One of the most difficult aspects of being a Respiratory Therapy Student is trying to apply what you learn in the classroom to real-life clinical scenarios.

We created this study guide to help.

Below, we’ve provided a clinical scenario on the topic of COPD that covers a patient who is a dyspneic smoker.

Let’s see if you can determine how to diagnose and treat this patient.

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CLINICAL SCENARIO: A DYSPNEIC SMOKER

John Doe is a 56-year-old man that presents to the ED with increased work of breathing. He felt mildly short of breath when he woke up this morning but became extremely dyspneic after climbing a few flights of stairs. He is even too short of breath to finish full sentences.

His wife is present in the room and revealed that Mr. Doe has a history of liver failure, is allergic to penicillin, and has a 15 pack-year smoking history. He builds cabinets for a living and is constantly required to work around a lot of fine dust and debris.

Head-to-Toe Exam

HEENT:

  • Pupils are reactive and equal
  • The patient is alert and oriented
  • He is pursed-lip breathing
  • His trachea is midline and there is no jugular venous distention present

Vital Signs:

  • Heart rate is 92 beats/min
  • SpO2 is 84%
  • Respiratory rate is 22 breaths/min

Chest Assessment:

  • Mr. Doe presents with a larger than normal anterior-posterior diameter
  • There is equal, bilateral chest expansion
  • Auscultation reveals a prolonged expiratory phase and diminished breath sounds
  • Palpation returns no tactile fremitus
  • When percussed, Mr. Doe has increased resonance
  • The patient is having subcostal retractions

Abdomen:

  • His abdomen is soft and tender
  • No distention is present

Extremities:

  • Mr. Doe’s capillary refill results are two seconds
  • Digital clubbing is present in his fingertips
  • There is no pitting edema present in his legs
  • His skin appears to have a yellow tint to it

Lab and Radiology Results:

  • ABG Results — pH 7.35 mmHg, PaCO2 59 mmHg, HCO3 30 mEq/L, and PaO2 64 mmHg.
  • Chest X-ray — Shows flat diaphragms, an increase in retrosternal space, dark lung fields and slight hypertrophy of the right ventricle and a narrow heart
  • Blood Work — RBC of 6.5 mill/m3, Hb of 19 g/100 mL, and Hct of 57%

Taking everything into consideration, now let’s determine how to diagnose the patient.

Diagnosing the Patient:

Based on the information given, what condition does the patient have?

This patient has Chronic Obstructive Pulmonary Disease (COPD).

What key findings from the patient’s history and assessment help with the diagnosis?

Here are some of the important signs and symptoms that the patient displayed which are common in those with COPD:

  • Barrel chest
  • Tachypnea
  • A long expiratory time
  • Diminished breath sounds
  • Use of accessory muscles while breathing
  • Digital clubbing
  • Pursed lip breathing
  • History of smoking
  • Exposure to dust from work

How do the abnormal lab and radiology results justify your diagnosis of this patient?

Mr. Doe’s chest x-ray showed the classic signs of chronic COPD which include hyperexpansion, dark lung fields, and a narrow heart.

It is also important to note that while Mr. Doe doesn’t have a history of cor pulmonale, right-sided heart failure is common in COPD patients. Because his right ventricle is hypertrophied, this should be brought to the doctor’s attention for further investigation.

The lab values that point to COPD are his increased RBC, Hct, and Hb levels. These levels can increase in response to the chronic hypoxemia that COPD patients often experience.

His ABG results also indicate that COPD is present because the interpretation shows compensated respiratory acidosis with mild hypoxemia. Compensated blood gases indicate an issue that has been present for an extended period of time.

Bonus Assessment: If you were able to correlate the patient’s elevated bilirubin and ALT levels to his history of liver failure, great job — you get bonus points.

While these values don’t help us diagnose the patient with a respiratory condition, it’s important to have a general understanding of what all of the lab values, signs, and symptoms can mean.

The NBRC may give you certain information about a patient (including lab values) that is irrelevant to their cardiopulmonary condition just to throw you off. Being aware of this helps you know which data doesn’t relate to the respiratory issue at hand so that it can be ignored.

What other tests would be helpful in confirming the suspected diagnosis?

A series of pulmonary function tests (PFT) could be ordered to assess the patient’s lung volumes and capacities. This would help confirm the diagnosis of COPD and tell you how severe the condition is.

In general, COPD patients tend to have an FEV1/FVC ratio below 70% with an FEV1 that is less than 80%.

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Treating the Patient:

What is the initial treatment for this patient?

Because Mr. Doe has COPD, you can initiate low-flow oxygen to treat hypoxemia while avoiding knocking out the hypoxic drive.

It is acceptable to start with a nasal cannula at 1-2 L/min, however, it is often recommended to use an air-entrainment mask on COPD patients in order to provide an exact FiO2.

Either way, you want to start with the lowest FiO2 possible and titrate from there based on how the patient responds to the oxygen that is being delivered.

Let’s say you start the patient with an FiO2 of 28% via an air-entrainment mask and titrate it up to 32% after no improvement is shown in the patient’s oxygenation status.

The SpO2 was at 84% and has now decreased to 80% and his retractions are worsening. He is sitting in the tripod position and continues to demonstrate pursed-lip breathing.

Another blood gas was collected and the results show a PaCO2 of 65 mmHg and a PaO2 of 59 mmHg.

What is your next treatment recommendation?

The patient’s condition clearly appears to be getting worse due to an increased work of breathing. The latest ABG results confirmed this with a PaCO2 that is increasing and a PaO2 that is decreasing.

This indicates that the patient needs further assistance with both ventilation and oxygenation.

In general, mechanical ventilation is to be avoided with COPD patients if possible because they are often difficult to wean from the machine. So this means that the most appropriate treatment method is to initiate Bilevel Positive Airway Pressure (BiPAP).

After speaking with the physician, he agrees that the patient should be placed on BiPAP.

What initial BiPAP settings would you recommend?

In general, the recommended initial BiPAP settings for an adult patient are as follows:

  • An IPAP of 8-12 cmH2O
  • An EPAP of 5-8 cmH2O
  • A rate of 10-12 breaths/min
  • An FiO2 of what they were previously on

So let’s say you initiate BiPAP with an IPAP of 10 cmH20, an EPAP of 5 cmH2O, a rate of 12, and an FiO2 of 32% since that is what they were previously receiving.

After 30 minutes, the physician requests for another ABG to be drawn. After analysis, the results reveal Acute Respiratory Acidosis with mild hypoxemia.

What adjustments would you make to the BiPAP settings?

The latest ABG results indicate that there are two parameters that must be corrected:

  • Their high PaCO2
  • Their low PaO2

We can address the patient’s PaO2 by increasing either the FiO2 or EPAP setting. EPAP functions as PEEP which works to increase oxygenation.

The PaCO2 can be lowered by increasing the IPAP setting. Doing so helps to increase the patient’s tidal volume which helps them blow off more CO2.

In general, you should adjust BiPAP settings moderately. It’s usually acceptable to increase the pressure settings by 2 cmH2O at a time and the FiO2 setting by 5%.

Respiratory Therapist Making Adjustments to BiPAP Settings
First, let’s fix the patient’s oxygenation. To do so, you can increase the EPAP setting to 7 cmH2O. This would decrease the pressure support by 2 cmH2O because, remember — pressure support is the difference between the IPAP and EPAP.

That means, since you increased the EPAP, you will now also need to increase the IPAP by the same amount in order to keep the pressure support level the same.

But we know that the PaCO2 is still increased, which means that we need to increase the IPAP setting even more. So now the pressure settings on the machine are an IPAP of 14 cmH2O and an EPAP of 7 cmH2O.

Now, after further assessment, the patient’s condition appears to be improving.

Two days later, the patient has been successfully weaned off of BiPAP and oxygen support. He now appears ready to be discharged. The doctor wants you to recommend home therapy and treat modalities that could benefit a chronic COPD patient.

What home therapy would you recommend?

You can recommend home oxygen therapy if the patient’s PaO2 drops below 55 mmHg or their SpO2 goes below 88% more than two times in a three week period.

Remember, we use a more conservative approach when giving COPD patients oxygen. You could also consider the following pharmacological agents:

  • Short-acting bronchodilator (Albuterol)
  • Long-acting bronchodilator (Formoterol)
  • Anticholinergic agent (Ipratropium bromide)
  • Inhaled corticosteroids (Budesonide)
  • Methylxanthines (Theophylline)

Smoking cessation education is always important for patients who smoke. Nicotine replacement therapy may be indicated as well. Bronchial hygiene therapy, such as an oscillatory positive expiratory pressure (PEP) device, can be recommended if indicated.

Also, you should provide education on the importance of staying active, maintaining a healthy diet, avoiding infections, and getting an annual flu vaccine. Lastly, cardiopulmonary rehabilitation may need to be recommended for COPD patients if indicated.
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Final Thoughts

There are two key points to remember when treating a COPD patient. First, you always want to be mindful of the amount of oxygen that is being delivered and try to keep the FiO2 as low as possible.

Second, you should try to use noninvasive ventilation if possible before performing intubation and conventional mechanical ventilation.

Too much oxygen can knock out the patient’s drive to breathe and once intubated, these patients can be difficult to wean from the ventilator. And once the patient is ready to be discharged, you want to ensure that you are sending them home with the tools and therapies that they need to stay healthy and avoid readmission.

Hopefully you found this clinical scenario to be helpful. Thank you for reading and as always, breathe easy my friend.

References

The following are the sources that were used while doing research for this article:

  • Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020. [Link]
  • Chang, David. Clinical Application of Mechanical Ventilation. 4th ed., Cengage Learning, 2013. [Link]
  • Rrt, Cairo J. PhD. Pilbeam’s Mechanical Ventilation: Physiological and Clinical Applications. 7th ed., Mosby, 2019. [Link]
  • Faarc, Gardenhire Douglas EdD Rrt-Nps. Rau’s Respiratory Care Pharmacology. 10th ed., Mosby, 2019. [Link]
  • Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017. [Link]
  • Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019. [Link]

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