This is an official Northern Trust policy and should not be edited in any way Respiratory Physio Protocol for Paediatric Patients on BIPAP via a tracheotomy (uncuffed tube) Reference Number: NHSCT/12/547 Target audience: Respiratory physiotherapists and registered nursing staff within the community paediatric/children s nursing service Sources of advice in relation to this document: Kathryn Sloan, Paediatric Respiratory Physiotherapist Mary McAuley, Paediatric Respiratory Physiotherapist Rebecca Getty, Assistant Director Acute Services Operational Support Replaces (if appropriate): N/A Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 24 May 2012 Date Issued by Policy Unit: 7 June 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves
Children s Physiotherapy Respiratory Physio Protocol for Paediatric Patients on BIPAP via a tracheotomy (uncuffed tube) May 2012
Children s Physiotherapy Respiratory Physio Protocol for Paediatric Patients on BIPAP via a tracheotomy (uncuffed tube) Child s Name: DOB:.. Statement: Children on BIPAP via a tracheotomy have problems with pooling of secretions and impaired cough resulting in an increased risk of respiratory infections. They are also at risk of loss of lung volume from airway closure due their immobility or airways becoming blocked by secretions. Respiratory physiotherapy aims to maintain/improve lung volume and remove secretions which in turn reduces the risk of respiratory infection, reduces the work of breathing and improves oxygenation. Two competent people are required to do respiratory physiotherapy for patients on BIPAP via a tracheotomy. Respiratory physiotherapy should be performed 45 minutes after DNase or 15 minutes after any other nebuliser to allow them to take effect. It should not be done immediately after a feed due to the risk of aspiration. The child routinely has two sessions of respiratory physiotherapy daily, one in the morning and one in the afternoon. However more sessions may be required if the child s secretions change in consistency or volume. If they are requiring more respiratory physiotherapy than normal contact the Paediatric Respiratory Physiotherapist and/or Community Children s Nurse. Equipment Required: Portable suction machine that has all constituent parts Suction catheters Oral suction catheter size Nasal suction catheter size Trache suction catheter size Sterile water for cleaning suction catheter Disposable apron and gloves Bagging set with 0.5l open tail bag and manometer Oxygen cylinder Pulse oximeter 0.9% Saline and 5ml syringe Emergency tray readily available 1
Aim To provide physiotherapists within the paediatric service with an evidence based framework for theoretical and skills based training when delegating physiotherapy care to registered nurses, home care support workers and parents. Responsibilities Assistant Director The Assistant Director for Acute Services has overall responsibility for monitoring the implementation and operation of this policy. Physiotherapy Services Manager The Physiotherapy Services Manager has operational responsibility for monitoring the implementation and operation of this policy. Paediatric Respiratory Physiotherapists The Paediatric Respiratory Physiotherapists have responsibility for reviewing and updating this protocol in line with evidence based practice. Community Children s/paediatric Nursing Staff The community children s/paediatric nursing staff have responsibility to familiarise themselves with the children s physiotherapy protocol and utilise it appropriately within their scope of practice. They will also be expected to support the Paediatric Respiratory Physiotherapist to review the protocol. Target Audience Respiratory physiotherapists and registered nursing staff within the community paediatric/children s nursing service. Equality, Human Rights and DDA This protocol is purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This protocol can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 2
Respiratory Physiotherapy ACTION Establish need for paediatric respiratory physiotherapy Establish baseline respiratory status of child by checking respiratory rate, heart rate and oxygen saturation. Explain to the child you are going to do respiratory physiotherapy Wash hands with warm soapy water. Dry thoroughly. Put on gloves and aprons Carer A: Prepare suction machine as per suction protocol. Carer B: Attach the bagging set to the oxygen cylinder, turn on the oxygen cylinder and set the flow to 6 litres. Ensure manometer is attached to bagging set. Position child on their right side Disconnect child from Ventilator by removing the ventilator tubing from their trache. Put the ventilator on stand by mode. Carer B: Attach the bagging circuit to the child s trache. Carer B: Augment the child s own breaths by squeezing the bag in time with his own respiratory effort. Watch the manometer closely whilst bagging and aim to give peak pressure of 25mmHg. DO NOT go above 30mmHg. Once a comfortable breathing pattern has been established Carer A should begin vibrations. Position both hands on the child s left rib cage underneath his arm, one on the front of his chest, one on the back. RATIONALE To clear secretions that cannot be cleared by suction alone and to maintain lung volume To establish treatment required and to determine effectiveness of treatment NB. The pulse oximeter should be attached to the child throughout the treatment in order to monitor them. To reassure the child during procedure To reduce fear/anxiety To reduce risk of infection To ensure the machine is working correctly and safe to use. To prevent damage to the child s airways by using the appropriate pressure and size of catheters. To ensure there is oxygen in the cylinder and the flow rate is sufficient to inflate the bag. To ensure appropriate pressure of oxygen is delivered to the lungs. To aid ventilation of left lung and assist with drainage of secretions. To enable the child to be connected to the bagging circuit in order for manual hyperinflation to be performed. To prevent the need to keep silencing alarms during the procedure. To enable manual hyperinflation to be administered. To make the procedure more comfortable for the child and to establish a baseline status. To provide a pressure greater than the child normally gets through the ventilator, i.e. giving them a big breath to open up their lungs and aid secretion clearance. To prevent giving high pressure which could cause trauma to the child s airways. Correct hand position is necessary for patient comfort and for maximum effect in airway clearance. 3
ACTION After each deep breath has been given press down on the child s rib cage and generate small oscillations in the direction of the normal movement of the ribs. ONLY apply pressure during the exhalation phase of each breath. Do 10 big breaths with vibrations and then Carer A should perform suction via the child s trache, going slightly deeper than the distance stated on his trache suction protocol. Observe the colour, consistency and amount of secretions obtained. If indicated, draw up 0.9% saline into the 5ml syringe and administer 0.5ml into the child s trache. N.B. Unlike the trache suction protocol, when using saline during respiratory physiotherapy DO NOT suction immediately. If saline has been used repeat the bagging with vibrations 10 times in the same position before doing a further suction. Otherwise move onto the next step. Reposition the child on their left side If indicated instil a further 0.5ml of saline via the child s trache. Repeat the bagging and vibrations cycle a further 10 times in this position. Perform trache suction, going deeper than the distance stated on his trache suction protocol. Reposition the child on his back. If indicated instil a further 0.5ml of saline via the child s trache Repeat the bagging and vibrations cycle a further 10 times in this position. Perform trache suction, going deeper than the distance stated on his trache suction protocol. RATIONALE To loosen secretions from the airway walls and increase the expiratory flow to aid removal of secretions. To ensure patient comfort and so as not to restrict airflow during inspiration. To remove secretions that have been mobilised. To stimulate a cough. To enable accurate records to be kept, monitor for signs of infection, and to know if saline is required. If the secretions are thick/sticky and seem difficult to obtain then saline is indicated. To liquefy and mobilise secretions. To allow saline to be distributed throughout the lung field to mobilise secretions. To remove secretions not obtained the first time due to them being too thick/sticky. To aid ventilation of right lung and assist with drainage of secretions. To liquefy and mobilise secretions. To loosen secretions from the airway walls and increase the expiratory flow to aid removal of secretions. To remove secretions and to stimulate a cough. To aid ventilation of the apical areas (top part) of the lungs and assist with drainage of secretions. To liquefy and mobilise secretions. To loosen secretions from the airway walls and increase the expiratory flow to aid removal of secretions. To remove secretions and to stimulate a cough. 4
ACTION N.B. If you can hear or feel that secretions remain then further cycles of bagging, vibrations and suction can be performed in any or all of the positions already covered, as long as the child is not showing signs of distress (increased heart rate, decreased saturations) Child may need nasal and/or oral suction to remove visible secretions. If required perform this suction according to the oral and nasal suction protocol. Restart the ventilator and check there is air flow. Disconnect the bagging set from the child s trache and reattach the ventilator tubing to their trache. Throughout the procedure monitor the child s colour, heart rate and saturation levels. Throughout the procedure talk to the child and give them some toys to play with. RATIONALE To remove secretions from the child s nose and mouth. To ensure there is airflow through the ventilator prior to connecting to child s trache. To ensure the child maintains stable throughout the procedure. To provide distraction and minimise any distress. To aid compliance with future treatments. If you have any concerns contact the Paediatric Respiratory Physiotherapist or Community Children s Nurse October 2011 Signature.. Position... Date... Review Date Signature Review Date Signature Review Date Signature Review Date Signature 5
Children s Physiotherapy Competency Respiratory Physiotherapy Child s Name: DOB:.. Performance Criteria Knowledge The carer will be able to : Assess the child and identify the factors that indicate the need for respiratory physiotherapy Identify signs of deterioration in the child s respiratory status and what action should be taken. Describe the procedure for respiratory physiotherapy including infection control measures Identify the potential risks/contraindications associated with performing respiratory physiotherapy Explain the different postural drainage positions used in respiratory physiotherapy. Discuss observations to be made both during/after procedure and how to evaluate the outcome. Taught Date/Sign Competency Assessment Date/Sign Competency Achieved Performance Criteria Skills The carer will be able to : Prepare the suction machine and bagging set for use. Place child in postural drainage positions Demonstrate use of bagging set with oxygen cylinder & manometer Demonstrate how to check bagging pressures Demonstrate dates Practiced Dates Competency Assessment Date 6
Skills The carer will be able to : Demonstrate how to perform vibrations Demonstrate suction according to protocol Demonstrate disposal of clinical waste Correctly record outcome of respiratory physiotherapy Demonstrate dates Practiced Dates Competency Assessment Date I have received training and consider myself competent in all of the above Name. Signature.. Date Assessor Qualifications Signature Date 7