Tuesday, September 7, 2010

In the News -CMS Finalizes Inpatient Hospital Rules

The Centers for Medicare & Medicaid are proposing to change regulations which would allow Physician Assistants and Nurse Practitioners’ to write orders for Respiratory Care Services without a co-signature from a physician.

I believe this is an area of concern since respiratory care services specifically ventilator management is highly specialized. Additionally, there is no formal training regarding ventilator management in PA or NP programs, as a minimum pulmonary physicians have to train as fellow.
The below case study submitted from a colleague will articulate my point of view.

Day One:
48 y/o male patient was admitted to LTAC for ventilator weaning; patient had a history of multiple sclerosis.
-Pulmonary Nurse Practitioner consulted, patient has assessed and no recommendations were documented or communicated to respiratory staff.

Day Two:
Respiratory Assessment Note

Assessed patient this morning on the following transfer ventilator settings:

Mode- Volume Control-Intermittent Mandatory Ventilation (VC-IMV)
Tidal Volume (Vt)- 900 ml (12ml/kg/IDBW)
Frequency- 12
FiO2- 40%
Pressure Support- Zero (0)

Patient was apneic (adding no spontaneous rate) and “air-trapping” as evidence from expiratory flow not returning to baseline. I was concerned that the patient was not adding spontaneous rate due to hyperventilation from the baseline settings (minute ventilation (VE) 10.8 l/min, which is ~ 150% of predicted VE requirements).

Initiated capnography to analyze end-tidal CO2 (EtCO2), measured EtCO2 <> 20 mmHg over baseline). Patient was switched back to a higher level of pressure support (18 cmH2o) to off-load respiratory muscles.

Approximately, fifteen minutes after switching to a higher level of support, patient developed rapid A-fib with a measured heart rate of 160. Attending physician called and patient was placed back on basal ventilator settings.

VIDD, mechanically induced hyperventilation, air-trapping, and acid base status all related to basal ventilator settings.
Hypertension & A-fib control.

Note: This note was placed in the physician progress note on day two.

Day 10 (9 days post respiratory assessment)

-Patient remains on transfer settings.

Pulmonary NP Note:

“The patient has been on SIMV-VC since admission. This is concerning because he might be hyperventilating and dropping his paCO2 levels. We will obtain baseline ABG and if it in fact shows that he has hypocapnia, we will likely switch him to pressure control ventilation”.


This is an actual case study which shows that issues do not get addressed, or put off when someone not familiar with mechanical ventilation is micro-managing the care. Ideally protocols should be in place which allows the Respiratory Care Practitioner to manage the ventilator from initial admission/ respiratory assessment. In the above case the RCP could have addressed the issues on day two, without having to wait for 9 days before NP intervention.
On another note, if Adaptive Support Ventilation (ASV) was utilized in this patient the ventilator would have titrated settings to prevent air-trapping, prevent hyper-ventilation, allow for spontaneous breathing, wean controlled breaths and wean driving pressure (this helping prevent VIDD).

Additional Reading