Respiratory Therapy - Lindsey Jones/Clinical Simulations 459 Questions with Verified Answers
Information Gathering - Emphysema:
(Abnormal condition
... [Show More] of the alveoli resulting destruction and loss of elasticity) - CORRECT ANSWER LEVEL I : Cyanosis, Barrel chest, increased A-P diameter, Accessory muscle use, Digital clubbing of the nail beds, Significant history of smoking and/or occupational exposure to smoke or other pulmonary irritant
LEVEL II : Dyspnea, Wheezing breath sounds
LEVEL III : Chest X-ray—flattened diaphragms, hyperlucency, diminished pulmonary vascular markings.
CBC—polycythemia, increased WBC due to possible infection.
ABGs—Compensated respiratory acidosis (high PaCO2, normal pH), moderate to severe hypoxemia.
Sputum cultureoften positive for bacteria.
LEVEL IV : FT—flows are decreased especially middle sized airways (FEF 25-75%) Fev1 and Fev1/FVC%, reduced DLCO (less than 20).
Decision Making - Empysema:
(Abnormal condition of the alveoli resulting destruction and loss of elasticity) - CORRECT ANSWER Oxygen therapy—low FIO2 (0.24 to 0.28) or 1 to 2 lpm nasal cannula
Oxygen conserving devices such as liquid oxygen or trans-tracheal oxygen
Home care education on devices and equipment cleaning
Rehabilitation efforts (specifics not usually required)
Aids to help quit smoking such as nicotine replacement therapy
Bronchodilation medication via MDI or aerosol nebulizers
Antibiotics for infection
Smoking cessation products (nicotine replacement therapy).
Information Gathering - Chronic Bronchitis
(Defined: Condition where the patient has a productive cough 25% of the year for at least two consecutive years.) - CORRECT ANSWER LEVEL I : Productive cough, purulent sputum production
Exposure to pulmonary irritants, like history of smoking
Frequent infections
LEVEL II : Dyspnea
LEVEL III : Chest X-ray—could be normal, or may show hyperlucency, diminished, pulmonary markings.
CBC—possibly increased WBC due to possible infection.
ABGs—could be normal or very slight respiratory acidosis and hypoxemia
LEVEL IV : PFT—flows are decreased especially middle sized airways (FEF 25-75%) FEV1, Normal DLCO
Decision Making - Chronic Bronchitis
(Defined: Condition where the patient has a productive cough 25% of the year for at least two consecutive years.) - CORRECT ANSWER Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick.
Fluid therapy if dehydrated.Oxygen therapy for hypoxemia
Aerosolized bronchodilator therapy, Antibiotic Tetracycline may be preferable
Information Gathering - Bronchiectasis
(Defined: Abnormal condition where the bronchi
secrete large volumes of pus during abnormal
dilation.) - CORRECT ANSWER LEVEL I : Productive cough, often with blood, digital clubbing of the nail beds, significant history if infections (recurrent)
LEVEL II : Dyspnea
LEVEL III : Chest X-ray—generally normal
Sputum culture—gram negative bacteria
LEVEL IV : Bronchogram is the primary test. Characterized by a "tree in winter pattern"
Decision Making - Bronchiectasis
(Defined: Abnormal condition where the bronchi
secrete large volumes of pus during abnormal
dilation.) - CORRECT ANSWER Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick.
Fluid therapy if dehydrated.Oxygen therapy for hypoxemia
Aerosolized bronchodilator therapy. May have to consider surgical intervention on some highly affected segments
Information Gathering - OSA
(Defined: the cessation of breathing during sleep.
Is usually obstructive in nature but sometimes can be central or a combination of the two (mixed). - CORRECT ANSWER LEVEL I : Spouse or bed partner will complain of snoring and will often report witnessing periods of apnea that exceed 10 seconds. Excessive upper airway tissue, obesity, thick neck (greater than 16 inch collar size. Ability to fall asleep quickly
Sleepiness during daytime and while watching TV or in front of a computer
LEVEL II : Dyspnea, Frequent urination during sleeping hours
LEVEL III : ABGs—could be normal or very slight respiratory acidosis and hypoxemia
LEVEL IV : Polysomnography (sleep study) - determines if obstructive or central, If no nasal flow AND no chest movement—then CENTRAL sleep apnea. If no nasal flow WITH chest movement—then OBSTRUCTIVE sleep apnea
Decision Making - OSA
(Defined: the cessation of breathing during sleep.
Is usually obstructive in nature but sometimes can be central or a combination of the two (mixed). - CORRECT ANSWER If central, ventilatory stimulant medication may be used, If obstructive, nocturnal nasal or full-face CPAP or BiPAP (NIPPV) is usually initially indicated with follow-up weight loss or upper airway tissue removal through surgery.
Problem must be corrected immediately, so even if discharging, send devices home with
patient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cmH20.
Information Gathering - Asthma
(Defined: Abnormal constriction of the bronchials
resulting in sputum productionand narrowed
airways. - CORRECT ANSWER LEVEL I : Accessory muscle use, Tachycardia
LEVEL II : Dyspnea, Wheezing, Congested cough, Wet, clammy skin
LEVEL III : ABGs—possible respiratory acidosis, could be hypoxic, Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. In allergic cases, may see elevated eosinophil count which can cause yellow sputum
LEVEL IV : PFT—Decreased flows in FEV1 but diffusion is normal as manifested by DLCO
Decision Making - Asthma
(Defined: Abnormal constriction of the bronchials
resulting in sputum productionand narrowed
airways. - CORRECT ANSWER Oxygen therapy for hypoxemia
Aerosolized bronchodilator therapy
Continuous bronchodilator therapy, Albuterol (7-10 mg/hr)
Xanthine medication given IV (Aminophylline, etc)
Promote pulmonary hygiene
Inhaled sterioids such as oral or IV prednisone
Information Gathering - Status Asthmaticus
(Defined: Asthma that will not respond to bronchodilation therapy,usually persists more
than 24 hours.) - CORRECT ANSWER LEVEL I : Historically non-responsive to bronchodilators. Patient will report the need to take many bronchodilator treatments before feeling better. Accessory muscle use and retractions
Dyspnea, Wheezing, Congested cough, Wet, clammy skin
LEVEL II : Pulses paradoxus
LEVEL III : ABGs—possible respiratory acidosis when tiring, alkalosis at first due to anxiety, could be hypoxic
Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms.
Decision Making - Status Asthmaticus
(Defined: Asthma that will not respond to bronchodilation therapy,usually persists more
than 24 hours.) - CORRECT ANSWER May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate before full ventilatory failure.
Use subcutaneous epinephrine—1 mL of 1:1000 strength. May need to give every 20—30 minutes for up to three consecutive doses (if no improvement between doses)
Continuous beta II agonist (bronchodilator medication). Albuterol 7-10 mg/hr.
Information Gathering : Myasthenia Gravis
(Defined: Neuromuscular abnormality where muscles
experience paralysis starting from the head down to the feet including ventilatory muscles.) - CORRECT ANSWER LEVEL I : May have a history of Myasthenia Gravis if not a new onset, Droopy facial muscles and eyelids (Ptosis)
LEVEL II : Patient will describe slowly feeling weakness generally but feels better with rest. Double vision (diplopia)
Dysphagia (difficulty swallowing) Drooping eyelid (Ptosis)
Shrinking Vt, VC, MIP
LEVEL IV : Tensilon Challenge Test—positive for Myasthenic crisis if improvement is noted upon the administration of Tensilon.
Decision Making : Myasthenia Gravis
(Defined: Neuromuscular abnormality where muscles
experience paralysis starting from the head down to the feet including ventilatory muscles.) - CORRECT ANSWER If Tensilon improves condition then, anticholinesterase therapy is indicated including: Neostigmine (prostigmine), Mestinon (pyridostigmine) Ok to do additional Tensilon challenge test to observe progression. If symptoms improve with Tensilon and then worsen, must reverse with Atropine. This condition is termed a cholinergic crisis. Always monitor spontaneous ventilatory volumes (Vt and VC) as well as MIP. Never treat Myasthenia gravis with Tensilon—only use to diagnose. Use the above mentioned drugs to provide maintenance.
Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since it could take out the respiratory drive
When VC falls off rapidly (especially if below 1.0 L) , then intubate and mechanically ventilate.
Information Gathering : Drug Overdose
(Defined: Potential loss of ventilatory drive as a
result of drug overdose (usually a narcotic). ) - CORRECT ANSWER LEVEL I : Historical drug use as told by previous admissions or family, Sometimes poor self-hygiene, emaciated
LEVEL II : Looks and acts sleepy, difficult to arouse, Respiratory rate and pattern is low and/or shallow
LEVEL III : ABG—often show pure respiratory acidosis and/or ventilatory failure
Decision Making : Drug Overdose
(Defined: Potential loss of ventilatory drive as a
result of drug overdose (usually a narcotic). )
**The most important part of this simulation is the need for immediate intubation while recognizing that there may not be a need to mechanically ventilate
until ventilatory status deteriorates. - CORRECT ANSWER Important priority is to protect the airway through intubation, prevent aspiration of stomach
contents, and facilitate manual ventilation.
If narcotic overdose (usually is) then use narcotic reversing medication such a Narcan
(Nalaxon)
Support ventilation until drugs are out of system.
Information Gathering : Other Neuromuscular
(Defined: Other neuromuscular diseases or states include: Poliomyelitis, Tetanus, Muscular dystrophy, and even botulism poisoning.) - CORRECT ANSWER LEVEL I : History of illness
LEVEL II : Shrinking Vt, VC, MIP
Decision Making : Other Neuromuscular
(Defined: Other neuromuscular diseases or states include: Poliomyelitis, Tetanus, Muscular dystrophy, and even botulism poisoning.)
**If faced with these diseases, simply apply general respiratory monitoring principles and facilitate ventilation when needed. These are somewhat rare. - CORRECT ANSWER Monitor for ventilatory failure generally through Vt, VC, MIP and ABGs
As VC falls below 1.0 L, consider intubation and mechanical ventilatory support.
Paralytics are indicated if conditions, such as locked-jaw or other muscle contractions are
present due to Tetanus or Botulism.
Information Gathering - Head Trauma
(Defined: Physical Trauma to the head) - CORRECT ANSWER LEVEL I : Sometimes trauma is visible with blood contusions on the head, History is trauma related, often automobile accident
LEVEL II : Looks and acts sleepy, difficult to arouse
Respiratory rate and pattern is low and/or shallow and irregular
Pupillary response to light may be unequal or inadequate
LEVEL IV : If intracranial pressure monitor is in place, may see ICP greater than 20cm H2O
Decision Making - Head Trauma
(Defined: Physical Trauma to the head)
**Unique to this simulation is the need to monitor ICP readings and avoid anything that increases MAP. You will likely need to suction this patient to keep peak
pressures down but the very act of doing so my elevate ICPs. - CORRECT ANSWER Must constrict vessels in the head by keeping PaCO2 between 25-30 mm Hg.
Adjust FIO2 to maintain high normal levels (PaO2 of 100 mm Hg).
Avoid increased ICP by minimizing PEEP usage.
Suction only when needed, due to elevating peak pressures.
Avoid anything that will increase mean arterial pressure (MAP).
Sedation is important, but should monitor exhaled volumes and pressures closely
Use of drugs such as Mannitol (cerebral diuretic medication) when ICP is above 20 cm
H20
Use Dilantin and establish an airway if grand mal seizure activity is observed
Information Gathering - Chest Trauma
(Defined: May be any trauma leading to fractured ribs or flail chest.) - CORRECT ANSWER LEVEL I : Circumstantial history (motor vehicle accident, etc)
Respiratory rate and pattern is fast and shallow due to pain
May have obvious trauma (bruising) on chest wall
LEVEL II : Sharp chest pain, especially at the top of each breath
Paradoxical chest movement if ribs are broken in two places (flail chest) Pneumothorax is possible (see signs and symptoms of pneumothorax)
LEVEL III : Chest x-ray—may reveal broken ribs, usually isolated in same area
Decision Making - Chest Trauma
(Defined: May be any trauma leading to fractured ribs or flail chest.)
**This case is usually easy to recognize. You may be tempted by options that address the broken ribs when, in fact, you simply need to address ventilation. Very commonly, this case will lead to pneumothorax or partial pneumothorax or hemothorax. - CORRECT ANSWER Anything that encourages deep (adequate) breathing in spite of pain such as IPPB, incentive
spirometry, coughing.
Watch for ventilatory fatigue and eventual ventilatory failure
Mechanically support ventilation when it is evident ventilatory failure is impending. If possible
do not wait until full ventilatory failure.
Treat partial pneumothorax if greater than 20% - ie insert chest tubes
Treat hemothorax, with chest tubes or thoracentesis
Treat tension pneumothorax with a large-bore needle
Information Gathering - Hemothorax/Pneumothorax
(Defined: Defined: Loss of adherence of the lung to the
pleural wall causing the space to be filled with air or fluid (bloody). ) - CORRECT ANSWER LEVEL I : Rapid and shallow respirations
LEVEL II : Percussion: hyperresonant if pneumothorax, dull if hemothorax, Tracheal shift: to affected side if pneumothorax, away if tension pneumothorax, Severe dyspnea, Very diminished or absent breath sounds, Pulses paradoxes
LEVEL III : Chest x-ray—definitive—show hyperlucency, tracheal or mediastinal shift
Decision Making - Hemothorax/Pneumothorax
(Defined: Defined: Loss of adherence of the lung to the
pleural wall causing the space to be filled with air or fluid (bloody). )
**Pneumothorax, hemothorax, tension pneumothorax occurs very frequently on the exam. May include the troubleshooting of chest tube drainage devices - CORRECT ANSWER Usual treatment is insertion of chest tubes
Upper anterior chest tube placement for pneumothorax (involving air)
Lower chest tube placement for hemothroax (involving blood and body fluid)
Treat partial pneumothorax if greater than 20% - insert chest tubes
Treat hemothorax, with chest tubes or thoracentesis
Treat tension pneumothorax with a large-bore needle
Information Gathering : Thoracic Surgery
(Defined: Can have a variety of complications from thoracic surgery.) - CORRECT ANSWER LEVEL II : Always monitoring chest tube drainage adequacy
Looking for potential complications: Hypovolemic shock, low hemodynamic values including blood pressure, Subcutaneous emphysema, Elevated ventilatory pressures
LEVEL III : Chest x-ray—to confirm proper re-inflation of the lung and proper placement of chest tubes
Decision Making : Thoracic Surgery
(Defined: Can have a variety of complications from thoracic surgery.)
**Your ability to deal with and troubleshoot chest tube
maintenance is tested in this simulation. Sometimes this case is combined with chest trauma. - CORRECT ANSWER Anything that promotes expansion of the lungs including incentive spirometry, IPPB, and positive pressure mechanical ventilation. If a lobectomy or pneumonectomy, ventilatory volumes should set lower. Fluid therapy if volume is a problem (often is). If mechanical ventilation is used, use VT of 8-9 mL/kg to reduce ventilatory pressures.
Information Gathering : Neck/Spinal Injury
(Defined: Any trauma threatening the physical structure of the neck. Can include neck or spinal surgery.) - CORRECT ANSWER LEVEL I : Historical relevance, some sort of accident such as diving, automobile. Visible damage to the neck. Altered conscious level. Pulse must be palpated brachially or femorally
LEVEL II : Vt, VC, PEFR, and other ventilatory volumes may quickly deteriorate
LEVEL III : Neck x-ray—will show injury
Decision Making : Neck/Spinal Injury
(Defined: Any trauma threatening the physical structure of the neck. Can include neck or spinal surgery.)
**Your knowledge of special intubation techniques is what is being tested in this type of simulation. - CORRECT ANSWER Always be prepared to quickly assist and/or promote ventilation.
If intubation is required, always use MODIFIED jaw thrust.
If given option, always intubate with a bronchoscope so damage can be visualized and care can be taken to avoid inflicting further damage.
Alternatively, a blind nasal intubation is acceptable to prevent neck manipulation and further
injury
Information Gathering : Abdominal Surgery
(Defined: Surgery in the abdominal area for various
reasons.) - CORRECT ANSWER LEVEL I : All general visual assessments
LEVEL II : All general beside assessment including all vitals
LEVEL III : Ventilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines
Decision Making : Abdominal Surgery
(Defined: Surgery in the abdominal area for various
reasons.)
**Abdominal surgery is usually a very general, non-complicated case involving preventative care and follow-up. - CORRECT ANSWER Establishing baselines in pulmonary function testing flows and volumes.
Start patient on incentive spirometry prior to surgery, every hour after surgery
Initial IS goal is 1/2 of the preoperative inspiratory capacity value.
Use positive pressure (IPPB) if needed after surgery if patient is unconscious.
Information Gathering : ARDS
(Defined: A condition that results in significantly
decrease lung compliance and consequent profound
hypoxemia.) - CORRECT ANSWER LEVEL I : Record may show a variety of insults to the lung including massive surgery, near drowning, inhalation of gasoline, hypothermia, and others. Rapid respiratory rate
Cyanosis
LEVEL II : Decreased lung compliance as manifested by increased plateau pressures (decreasing static compliance)
LEVEL III : ABGs—persistent hypoxemia in spite of elevated FIO2 (may be refractory) Chest x-ray—show granular, ground glass, reticulogranular, or honeycomb patterns. Often accompanied by diffuse infiltrates.
LEVEL IV : All hemodynamic values could deteriorate when positive ventilatory pressures become significant.
Decision Making : ARDS
(Defined: A condition that results in significantly
decrease lung compliance and consequent profound
hypoxemia.)
**ARDS can be a very disquieting case to deal with. Usually persistent increases in PEEP are needed. Do not be afraid to increase PEEP significantly. Also, most often, cardiac output or some other hemodynamic value will fall indicating a need to
decrease PEEP in spite of profound hypoxemia. - CORRECT ANSWER As positive pressure is required increasingly, negative effects may be seen. All should be
done to minimize the mean pressure being put on the pulmonary system, while trying to
balance the need to ventilate with higher pressures and utilize PEEP to maintain oxygenation.
After emergency situation is past, keep FIO2 no more than 0.6 and use PEEP
Keep increasing PEEP until an obvious degradation in hemodynamic values is witnessed.
As ventilatory pressures become higher, OK to consider alternate methods of ventilation
including pressure control, high frequency, APRV, inverse I:E ratio, etc
If patient is described as having ARDS before being placed on a ventilator, initial ventilator
setting should include a PEEP of at least 10. It is also appropriate to start right off at
pressure/control ventilation as an initial setting.
Information Gathering : Laryngectomy
(Defined: Surgery done to address or remove
cancer of the larynx.) - CORRECT ANSWER LEVEL I : Surgical record : Surgery radical (entire larynx) or simple (cord removal) Medical history will show cancer in upper airway
LEVEL II : Signs of airway obstruction after surgery. Usually caused by blood within a few
hours after the surgery.
Decision Making : Laryngectomy
(Defined: Surgery done to address or remove
cancer of the larynx.)
**In this case, you are always looking for post-surgical
complications like blood clots in the laryngeal tube. Often, you will have to mechanically ventilate
this patient through the laryngectomy tube. - CORRECT ANSWER If radical surgery (entire larynx removed) then the tracheostomy becomes permanent.
If not radical then a temporary laryngectomy tube is placed but must be replaced in 3 to 6
weeks.
Prevent aspiration! Wait at least a week before oral ingestion of liquid and longer for food.
Thorough pulmonary hygiene through suctioning
Use cool aerosol or ultrasonic nebulizer to keep secretions thin and hydrated.
Once the surgery is done, you can no longer, orally intubate the patient. Even if the temporary
laryngectomy tube is in place, you must intubate and/or ventilate through that tube !
Information Gathering : Guillian Barre
(Defined: An insidious neuromuscular problem
involving muscle paralysis. Paralysis begins in the lower extremities and moves upward, including the
ventilatory muscles.) - CORRECT ANSWER LEVEL I : Medical history or patient complaint of recent influenza-type sickness.
LEVEL II : Complaint of sluggish lower extremities, Shrinking Vt, VC, MIP
LEVEL III : ABGs—impending or current ventilatory failure.
LEVEL IV : Spinal tap—will show increased protein in the spinal fluid
Decision Making : Guillian Barre
(Defined: An insidious neuromuscular problem
involving muscle paralysis. Paralysis begins in the lower extremities and moves upward, including the
ventilatory muscles.)
**Like most neuromuscular cases, you will be tested in your ability to recognize deterioration in ventilatory muscles. In this case,onset can be slow, so don't
jump-the-gun and mechanically ventilate too early. Only do so as VC falls below 1.0 L. Otherwise, you will be manipulating the ventilator and possibly weaning. - CORRECT ANSWER Be primarily concerned with loss of ventilation, monitor ventilatory volumes (VC, Vt) and
MIP. Begin mechanical ventilation when VC falls below 1.0 L.
Be patient about intubation and mechanical ventilation. Onset can be slow.
Anti-coagulant therapy and pressure leg stockings to prevent clot development
Primary treatment will involve mechanical ventilation and letting the syndrome run its
course.
Therapies to mobilize secretions
Plasmapheresis, immunosuppressor medications.
Higher propensity for pulmonary embolism due to clot formation in the lower body due to
inactivity.
Information Gathering : Shock
(Defined: Condition where tissues oxygenation is in
jeopardy due to a sudden decrease in blood flow.) - CORRECT ANSWER LEVEL I : Historical evidence of an event, massive trauma, or hypothermia, etc General appearance—cold, clammy, dusky, cyanotic, Tachycardia, tachypnea
LEVEL II : Hypotensive, Temperature may be below normal
Reduction in urine output
LEVEL III : ABGs—hypoxemia and ventilatory failure
LEVEL IV : Reduction in common hemodynamic values (CVP, PAP, PCWP) and cardiac output.
Decision Making : Shock
(Defined: Condition where tissues oxygenation is in
jeopardy due to a sudden decrease in blood flow.)
**Shock will test your ability to recognize it and monitor the patient for ventilatory failure. Most of the simulation is dealing with typical ventilatory considerations such as ventilator manipulation. - CORRECT ANSWER Mechanically ventilate with ventilatory failure.
Oxygen is key. Start it as evidence of shock is presented.
Administer blood if needed to treat anemia.
Use oxygen at least 40% but may use up to 100%
Main treatment involves treating the original problem (that which caused the shock). This can be highly variable.
Information Gathering : Heart Surgery
(Defined: Any surgery on the heart.) - CORRECT ANSWER LEVEL I : Do well-rounded assessment prior to surgery including vital signs and family history of cardiac illness.
LEVEL II : Preoperative assessments of breath sounds
Baseline data including basic spirometry of all types including FEV1/FVC and pre and post bronchodilator studies
LEVEL III : ABGs—preoperative for baseline
Decision Making : Heart Surgery
(Defined: Any surgery on the heart.)
**This case is not too complicated. You may feel hesitant to do CPR on someone fresh out of surgery.
Just do it. - CORRECT ANSWER Always assess ventilatory volumes and be prepared to mechanically ventilate
Incentive spirometry every hour after surgery for lung expansion and alveolar ventilation.
If unable (unconscious) use simple ventilatory assisting devices such as IPPB or CPAP
with mask.
Be on the alert for cardiac arrest—perform CPR without reservation or consideration of
the heart surgery.
Information Gathering - Pulmonary Edema/ CHF
(Defined: Significant reduction in cardiac output. Involvement of fluid penetrating the alveolar capillary
membrane into the lungs.) - CORRECT ANSWER LEVEL I : History of CHF or pulmonary hypertension
Tachypnea, tachycardia, anxiety
LEVEL II : Cold, clammy, diaphoretic, Pink frothy secretions
Edema of fluids (especially pedal edema) Pitting edema (+2, +3) Breath sounds reveal fine, wet rales
LEVEL III : ABGs—ventilatory failure with moderate to severe hypoxemia. Chest X-ray—Butterfly pattern, fluffy infiltrates
LEVEL IV : Increased hemodynamic pressure (PCWP, PAP, CVP)
Decision Making - Pulmonary Edema/ CHF
(Defined: Significant reduction in cardiac output. Involvement of fluid penetrating the alveolar capillary
membrane into the lungs.)
**This case may feel complicated because it involves the heart and hemodynamic values. It is usually easily identified by pink frothy secretions and butterfly pattern on the chest X-ray.You may need to make the distinction between pulmonary edema caused by cardiac problems and that which is caused by alveolar capillary membrane problems (ARDS). If it is cardiac,
then you must treat the heart. - CORRECT ANSWER Treat as an emergency !
100% oxygen
Administer diuretic medication furosemide (Lasix)
Cardiac intotropic stimulating drugs such as digoxin, digitalis if increased PCWP and PAP
Be prepared to treat ventilatory failure with mechanical ventilation
Instill ethyl alcohol down the ET tube if patient is severely congested with fulminating
edema.
Information Gathering - M.I/Arrhythmia
(Defined: Ischemia to the heart causing muscle
damage and potential failure.) - CORRECT ANSWER LEVEL I : History of chest pain, radiating pain down the left arm
Family history of disease, Diaphoretic, History of nausea
Tachycardia, Nausea
Level II : Cold, diaphoretic and clammy to the touch, Dyspnea
Level III : ABGs—hypoxemia, ECG (EKG) - pronounced Q waves and S-T segment elevation
Level IV : Cardiac enzymes including CPK, LDH, SGOT are elevated
Decision Making - M.I/Arrhythmia
(Defined: Ischemia to the heart causing muscle
damage and potential failure.)
**Will likely need to treat arrhythmias with appropriate
medication and/or defibrillation - CORRECT ANSWER Emergency—100% oxygen. Oxygen at adult therapeutic level (40 to 60 %) upon suspicion or first presentation of signs
and/or symptoms. Treat arrhythmias, Bradycardia with Atropine or Isuprel, PVCs with Lidocaine or oxygen, Pulseless ventricular tachycardia with defibrillation with synchronization OFF
Ventricular fibrillation with defibrillation. Note: For ventricular fibrillation, defibrillate at ascending watt/sec or joule settings
360 joules—repeat as needed, Do not exceed 360 joules
Note: For atrial fibrillation or flutter, do synchronized cardioversion—start at 50 joules
Information Gathering - Pulmonary Emboli
(Defined: Situation where the pulmonary artery
becomes obstructed and dead-space ventilation
results. Sometimes called deadspace disease.) - CORRECT ANSWER Level I : History of recent major surgery or trauma (amputations, clotted massive bleeding sites) Complaint of chest pain and dyspnea
Level II : Elevated vitals including pulse, respirations, and blood pressure, Breath sounds - wheezing and medium rales
PECO2 (Capnography) decreasing PECO2 during normal PaCO2
Level III : ABGs—persistent hypoxemia in spite of increasing FIO2
Level IV: V/Q scan will show ventilation without adequate perfusion
Decision Making - Pulmonary Emboli
(Defined: Situation where the pulmonary artery
becomes obstructed and dead-space ventilation
results. Sometimes called deadspace disease.)
**This case primarily involves recognizing the pulmonary emboli and treating it with anticoagulation medications. You will likely have to monitor
clotting times, PTT or PT.Otherwise, involves general
respiratory therapy. - CORRECT ANSWER Anticoagulation therapy with Heparin or Coumadin
Note: must monitor clotting tests
PTT for Heparin
PT for Coumadin
Clot-busting medication such as steptokinase. May also use a bolus of heparin
Mechanical ventilation as needed.
Emergency level oxygen—100%
Information Gathering - SIDS
(Defined: Condition in infants where alveolus
maturity is below normal.) - CORRECT ANSWER Level I : History may show pre-term infant
Onset can be immediately after birth or within a few hours
General respiratory distress, ie grunting, nasal flaring, retractions, Cyanosis
Level II : APGAR score between 0 and 6
Level III : Chest-Xray—radiological description such as ground glass, honeycomb, reticulogranular
ABGs—persistent hypoxemia in spite of elevated FIO2
Level IV : L/S ratio—2:1 or higher is normal. Less than that shows lung immaturity
Decision Making - SIDS
(Defined: Condition in infants where alveolus
maturity is below normal.)
**This is a common case on the test. Key is remembering to address lung maturity. Also, if prolonged ventilation is required, Bronchopulmonary
Dysplasia may develop. Be patient and treat moment to moment. - CORRECT ANSWER Help lung maturity through surfactant therapy with agents like Exosurf or Survanta 2 to 5 ml/kg split among 2 to 4 doses
Administer directly down the airway, Change infant's position after every dose for 30 seconds to distribute the agent
Provide oxygen via a hood. May use CPAP to oxygenate
Mechanically ventilate with ventilatory failure, use SIMV mode on all infants. May consider reverse I:E ratio
Note: If X-ray changes from signs of IRDS to hyperinflation and fibrosis, then the problem may have developed into Bronchopulmonary Dysplasia. Treat as prolonged IRDS by:
maintaining pH of 7.25 to 7.40, PaCO2 45 to 60 torr, PaO2 55 to 70 torr.
Use low FIO2
Keep mean airway pressure at a minimum
Wean only gradually and as tolerated, often fails initial attempts
Extubate if respiratory rates are between 5 and 15 breaths
Information Gathering : Congenital Heart Defects
(Defined: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart.) - CORRECT ANSWER Level I : History of pre-term birth, General signs of respiratory distress (grunting, nasal flaring, retractions), Cyanosis that persists in spite of high FIO2
Level II : Heart sounds are abnormal upon auscultation (murmur present)
Level IV : Echocardiogram is the best diagnostic test for all cardiac defects
Decision Making : Congenital Heart Defects
(Defined: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart.)
**Your skills in recognizing common, congenital heart problems will be tested. Otherwise, you will be simply
providing supportive care until surgery. - CORRECT ANSWER Specific Defect Attributes, Coarctation of the Aorta (narrowing of aorta) Hypertension in the upper extremities, hypotension in lower extremities, Transposition of the Great Vessels, Aorta and pulmonary artery are switched. "Aorta rising from the right heart, pulmonary artery rising from the left heart" "Egg-shaped heart" on x-ray. Patent Ductus Arteriosis (ductus arteriosis never closes) Diagnosed by comparing blood gases from the radial or brachial artery and the umbilical artery. Positive for PDA if difference is greater than 15 torr. (PDA with a right to left shunt)
Other Problems: Tetralogy of Fallot-boot-shaped heart, overriding aorta, Atrial septal defect (ASD), Ventricular septal defect (VSD), Truncus arteriosis (pulmonary artery same as aorta—combined vessel)
ALL CONGENITAL DEFECTS ARE TREATED WITH SURGERY !!
Prior to surgery simply provide supportive care such as:
oxygen to keep PaO2 between 60 -80 mmHg.
mechanical ventilation when ventilatory failure is shown by ABGs
Information Gathering : Neonatal Diaphragmatic Hernia
(Defined: Condition where the diaphragm never
grows closed. Usually occurs on the left side.) - CORRECT ANSWER Level I : General respiratory distress, ie grunting, nasal flaring, retractions, Cyanosis, Barrel chest and scaphoid abdomen
Mediastinal shift
Level II : Breath sounds absent (usually on left), increased on the right
Level III : Chest-Xray—show intestinal parts in the chest area. Also may see a mediastinal shift away from the affected side.
ABGs—Poor
Decision Making : Neonatal Diaphragmatic Hernia
(Defined: Condition where the diaphragm never
grows closed. Usually occurs on the left side.)
** This case is more about what you
should not do. Otherwise use
general supportive care. - CORRECT ANSWER TREATMENT IS SURGERY
Use low ventilatory pressures
Do not use manual bag and resuscitation if possible
May use gastric tube to decompress stomach and intestines.
All other care is supportive
Information Gathering : Choanale Atresia
(Defined: Infant is born with an anatomical closure of the nasal passages. - CORRECT ANSWER Level I : Normal appearing, normal color, cyanosis during feeding
Level II : During breast or bottle feeding, baby becomes apneic and cyanotic, Slight inspiratory stridor
Level IV : Neck and chest x-rays rule out airway inflammation
Diagnosis by attempting to pass a suction catheter through the nares. If unable to pass, then positive
Decision Making : Choanale Atresia
(Defined: Infant is born with an anatomical closure of the nasal passages. - CORRECT ANSWER Care in feeding
Correct with surgery
Keep ventilatory pressure low
Information Gathering : Laryngotracheobronchitis
(Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.) - CORRECT ANSWER Level I : History of cold in the past few days, Barking cough, Age is 5 months to 3 years, Stridor at rest, Tachypnea
Level IV : Lateral Neck X-ray—swelling below the glottis (subglottic swelling) sometimes described as steeple-sign, pencil point, or haziness below the glottis.
Decision Making : Laryngotracheobronchitis
(Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.)
**You will likely be tempted to treat this like Acute Epiglottitis in an emergency fashion. Repeated racemic epinephrine treatments may make you feel
uncomfortable - CORRECT ANSWER Priority—placement in an oxygen tent with 30 to 40%
Aerosolized Racemic Epinephrine
Intubation if patient is described as lethargic, markedly diminished breath sounds, severe
or marked stridor, extreme accessory muscle use
Extubation should be done when swelling has ceased.
Information Gathering : Acute Epiglottitis
(Defined: Condition where the epiglottis and adjacent
upper airway tissues are infected with a bacteria causing inflammation and commonly threatening
airway patency.) - CORRECT ANSWER Level I
Sudden onset of sickness, within 12 hours, often occurs in the evening
Age 3 to 10 years
General appearance may show drooling, hoarseness, quiet cough
May hear a softened inspiratory stridor
Tachypnea and tachycardia
Level II
Patient unable to swallow, will usually not be crying, eyes are big
Significantly elevated body temperature, taken axillary, or tympanically
Level IV
Lateral neck x-ray will show supraglottic inflammation
Decision Making : Acute Epiglottitis
(Defined: Condition where the epiglottis and adjacent
upper airway tissues are infected with a bacteria causing inflammation and commonly threatening
airway patency.)
**This case will test your immediately ability to realize that it is an emergency. Stridor may tempt you to treat it more casually like croup. There is a good chance you will see Epiglottitis or Croup on the test. - CORRECT ANSWER Primary and immediate concern is establishing an airway as complete closure from
inflammation is possible. Since inadvertent stimulation from oral intubation attempts could
immediately illicit an inflammatory response, intubating in a surgical environment is very
helpful. There may be need to place a tracheostomy tube.
May need to immediately get an airway. Should intubate with a bronchoscope or send to surgery
for a tracheostomy.
Antibiotic therapy to correct bacterial infection
Oxygen therapy at 30 to 50%
Extubate only when inflammation is gone
Information Gathering : Bronchiolitis /RSV
Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than 18 months old.
Commonly caused by the respiratory syncytial virus. - CORRECT ANSWER Level I
General signs of respiratory distress including retractions and accessory muscle
use.
Tachypnea and tachycardia
History of recent sickness from ages 2 months to 3 years old
Level II
Low grade fever
Wheezing, rales, and rhonchi
Level III
Chest X-ray show scattered infiltrates and hyperlucency
Decision Making : Bronchiolitis /RSV
Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than 18 months old.
Commonly caused by the respiratory syncytial virus.
**There is nothing particularly difficult about this case. You must be prepared to recommend the use of
a SPAG unit. Not commonly seen on the exam. - CORRECT ANSWER Primary treatment is delivery of the drug Ribavirin which must be administered via a
SPAG unit (small volume particle aerosol).
Utilize a scavenger system, filters, and masks.
Information Gathering : Cystic Fibrosis
Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs. - CORRECT ANSWER Level I
Family history of disease, siblings may have it.
Emaciated in appearance and body frame may be small for age
Sputum production of thick voluminous purulent secretions
Can look like a young COPD patient, barrel-chested
Level II
Decreased flow rates such as FEV1
Level III
Chest X-ray—looks like COPD, hyperinflation, increased A-P diameter, diaphragm
flattening
Level IV
Sweat Chloride Test—show sweat chloride > 60 mEq/L
Decision Making : Cystic Fibrosis
Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs.
**Not commonly seen on the exam.Tests your ability to recognize secretion removal therapies and may check your understanding of when and how to modify therapy. Ex, when CPT doesn't work, use PEP therapy or ultrasonic nebulization. - CORRECT ANSWER Primary treatment relates to the need to mobilize and remove secretions.
Secretion removal promotion therapies:
PEP therapy devices
Chest physiotherapy with postural drainage
Hydration devices such as heated aerosol or ultrasonic nebulization
Vibration therapy
Oxygen as needed
Antibiotic therapy when infection is present—often is
Medications used commonly include Tobramycin and Pulmozyme (Dornase alpha)
Information Gathering : Hypothermia
Defined: Exposure to cold such that body
temperature falls significantly. - CORRECT ANSWER Level I
History of exposure to cold. May be seen in homeless persons.
Lethargy and unconsciousness
Bradycardia, bradypnea
Level II
Body temperature less than 36 deg C
Level IV
Lateral neck x-ray—Thumb sign or pencil point.
Decision Making : Hypothermia
Defined: Exposure to cold such that body
temperature falls significantly.
*Not very common. However when seen, may be seen in conjunction with other problems such as AIDS, or tuberculosis. - CORRECT ANSWER Oxygen via a heated aerosol at 40 to 100%
Keep resuscitation efforts going until body temperature is normal.
Mechanically ventilate as needed.
Keep in mind that blood gas values may be altered because of the difference in blood temperature
and analyzed temperature. Watch out for oxygen (PaO2). In cold, uncorrected
blood, PaO2 may appear higher than it actually is.
Information gathering : Burn Trauma/CO Poisoning [Show Less]