nbrc cse practice
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
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,(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). -
2|Page
, 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.
3|Page
, 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
4|Page
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
1|Page
,(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). -
2|Page
, 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.
3|Page
, 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
4|Page
