How to Handle the Most Common Cases
Let's wrap up our week with practical approaches to the most common respiratory scenarios you'll encounter. Think of this as your clinical playbook for handling respiratory cases with confidence!
Scenario 1: The COPD Exacerbation
The Presentation: 68-year-old with increased dyspnea, productive cough with green sputum, wheezing, and reduced exercise tolerance.
The Quick Assessment Protocol:
Check vitals with focus on RR, HR, SpO2
Assess work of breathing - tripod position? Accessory muscles?
Auscultate for wheezes, crackles, diminished sounds
Check for pedal edema (right heart involvement)
Review medication adherence and recent changes
The RT Game Plan:
Oxygen: Titrate to SpO2 88-92% (beware CO2 retention!)
Bronchodilators: SABA + SAMA (albuterol + ipratropium) via nebulizer or MDI
Steroids: Systemic corticosteroids for inflammation
Antibiotics: If signs of infection present
Ventilatory support: Consider NIPPV if respiratory acidosis present
Pro Tip: In COPD exacerbations, don't chase "normal" oxygen saturations! Too much O2 can suppress respiratory drive in chronic CO2 retainers.
Scenario 2: The Asthma Attack
The Presentation: 22-year-old with acute onset wheeze, chest tightness, cough, and dyspnea after exposure to trigger.
The Severity Assessment:
Mild: Speaking in sentences, RR <20, wheeze at end-expiration only
Moderate: Speaking in phrases, RR 20-30, loud wheezing throughout expiration
Severe: Speaking in words only, RR >30, loud inspiratory & expiratory wheezes
Life-threatening: Altered consciousness, silent chest (no wheezes!), poor respiratory effort
The RT Game Plan:
Oxygen: To maintain SpO2 >94%
Bronchodilators: Aggressive SABA therapy, continuous nebs for severe cases
Steroids: Early administration of systemic corticosteroids
Magnesium sulfate: Consider for severe cases not responding to initial treatment
Ventilatory support: Avoid intubation if possible through aggressive medical management
Pro Tip: A "silent chest" in severe asthma is NOT improvement - it's an ominous sign of severe airflow limitation and fatigue!
Scenario 3: The Post-op Atelectasis
The Presentation: Day 2 post-abdominal surgery patient with decreased SpO2, diminished breath sounds at bases, low-grade fever.
The Quick Assessment Protocol:
Review SpO2 trend (when did it start dropping?)
Auscultate bases and compare to previous assessments
Check incentive spirometer volumes and frequency of use
Assess pain level and whether it's limiting deep breathing
Review CXR if available
The RT Game Plan:
Position: Upright position as much as tolerated
Pain control: Advocate for adequate pain management to allow deep breathing
Lung expansion: Aggressive IS use, targeting 10 breaths every hour while awake
Mobility: Early ambulation as permitted
Airway clearance: Consider PEP therapy or flutter device if secretions present
CPAP/HFNC: Consider for persistent hypoxemia despite conservative measures
Pro Tip: Prevention is easier than treatment! Set up hourly IS reminders for all post-op patients from Day 0.
Scenario 4: The Weaning Failure
The Presentation: Patient on mechanical ventilation for 5 days, failed spontaneous breathing trial with increased RR, desaturation, and anxiety.
The Systematic Evaluation:
Respiratory load: Increased WOB? Secretions? Bronchospasm?
Respiratory strength: Adequate MIP/NIF? Diaphragm weakness?
Cardiovascular status: Heart failure? Fluid overload?
Neurological status: Delirium? Anxiety? Pain?
Metabolic factors: Electrolyte abnormalities? Acid-base disorders?
The RT Game Plan:
Optimize before next attempt: Treat the "why" of failure first
Gradual approach: Consider PSV step-down before SBT
Timing matters: Attempt early in day when patient is rested
Psychological support: Explain process and provide reassurance
Consider tracheostomy: If multiple failures and long-term ventilation expected
Pro Tip: The mnemonic "WEANING" helps remember causes of failure:
Weakness of respiratory muscles
Emphysema/COPD
Airway issues (secretions)
Nutrition inadequate
Infection/inflammation
Neurological issues
Gas exchange problems
Final Thoughts
Remember that respiratory care is both an art and a science. The best RTs combine sharp assessment skills with compassionate care and clear communication. Don't just treat the numbers – treat the whole person!
What topics would you like to see covered next? Drop your suggestions in the comments below!