Best Practices


Image of patient being monitored.

Patient Monitoring: Supervising Patients During Every Life Stage

by Phyllis Hanlon

Image of patient being monitored.Patients diagnosed with respiratory/pulmonary illnesses come in all shapes, sizes, and ages. In the course of their careers, respiratory care professionals often have an opportunity to work with more than one of these different populations. While treatment methods and medical devices are basically the same, nuances within each age group require understanding and knowledge of the challenges that exist during every stage of life. Careful oversight can detect early signs of distress, patient instability, and changes that might signify a worsening medical condition, including potential failure of the cardiovascular, nervous, respiratory, and/or excretory systems. Most protocols have embedded monitoring practices, but often need to be modified for different patient populations and situations.

Scott Marlow, RRT, certified asthma educator at the Cleveland Clinic, is intimately familiar with a variety of disorders from pulmonary fibrosis and COPD to respiratory thoracic disorder and lung cancer, but focuses his attention on adults with asthma. Typically maintained on an outpatient basis, asthma requires an action plan in which baseline is established via peak flow meter readings and pharmacological intervention. “We want to maintain a certain respiratory percentage,” said Marlow, noting that he works with physicians to encourage compliance with anti-inflammatory medication.

In outpatient clinics, Marlow watches for flares, which might be triggered by pet dander, dust, increased pollen counts, ozone, glutens, and/or anxiety. “Depending on the severity of the exacerbation, the patient with asthma might need to be hospitalized,” he said. “The patient would then be given frequent inhaled medication treatments and occasionally might be intubated. Constant monitoring takes place from the nursing staff, physicians, and respiratory therapy department.”

Marlow’s patients with COPD often require hospitalization to bring their disease under control, but follow up with outpatient pulmonary rehabilitation. “This is where patients learn the best way to deal with the illness,” Marlow said. Since activity is a key component of the rehabilitation process, he monitors progress by giving patients a pedometer to encourage walking. “They call me regularly to report how many steps they’ve taken,” he said.

Comorbid Illnesses Compromise Geriatric Monitoring

Elderly patients present a special challenge for respiratory therapists due to comorbid illnesses and age-related conditions. For instance, elders who carry a COPD diagnosis also may have a compromised cardiac status, according to Jane Martin, BA, LRT, CRT, associate director of education at the COPD Foundation. “Comorbidity is common in COPD patients because the lungs are closely associated with body systems,” said Martin.

Frailty in this population also means less invasive interventions are preferable. “A bilevel positive airway pressure system, CPAP, or noninvasive ventilator with a snug fitting mask on the nose and mouth is an easy way to relieve the work of breathing without putting tubes into the patient,” Martin said, noting that these interventions minimize the risk of pneumothorax and inadvertent lung infections.

Depending on the facility, some respiratory therapists become heavily involved in hemodynamic processing and also monitor patients in intensive care units, Martin points out. In addition to supplemental oxygen with pulse oximetry, respiratory therapists may place these patients on heart monitors and pay close attention to lung sounds to manage the patient’s condition.

Swallowing becomes another issue with an elderly patient on any type of ventilation. “People on ventilators do not eat so they don’t have to swallow,” said Martin. “That might affect an already weak person who doesn’t have to swallow for a while.” Round-the-clock monitoring, during which the respiratory care professional assesses the pressure and position of the equipment followed by detailed documentation, helps to ensure optimal intervention with minimal adverse effects in these cases.

Monitoring geriatric patients becomes even more critical once they are discharged, said Martin. “It’s real important with the geriatric population to assess activity level,” she said. “Over time, people’s lives become much less active. Muscles get weaker and require more oxygen.”

Pediatric Patients Require a Different Approach

At the other end of the spectrum, pediatric patients require respiratory therapists with age-specific competencies in order to monitor effectively. “You have to have patience and the know-how to improvise, interact, and learn all the special needs of children. The diagnostic process is different, as is the equipment and approach,” said Kathy Fedor, CRT, RRT, NPS, respiratory department manager at the Cleveland Clinic.

In-depth knowledge of the anatomy and physiology of children leads to more effective oversight. For instance, an adult with a congenital heart defect might have an oxygen saturation level of 75%, which would not be normal. “But this might be normal for a child. It’s a matter of understanding physiology and what is baseline for this child,” Fedor said.

When it comes to medical devices, pulse oximetry is a mainstay, but often the equipment doesn’t account for the size of the child. “The probes are rated for weight because of the intensity of the infrared and where they need to be placed on the patient. It’s important to pay attention to ensure accuracy on what you are measuring,” Fedor said, adding that nasal cannulas also need to be appropriately sized for neonatal, infant, and pediatric use.
Pediatric intubation poses another challenge, Fedor noted, citing the importance of choosing the appropriate size tubing to minimize kinking and overexposure to air. “The outside [of the tubing] is the same weight and size of that used for an adult, but inside the volume is different. So we worry about unplanned extubation,” she said. “The best way to do continuous monitoring is to choose an alternative, like transcutaneous.”

Also much like seniors with dementia or hearing or vision problems that inhibit effective interaction, children have difficulty communicating, depending on their age. “Children can’t tell you what’s wrong. They give no verbal cues so you have to be able to recognize the signs,” said Fedor. Certain indicators might mean an increased heart rate or blood pressure, but also could be a clinical condition. “The therapist has to look at the systems and put them together to figure out what’s going on. Clinical assessment skills are really important. With pediatric patients, you need more hands-on, more one-on-one,” she added.

“You have to recognize that they’re a special population even when their illness is not as acute and devastating as an adult’s.”

Collaboration Enhances Monitoring Efforts

For all patient populations, collaboration among physicians, nursing staff, and the respiratory care department enhances monitoring efforts and helps to facilitate patient well-being. Amelia Ng, MD, private physician at Park Plaza Hospital and Medical Center in Houston, specializes in critical care and pulmonology and notes that oversight by respiratory therapists is important in ensuring efficient and effective intervention when her patients are admitted to the hospital. She reported that these therapists work quickly to set up CPAP and bilevel positive airway pressure machines, adjusting and monitoring inspiration and expiration pressure and other settings based on patient comfort level, blood gas, and other indicators. “Respiratory therapists know how to troubleshoot. If there is noise, leaking, or some other problem, they make recommendations about changes in the setting. For instance, the patient might need more oxygen, so they suggest adjusting the flow,” she said.

Bedside observations by respiratory care professionals also augment the physician’s involvement through routine charting, according to Ng. Information recorded during breathing treatments, routine visits, and other interventions helps keep the entire team apprised of a patient’s progress or decline and subsequent recommended treatment changes. “I can see how many treatments the patient is getting. Everything is written down and the reason for it,” Ng said. “Therapists who have been in the profession for many years have a ‘gut feeling’ when it comes to patient care. They use their clinical judgment.”

Ellen Davis, RRT, works at the Levindale Hebrew Geriatric Center and Hospital, a specialty hospital and nursing home, which is part of LifeBridge Health in Baltimore, and agrees that collaboration maximizes patient monitoring and care. “We work as a team to treat the whole patient. You have to look at physical health as well as mental health. You can’t pay attention to one piece and ignore the rest,” she said. In addition to bilevel positive airway pressure system, CPAP, nebulizer, and inhaler treatments, the respiratory department performs chest physical therapy and bronchoscopies, monitors tracheostomy tube changes, and does speech treatments. By monitoring various systems and performing an assortment of procedures, the respiratory care professionals are in a position to determine if and when other medical staff should be involved in the patient’s care.

One of the key areas that require strong partnership involves weaning, particularly when dealing with seniors. Davis noted that some elderly patients experience anxiety, which must be treated before continuing the process. She indicated that good rapport with other medical professionals helps to maximize effectiveness. “All the disciplines get together and create care plans. The doctors, nursing staff, and occupational, physical, and respiratory therapy might meet once or twice a week to discuss the patient,” she said.
While respiratory care professionals have the skills, training, and hands-on experience to effectively monitor patients, the proliferation of technological tools could open the door to patient self-monitoring and better opportunities to interact with the respiratory therapist, according to Marlow. He noted that adults and many seniors are comfortable with smartphones and would welcome the chance to work with respiratory care professionals to manage their disease. RT


Phyllis Hanlon is a contributing writer for RT. For further information, contact rtmagazine@nullallied360.com.