discussion

MY PLAN

PRE INTUPATION PLAN:

· Order Nebulizer treatment: Albuterol 0.5% neb 5 mg, Albuterol/ Ipratropium neb (Duoneb 2.5 mg/0.5 mg/3 ml), continue steroids, antibiotics, and breathing treatments for COPD exacerbation.

· Order and review clinical lab tests, blood culture test, and repeat CXR and ABGs.

· Consult pulmonary and discuss the case with critical care attending physician.

· Patient’s family should be updated about the treatment plan and encourage (Sitter/ Caregiver) to remain with patient

· Tobacco abuse: counseled for cessation and recommend nicotine patch p.r.n

POST INTUBATION PLAN:

· Follow up of respiratory failure and continue mechanical ventilation, consult RT for vent settings, and follow blood and sputum cultures, and plan to wean down MV as tolerated.

· Obtain Blood gas sample after ventilator settings changes to confirm adequate ventilation and oxygenation status.

· Administration Duoneb and Pulmicort to prevent coughing in people with COPD. (MedlinePlus, 2020).

· Continue oxygen saturation monitoring and wean FiO2 as tolerated.

· Promote infection prevention standards.

· Keep HOB elevated >30 degree, perform oral care to prevent ETT infection; subglottic suctioning to help mobilize sputum or secretion.

· Skin care/ wound prevention.

· Nutrition: NPO and consult clinical nutrition for tube feeds.

· As patient will be progressing, try daily spontaneous breathing trails and sedation vacation.

· Once pt. tolerate daily sedation vacation and spontaneous breathing trial, RCP (Respiratory care practitioner) must proceed for extubation assessment.

· If pt. is comfortable, awake, following command, and met the criteria for extubation which is having strong cough and good gag reflexes, positive leak test, RR less than 25, VD/VT less than 0.5, capacity to maintain adequate arterial partial pressure of O2 (PaO2/FiO2 ratio >150 to 200) on inspired O2 fractions provided with simple O2 devices (FiO2 ≤ 0.4 to 0.5) and with low levels of PEEP (≤5 to 8 cm H2O), pH ≥ 7.25, Maximum negative inspiratory pressure greater than −30 cm H2O, Vital capacity greater than 10 ml/kg, RSBI less than 105, then pt. can be extubatable and closely observed. (Egan’s, P.776)

· Encourage ambulating the patient with an assist of nurse or PT.

· Upon discharge, pulmonary rehab should be a part of the discharge planning process when the patient is released from the hospital after an exacerbation.

HOMECARE:

· continue neb treatment (Albuterol) PRN for COPD.

· Patient should seek complete tobacco cessation or reduce the amount of cigarette smoked daily to help increase the effectives of the provided treatment and prevent developing serious pulmonary issues such as pneumonia, nicotine patch.

· Take medicine exactly as directed and manage stress.

· Place patient on home o2, BIPAP, or CPAP if needed for COPD condition.

· Maintain unique nutritional intake; Malnutrition can impact the function of respiratory muscles, reduce ventilator drive, and decrease lung defense mechanism.