RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Emphysema Weakening and permanent enlargement of the air spaces distal to the terminal
bronchioles
Etiology of Emphysema Cigarette smoking >80% of all cases
Genetic predisposition
Occupational exposure
Atmospheric pollutants
Primary Assessment of Emphysema Past medical history
Shortness of breath
Cough
Appearance of the chest
Respiratory Pattern
Color
Appearance of the nail beds
Diagnostic chest percussion
Breath sounds
Secondary Assessment of Emphysema CXR
Arterial Blood Gas
Pulmonary Function
CBC
Sputum
Appearance of CXR in patient with Emphysema Hyperlucent lung fields
Depressed or flattened diaphragm
Narrow heart
Increased retro sternal air space (lateral film)
Arterial Blood Gas findings in patient with Emphysema Mild to moderate Emphysema
Acute alveolar hyperventilation with hypoxemia
Severe Emphysema
Chronic ventilatory failure with hypoxemia
Pulmonary Function Findings in patient with Emphysema Decreased flow rates and Decreased DLco
CBC findings in a patient with Emphysema Increased RBC, Hb, HCT
Sputum findings in a patient with Emphysema May indicate bacterial infection
Treatment/Management of Emphysema Low Flow (FiO2) oxygen therapy 1-2 L/min (.24-.28)
Antibiotics as indicated by sputum culture
Pulmonary Rehab and Home Care
Aerosolized medications
Consider NPPV for acute exacerbation of ventilatory failure
Annual Flu injection
Smoking cessation
Pulmonary Hygiene
Chronic Bronchitis Daily productive cough for at least 3 consecutive month each year for 2 years in
a row
Etiology of Chronic Bronchitis Cigarette smoking
Pollution
Infection
GERD
, RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Primary Assessment of Chronic Bronchitis Past medical history
Shortness of Breath
Cough
Appearance of the Chest
Respiratory Pattern
Color
Appearance of Nail beds
Diagnostic Chest Percussion
Breath Sounds
Secondary Assessment of Chronic Bronchitis CXR
Arterial Blood Gas
Pulmonary Function
CBC
Sputum Electrolytes
CXR findings in a patient with Chronic Bronchitis Hyper lucent lung fields
Depressed or flattened diaphragm
Enlarged or elongated heart
Arterial Blood gas in a patient with mild to moderate Acute alveolar hyperventilation with hypoxemia
Chronic Bronchitis
ABG in a patient with severe Chronic Bronchitis Chronic ventilatory failure with hypoxemia
Pulmonary Function test in a patient with Chronic Decreased flow rates
Bronchitis
CBC in a patient with Chronic Bronchitis Increased Hb and HCT
Sputum findings in a patient with Chronic Bronchitis May indicate infection
Electrolyte findings in a patient with Chronic Bronchitis Increased HCO3 (chronic ventilatory failure)
Treatment and Management of a patient with Chronic Pulmonary Hygiene therapy
Bronchitis Antibiotics for infection
Oxygen for hypoxemia
Aerosolized mediations
Consider NPPV for acute exacerbations
Smoking cessation
Reduce risk factors
What aerosolized medications should be considered for Short acting Beta 2 agonists
Chronic Bronchitis Anticholinergics
Long acting Beta 2 agonists
Inhaled corticosteroids
Bronchiectasis Chronic dilation and distortion of one or more bronchi as a result of excessive
inflammation and destruction of bronchial walls, blood vessels, elastic tissue and
smooth muscle. Can create an obstructive or restrictive pattern
Etiology of Bronchiectasis Not always clear
Can be either acquired or congenital
, RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Primary assessment of Bronchiectasis Past medical history
Shortness of breath
Cough- productive with purulent foul smelling sputum, hemoptysis and 3 layer
sputum
Appearance of chest
Respiratory pattern
Color
Appearance of nail beds
Diagnostic chest percussion
Breath sounds
Secondary Assessment of Bronchiectasis CXR
ABG
Pulmonary Function
CBC
Sputum
Special Diagnostic tests
CXR findings in Bronchiectasis Hyperlucent lung fields
Depressed or flattened diaphragm
Enlarged or elongated heart
ABG of mild to moderate Bronchiectasis Acute alveolar hyperventilation with hypoxemia
ABG of severe Bronchiectasis Chronic ventilatory failure with hypoxemia
Pulmonary findings in Bronchiectasis Decreased flow rate
CBC findings in Bronchiectasis Increase RBC, Hb, HCT
Sputum findings in Bronchiectasis May indicate infection
Special Diagnostic findings in Bronchiectasis CT scan or bronchogram indicates a tree in winter pattern
Treatment and management of Bronchiectasis Pulmonary hygiene
Antibiotics for infection
Aerosolized medications
Surgical resection of involved segments if necessary
Oxygen for hypoxemia
What aerosolized medications can be used for Short acting Beta 2 agonists
Bronchiectasis Anticholinergics
Inhaled corticosteroids
Sleep Apnea Cessation of breathing for a period of 10 seconds or longer. Sleep apnea is
diagnosed in patins who have more that 5 episodes of apnea per hour during
sleep over a 6 hour peroid
Central Sleep Apnea Caused by failure of the respiratory center of the brain to send signals to the
respiratory muscles
Obstructive Sleep Apnea Caused by anatomic obstruction of the upper airway in the presence of continued
ventilatory effort
, RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Mixed Sleep Apnea Combination of both central and obstructive. Usually begins as central apnea
followed by onset of ventilatory effort without airflow
Primary Assessment of Sleep Apnea Past medical history- daytime sleepiness, insomnia at night, loud snoring with
periods of apnea, morning headaches, hypothyroidism
Physical Appearance- Obese, short stocky neck, large tongue
Secondary Assessment of Sleep Apnea CXR
ABG
Pulmonary Function
Special Tests
CXR of Sleep Apnea May be normal or demonstrate right and/or left sided heart failure
ABG of Sleep Apnea Chronic ventilatory failure with hypoxemia (severe sleep apnea)
Pulmonary Function of Sleep Apnea Decreased volumes
With obstructive sleep apnea a saw tooth pattern is seen on maximal inspiratory
and expiratory flow volume loops
Special tests for Sleep Apnea Sleep study (polysomnography)
If both flow and respiratory effort decrease then desaturation is caused by
Central Apnea
If nasal flow decrease with an increase in respiratory effort then desaturation is
caused by obstructive sleep apnea
Treatment and management of Central Sleep Apnea Drug therapy
Phrenic nerve pacer
Nocturnal ventilation
What drugs are used to manage Central Sleep Apnea REM inhibitors (Vivactil)
Carbonic anhydrase inhibitors (Diamox)
Respiratory Stimulants (Aminophylline, caffeine)
Treatment and management of Obstructive Sleep Apnea Weight loss
Sleep posture (lateral or upright)
Oxygen therapy for hypoxemia
NIPPV
Nasal CPAP
BiPAP
Oral surgery
Tracheostomy
Oral appliances
Neck Collar
Asthma A chronic, inflammatory, obstructive, non contagious airway disease with varying
levels of severity and characterized by exacerbation's. A reversible condition
characterized by increased responsiveness of the small airways to stimuli
Etiology of Asthma External or environmental agents
Infections
Exercise
Cold air exposure
Chemical exposure
GERD
Sleep
Emotional stress
PMS
Emphysema Weakening and permanent enlargement of the air spaces distal to the terminal
bronchioles
Etiology of Emphysema Cigarette smoking >80% of all cases
Genetic predisposition
Occupational exposure
Atmospheric pollutants
Primary Assessment of Emphysema Past medical history
Shortness of breath
Cough
Appearance of the chest
Respiratory Pattern
Color
Appearance of the nail beds
Diagnostic chest percussion
Breath sounds
Secondary Assessment of Emphysema CXR
Arterial Blood Gas
Pulmonary Function
CBC
Sputum
Appearance of CXR in patient with Emphysema Hyperlucent lung fields
Depressed or flattened diaphragm
Narrow heart
Increased retro sternal air space (lateral film)
Arterial Blood Gas findings in patient with Emphysema Mild to moderate Emphysema
Acute alveolar hyperventilation with hypoxemia
Severe Emphysema
Chronic ventilatory failure with hypoxemia
Pulmonary Function Findings in patient with Emphysema Decreased flow rates and Decreased DLco
CBC findings in a patient with Emphysema Increased RBC, Hb, HCT
Sputum findings in a patient with Emphysema May indicate bacterial infection
Treatment/Management of Emphysema Low Flow (FiO2) oxygen therapy 1-2 L/min (.24-.28)
Antibiotics as indicated by sputum culture
Pulmonary Rehab and Home Care
Aerosolized medications
Consider NPPV for acute exacerbation of ventilatory failure
Annual Flu injection
Smoking cessation
Pulmonary Hygiene
Chronic Bronchitis Daily productive cough for at least 3 consecutive month each year for 2 years in
a row
Etiology of Chronic Bronchitis Cigarette smoking
Pollution
Infection
GERD
, RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Primary Assessment of Chronic Bronchitis Past medical history
Shortness of Breath
Cough
Appearance of the Chest
Respiratory Pattern
Color
Appearance of Nail beds
Diagnostic Chest Percussion
Breath Sounds
Secondary Assessment of Chronic Bronchitis CXR
Arterial Blood Gas
Pulmonary Function
CBC
Sputum Electrolytes
CXR findings in a patient with Chronic Bronchitis Hyper lucent lung fields
Depressed or flattened diaphragm
Enlarged or elongated heart
Arterial Blood gas in a patient with mild to moderate Acute alveolar hyperventilation with hypoxemia
Chronic Bronchitis
ABG in a patient with severe Chronic Bronchitis Chronic ventilatory failure with hypoxemia
Pulmonary Function test in a patient with Chronic Decreased flow rates
Bronchitis
CBC in a patient with Chronic Bronchitis Increased Hb and HCT
Sputum findings in a patient with Chronic Bronchitis May indicate infection
Electrolyte findings in a patient with Chronic Bronchitis Increased HCO3 (chronic ventilatory failure)
Treatment and Management of a patient with Chronic Pulmonary Hygiene therapy
Bronchitis Antibiotics for infection
Oxygen for hypoxemia
Aerosolized mediations
Consider NPPV for acute exacerbations
Smoking cessation
Reduce risk factors
What aerosolized medications should be considered for Short acting Beta 2 agonists
Chronic Bronchitis Anticholinergics
Long acting Beta 2 agonists
Inhaled corticosteroids
Bronchiectasis Chronic dilation and distortion of one or more bronchi as a result of excessive
inflammation and destruction of bronchial walls, blood vessels, elastic tissue and
smooth muscle. Can create an obstructive or restrictive pattern
Etiology of Bronchiectasis Not always clear
Can be either acquired or congenital
, RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Primary assessment of Bronchiectasis Past medical history
Shortness of breath
Cough- productive with purulent foul smelling sputum, hemoptysis and 3 layer
sputum
Appearance of chest
Respiratory pattern
Color
Appearance of nail beds
Diagnostic chest percussion
Breath sounds
Secondary Assessment of Bronchiectasis CXR
ABG
Pulmonary Function
CBC
Sputum
Special Diagnostic tests
CXR findings in Bronchiectasis Hyperlucent lung fields
Depressed or flattened diaphragm
Enlarged or elongated heart
ABG of mild to moderate Bronchiectasis Acute alveolar hyperventilation with hypoxemia
ABG of severe Bronchiectasis Chronic ventilatory failure with hypoxemia
Pulmonary findings in Bronchiectasis Decreased flow rate
CBC findings in Bronchiectasis Increase RBC, Hb, HCT
Sputum findings in Bronchiectasis May indicate infection
Special Diagnostic findings in Bronchiectasis CT scan or bronchogram indicates a tree in winter pattern
Treatment and management of Bronchiectasis Pulmonary hygiene
Antibiotics for infection
Aerosolized medications
Surgical resection of involved segments if necessary
Oxygen for hypoxemia
What aerosolized medications can be used for Short acting Beta 2 agonists
Bronchiectasis Anticholinergics
Inhaled corticosteroids
Sleep Apnea Cessation of breathing for a period of 10 seconds or longer. Sleep apnea is
diagnosed in patins who have more that 5 episodes of apnea per hour during
sleep over a 6 hour peroid
Central Sleep Apnea Caused by failure of the respiratory center of the brain to send signals to the
respiratory muscles
Obstructive Sleep Apnea Caused by anatomic obstruction of the upper airway in the presence of continued
ventilatory effort
, RRT Clinical Simulations (CSE) - NBRC Practice Scenarios
Mixed Sleep Apnea Combination of both central and obstructive. Usually begins as central apnea
followed by onset of ventilatory effort without airflow
Primary Assessment of Sleep Apnea Past medical history- daytime sleepiness, insomnia at night, loud snoring with
periods of apnea, morning headaches, hypothyroidism
Physical Appearance- Obese, short stocky neck, large tongue
Secondary Assessment of Sleep Apnea CXR
ABG
Pulmonary Function
Special Tests
CXR of Sleep Apnea May be normal or demonstrate right and/or left sided heart failure
ABG of Sleep Apnea Chronic ventilatory failure with hypoxemia (severe sleep apnea)
Pulmonary Function of Sleep Apnea Decreased volumes
With obstructive sleep apnea a saw tooth pattern is seen on maximal inspiratory
and expiratory flow volume loops
Special tests for Sleep Apnea Sleep study (polysomnography)
If both flow and respiratory effort decrease then desaturation is caused by
Central Apnea
If nasal flow decrease with an increase in respiratory effort then desaturation is
caused by obstructive sleep apnea
Treatment and management of Central Sleep Apnea Drug therapy
Phrenic nerve pacer
Nocturnal ventilation
What drugs are used to manage Central Sleep Apnea REM inhibitors (Vivactil)
Carbonic anhydrase inhibitors (Diamox)
Respiratory Stimulants (Aminophylline, caffeine)
Treatment and management of Obstructive Sleep Apnea Weight loss
Sleep posture (lateral or upright)
Oxygen therapy for hypoxemia
NIPPV
Nasal CPAP
BiPAP
Oral surgery
Tracheostomy
Oral appliances
Neck Collar
Asthma A chronic, inflammatory, obstructive, non contagious airway disease with varying
levels of severity and characterized by exacerbation's. A reversible condition
characterized by increased responsiveness of the small airways to stimuli
Etiology of Asthma External or environmental agents
Infections
Exercise
Cold air exposure
Chemical exposure
GERD
Sleep
Emotional stress
PMS
