RRT CLIN SIMS EXAM QUESTIONS AND
ASWERS
Decision Making: Sleep apnea (Central or Obstructive) - 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 - ANSWER-- Abnormal constriction of the bronchioles
resulting in sputum production and narrowed
airways.
- Presents with accessory muscle use, tachycardia, dyspnea, wheezing, congested
cough, and/or clammy skin (diaphoresis)
- ABGs: possible respiratory acidosis, could be hypoxic
- CXR: hyperinflation, scattered infiltrates, flattened diaphragms.
- In allergic cases, may see elevated eosinophil count which can cause yellow sputum
- PFT: ↓ flows in FEV1 but diffusion is nx as manifested by DLCO
Decision Making: Asthma - ANSWER-- Tx: Oxygen therapy for hypoxemia, aerosolized
bronchodilator therapy, continuous bronchodilator therapy, albuterol (7-10 mg/hr),
xanthine medication given IV (Aminophylline, etc), promote pulmonary hygiene, and
sterioids such as oral or IV prednisone
Information Gathering: Status Asthmaticus - ANSWER-- Asthma that doesn't respond to
bronchodilation therapy, usually persists more than 24 hours
- Pt will report the need to take many bronchodilator treatments before feeling better.
accessory muscle use, retractions, dyspnea, wheezing, congested cough, and
diaphoresis. Pulsus paradoxus may be present
- ABGs: Respiratory alkalosis leading to respiratory acidosis when tiring, hypoxemia
- CXR: hyperinflation, scattered infiltrates, flattened diaphragms.
Decision Making: Status Asthmaticus - 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 3 consecutive doses (if no improvement between doses)
- Continuous beta II agonist (bronchodilator medication). Albuterol 7-10 mg/hr.
Information Gathering: Myasthenia Gravis - ANSWER-- Neuromuscular abnormality
where muscles
,experience paralysis starting from the head down to the feet including ventilatory
muscles
- Droopy facial muscles and eyelids (Ptosis), pt will describe slowly feeling weakness
generally but feels better with rest, double vision (diplopia), dysphagia (difficulty
swallowing), drooping eyelid (Ptosis), and shrinking Vt, VC, MIP
-Tensilon Challenge Test: positive if improvement is noted upon the administration of
Tensilon.
Decision Making: Myasthenia Gravis - 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 with Tensilon—only use to diagnose.
- 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 1.0L), then intubate and mechanically
ventilate.
Information Gathering: Drug Overdose - ANSWER-- Potential loss of ventilatory drive as
a
result of drugs (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 - ANSWER-**The most important part of this
simulation is the need for immediate intubation while recognizing that there may not be
a need to mechanically ventilated until ventilatory status deteriorates.
- Important priority is to protect the airway through intubation, prevent aspiration of
stomach
contents, and facilitate manual ventilation.
- For narcotics reverse using medication such a Narcan (Nalaxon)
- Support ventilation until drugs are out of system.
Pneumonia: - ANSWER-- Collection and/or consolidation of sputum as a result of a
bacterial or viral agent entering the lung on inhalation.
- Presents with fever, dyspnea, chills, cyanosis, rhonchi and rales
- CXR: scattered infiltrates
- CBC: Increased WBC if bacterial, decrease WBC if viral
- Interventions: O2 therapy first, suctioning and other bronchial hygiene efforts.
- Antibiotics: Penicillin for gram positive organisms, Gentamycin, or other 'mycin
antibiotics for gram negative organisms.
,Information gathering: Emphysema - ANSWER-- Abnormal condition of the alveoli
resulting destruction and loss of elasticity.
- Can present with cyanosis, barrel chest, accessory muscle use, digital clubbing,
dyspnea, and wheezing breath sounds
- Due to significant hx of smoking and/or occupational exposure to smoke or asbestos,
other pulm. irritant
- CXR: ↑ A-P diameter, 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.
- PFT: flows are ↓ especially middle sized airways (FEF 25-75%) Fev1 & Fev1/FVC%,
reduced DLCO (less than 20).
Descision Making: Empysema - ANSWER-- Tx: 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. Bronchodilators medication via MDI or aerosol nebulizers,
antibiotics for infection, smoking cessation products (nicotine replacement therapy).
- Home care education on devices and equipment cleaning
- Rehabilitation efforts (specifics not usually required)
Information Gathering: Chronic Bronchitis - ANSWER-- Condition where the patient has
a productive cough 25% of the year for at least two consecutive years.
- Presents with productive cough, purulent sputum production, dyspnea, and frequent
infections
- Due to exposure to pulmonary irritants and like hx of smoking
- CXR: may show hyperlucency, diminished pulmonary markings.
- CBC: possibly ↑ WBC due to possible infection.
- ABGs: very slight respiratory acidosis and hypoxemia
- PFT: flows are ↓ especially middle sized airways (FEF 25-75%) FEV1, Normal DLCO
Decision Making: Chronic Bronchitis - ANSWER-- Tx: 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
Decision Making: Bronchiectasis - ANSWER-- Anything that promotes good pulmonary
hygiene such as CPT, 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: Bronchiectasis - ANSWER-- Abnormal condition where the
bronchi
secrete large volumes of pus during abnormal
dilation
- Presents with productive cough, often with blood, digital clubbing of the nail beds,
significant hx of infections (recurrent), and dyspnea
- CXR: generally normal. Used in dx: Air bronchogram. Characterized by a "winter tree
pattern".
- Sputum culture: gram negative bacteria
Information Gathering: Sleep apnea (Central or Obstructive) - ANSWER-- Cessation of
breathing during sleep.
Is usually obstructive in nature but sometimes can be central or a combination of the
two (mixed)
- Characterized by excessive daytime sleepiness, dyspnea, frequent urination during
sleeping hours, morning headaches, spouse or bed partner may complain of snoring
and will often report witnessing periods of apnea that exceed 10 seconds.
- Causes include excessive upper airway tissue, obesity, thick neck (> 16 inch
circumference).
-ABGs: very slight respiratory acidosis and hypoxemia
-Dx by polysomnography to determine if obstructive (no air flow WITH effort) or central (
no air flow AND no effort)
Information Gathering: Other Neuromuscular disorder - ANSWER-Include: Poliomyelitis,
Tetanus, Muscular dystrophy, and even botulism poisoning
LEVEL I : History of illness
LEVEL II : Shrinking Vt, VC, MIP
Decision Making: Other Neuromuscular disorder - ANSWER-- Tx: 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 - ANSWER-LEVEL I : Sometimes trauma is visible
with blood contusions on the head, hx 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
LEVEL III: 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
ASWERS
Decision Making: Sleep apnea (Central or Obstructive) - 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 - ANSWER-- Abnormal constriction of the bronchioles
resulting in sputum production and narrowed
airways.
- Presents with accessory muscle use, tachycardia, dyspnea, wheezing, congested
cough, and/or clammy skin (diaphoresis)
- ABGs: possible respiratory acidosis, could be hypoxic
- CXR: hyperinflation, scattered infiltrates, flattened diaphragms.
- In allergic cases, may see elevated eosinophil count which can cause yellow sputum
- PFT: ↓ flows in FEV1 but diffusion is nx as manifested by DLCO
Decision Making: Asthma - ANSWER-- Tx: Oxygen therapy for hypoxemia, aerosolized
bronchodilator therapy, continuous bronchodilator therapy, albuterol (7-10 mg/hr),
xanthine medication given IV (Aminophylline, etc), promote pulmonary hygiene, and
sterioids such as oral or IV prednisone
Information Gathering: Status Asthmaticus - ANSWER-- Asthma that doesn't respond to
bronchodilation therapy, usually persists more than 24 hours
- Pt will report the need to take many bronchodilator treatments before feeling better.
accessory muscle use, retractions, dyspnea, wheezing, congested cough, and
diaphoresis. Pulsus paradoxus may be present
- ABGs: Respiratory alkalosis leading to respiratory acidosis when tiring, hypoxemia
- CXR: hyperinflation, scattered infiltrates, flattened diaphragms.
Decision Making: Status Asthmaticus - 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 3 consecutive doses (if no improvement between doses)
- Continuous beta II agonist (bronchodilator medication). Albuterol 7-10 mg/hr.
Information Gathering: Myasthenia Gravis - ANSWER-- Neuromuscular abnormality
where muscles
,experience paralysis starting from the head down to the feet including ventilatory
muscles
- Droopy facial muscles and eyelids (Ptosis), pt will describe slowly feeling weakness
generally but feels better with rest, double vision (diplopia), dysphagia (difficulty
swallowing), drooping eyelid (Ptosis), and shrinking Vt, VC, MIP
-Tensilon Challenge Test: positive if improvement is noted upon the administration of
Tensilon.
Decision Making: Myasthenia Gravis - 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 with Tensilon—only use to diagnose.
- 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 1.0L), then intubate and mechanically
ventilate.
Information Gathering: Drug Overdose - ANSWER-- Potential loss of ventilatory drive as
a
result of drugs (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 - ANSWER-**The most important part of this
simulation is the need for immediate intubation while recognizing that there may not be
a need to mechanically ventilated until ventilatory status deteriorates.
- Important priority is to protect the airway through intubation, prevent aspiration of
stomach
contents, and facilitate manual ventilation.
- For narcotics reverse using medication such a Narcan (Nalaxon)
- Support ventilation until drugs are out of system.
Pneumonia: - ANSWER-- Collection and/or consolidation of sputum as a result of a
bacterial or viral agent entering the lung on inhalation.
- Presents with fever, dyspnea, chills, cyanosis, rhonchi and rales
- CXR: scattered infiltrates
- CBC: Increased WBC if bacterial, decrease WBC if viral
- Interventions: O2 therapy first, suctioning and other bronchial hygiene efforts.
- Antibiotics: Penicillin for gram positive organisms, Gentamycin, or other 'mycin
antibiotics for gram negative organisms.
,Information gathering: Emphysema - ANSWER-- Abnormal condition of the alveoli
resulting destruction and loss of elasticity.
- Can present with cyanosis, barrel chest, accessory muscle use, digital clubbing,
dyspnea, and wheezing breath sounds
- Due to significant hx of smoking and/or occupational exposure to smoke or asbestos,
other pulm. irritant
- CXR: ↑ A-P diameter, 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.
- PFT: flows are ↓ especially middle sized airways (FEF 25-75%) Fev1 & Fev1/FVC%,
reduced DLCO (less than 20).
Descision Making: Empysema - ANSWER-- Tx: 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. Bronchodilators medication via MDI or aerosol nebulizers,
antibiotics for infection, smoking cessation products (nicotine replacement therapy).
- Home care education on devices and equipment cleaning
- Rehabilitation efforts (specifics not usually required)
Information Gathering: Chronic Bronchitis - ANSWER-- Condition where the patient has
a productive cough 25% of the year for at least two consecutive years.
- Presents with productive cough, purulent sputum production, dyspnea, and frequent
infections
- Due to exposure to pulmonary irritants and like hx of smoking
- CXR: may show hyperlucency, diminished pulmonary markings.
- CBC: possibly ↑ WBC due to possible infection.
- ABGs: very slight respiratory acidosis and hypoxemia
- PFT: flows are ↓ especially middle sized airways (FEF 25-75%) FEV1, Normal DLCO
Decision Making: Chronic Bronchitis - ANSWER-- Tx: 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
Decision Making: Bronchiectasis - ANSWER-- Anything that promotes good pulmonary
hygiene such as CPT, 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: Bronchiectasis - ANSWER-- Abnormal condition where the
bronchi
secrete large volumes of pus during abnormal
dilation
- Presents with productive cough, often with blood, digital clubbing of the nail beds,
significant hx of infections (recurrent), and dyspnea
- CXR: generally normal. Used in dx: Air bronchogram. Characterized by a "winter tree
pattern".
- Sputum culture: gram negative bacteria
Information Gathering: Sleep apnea (Central or Obstructive) - ANSWER-- Cessation of
breathing during sleep.
Is usually obstructive in nature but sometimes can be central or a combination of the
two (mixed)
- Characterized by excessive daytime sleepiness, dyspnea, frequent urination during
sleeping hours, morning headaches, spouse or bed partner may complain of snoring
and will often report witnessing periods of apnea that exceed 10 seconds.
- Causes include excessive upper airway tissue, obesity, thick neck (> 16 inch
circumference).
-ABGs: very slight respiratory acidosis and hypoxemia
-Dx by polysomnography to determine if obstructive (no air flow WITH effort) or central (
no air flow AND no effort)
Information Gathering: Other Neuromuscular disorder - ANSWER-Include: Poliomyelitis,
Tetanus, Muscular dystrophy, and even botulism poisoning
LEVEL I : History of illness
LEVEL II : Shrinking Vt, VC, MIP
Decision Making: Other Neuromuscular disorder - ANSWER-- Tx: 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 - ANSWER-LEVEL I : Sometimes trauma is visible
with blood contusions on the head, hx 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
LEVEL III: 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
