Respiratory Therapy - Lindsey Jones/Clinical Simulations 100% correct answers already graded A+

Information Gathering - Emphysema: (Abnormal condition of the alveoli resulting destruction and loss of elasticity.) 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 culture—often 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). Descision Making - Empysema: (Abnormal condition of the alveoli resulting destruction and loss of elasticity.) 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.) 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.) 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.) 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.) 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). 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). 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. 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. 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.) 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.) 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.) 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.) 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). ) 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. 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.) 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. 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) 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. 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.) 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. 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). ) 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 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.) 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. 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.) 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. 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.) 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. 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.) 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. 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.) 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. 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 h