Respiratory and Sleep Science 2 Critical Care

Module details

Title

Respiratory and Sleep Science 2 Critical Care

Type

Specialist

Module code

SPS135

Credits

20

Requirement

Compulsory

Aim of this module

This rotation will enable critical care trainees to perform a range of clinical diagnostic investigations undertaken to investigate disorders of or affecting the respiratory system, interact with patients and demonstrate safe, patient- centred practice. Trainees will be expected to build on the competence gained in the earlier module, explaining procedures to patients and gaining informed consent (including the unconscious patient), enhancing and extending practical skills in undertaking diagnostic investigations, setting up and maintaining the equipment used, producing and interpreting results, and building their professional practice.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1, 2, 3,5	Competency Control infection risks in accordance with departmental protocols.	Action View
# 2	Learning outcome 1, 2, 3,4,5	Competency Minimise risks and hazards in compliance with health and safety policies.	Action View
# 3	Learning outcome 1, 2, 3, 5	Competency Select suitable technology for each type of investigation, choosing and adapting the appropriate diagnostic technique, patient position, machine settings and transducer for each patient.	Action View
# 4	Learning outcome 1, 2, 3, 4, 5	Competency Set up equipment ready for use for each type of investigation.	Action View
# 5	Learning outcome 1, 2, 3	Competency Obtain a suitably completed request form, greet the patient, check patient ID and ensure that the patient’s identity is confirmed as correct and fully identified on each type of recording system.	Action View
# 6	Learning outcome 1, 2, 3	Competency Explain the procedure for each type of investigation to the patient and address any questions they may have relating to the procedure, including the process after the procedure and how the patient will be informed of the results.	Action View
# 7	Learning outcome 1, 2, 3	Competency Gain appropriate consent for each investigation/consultation as appropriate to the individual patient in the critical care setting.	Action View
# 8	Learning outcome 1, 2, 3	Competency Initiate a consultation, elicit information, clarify as necessary, summarise, and empathise and use active listening techniques while taking a patient history.	Action View
# 9	Learning outcome 1, 2, 3, 5	Competency Treat patients in a way that respects their dignity, rights, privacy and confidentiality, taking appropriate action to respond to the specific needs of the patient, as defined by department protocol.	Action View
# 10	Learning outcome 1	Competency Assess the patient’s suitability for the proposed investigation and obtain a blood gas sample suitable for the assessment of blood gas status using a recognised technique.	Action View
# 11	Learning outcome 1	Competency Analyse and interpret a range of blood gas results and take appropriate action with the required degree of urgency in a range of conditions, including normal, Type 1 and Type 2 respiratory failure.	Action View
# 12	Learning outcome 1,6	Competency Identify requirements for long-term oxygen therapy, including ambulatory, and undertake assessments in accordance with national guidelines, titrating oxygen according to patient requirements and clinical indications.	Action View
# 13	Learning outcome 1	Competency Complete appropriate documentation based on the results of the assessment undertaken and the patient’s clinical needs, and identify further investigations and/or future management plans.	Action View
# 14	Learning outcome 2	Competency Assess the patient and undertake cardiopulmonary exercise testing using an appropriate protocol in patients with respiratory, vascular and cardiac disease.	Action View
# 15	Learning outcome 2	Competency Record results of cardiopulmonary exercise testing accurately in an appropriate format and analyse and technically interpret full cardiopulmonary exercise tests.	Action View
# 16	Learning outcome 3, 5, 6	Competency Assess the patient, determine the appropriate settings and obtain accurate baseline measurements of NIV therapy where appropriate.  Initiate appropriate NIV therapy and monitor clinical status.	Action View
# 17	Learning outcome 7	Competency Undertake consultations with patients to explain and agree therapeutic strategies for the management of their respiratory conditions.	Action View
# 18	Learning outcome 1, 2, 3, 5	Competency Decontaminate equipment and leave in a suitable condition for reuse.	Action View
# 19	Learning outcome 4	Competency Set ventilator alarms in a range of patients.	Action View
# 20	Learning outcome 4	Competency Assist in the interpretation of data from ventilator alarms recognising and rectifying common problems associated with ventilator troubleshooting and the use of ventilators in a range of patients.	Action View

Assessments

You must complete:

• 3 case-based discussion(s)
• 2 of the following DOPS/ OCEs:

Participate in the ventilator set up and selection of appropriate ventilator settings ready for a new patient.	DOPS
Set up for and connect NIV ventilator to patient. Discuss ventilator settings with staff.	DOPS
Participate in a CPET investigation. Assist with the patient interface and monitoring.	DOPS
Analyse a blood gas sample and make references to the possible care pathway of the patient	DOPS
Provide clinical technical support to nurse at the bedside regarding safe use of ventilation.	OCE
Initiate the ECG, Resp, and SpO2 monitoring on an awake patient, explaining to the patient the reasons and benefits of each parameter.	OCE
Discuss and agree ventilator mode and settings up for a new patient with medical staff.	OCE
Discuss the key components for consideration when planning a safe transfer of a patient with medical staff.	OCE

Learning outcomes

1. Perform and interpret assessments of blood gas status and identify the requirements for supplemental oxygen therapy.
2. Observe and assist during full cardiopulmonary exercise testing in the investigation of respiratory, vascular and cardiac disease.
3. Perform the selection the appropriate mode and pattern of ventilation with respect to the patient’s sedation level and lung pathology and pathophysiology.
4. Set and assist in the interpretation of data from ventilator alarms and the recognition and rectification of common problems associated with ventilator testing and application in a range of patients.
5. Perform routine non-invasive monitoring in a critical care setting and responds to trends in physiological variables.
6. Identify the requirement for and initiate non-invasive ventilation (NIV) in patients with both acute and chronic respiratory failure.
7. Discuss and agree ventilation and monitoring strategies for critically ill patients and demonstrate the communication skills required to discuss subjects that may be difficult.

Learning outcomes

1. Describe blood gas physiology and acid-base balance.
2. Discuss the principles and role of short- and long-term oxygen therapy in the treatment of disease.
3. Describe the evidence base for oxygen prescription and assessment of patients for long-term oxygen therapy.
4. Describe the role of field exercise testing in the assessment for ambulatory oxygen.
5. Describe the process for ordering oxygen therapy.
6. Discuss the pathophysiology of common causes of respiratory failure.
7. Describe the role of non-invasive ventilation in the treatment of acute and chronic respiratory failure in a range of disorders, to include airway, chest wall and muscle disorders.
8. Discuss the range of ventilators available for the provision of non-invasive ventilation, their modes of action and functions.
9. Discuss the assessment and monitoring of patients receiving non-invasive ventilation in the acute and chronic setting.
10. Describe the structure, function, mechanics and control of the cardiorespiratory system, to include ventilation, gas transport and exchange, haemodynamics and cardiac output during rest and exercise.
11. Recognise the physiological adaptations that occur with exercise training.
12. Describes the range of exercise tests available and their clinical importance.
13. Describe the application of cardiopulmonary exercise testing in the assessment of limitations to exercise.
14. Describe the common protocols used in cardiopulmonary exercise testing.
15. Recognise the uses and limitations of cardiopulmonary exercise testing and its value in clinical practice.
16. Discuss the application of interpretation strategies to respiratory investigations.

Indicative content

Anatomy and physiology

Cardiorespiratory responses to exercise

• Normal response to exercise, to include:
  • Muscles – structure, metabolism, substrates
  • Cardiac response to exercise – control of response, cardiac frequency and stroke volume, cardiac output
  • Ventilatory response to exercise – control of response, breathing frequency, tidal volume, ventilation perfusion ratio during exercise
  • Circulatory response to exercise – redistribution of blood flow to muscle

• Limitations to exercise subjects in normal subjects
• Exercise response in disease, to include:
  • Cardiac and respiratory (obstructive and restrictive disease) – patterns of response, major limiting factors and assessments of symptoms
  • Other disorders – obesity, unfitness, malingering, deconditioning
  • Contraindications to exercise testing and safety during exercise tests
  • Recognition of indications to terminate the exercise test prematurely,e.g. symptoms

Respiratory failure

• Assessment of respiratory failure and control
• Differentiation of Type 1 and Type 2 respiratory failure
• Acute and chronic respiratory failure
• Metabolic disorders
• Treatment pathways for patients in respiratory failure
• Diagnostic procedures used in the assessment of patients with respiratory failure

Oxygen therapy and assessment

• National guidelines for assessment of long-term oxygen therapy and ambulatory oxygen in adults
• Protocols for the performance and assessment for oxygen therapy in adults
• Methods of oxygen delivery and interfaces
• Ordering of oxygen therapy using home oxygen order form (HOOF)
• Long-term follow-up of patients using oxygen therapy
• The use of hypoxic challenge in patients wishing to fly

Non-invasive ventilation

• Clinical indications for NIV
  • Acute
    • Protocols for initiation and withdrawal
    • Monitoring
    • Requirements for invasive ventilation
  • Chronic
    • Assessment for domiciliary ventilation
    • Nocturnal and diurnal monitoring of patients for domiciliary ventilation
    • Long-term monitoring
  • Modes of ventilation (positive and negative)
    • Pressure support
    • Volume support
    • Spontaneous intermittent mechanical ventilation
  • Interfaces
  • Operational parameters
    • Inspiratory positive airway pressure (IPAP)
    • Expiratory positive airway pressure (EPAP)
    • Respiratory rate
    • Rise time
    • Vt

Field exercise testing

• Indications for performing field exercise tests
  • Objective assessment of exercise capacity
  • Assessment of symptoms
  • Unexplained dyspnoea on exertion
  • Assessment of disability
  • Desaturation on exercise
  • Serial monitoring
  • Assessment for ambulatory oxygen

• Field exercise protocols
  • Equipment
  • How to decide the most appropriate protocol to use
  • Advantages and disadvantages of each protocol
  • Six-minute walk, incremental shuttle walk, endurance shuttle walk
  • Manual calculation of results and predicted values
• Measurements
  • Heart rate, oxygen saturation
  • Assessment of symptoms: Borg scale, Visual Analogue Scale, Rating of Perceived Exertion
  • Observation of full cardiorespiratory exercise tests
• Interpretation and reporting of results
  • Common patterns of results in disease: cardiac vs respiratory disease
  • Symptoms
  • Obstructive vs restrictive lung disease

Full cardiopulmonary exercise testing

• Indications for performing full cardiopulmonary exercise tests
  • Assessment of symptoms
  • Differentiation of cardiac versus respiratory impairment
  • Unexplained dyspnoea
  • Assessment for surgery
• Exercise protocols
  • Maximal vs submaximal
  • Advantages and disadvantages
  • Cycle ergometer vs treadmill
  • How to decide on the most appropriate protocol

Principles of equipment

• Gas analysis
• Volume measurement
• Blood gases
• Quality control and calibration
• Graphical representation of results

• Measurements
  • Ventilation and frequency
  • Oxygen uptake and carbon dioxide output
  • Heart rate and oxygen pulse
  • Respiratory exchange ratio
  • Oxygen saturation
  • Assessment of symptoms
• Exercise facilities
  • Health and safety requirements
  • Basic Life Support/Advanced Life Support, resuscitation equipment and oxygen
• Concepts of interpretation of results
  • Graphs and flow charts
  • Common patterns of results in disease: cardiac vs respiratory
  • Symptoms
  • Breathing reserve
  • Cardiac reserve
  • Obstructive vs restrictive lung disease
  • Cardiac disease
  • Use of anaerobic threshold in interpretation

Interpretation

• Application of various respiratory tests in the confirmation of disease
• Awareness of clinical guidelines, e.g. COPD, asthma
• Clinical report writing techniques
• The role of the respiratory physiologist and critical care scientist in the multidisciplinary team

 Lifestyle changes

• Smoking cessation strategies
• Exercise prescription
• Weight management
• Pulmonary rehabilitation

Activities

• Observe the preparation and planning for the transfer of an acutely unwell patient, including the pre-transfer communication, and discuss the role of the critical care scientist and other members of the transfer team in ensuring safe transport.
• Identify a patient with clinical indications requiring non-invasive ventilation and, with permission, meet and discuss the impact of NIV on the patient and their family, and reflect on your learning from this meeting.
• Identify a patient who is transferred from a critical care environment to a ward, observe the transfer and discuss with the patient and ward staff the positive aspects of transfer and areas that could be improved, and reflect on the experience from a patient perspective, based on your discussions with the patient.
• Observe the role of the critical care scientist in critical care environments caring for patients with neurological and other conditions, including burns, and discuss the different approaches needed with your training supervisor.
• Attend a meeting at which the outcome of a clinical audit, research, innovation or service development is presented and discuss with your training supervisor how evidence-based practice is implemented with respect to ventilation and monitoring in a critical care environment.