PIE)

f. Congenital heart anomalies

2. Pediatric

a. Respiratory syncytial virus (RSV)

b. Respiratory distress syndrome (RDS)

c. Sepsis

d. Neuromuscular disorders

e. Head injury

f. Asthma

g. Bronchiolitis

h. Croup

i. Epiglottitis

G. Demonstrate the ability to select and obtain equipment appropriate to the respiratory care plan and discuss specific applications and considerations for the neonatal and pediatric population.

1. O2 therapy (isolette, cannula, mask, oxyhood, croup tent, CPAP)

2. Aerosol and humidity therapy

3. Bronchial hygiene procedures

4. Suction and airway care

5. Ventilation, including high frequency oscillator

6. Monitoring TcO2, pre/post ductal oxygenation studies, umbilical arterial catheter/ umbilical venous catheter (UAC/UVC), temperature probes, oxygen analyzers, oxygen saturation monitors, ECG)

H. Demonstrate the ability to recognize indications, contraindications and possible adverse effects relating to respiratory therapy and management of the neonatal and pediatric patient.

I. Demonstrate the ability to recognize indications, contraindications, possible adverse effects and discuss delivery methods for respiratory related pharmacological agents as they apply to the neonatal and pediatric patient:

1. Sympathomimetics

2. Anti-asthmatics

3. Mucolytics

4. Aerosolized anti-viral agents

5. Aerosolized corticosteroids

6. Aerosolized antibiotics

7. Methylxanthines

8. Benzodiazepines

9. Neuromuscular blocking agents

10. Morphine

11. Corticosteroids

12. Indomethacin

13. Resuscitation drugs

14. Magnesium Sulfate

15. Surfactant replacement

J. Discuss Pediatric Advanced Life Support (PALS) and Neonatal Resuscitation Program (NRP) protocols for treatment of cardiopulmonary collapse including necessary equipment and techniques.

K. Observe a high-risk delivery as available.

L. Discuss neonatal/pediatric transport needs to include necessary equipment considerations.

M. Discuss modification of neonatal respiratory care procedures for use in the home while ensuring safety and infection control.

VII. Physician Rounds

A. Determine if data is missing from the patient record for a complete patient assessment.

B. Assess overall patient cardiopulmonary status by inspection and auscultation.

C. Assess overall patient cardiopulmonary status by percussion and palpation.

D. Participate in taking a patient history.

E. Review findings of X-ray and other diagnostic tests.

F. Demonstrate the ability to review therapy to establish therapeutic goals and need for modification.

G. Discuss how the respiratory care practitioner may assist the physician in performing special procedures:

1. Cardioversion

2. Intubation

3. Bronchoscopy

4. Thoracentesis

5. Insertion of chest tubes

6. Conscious sedation

7. Transtracheal aspiration

8. Percutaneous needle biopsy

9. Insertion of monitoring lines

10. Cardiopulmonary Stress Testing

11. Sleep studies

12. Tracheostomy

H. Practice communication occurring between the respiratory care practitioner and healthcare team for:

1. Patient assessment

2. Response of therapy

3. Clinical indications for therapy

4. Recommendations for modification in therapy

5. Diagnostic testing

VIII. Pulmonary Rehab

A. Recommend procedures for obtaining additional data following review of the patient record.

B. Assess overall patient cardiopulmonary status, including:

1. Exercise tolerance

2. Activities of daily living (ADL)

3. Physical environment

4. Social support systems

5. Nutrition status

6. Patient learning needs.

C. Review the interdisciplinary patient care plan.

D. Identify the goals of a rehab program for a pulmonary patient.

E. Demonstrate the ability to discuss the guidelines, basic components and implementation of a pulmonary rehab program including:

1. Resources

2. Staffing

3. Medical direction

4. Patient selection and evaluation

5. Patient instruction

6. Equipment selection

7. Follow-up

8. Reimbursement

F. Explain planned therapy and goals to patients and family regarding:

1. General patient education and the aids used for patient understanding and participation.

2. Specific patient instruction for:

a. Graded exercise breathing pattern

b. Home respiratory equipment cleaning procedures

c. Breathing patterns to accommodate activities of daily living

3. The role of exercise and breathing exercises in pulmonary rehab.

G. Discuss the elements of a smoking cessation program needed to counsel patient and family members about smoking cessation.

H. Demonstrate the ability to discuss the elements of a disease management education program and counsel patient and family members concerning disease management education.

I. Communicate information relevant to coordinating patient care and discharge planning and scheduling.

J. Participate in the development of a respiratory care plan.

K. Discuss implementation of a graded exercise program and cardiopulmonary stress testing.

IX. Pulmonary Function Rotation

A. Demonstrate the ability to appropriately contact the instructor, staff and others for assistance.

B. Recommend procedures for additional data following review of the patient record.

C. Demonstrate the ability to perform, measure and interpret results:

1. Pulmonary function testing

a. Spirometry before/ after bronchodilator

b. Maximum voluntary ventilation (MVV)

c.Maximal expiratory pressure (MEP)

d. Functional Residual Capacity (FRC)

e. Flow-volume loops

f. Body box

g. Nitrogen washout

h. CO2 response curve

i. Total lung capacity (TLC)

j. Closing volume

k. Airway resistance

l. Bronchoprovocation

m. Maximum Inspiratory Pressure (MIP)

D. Demonstrate the ability to analyze available data to aid in determining a pathophysiological state.

1. Spirometry

2. Flow-volume loop

3. Volume of iso flow

4. Functional Residual Capacity (FRC), residual volume (RV) and total lung capacity (TLC) determinations

5. Body plethysmography

6. Single breath nitrogen test

7. Closing volume

8. Diffusing capacity

9. Diffusion capacity (DLCO)

E. Demonstrate the ability to select the following equipment for performing PFTs:

1. Spirometers

2. Plethysmography

3. Pneumotachometers

4. Carbon Monoxide (CO), helium (He), Nitrogen (N2) and other specialty gas analyzers

5. Respirometer

6. Manometers

F. Describe the function, principle(s) of operation, characteristics, advantages and disadvantages of the selected equipment and procedures, to include:

1. Applicable gas laws

2. Available measurements

G. Demonstrate the ability to assemble, check for proper function, identify and correct malfunctions for equipment.

H. Perform quality control (QC) procedures for pulmonary function equipment.

I. Demonstrate the ability to coach and explain procedures to patients.

J. Interpret pulmonary function test reports.

1. Differentiate and obstructive versus restrictive process using forced expiratory volume ratio and flow volume tracing

2. Bronchial provocation tests

3. Pre- and post-bronchodilator studies

4. Lung volume and capacities

5. Specialty evaluations:

a. Volume of iso flow

b. Closing volume

c. Single breath nitrogen test

d. Bedside pulmonary function test (PFT) assessments

K. Demonstrate the ability to perform appropriate communication between the respiratory care practitioner and physician for assessment, benefits and responses to therapy, continuing clinical indications for therapy and recommendations for modification in therapy or diagnostic testing.

X.  Advanced Cardiovascular Life Support

A. Demonstrate the ability to review data and recommend procedures to obtain additional information, as it applies to Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS.)

B. Interpret results of patient assessment in relation to BLS and ACLS.

C. Demonstrate the ability to analyze available data and determine the pathophysiological state.

D. Demonstrate the ability to select and obtain equipment appropriate to the respiratory care plan, for BLS and ACLS.

1. Oxygen administration

2. Gas delivery systems

3. Secretion clearance

4. Resuscitation devices

5. Artificial airways

6. Monitoring devices

E. Demonstrate the ability to assemble, check for proper function and correct malfunctions for equipment identified.

F. Demonstrate the ability to perform therapeutic procedures to maintain a patent airway and remove secretions.

1. Oro/nasal pharyngeal airways

2. Intubation/extubation procedures

3. Proper tube placement

4. Proper cuff inflation

5. Proper patient position

6. Suction

G. Demonstrate the ability to perform therapeutic procedures to achieve adequate ventilation and oxygenation.

1. Oxygen administration

2. Prevention of procedure associated hypoxemia

3. Resuscitation efforts

H. Demonstrate the ability to evaluate and monitor patient’s responses to care and modifications in procedures.

I. Treat cardiopulmonary collapse according to BLS/ACLS protocols.