Case studies Unit 1

Name: roster # Date: 2006

Case study # 1:Mr. Murphy

Your patient is a 45-year-old white male [WM] who has a chest tube between the 2nd the 3rd ribs in the anterior of his left chest. The chest tube is draining blood and air from the pleural space. Before the chest tube was put in, Mr. Murphy’s skin was sweaty and dusky looking. We know he was working hard to breathe, because Mr. Murphy had intercostal and substernal retractions. Mr. Murphy’s respiratory rate was rapid at 40 bpm but dropped down to 25 bpm after the tube was placed and he was placed on supplementary 02 by nasal cannula at 4 lpm.

  1. Describe the effect this disease/problem creates on his ability to breathe? To cough?
  2. The addition of blood & air into the pleural cavity will:
  3. reduce the size of the lung tissue right next to it which will make it stiffer and less compliant,
  4. it will prevent the lung from adhering to the chest wall as it rises so that the patient will have to create a higher driving pressure which will increase his WOB,
  5. the fluid & air will stimulate the pain receptors so that the patient may refuse to take a deep breath to cough effectively.
  1. Explain why we saw retractions over his chest. What causes retractions?
  2. Because this patient’s stiff lungs have decreased compliance, the driving pressure he needs to inhale the same volume has to increase and to do this he must create more negative pressure inside the thorax.
  3. The soft tissue in the intercostal spaces will collapse as the negative intrathoracic pressure rises.
  1. Why did the respiratory rate change after we placed the chest tube? The normal respiratory rate is 12-20 bpm. [reference: Wilkins’ assessment]
  2. If he is unable to breathe deeply when his lung was compressed, to maintain his VE, Mr. Murphy must breath faster.
  3. Once the problem was solved, his RR should return to normal
  4. Starting him on supplementary oxygen also will reduce his RR
  1. Which lung lobe[s] might start to collapse first under these conditions?
  2. The chest tube was placed in the chest over the LUL to drain the air and fluid found there, so we expect the LUL to have a degree of atelectasis [collapse.]

Case study # 2 Miss Rustin

Your patient is a 33-year-old black female [BF] who has broken ribs # 3-6 on the right side of the sternum. When Miss Rustin breaths in, you see that while the rest of her chest rises and spreads out, where the ribs are broken, her chest dips down into the thorax on inspiration. Miss Rustin’s respiratory rate is rapid at 29 bpm.

  1. Describe the effect this disease/problem creates on her ability to ventilate. To cough?
  2. When her rib cage attempts to move up and out, only part of it rises, so that as the intrathoracic volume fails to rise, driving pressure cannot be created, so that this patient cannot move air well.
  3. If she cannot take a deep breath, she cannot cough
  4. Why are we seeing the rib cage move abnormally? [hint: this is similar to retractions]
  5. The detached portions of the rib are sucked in by the increased vacuum created by the patient
  6. Why is her respiratory rate fast?
  7. Because her VT is so low, her RR must rise to keep the VE the same
  8. Which lung lobe[s] might start to collapse first under these conditions?
  9. The RUL and even the superior aspect of the RML could collapse under this circumstances, but if the patient’s ability to create suction is seriously hampered, the lungs in the basal areas [Zone 3] will also collapse because they are harder to inflate normally anyway.

Case study # 3

Your patient is an 18-year-old Latin American male [LAM] who hasaccumulated about a liter of fluid in his pleural spacedue to kidney failure. His respiratory rate is rapid at 31 bpm and he has marked intercostal retractions.

  1. Describe the effect this disease/problem creates on his ability to ventilate. To cough?
  2. reduce the size of the lung tissue right next to it which will make it stiffer and less compliant,
  3. it will prevent the lung from adhering to the chest wall as it rises so that the patient will have to create a higher driving pressure which will increase his WOB,
  4. What would be the effect on his breathing, if this fluid was removed?
  5. It should be easier to breath, because the compliance will return to normal so that the driving pressures will drop
  6. Why do we see retractions?
  7. Because this patient’s stiff lungs have decreased compliance, the driving pressure he needs to inhale the same volume has to increase and to do this he must create more negative pressure inside the thorax.
  8. The soft tissue in the intercostal spaces will collapse as the negative intrathoracic pressure rises.
  9. Which lung lobe[s] might start to collapse first under these conditions?
  10. Due to gravity, we expect the fluid to collect in the basal areas, so the RLL and the LLL will be affected.

Case study # 4

Your patient is a 19-year-old WM who has suffered a motor-vehicle accident [MVA] in which he has ruptured his left diaphragm. You don’t see retractions on the left side, but his respiratory rate is rapid at 33 bpm.

  1. Describe the effect this disease/problem creates on his ability to ventilate. To cough?
  2. His left hemi-diaphragm is damaged so that he cannot increase the intrathoracic volume in order to decrease the pressure to get air into the lungs.
  3. Can he breathe at all without help at this point? Why or why not?
  4. His right hemi-diaphragm is undamaged and because it has a separate nerve, it can work independent of the left.
  1. Why do we not see retractions on the left side? Could this sign be good or not?
  2. If his left hemi-diaphragm cannot drop down to create negative pressure to suck on the intercostal spaces, we will not see retractions on the right.
  3. In this case, the lack of retractions is not a good sign
  4. Which lung lobe[s] might start to collapse first under these conditions?
  5. the left lung will be most effected, and because zone 3 is the hardest to keep inflated under normal conditions we expect the LLL to become collapsed first in this case.

Case study # 5

Your patient is a 44 year-old WF who is admitted to the hospital for observation of an ascending paralysis thatstartedin her feet last night. It has reached her hips and she just started feeling tingling in her lower rib cage. Her respiratory rate at 8 AM was 20 bpm, but at 2 PM, it is now rapid at 25 bpm.

  1. Describe the effect this disease/problem creates on her ability to ventilate. To cough?
  2. If her accessory muscles of inspiration in her chest wall are affected she cannot take a deep breath to cough.
  3. If her abdominal muscles are effected by this paralysis, she will not be able to create the positive pressures she needs to cough,
  4. If the paralysis reaches her diaphragms she will not be able to breath at all
  5. How far could this paralysis go up her spinal cord till she might not be able to cough?
  6. She needs both the abdominal muscles and the chest wall muscles to cough effectively, so if the paralysis reaches the middle to thoracic spinal cord she will be in trouble
  7. How far could this paralysis go up her spinal cord before she couldn’t breathe at all?
  8. The diaphragm is innervated by the cervical spinal cord, so damage up this high will cause the patient to not be able to breath at all
  9. Which lung lobe[s] might start to collapse first under these conditions?
  10. The basal areas are in zone 3 so they will be affected first

Case study # 6

Your patient is a 34 year-old BM who has a chronic neuromuscular disorder. His diaphragm is minimally involved, but his chest wall muscles are quite limited in their action. In fact, his chest wall muscles are so flaccid that his spine has started to curve. His respiratory rate is rapid at 25 bpm and his HR is rapid at 115 bpm. He has a fever.His Sp02 is 89% on nasal cannula at 3 lpm.

  1. Describe the effect this disease/problem creates on his ability to ventilate. To cough?
  2. His muscles in his chest are weak so that he has trouble getting deep breaths
  3. His rib can will be compressed by the spinal curvature so that it will not be able to increase in size as much as it should to create negative pressures needed for deep breaths
  4. While this man might be able to breathe, what serious problem will arise from the weakness in the intercostal muscles?
  5. His intercostal spaces will collapse so that he will need increased WOB to get the lungs inflated and he lacks that ability
  6. Under these circumstances, might the lack of retractions be a good sign or not?
  7. Lack of retractions in a muscular problem is not a sign that things are OK. You have to have muscle strength in order to create the pressures needed to retract soft tissue
  8. Which lung lobe[s] might start to collapse first under these conditions?
  9. He will have trouble with deep breathing so the bilateral basal areas in Zone 3 will be effected most