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Real Life Clinical Scenario From a Respiratory Therapist

Have you been wondering how exactly a respiratory therapist helps someone to breathe? I will present you with a clinical scenario so that you can follow a patient from beginning to end.

Mr. T. is admitted to the emergency room (ER) with difficulty breathing. His respiratory rate is 40 (normal is 16-20), his lips are cyanotic (lips are blue) and his oxygen (O2) saturation is 85% (normal is 93-100%). The first thing you will do is place him in oxygen to bring up his O2 saturation (O2 Sat). The O2 Sat is measured via oximetry (an infrared finger probe that senses how saturated the blood hemoglobin is with O2).

You will assess his lung sounds and give him a nebulizer treatment with a bronchodilator. The ER doctor will want an arterial blood gas (ABG). You will draw the blood sample from either the radial artery in the wrist or brachial artery in the arm. You place the ABG sample on ice and then walk it to the blood gas lab to run it in a blood gas analyzer.

These results will give you and the doctor a clear picture as to what is causing the patient such distress. An ABG will give you levels of: pH, O2, carbon dioxide (CO2), bicarbonate, and base excess, These numbers will tell you if the patient is unable to manage ventilating (moving air) to cause the exchange of gases in the lungs. The kidneys also help to rid the body of unwanted acids in the body (CO2).

We want the O2 to get in and the CO2 to get out. Someone in respiratory distress will have a high CO2 level because they are not ventilating (moving air) to blow off the CO2 (remember it’s a waste). They also may not be oxygenating well secondary to poor gas exchange caused by pneumonia (fluid consolidation in the lungs) or congestive heart failure (CHF), which is caused when the kidneys are tired or malfunctioning and they are not able to rid the body of unwanted fluid.
Of course, there are other clinical reasons but we will stick with the most common for now.

If the chest x-ray (CXR) comes back positive for pneumonia then the patient will start on antibiotics immediately to clear up this infection. If the CXR shows CHF then the patient will receive diuretics to decrease the amount of fluid in the body. In this case it means the patient will pass urine more than normally to reduce the fluid on board in the body. While the patient is receiving these medications you closely observe his or her oxygenation via oximetry (O2 Saturation). You titrate (adjust) the patient’s oxygen liter flow so he or she is getting only the amount of oxygen that they need. Oxygen is a drug and is prescribed by the physician. You give respiratory medications to the patient’s to help ease their work of breathing as they heal. At each stage of this you document everything in the patient’s medical record.

You educate your patient so he or she will understand what is happening in their body and tell them what they can expect as they begin to feel better and think about going home. If they smoke you offer smoking cessation counseling and refer them to a transitional care/rehabilitative facility if they need to recover from de-conditioning following their illness.

Of course, throughout this entire scenario you are communicating with the doctors and nurses so that you are all working toward the common goal of making your patient well.