The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

THE CHALLENGES AND BENEFITS OF TRANSITIONING FROM VOLUME EXPANSION THERAPY TO POSITIVE AIRWAY PRESSURE THERAPY FOR PREVENTION AND TREATMENT OF ATELECTASIS

-David Mussetter, BA, RRT, Tim Frymyer, BS, RRT, Mike Trevino, MS, RRT, Gary Weinstein, MD, FCCP, Presbyterian Hospital of Dallas, Dallas, Texas

Background: Our clinical practice model incorporates a literature based, house-wide, therapist-driven protocol. We average 10,000 initial protocol evaluations, 10,000 re-evaluations and 21,000 incentive spirometry treatments annually. We are a 903-bed teaching facility in a major metropolitan area. It is incumbent upon the respiratory care practitioner (RCP) to continuously evaluate practice standards through regular examination of scientific data, from which current treatments and protocols should be benchmarked. In one such review, we contrasted positive airway pressure (PAP) therapy against traditional volume expansion therapy for patients both at risk for or who currently do have atelectasis. We concluded the evidence was pointing us toward changing our clinical approach in this patient population.

Method: A literature review was initiated; the best study data available was selected and presented in Journal Club. Agreement to add PAP as an integral part of our protocol was reached. Subsequently, a six-step action plan was outlined to support this change, of which the first four have been completed: 1) equipment evaluation 2) documentation modification 3) development of related policy and procedures 4) development of treatment algorithms 5) education and competency verification of all stakeholders and 6) determination and collection of outcome data.

Results: Our product evaluation brought us to select the DHD TheraPEPâ orifice-type positive expiratory pressure (PEP) device over the threshold-type resistors. Indications and administration guidelines were created. After modifying our documentation and procedure formats, we generated treatment algorithms to guide the RCP during the transition. These will be crucial during final implementation to help the RCP become familiar with the initiation, modification and termination of therapy. We secured the approval of the pulmonary physician groups and have begun competency verification for all staff members. We are now faced with three hurdles: 1) the increased cost of therapy through a more expensive device 2) intensifying care with PAP, thereby artificially skewing the data and 3) defining and demonstrating clinical significance, likely our most difficult challenge. To accomplish this, we will compare for each physician group, all surgical patients 30 days prior to implementation to that of a similar group of patients 30 days post implementation. Vital capacity measurements will be captured daily, along with chest x-ray and A-a gradient results (both as available), total hours on oxygen, SpO2s, transfers back to ICU, RCP-patient interactions and number of therapy treatments.

Conclusion: We expect the change in therapy to have many benefits. For example, the patient will have a less painful, more effective treatment option; the RCP will be able to offer a treatment modality, purported in the science, to not only prevent but also treat atelectasis. Costs may, in fact, be decreased by avoiding pulmonary complications and slower convalescence times. While change is difficult, we must always seek to treat our patients in the most clinically appropriate manner. Habitual therapy paradigms must be set aside when more efficacious methods are available and promoted in the literature. Our decision to switch from the conventional volume expansion therapies to PAP is such an example.

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