Case studies in A & P Unit 3 : Airways KEY
Name:
roster #
Date:
2005
Case study # 1
Your patient is a 25 year-old WF who presents with respiratory distress. Her HR is 110
bpm, her respiratory rate is 25 bpm. Her BP is 120/65. Her temperature is 102.5 degrees
On auscultation, you hear diminished breath sounds in the basal areas and crackles in
the RML, RUL, and LUL. Her X-ray shows consolidation in all lung fields. Her Sp02 is 88%
on Room air. She has no prior medical history
1.
How do you want to assess this patient?
a. get Sp02 or ABG to assess level of hypoxemia
b. assess her sputum for possible need for CPT
2.
What do you want to do for her first?
a. because she is tachypnic I would start her on 1-2 lpm nasal cannula
b. start her on SVN with SMI to deliver mucolytics
c. based on the breath sounds she may or may not benefit from CPT
d. if she cannot move 10 ml Kg IBW consider IPPB or ezPAP
3.
What do you think is wrong with her?
a. the fever ,X-ray and the breath sounds imply there is a pneumonia
b. she has consolidation and possibly atelectasis in the basal lobes
4.
What portion of her airway is affected in this disorder?
breathsounds imply a lower airway disorder that involves respiratory zone. This is an
alveolar problem
5.
Why is there a difference between the upper lobes and the lower lobes?
If this is a lobar pneumonia then different parts of the lungs are involved, but also the
basal alveoli tend to collapse more quickly than the upper and middle portions of the
airway so it is not surprising that the basal breath sounds are diminished
6.
Do you think she has increased Raw?
No. The breath sounds and the X-ray both imply this is strictly alveolar disorder, so no
airway involvement, but as secretions move up from the respiratory zone, we might start
getting rhonchi and then we would have an airway issue
7.
Do you think she has decreased compliance?
Yes, she would certainly have a restrictive lung disorder that would decrease her lung
volumes and decrease her lung compliance. Her lungs would be stiff
Case study # 2
Your patient is an 85 year-old LAM who presents with respiratory distress. His HR is 130
bpm; his respiratory rate is 28 bpm. His BP is 110/55. His skin is cool and edematous.
On auscultation, you hear diminished breath sounds in the basal areas and crackles in
the RML RUL, and LUL. His X-ray shows consolidation in all lung fields, an enlarged
heart and prominent hilar densities. His Sp02 is 84% on Room air. He has a history of
[MI] myocardial infarction and he currently has an EKG with frequent arrhythmias. His
pulse is thready and irregular.
1.
How do you want to assess this patient?
a. get an ABG to assess the pH and the carbon dioxide levels
b. assess his mental status; is he confused, alert?
c. Get a better history
d. Check his urine output, is he peeing off the fluid
2.
What do you want to do for him first?
a.
Start him on 3 lpm nasal cannula to raise the Sp02 to above 90% , but expect
to have to raise the Fi02, He may be in refractory hypoxemia
b. Get Cardiology involved: he needs cardiac drugs and possibly diuretics to get rid
of excessive water
c. Consider intubation and mechanical ventilation if patient is in respiratory
acidosis or has refractory hypoxemia
d. Consider BiPap if patient C02 is ok but he is in refractory hypoxemia
3.
What do you think is wrong with her?
With the history of MI there is a chance that he has gone into heart failure that has
caused his blood to backup into the pulmonary capillary bed..congestive heart failure
4.
What portion of her airway is affected in this disorder?
Based on the x-rays & the breath sounds, this is alveolar or interstitial or both
5.
Why is there a difference between the upper lobes and the lower lobes?
Because there is more blood flow in the dependent portions of the lung, the water will
collect there first.
6.
Do you think she has increased Raw?
Problem is alveolar and interstitial so most likely not, but if the patient started to
wheeze, he is most likely getting some compression on the airways from outside the airway
7.
Do you think she has decreased compliance?
Yes, this will decrease the lung compliance because the alveoli are collapsing due to
increased water in the interstitial spaces and water may actually drip into the alveoli
Case study # 3
Your patient is a 46 year-old BM who presents with respiratory distress. His HR is 118
bpm; his respiratory rate is 28 bpm. His BP is 120/74. He has no fever. On auscultation,
you hear wheezing over the RML. He is coughing blood. His X-ray shows air trapping in
the RML but the rest of the lung fields look normal. His Sp02 is 89% on Room air. He has
a long history of smoking and works with asbestosis.
1.
How do you want to assess this patient?
a. get an ABG to assess his acid base balance—he may have chronic hypercapnia
b. get PEFR, but he needs to go to PFT lab for more detailed assessment of his
RAW
c. Get sputum for c/s [we need to r/o TB due to the bleeding]
2.
What do you want to do for him first?
a. start 1-2 lpm 02 to get his Sp02 to above 90%, watch raising his Pa02 too much
because he might have a hypoxic drive
b. give him inhaled beta II bronchodilators, cholinergic blockers, and later inhaled
steroids for wheezing, but if the localized wheeze over the RML doesn’t
disappear consider a tumor causing the airtrapping and the wheezing
3.
What do you think is wrong with him?
With his history of smoking and asbestosis use we have to r/o lung cancer. The localized
wheezing and airtrapping could reflect the presence of a tumor in the RML lobar
bronchus
He might have a FB in the airway, but with his age and history we will assume CA first
4.
What portion of his airway is affected in this disorder?
a. Central airway; specifically the RML
5.
Why is there a difference between the upper lobes and the lower lobes?
This is a localized problem
6.
Do you think he has increased RAW?
a. He may have increase RAW only in the RML
Do you think he has decreased compliance?
a. doubtful
Case study # 4
Your patient is a 2 year-old WM who presents with respiratory distress. His HR is 130
bpm; his respiratory rate is 35 bpm. His BP is 120/74. He has a fever, runny nose and
his cough is ‘barky.’ On auscultation, you hear inspiratory stridor. The toddler has supraclavicular retracting. His X-ray shows a ‘steeple sign’ [narrows at the top over the upper
portion of the trachea]. His Sp02 is 89% on Room air. He has no prior medical history.
1.
How do you want to assess this patient?
Get better history; not really bad enough to get ABG [this is a 2 year old]
2.
What do you want to do for him first?
a. Start him on 02 by croup tent; get his Sp02 to 95%
b. Start him on inhaled racemic epinephrine
3.
What do you think is wrong with him?
Based on his age and on his PE, he most likely has croup—laryngitis in the small child
4.
What portion of his airway is affected in this disorder?
Due to the inspiratory stridor, and the steeple sigh on the X-ray we know the larynx and
Subglottic structures are edematous
5.
Why is there a difference between the upper lobes and the lower lobes?
The problem is limited to the larynx
6.
Do you think he has increased Raw?
Yes, because the glottis is narrowed, but it could get worse if he gets bronchitis
7.
Do you think he has decreased compliance?
No, his problem is upper airway, but if he gets pneumonia that could change
Case study # 5
Your patient is an 18 year-old LAF who presents with respiratory distress. Her HR is 128
bpm; respiratory rate is 38 bpm and very labored. Her BP is 121/73. She was brought to
the hospital because of a train accident in which chlorine gas has escaped. Her eyes are
red and running. She has inspiratory stridor and on auscultation you hear wheezing,
rhonchi and crackles to all lobes. On X-ray you see diffuse interstitial infiltrates or
consolidation in all lobes. Her Sp02 is 83% on Fi02 100% Non-rebreather mask.
1.
How do you want to assess this patient?
a. get ABG to assess her acid/ base balance
b. assess her mental status; is she conscience? Can she protect her airway?
7.
2.
3.
4.
5.
What do you want to do for her first?
a. She is in refractory hypoxemia, get her on BiPap
b. consider intubation and mechanical ventilation if she is in respiratory acidosis
or if she has lost consciousness
c. Give her IPPB with Beta II bronchodilator, inhaled steroids and follow up with
IPPB with racemic epinephrine
What do you think is wrong with her?
a. The gas has caused swelling all up and down her airways
What portion of her airway is affected in this disorder?
a. Upper airways, larynx because of the stridor
b. Peripheral airways because of the wheezing
c. Alveolar because of the consolidation on Xray and the crackles
Why is there a difference between the upper lobes and the lower lobes?
a. Upper airways, larynx because of the stridor
b. Peripheral airways because of the wheezing
c. Alveolar because of the consolidation on Xray and the crackles
6.
Do you think she has increased Raw?
Yes, because of the wheezing and the stridor there is airway involvement
7.
Do you think she has decreased compliance?
Yes, because of the consolidation and the crackles we know there is alveolar involvement
Case study # 6
Your patient is a 48 year-old Asian F who presents with respiratory distress. Her HR is
118 bpm; respiratory rate is 36 bpm. Her BP is 110/64. Her chest excursion is shallow
and she cannot move her lower extremities. She cannot raise her head, nor turn it. On
auscultation you hear diminished breath sounds to all lobes. There is no wheezing. On Xray you see consolidation in the basal areas. Her Sp02 is 83% on room air.
1.
How do you want to assess this patient?
a. Get a better history; does she have a chronic neurological disorder or is this
acute [sudden?]
b. Get an ABG to assess her acid base balance—she might need to go onto
ventilator
c. Assess her ability to protect her airway; check her mental status
d. Assess her Vt and her IC; can she cough?
e. Make her NPO until we assess her ability to swallow effectively
2.
What do you want to do for her first?
a. Start her on 02, but consider intubation to protect her airways
b. Consider placing her on mechanical ventilation if she cannot move enough Vt
3.
What do you think is wrong with her?
She may have a neurological or neuromuscular disorder that interferes with her
ability to breathe, to cough and to maintain her airway
4.
What portion of her airway is affected in this disorder?
a. Upper airway if she has soft tissue obstruction
b. Upper airway if she cannot swallow
c. Central airways if she aspirates food or saliva
d. Lower airway if she cannot take a deep breath
5.
Why is there a difference between the upper lobes and the lower lobes?
a. She may be able to move gas into her central airways and into the upper lobes
but not into the lower lobes
6.
Do you think she has increased RAW?
Not now; but if she aspirates she could start to wheeze or have increased secretions
7.
Do you think she has decreased compliance?
yes, because her alveoli are collapsing and they are getting stiffer