Interactive Case Studies In
Respiratory Care
Doug Pursley, M.Ed., RRT
Program Director
Ozarks Technical Community College
Springfield, MO
Case 1
• A 74 year old female with COPD is admitted to
the ED with mild chest pain. She is on her
portable liquid system at 3 l/m.
• B/S, CXR clear, pt. is alert and oriented
• ABGs: pH 7.32, PaCO2 84, HCO2 42, BE +15,
PaO2 68
• The physician sees the initial ABG and wants
to place the patient on BiPAP.
• The RCP disagreed and convinced the physician
that BiPAP is not indicated at this time since the
patient is not in respiratory distress and has
“classic” chronic hypercarbia.
• She is moved to a regular room from triage to
await labs and speak with the physician
• 30 minutes later the physician pops his head in
the door and finds the patient lethargic and on
10 l/m per nasal cannula.
• ABG at this time is: pH 7.20, PaCO2 110, HCO3
41, BE +13, PaO2 117
• Now she is BiPAPed 10/5 and 40%
• Next ABG shows: 7.22, PaCO2 103, HCO3 41, BE
+13, PaO2 64
• The patient’s BiPAP settings are changed to 15/5
and she is transferred to the MICU.
• She is removed from BiPAP a few hours later and
had the following ABG on 3 l/m: pH 7.30, PaCO2
87, HCO3 41, BE +14, PaO2 61
• Obviously a case of oxygen-induced hypercarbia
Case 2
• A 53 year old female with diabetes and COPD
is admitted to the ED.
• She walks in under her own power and has
the following ABG drawn 10 minutes later:
pH 6.65, PaCO2 76, HCO3 8, BD -25
• Glucose 620, increased WBCs
• She is placed on BiPAP 20/15, 100% for a few
minutes and then intubated
• She develops asystole as she is being
intubated and is resuscitated unsuccessfully
for 45 minutes.
Case 3
• The patient is a 34 year old male that has just
been brought to the ETC after a narcotic
overdose. He is currently being mechanically
ventilated. What is your recommendation
after seeing his CXR?
Case 4
• 450 lb. 45 year male is brought to a local ETC
(PB 730 mmHg) in acute respiratory distress.
Someone places him on a nasal cannula but
they forget to turn the O2 on. He is also
placed on a pulse oximeter and ABG’s are
drawn.
• Good pleth waveforms are seen on the pulse
oximeter which measured 81% at the time the
ABG was drawn. Ten minutes later, you arrive,
turn the oxygen on, and titrate the O2
achieving an SpO2 of 94%.
• The patient’s vital signs improve and he says
he is less short of breath.
ABGs on room air were:
FI02
pH
PaC02
HCO3
Base
Pa02
Sp02
.21
7.33
64
32.6
+7
84
81% (at time of blood draw)
What is your recommendation
after seeing the ABG?
Case 5
• K.B. is a 55 kg., 72 year old documented CO2
retainer with end-stage COPD who also has a
history of severe air trapping and dynamic
flow limitation.
• Admitted the previous day for exacerbation of
his COPD.
• Intubated and placed on a ventilator after
failing NIV.
• Current ventilator settings are: PRVC, 500 X
16 (total f 16), Set PEEP 5, and FIO2 0.35
• Total PEEP is measured at 10 cmH2O
•
•
•
•
•
•
•
•
ABG’s on those settings are:
pH 7.50
PaCO2 40 mmHg
HCO3 30.1
BE +6
PaO2 65
SaO2 94%
Hb 18 g%
What is your recommendation?
Case 6
• An 8 year old boy is brought to the ETC after
being hit by a car while walking across a
Walmart parking lot.
• He was intubated prior to arrival and is
currently being manually ventilated.
• A chest x-ray is taken with the boy in the
supine position.
The CXR shows an
ETT just inside the
RMS and fractures
of the 4th and 5th
posterior ribs on the
right. What other
major finding is
seen on the CXR?
What is the major finding?
1.
2.
3.
4.
Left pleural effusion
Right pneumothorax
Left pneumonia
Pulmonary edema
His ABG’s are: pH 7.19, PaCO2 60,
HCO3 22. Interpretation?
Case 7
• You are taking care of a post-op
cholecystectomy patient on a 40% ventimask.
The recommended flow stamped on the
device is 6 l/m, which is what the device is set
for.
• On further examination, you notice that the
patient’s work of breathing seems to be slightly
increased and that her SpO2 is 88%
• You then perform a quick calculation and
determine that the total flow exiting a 40%
ventimask running @ 6 l/m is 24 l/m (3:1 ratio)
and remember your old instructor in school
saying that a normal, resting inspiratory flowrate
for an adult is about 25-35 l/m.
• What is the most appropriate action to take at
this time?
Most appropriate action?
1. Take her off the venti
and place her on a 6 l/m
cannula
2. Increase the FIO2 on the
ventimask to 50%
3. Increase the flow on the
40% ventimask
4. Do nothing. The
stamped flow says 6
therefore it has to be
set on 6.
Case 8
• A nurse hears cries of help from a 64 year old
female COPD, lung cancer patient. She is on
oxygen.
• When she gets to the patient’s room, she finds
the O2 tubing, pillow, and patient’s hair on fire.
• She quickly extinguishes the fire but the patient
suffered burns to the face, neck, right shoulder,
and upper back while trying to light a cigarette.
• The patient is then transferred to the Burn Unit.
• According to data from the Consumer Product
Safety Commission, approximately how many
medical oxygen related thermal burns were
seen in US emergency rooms in the four years
from Jan 1,2003 to Dec 31, 2006?
FIRES AND BURNS INVOLVING HOME MEDICAL OXYGEN
Marty Ahrens
Fire Analysis and Research Division
National Fire Protection Association
August 2008
How many O2 induced thermal burns do
you think were reported in the US from
Jan 1, 2003-Dec 31, 2006?
1.
2.
3.
4.
1,000
5,000
25,000
100,000
Case 9
• A 76 year-old, 58 kg IBW, male is admitted
with extreme hypothermia
Vitals on admission
•
•
•
•
•
Temperature 30 C
Pulse 74
f 41 and shallow
Crackles
Atrial fibrillation
76 year-old, 58 kg IBW
• In the ER he is placed on a ventilator with the
following settings: PC, pressure 23 cmH20, f
12, PEEP 8, FIO2 0.35, exhaled tidal volume
570 ml.
• ABG’s reported at 37 C are:
• pH 7.40
• PaCO2 40
• PaO2 80
• Because he was hypothermic when the blood gas
was drawn, the physician requested that the lab
correct the ABG to 30 C.
• The corrected ABG is:
• pH 7.50
• PaCO2 30
• PaO2 54
• The ER doc asks for your opinion on what
ventilator changes to make.
• What is your recommendation at this time?
What is your recommendation?
1. Decrease rate from 12 to 8
2. Increase FIO2 from 0.35 to
0.60
3. Increase PEEP from 8 to 15
4. Do all three
5. Make no changes at this time
37 C 30 C
pH
PaCO2
PaO2
7.40
40
80
7.50
30
54
Case 10
• A 64 year old male
presents to the ED with
extreme shortness of
breath. A CXR is
obtained.
What immediate treatment is
indicated?
1.
2.
3.
4.
5.
IPV
Bilalateral chest tubes
Bronchoscopy
Albuterol and CPT Q2
CPAP and 40 mg of Lasix
Case 11
• A 37 year old male presents with bronchial
breath sounds and crackles in the left lower
lobe, E to A egophony on the left, increased
tactile fremitus on the left, dull percussion
note on the left, and decreased chest
expansion on the left.
What do the findings suggest?
1.
2.
3.
4.
5.
Pneumothorax
Pneumonia
Pleural effusion
Bronchitis
Asthma
Case 12
• A 40 kg., 32 year old female MVA is being
ventilated and has a 6.0 ETT in place.
• She is currently being suctioned with a 14 F
catheter.
• You and a co-worker get into a discussion
about the proper size of catheter to use on a
6.0 ETT
What is the ideal suction catheter size
for a 6.0 ETT?
•
•
•
•
1. 10 F
2. 12 F
3. 14 F
4. Doesn’t matter
Case 13
• Just as you are about to go home for the day,
you notice a group of people in the ED
gathered around the lateral neck x-ray of a 13
year old male just admitted for extreme
shortness of breath.
The lateral neck x-ray shows:
1. Epiglottitis
2. Croup
3. Foreign body
obstruction
4. Retropharyngeal
abscess
5. Cervical fracture