Class Hours: 3 Laboratory Hours: 3 Credit Hours: 4 Chattanooga State Community College Chattanooga, Tennessee Nursing and Allied Health Division-Respiratory Care Course Syllabus RC 210 Fundamentals of Respiratory Care Course Description: An in-depth study of mechanical ventilation is provided through a combination of didactic and guided laboratory experiences. The principles of critical care medicine as applied to the rationale, institution and discontinuance of mechanical ventilation are presented. Fundamental concepts of ventilator operation and modification are also included. Entry Level Standards: Advancement to Semester IV in the Respiratory Care Program. Prerequisites: RC 113, RC 143 Corequisites: RC 221, RC 243 Textbook: Mechanical Ventilation, Physiological and Clinical Applications Pilbeam, Susan 4 rd edition Course Delivery Format: Standard 1. Lecture 2. Audiovisual aids, including transparencies and videos 3. Demonstration and student use of mechanical ventilators in lab 4. Instructor prepared class handouts 5. Written laboratory exercises coordinated with classroom topics 6. Student discussion groups in classroom and laboratory 1
Respiratory Care Program Student Learning Outcomes: (PSLO) and Course Student Learning Outcomes (CSLO) PSLO-1): Show the ability to interpret, comprehend, apply and evaluate patient data and clinical information relative to their role as an Advanced-Level Respiratory Therapist. CSLO# 2: Identify respiratory failure by observation, clinical measurements, and lab tests. CSLO#4: Evaluate patient to document and improve tolerance of mechanical ventilation CSLO #5: Describe the different modes of mechanical ventilation, how these are applied, and identify when each mode should be used. CSLO #6: Identify and perform methods of improving oxygenation in patients. CSLO #7: Using appropriate formulas and ABGS, determine correct ventilator changes. CSLO # 8: Explain other factors which should be observed and controlled in ventilator patients, including I:E ratios, time constants, and mean airway pressures. CSLO # 9: Analyze and minimize physiological effects and complications of ventilation PSLO-2). Demonstrate the proficiency in all the mechanical and physical skills necessary to fulfill their role as an Advanced-Level Respiratory Therapist. CSLO #1: Assess a patient to determine normal respiratory function. CSLO# 3: Initiate mechanical ventilation on several models of mechanical ventilators with appropriate settings for any patient. CSLO #10: Troubleshoot the ventilator and take appropriate steps to maintain patient safety. PSLO --3). Demonstrate behaviors and attitudes consistent with professional and employer expectations for an Advanced-Level Respiratory Therapist. This PSLO is not addressed in this course. PSLO-4) Provide the community with qualified individuals who can meet current and future needs of the workplace as respiratory therapists. This PSLO is not addressed in this course 2
Student Indicators At the end of the course, the student will be able to: For CSLO#1 1. Identify the muscles which are used in respiration. 2. Describe the neurological control of respiration by peripheral and central receptors. 3. Calculate alveolar ventilation, anatomic dead space, minute volume, tidal volume. 4. Define physiologic shunting, anatomic shunting and shunt. 5. Describe the 4 major causes of increased work of breathing. 6. Compare the causes of resistance and compliance 7. Explain dyspnea, refractory hypoxemia, and ventilatory pattern. For CSLO #2 1. Analyze a patient s clinical symptoms, vital signs and arterial blood gases to determine if he is in acute respiratory failure. 2. Analyze arterial blood gases to identify respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. 3. Assess patient for clinical signs of hypoxemia or hypercarbia. 4. List numerous conditions that put a patient at risk for respiratory failure. 5. Perform all pulmonary mechanics on lab partner, which include maximal inspiratory force, maximal expiratory force, forced vital capacity, minute volume, tidal volume and respiratory rate and evaluate results. 6. Describe Adult Respiratory Distress Syndrome, including causes, early and late clinical signs, and how it is treated.. For CSLO#3 1. Compare the similarities and differences between volume-cycled and pressure-cycled ventilation. 2. Analyze the effect a change in compliance or resistance would have on a patient in pressure-cycled ventilation. 3. Analyze the effect a change in compliance or resistance would have on a patient in volume cycled ventilation.. 4. Calculate the appropriate ventilator settings for a patient when given his weight, age, 3
clinical condition and previous arterial blood gases. 5. List, in order, the steps necessary to start mechanical ventilation for the first time. 6. Set high pressure, low pressure, apnea and minute volume alarms appropriately. For CSLO#4 1. Document all required pressures and volumes on a ventilator charting forms. 2. Calculate both static and dynamic compliance and note any trends. 3. Assess patient for respiratory distress, including all vital signs. 4. Chart all calculations and patient assessments in legible, medically acceptable language. 5. Adjust ventilator settings to improve patient comfort and tolerance of ventilation. 6. Recognize clinical conditions that could trigger a low pressure or high pressure alarm. 7. Provide adequate artificial airway care, such as suctioning, taping the endotracheal tube and measuring cuff pressure. 8. Explain significance of tubing compliance factor and use it correctly in a formula. For CSLO#5 1. Explain differences between and the uses for full ventilatory support versus partial ventilatory support. 2. Describe what parameters are set by the therapist and which are set by the patient in the following modes: control, assist/control, pressure control, SIMV, pressure support, CPAP, PEEP. 3. Recognize the flow, pressure and volume graphics for each of these modes. 4. Evaluate patient to determine which mode or modes are most appropriate. 5. Physically adjust the settings on a mechanical ventilator to initiate and operate each mode. 6. Describe the indications to change a patient from volume ventilation to pressure ventilation. For CSLO #6 1. Identify those with oxygenation problems, by assessing patients using clinical signs and arterial blood gases. 2. Explain the methods used to improve oxygenation which include: changing oxygen concentrations, adding PEEP/CPAP, changing to pressure control and inverse ratio ventilation. 2. Perform oxygen concentration changes correctly and appropriately on the ventilator. 3. Describe the indications for the use of CPAP or PEEP. 4. Assemble and initiate a CPAP setup, using either a Downs flow or a GIN, on a lab partner. 5. Adjust PEEP settings correctly on a mechanical ventilator. 6. List the most common complications which could occur with CPAP or PEEP. 4
7. Describe the technique used to discontinue or decrease CPAP or PEEP. 8. Document and chart all procedures done to improve a patient s oxygenation. 9. Perform and optimal PEEP study. 10. List absolute and relative contraindications to using CPAP/PEEP. 11. Identify some hazards specific to mask CPAP. 12. Explain the use, indications, benefits and complications of inverse ratio ventilation. 13. Analyze patient scenarios for the existence of auto-peep. 14. Identify patients which are at high risk for auto-peep. 15. List methods which can reduce the amount of auto-peep present. For CSLO#7 1. Analyze arterial blood gases for the presence of hypoxemia, respiratory acidosis, respiratory alkalosis, metabolic alkalosis or metabolic acidosis. 2. Assess patients to determine if excessive work of breathing or dyspnea exists. 3. Using the ventilator change guidelines, determine if a patient needs more or less ventilation. 4. Using math formulas, determine the exact ventilator change to be made. 5. Understand the effects that abnormal arterial blood gases have on spontaneous work of breathing, electrolyte values, and cardiac function. 6. Explain how long-term abnormal arterial blood gases can affect weaning. For CSLO#8 1. Compare how slow flow rates versus high flow rates affect peak inspiratory pressure, inspiratory time, expiratory time, alveolar gas distribution and mean airway pressure. 2. Explain what flow rates should be used on different types of patients and why. 3. Contrast the effects created by square, sine, descending, and ascending ramp flow patterns on gas distribution, mean airway pressure and peak inspiratory pressure. 4. Calculate inspiratory time, expiratory time, total cycle time, tidal volume or flow rate when given all but one of these variables. 5. Describe how mean airway pressure is affected by different ventilator modes, inspiratory flow rates, PEEP, inflation hold, I:E ratio, and the patient s compliance and resistance. 6. Define time constants and how lung characteristics influence them. For CSLO#9 1. Know the potential effects of mechanical ventilation on the cardiovascular system, and on the intracranial pressure and renal system. 5
2. Describe how mechanical ventilation changes distribution of blood and ventilation. 3. Define absorption atelectasis, oxygen toxicity and oxygen-induced bradypnea. 4. Explain the different types of barotrauma that can occur. 5. List the common conditions that increase the risk of barotrauma. 6. Recognize all of the clinical signs and symptoms of a tension pneumothorax. 7. State some psychological and nutritional complications of mechanical ventilation. For CSLO#10 1. Recognize all clinical signs of respiratory distress. 2. List the steps, in order, you should take when you suspect there is a problem with either the patient or the ventilator. 3. Describe the signs and symptoms of various potential artificial airway problems, pneumothorax, bronchospasm, and pulmonary embolus. 4. Analyze changes in peak inspiratory pressures and plateau pressures to determine whether a change has occurred in static compliance or airway resistance. 5. Perform an assessment of the ventilator function to determine if leaks are present. 6. List numerous causes for either a low pressure alarm or a high pressure alarm to sound. Required assessments: Assessment Names and Descriptions Class Test # 1: Identify respiratory failure by vital signs, arterial blood gases, and lab measurements. Class Test # 2: Describe the operation of, and uses for different mechanical ventilation modes. Class Test # 3: Describe methods of improving oxygenation and apply appropriately to patients. Class Test # 4: Initiating noninvasive ventilation, making appropriate ventilator changes. Comprehensive Final: Includes previous CLSOS plus troubleshooting ventilator and techniques to decrease patient complications and improve safety Comprehensive Lab Final: Written questions and demonstration of physical skills including setting up, troubleshooting and manipulating different ventilator models, adjusting settings. CSLO/Assessment Alignment: RC 210 CSLO: CSLO#1 CSLO#2 CSLO#3 CSLO#4 CSLO#5 Assessments: Test #1, Final Test#2 Test #2 Class&Lab Finals Test # 2, Final CSLO: CSLO#6 CSLO #7 CSLO#8 CSLO#9 CSLO#10 Assessments: Test # 3, Final Test # 4, Final Test #2, Final Test #4, Final Class&Lab Finals 6
III Instructional Activities Week/Topic Unit Basis A systemic, orderly list of activities and events that will comprise the allotted time for the course. Week I Week II Week III Introduction, Review Handout, W.O.B. Oxygen consumption, ABGS, etc. Chapter 5, pgs. 63-78 Establishing Need for Mechanical Ventilation, Handout, Chapter 5, pgs. 63-78 continued Chapter 2, pgs. 15-29 Basic Terms, Concepts of Mechanical ventilation Chapter 3 How Ventilators Work Pgs. 32-43 Week IV Chapter 4 How a Breath is Delivered, pgs. 45-62, Test # 1 Chapters 2 & 5 Week V Continue Chpt 4, handout, Chapter 6, 82-96 Selecting the Ventilator and mode Week VI Week VII Week VIII Week VIIII Continue Chapter 6, Chapter 7 pgs. 105-120, Initial Ventilator Settings Chapter 8 pgs 128-136 Final Considerations in Mechanical Ventilator Setup Test # 2 new material from Chapters 3, 4, 6 and part of 7 Chapter 9 pgs. 152-173 Initial Assessment of Ventilated Patient Chapter 14 pgs. 296-321 Improving Oxygenation and Management of ARDS pgs. 128-129, Box 8-1, handout on PCIRV Week IX Chapter 13 Methods to Improve Ventilation pgs. 258-264 Chapter 13 continued pgs. 266-277 (Chapter13 on Test # 4) Week X *** Test # 3 *** new material from Chapters 7, 8, 9, 14 Chapter 19 pgs. 417-437 Noninvasive Positive Pressure Ventilation Also 72-75, 82-83, 96, 120-121, Boxes 5-6, 5-7, 5-8 on pg. 73-75 Week XI Chapter 16 Effects of Positive Pressure Ventilation (PPV) pgs. 345-355 Week XII Chapter 17 Effects of PPV - Pulmonary Systems 82-83, 357-385, Test # 4 Week XIII Chapter 18 Troubleshooting and Problem Solving pg. 391-412, also 132-133 7
Week XIV Week XV Chapter 18 continued, Lab Final (all sections) TBA Review for class final, Comprehensive Class Final Lab Schedule of Events Week I Week II Do worksheet to practice recognizing respiratory failure, including interpretation of arterial blood gases and ventilatory mechanics, and assessing patient vital signs and symptoms. CSLO #1, #2 Perform ventilatory mechanics on classmates and calculate normal values. Tests include MIP, MEP, VC, Vt, and exhaled minute volume. CSLO#2 Week III Review results of Test #1. Show parts of IPPB and ventilator circuits. Demonstrate resistance and compliance changes on a test lungs. Connect results with time constants and I and E times. Show Bird Mark 7 results when Raw and Cs changed (use respirometer). Show PIP, plateau and baseline pressures. Show Bear II with Raw and Cs changes. CSLO #3, #8 Week IV Week V Week VI Week VII Demonstrate mechanical ventilator modes and pressure, flow and time waveforms on Puritan Bennett 840 ventilator. CSLO # 3, # 5, #8 Perform initial ventilator checks on notebook paper, put in ventilator patient settings, and record PIP, plateau pressures, etc. CSLO #3, #4 Calculate appropriate settings for ventilator Vt, RR, VE, mode, FiO2,when given type of lungs-normal, obstructive, restrictive, BSA, and male or female. Perform ventilator checks using these calculated settings. Review class test #2 results. CSLO #3, #4, Demonstrate Drager Evita 2 ventilator and Drager XL ventilator. Review hospital charting sheets and perform ventilator checks based on scenarios. CSLO #3, #4, # 8 8
Week VIII Demonstrate PEEP effects on patients and on mechanical ventilator using traditional water container method. Add peep to ventilator settings, add PEEP to Cs calculations, and show mechanical dead space CSLO # 5, # 6, #10 Week IX Practice formula to calculate desired FiO2. Do optimal PEEP, O2, ventilator and PEEP scenarios without calculating numbers. Do ventilator changes worksheet. Review class test # 3 results. CSLO # 3, # 7, #8 Week X Week XI Week XII Week XIII Week XIV Week XV Demonstrate Puritan Bennett 840 ventilator. Perform initial setup and ventilator checks on all ventilator models in groups of two-three. CSLO # 3, #8 Perform initial setup and ventilator checks on all ventilators in groups of two- three. Do ventilator changes worksheet. CSLO # 3, #5, #8 Review objectives for lab test at end of semester. Rotate through all ventilator models, doing initial setup and checks individually. Show BiPAP Vision DVD. Demonstrate Vision BiPAP for noninvasive ventilation, including circuit, settings, alarms and troubleshooting. Students perform initial setup and chart results. CSLO # 3, #5, #9, Discuss unique troubleshooting problems for each type of mechanical ventilator. Students practice identifying problems created by instructor. CSLO # 6, # 4, # 10 Students review and practice all lab test objectives. Practical and written lab test. IV Assessment Grading : Each test must be passed with a minimum grade of 75. Any test below a 75 must be retaken within seven days to achieve a 75 or better. Either the original grade or 70%, whichever is higher, will be used to calculate the class average. Only one retest will be given for an exam. Only two tests may be retaken during the semester. A 75 on every test (or retake) is required to pass the course, regardless of overall average. A grade less than 70 on the final exam or on the 9
laboratory final will result in a grade of D or F; there will be no retake on a final exam or a laboratory final. Students making a score less than 75% on a retest or making less than 75% on a third initial examination will not be eligible to continue in this class or associated laboratory. Each exam will have some items based on objectives from any or all previous exams ( old material ) in RC 210. Make up exams will be given without penalty only for excused absence (doctor s excuse for illness, subpoena, jury duty, court order). Unexcused makeup test grades will be reduced 5 points per day that the testing enter is available until made up. See test center schedule. 1. Four (4) objective/essay tests @ 15% each 60% 2. Comprehensive final test 20% 3. Comprehensive lab test 20% 100% V Grading Scale (per college) A = 90-100 B = 80-90 C = 70-79 D = 65-69 ( see Respiratory Care program retention policy) F = 64 or less Instructor: Sharon Hall Office: HSC 2078 Office hours are announced at the beginning of the semester, appointments are available) Telephone 423 697-4772 E-mail: sharon.hall@chattanoogastate.edu VI College Policies This class is governed by the policies and procedures stated in the current Chattanooga State Student Handbook. Additional or more specific guidelines may apply. ADA Statement Students who have educational, psychological, and/or physical disabilities may be eligible for accommodations that provide equal access to educational programs and activities at Chattanooga State. These students should notify the instructor immediately, and should contact Disabilities Support Services within the first two weeks of the semester in order to discuss individual needs. The student must provide documentation of the disability so that reasonable accommodations can be requested in a timely manner. All students are expected to fulfill essential course requirements in order to receive a passing grade in a class, with or without reasonable accommodations. 10
Disruptive Students The term classroom disruption means- student behavior that a reasonable person would view as substantially or repeatedly interfering with the activities of a class. A student who persists in disrupting a class will be directed by the faculty member to leave the classroom for the remainder of the class period. The student will be told the reason(s) for such action and given an opportunity to discuss the matter with the faculty member as soon as practical. The faculty member will promptly consult with the division dean and the college judicial officer. If a disruption is serious, and other reasonable measures have failed., the class may be adjourned, and the campus police summoned. Unauthorized use of any electronic device constitutes a disturbance. Also, if a student is concerned about the conduct of another student, he or she should please see the teacher, department head, or division dean. Affirmative Action A student who feels that he or she has not received equal access to educational programming should contact the college affirmative action officer. Academic Integrity/Academic Honesty In their academic activities, students are expected to maintain high standards of honesty and integrity. Academic dishonest is prohibited. Such conduct includes, but is not limited to, an attempt by one or more students to use unauthorized information in the taking of an exam, to submit as one s one work, themes, reports, drawings, laboratory notes, computer programs, or other products prepared by another person, or to knowing assist another student in obtaining or using unauthorized materials, Plagiarism, cheating, and other forms of academic dishonesty are prohibited. Students guilty of academic misconduct, either directly or indirectly through participation or assistance, are immediately responsible to the instructor of the class. In addition to other possible disciplinary sanctions, which may be imposed through the regular institutional procedures as a result of academic misconduct, the instructor has the authority to assign an?f> or zero for an activity or to assign an F for the course. VII Instructor Policies Lab Attendance For each unexcused lab absence, 3 points will be subtracted from the final grade for the class. The student may not change lab sections, even temporarily, without prior permission from instructor. Attendance and Punctuality Punctual attendance at all scheduled classes is expected. The final class grade will be reduced 1% for each unexcused absence (acceptable excuses are doctor s excuse for illness, subpoena, jury duty, court orders) after the second absence. Students are responsible for signing attendance sheet. Final grade will be reduced ½ % for each tardiness (greater than 5 minutes) starting with the second tardy. The student is solely responsible for signing attendance logs. Notifying the 11
instructor about an absence does not guarantee an excused absence. Electronic Devices The use of any electronic devices is at the discretion of the instructor. All electronic devices, including cell phones, beepers, MP3 players, and any similar devices, must be turned OFF during class, not just set to silent or vibrate. Students violating this policy, even if the device isn t answered, will be asked to leave the classroom and will be recorded as absent for that day. Violation of this policy during an examination will result in a grade of 0" for that exam. Cameras, tape recorders and video cameras may only be used with the specific permission of the instructor. Use of these devices must not interfere with the normal activities of the classroom. Laptop computers may only be used in class for note taking and classroom related activities. It must be operated in a totally silent manner. Internet Access Students will access elearn on the Chattanooga State Tiger web site. The site for RC 210 will contain syllabi, test objectives, supplemental material, announcements and academic references. Each student is expected to access this site at least once a week and whenever he or she is notified of a new posting to the site by the instructor. Students may access several computer labs on campus including HSC 1002, which allows printing, and the Respiratory lab HSC 2057, when it is not in use. The instructor reserves the right to modify this syllabus in writing during the course of the semester. 12
Student Acceptance of Policies I have read all of the policies contained in the syllabus for Respiratory Care (RC ) 210, understand them and agree to abide by them. Student Name (please print) ------------------------------------------------------------ Signature Date 13