1
Q
Emphysema
A
irreversible destruction of the alveolar walls causing enlargement of the distal air spaces, collapse of the small airways, air trapping, and hyperinflation
2
Q
Chronic bronchitis
A
productive cough for at least 3 months per year for at least 2 years
3
Q
COPD patient assesment
A
- barrel chest
- increased AP diameter
- clubbing
- cyanosis
- pursed lip breathing
- tympanic or hyperresonant
- productive cough
4
Q
COPD diagnostic testing
A
- CXR –> hyperluceny, hyperinflation, flat diaphragms
- ABG –> compensated respiratory acidosis with hypoxemia
- PFT –> decreased flows
5
Q
COPD stage 1 care: mild
FEV1/FVC <70%
FEV1 >80% predicted
A
- SABA or inhaled anticholinergic (tiotropium PRN)
6
Q
COPD stage 2 care: moderate
FEV1/FVC <70%
FEV1= 50-79% predicted
SOB on exertion
A
- regular use of LABA
- combined LABA and long acting anticholinergic
7
Q
COPD stage 3 care: severe
FEV1/FVC <70%
FEV1=30-49%
SOB on exertion
Frequent exacerbations
A
- inhaled steriod for exacerbation
- steriod + LABA (fluticasone+salmeterol)
8
Q
COPD stage 4 care: very severe
FEV1/FVC <70%
FEV1 <30%
FEV1 <50% predicted + chronic respiratory failure
A
- long term O2
- lung volume reduction surgery (EMPHYSEMA ONLY)
9
Q
COPD emergency assessment
A
- dyspnea at rest
- cyanosis
- RR > 25
- heart rate > 110
- use of accessory muscle
10
Q
COPD emergency treatments
A
- Provide supplemental O2 to maintain PaO2 of 60–65 torr/SpO2 of 88–92%.
- Recommend increasing the beta-agonist dose.
- Recommend adding inhaled anticholinergic (if not already prescribed).
- Recommend systemic steroids (in addition to inhaled steroids).
- Recommend antibiotic therapy if secretions copious and purulent
11
Q
COPD BIPAP
A
- IF patient is getting worse
- IPAP= 10 cm H2O, EPAP = 5 cm H2O
- Backup rate = 10/min
- Sufficient expiratory time to allow complete exhalation
- FIO2 to assure SpO2 ≥ 90%
12
Q
COPD ventilator
A
- Worsening of ABGs in first 1 to 2 hrs
- Lack of improvement in ABGs after 4 hrs
- Severe acidosis (pH < 7.25) and hypercapnia (PaCO2 > 60 torr)
- Severe hypoxemia (P/F ratio < 200)
- Severe tachypnea (> 35 breaths/min)
- Other complications (e.g., metabolic abnormalities, sepsis, pneumonia, pulmonary embolism, barotrauma, or massive pleural effusion)
13
Q
Asthma patient assessment
A
- SOB, pursed lip breathing, chest tightness
- increased AP diameter
- retractions (seen in children)
- hyperresonant, tympanic
- dimished breath sounds
- diaphoresis
- pulus paradoxus
14
Q
Asthma diagnostic testing
A
- CXR –> translucent lung fields, depressed or flat diaphragms
- ABG –> acute alveolar hyperventilation with hypoxemia then hypercarbia
- PFT –> reduced flow rates
15
Q
Asthma green zone: level 1 treatment
Peak flow= 80-100%
- no symptoms
- able to perform activites
- no coughing, wheezing, chest tightness
A
- continue medication plan
- use preventative (anti-inflammatory steriod)
16
Q
Asthma yellow zone: level 2 care
Peak flow= 50-80%
- increased need for inhaled quixk relief
- increased asthma symptoms at night
- awakening at night with symptoms
A
- preventative (anti inflammatory) inhaler
- quick relief
- oral steriod
- return to level 1 when improved
17
Q
Asthma red zone: level 3 care
Peak flow <50%
- no improvement after increasing level 2 (yellow) treatment
A
- quick relief
- oral steriod
18
Q
Bronchiectasis patient assessment
A
- history of pulmonary infections or cystic fibrosis
- cyanosis
- barrel chest
- clubbing
- wheezing, diminished breath sounds
- hyperresonat/tympanic
- purluent, foul smelling secretions, hemoptysis
19
Q
Bronchiectasis diagnostic tests
A
*best confirmed via high-resolution CT scan)
1. CXR –> hyperlucent lung fields, depressed or flat diaphragms, enlarged heart
- ABG –> mild to moderate= acute alveolar hyperventilation with hypoxemia
severe= chronic ventilatory faliure with hypoxemia - CT scan –> dilated bronchi, increased bronchial wall
20
Q
Bronchiectasis treatment
A
- O2 therapy
- bronchial hygiene
- lung expansion therapy
- antibiotics
- expertorants
- SABA and anticholinergic
- surgical resection if necessary
21
Q
Cystic Fibrosis patient assessment
A
- Chronic cough with sputum production
- History of sinusitis
- History of bowel obstruction or steatorrhea (fatty stool)
- Wheezes, crackles, rhonchi
- Body mass index (BMI) < 19
- Presence of nasal polyps
- Digital clubbing
- Signs of pancreatic
- Abdominal distension and flatulence
- fatigue
22
Q
Cystic Fibrosis diagnostic testing
A
- Recommend a sweat chloride test (positive for CF if > 60 mmol/L)
- Recommend sputum Gram stain as well as culture and sensitivity –> The presence of P. aeruginosa supports a diagnosis of CF
- CXR –> translucent, right ventricular enlargment, atelectasis, fibrosis
- ABG –> acute alveolar hyperventilation then chronic ventilatory faliure
- PFT –> decreased flow rates
- CBC –> increased HCT and HB
23
Q
Cystic Fibrosis acute respiratory distress
A
Recent history:
- Development of fever
- Increase in productive cough with purulent sputum
- Increased fatigue, weakness, or poor appetite or weight loss
- New-onset or increased hemoptysis
Physical assessment:
- Labored breathing with intercostal retractions and use of accessory muscles
- Severe wheezing, rhonchi, or rhonchial fremitus
Diagnostic tests:
- New infiltrate on chest x-ray
- Labs: leukocytosis; low Na+, Cl–, and K+; hypochloremic metabolic acidosis
- ABG/pulse oximetry: moderate hypoxemia, SpO2 < 90% on room air
24
Q
Cystic Fibrosis treatment
A
- Provide supplemental O2 to maintain a SpO2 above 90%
- An aerosolized bronchodilator (e.g., albuterol) –> aerosolized dornase alfa (Pulmozyme) or hypertonic saline –> airway clearance therapy (PEP)
1. bronchodilator
2. mucolytic
3. corticosteriod
4. antibiotic
5. digestive enzymes
*If P. aeruginosa confirmed –> Tobramycin (TOBI) via breath-enhanced nebulizer, Polymyxin E (Colistin), or Aztreonam (Cayston) via mesh nebulizer (e.g., Altera)
25
Cystic Fibrosis stablized care
- Annual influenza immunizations
- A high-energy/high-fat diet with increased salt intake, pancreatic enzyme replacement, and vitamin supplements
- Regular exercise activity (improves airway clearance and reduces exacerbations)
26
Sleep apnea
confirmed if the number of abnormal events exceeds 5 per hour
5–15 events/hr = mild
15–30 events/hr = moderate
> 30 events/hr = severe.
27
Central sleep apnea
if both nasal flow and respiratory effort decrease then desaturation
28
Obstructive sleep apnea
if nasal flow decreases with INCREASED respiratory effort then desaturation
29
CSA treatment
NPPV
30
OSA treatment
- nasal CPAP
- weight loss
- sleep posture (lateral or upright)
- O2 therapy
- surgery (UPPP or trach)
- oral applications
- neck collar
31
Chest trauma patient assessment
- anxious
- cyanosis
- bruising
- diminished breath sounds
- tympanic notes
32
Chest trauma diagnostic testing
Recommend diagnostic tests according to type of trauma -->
- CBC
- hemoglobin
- hematocrit (to assess for blood loss or hemodilution)
- coagulation tests
- arterial blood gasses (ABGs)
*Do not recommend an initial chest x-ray or computed tomography (CT) scan if there are clear signs of tension pneumothorax
- Fractures of the lower “floating” ribs (11–12) may be associated with diaphragmatic tears and trauma to the liver or spleen
- recommend abdominal ultrasound for hemoperitoneum
- CT scan to assess organ damage
33
Chest trauma treatment
- Recommend epidural analgesia for ribcage fracture pain
- Aggressive bronchial hygiene therapy (to prevent pneumonia)
*Do not recommend steroids for treatment of pulmonary contusion.
- Only recommend mechanical ventilation to correct abnormal gas exchange (with pulmonary contusion)
- Recommend high-frequency oscillatory ventilation (HFOV) for patients failing A/C or SIMV with PEEP
- Recommend independent lung ventilation for patients with severe unilateral contusion if (1) severe shunting persists or (2) “cross-over” bleeding is affecting the good lung
34
Hemothorax diagnostic testing
CBC= Increased RBC, HB, HCT
35
Pneumothorax and Hemothorax treatment
- thoracentesis
- chest tube
- hyperinflation therapy (IPPB, IS, SMI)
- vent with PEEP for acute ventilatory faliure
36
Burn/smoke inhalation patient assessment
- facial/neck burns
- singed nasal hairs
- sooty sputum
- dyspnea
- cyanosis
- hoarseness
- coughing
- stridor
37
Cyaonide poisoning patient assessment
- headache
- confusion
- seizures or coma
- chest tightness
- nausea or vomiting, and mydriasis
- dyspnea
- tachypnea
- hyperpnea
- hypertension (early)
- hypotension (late)
*blood lactate is typically high (≥ 8 mmol/L), indicating tissue hypoxia/anaerobic metabolism.
38
Burn/smoke inhalation diagnostic testing
- CBC
- electrolytes
- lactate
- ABG
- CO-oximetry
- Assess sensorium
- coma level (Glasgow Coma Scale) if the patient is unresponsive
- Recommend chest x-ray (may be negative early on).
*recommend fiberoptic bronchoscopy to assess airway damage.
39
Burn/smoke inhalation treatment
- Recommend covering the patient to prevent heat and fluid loss
- Immediately administer as high an O2 concentration as possible (via nonrebreathing mask or high-flow cannula)
- Recommend immediate IV access and fluid and electrolyte replacement therapy
- Recommend urinary catheterization to help monitor fluid balance
- Recommend morphine analgesia for severe pain
- Recommend a 12-lead ECG and cardiac biomarkers.
- Bronchospasm --> aerosolized bronchodilators, N-acetylcysteine (Mucomyst), and heparin
40
Cyanide treatment
- recommend immediate treatment with either hydroxocobalamin (also known as vitamin B12a or “cyanokit”) or sulfanegen TEA
41
CHF patient assessment
- restlessness, confusion, diaphoresis, dyspnea, increased work of breathing, tachypnea, and tachycardia
- cool, pale, cyanotic, or mottled skin and slow capillary refill
- frothy or pinkish or blood-tinged sputum.
- bilateral crackles and wheezing indicate acute decompensation
- chest pain (its presence suggests acute myocardial ischemia/infarction)
42
CHF diagnostic tests
- Recommend an immediate chest x-ray (which typically reveals bilateral fluffy infiltrates).
- Recommend cardiac biomarkers (troponin, CK, and CK-MB) to assess for MI
- increased BNP
- Recommend an echocardiogram (to help determine possible mechanical causes such as cardiac tamponade or valve problems).
* Do not recommend pulmonary artery (PA) catheter insertion unless the patient’s diagnosis cannot be confirmed without it or there are unexpected responses to therapy.
43
CHF treatments
- Initiate O2 therapy with the highest FIO2 possible
- Recommend CPAP or BiPAP with 100% O2
- Recommend morphine or a benzodiazepine such as lorazepam to reduce anxiety
- A vasodilator such as nitroglycerin, sodium nitroprusside, or nesiritide (to decrease preload and afterload)
- A rapid-acting loop diuretic such as furosemide or torsemide
- If the patient is hypotensive, recommend an inotropic agent such as dobutamine to maintain a mean arterial pressure of at least 70–75 mm Hg.
*Recommend intubation and invasive ventilation if the patient develops severe respiratory acidosis on CPAP/BiPAP.
44
Pulmonary hypertension group 1 treatment
1. pulmonary vasodilators
2. atrial septostomy
3. lung/heart-lung transplantation
45
Pulmonary hypertension group 2 treatment: left heart disease
1. Diuretics, beta blockers, ACE inhibitors
2. Repair/replace valves
46
Pulmonary hypertension group 3 treatment: lung disease
1. O2 therapy
2. CPAP/BIPAP
47
Pulmonary hypertension group 4 treatment: thrombo-embolic
1. anticoagulant/thrombolytics
- apixaban (eliquis)
- fondaparinux (arixtra)
- heparin (lovenox)
- rivaroxaban (comuadin)
- warfrain (digitalis)
2. pulmonary thromboendarterectomy
48
Myocardial infarcation treatment
- 100% O2
- aspirin
- morphine
- anti-arrythmic agents
1. amiodarone
2. procainamide
3. atropine
- nitrates for chest pain
49
Pulmonary embolism treatment
- anticoagulant
- antiemoblism (heparin)
- pnuematic compression device
- early ambulation
- O2 therapy
- analgesics for chest pain
- digitalis, digoxin
- thrombolytic agent --> urokinase, streptokinase, tPA
50
Myasthenia gravis patient assessment
- dropping eyelids (ptosis)
- double vision (diplopia)
- difficulty swallowing (dysphagia)
- diminished with crackles
51
Myasthenia gravis diagnostic tests
1. Edrophonium test (tensilon challenge) --> administer atropine to reverse test
2. ice pack test (if drooping (ptosis) improves
3. PFT --> reduced volumes
52
Myasthenia gravis & Gulliain bare treatment
*monitor vT, VC, MIP
--> intubate and institute mechanical ventilaton
- plasmapheresis and intravenous IVG therapy for GB
53
Drug overdose treatment
Naloxone, Narcan= narcotic overdose
Flumazenil, Romazicon= benzo sedative overdose
Acetylcysteine= acetaminophen overdose
54
ARDS patient assessment
*SEPSIS IS MOST COMMON CAUSE
respiratory distress (i.e., tachypnea, use of accessory muscles of respiration, thoracoabdominal paradox, diaphoresis)
- flat/dull percussion
- diffuse crackles on auscultation
Mild= 201-300
Moderate= 101-200
Severe= < 100
55
ARDS diagnostic testing
- ABG for objective assessment of PaO2, P/F ratio
- CXR or CT scan (honeycomb or ground glass)
- Recommend BNP to help rule out congestive heart failure (CHF)
- Recommend echocardiography to rule out cardiogenic pulmonary edema
- Recommend CVP to help rule out overhydration, adjust fluid balance, and assess ScvO2
56
ARDS ventilation treatment
-initial tidal volume (VT) of 8 mL/kg predicted body weight (PBW).
- keep the plateau pressure (Pplat) at or below 30 cm H2O.
- Set an initial respiratory rate sufficient to the patient's minute ventilation requirements (generally 7–9 L/min for adults).
- Set an initial I:E ratio of 1:2 or 1:3.
- use higher PEEP to keep FIO2 in safe range with low tidal volume
57
Shock general appearance
- pale
- clamy
- cold
- cyanotic
- lethargic
- unresponsive
- diaphoretic
- poor capillary refill
58
Shock diagnostic testing
- decreased CVP, PAP, PCWP, Qt
- decreased urine out
59
Shock treatment
- vent support
- vasopressor (dopamine, dobutamine)
- inotopic agents (digitalis, digoxin)
- antibiotics
- IV fluids
60
Laryngectomy treatment
- meticulous suctioning (watch for bleeding/clots post op)
- cool aersol
- tube removed after 3-6 weeks when stoma stable
- monitor basic lab tests
61
Head trauma patient assessment
- hemiparesis or aphasia
- unequal or sluggish pupillary responses
- decline in mental status
- coma
- irregular breathing pattern
- cheyne stokes or biots breathing
62
Head trauma diagnostic testing
- CT
- MRI
- PET scan
- ICP montoring (5-10 normal)
63
Head trauma treatment
- 100% O2
- place patient in cervical callor
- monitor A-line
- monitor ICP
- monitor Spo2
- recommend vasopressors (norepinephrine)
- elevating the head of the bed 30–40°
- sedating patient with benzodiazepine or propofol
- recommend osmotherapy (mannitol/hypertonic saline)
- recommend an anticonvulsant (phenytoin)
- recommend neuromuscular blockade, high-dose barbiturate coma, or decompressive craniectomy if ICP remains high.
*Do not recommend high-dose steroids
64
Mild hypothermia (32-35C) (90-95F)
- tachypnea
- tachycardia
- increased BP
- confusion
- ataxia
- dysarthria
- shivering
- excessive diuresis
65
Moderate hypothermia (28-32C) (82-90F)
- reduced RR
- reduced HR
- reduced CO
- reduced consiousness
- hallucinations
- mydriasis
- loss of shivering
- loss of airway protection
66
Severe hypothermia (<28C) (<82F)
- coma
- areflexia
- apnea
- pulmonary edema
- oluguira
- bradycardia
- ventricular arrthymia
- asystole
67
Hypothermia diagnostic testing
- low-temperature probe placed in the esophagus, bladder, or rectum
- recommend electrolytes, glucose, BUN and creatinine, creatine phosphokinase, a coagulation panel
- monitor SpO2—consider using an ear or forehead probe instead
- Obtain an ABG and assess and apply the values uncorrected for temperature
- continuous ECG
-recommend a chest x-ray
- recommend urinary catheterization to monitor fluid balance and assess renal sufficiency.
68
Hypothermia treatment
- Mild/moderate hypothermia with a perfusing rhythm --> passive external warming (warm blankets)
- Severe hypothermia with a perfusing rhythm --> active external warming oractive internal rewarming using IV solutions heated to 40–42°C
--> gastric lavage with warm isotonic solutions (no more than 45°C)
--> heated, humidified O2 (40–42°C)
--> recommended unless the patient is intubated.
Severe hypothermia and cardiac arres --> cardiopulmonary bypass
--> hemodialysis, thoracic or pleural lavage with warm isotonic solutions
--> full-body immersion in warm water, such as via a Hubbard tank
69
Childhood asthma step 1 treatment
SABA
- albuterol
- levalbuterol
70
Childhood asthma step 2 treatment
SABA and add low dose of corticosteriod
- beclomethasone
- budesonide
- fluticasone
71
Childhood asthma step 3 treatment
Add LABA, LTRA, or theophylline to the low dose corticosteriod or step up medium dose inhaled corticosteriod
- salmaterol
- formoterol
- arformoterol
72
Childhood asthma step 4 treatment
Medium dose inhaled corticosteriod + LABA
73
Childhood asthma step 5 treatment
High dose inhaled corticosteriod + LABA
74
Childhood asthma step 6 treatment
High dose corticosteriod + LABA + oral systemic corticosteriod
- predinose
- methylprednisolone
75
Moderate childhood asthma exacerbation treatment
- O2 100%
- SABA by SVN or MDI with holding chamber
* up to 3 doses in first hour
76
Severe childhood asthma exacerbation treatment
- O2 100%
- heliox
- high dose SABA plus ipatropium every 20 minutes for 1 hour
- oral steriods
- trial application of NPPV
77
Life threating childhood asthma exacerbation treatment
- intubation and vent on 100%
- inhaled SABA + ipatropium
- IV steriod
_ IV MgSo4
78
Croup treatment
- O2 theraoy
- aerosolized raceepi (0.25-0.5 mL 2.25% solution with 3.0 mL saline) 3x
- if raceepi fails --> heliox treatment HFNC or nonrebreather
- intubation if becomes worse
79
Epiglottis treatment
- O2 therapy
- acute respiratory distress --> ventilate child with 100% bag-mask and intubate
- fiberoptic assist nastracheal intubation under controlled conditions
- cricothyriodotomy or emergency tracheotomy if intubation is not possible
80
Bronchiolitis/RSV patient assessment
- nasal discharge
- lethargic
- nasal flaring
- cyanosis
- tachypnea
- apnea
- grunting
- intercoastal and substernal retractions
- wheezes
- crackles
- hyperresonance in severe cases
81
Bronchiolitis/RSV diagnostic tests
- RSV enzyme immunoassay (EIA)
- respiratory infectious disease panel (RIDP)
82
Bronchiolitis/RSV treatment
- O2 therapy
- antibody palivizumab (Synagis) for prophylaxis against RSV for high-risk infants or innume globin (respigam)
- humdification
- oral decongestion
- raceepi or albuterol for wheezing
*not ribavirin
* not ICS
* not antibiotics
83
Bronchopulmonary dysplasia (BPD) patient assessment
- tachypnea
- retractions
- expiratory wheezing
- crackles
- persistant cyanosis
- lengthy vent support
- CXR showing small areas of luceny
84
Bronchopulmonary dysplasia (BPD) treatment
- lowest level of supplemental O2
- administer prophylactic surfactant treatment
- bronchodilators
- prophylactic vitamin A administration
- early (before the infant is a few days old) prophylactic caffeine administration
- careful fluid managment
- diuretics to reduce lung edema
85
Bronchopulmonary dysplasia (BPD) vent treatment
- select volume-control (VC) ventilation
- implement permissive hypercapnia to avoid volutrauma by using low tidal/minute volumes
- wean the infant to nasal CPAP as soon as possible, accepting PaCO2 levels as high as 60–65 torr with pH can be kept at or above 7.3
* Do not recommend inhaled nitric oxide unless persistent pulmonary hypertension of the newborn is a coexisting diagnosis
* Do not recommend high-frequency ventilation
86
Infant respiratory distress syndomre patient assessment
- < 38 weeks
- low APGAR score
- L:S ratio < 2:1
- cyanosis
- tachypnea with possible apnea
- intercostal retractions
- nasal flaring
- grunting
- bronchial or harsh respiratory pattern
- fine crackles/rales
87
IRDS diagnostic testing
-CXR for increased opacities, ground-glass” appearance, and air bronchograms
- ABG --> respiratory acidosis with severe hypoxemia
- appropriate cultures to rule out an infectious cause, such as streptococcal pneumonia or sepsis.
- recommend a hyperoxia test to rule out a critical congenital heart defect (CCHD)
- recommend an echocardiogram if extrapulmonary shunting (patent ductus arteriosus [PDA])
88
IRDS treatment
- For women at risk of giving birth between weeks 24 and 34 of pregnancy --> recommend corticosteroid administration prior to birth
- recommend or implement early prophylactic surfactant therapy
--> infant is briefly intubated after birth, administered surfactant, and immediately extubated and placed on nasal CPAP at 4–6 cm H2O
- HFNCt 1–6 L/min
- maintenan of a neutral thermal environment using an incubator or radiant warmer
- provide sufficient FIO2 to maintain the PaO2 between 50–70 torr or the SpO2 between 85–92%
89
IRDS vent treatment
- recommend or implement permissive hypercapnia
--> volume-controlled ventilation with low tidal volumes (4–5 mL/kg corrected) and letting the PaCO2 rise as long as the pH remains greater than 7.20.
*Do not recommend high-frequency ventilation
*Do not recommend INO therapy unless the IRDS is accompanied by PPHN
90
Persistent pulmonary hypertension of newborn patient assessment
- tachypnea
- tachycardia
- cyanosis
- grunting
- nasal flaring
- chest retractions
- systemic hypotension
- 1/5 min Apgar scores ≤ 5)
91
PPHN diagnostic testing
- Echocardiography (gold standard for diagnosing PPHN)
- left deviated septum and tricuspid insufficiency
- ABG assess oxygenation and presence of acidosis/hypercapnia
- CBC with differential evaluates for high Hct
- electrolytes --> with focus on calcium and magnesium
- blood glucose levels
- coagulation studies
92
PPHN treatment
- Maintain a neutral thermal environment
- Correct any electrolyte imbalances
- Correct metabolic acidosis (acidosis worsens PPHN)
- Maintain normal blood glucose levels
- Maintain adequate systemic blood pressure via fluid therapy and inotropes
- minimize suctioning and stress
- provide adequate sedation
- recommend a selective pulmonary vasodilator. --> preferred agent is INO
--> Typically initiated at 20 ppm via conventional or high-frequency oscillation ventilation
--> If infant not responsive to INO or INO not available, recommend a phosphodiesterase inhibitor such as sildenafil (Viagra, Revatio) or milrinone (Primacor)
--> Inhaled prostacyclins (epoprostenol [Flolan] or iloprost [Ventavis]) may act synergistically with INO
93
Congential heart defect for infant treatment
- infant with a confirmed ductal-dependent defect exhibits severe cyanosis with evidence of heart failure and pulmonary edema --> recommend IV prostaglandin E1 (PGE1 or alprostadil) to dilate the ductus arteriosus
- infant in heart failure exhibits systemic hypotension or low cardiac output --> recommend an inotropic agent such as dopamine.
RCP
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