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•Eosinophils 2% to 4%

•Basophils 0.5% to 1%

Nongranular Leukocytes

•Lymphocytes 20% to 25%

•Monocytes 3% to 8%

TABLE 9.3

Common Causes of White Blood Cell Increase

Granular Leukocytes.

The granular leukocytes (also called granulocytes) are so classified because of the granules present in their cytoplasm. The granulocytes are further divided into the following three types according to the staining properties of the granules: neutrophils, eosinophils, and basophils. Because these cells have distinctive multilobar nuclei, they are often referred to as polymorphonuclear leukocytes.

Neutrophils.

The neutrophils make up about 60% to 70% of the total number of WBCs. They have granules that are neutral and therefore do not stain with an acid or a basic dye. The neutrophils are the first WBCs to arrive at the site of infection or inflammation, usually appearing within 90 minutes of the injury. They represent the primary cellular defense against bacterial organisms through the process of phagocytosis (ingestion of foreign material). The neutrophils are one of several types of cells called phagocytes that ingest and destroy bacterial organisms and particulate matter. The neutrophils also release an enzyme called lysozyme, which destroys certain bacteria. An increased neutrophil count is associated with

(1) bacterial infection, (2) physical and emotional stress, (3) tumors, (4) inflammatory or traumatic disorders, (5) some leukemias, (6) myocardial infarction, and (7) burns.

Early (immature) forms of neutrophils are nonsegmented and are called “band” forms. They almost always signify infection if elevated above 10% of the differential. More mature forms of neutrophils have segmented nuclei. They may increase even in the absence of infection (e.g., with stress [exercise] or the use of corticosteroid medication).

Eosinophils.

The cytoplasmic granules of eosinophils stain red with the acid dye eosin. These leukocytes make up 2% to 4% of the total number of WBCs. Although the precise function of the eosinophils is unknown, they are thought to play an important role in the breakdown of protein material. It is known, however, that the eosinophils are activated by allergies (such as an allergic asthmatic episode) and parasitic infections. Their role in the pathogenesis of asthma (see Chapter 14, Asthma) appears to be increasingly important, e.g., eosinophilic asthma. Eosinophils are thought to detoxify the agents or chemical mediators associated with allergic reactions. An increased eosinophil count also may be associated with lung cancer, chronic skin infections (e.g., psoriasis, scabies), polycythemia, and tumors.

Basophils.

The basophils make up only about 0.5% to 1.0% of the total WBC count. The granules of the basophils stain blue with a basic dye. The precise function of the basophils is not clearly understood. Increased basophils are primarily associated with certain myeloproliferative disorders. It is thought that the basophils are involved in allergic and stress responses. They are also considered to be phagocytic and contain heparin, histamines, and serotonin.

Nongranular Leukocytes.

There are two groups of nongranular leukocytes: the monocytes and lymphocytes. The term mononuclear leukocytes is also used to describe these cells because they do not contain granules but have spheric nuclei.

Monocytes.

The monocytes are the second order of cells to arrive at the inflammation site, usually appearing about 5 hours or more after the injury. After 48 hours, however, the monocytes are usually the predominant cell type in the inflamed area. The monocytes are the largest of the WBCs and make up about 3% to 8% of the total leukocyte count. The monocytes are shortlived, phagocytic WBCs, with a half-life of about 1 day. They circulate in the bloodstream, from which they move into tissues—at which point they may mature into long-living macrophages (also called histiocytes).

Macrophages are large wandering cells that engulf larger and greater quantities of foreign material than the neutrophils. When the foreign material cannot be digested by the macrophages, the macrophages may proliferate to form a capsule that surrounds and encloses the foreign material (e.g., fungal spores). Although the monocytes and macrophages do not respond as quickly to an inflammatory process as the neutrophils, they are considered one of the first lines of cellular inflammatory defense. Therefore an elevated number of monocytes suggests infection and inflammation. The monocytes play an important role in chronic inflammation and are also involved in the immune response and malignancies.

Lymphocytes.

Increased lymphocytes are typically seen in viral infections (e.g., infectious mononucleosis). The lymphocytes are also involved in the production of antibodies, which are special proteins that inactivate antigens. For a better understanding of the importance of the lymphocytes and the clinical significance of their destruction or depletion (e.g., in acquired immunodeficiency syndrome [AIDS]), a brief review of the role and function of the lymphocytes in the immune system is in order.

The lymphocytes can be divided into two categories: B cells and T cells. These cells can be identified with an electron microscope according to certain distinguishing surface marks, called rosettes. T cells have a smooth surface; B cells have projections. B cells make up 10% to 30% of the total lymphocytes; T cells account for 70% to 90% of the total lymphocytes.

The B cells, which are formed in the bone marrow, further divide into either plasma cells or memory cells. The plasma

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TABLE 9.4

Blood Chemistry Tests Monitored in Respiratory and Cardiac Care

Electrolytes

For the cells of the body to function properly, a normal concentration of electrolytes must be maintained, especially for normal cardiac function. Therefore the monitoring of electrolytes is extremely important in the patient whose body fluids are being endogenously or exogenously manipulated (e.g., intravenous therapy, renal disease, diarrhea). Table 9.5 lists electrolytes monitored in respiratory care. Normal values for blood sodium, potassium, chloride, and bicarbonate should be memorized by the respiratory care practitioner.

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d.8,000,000/mm3

6.What is the normal white blood cell count?

a.1000 to 5000/mm3

b.5000 to 10,000/mm3

c.10,000 to 15,000/mm3

d.15,000 to 20,000/mm3

7.Which of the following are activated by allergies (such as an allergic asthmatic episode)?

a.Eosinophils

b.Neutrophils

c.Monocytes

d.Basophils

8.Various clinical procedures such as bronchoscopy or the insertion of an arterial catheter are generally safe when the platelet count is no lower than which of the following?

a.100,000/mm3

b.75,000/mm3

c.50,000/mm3

d.20,000/mm3

9.Which of the following are associated with hyperglycemia?

1.Diabetes mellitus

2.Myocardial infarction

3.Thiazide and loop diuretics

4.Acute infection

a.2 and 4 only

b.2, 3, and 4 only

c.1, 2, and 3 only

d.1, 2, 3, and 4

10.Which of the following are clinical manifestations associated with hyponatremia?

1.Seizures

2.Confusion

3.Muscle twitching

4.Abdominal cramps

a.2 and 4 only

b.2, 3, and 4 only

c.1, 2, and 3 only

d.1, 2, 3, and 4

1TomoTherapy is a type of therapy in which radiation is aimed at a tumor from many different directions. The patient lies on a table and is moved through a donut-shaped device. The radiation source in the machine rotates around the patient in a spiral pattern. Before radiation, a 3D image of the tumor is taken. This helps the physician find the highest dose of radiation that can be used to kill tumor cells while causing less damage to nearby tissue. Tomotherapy is a type of intensity-modulated radiation therapy (IMRT), also called helical tomotherapy.

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C H A P T E R 1 0

The Therapist-Driven Protocol

Program

CHAPTER OUTLINE

The “Knowledge Base” Required for a Successful Therapist-Driven Protocol Program

The “Assessment Process Skills” Required for a Successful Therapist-Driven Protocol Program

Severity Assessment

The Essential Cornerstones of a Successful Therapist-Driven Protocol Program

Summary of a Good Therapist-Driven Protocol Program

Common Anatomic Alterations of the Lungs

Clinical Scenarios Activated by Common Anatomic Alterations of the Lungs

Self-Assessment Questions

CHAPTER OBJECTIVES

After reading this chapter, you will be able to:

•Describe the therapist-driven protocol (TDP) program and the role of the respiratory care practitioner now and in the future.

•Discuss the knowledge base required for a successful TDP program.

•Explain the assessment process skills required for a successful TDP program.

•Describe the essential cornerstones (Protocols) for a successful TDP program.

•List the anatomic alterations of the lungs commonly seen in clinical practice.

•Describe the clinical scenarios—chain of events—activated by the common anatomic alterations of the lungs.

•Identify the most common anatomic alterations associated with the respiratory disorders presented in this textbook.

•Understand in depth the differences between obstructive and restrictive pathophysiology.

•Identify the bases for resistance to development of protocol programs, and outline steps to overcome them.

•Define key terms and complete self-assessment questions at the end of the chapter and on Evolve.

KEY TERMS

Aerosolized Medication Therapy Protocol

Airway Clearance Therapy Protocol

Anatomic Alterations of the Lung

Assess, Treat, and Teach Protocols

Atelectasis

Bronchospasm

Clinical Manifestation

Clinical Scenarios

Diagnostic Coding

Discharge Planning

Disease-Specific Protocols

Distal Airway and Alveolar Weakening

Evidence-Based Clinical Practice Guidelines

Excessive Bronchial Secretions

Increased Alveolar-Capillary Membrane Thickness

Length of Stay (LOS)

Lung Expansion Therapy Protocol

Oxygen Therapy Protocol

Pathophysiologic Mechanisms

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All-Modality) program in place. According to the study, the department medical directors, managers, nurses, and administrators were not perceived as barriers.

Of significant interest was the fact that the biggest barrier to the implementation of protocols was perceived to be the medical staff itself. The primary reason for the medical staff's resistance was their perception that “staff therapists did not have the skills (i.e., assessment skills) to function under protocols.” The AARC Protocol Implementation Committee stated that “[this] perception must change….”2 To address this concern, many respiratory care departments have established mandatory protocol competency testing on a periodic basis to ensure their employees are “TDP safe and ready respiratory therapists”—that is, up-to-date on the medical staff and specific hospital-approved TDPs used in their place of work. It goes beyond what the respiratory therapy student learns at school, and beyond what is being tested on the National Board for Respiratory Care (NBRC) examinations. It gets right at the issue of the individual therapist's assessment and treatment (i.e., protocol) skills in this hospital at this point in time.

As of the date of this writing there has been some, but far from complete, improvement in this diagnosis/delivery paradox. Overlap of many of the functions potentially seen as within the scope of practice of the respiratory therapist is now being assumed by the physical therapist and certified nurse practitioner. The Advanced Practice Respiratory Therapist (APRT) is a long way from being fully implemented. Only a handful of therapist training programs in this county are training at the level of competency required in the knowledge and skills base described in the following material. Furthermore, the NBRC has not yet developed, let alone implemented, a certifying examination at the APRT level. In fact, licensure at the level of TDP competency is currently available in only a handful of states.

TDPs must be recognized as different from disease-specific protocols (sometimes called disease management protocols), which involve the diagnosis and treatment of individual diseases rather than the use of modalities or medications—for example, an Initial Asthma Management Protocol such as might be used in an emergency department (see Chapter 14, Asthma). Respiratory therapists may be asked to be familiar with certain disease-specific protocols, depending on their work site, but at this juncture should be required to be competent in the use of all the general modalityspecific TDPs (i.e., Oxygen Therapy Protocol, Airway Clearance Therapy Protocol, Lung Expansion Therapy Protocol, Aerosolized Medication Therapy Protocol, and Mechanical Ventilation Protocol).

The essential components of a good TDP program do not come easy. This is because a strong TDP program promises that the respiratory therapist who is identified as “TDP safe and ready” will be qualified to (1) systematically collect the appropriate clinical data, (2) formulate a uniform and accurate assessment, and (3) select a uniform and optimal treatment plan within the limits set by the protocol (Fig. 10.1).

FIGURE 10.1 The promise of a good therapist-driven protocol program.

The converse, however, is also true: When the respiratory therapist is not TDP safe and ready, the systematic collection of clinical data is not done at all or is incomplete. As a result, nonuniform or inaccurate assessments are made, resulting in nonuniform or inaccurate treatment selections (Fig. 10.2). This inappropriate and ineffective type of respiratory therapy leads to the misallocation of care, the administration of unneeded care, and—most important—the nonprovision of needed patient care. The bottom line is poor-quality patient care and unnecessary costs. To be sure, the development and implementation of a strong TDP program require a good deal of fundamental knowledge, training, and practice, but the benefits are worth the price. The essential components of a good TDP program are discussed in the following paragraphs.

FIGURE 10.2 No assessment program in place.

The “Knowledge Base” Required for a Successful Therapist-Driven Protocol Program

As shown in Fig. 10.3 the essential knowledge base for a successful TDP program includes (1) the anatomic alterations of the lungs caused by common respiratory disorders, (2) the major pathophysiologic mechanisms activated throughout the respiratory and cardiac systems as a result of the anatomic alterations, (3) the common clinical manifestations that develop as a result of the activated pathophysiologic mechanisms, and (4) the treatment modalities used to correct them. In other words, the clinical manifestations demonstrated by the patient do not arbitrarily appear but are the result of specific anatomic lung alterations and pathophysiologic events.

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FIGURE 10.3 Foundations for a strong therapist-driven protocol program. Overview of the essential knowledge base for outcome assessment of respiratory disease.

Hence, it is essential that the respiratory therapist knows and understands that certain anatomic alterations of the lung will lead to specific and often predictable clinical manifestations. Each respiratory disease presented in this textbook describes these four essential knowledge components necessary for TDPs to successfully work in the modern health care setting. In the clinical setting, this knowledge base enhances the assessment process essential to a good TDP program.

The “Assessment Process Skills” Required for a Successful Therapist-Driven Protocol Program

Using the knowledge base described previously, the respiratory therapist must be competent in performing the actual assessment process. This means that the practitioner can (1) quickly and systematically gather the clinical information demonstrated by the patient, (2) formulate an accurate assessment of the clinical data (i.e., identify the cause and severity of the problem), (3) select an optimal treatment modality, and (4) document the use and evaluation of this process quickly, clearly, and precisely. In the clinical setting, the practice and mastery of the assessment process are absolutely central and essential to the success of a good TDP program (Fig. 10.4). Simply stated, immediately after the respiratory therapist identifies the clinical manifestations (clinical indicators) present, an assessment of the data must be performed and a treatment plan must be formulated. For the most part, the initial assessment is primarily directed at the anatomic alterations of the lungs that are causing the clinical indicators (e.g., bronchospasm) and the severity of the clinical indicators.

FIGURE 10.4 Overview of TDP program. The way knowledge, outcome assessment, and a therapist-driven protocol program interface between each other.

For example, an appropriate assessment for the clinical cause and indicator of wheezing might be bronchospasm—the anatomic alteration of the lungs. If the therapist assesses the cause of the wheezing correctly as bronchospasm, the correct treatment selection would be a bronchodilator treatment from the Aerosolized Medication Therapy Protocol, Protocol 10.4, page 144. If, however, the cause of the wheezing is correctly assessed to be excessive airway secretions, the appropriate treatment plan would entail a specific treatment modality found in the Airway Clearance Therapy Protocol, such as deep breathing and coughing or chest physical therapy, Protocol 10.2, page 140.

Protocol 10.4

Aerosolized Medication Therapy Protocol