Respiratory Care in Alternative Settings: An Overview (2023)

Respiratory care is often associated with a hospital-based environment where the management of acute and chronic respiratory disorders is guided by a team of specialized healthcare providers.

However, as healthcare systems evolve and patient needs change, respiratory care is increasingly being delivered in alternative settings such as homes, ambulatory clinics, long-term care facilities, and specialized rehabilitation centers.

This shift reflects not only advancements in portable medical technologies but also the growing demand for cost-effective, patient-centered care.

This article delves into the various alternative settings where respiratory care is provided, highlighting the challenges and opportunities in these less conventional environments.

Advantages and Challenges of Respiratory Care in Alternative Settings

The provision of respiratory care in non-acute, alternative settings comes with a variety of benefits, most notably in terms of cost-efficiency and patient comfort.

Traditional hospital settings often involve high overhead costs, which are passed down to patients and their insurers.

In contrast, alternative care facilities often operate at a lower cost base, making treatment more affordable for both healthcare systems and patients.

Moreover, patients tend to feel more at ease in less clinical, more familiar environments such as their own homes, which can positively impact their overall well-being and recovery.

Examples of Alternative Settings for Respiratory Care

• Subacute Facilities: These are designed for patients who no longer require acute care but still need medical supervision. They offer a step-down level of care that often includes respiratory support.
• Long-Term Acute Care Hospitals (LTACHs): These are specialized hospitals equipped to handle more severe, long-term cases. Respiratory patients here often require extended periods of ventilator support.
• Rehabilitation Facilities: These focus on restoring lost abilities and improving quality of life. Respiratory care often includes exercises to improve lung function.
• Skilled Nursing Facilities (SNFs): These provide long-term care, including respiratory support, for patients who are unable to live independently but do not require hospital-level care.
• Patient’s Home: Home healthcare is becoming increasingly popular, supported by advancements in portable medical technology. Respiratory care can now be effectively administered at home, provided that a clear and comprehensive care plan is in place.

Despite these benefits, alternative settings for respiratory care are not without challenges. One significant risk is poor care planning, which could lead to premature patient discharge.

Should this occur, the patient may experience complications that necessitate readmission to an acute-care facility, thereby negating the initial advantages of the alternative setting.

This outcome is counterproductive and highlights the importance of meticulous care planning, oversight, and a multidisciplinary approach to patient care in these non-traditional settings.

Diverse Forms of Respiratory Care in Alternative Settings

Alternative settings for respiratory care offer an extensive array of respiratory care services tailored to patient needs, from the treatment of chronic conditions to the provision of long-term ventilatory support.

The versatility in treatment modalities stems from advancements in medical technologies and a better understanding of respiratory disorders.

Types of Respiratory Care in Non-Acute Settings

• Aerosol Drug Therapy: This involves the inhalation of medications in aerosol form, commonly used to treat conditions like asthma or COPD. The administration of such therapies is increasingly possible in settings like homes and subacute facilities, thanks to portable nebulizers.
• Airway Care: Management of the airway includes procedures like tracheostomy care and suctioning. These are often needed for patients with obstructed airways and can be adequately performed in long-term acute care hospitals (LTACHs) or skilled nursing facilities (SNFs).
• Sleep Apnea Care: Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) machines can be used to treat sleep apnea. These machines are portable and ideally suited for home use, under the proper supervision of healthcare providers.
• Pulmonary Rehabilitation: This holistic approach aims to improve the overall physical condition and psychological well-being of people with chronic respiratory conditions. Rehabilitation facilities and even some subacute settings can offer tailored exercise regimens and education to manage symptoms effectively.
• Noninvasive Ventilation: Often used to treat acute exacerbations of conditions like COPD, noninvasive ventilation techniques such as BiPAP can be administered in long-term acute care settings or even in some skilled nursing facilities, depending on the level of care required.
• Long-term Mechanical Ventilation: For patients who require extended periods of ventilatory support, mechanical ventilation can be safely managed in specialized settings like LTACHs, which are equipped to monitor and treat complex respiratory conditions.

Note: This is not an exhaustive list; various other forms of respiratory care can be customized according to patient needs and the resources available in the setting. For example, oxygen therapy and pulmonary function testing are also commonly performed in these alternative settings. These diverse offerings make non-acute settings increasingly viable options for effective, patient-centered respiratory care.

Practice Questions About Respiratory Care in Alternative Settings

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

2. Subacute care aims to 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 the TJC.

4. How do acute and alternative care settings differ?
They differ in regard to resource availability, supervision, work schedules, documentation, 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?
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 either a nasal cannula or conserving devices such as a transtracheal catheter or reservoir cannula, and demand-flow oxygen systems 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 respiratory therapists.

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?
It 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 and the 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 in what setting?
In alternative sites

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

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

24. What is one of the most notable changes of respiratory care in alternative sites?
The 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. Why is good discharge planning important?
Because these services typically are provided after an acute episode of hospitalization.

27. What are the most common respiratory care services provided in 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 respiratory therapists 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 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 healthcare services to clients in their home, thus minimizing their dependence on institutional care.

32. What can respiratory home care contribute to?
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. To 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, reduces PAP, and lowers vascular resistance.

44. What must an oxygen prescription be based on?
Documented hypoxemia

45. What must a prescription for oxygen therapy in a post-acute care setting include?
Flow rate; frequency; duration; diagnosis; laboratory evidence; and 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 lower flow rates, what should a respiratory therapist select whenever possible while delivering oxygen in a patient’s home?
They should select calibrated low-flow flowmeters.

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

52. What temperature is 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 alternative care 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, the mishandling of liquids, and fires.

65. What is a potential infection control-related 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?
Nasal cannula

69. What is used for long-term oxygen delivery 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 and 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?
CPAP

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 of 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 is a contraindication of nasal CPAP?
Reversible upper airway obstruction

96. What is the most common problem with an 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 healthcare systems worldwide adapt to changing demographics, technological advancements, and cost constraints, respiratory care in alternative settings is becoming more commonplace.

These settings offer a unique blend of challenges and opportunities, from the need for more self-management in home-based care to the specialized requirements of long-term care facilities.

The evolution is not without its hurdles, such as issues of accessibility, quality assurance, and staff training.

However, the potential benefits—increased patient comfort, lowered healthcare costs, and more personalized care—make it a crucial area for ongoing research, policy development, and clinical practice.

Recognizing and addressing the unique aspects of delivering respiratory care in these alternative settings is essential for maximizing both patient outcomes and healthcare resource utilization.