Respiratory Care in Alternative Settings [Overview]

Respiratory therapists are well-known for working and treating patients in the hospital setting. With that said, people often forget that respiratory care can be provided in alternative settings as well.

This guide covers the basics of this topic. It provides an overview of the alternative work sites of respiratory therapists that take place outside of the hospital. So, if you’re ready, let’s get into it.

Respiratory Care Alternative Setting Examples

There are several advantages of providing respiratory care in alternative non-acute facilities. In general, this includes lower costs and more patient comfort.

Here are some examples of alternative sites for providing respiratory care:

• Subacute facilities
• Long-term acute care hospitals (LTACHs)
• Rehabilitation facilities
• Skilled nursing facilities (SNFs)
• Patient’s home

While these settings do offer some advantages, there are some important drawbacks to remember.

If there is poor care planning and a patient is discharged too early, it can result in readmission to an acute facility. This, essentially, would erase the benefits that were mentioned which is something that we strive to avoid.

Types of Respiratory Care in Alternative Settings

Here are some examples of the types of respiratory care that can be administered in non-acute care settings:

• Aerosol drug therapy
• Airway care
• Sleep apnea care
• Pulmonary rehabilitation
• Noninvasive ventilation
• Long-term mechanical ventilation

Keep in mind that these are just a few of the most common examples. Other forms of respiratory care can be delivered depending on resource availability.

Respiratory Care in Alternative Settings Practice Questions:

1. An increasing number of health services are being provided where?
In alternative care settings.

2. Subacute care aims achieve what?
It aims to achieve the highest level of patient functioning—ideally self-care.

3. Standards for subacute and home health care derive from what?
Federal and state laws and private-sector accreditation, mainly TJC.

4. Acute and alternative care settings differ how?
They differ in regard to resource availability, supervision and work schedules, documentation and assessment, and professional-patient interaction.

5. Effective discharge planning does what two things?
(1) It guides the multidisciplinary team in transferring patients to alternative sites of care and (2) It ensures the safety and efficacy of the patient’s continuing care.

6. Alternative site caregivers must have what?
They must have all the competencies required to meet the patient’s ventilatory and respiratory needs and provide adequate 24-hour coverage. The selected site also must be safe and suitable for the patient’s specific condition.

7. Oxygen prescriptions for patients in alternative settings must be based on what?
The documented hypoxemia, as determined by either blood gas analysis or oximetry.

8. In most alternative care sites, oxygen normally is most often supplied by what?
Concentrators with gaseous cylinders as backup and for portability.

9. Most patients in alternative care settings needing oxygen use what?
They use a nasal cannula; conserving devices such as a transtracheal catheter, reservoir cannula, and demand-flow oxygen system can decrease oxygen use and costs and provide greater patient mobility.

10. Because most problems with long-term oxygen therapy are “people” problems, caregivers should be allowed to do what?
They should be allowed to operate and maintain oxygen delivery devices only after they have been properly instructed by credentialed RTs.

11. What are the key factors needed for successful ventilatory support in alternative sites?
(1) Careful patient selection, (2) Effective discharge planning, (3) Interdisciplinary team approach, (4) Effective caregiver and family education, (5) Thorough assessment and preparation of the environment, and (6) Careful selection of needed equipment and supplies.

12. Patients being considered for ventilatory support in alternative settings must be what?
They must be medically and psychologically stable.

13. Most patients requiring mechanical ventilation in alternative settings can be supported with what?
They can be supported with NIV if they are alert and cooperative, can maintain acceptable oxygenation without high FiO2, and have intact airway reflexes and adequate clearance mechanisms.

14. Positive pressure ventilators used in alternative settings should be what?
They should be electrically powered, easy to operate, and portable (run on both AC and DC power). Loss-of-power alarms are essential, high-pressure alarms are needed on volume-cycled ventilators, and patient-disconnect (low-pressure) alarms should be provided.

15. Negative pressure ventilators, such as the chest cuirass and “pneumosuit,” are what?
They are a second-line choice for ventilatory support in alternative care settings.

16. Patients with tracheostomies in alternative care settings require what?
They require both daily stoma care and secretion clearance; tube changes should be performed only by a qualified health professional.

17. A typical nocturnal CPAP system consists of what?
It consists of a flow generator or blower, PEEP or CPAP valve, and nasal or full-face mask; some units can increase pressure to the prescribed level over time (ramping); others can auto-adjust the CPAP level in response to apnea, hypopnea, airflow limitation, or snoring.

18. The proper CPAP level can be determined by what?
Polysomnography, continuous monitoring of hemoglobin

19. What is a common problem with nocturnal CPAP systems?
An inability to reach or maintain the set pressure, usually because of either inadequate flow or system leaks.

20. Proper caregiver hand hygiene, limiting visits by persons with respiratory infections, providing sterile or disposable clean equipment, and proper equipment processing are the keys to what?
These are the keys to infection control in alternative settings.

21. Providing palliative care to keep terminally ill patients as comfortable as possible is an important aspect of respiratory care what?
In alternative sites.

22. What remains the most common alternative site for providing health care, and what are other post-acute care settings?
Home care is the most common; other settings include: subacute, rehabilitation, and skilled nursing facilities.

23. What advantage do alternative health care settings offer?
Lower costs and enhanced patient comfort.

24. What is one of the most notable changes of respiratory care in alternative sites?
Introduction of Medicare’s prospective patient system.

25. What is a further development stemming mainly from our aging population that is a significant increase in popularity?
Assisted living facilities.

26. Because these services typically are provided after an acute episode of hospitalization, good what is critical?
Good discharge planning.

27. What is the most common respiratory care service provided in these alternative settings?
Continuous oxygen therapy, long-term MV, aerosol drug administration, airway care, sleep apnea treatment, sleep/apnea home monitoring, and pulmonary rehabilitation.

28. What is one of the main goals of the Respiratory Therapist in alternative settings?
Educating the patient, family, and caregivers on the safe and effective use of such equipment.

29. What does subacute care aim to restore?
The whole patient back to the highest practical level of function (self-care).

30. What does the AARC define respiratory home care as?
Specific forms of respiratory care provided in the patient’s home by personnel trained in respiratory care, working under medical supervision.

31. What is the primary goal of home care?
To provide quality health care services to clients in their home, thus minimizing their dependence on institutional care.

32. What can respiratory home care contribute too?
Supporting/maintaining life, improving the patient’s well-being, promoting self-sufficiency, cost-effective delivery, and improving patient comfort at the end of life.

33. Most patients for whom respiratory home care is considered are those with what disorders?
Chronic respiratory diseases like COPD, CF, chronic neuromuscular disorders, chronic restrictive conditions, and lung carcinomas.

34. What is the majority of reimbursement for post-acute care through?
Federal Medicare or federal/state Medicaid.

35. What is the federal agency responsible for the overall administration of Medicare and Medicaid?
Centers for Medicare and Medicaid Services.

36. What is the primary organization responsible for standard setting and voluntary accreditation of post-acute care providers?
The Joint Commission.

37. What are the primary factors in determining the appropriate site for discharge?
The goals and needs of the patient.

38. What is essential for discharge to the home?
Evaluation

39. What is imperative for the discharge team to ensure?
An adequate number of caregivers are part of the care plan.

40. What is an all too common discharge planning mistake?
Reliance on too few individuals/overestimation of caregiver capabilities.

41. Wo help ensure a basic level of quality, one should select a DME supplier that is what?
JCAHO accredited.

42. What is by far the most common mode of respiratory care in post-acute care settings?
Oxygen therapy.

43. What are the benefits of oxygen therapy in alternative settings?
Helps with basic survival, improves quality of life; helps with nocturnal oxygen saturation, reduced PAP, lower vascular resistance.

44. What must oxygen prescriptions be based on?
Documented hypoxemia.

45. What all must a prescription for oxygen therapy in a post-acute care setting include?
Flow rate; frequency; duration; diagnosis; laboratory evidence; additional documentation.

46. How is oxygen therapy normally supplied in alternative care sites?
Compressed oxygen cylinders, liquid oxygen systems, and oxygen concentrators.

47. What is the primary use of compressed oxygen cylinders?
Ambulation or as a backup to liquid or concentrator supply systems.

48. In addition to the cylinder gas, what else is needed to deliver oxygen?
A pressure-reducing valve with a flowmeter.

49. How much flow do standard clinical flowmeters deliver compared to the flow in alternative sites?
The standard flowmeters provide 15 L/min, while in an alternative site, it can be as little as 0.25-5.0 L/min.

50. Because of this, what should the Respiratory Therapist select whenever possible?
You should select a calibrated low-flow flowmeter.

51. If humidification is needed, what is to be used?
A simple unheated bubble humidifier.

52. What temperature is the liquid oxygen kept at?
-300 degrees F

53. When the cylinder is not in use, vaporization maintains pressures of?
20-25 psi

54. How much do small liquid oxygen cylinders hold?
45-100 lbs of liquid oxygen.

55. How much do typical portable units weigh?
5-14 lbs

56. What is an oxygen concentrator?
An electrically powered device that physically separates the oxygen in room air from nitrogen.

57. The most common type of concentrator uses what to extract oxygen?
A molecular sieve.

58. How much oxygen does the typical molecular sieve concentrator provide?
92%-95%

59. What is an example of a device that enhances oxygen production and delivery devices?
Inogen One System (battery-powered concentrator).

60. What is the most cost-efficient supply method for patients in alternative settings who need continuous low-flow oxygen?
Oxygen concentrators.

61. What are two ways to prevent problems for patients in alternative settings?
Provide instructions and document the caregivers’ abilities.

62. What must always be checked in these settings?
Oxygen delivery equipment.

63. What must the clinician ALWAYS ensure?
That all systems have an emergency backup supply.

64. What are some possible physical hazards to patients and caregivers?
Unsecured cylinders, ungrounded equipment, mishandling liquid, and fire.

65. What is another potential problem?
Bacterial contamination of the nebulizer or humidification system.

66. In the home, what should be checked and confirmed as part of a routine monthly maintenance visit?
The FiO2.

67. When 50 psi of oxygen is needed, what is the storage system of choice?
Large gas cylinders.

68. What is the most common oxygen delivery system for long-term care?
A nasal cannula.

69. What is also used for long-term care, but is a lot less common?
Simple oxygen masks/air entrainment masks.

70. How is oxygen delivered via a catheter with a small orifice that is inserted through the skin and neck tissue into the trachea?
Using transtracheal oxygen therapy.

71. What are the indications that patients must meet for transtracheal oxygen therapy?
(1) Not oxygenated by standard approaches, (2) doesn’t comply well with other devices, (3) complications with a nasal cannula, (4) for cosmetic reasons, and (5) the need for increased mobility.

72. What are the key patient responsibilities for transtracheal oxygen therapy?
Routine catheter cleaning and recognizing and troubleshooting common problems.

73. What demand-flow oxygen delivery device uses a flow sensor and valve to synchronize gas delivery with the beginning of inspiration?
Pulsed-dose oxygen-conserving devices.

74. When does most of the effective oxygen delivery occur?
During the first half of inspiration.

75. What provides the greatest savings in oxygen use for a given level of arterial saturation?
Demand-flow oxygen systems.

76. What are the “three P’s” when selecting a long-term oxygen system?
Purpose, patient, and performance. The goal of this is to match the performance of the equipment to both the objectives of therapy and the patient’s special needs.

77. What problems are most common with transtracheal oxygen therapy and demand-flow systems?
Technical problems.

78. What are most problems with transtracheal oxygen therapy related to?
Initial catheter insertion or ongoing maintenance.

79. What are most problems with demand-flow systems based on?
Current limits to this technology.

80. What are the 3 categories of patients that need ventilatory support outside the acute care hospital?
(1) Unable to maintain adequate ventilation for a while, (2) Continuous mechanical ventilation for survival, and (3) They are terminally ill.

81. What must patients be regardless of the diagnosis to be considered for ventilatory support in alternative settings?
Medically/psychologically stable.

82. The most common setting for ventilatory support outside of acute care is the?
Home

83. What are the 2 major support approaches of mechanical ventilation outside of acute care?
Invasive/noninvasive.

84. How do post-acute care institutions that provide ventilatory support differ from acute care facilities?
They differ in the level of technical support.

85. What are the prerequisites for home ventilatory support to be successful?
The willingness to accept responsibility; support; viability of plan; patient stability; and the adequacy of the home.

86. What are 5 caregiver education skills?
Patient assessment, airway management, CPT techniques, cleaning/disinfecting, and emergency procedures.

87. What are the emergency situations that caregivers must be trained to recognize and properly deal with?
Ventilator/power failure, ventilator circuit problems, airway emergencies, and cardiac arrest.

88. What is the first choice of noninvasive support?
Noninvasive positive pressure ventilation.

89. What is a popular route for drug administration to respiratory patients undergoing post-acute care?
The aerosol route.

90. What do post-acute care patients with tracheostomies require?
They require daily stoma care and tracheobronchial suctioning.

91. What has become an accepted form of home care used to treat sleep apnea-hypopnea syndrome?
Nasal CPAP.

92. The diagnosis for sleep apnea must be confirmed by what?
Polysomnography.

93. What is the most common method in determining the proper CPAP level?
A sleep study to titrate different levels of CPAP.

94. What is the prescribed level of CPAP?
The lowest pressure at which apneic episodes are reduced to an acceptable frequency and duration.

95. What contraindicates of nasal CPAP?
Reversible upper airway obstruction.

96. What is the most common problem with the actual CPAP apparatus?
The inability to reach or maintain the set pressure.

97. What condition requires an apnea monitor and for how long?
Sudden infant death syndrome; 2-4 months.

98. What are the 4 key components of assessment and documentation that institutions providing subacute or long-term care require?
Screening, treatment plan, ongoing assessment, and discharge.

99. What are 5 factors to consider when deciding on the frequency of home visits?
The patient’s condition/needs, the environment, the level of support, the type/complexity of equipment, and the ability to provide self-care.

100. What are the 5 functions a Respiratory Therapist must provide when visiting a patient in the home?
Patient assessment, patient compliance with care, equipment assessment, identification of problems/concerns, and a statement of the goals/plans.

Final Thoughts

As previously mentioned, the ability to deliver respiratory care in alternative settings is often forgotten by many in the healthcare industry.

It is true that most respiratory therapists prefer to work in the traditional hospital setting. However, some who work in alternative settings find it rewarding to be able to build stronger relationships with their patients.

If you enjoyed this topic, we have a similar guide that covers the code of ethics for respiratory therapists that I think you’ll find useful. Thank you so much for reading and, as always, breathe easy, my friend.