Case 1
Airway (A)
✅ Patent
✅ Spontaneous Ventilation (SV)
Breathing (B)
SpO₂: 86%
FiO₂: 2L via nasal specs
Respiratory Rate (RR): 26
Clinical Findings:
Accessory muscle use
Apical breathing pattern
No tactile fremitus
No sputum
Weak cough
Auscultation: Diminished breath sounds bilaterally
Arterial Blood Gas (ABG): Type I respiratory impairment
Chest X-Ray (CXR): Reduced expansion bilaterally
Circulation (C)
Heart Rate (HR): 135
Blood Pressure (BP): 142/92
Temperature: 37.1°C
Urine Output (UO): Good
Fluid Balance (FB): -540 mL
Capillary Refill Time (CRT): <2s
White Cell Count (WCC): Normal
C-Reactive Protein (CRP): Slightly raised
Disability (D)
Alertness: ACVPU
Pain: Complains of pain VAS 8/10
Exposure (E)
Wound: Abdominal wound with dressing
Drains & Catheters:
Abdominal drain
Catheter
Management:
IV fluids
Patient-controlled analgesia (PCA)
Appearance: Slightly pale and clammy
History
History of Presenting Complaint (HPC):
Had a laparotomy and abdominal exploration 2 days ago
Past Medical History (PMH):
Crohn’s Disease
Case 1 Problem list
- Low SpO₂ & Type 1 Respiratory Impairment – SpO₂ 86% despite O₂ therapy, ABG confirms hypoxemia, likely due to post-op reduced lung expansion and pain.
- Increased Work of Breathing (WOB)– RR 26, accessory muscle use, and diminished breath sounds indicate respiratory distress from pain, reduced lung compliance, or fluid shifts.
- Weak Cough– Pain limits effective secretion clearance, increasing risk of atelectasis/pneumonia.
- Reduced Lung Volume – CXR shows reduced expansion bilaterally, suggesting shallow breathing and atelectasis risk.
- Cardiovascular (CV) Instability – HR 135, BP 142/92, pale/clammy, mild hypovolemia (-540mL balance) suggest stress response or fluid shifts.
- Pain – VAS 8/10, limiting deep breathing, mobility, and recovery.
Case 1 Clinical impression
Loss of volume secondary to abdominal surgery and post-operative pain
Case 1 treatment plan
- Increase Fi02 to reach target Sp02
- Medical management of pain (encourage use of PCA)
- Positioning and Cs! Upright positioning enhances lung expansion, circulation, and secretion clearance.
- ACBT (focus onTEE) Improves lung volume and secretion clearance.
- Incentive spirometer -Encourages deep breathing to prevent atelectasis.
- IPPB intermittant positive pressure breathing- Enhances lung expansion and clearance.
- Mobilise
Case 2
Airway (A)
✅ Patent
✅ Spontaneous Ventilation (SV)
Breathing (B)
SpO₂: 86%
FiO₂: 2L via nasal specs
Respiratory Rate (RR): 26
Clinical Findings:
Accessory muscle use
Apical breathing pattern
Tactile fremitus present
Thick, green sputum
Weak cough
Auscultation:
Bilateral breath sounds throughout
Coarse crackles on the left side
Arterial Blood Gas (ABG): Type I respiratory impairment
Chest X-Ray (CXR): Left lower lobe (LLL) consolidation
Circulation (C)
Heart Rate (HR): 135
Blood Pressure (BP): 142/92
Temperature: 37.8°C
Urine Output (UO): Good
Fluid Balance (FB): -540 mL
Capillary Refill Time (CRT): <2s
White Cell Count (WCC): Elevated
C-Reactive Protein (CRP): Elevated
Disability (D)
Alertness: ACVPU
Pain Score: Complains of pain VAS 8/10
Exposure (E)
Wound: Abdominal wound with dressing
Drains & Catheters:
Abdominal drain
Catheter
Management:
IV fluids
Patient-controlled analgesia (PCA)
Appearance: Slightly flushed and clammy
History
History of Presenting Complaint (HPC):
Had a laparotomy and abdominal exploration 2 days ago
Past Medical History (PMH):
Crohn’s Disease
Bronchiectasis
Case 2 problem list
Low SaO₂ & Type I Respiratory Impairment
* SpO₂ 86% despite O₂ (FiO₂ 2L), ABG confirms hypoxemia.
* LLL consolidation on CXR reduces gas exchange.
Increased Work of Breathing (WOB)
* RR 26, accessory muscle use, apical breathing → signs of respiratory distress.
* Weak cough → risk of fatigue & worsening failure.
Sputum Retention
* Thick, green sputum with tactile fremitus, coarse crackles → impaired clearance.
* Risk of infection & worsening lung function.
Cardiovascular (CV) Instability
* HR 135, BP 142/92, flushed → possible infection, stress response, or dehydration.
* Negative fluid balance (-540 mL) suggests fluid shift post-op.
Infection
* Elevated WCC & CRP → suggests pneumonia or post-op infection.
* Recent laparotomy increases risk.
Pain
* VAS 8/10 → limiting deep breathing & coughing.
* * Poor control → worsens WOB, secretion clearance, and CV stress.
Case 2 clinical impression
Post-operative chest infection with sputum retention as a result of:
- Effects of general anesthesia (GA)
- Pain affecting the ability to deep breathe and cough
- History of bronchiectasis
Case 2 treatment plan
- Increase FiO₂ ± Humidification→ Improve oxygenation & secretion clearance.
- Encourage PCA Use → Optimize pain relief for better breathing & airway clearance.
- Positioning → Improve ventilation & secretion drainage.
- Airway Clearance (ACBT - FET & Coughing)→ Mobilize secretions & expand lungs.
- Manual Techniques (MTs) → Assist in sputum mobilization.
- Nebulizers (Nebs) → Hydrate airways, reduce inflammation.
- PEP Device / Bubble PEP → Aid airway clearance & lung recruitment.
- Cough Assist / Suction → Support weak cough & secretion removal.
Case 3
A - Airway
Patent
Spontaneous Ventilation (SV)
B - Breathing
SpO₂: 86% (on FiO₂ 2L via nasal specs)
Respiratory Rate (RR): 26
Signs of Respiratory Distress:
Accessory muscle use
Apical breathing pattern
Tactile fremitus
Frothy white sputum
Good cough
Auscultation: Bilateral breath sounds throughout, end-inspiratory crackles bibasally
Arterial Blood Gas (ABG): Type I Respiratory Failure
CXR Findings:
Enlarged heart
Small bilateral pleural effusions
Diffuse increased lung markings bilaterally (‘batwing’ appearance)
C - Circulation
Heart Rate (HR): 135
Blood Pressure (BP): 142/92
Temperature: 36.8°C
Urine Output (UO): Poor
Fluid Balance (FB): +1700mL
Capillary Refill Time (CRT): <2 seconds
Blood Results:
WCC: Normal
CRP: Slightly elevated
D - Disability
ACVPU Score: Alert
Pain Score: 3/10 (VAS)
E - Exposure
Abdominal wound (covered with dressing)
Abdominal drain in situ
Catheter present
Receiving IV fluids
PCA (Patient-Controlled Analgesia) in use
Pitting edema extending to thighs
History
HPC (History of Presenting Complaint)
Underwent laparotomy and abdominal exploration 2 days ago
PMH (Past Medical History)
Crohn’s Disease
Myocardial Infarction (MI) 1 year ago
Heart Failure
Case 3 problem list
- Low SaO₂ & Type 1 Respiratory Failure – Due to pulmonary edema from heart failure and post-op fluid shifts.
- Increased Work of Breathing – Accessory muscle use, apical breathing, and crackles indicate distress.
- Frothy White Sputum – Suggests pulmonary edema.
- CV Instability – Tachycardia, high BP, poor urine output, and fluid retention.
- Fluid Overload – Positive fluid balance, pleural effusions, and pitting edema.
Case 3 clinical impression
Pulmonary edema in a post-operative patient with a cardiac history.
Treatment Plan:
✅ Increase FiO₂ to achieve target SpO₂
✅ Optimize positioning for better oxygenation
✅ Medical management of fluid overload
✅ Initiate CPAP therapy as needed
Case study 4
Airway (A)
Patent
Spontaneous Ventilation (SV)
Breathing (B)
- SpO₂: 83%
- FiO₂: 40% via Venturi Mask
- Respiratory Rate (RR): 30
Observations:
- No accessory muscle use
- Apical breathing pattern with equal expansion
- Tactile fremitus present
- Unable to cough
Auscultation:
- Coarse crackles transmitted throughout
Arterial Blood Gas (ABG):
- pH: 7.31
- pO₂: 8.5
- pCO₂: 9.0
- HCO₃: 29
- Base Excess (BE): 3.1
Chest X-ray (CXR):
- Bilateral patchy opacification with air bronchograms
Circulation (C)
Heart Rate (HR): 100 bpm
Blood Pressure (BP): 95/42 mmHg
Temperature: 38.9°C
Urine Output (UO): 20 ml/hr
Capillary Refill Time (CRT): >2 seconds
Blood Markers:
- White Cell Count (WCC): 54
- C-Reactive Protein (CRP): 200
Disability (D)
Consciousness: AcVPU
Pain Score: 2/10 on Visual Analog Scale (VAS)
Exposure (E)
Findings:
Abdominal wound with dressing
Abdominal drain present
Urinary catheter in place
IV fluids administered
Patient-Controlled Analgesia (PCA)
Slightly flushed appearance
Slumped in bed
History of Presenting Complaint (HPC):
Underwent laparotomy and exploration 2 days ago
Past Medical History (PMH):
Crohn’s Disease
Motor Neuron Disease (MND)
Case 4 problem list
- Low SpO₂ on oxygen – The patient has low oxygen saturation despite being on supplemental oxygen, indicating respiratory compromise.
- Sputum retention – Due to neuromuscular weakness (MND), the patient is unable to cough effectively, leading to mucus buildup.
- Type 2 respiratory failure (partially compensated) – Elevated pCO₂ with low pO₂ suggests ventilatory failure, likely due to weak respiratory muscles.
- Reduced lung expansion – Apical breathing pattern and inability to cough suggest decreased lung compliance and ventilation.
- High respiratory rate (RR) – Tachypnea (RR 30) indicates increased respiratory effort, possibly due to hypoxia or infection.
- Cardiovascular instability (CV unstable) – Hypotension (BP 95/42) and signs of sepsis (high WCC, CRP) suggest hemodynamic compromise.
- Poor urine output (UO) – 20 ml/hr suggests possible dehydration, shock
Case 4 clinical impression
Post-op chest infection and sputum retention causing Type 2 Respiratory Failure (T2RF) due to neuromuscular weakness secondary to MND
Case 4 treatment plan
- Increase oxygen – NRBM (Non-Rebreather Mask) – To improve oxygenation and address hypoxia.
- Positioning – Optimizing posture to enhance lung expansion and secretion clearance.
- MTs (Manual Techniques) – Techniques like percussion and vibrations to help clear retained sputum.
- ?ACBT (Active Cycle of Breathing Techniques) – Possible breathing exercises to improve secretion clearance.
- Nebs (Nebulizers) – Likely bronchodilators or saline to loosen secretions.
- Cough assist – Mechanical assistance to improve cough effectiveness in clearing secretions.
- Manually assisted cough – Caregiver-assisted technique to aid mucus clearance.
- Suction – Direct removal of secretions to prevent airway obstruction.
- BiPAP (Bilevel Positive Airway Pressure) – Non-invasive ventilation to support breathing and offload respiratory muscles.**
