1. Unit 5 SVN case studies By Elizabeth Kelley Buzbee AAS, RRT-NPS RCP

2. Mrs. Mosby is a 45 year old who presents in the ER with c/o [complaints of ] SOB [shortness of breath]. She is wearing a pulse oximeter on her finger that says 99% How do you assess her? Mrs. Mosby is a 45 year old who presents in the ER with c/o [complaints of ] SOB [shortness of breath]. She is wearing a pulse oximeter on her finger that says 99% How do you assess her?

3. answer Collect VS [vital signs] to assess her dyspnea Collect VS [vital signs] to assess her dyspnea Interview her to discover her history of recent exposures or underlying lung disease Interview her to discover her history of recent exposures or underlying lung disease Observe her for retractions, and other signs of increased WOB Observe her for retractions, and other signs of increased WOB Listen to her breath sounds Listen to her breath sounds

4. Her HR is 120 bpm and her respiratory rate is 31 bpm. Her HR is 120 bpm and her respiratory rate is 31 bpm. She is a waitress who came into the ER after a kitchen fire. She has no history of lung disease and does not smoke. She is a waitress who came into the ER after a kitchen fire. She has no history of lung disease and does not smoke. She has nasal flaring and mild supraclavicular retractions and mild intercostal retractions. She has nasal flaring and mild supraclavicular retractions and mild intercostal retractions. She has inspiratory and expiratory wheezing in all lobes She has inspiratory and expiratory wheezing in all lobes What do you suggest? What do you suggest?

5. answer A bronchodilator to treat the wheezing A bronchodilator to treat the wheezing Remove the pulse ox, it is unhelpful at this point Remove the pulse ox, it is unhelpful at this point Assess her HbC0 with a co-oximeter reading and get her started on supplementary 02 at 100% NRB to washout the CO. Assess her HbC0 with a co-oximeter reading and get her started on supplementary 02 at 100% NRB to washout the CO.

6. Her HbCO is 5% so the doctor orders a NRM to washout to Carbon Monoxide Her HbCO is 5% so the doctor orders a NRM to washout to Carbon Monoxide The doctor also orders Atrovent [Iprotropium bromide ] You suggest? The doctor also orders Atrovent [Iprotropium bromide ] You suggest?

7. answer Atrovent [iprotropium bromide] is a Cholinergic blocker. You might be better starting with the Beta II first because that stimulates bronchodilator rather than blocks bronchospasm. Atrovent [iprotropium bromide] is a Cholinergic blocker. You might be better starting with the Beta II first because that stimulates bronchodilator rather than blocks bronchospasm. You could keep the iprotropium bromide, but add Albuterol You could keep the iprotropium bromide, but add Albuterol

8. The doctor orders.25mL of 5% Alupent [ Metaproterenol ] in 3 ml of normal saline. The doctor orders.25mL of 5% Alupent [ Metaproterenol ] in 3 ml of normal saline. You suggest? You suggest?

9. answer Agree, this is the correct dose, and this is a Beta II agonist Agree, this is the correct dose, and this is a Beta II agonist

10. What other inhaled drug might be helpful with the inflammation one sees with thermal damage and chemical irritation What other inhaled drug might be helpful with the inflammation one sees with thermal damage and chemical irritation

11. answer Inhaled or IV steroids might be helpful in this case Inhaled or IV steroids might be helpful in this case

12. Case study # 2 Your patient is a 4 year old LAF who is admitted to the ER with respiratory distress. You suggest: Your patient is a 4 year old LAF who is admitted to the ER with respiratory distress. You suggest:

13. answer Assess her VS Assess her VS Assess her 02 status by pulse oximeter Assess her 02 status by pulse oximeter Assess her breath sounds Assess her breath sounds

14. Her VS shows a respiratory rate of 29 bpm [slightly respiratory rate for age] Her HR is 135 again slightly high Her VS shows a respiratory rate of 29 bpm [slightly respiratory rate for age] Her HR is 135 again slightly high Her Sp02 is 98% Her Sp02 is 98% On auscultation, you hear scattered rhonchi to both lungs On auscultation, you hear scattered rhonchi to both lungs What do you suggest? What do you suggest?

15. answer Continue to monitor her for hypoxemia but for now no 02 is indicated. She has no s/s of respiratory distress now—but something brought her to the hospital Continue to monitor her for hypoxemia but for now no 02 is indicated. She has no s/s of respiratory distress now—but something brought her to the hospital Continue to assess Continue to assess

16. The doctor orders an X-Ray that shows areas of consolidation in the Right Middle Lobe. He orders 2 cc of 10 % Acetylcysteine. Why? The doctor orders an X-Ray that shows areas of consolidation in the Right Middle Lobe. He orders 2 cc of 10 % Acetylcysteine. Why?

17. answer He wants to mobilize the secretions by breaking up the chemical bonds of the mucus He wants to mobilize the secretions by breaking up the chemical bonds of the mucus

18. You suggest what else might be necessary for this patient? You suggest what else might be necessary for this patient? When you administer this aerosol, you will use what kind of device? When you administer this aerosol, you will use what kind of device?

19. answer She needs a Beta II bronchodilator with the mucolytic which irritates the lungs She needs a Beta II bronchodilator with the mucolytic which irritates the lungs Both of these drugs can be given with a pneumatic aerosol generator SVN Both of these drugs can be given with a pneumatic aerosol generator SVN

20. When you add this drug to the SVN you notice that is smells like rotten eggs and that it seems to have an oily sheen. When you add this drug to the SVN you notice that is smells like rotten eggs and that it seems to have an oily sheen. What is going on? What is going on?

21. answer Nothing, Acetylcysteine smells like rotten eggs and it has a sheen Nothing, Acetylcysteine smells like rotten eggs and it has a sheen

22. When you administer this drug, the child starts to breath faster and her heart rate increases. When you administer this drug, the child starts to breath faster and her heart rate increases. What do you do? What do you do?

23. answer Listen to her breath sounds. Listen to her breath sounds. Assess her pulse ox for increased hypoxemia Assess her pulse ox for increased hypoxemia

24. Her breath sounds have scattered inspiratory and expiratory wheezes Her breath sounds have scattered inspiratory and expiratory wheezes Her Sp02 has dropped from 95% to 89% Her Sp02 has dropped from 95% to 89% You suggest? You suggest?

25. answer Stop the treatment and give her a Beta II drug alone Stop the treatment and give her a Beta II drug alone Give the TX with 02 and the Sp02 should go back up. Give the TX with 02 and the Sp02 should go back up. Continue to monitor Continue to monitor Consider another mucolytic Consider another mucolytic

26. Case study # 3 Your patient is a 35 year old WM with a history of AIDS. He is admitted to the ER with increased respiratory distress Your patient is a 35 year old WM with a history of AIDS. He is admitted to the ER with increased respiratory distress What do you suggest? What do you suggest?

27. answer Get VS Get VS Assess 02 status with Sp02 Assess 02 status with Sp02 Listen to breath sounds Listen to breath sounds Get sputum culture to send to lab because AIDS patients get infections Get sputum culture to send to lab because AIDS patients get infections

28. His Sp02 is 89% on R.A His Sp02 is 89% on R.A His respiratory rate is 31 bpm His respiratory rate is 31 bpm He is retracting and flaring He is retracting and flaring You hear diffuse crackles You hear diffuse crackles The doctor asks you to help collect the sputum using whatever tools you have. The doctor asks you to help collect the sputum using whatever tools you have. You suggest: You suggest:

29. answer We could give him a combination of Albuterol and Acetylcysteine to mobilize secretions without stimulation of bronchospasm We could give him a combination of Albuterol and Acetylcysteine to mobilize secretions without stimulation of bronchospasm We could also give him hypotonic or hypertonic saline to cause him to cough, but we need to monitor him for wheezing triggered by the hypertonic We could also give him hypotonic or hypertonic saline to cause him to cough, but we need to monitor him for wheezing triggered by the hypertonic

30. The doctor performs a bronchoscopy and obtains sputum that is sent to the lab. The doctor performs a bronchoscopy and obtains sputum that is sent to the lab. The lab diagnosis is a PCP infection of the lung. The lab diagnosis is a PCP infection of the lung. You suggest? You suggest?

31. answer Pentamidine to control the parasitic infection Pentamidine to control the parasitic infection If the pentamidine causes bronchospasm you would like some Beta II drug ordered PRN If the pentamidine causes bronchospasm you would like some Beta II drug ordered PRN

32. What SVN do you select to deliver this drug? And why? What SVN do you select to deliver this drug? And why?

33. answer The Respirgard II, because it has bacteria filters in the exhalation line to protect the RCP The Respirgard II, because it has bacteria filters in the exhalation line to protect the RCP It has baffles to reduce the particle sizes to less than 1 micron to enter the alveoli where it is needed It has baffles to reduce the particle sizes to less than 1 micron to enter the alveoli where it is needed

34. Case study # 4 Your patient is a newborn who presents with increased respiratory distress. He is tachypnic and tachycardia. Your patient is a newborn who presents with increased respiratory distress. He is tachypnic and tachycardia. You suggest: You suggest:

35. answer Assess hypoxia with pulse oximeter Assess hypoxia with pulse oximeter Assess breath sounds Assess breath sounds

36. The Sp02 is 89% and the doctor orders a heated hood at 30% for the baby whose respiratory rate decreases. The Sp02 rises to 93% The Sp02 is 89% and the doctor orders a heated hood at 30% for the baby whose respiratory rate decreases. The Sp02 rises to 93% You listen to breath sounds and hear diffuse wheezing and inspiratory stridor You listen to breath sounds and hear diffuse wheezing and inspiratory stridor You suggest: You suggest:

37. answer Give Beta II bronchodilator for wheezing Give Beta II bronchodilator for wheezing Give racemic epinephrine for stridor Give racemic epinephrine for stridor

38. How do you administer the Beta II bronchodilator? How do you administer the Beta II bronchodilator?

39. answer Via the pneumatic SVN Via the pneumatic SVN

40. How do you administer the racemic epinephrine? How do you administer the racemic epinephrine?

41. Via the pneumatic SVN Via the pneumatic SVN

42. The doctor orders a nasal wash on this child because she suspects he has RSV pneumonia. The doctor orders a nasal wash on this child because she suspects he has RSV pneumonia. What do you suggest? What do you suggest?

43. answer Administer 6 grams of Ribavirin in 300 ml sterile water to run over 18 hours for three days. If the nasal wash is negative for RSV, we can just stop the TX, but we have to start within 24 hours of symptoms, otherwise Ribavirin is useless Administer 6 grams of Ribavirin in 300 ml sterile water to run over 18 hours for three days. If the nasal wash is negative for RSV, we can just stop the TX, but we have to start within 24 hours of symptoms, otherwise Ribavirin is useless

44. How do you administer this drug? How do you administer this drug?

45. answer Via the SPAG unit into the baby’s heated hood. Via the SPAG unit into the baby’s heated hood.

46. Case study # 5 Your patient comes into the ER in great respiratory distress. This 22 year old has a long history of severe asthma. Your patient comes into the ER in great respiratory distress. This 22 year old has a long history of severe asthma. You suggest? You suggest?

47. answer Assess VS Assess VS Assess Sp02 Assess Sp02 Assess breath sounds Assess breath sounds If she is wheezing, and if she can handle it offer a PERF If she is wheezing, and if she can handle it offer a PERF

48. Her respiratory rate is 34 bpm, her heart rate is 130 bpm Her respiratory rate is 34 bpm, her heart rate is 130 bpm Her Sp02 is 88% on 2 lpm nasal cannula started by the EMT Her Sp02 is 88% on 2 lpm nasal cannula started by the EMT Her breath sounds show diminished breath sounds in the Right middle lobe and scattered expiratory and inspiratory wheezes to all other lobes. Her breath sounds show diminished breath sounds in the Right middle lobe and scattered expiratory and inspiratory wheezes to all other lobes. Her exhalation is prolonged Her exhalation is prolonged She refuses to even try the PERF She refuses to even try the PERF You suggest? You suggest?

49. answer She needs more 02, increase her from 2 lpm to 5 or 6lpm She needs more 02, increase her from 2 lpm to 5 or 6lpm Start her on 2.5 mg Albuterol now Start her on 2.5 mg Albuterol now Disregard the PEFR, it will only confirm what we already know—she is in bronchospasm Disregard the PEFR, it will only confirm what we already know—she is in bronchospasm

50. After the 2.5 mg of Albuterol, and getting a steroid IV started, the doctor orders another TX in 30 minutes. It does no good. After the 2.5 mg of Albuterol, and getting a steroid IV started, the doctor orders another TX in 30 minutes. It does no good. He decides to start continuous treatments. You set up what? He decides to start continuous treatments. You set up what?

51. answer A “Heart” SVN with a deeper medication cup will hold enough bronchodilator for a continuous TX. A “Heart” SVN with a deeper medication cup will hold enough bronchodilator for a continuous TX. She needs an arterial blood gas [ABG] to assess her C02 for her ventilatory status She needs an arterial blood gas [ABG] to assess her C02 for her ventilatory status Continue to monitor Sp02, VS and breath sounds. Get serial ABGs because if her C02 rise in 15 minutes she needs to be intubated Continue to monitor Sp02, VS and breath sounds. Get serial ABGs because if her C02 rise in 15 minutes she needs to be intubated