406

Respiratory Therapy
Pulmonary, Allergy, & Critical Care Medicine

SUBJECT
DATE ISSUED
AREAS AFFECTED
PREPARED BY
APPROVAL
REVISION DATES

CONSULT SERVICE HANDBOOK

All Hospital Floors
Lucy Kester
James K. Stoller, M.D.
May 2004, 2007, 2008

RESPIRATORY THERAPY CONSULT SERVICE

A survey conducted at The Cleveland Clinic Foundation in 1987 demonstrated that approximately
25% of Respiratory Therapy treatments were ordered inappropriately, that is, either there were no
indications for therapy or the wrong therapy was selected. In an attempt to remedy this situation
and improve patient care, the Respiratory Therapy Consult Service has been created to assist the
physician with evaluating patients respiratory care needs, determining the indications for
respiratory therapy, and selecting the appropriate modalities.
This booklet is designed to inform you about the procedure for ordering a Respiratory Therapy
Consult, the process (algorithms) used to determine specific therapies, the evaluation form used
in the charts, and the re-evaluation process. If you have any questions regarding this service
please feel free to ask any of the therapists or call Respiratory Therapy at 45797 and talk with a
Supervisor or the Education Coordinator.

406
RESPIRATORY THERAPY CONSULT SERVICE
NEW EVALUATIONS
A.

A physician may write an order for a Respiratory Therapy Consult by,

1.
Writing on a Physician Order Form
2.
Using the Computer Physician Order Entry (CPOE) system

B.

Respiratory Therapy Consults are provided for all patients for whom respiratory therapy
orders are written with the exceptions of:

C.

1.

Post-Cardiac surgery patients

2.

Patients admitted to the short stay unit, unless they are admitted to the
hospital.

When a physician writes an order for a Respiratory Therapy Consult:

1.
An evaluation will be performed according to the Respiratory Therapy Consult
Service (RTCS) standardized evaluation guidelines and a care plan written.
2.
Discussion between the physician and a Respiratory Therapist concerning the
rationale for therapy is encouraged.
3.
The RTCS care plan (which will include physician orders for specific medications)
will be followed until the indications for therapy are resolved.
4.
During the course of therapy, the physician will be called if the patients clinical
status worsens, or if an adverse event occurs.
5.
Physician written medication orders will be followed for 24 hours and the patient
reassessed. If therapy is not indicated at this time, the physician will be contacted
and asked to discontinue treatment.
6.
Short-term orders (orders < 24 hour duration) for a single modality (e.g., oxygen,
aerosol) will be followed without generating a Respiratory Therapy Consult Service
(RTCS) evaluation.

For questions:
Please PAGE #23406 or call ext. 45797
RE-EVALUATIONS
A.

Daily assessment will be made by the Therapist treating the patient and if changes are
indicated, they will be presented during Consult Rounds with a Supervisor or a Clinical
Specialist. If the changes are in accordance with the Consult Service guidelines/algorithms,
they will be instituted at this time.

B.

Changes will be recorded in our management information system (MediServe) and will be
available for review in the hospital EPIC system.

406
CARE PLAN PROCESS
STEP 1
Perform patient evaluation using evaluation guidelines. Determine appropriate Triage number.
STEP II
Determine indications and related therapy using indication guideline sheet.
STEP III
Follow appropriate therapy flow sheet (algorithm):
a. aerosol therapy
b. hyperinflation therapy
c. bronchopulmonary hygiene
d. oxygen therapy
STEP IV
Write care plan to include:
a. therapy
b. frequency
c. indications
d. objectives

406

406

MINIMUM PREDICTED VOLUMES

hgt
49
410
411
50
51
52
53
54
55
56
57
58
59
510
511
60

Women
ibw
38
40.4
42.6
45
47.4
49.8
52.2
54.6
57
59.4
61.8
64.2
66.6
70
72.4
74.8

pred
.570
.606
.639
.675
.711
.747
.783
.819
.855
.891
.927
.963
.999
1.05
1.08
1.12

hgt
55
56
57
58
59
510
511
60
61
62
63
64
65
66
67
68

Men
ibw
62
64.4
66.8
69.2
71.6
74
76.4
78.8
81.2
83.6
86
88.4
90.8
93.2
95.6
98

pred
.930
.968
1.00
1.03
1.07
1.11
1.14
1.18
1.22
1.25
1.29
1.32
1.36
1.40
1.43
1.47

406
INDICATION GUIDELINES
Indications
A.

Aerosol Therapy
1. bronchospasm (bronchodilator)
2. history of bronchospasm (beta agonist, anti-cholinergic, steroid)
3. home regimen
4. physician order
5. proteinaceous secretions (mucolytic)
6. inflammation, mucosal edema (steroid, vasoconstrictor)

B.

Bronchopulmonary Hygiene
1. productive cough
2. history of mucus producing disease
3. rhonchi on auscultation
4. patient is unable to deep breathe and cough spontaneously

C.

Hyperinflation Therapy
1. atelectasis
2. upper abdominal or thoracic surgery, or COPD & surgery
3. restrictive disease associated with quadriplegia and, or dysfunctional
diaphragm

D.

Oxygen Therapy
1. Pa02 < 65 torr on room air
2. Sp02 < 92% on room air
3. clinical signs of hypoxemia*
4. chest pain with cardiac history
5. home O2
6. post-op care

NOTE: For acute symptoms of hypoxemia or bronchospasm associated with

tachycardia, tachypnea, or decreased oxygen saturation, treat the patient with the appropriate
oxygen device or a bronchodilator via a SVN first, before completing the entire evaluation process.
Bronchodilators may be given q2-q4, ATC and PRN x 24 hours until symptoms subside. In such
an acute situation, any immediate physician orders will be followed until a complete RTCS
evaluation has been made.
*Increased respiratory rate, increased pulse rate, diaphoresis, confusion, cyanosis

406
FREQUENCIES (Guidelines)
A.
1.

Aerosols
Q2 to Q4, ATC, PRN*

Indications
Severe SOB, wheezing, unable to sleep
Moderate SOB, wheezing

Triage
1 &2

2.

QID & PRN at night

(Q 12 hr. for Serevent)

Hx of asthma, mild wheezing, or facilitate

secretion removal

3.
B.
1.
2.

PRN Q 6
Intermittent wheezing
4
Bronchopulmonary Hygiene
Q4 ATC
Copious secretions, SOB, unable to sleep, suspect
mucus plug
1
QID & PRN at night
Moderate amounts of secretions
2

3.

TID

C.
1.

Small amounts of secretions + poor cough,

history of secretions
Q shift WA
Patient unable to deep breathe & cough
spontaneously
Hyperinflation Techniques**
Q4 WA & PRN
Patients with severe atelectasis, + low Pa02

2.

QID

4.

3
4
1

Patients at high risk for, or with persistent

atelectasis

3.

TID

Patients at risk for developing atelectasis

4.

Q shift, WA

Prevention of atelectasis

5.

Instruct, D/C, video

Patients able to perform well on their own
follow-up
Pulse Oximetry ***
Continuous until stable,
Unstable patients
then Q4 + PRN in between

D.
1.

2.

QID, + PRN in between

Low Pa02 with variances

3.

PRN

To titrate Fi02

4.

Daily x 2 days

If, after titration, Sp02 remains at least 92%,

D/C pulse oximetry

Note:

5
1

2
3, 4, or 5
4 or 5

*If patient requires more frequent aerosols, please contact supervisor or work leader.
**IS and PEP must be performed by patient on their own Q 1 hr WA.
***Patients not on 02, with Sp02 > 92% should have pulse oximetry DCd and
restarted only when clinical signs indicate a need for 02.
PRN orders (except for oximetry or suctioning) must always accompany a frequency - e.g.
Aerosol Q4 WA and PRN.

406

406

406

10

406

11

406
ADULT RESPIRATORY THERAPY CONSULT MEDICATION ORDER FORM

12

406
GUIDELINES FOR PRIMING MDIs
DRUG NAME
Proventil HFA (albuterol)
ProAir HFA (albuterol)
Ventolin HFA (albuterol)
Atrovent HFA (ipratropium)
Flovent HFA (fluticasone)
Advair HFA
(fluticasone/salmeterol)
Xopenex HFA (levalbuterol)
Symbicort
(formoterol/budesonide)
Qvar HFA (beclomethasone)
Combivent
(ipratropium/albuterol)
Azmacort (triamcinolone)
Maxair (pirbuterol)
Alvesco (ciclesonide)
Aerospan HFA (flunisolide)

# OF SPRAYS
TO PRIME
4
3
4
2
4
4

WHEN TO REPRIME

4
2

after 2 wks of no use

after 2 wks of no use
after 2 wks of no use, or if dropped
after 3 days of no use
after 7 days of no use, or if dropped
after 4 wks of no use, if dropped
only 2 sprays to reprime
after 3 days of no use
after 7 days of no use, or if dropped

2
3

after 7 days of no use

after 24 hrs of no use

2
2
3
2

after 3 days of no use

after 48 hrs of no use
after 10 days of no use
after 2 wks of no use

RECOMMENDED INSTRUCTIONS FOR DRY POWDERED INHALER USE

Pulmicort Flexhaler- (budesonide)
Must be primed before 1st use. To prime, twist the brown grip in one direction & fully back in the
opposite direction. Repeat once more. When loading a dose, flexhaler must be in the upright
position (mouthpiece up).
Spiriva-(tiotropium)
Do not press green piercing button more than once. Pierce with mouthpiece pointing up. Breathe
in medication with the handihaler in the horizontal position.
Asmanex- (mometasone)
No need to prime it. Hold inhaler in the upright (pink on bottom) position, twist cap off in
counterclockwise direction. Inhale medication with inhaler in the horizontal position. Cap must be
replaced to load the next dose. Cap will not come off if medication is gone.
Advair (fluticasone/salmeterol), Flovent (fluticasone), Serevent (salmeterol) (Diskus)Place Diskus in horizontal position. Slide lever away until it clicks. Inhale the medication with the
Diskus in the horizontal position. Tilting the Diskus will cause the medication to fall out. (the
patient will not get any medication)
Foradil-(formoterol)
Hold Aerolizer in the upright position. Push both buttons at the same time and only once. With the
buttons facing left and right and the aerolizer in the horizontal position, inhale medication.

13

406

14

406

15

406

16

406

17

406

18

406

19

406

20

406

21

406

22

406

23

406

24

406

25

406

26

406
HOME O2 QUALIFICATION
I.

Qualifying Conditions
A. Chronic Cardio- Pulmonary Diagnosis
1. example: COPD/ Asthma/ Lung Cancer/IPF/
2. CHF/Pulmonary hypertension
B. Hypoxemia as defined by:
1. ABG results: PaO2 < 56, and/or, SaO2 <89% on room air.
2. Pulse oximetry results: SpO2 <89% on room air.

II.

Medicare/Private Insurance Carrier

A. Home O2 qualification
1. SpO2, at rest, of <89%
a. always check more than one site
b. check a manual pulse
c. document on desaturation study form
2. ABG at rest with PaO2 of <56 and /or SaO2 of <89% on room air
a. SpO2 may be used to determine O2 requirements
3. Either ABG or Pulse oximetry results may be used for qualification
a. qualifying studies must be done within 48 hours of discharge home
b. patients going to another facility after leaving the hospital must be qualified for
home oxygen at that facility before discharge home.
B. Determining needed O2 requirement
1. Determine lowest O2 level that will maintain an SpO2 of 92% (not to exceed 94%)
at rest.
2. Ambulate patient on resting O2 requirement for six minutes or as tolerated.
a. SpO2 on exertion should be > 90%
b. Document the SpO2, the required liter flow and the distance traveled before
desaturation.
c. also document the resting SpO2 on the liter flow required to maintain an SpO2 of
> 90% on exertion
C. Exertional Home O2
1. Patients with a chronic pulmonary diagnosis whose resting SpO2 is >88% but
desaturate
to < 89% with exertion
2. A desaturation study is required
a. ambulate patient at a normal pace for six minutes or as tolerated
3. Determine lowest O2 level required to maintain an SpO2 of >88% to <93% with
exertion
a. document exertional SpO2 and liter flow required
b. document a resting liter flow on the exertional liter flow

27

406
III.

Medicaid ( Ohio Department of Welfare) Patients

A. Follow Medicare guidelines

IV.

Documentation for all patients

A. Fill out Desaturation study form ( see example)
a. white copy goes in patients chart
b. yellow copy goes to the department
c. document all patient education on this form
B. Follow Respiratory Therapy Section documentation procedure

28