Case studies in respiratory physiotherapy

CHAPTER FIVE Case studies in respiratory physiotherapy



Lead authorJanis Harvey, with contributions fromSarah Ridley, Jo Oag, Elaine Dhouieb, Billie Hurst



Case study 1: Respiratory Medicine – Bronchiectasis Out-patient 34

Case study 2: Respiratory Medicine – Lung Cancer Patient 36

Case study 3: Respiratory Medicine – Cystic Fibrosis Patient 38

Case study 4: Respiratory Medicine – COPD Patient 41

Case study 5: Surgical Respiratory – Anterior Resection 43

Case study 6: Surgical Respiratory – Division of Adhesions 44

Case study 7: Surgical Respiratory – Hemicolectomy 46

Case study 8: Surgical Respiratory – Bowel Resection 48

Case study 9: Intensive Care – Patient for Extubation 50

Case study 10: Intensive Care – Surgical Patient 51


Case study 11: Intensive Care – Medical Patient 52

Case study 12: Intensive Care – Patient Mobilisation 54

Case study 13: Cardiothoracic Surgery – Self Ventilating Patient 55

Case study 14: Cardiothoracic Surgery – Intensive Care Patient 57

Case study 15: Paediatric Respiratory Care – Medical Patient 59

Case study 16: Paediatric Respiratory Care – Intensive Care Patient 61


Introduction


The area of respiratory physiotherapy reaches a number of patient groups, both in the in-patient and out-patient settings. The case studies that follow are based predominantly in the in-patient environment; however, the components of a respiratory assessment and the subsequent identification of physiotherapy problems and treatment plan could be applied to any patient with respiratory compromise in any clinical setting.


Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. Respiratory assessment should include certain key elements: general observations of the patient; consideration of trends in physiological observations (e.g. HR, BP, oxygen saturations); patient position; auscultation, palpation and, where available, analysis of arterial blood gases and chest X-ray (CXR).


Patient problems identified from the assessment generally fall into three main categories: loss of lung volume, secretion retention and increased work of breathing. The extent of any resulting respiratory compromise can vary greatly between patients and may not always be reflected by the ward area in which the patient is being treated. On occasion the most acutely unwell patients are in the general ward areas and not within critical care as expected.


A problem-orientated treatment plan may include a combination of a number of interventions such as mobilisation, positioning, breathing techniques (e.g. ACBT, AD), manual techniques (percussion, vibrations), mechanical aids (e.g. IPPB, CPAP) or more invasive measures (e.g. airway suctioning).


A respiratory assessment is mainly indicated for patients who have undergone surgery, those with medical respiratory conditions, e.g. exacerbation of COPD, and those requiring critical care. Cardiothoracic surgery and paediatrics are other specialist clinical areas that physiotherapists are involved in providing respiratory care. However, it must be remembered that patients requiring such care may not be in these ward areas exclusively. Physiotherapists working in any clinical area may be required to undertake a respiratory assessment and provide respiratory care. For example, assessment of a stroke patient who has aspirated or an oncology patient who develops respiratory failure following chemotherapy. It is important, therefore, that all physiotherapists are familiar with respiratory assessment and intervention.


Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. Such services are available to patients who have a condition amenable to physiotherapy, which has either deteriorated or is likely to deteriorate without intervention before daytime service resumes (Scottish Intercollegiate Guideline Network 2004). This can be a very challenging area of work for the physiotherapist on-call, who needs to think clearly while being faced with an acutely unwell patient who is in need of their attention, whatever the time of day. Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence (Chartered Society of Physiotherapy 2002).



CASE STUDY 1 Respiratory medicine – bronchiectasis out-patient



Subjective assessment



PC


35-year-old female


Attending routine multidisciplinary bronchiectasis clinic appointment



HPC


Diagnosed 6/12 ago with bronchiectasis following an in-patient admission with community-acquired pneumonia (CAP) in her right lower lobe. This resulted in the development of bronchiectatic changes. Since diagnosis the patient reports daily production of mucopurulent secretions with excessive coughing and feelings of fatigue



PMH


CAP


Gastric oesophageal reflux



SH


Married with two children


Lifelong non-smoker


Full-time employment as drug company representative, involving frequent travel around the United Kingdom


Normally leads an active lifestyle with two to three visits a week to the gym, although this has decreased over the past 3/12



DH


Omeprazole



Consultant handover


Patient is currently stable but is concerned about the impact of her cough and increased sputum on everyday life, especially in relation to her work, where she frequently does formal presentations



Objective assessment



Respiratory



Ventilation


SV room air SpO2 99% RR 12



CXR


Bronchiectatic changes present in right lower lobe



ABG


Not appropriate to be taken as stable



CVS


Temp 37°C HR 70 BP 120/70



CNS


Nil of note



Renal


Nil of note



MSK


Nil of note



Microbiology


Staphylococcus aureus in sputum sample 6/12 ago



Patient position


Sitting in chair



Observation


Looks well, good colour, breathing pattern normal


Patient actively trying to suppress cough and noise of secretions



Auscultation


Breath sounds throughout both lung fields with mid inspiratory crackles right lower lobe



Questions



1. You feel this lady seems a little vague regarding her diagnosis, how will you deal with this issue?

2. Following discussion it is now evident that the patient’s knowledge about her condition is sparse. How will you resolve this issue?

3. What is the range of airway clearance techniques commonly taught to this group of patients?

4. Considering this patient’s condition and lifestyle what would be the advantages and disadvantages to each of the treatments mentioned in the previous question?

5. Your patient seems reluctant to undertake airway clearance management, how will you motivate your patient to undertake regular treatment?

6. What frequency and duration may you suggest to this patient for performing airway clearance techniques?

7. What signs and symptoms would you highlight to your patient to recognize at the start of an exacerbation?

8. Your patient asks what she should do if she has an exacerbation, what advice do you give her?

9. Why would you consider asking this patient if she has any urinary stress incontinence problems?


CASE STUDY 2 Respiratory medicine – lung cancer patient



Subjective assessment



PC


70-year-old male


Non-small-cell lung cancer (NSCLC) in the right main bronchus


Admitted with an acute deterioration in condition and the family are no longer able to cope with the patient at home



HPC


Diagnosed 9/12 ago following a 3/12 history of increasing shortness of breath and cough. Two episodes of frank haemoptysis also reported. Following diagnosis, patient was deemed appropriate for a course of chemotherapy, but had limited response to intervention. As an out-patient he had a CT scan, which showed brain and spinal metastases, and he has been suffering uncontrollable pain. As a result he has been bed bound for the past month and has required increasing support from Macmillan oncology nurse specialists



PMH


Nil of note



SH


Lives with wife in a bungalow


Smokes 40 cpd


Retired teacher


Close family network


Until 2/12 ago independent with walking stick, able to walk to local shops approximately 100 m



DH


Paracetamol


Co-codamol


Oramorph


Lactulose


Build up drinks



Handover


Patient admitted with a decreased GCS, frail, emaciated Family very concerned, emotional and distressed by patient’s breathing pattern and audible secretions


Pain management sub-optimal



Objective assessment



Respiratory



Ventilation


SV 4L O2 via non-venturi system mask, unhumidified SpO2 95% RR 10–22



CXR


No CXR taken on admission


Previous CXR (1/12 ago): white out of right lung field, secondary to bronchus obstruction



ABG


None available



CVS


Temp 39°C HR 120 BP 105/65



CNS


GCS fluctuating between 5 and 8



Renal


Catheterised on admission



MSK


Pain at lower back region in keeping with spinal metastases



Microbiology


None



Patient position


Supine



Observation


Flushed, drowsy, intelligible speech with audible secretions. Agitated at times, with arms flailing and pulling at oxygen mask


Normal chest shape with altered breathing pattern illustrated by Cheyne–Stoking



Auscultation


Breath sounds diminished throughout right lung field with widespread coarse inspiratory/expiratory crackles transmitting throughout left lung field



Palpation


Decreased chest excursion on right with palpable secretions over trachea and left apex



Questions



1. How would you describe Cheyne–Stoking?

2. If a patient is performing a Cheyne–Stoke breathing pattern, what does this indicate?

3. Prior to assessing and treating this patient, what further information do you require?

4. What are the main physiotherapy problems?

5. What are the associated problems for this patient that may affect your physiotherapy intervention?

6. How will you treat the problems that you have highlighted?

7. What outcome measures will you use to evaluate the effectiveness of your intervention?

8. In this scenario, which medical and physiotherapy interventions are inappropriate and why?

9. What do you see as the role of the palliative care team in this scenario?


CASE STUDY 3 Respiratory medicine – cystic fibrosis patient



Subjective assessment



PC


19-year-old female


Admitted with acute exacerbation of cystic fibrosis (CF)



HPC


Diagnosed at birth. Multiple hospital admissions over last 3 years due to exacerbation of CF. On admission patient reporting 1/52 history of increased breathlessness, sputum volume and cough. These symptoms have not responded to a 2/52 course of intravenous antibiotics. In respiratory distress. Dehydrated. Recent weight loss and current BMI 17. Under review for lung transplantation assessment. Patient previously agreed to perform twice daily ACBT in alternate side lying/supine for 20 minutes, but generally non-compliant with suggested airway clearance programme and prescribed medications



PMH


Asthma


Osteoporosis



SH


Lives at home with parents and sister (non-CF)


Unemployed and sedentary lifestyle due to health status



DH


Ventolin via nebuliser


Becotide via inhaler


Dnase via nebuliser


Colomycin via nebuliser


Azithromycin


Creon


Alendronate


Vitamins A, D, E, K


Long-term oxygen therapy



Handover


Patient exhausted and only able to clear small amounts of very thick, purulent bronchial secretions with difficulty. Pyrexial and requiring intravenous fluids. C/O nausea following overnight feed via PEG tube



Objective assessment



Respiratory



Ventilation


SV 28% O2 via venturi system mask SpO2 85% RR 34



CXR (Figure 5.1)


Hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally Intravenous access device in situ


image

Figure 5.1 X-ray for Case Study 3 showing hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally. Intravenous access device in situ.



ABG


H+ 50 nmol/L pCO2 13 kPa pO2 7 kPa HCO3− 30 mmol/L BE −9.0



CVS


Temp 38.5°C HR 129 BP 100/85



CNS


Nil of note



Renal


Nil of note



MSK


Kyphotic with history of osteoporosis



Microbiology


Pseudomonas in sputum



Patient position


Sitting upright in bed holding onto cot sides



Observation


Pale with signs of central cyanosis. Unable to speak due to SOB and excessive cough. Looks distressed. Breathing pattern shallow, apical with active expiration



Auscultation


Coarse inspiratory crackles transmitting throughout chest on background of high-pitched expiratory wheeze



Palpation


Limited chest excursion on inspiration (right = left) Secretions palpable upper, anterior chest wall



Questions



1. Considering the above information, list this patient’s physiotherapy problems.

2. What information from the objective assessment led you to this problem list?

3. What does the ABG result tell you?

4. What are the specific signs of hyperinflation on this patient’s X-ray (Figure 5.1)?

5. During this admission, how might you initially modify this patient’s normal daily routine of alternate side lying and ACBT for 20 minutes twice a day?

6. Having decided on an acceptable airway clearance technique, what else would you include in your initial treatment plan?

7. Following two physiotherapy sessions with modified ACBT that morning, you feel that the patient is becoming more exhausted and unable to clear her secretions effectively. How might you change your physiotherapy management and with whom would you want to discuss these potential changes?

8. How might your treatment/management change if your patient was commenced on NIV?

9. Why would it be inappropriate to introduce activity/exercise at this stage?


CASE STUDY 4 Respiratory medicine – copd patient



Subjective assessment



PC


65-year-old male


Admitted to respiratory ward with acute exacerbation of COPD



HPC


Diagnosed 5 years ago with severe emphysema. Recent viral illness that has resulted in a dry cough, wheeze and breathlessness for 1/52. Has been house bound last few days. Normally 1–2 exacerbations per year that are managed by GP. No previous hospital admissions for COPD



PMH


Hypertension



SH


Retired engineer. Lives alone in third-floor flat. No lift. Normally manages all ADL independently. Exercise tolerance 50 m on flat – no aid required. Drives a car. No family living locally. No social services required. Smokes 30 cpd



DH


Salbutamol inhaler


Becotide inhaler


Atenolol


GP letter states that patient has not picked up repeat prescription for inhalers from 1/12 ago



Handover


Admitted overnight. Patient noted to be drowsy but able to be roused for short periods. When awake, able to talk in short sentences but appears slightly disorientated. Breathing pattern laboured and has a dry, spontaneous cough. Dehydrated but receiving IV fluids



Objective assessment



Respiratory



Ventilation


SV 6 L O2 via a simple face mask SpO2 97% RR 9



CXR


Hyperinflated lung fields with flattened diaphragms Emphysematous bullae upper zones No focal signs of collapse/consolidation



ABG


H+58 mmol/L pCO2 12 kPa pO2 12 kPa HCO3− 30 mmol/L BE +9



CVS


Temp 37.5°C HR 115 BP 130/90



CNS


Drowsy but able to be roused for short periods Disorientated and confused. Moving all four limbs



Renal


Nil of note



MSK


Nil of note



Microbiology


None available



Patient position


Slumped lying in bed



Observation


Obese man with barrel shaped chest and large abdomen. Colour – flushed. Breathing through an open mouth. Predominately a shallow, apical breathing pattern with increased use of accessory muscles. Also demonstrating in-drawing of his lower chest wall on inspiration. Active expiration



Auscultation


Quiet BS generally with end expiratory polyphonic wheeze throughout



Palpation


Decreased expansion bi-basally (right = left). No palpable secretions



Questions



1. The patient is drowsy with a RR of 9. What may be the contributing factors?

2. What is the difference between fixed and variable oxygen therapy?

3. Which type of oxygen therapy would be more suitable for the patient at this point?

4. What is this patient’s main physiotherapy problem?

5. What led you to this conclusion?

6. What factors may be contributing to this increased WOB?

7. How might your initial treatment plan address this problem of increased WOB?

8. Consider this patient’s CXR report, chest shape and breathing pattern. Would he benefit from lower lateral costal breathing exercises to improve basal chest excursion once he was less drowsy?

9. What goals would you hope to have achieved before this patient was discharged home?


CASE STUDY 5 Surgical respiratory – anterior resection



Subjective assessment



PC


63-year-old male


Day 2 post-laparotomy for anterior resection (end to end anastomosis)



HPC


Emergency admission yesterday with increasing abdominal pain


2/12 altered bowel habit



PMH


Nil of note- previously fit and well



SH


Lives with wife, recently retired, independent with ADL, plays golf three times a week, smoker 5 cpd



DH


Nil of note



Handover


Acute desaturation this morning. Patient has been coughing – effective and occasionally moist, nil expectorated. Otherwise stable


Not been out of bed as yet



Objective assessment



Respiratory



Ventilation


SV 4 L O2 via nasal cannulae SpO2 90% RR 12



CXR


Right basal collapse



ABG


None available



CVS


Temp 37.4°C HR 80 BP 130/60



CNS


GCS E4 V5 M6


Pain score VAS 2/10 at rest 4/10 on movement/coughing


Morphine PCA



Renal


UO 20–30 mL/hr +1.5 L cumulative balance to date



MSK


Nil of note



Microbiology


Nil of note



Patient position


Slumped in bed



Observation


Talking freely



Auscultation


Breath sounds throughout, fine end inspiratory crackles right base



Palpation


Reduced expansion right base, no secretions palpable



Questions



1. Is this patient adequately oxygenated? What suggestions might you make?

2. List this patient’s physiotherapy problem(s).

3. What information from the objective assessment led you to this problem list?

4. Why are patients who have undergone surgery/anaesthetic at risk of developing respiratory compromise?

5. What are the treatment options for this patient?

6. What would your initial treatment plan include?

7. How would you progress this patient?

8. HDU patients can have many attachments including monitoring (ECG, sats probe), oxygen therapy, catheter and wound drains. What considerations would you have to give before mobilising such a patient?


CASE STUDY 6 Surgical respiratory – division of adhesions



Subjective assessment



PC


74-year-old female


Day 3 post-laparotomy and division of adhesions



HPC


Existing ileostomy – no output for 48 hours, vomiting and no significant fluid intake



PMH


Small bowel resection and formation of ileostomy 2 years previous for incarcerated hernia


COPD


Right axillary node clearance


Previous pulmonary TB



SH


Lives alone, housebound, home help three times/day, smokes 10 cpd



DH


Ventolin inhaler


Seretide inhaler



Handover


Initially in intensive care, intubated and ventilated. Extubated yesterday and transferred to HDU. Stable overnight, difficulty clearing secretions



Objective assessment



Respiratory



Ventilation


SV FiO2 0.28 via face mask cold humidification RR16 SpO2 89%



CXR – taken prior to extubation (Figure 5.2)


Scoliosis, rotated, hyperinflated, nil focal


image

Figure 5.2 X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields.



ABG


H+ 36.35 nmol/L pCO2 5.91 kPa pO2 7.42 kPa HCO3− 28.2 mmol/L BE+ 4.7



CVS


Temp 36.5°C HR 85 BP 110/50 Noradrenaline 8 mL/hr



CNS


GCS E4 V5 M6


Pain score VAS 3/10 at rest 8/10 on movement/coughing


Morphine PCA



Renal


UO 50 mL/hr +3.2 L cumulative balance to date



MSK


Nil of note



Microbiology


Nil of note



Patient position


Sitting upright in bed, frail



Observation


Hyperinflated chest, looks well, chatting freely, dry mouth



Auscultation


Breath sounds throughout, coarse expiratory crackles throughout



Palpation


Expansion equal, palpable secretions bilateral upper zones



Questions



1. Describe the advantages and disadvantages of patient-controlled analgesia (PCA).

2. Considering this patient’s CXR (Figure 5.2), what additional hardware/monitoring is visible?

3. List this patient’s physiotherapy problem(s).

4. What information from the assessment led you to this problem list?

5. From the assessment information, what suggestions should the physiotherapist make before physiotherapy care commences?

6. What would be your initial treatment plan?

7. Given this patient’s present condition and past history, how might you need to modify the treatments delivered?

8. How would you know if your treatment had been effective (outcome measures)?

9. If the initial treatment plan were to be unsuccessful in clearing secretions, how would you modify your treatment?


CASE STUDY 7 Surgical respiratory – hemicolectomy



Subjective assessment



PC


55-year-old male


Day 2 post laparotomy for right hemicolectomy (end to end anastomosis)



HPC


Elective admission for bowel resection – investigated 6/12 ago due to altered bowel habit and weight loss. Tumour identified and biopsy taken during colonoscopy



PMH


Nil of note



SH


Lives alone, independent with ADL, non-smoker



DH


Nil of note



Handover


Acute desaturation this morning requiring increased FiO2, not been out of bed as yet due to reduced blood pressure, otherwise stable



Objective assessment



Respiratory



Ventilation


SV FiO2 0.6 via face mask cold humidification RR 12 SpO2 96%



CXR


Left lower lobe collapse



ABG


None available



CVS


Temp 37.4°C HR 80 BP 80/45



CNS


GCS E4 V5 M6


Pain score VAS 2/10 at rest 3/10 on movement/coughing


Epidural analgesia (Bupivacaine and Morphine mix)



Renal


UO 30 mL/hr +1.5 L cumulative balance to date



MSK


Nil of note



Microbiology


Nil of note



Patient position


Slumped in bed



Observation


Looks well, talking freely



Auscultation


Breath sounds throughout, reduced at left base



Palpation


Reduced expansion left base, no secretions palpable



Questions



1. What does the procedure of a right hemicolectomy involve?

2. Why can the presence of an epidural lead to hypotension?

3. List this patient’s physiotherapy problem(s).

4. What information from the objective assessment led you to this problem list?

5. What would be your initial treatment plan?

6. After identifying an appropriate treatment plan, what information/instructions would you handover to the nursing staff caring for the patient?

7. How would you determine if your treatment plan had been effective (outcome measures)?

8. What goals would you hope to have achieved before this patient was discharged home?


CASE STUDY 8 Surgical respiratory – bowel resection



Subjective assessment



PC


80-year-old male


Day 3 post-laparotomy for bowel resection



HPC


Presented to A&E with painful distended abdomen. Bowels not opened for 2/7 previous. Distended loops of bowel and sigmoid volvulus on AXR. Attempted decompression by colonoscopy unsuccessful therefore proceeded to theatre for open procedure



PMH


Hypertension



SH


Lives with wife, independently mobile



DH


Atenolol



Handover


Patient confused and drowsy since return from theatre.


Has a moist, ineffective cough that is not productive



Objective assessment



Respiratory



Ventilation


SV 2L O2 via nasal cannulae RR 17 SpO2 94%



CXR (Figure 5.3)


Reduced lung volume bibasally


image

Figure 5.3 X-ray for Case Study 8 showing reduced lung volume bi-basally.



ABG


H+ 49.8 nmol/L pCO2 4.87 kPa pO2 10.16 kPa HCO3− 18.0 mmol/L BE –8



CVS


Temp 37°C HR 100 BP 160/70 CVP +9



CNS


GCS E3 V4 M5


Pain score – unable to score reliably



Renal


UO 35 mL/hr +6 L cumulative fluid balance to date



MSK


Nil of note



Microbiology


Nil of note



Patient position


Slumped in bed



Observation


Drowsy, audible added sounds at mouth



Auscultation


Breath sounds throughout reduced bibasally, expiratory crackles upper zones



Palpation


Expansion equally reduced bilaterally, no secretions palpable



Questions



1. Explain the patient’s drug history in relation to the past medical history.

2. Why do post-operative patients tend to have a significant positive fluid balance?

3. Why is metabolic acidosis a common finding when analysing the ABG of a post-operative patient?

4. List this patient’s physiotherapy problem(s).

5. What information from the objective assessment led you to this problem list?

6. Systematically analysing this patient’s CXR (Figure 5.3), what signs do you find that would confirm bibasal loss of lung volume?

7. What would be your initial treatment plan?

8. What could be suggested as a management strategy if the patient required regular suctioning and why?


CASE STUDY 9 Intensive care – patient for extubation



Subjective assessment



PC


55-year-old female


Day 7 post-laparotomy for subtotoal colectomy and extensive bowel resection, formation of ileostomy



HPC


Emergency admission from A&E in shock with reduced BP, abdominal pain


Unwell for 3–4 days, intermittent diarrhoea and vomiting


Theatre findings – patchy infarction of small and large bowel



PMH


Hypertension



SH


Lives with son, 10 cpd smoker



DH


Bisoprolol



Handover


Stable overnight


Possibly for extubation. Just weaned to ASB from SIMV



Objective assessment



Respiratory



Ventilation


ASB (PEEP 5 PS 5) ETT size 7.0 FiO2 0.35 RR 19 Tv 0.46 L SpO2 97% M1 secretions



CXR


Nil focal



ABG


H+ 39.7 nmol/L pCO2 5.06 kPa pO2 14.15 kPa HCO3− 23.1 mmol/L BE –1.5



CVS


Temp 38.6°C HR 135 BP 169/88 CVP +11



CNS


GCS E3 VT M4 Propofol 10 mL/hr Alfentanil 2 mL/hr



Renal


UO 50 mL/hr overall +500 mL



MSK


Nil of note



Microbiology


Sputum and urine – no growth



Patient position


Head-up tilt in bed



Observation


Intubated and ventilated, settled, relaxed breathing pattern



Auscultation


Breath sounds throughout, no added sounds



Palpation


Expansion equal, no secretions palpable



Questions



1. Define and explain the difference between SIMV and ASB modes of ventilation.

2. What would you look for in a patient assessment that might indicate to you a patient is ready for extubation?

3. The Glasgow Coma Scale (GCS) is used to assess level of consciousness. What are the components of the scoring system?

4. On assessment this patient GCS is E3 VT M5. What is the patient ‘doing’ and what are the implications of this for the patient with regard to readiness to extubate?

5. List this patient’s physiotherapy problem(s).

6. What information from the objective assessment led you to this problem list?

7. What would be your initial treatment plan?

8. How would you assess as to whether the deep breaths the patient was attempting to take were effective?


CASE STUDY 10 Intensive care – surgical patient



Subjective assessment



PC


51-year-old female


Day 1 post laparotomy – drainage of pelvic abscess and over sew of serosal tears



HPC


Admitted previous day with abdominal pain and distension. CT revealed free gas, fluid and faeces in the abdomen and a pelvic collection



PMH


Ischaemic colitis


Hartmans procedure 1 year ago



SH


Lives with husband


Independent with all ADL



DH


Nil



Handover


Problems with cuff leak on repositioning. Aiming to place NG tube then reduce sedation



Objective assessment



Respiratory



Ventilation


SIMV ETT size 7.0 FiO2 0.35 PEEP 5 PS 10 Tv 0.419 L RR 14 SpO2 92% HMEF brown secretions



CXR


Nil focal



ABG


H+ 52.19 nmol/L pCO2 4.6 kPa pO2 10.96 kPa HCO3− 16.6 mmol/L BE –9.8



CVS


Temp 36.5°C HR 100 BP 140/90 CVP +10



CNS


GCS E3 VT M5 Propofol 7 mL/hr Alfentanil 2 mL/hr



Renal


UO 35 mL/hr +2.5 L cumulative balance



MSK


Nil of note



Microbiology


Nil of note



Patient position


Head-up tilt in bed



Observation


Intubated, ventilated, settled



Auscultation


Breath sounds throughout, coarse expiratory crackles right upper/middle zones



Palpation


Expansion equal, palpable secretions right upper zone



Questions



1. Analyse the ABG presented.

2. On handover the presence of a cuff leak has been highlighted. What is the significance of this information?

3. List this patient’s physiotherapy problem(s).

4. What information from the objective assessment led you to this problem list?

5. Positioning is integral to all respiratory physiotherapeutic input. Which position would you choose for this patient and why?

6. What would be your initial treatment plan?

7. If your initial treatment was unsuccessful in clearing the secretions, how might you modify your treatment?

8. What are the potential hazards associated with endotracheal suctioning?


CASE STUDY 11 Intensive care – medical patient



Subjective assessment



PC


72-year-old male


Bilateral pneumonia and sepsis, 4 hours post ICU admission



HPC


Presented to Acute Receiving Unit today. Poor oral intake for 1/52 – dehydrated and weak



PMH


Mild learning difficulties, irritable bowel syndrome



SH


Lives with partner, home help twice a week, otherwise independent



DH


Nil of note



Handover


Stable since admission; plan to keep sedated for at least 24 hours



Objective assessment



Respiratory



Ventilation


Uncut ETT size 8.0 SIMV FiO2 0.65 PEEP 10 SpO2 96% RR 25/0 mandatory/spontaneous Tv 0.55 L nil-M1 secretions



CXR


Collapse consolidation left lower zone, patchy changes right middle zone



ABG


H+ 53.8 nmol/L pCO2 6.9 kPa pO2 10.7 kPa HCO3− 24 mmol/L BE –1.2



CVS


Temp 38°C HR 90 BP 95/55 CVP +12 Noradrenaline 26 mL/hr



CNS


Pupils 2+ 2+ GCS E2 VT M4


Sedation – Propofol 10 mL/hr, Alfentanil 2 mL/hr



Renal


UO 30+ mL/hr +1 L balance



MSK


Nil of note



Microbiology


No result as yet, commenced on broad-spectrum antibiotics



Patient position


Head-up tilt in bed



Observation


Intubated, ventilated, sedated



Auscultation


Breath sounds throughout, bronchial breathing left lower zone



Palpation


Reduced expansion left base, no secretions palpable



Questions



1. The patient is septic. What information from the objective assessment indicates this?

2. Analyse the ABG presented.

3. Describe bronchial breathing.

4. List this patient’s physiotherapy problems(s).

5. What information from the objective assessment led you to this problem list?

6. What could be your initial treatment plan for each of these problems?

7. Clinically reason through whether MHI would be appropriate for this patient.

8. What would be your short-term goals for this patient?


CASE STUDY 12 Intensive care – patient mobilisation



Subjective assessment



PC


50-year-old male


Community-acquired pneumonia


Day 41 in ICU



HPC


Admitted via A&E drowsy, sweaty and ‘unwell’. Quickly deteriorated with respiratory failure, requiring intubation and ventilation


Complicated ICU stay with ARDS and two failed extubations



PMH


Alcohol excess (½ bottle vodka a day)


Previous IV drug abuser


Previous ICU admission with pneumonia



SH


Lives alone, first floor flat



DH


Nil of note



Handover


Been on CPAP overnight via tracheostomy, now on speaking valve


Patient is keen to mobilise



Objective assessment



Respiratory



Ventilation


Trache size 8.0 (with inner tube, non-fenestrated) Speaking valve in situ. 2 L O2 SpO2 96% RR 20 MP2 secretions on suction



CXR


No recent



ABG


H+ 39.42 nmol/L pCO2 5.34 kPa pO2 11.5 kPa HCO3− 24.1 mmol/L BE –0.2



CVS


Temp 36.5°C HR 80 BP 140/80



CNS


GCS E4 V5 M6



Renal


UO 100 mL/hr overall negative balance



MSK


Nil of note



Microbiology


MRSA +ve in sputum



Patient position


High sitting in bed



Observation


Looks well, strong clear voice



Auscultation


Breath sounds throughout, no added sounds



Palpation


Expansion equal, no secretions palpable



Questions



1. This patient developed ARDS due to severe pneumonia. What is ARDS?

2. This patient failed two attempts at extubation and so had a tracheostomy inserted to facilitate weaning. What other indications are there for tracheostomy tube insertion?

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Mar 17, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Case studies in respiratory physiotherapy

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