My Canadian Pharmacy: Investigation of Respiratory Care in the Absence of a Respiratory Care Unit

Respiratory failureRespiratory failure is one of the most critical clinical entities which can be treated with intensive life support. Reasonable success in its treatment has been claimed by those clinicians in special respiratory intensive care areas.

Notwithstanding, the majority of patients in respiratory failure within this country are presently treated outside of respiratory intensive care units (RICU’s). Because of limited bed capacity, nursing shortages and expense plus the fact that RIClTs simply do not exist, there are little statistical data concerning present treatment of longterm mechanically ventilated patients. The primary purpose of this investigation was to study the effects and results of respiratory care of longterm ventilation in patients in seven intensive care units all separated geographically within a 750-bed general hospital in a large metropolitan area.

This study was made by a small respiratory care team composed of one senior staff member (Dr. Cold) within the department of anesthesiology plus various anesthesiology residents who rotated through its division of respiratory care from July, 1971 to and including June, 1972 (12 months). This physician team kept detailed records and a prearranged questionnaire on all patients ventilated for more than 12 hours. The latter had been modified from a similar study which was made during a previous period by the same anesthesia staff member with the help of medical students for the purpose of laying the groundwork and organizing the present respiratory care team (RCT).

The RCT originated at this large University Hospital during 1969, when there were consultations with patients requiring respiratory care within the surgical and medical ICU’s. As time elapsed, primary responsibility for respiratory care was transferred partially or entirely to this team making rounds twice daily, except Sunday when the on-call anesthesiology resident made rounds and communicated by telephone with the senior staff man who was available at all times for bedside consultation. Management of patients on longterm ventilatory care and most aspects of respiratory care also included management of tracheostomy, weaning, withdrawing of blood gases and interpretation of results, performance of bedside pulmonary function tests, inservice education of nurses, inhalation therapists and house staff, and management of inhalation therapy and personnel.

With respiratory support, medical patients were managed in close cooperation with residents in medicine, while surgical patients were managed entirely by the RCT. Respiratory care patients in the pediatric and neurologic ICU’s were usually treated on a consultation basis and not necessarily on a constant care basis, although there were exceptions. After 5:00 PM and until 7:00 AM, anesthesiology residents on call were responsible for respiratory care. The nurse-to-patient ratio differed from unit to unit and shift to shift. Some of the ICU’s had a ratio of one-to-five, while others enjoyed a ratio of one-to-two. Inhalation therapists were available during the day and evening periods but were not available from 11:00 PM until 7:00 AM. Remember avoid or overcome respiratory failure is possible with the participation of My Canadian Pharmacy

There were seven ICU’s, almost all on different floors simply because various specialties occupied these floors: 1) general medical ICU (3rd floor); 2) neurology ICU (3rd); 3) pediatric ICU (5th); 4) premature nursery ICU (6th); 5) neurosurgical ICU (9th); 6) coronary care ICU (11th); and 7) general surgical ICU (12th). On occasion certain patients were ventilated on wards. Pediatric ICU and premature nursery ICU maintained a consistently independent respiratory care situation: pediatric residents wrote all of the orders and utilized the RCT on a consultation basis only. However, daily rounds were made on all units by the team and all patients on ventilators were seen, a diagnosis of gross errors was made and corrected.

Not all of these intensive care units were equipped with monitoring devices; patients in respiratory failure had blood gas analysis and simple pulmonary function tests at least once daily. During critical periods chest x-ray films, sputum cultures, ECG’s, and calculation of alveolar-arterial oxygen tension differences, venous admixture and ratio of dead space to total ventilation (VD/VT) ratios were performed daily, or more often. Weaning involved special orders, studies and attention.

One hundred ninety-two patients were included in this investigation. Subjects ventilated less than 12 hours and patients receiving only intermittent positive pressure breathing (IPPB) therapy were not included. Generally, respiratory failure was treated conservatively by the patients* primary physicians before the RCT was called. The procedure for placing patients on ventilators was as follows: Patients were clinically evaluated and blood gases were withdrawn and interpreted. In general, when the Pacc>2 rose above 50 torr and Раог fell below 45-50 torr, mechanical ventilation was used. The choice of type of ventilator was made according to the type of respiratory failure, but this also depended on availability of ventilators. Some patients were ventilated with more than one machine type. During the study the following ventilators were used: pressure guaranteed machines: Bird Ventilators, 16; volume-guaranteed ventilators: Bennet MAl’s, 6; Emerson postoperative ventilators, 3; Engstrom model 300’s, 1; Ohio 560 ventilators, 1. The routine was for inhalation therapy personnel to change Y pieces, valves, humidifier jars, and other parts, which were sterilized once daily.