Patient Assessment and Care Management

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1 Patient Assessment and Care Management

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care’s (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and WRE, it is shown simply as (Code: …). If an item is testable only on the ELE, it is shown as (ELE code: …). If an item is testable only on the WRE, it is shown as (WRE code: …).

Following each item’s code, the difficulty level is indicated for the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder, because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown that an average of 9 questions out of 140 (7% of the exam) cover patient assessment and care management. A review of the most recent Written Registry Examinations (WRE) has shown that an average of 15 questions out of 100 (15% of the exam) cover patient assessment and care management. Of these 15 questions, an average of 11 cover patient assessment and an average of 4 cover care management. Typically, 9 of the patient assessment questions deal with adult patients. The remaining two patient assessment questions deal with neonatal or pediatric patients. The Clinical Simulation Examination is comprehensive.

Note 3: The Entry Level Examination has shown an average of 2 questions that directly cover a cardiopulmonary pathology issue; the Written Registry Examination has shown an average of 1 question. It is beyond the scope of this book to cover all the cardiopulmonary diseases and conditions that befall patients for whom respiratory therapists may provide care. It is recommended that asthma, chronic obstructive pulmonary disease (COPD; emphysema or chronic bronchitis or both), pneumonia, pneumothorax, flail chest, congestive heart failure with pulmonary edema, myasthenia gravis, Guillain-Barré syndrome, head (brain) injury with increased intracranial pressure, pediatric croup and epiglottitis, infant respiratory distress syndrome, acute respiratory distress syndrome (ARDS), and smoke inhalation with carbon monoxide poisoning be studied. Some limited discussion of these topics is covered in this book. The Written Registry Examination frequently ask questions about the respiratory therapy procedures that patients with these types of problems are receiving. In addition, the 11 Clinical Simulation Examination scenarios are built around the care of patients with these types of diseases and conditions. See Box 1 in the Introduction.

PART 1. PATIENT ASSESSMENT

MODULE A

Review the patient’s chart for the following data and recommend the following diagnostic procedures based on current information

Note: The following discussion involves noninvasive, bedside activities that apply to adults in most respiratory care settings. Some assessment items have been placed in later chapters, because they are procedure specific. Topics that relate to neonates and children are included in Module H.

1. Review the patient’s history: present illness, admission notes, progress notes, diagnoses, respiratory care orders, medication history, do not resuscitate (DNR) status, and previous patient education (Code: IA1) [Difficulty: ELE is R; WRE: Ap]

a. Patient history

Review the complete initial patient history and note the following:

1. Date of history taking
2. Patient data: name, age, gender, race, and occupation
3. Primary complaints
4. Secondary complaints
5. Present illness history and symptoms
6. Family history
7. Medical history of cardiopulmonary disease(s), including smoking history, cough, sputum production, and activities of daily living
8. Review of body systems

It is important that the respiratory therapist obtain a brief history before beginning therapeutic procedures. Determine how the patient has been doing since the last treatment. Has there been a change in dyspnea, cough and secretions, chest pain, and so on? This will help guide therapy as effectively as possible.

b. Admission notes

The attending physician writes up his or her key findings and how they are related to the reason the patient was admitted to the hospital.

c. Progress notes

Review the physician’s, nurse’s, and respiratory therapist’s patient progress notes before seeing the patient and beginning the therapeutic procedure. Look for any cardiopulmonary or other organ-system changes that will have an impact on the patient’s ability to take the treatment. You may need to revise the therapy, get different equipment, or seek help. Check for new patient care orders if the physician notes a change in the patient’s care plan.

d. Diagnoses

After the medical history, physical exam, and laboratory tests are completed, the patient will be placed into one of the following four diagnostic categories. Refer to Table 1-1 for examples of each category:

• Crisis/acute onset of illness
• Intermittent but repeated illness
• Progressive worsening
• Mixed patterns/multiple problems

TABLE 1-1 Patient Illness Categories

Category Examples
Crisis/acute onset of illness Trauma, heart attack, allergic reaction, aspiration of a foreign body, pneumothorax, pulmonary embolism, and some pneumonias
Intermittent but repeated Illness Asthma, chronic bronchitis, congestive heart failure, angina pectoris, myasthenia gravis, and some pneumonias
Progressive worsening Congestive heart failure, chronic bronchitis, emphysema, and upper respiratory tract infection leading to bronchitis or pneumonia
Mixed patterns/multiple problems Chronic obstructive pulmonary disease and cystic fibrosis complicated by multiple problems, mucous plugging or infection; mixes of congestive heart failure and chronic lung disease; mixes of neuromuscular and lung disease; mixes of renal failure and congestive heart failure with chronic lung disease

e. Current respiratory care orders

Physician orders must have the patient’s name, date, time, complete and proper orders for each therapeutic procedure, and the physician’s signature. Verbal orders from the physician to the nurse or respiratory therapist must follow hospital guidelines and include the preceding information. Incomplete, improper, or questionable orders must be confirmed by calling the physician for clarification or correction.

f. Medication history

Note the respiratory medications that the patient is currently taking. In addition, note any medications used to help manage cardiovascular, renal, or neurological problems that may also affect the patient’s respiratory status.

g. Do not resuscitate (DNR) status

The physician, patient, and family should determine the patient’s cardiopulmonary resuscitation status. A patient with a terminal condition, such as end-stage chronic obstructive pulmonary disease (COPD), often will choose not to be resuscitated. If it has been determined that the patient does not want to be resuscitated, his or her DNR status should be clearly posted in the chart and in the patient’s room. All members of the health care team should be aware of the patient’s decision.

h. Previous patient education

If the patient has asthma or COPD and has been admitted before, check for any record of a respiratory therapist teaching the patient about the disease and how it can be better managed.

2. Review the results of the patient’s physical examination and vital signs (Code: IA2) [Difficulty: ELE: R; WRE: Ap]

Review the results of the physical examinations performed by physicians, nurses, and respiratory therapists. Review the following organ systems:

• Pulmonary
• Cardiovascular
• Neuromuscular
• Renal

a. Current vital signs

Review the current vital signs in the patient’s chart. Compare them with the admission vital signs and what you observe in the patient now. Look for a change in pattern that suggests either worsening or improvement in the patient.

b. Temperature

The textbook “normal” oral body temperature is 98.6° F (37° C). However, some range from 96.5° F to 99.5° F (35.8° C to 37.4° C) is normal. Make sure the patient has not eaten any hot or cold foods recently and has not been smoking before taking an oral temperature.

A rectal or core temperature is commonly taken in very sick patients, because it is more accurate and reliable. The normal rectal temperature is 97.5° F to 100.4° F (36.4° C to 38° C). Some variance is normal, but less so than with oral temperatures. Axillary temperatures are used as a last resort in stable patients. These run 1° F lower than oral temperatures and are less accurate and reliable.

The variations in temperature noted depend on the time of day, activity level and, in women, stage of the menstrual cycle. For example, a lower body temperature is normal when a person is in a deep sleep. An oral temperature higher than 99.4° F (37.4° C) in a patient with a history of respiratory disease indicates a fever. Typically, it can be caused by atelectasis or a pulmonary or systemic infection. Patients commonly are treated to keep their temperature below 103° F, if possible. In general, a rectal temperature below 97° F (36° C) is considered hypothermic. In some procedures, such as open-heart surgery, a patient’s temperature is lowered to reduce metabolism and oxygen needs. The rectal temperature must be kept above 90° F (32° C) to prevent cardiac dysrhythmias caused by the cold.

c. Respiratory rate

The respiratory rate (f for frequency) is the number of breaths the patient takes in 1 minute. The number is counted by looking at or feeling the chest or abdominal movements, or both. The normal rate varies with age (Table 1-2). It is assumed that the patient is resting but awake and has a normal temperature and metabolic rate. A respiratory rate above or below normal is cause for alarm.

TABLE 1-2 Normal Resting Respiratory Rates

Age (Years) Male Female
0 31 ± 8 30 ± 6
1-2 26 ± 4 27 ± 4
2-4 25 ± 4 25 ± 3
5-7 22 ± 2 21 ± 2
8-11 19 ± 2 19 ± 2
12-14 19 ± 2 18 ± 2
15-16 17 ± 3 18 ± 3
17-18 16 ± 3 17 ± 3
Older 16 ± 3 17 ± 3

Modified from Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.

Hyperthermia (fever), acidemia, hypoxemia, fear, anxiety, and pain cause a patient to breathe more rapidly. Hypothermia, alkalemia, and hyperoxia in a patient breathing on hypoxic drive, sedation, and coma cause a patient to breathe more slowly.

Remember that even in healthy people, considerable variation is found in the respiratory rate. It is best to consider the respiratory rate and the patient’s tidal volume and minute volume to get a more complete impression of how the patient is breathing. Carefully measure the respiratory rate of any patient with cardiopulmonary disease or with a respiratory rate outside the normal range. The rate should be checked as often as needed to monitor the patient’s condition.

d. Blood pressure

The blood pressure (BP) is the result of the pumping ability of the left ventricle (made up of the heart rate and stroke volume), arterial resistance, and blood volume. Normal BP results when all three factors are in balance with each other. If one factor is abnormal, the other two have some ability to compensate. For example, if the patient has lost a lot of blood, the body attempts to maintain BP by increasing both arterial resistance and the heart rate.

Normal Blood Pressures

• Adults: lower than 120/80 mm Hg
• Infants and children younger than 10 years old: 60 to 100/20 to 70 mm Hg

As with the other vital signs, some variation in BP is noted among individuals. It is important to know the patient’s normal BP to compare it with the current value. Carefully measure the BP in any patient who has cardiopulmonary disease or a history of hypotension or hypertension.

Hypotension in the adult is a systolic BP of less than 80 mm Hg. Recommend a BP measurement for any patient who has a history of hypotension, appears to be in shock, has lost a lot of blood, has a weak pulse, shows mental confusion, is unconscious, or has low urine output.

Hypertension in the adult is a systolic BP of 140 mm Hg or greater or a diastolic BP of 90 mm Hg or greater, or both. Carefully measure the BP of any patient with a history of hypertension, bounding pulse, or symptoms of a stroke (mental confusion, headache, and sudden weakness or partial paralysis). Fear, anxiety, and pain also cause the patient’s BP to increase temporarily.

e. Heart/pulse rate

The heart/pulse rate (HR) is the number of heartbeats per minute. It can be counted by listening to the heart tones with a stethoscope or by feeling any of the common sites where an artery is easy to locate. Table 1-3 shows the normal pulse rates based on age. It is assumed that the patient is alert but resting when the pulse is counted. Carefully measure the heart/pulse rate in any patient with cardiopulmonary disease or any of the aforementioned conditions for hypotension or hypertension.

TABLE 1-3 Normal Pulse Rates According to Age

Age Beats/min
Birth 70–170
Neonate 120–140
1 year 80–140
2 years 80–130
3 years 80–120
4 years 70–115
Adult 60–100

From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.

3. Serum electrolytes and other blood chemistries

a. Review the results of the patient’s serum electrolyte levels and other blood chemistries (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

b. Recommend blood tests, such as the potassium level, to obtain additional data (WRE code: IC1) [Difficulty: WRE: R, Ap, An]

The serum (blood) electrolytes are measured in most patients when they are admitted to the hospital and as needed thereafter. This is to determine whether the values are within the normal ranges listed in Table 1-4. Any abnormality should be promptly corrected so that the patient’s nervous system, muscle function, and cellular processes can be optimized. Diet and a number of medications can affect the various electrolytes. Most abnormalities can be corrected by dietary adjustments or, if necessary, by oral or intravenous supplementation.

TABLE 1-4 Normal Serum Electrolyte and Glucose Levels

NORMAL ELECTROLYTE VALUES*
Chloride (Cl−) 95–106 mEq/L
Potassium (K+) 3.5–5.5 mEq/L
Sodium (Na+) 135–145 mEq/L
Calcium (Ca++) 4.5–5.5 mEq/L
Bicarbonate (HCO3−) 22–25 mEq/L
NORMAL GLUCOSE VALUES*  
Serum or plasma 70–110 mg/100 mL (dL)
Whole blood 60–100 mg/100 mL (dL)

* These values may vary somewhat among references.

1. Potassium (K+)

Potassium is the most important electrolyte to monitor because of its effect on general nerve function and cardiac function. Hyperkalemia is a high blood level of potas-sium. It causes the following electrocardiographic (ECG) changes: high, peaked T waves and depressed S-T segments; widening QRS complex; and bradycardia. Hypokalemia is a low blood level of potassium. It causes the following ECG changes: flat or inverted T waves, depression of the S-T segments, premature ventricular contractions (PVCs), and ventricular fibrillation (if severe enough). Chapter 11 offers a more complete discussion of ECG interpretation.

Exam Hint 1-1 (WRE)

Hypokalemia can be caused by the use of diuretic medications such as furosemide (Lasix). Signs of hypokalemia include the cardiac rhythm disturbances noted previously and muscle weakness. In addition, a metabolic alkalosis is found when the results of an arterial blood gas analysis are interpreted. Be prepared to recommend the administration of potassium if the serum level is low.

2. Chloride (Cl−)

Hyperchloremia is a high blood level of chloride, which causes significant prolongation of the ST segment and the QT interval on the ECG. Hypochloremia is a low blood level of chloride, which shortens the QT interval and perhaps widens and rounds off the T waves on the ECG.

3. Sodium (Na+)

Hypernatremia is a high blood level of sodium. It might be seen in a patient who is dehydrated or who has lost many gastrointestinal secretions because of vomiting, nasogastric tube drainage, or diarrhea. Hyponatremia is a low blood sodium level, which might be seen in a patient who is fluid overloaded.

4. Bicarbonate (HCO3−)

Altered bicarbonate levels are commonly seen in patients with pulmonary conditions. The kidneys of patients with a chronically elevated arterial partial pressure of carbon dioxide (Paco2) typically retain bicarbonate to moderate the respiratory acidosis caused by the elevated carbon dioxide level. Conversely, the kidneys of patients with a chronically decreased Paco2 level excrete bicarbonate to moderate the respiratory alkalosis caused by the decreased Paco2 level.

5. Calcium (Ca++)

Hypercalcemia is an elevated calcium level, which may be associated with patients taking diuretics. ECG changes associated with an increased calcium level include a shortened QT interval and widened, rounded T waves. Hypocalcemia is a decreased calcium level. It causes ECG changes such as lengthening of the S-T segment and the QT interval.

6. Glucose

The blood glucose level is important to monitor, because it directly relates to how much glucose is available to the patient for energy for daily activities. The normal values are listed in Table 1-4. Hypoglycemia is a low blood level of glucose; it can mean that the patient is malnourished. Hyperglycemia is a high blood level of glucose; this may indicate that the patient has diabetes mellitus or Cushing’s disease or is being treated with corticosteroids. More specific testing must be done to prove the diagnosis.

4. Complete blood count

a. Review the results of the patient’s complete blood count (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

b. Recommend a complete blood count for additional data. (Code: IC1) [Difficulty: WRE: R, Ap, An]

A complete blood count (CBC) is routinely done for all hospitalized patients, as well as for patients seen for a variety of illnesses and for routine physical examinations. The red blood cell (RBC, or erythrocyte) count, white blood cell (WBC, or leukocyte) count, and differential (Diff) provide a great deal of information about the hematologic system and many other organ systems.

The key normal values for the RBC count are listed in Table 1-5. The hemoglobin and hematocrit values also are important, because they directly relate to the patient’s oxygen-carrying capacity. Decreased hemoglobin and hematocrit values indicate that the patient is anemic. An anemic patient has less oxygen-carrying capacity, and as a result, more stress is placed on the heart during exercise. Hypoxemia resulting from a cardiopulmonary abnormality places this patient at great risk. A transfusion is indicated if the hematocrit is below the level the physician considers clinically safe.

TABLE 1-5 Normal Hemoglobin, Hematocrit, and Red Blood Cell Counts for Adults and Children *

image

An increased number of circulating erythrocytes indicates that the patient has polycythemia. When this is seen as a response to chronic hypoxemia from COPD, cyanotic congenital heart disease, or another disorder, it is labeled secondary polycythemia. This patient is at added risk because the thickened blood causes an increased afterload against which the heart must pump. These patients also are more prone to blood clots. With supplemental oxygen or other clinical treatment to increase the arterial partial pressure of oxygen (Pao2) to at least 55 to 60 torr, the erythrocyte and hematocrit levels, over time, return to normal.

The key normal leukocyte count and differential are listed in Table 1-6. A normal leukocyte count and a normal differential reveal two things about the patient. First, no active bacterial infection is present. Second, the patient’s body is able to produce the normal number and variety of WBCs to combat an infection.

TABLE 1-6 White Blood Cell and Differential Counts*

WHITE BLOOD CELL COUNT (mm3)
Adult 4,500-11,000
Infant and child 9,000-33,000
DIFFERENTIAL COUNT
Segmented neutrophil 40%
Lymphocytes 20%
Monocytes 2%
Eosinophils 0%
Bands 0%
Basophils 0%

* These values may vary somewhat among references.

A mild to moderate increase in the leukocyte count is called leukocytosis. It is seen as a WBC count of 11,000 to 17,000 per cubic millimeter (mm3). Usually, the higher the count, the more severe the infection. A WBC count above 17,000/mm3 is seen in patients with severe sepsis, miliary tuberculosis, and other overwhelming infections. When a patient has an acute, severe bacterial infection, the WBC differential count shows an increased number of neutrophils. Exceptions to this are patients who are elderly, those who have acquired immunodeficiency syndrome (AIDS), and those with other immunodeficiencies. These patients may have an infection but show only a mildly elevated WBC count.

Leukopenia is a low absolute WBC count of 3,000 to 5,000/mm3 or less. An acute viral infection can cause a mild to moderate decrease in the neutrophil count. A patient with a low WBC count is at great risk of bacterial or other infections.

5. Review the patient’s coagulation study results (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

Coagulation studies are routinely done for many hospitalized patients; for those who are to have surgery; and for those who have or are suspected of having a blood-clotting disorder. Also, many medications speed or slow clotting time (so-called blood thinners). It is important to review a patient’s coagulation studies before drawing a blood sample or performing a procedure that may lead to bleeding. Table 1-7 lists normal coagulation study results. If the patient’s clotting time is increased, the individual is at risk of bleeding. Be prepared to apply pressure to a blood sampling site (especially and arterial one) longer than expected.

TABLE 1-7 Normal Coagulation Study Results

Test Name Normal Value Critical Value
Bleeding time 1-9 min >15 min
Prothrombin time (PT or Pro-time) 11.0-12.5 sec; 85%-100% >20 sec
Partial thromboplastin time (PTT) 60-70 sec >100 sec
Activated partial thromboplastin time (APTT) 30-40 sec >70 sec

6. Gram stain results, culture results, and antibiotic sensitivity results

a. Review the patient’s Gram stain results, culture results, and antibiotic sensitivity results (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

The first step in the microbial analysis of sputum, mucus, or other body fluids or tissues is a Gram stain. Gram staining is a special process for colorizing bacteria that divides them into two groups. Gram-positive (g+) bacteria are stained violet. These are the most common types of bacteria that cause bronchitis and pneumonia. In general, penicillin or related drugs and sulfa-type antibiotics kill gram-positive bacteria. Gram-negative (g−) bacteria are stained pink. These organisms, unfortunately, are found in many of the sickest and weakest patients. Often the only way to kill gram-negative bacteria is with a specific antibiotic to which they have been proven sensitive. So-called broad-spectrum antibiotics, such as tetracycline, also may be used.

After Gram staining of the sample of fluid or tissue, a culture and sensitivity (C & S) study is performed. Culturing involves actively growing the organism or organisms to determine what they are. In a sensitivity test, the cultured organism is exposed to a variety of antimicrobial drugs. The goal is to determine which drug or drugs kill the pathogen most effectively. The patient then is treated with that antibiotic. It may take 1 to 3 days to get back the C & S results.

Gram staining cannot be used to identify Mycobacterium tuberculosis (TB) bacteria. Instead, the Ziehl-Neelson stain must be used. This is an acid-fast stain, and it gives the TB bacteria a red coloration. Other pathogens, such as viruses, protozoa, and fungi, cannot be identified by Gram staining. Protozoa and fungi must be identified with specialized stains. Fungi and M. tuberculosis may take 6 to 8 weeks to culture.

b. Recommend a Gram stain and C & S study for additional data (Code: IC4) [Difficulty: ELE: R, Ap; WRE: An]

Whenever an infection is suspected, it is important to obtain a sample of fluid or tissue from the site in question. This patient material is tested for possible bacterial infection by Gram staining and C & S study. Whenever bronchitis or pneumonia is suspected, it is important to obtain a mucus or sputum sample for evaluation. A sample of mucus suctioned from the lungs should show only pulmonary organisms. Sputum is the mix of mucus from the lungs and saliva from the mouth; therefore the organisms found in it may have come from either place. If the patient has pleural fluid, that also must be sampled. Often a blood sample also is taken to look for evidence of septicemia.

Note: The following two items have been listed as testable on the previous NBRC Content Outlines. They are included here in case they are tested again.

7. Review the patient’s urinalysis results

A urine sample routinely is taken from every patient admitted to the hospital and from pregnant women and presurgical patients. Much information about the functioning of the kidneys and other metabolic processes can be gathered from the urinalysis results. A urinalysis also is done for diagnostic purposes in patients with abdominal or back pain, hematuria, and chronic renal disease. Table 1-8 lists the normal findings for a urinalysis. Any abnormal findings should be further investigated to discover the cause.

TABLE 1-8 Normal Urinalysis Results

Test Item Normal Value
Appearance Clear
Color Amber yellow
pH 4.6-8.0 (average 6.0)
Specific gravity Adult: 1.005-1.030 (usually 1.010-1.025)
Newborn: 1.001-1.020
White blood cells 0-4
Red blood cells 0-2

8. Review the patient’s pleural fluid study results

If a patient has had a thoracentesis procedure to remove pleural fluid, the fluid is sent to the laboratory for further analysis. The fluid may turn out to be watery, bloody, infected, or lymphatic. See Chapter 18 for a complete discussion of the types of pleural fluids.

MODULE B

RADIOGRAPHIC IMAGING

Note: It is beyond the scope of this text to cover all the features of normal radiographic images. Review standard textbooks for this as needed. This discussion is limited to items listed as testable by the NBRC.

1. Review the patient’s imaging findings (Code: IA6) [Difficulty: ELE: R; WRE: Ap]

Look for the results of radiographs (x-rays), computed tomography (CT) scans, and magnetic resonance imaging (MRI) studies of the chest or upper airway. If possible, view these results to gain a better understanding of the patient’s condition. (Although not specified by the NBRC, the following should be studied, if possible: positron emission tomography [PET] scans, ventilation/perfusion [V/Q] scans of the lungs, angiograms, and barium swallow studies.)

2. Recommend radiographic and other imaging studies to obtain additional data (Code: IC2) [Difficulty: ELE: R, Ap; WRE: An]

a. Chest radiograph

A chest radiograph should be recommended in the following situations:

• After an endotracheal or tracheostomy tube has been placed or repositioned
• After the jugular/subclavian route has been used to insert a central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter
• After a chest tube has been placed in the pleural space to remove air or fluids
• Hemoptysis (bloody sputum) is noted
• A sudden deleterious change is noted in the patient’s cardiopulmonary condition
• The balloon on the pulmonary artery (Swan-Ganz) catheter has been inflated for a prolonged period, and a pulmonary infarct is suspected
• A pneumothorax is suspected

Exam Hint 1-2 (ELE, WRE)

Expect to see at least one question on the Entry Level Examination and the Written Registry Examination in which the respiratory therapist should recommend a chest radiograph to rule out or confirm a pneumothorax. Signs and symptoms that the patient may have a pneumothorax include the following: sudden chest pain with an increase in dyspnea and shortness of breath (SOB), absent breath sounds over a lung field, tracheal deviation and heart sounds shifted to the side opposite the pneumothorax, asymmetrical chest movement, hyperresonant percussion noted over the pneumothorax, a sudden increase in peak pressure or plateau pressure or both on the patient’s ventilator, or air in the soft tissues, or a combination of these.

b. Upper airway radiograph

An upper airway radiograph (anterior or lateral or both) should be recommended for a patient who presents with indications of upper airway obstruction. This can include:

• Aspirated foreign body
• Laryngeal edema
• Laryngeal tumor
• Laryngotracheal bronchitis (LTB or croup) versus epiglottitis (see Module H for more information)

c. CT scan

A CT scan provides a more detailed image than a conventional radiograph. It is able to depict abnormalities of the lungs and mediastinum. Indications include, but are not limited to, the following:

• Tumor
• Hematoma
• Abscess and cyst
• Pleural effusion
• Aortic or other vascular abnormalities (after an intravenous contrast material has been administered)

d. MRI scan

An MRI scan provides images of body organs without the use of radioactive materials. The images are created when the powerful magnet of the MRI machine is turned on and off, affecting the way hydrogen atoms align within the body. A limitation of MRI is that the patient cannot have any metallic implants. In addition, most mechanical ventilators cannot be used during an MRI scan because the magnetic field will interfere with the unit. Indications for an MRI scan include, but are not limited to, the following:

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