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Disclaimer:
Medicine and respiratory therapy are continuously changing
practices. The author and publisher have reviewed all information
in this report with resources believed to be reliable and accurate
and have made every effort to provide information that is up to
date with the best practices at the time of publication. Despite our
best efforts we cannot disregard the possibility of human error
and continual changes in best practices the author, publisher, and
any other party involved in the production of this work can
warrant that the information contained herein is complete or fully
accurate. The author, publisher, and all other parties involved in
this work disclaim all responsibility from any errors contained
within this work and from the results from the use of this
information. Readers are encouraged to check all information in
this book with institutional guidelines, other sources, and up to
date information.

This study guide is intended to help prepare users to take

credentialing exams. The information contained therein is not
intended to instruct, recommend, or direct medical practitioners
on how to provide care to actual patients.

All materials published in this study guide are in compliance with

the standards of ethics set forth by the governing testing
authority. This study guide does not disclose any insider exam
information. This content is based upon the content outlines,
specifications, summaries, or matrices published by the testing
authority.

Copyright ã Respiratory Therapy Zone

2
Table of Contents
Introduction .………………………………………………………………………..………………………….……6
CSE Test Preparation .……………………………………………………..………………………….……13
Scenario .………………………………………………………………………………………………………….……15
Information Gathering .……………………………………………………….…………………….……16
Decision Making .…………………………….………………………………..………………………………20
Pathology & Disease Management .….……………………..……………………..….……25
COPD (Conservative) .…………………………….……………………..……….………………….……26
COPD (Critical Care) .…………………………….……………..………..……….………………….……34
Trauma Cases .…………………………….……………..………..……………………………………….……39
Chest Trauma .…………………………….……………..…………………….……….………………….……40
Pneumothorax/Hemothorax .…………………………….……………..………..………….…..42
Burns/Smoke Inhalation .…………………………….……………..………..……….………………46
ARDS .…………………………….……………..……………………………………..……….………………….……48
Neuromuscular Disorders .…………………………….……………...………..……………….……51
Myasthenia Gravis .…………………………….…………………..……....……….………………….……52
Guillain-Barré Syndrome .…………………………….……………..……....……….…..…….……54
Drug Overdose .…………………………….……………..………..………………….………………….……56
Muscular Dystrophy .…………………………….……………..………..……….………………….……58
Stroke .…………………………….……………..………..……….………………………………………..…….……59
Tetanus .…………………………….……………………………………...………..……….………………….……60
Cardiovascular Diseases .…………………………….……………..………………….………….……61
Congestive Heart Failure .…………………………….……………..……….………………….……63
Myocardial Infarction .…………………………….……………..……...……….………………….……66
Shock .………………………………………………………….……………..………..……….……..………….……68
Cor Pulmonale .…………………………….……………..………..……….…………………………….……70
Pulmonary Embolism .…………………………….……………….…..……….……………….….……71
Pediatric Diseases .………………………..……….……………..………..……….………………….……73
Croup and Epiglottitis .…………………………….………...…..………..……….…………..….……74
Bronchiolitis .…………………………….……………..………….…………………….………………….……78

3
Cystic Fibrosis .…………………………….……………………..…..………..……….……..………….……80
Foreign Body Aspiration .…………………………….……………..……..….………………...……82
Neonatal Diseases .…………………………….….……………..………..……….………………….……84
Delivery Room Management .…………………………….……………..………………….……85
Meconium Aspiration .…………………………….……………..………..……………………….……87
Apnea of Prematurity .…………………………….……………..…….……….………………….……89
IRDS .…………………………….………………………………………..…..………..……….………………….……90
Congestive Heart Defects .…………………………………..………..……….…………….….……92
Bronchopulmonary Dysplasia .…………………………….…………....………………….……95
Congenital Diaphragmatic Hernia .………………………………….………………….……97
Other Adult Medical Conditions .…………………………….…………..……………….……99
Sleep Disorders .………………………………….….……………..………..……….….…………….……100
Hypothermia .…………………………….……………………..…..………..……….………………….……103
Pneumonia .…………………………………………………………..………..……….………………….……105
AIDS .…………………………….……………..……………………………………..……….………………….……107
Renal Failure (Diabetes) .…………………………….……………..……….………………….……108
Thoracic Surgery .…………………………….……………..………..………...….………………….……109
Head Trauma .………………….…………………….……………..………..……….……….………….……110
Spinal Cord Injuries .…………………………….……..………..………..……….…………..…….……112
Normal Values .…………………………….……………..…………………..……….………………….……113
Conclusion .…………………………….……………..…………………..……….…………..…………….……122
Appendix A .……………………………….……………..…………………..……….…………………….……125
References .…………………………….……………..…………………..……….………….…………….……126

4
“Breathe easy.”

5
Introduction

First and foremost, if you’re reading this right now then it most
likely means that you’ve already passed the TMC Exam.
Congratulations! That is an amazing accomplishment and it
means that you’re one step closer to becoming a Registered
Respiratory Therapist.

And I just want to say thank you for choosing this study guide as
your resource to prepare for the Clinical Simulations Exam. The
goal is to help you pass the exam on your very first attempt. This
study guide is designed to make learning easier for you because
the information is coming from the point of view of a Respiratory
Therapist who was recently in your shoes — not from a
professional textbook author or writer.

This study guide has the most current information needed to

prepare for the CSE. It covers all the information you will be
expected to know for the exam by the NBRC including how to
prepare adequately and even some tips and tricks on how to
study effectively.

You have already graduated from an accredited Respiratory

Therapy Program (or you’re about to), so this study guide isn’t
designed to re-teach that information over again. We’re assuming
that you know and remember most of it! This study guide does,
however, contain a condensed version of all the information you
need to know to be successful when you take the CSE.

To pass this exam, it will take a lot of hard work and dedication
from you. Read and learn this information. Then do it all over
again. Yes, it is hard, but I have faith in you. I know that you can do
this!

I truly hope that you will be able to use this study guide as a
means to pass the exam and earn your RRT credentials. I wish you
nothing but the best of luck! Now let’s get started! J

6
About the Clinical Simulations Exam
As I’m sure you already know, the CSE has a much different
structure than the TMC Exam. Yes, the CSE shares the same
topical content with the TMC. The difference is — if you only
master the topical content alone, you will not get you a passing
score because the CSE also tests your case-management abilities.

Our goal in this study guide is to help you master both — the
content and the comprehensive abilities you need to pass the
exam.

Clinical Simulation Exam Rules

The test is fully computer-based, and you will have four hours to
take the exam.

There will be a total of 22 problems on the exam that are selected

from 8 different categories. Two of the problems are pretested
scenarios that are individually scored based on the judgment of
the NBRC committee.

Each problem represents a clinical setting or patient situation that

is designed to simulate real-life situations in the clinical practice of
respiratory care.

You will not be able to bring a calculator to use for the exam. A
pencil and a sheet of scratch paper will be provided for you. No
outside notes or books are allowed. You must return your scratch
paper after completing the exam.

No personal belongings are allowed in the testing area. You will

need to leave them in your car.

You may leave the testing area at any time to stretch or use the
restroom. Keep in mind, though, that your test timer will not stop.

7
Be on time. If you arrive more than fifteen minutes late, you will
not be admitted to take the exam.

You will need to show two forms of identification, with at least one
showing a current photograph. Both forms must be current and
must include a signature. Forms that are accepted include:
• Driver’s license
• State I.D. card
• Valid passport
• Military I.D. card

What are the admission requirements for the

Clinical Simulation Exam?
To be eligible to take the CSE, you must have obtained the CRT
credential by successfully passing the TMC Exam (Therapist
Multiple-Choice Examination) with the high cut score.

This is the basic qualification for most students, although there are
others that can be found on the NBRC website.

Be aware of the 3-year time limit!

You must pass the Clinical Simulation Exam within three years
after graduating for a CoARC accredited Respiratory Therapy
Program.

If you do not pass it within this time limit, you will be required to
retake (and pass) the TMC Exam again at the high-cut score to
regain eligibility.

Outside of the three-year time frame, any previous passing

performance to earn the RRT credential is nullified — so please be
aware of this!

8
How much does it cost to take the Clinical
Simulation Exam?
The exam costs $200 for both new and repeat applicants. I realize
that this is a significant investment, which is why it is our goal to
help you pass the exam on your next attempt.

We’ve done our part by providing you with the information that
you need (in this study guide). Now it’s up to you to put in the
work!

What content will be on the CSE?

As we’ve already discussed, the same content that was on the TMC
Exam will be on the CSE as well. They just ask it to you in a totally
different way.

Not to worry — we will cover it all inside of this study guide. A big
focus of this study guide will be on Pathology. We will dive in to
the specific diseases that you must know and how to treat these
patients effectively.

That is the major focus of the CSE — like it or not.

The NBRC put out a detailed content outline of exactly what to

look for on the CSE.

I highly recommend that you take a look over it and you can do so
by visiting this link.

How are the problems structured on the CSE?

The CSE is designed to evaluate your patient management skills
and ability to evaluate ongoing treatment, recommend changes,
and adapt to circumstances and events.

9
So in order to accomplish this, they have laid out the problem in a
completely different way compared to the traditional multiple-
choice layout that we’re all accustomed to.

Here is an example of how the problems will be structured on the

computer screen:

Photo example by the NBRC.

As you can see, 3 windows will appear on the screen at all times
during the exam.

1) There is a window with the “Scenario” at top of the screen, and

your picture will be displayed in the upper right-hand corner of
this window.

Each simulation begins with a brief paragraph in this window that

provides preliminary information about the patient. The following
sections will contain information about the changing patient
situation in this window as well.

10
Each Scenario Window will also provide you with specific
instructions about whether to “CHOOSE ONLY ONE” response in
the section or to “SELECT AS MANY” responses as appropriate to
gather information.

It is super-important that you follow these directions!

2) The “Options” window is displayed in the lower left portion of

the screen. This window contains all options, choices, or possible
responses that you can choose from.

You select an option by clicking the check box next to the option.

3) The “Simulation History” window is displayed as the lower right

portion of the screen. This window shows the options chosen in
the current section and the results for each choice are displayed in
this window.

It also shows the “Simulation History” from all previous sections as

well as the options chosen.

Basically, it helps you see the results that you selected already, in
case you forgot.

When you are finished with a particular section, you can hit the
“Go To Next Section” button at the bottom left of the screen to
continue to the next section.

A box will pop up requesting that you confirm your wish to

continue to the next section. Be sure to only click the “Yes” button
when you are 100% ready to proceed to the next section, because
you can’t go back.

A timer button is shown in the lower right portion of the screen

and displays the time remaining for the exam. You may hide the
time remaining button if you wish, simply by clicking it.

11
What are the components of a Clinical Simulation
Problem?
There are (3) components of each CSE problem, and they are:

1. Scenario – This establishes the setting and general

parameters of the patient and (you) the Respiratory
Therapist.
2. Information Gathering – This section provides information
about the patient that is normally obtained in chart review or
diagnostic testing, such as vital signs, ABG results, etc.
3. Decision Making – This is the decision point that you will
need to recommend what happens next for the patient.

After being given the Scenario, you use the Information Gathering
section to access the patient and make an analysis and evaluation
according to the information that is provided. Then, in Decision
Making, you must decide what type of therapy or response is best
for the particular problem of the patient.

We will discuss each of these 3 components in more detail in the

next section of this study guide.

Be on the lookout for Exam Hints!

These are little boxes you will see through this study guide. Here is
an example:

Exam Hint: These Exam Hint boxes contain some very important
test-taking tips and strategies. You will see them throughout
this study guide.

Pay attention closely to these Exam Hints because they contain

some very helpful and important information. J

12
CSE Test Preparation

We’ve already talked some about the CSE in the Introduction

section. Now let’s dive a little bit deeper.

As I’m sure you know, this exam isn’t cheap to take. That’s why we
want to help you pass on your very next attempt. And in order to
do so, you need to be prepared for this unique exam structure.

As we said, the CSE covers much of the same topical content as

the TMC Exam, they just ask it in a totally different way.

You have to take what you know and apply it to a real-life situation
in order to make a decision to help the patient — just as if it were
in a real hospital.

Exam Hint: This is a little “hack” that I always recommend for

students. Now that you have completed the TMC Exam, you can
take the results score report and use it as a guide to prioritize
what you should focus on for the CSE.

Is there a section that you didn’t do so hot? You may want to

dedicate some extra time looking back over that section.

CSE Disease Categories

Now let’s talk about all the different diseases that you must know
for the exam.

As you know, Pathology is super-important! It’s what you should

spend most of your time on when preparing for the CSE.

We’ll cover each disease in more detail later in this study guide,
but for now, let’s familiarize your brain with all the possible disease
cases that you need to know.

13
Here are the 8 categories that we will be focusing on later in the
Pathology section:

Disease Category # of Cases Examples

COPD 2 Chronic Bronchitis,
(Management) Emphysema,
Asthma, &
Bronchiectasis.
COPD (Critical Care) 2 Mechanical
Ventilation & NIV
management.
Adult Trauma 3 Head or chest injury,
Pneumothorax,
Burns, Drowning
Smoke inhalation, &
Hypothermia.
Cardiovascular 3 CHF, Pulmonary
Diseases Edema, Heart
attack, Coronary
Artery Disease, &
Valvular Hear
Disease.
Neuromuscular 2 Guillain-Barre
Diseases Syndrome,
Myasthenia Gravis,
Muscular Dystrophy,
Stroke, & Drug
overdose.
Pediatric Diseases 2 Croup, Epiglottitis,
Asthma,
Bronchiolitis,
Foreign-body
aspiration, toxic
substance ingestion,
&
Bronchopulmonary
Dysplasia.

14
Neonatal Diseases 2 Meconium
aspiration, Apnea,
Delivery room
management,
Resuscitation, RDS,
& Congenital Heart
Defect.
Adult Medical or 4 Head & Neck
Surgical surgery, Thoracic
surgery, CO
poisoning, & AIDS.

Again, we’ll cover each of these diseases in more detail later on.
But for now, let’s talk about the structure.

CSE Structure
We already talked about this some earlier in the Introduction. But
now, let’s dive deeper into the Scenario, Information Gathering,
and Decision Making.

Scenario

This will describe the physical setting for the patient and you as
the Respiratory Therapist. This could include the hospital or clinic
type, the home, Med-Surg unit, ICU, time or day, etc.

This is also where you will find out the general information about
the patient, including their: age, sex, general appearance, and
general presenting conditions.

You will also learn about the patient’s history and a brief history of
the patient’s active illness or event.

15
 Exam Hint: While reading the Scenario, the first thing you want
to do is interpret if the situation is an emergency! If it is, you
must take immediate action to help the patient.

If you determine that the situation is not an emergency, then

you can proceed to gather more information in order to make a
clinical decision.

Information Gathering
This is the section that you will be directed to in order to find out
more about the patient.

They will list out 15-20 parameters for you to choose from.

For example, you will see vital signs, ABG, PFT, and various lab
studies.

You must select ONLY those that are important for this patient at
this particular time given what you know.

Avoid selecting anything that could be dangerous for the patient.

Also, of course, avoid selecting anything that you know is
unnecessary for the patient at this time.

Select only the desired information!

Once you click an option to make a selection, it will reveal that

results of what you clicked on the screen.

For example, if you select that the patient needs an ABG, as soon
as you click that option, it’s going to show you the patient’s ABG
results on the screen.

16
You can then act immediately, for example, if their results were to
show that they are in respiratory failure. If that were the case, what
would you do?

Of course, you know this — you would want to recommend

intubation and mechanical ventilation.

Exam Hint: This is important, so remember this. During the

Information Gathering, if you can already tell that the situation is
a medical emergency, you should act right then to help the
patient.

If it’s not an emergency, you can proceed to gather more

information.

Order of Progression when making your selections:

When your list of choices is available, there is a specific order that

you should go through when making your selections. I’m going to
share that with you now:

• Visual – first and foremost, you should go through the list a

select the visual things first — meaning the thing you can
see. For example, general appearance, appearance of the
chest, respiratory rate, respiratory pattern, posture,
sensorium, and color.
o These are the things that you can literally see with your
eyes. Choose all of these first. Then ask yourself, “Is there
an emergency?” If not, then move on to the bedside
choices.
• Bedside – Now you can go through the list and select the
choices that can be performed at the bedside. These should
all still be relatively easy to obtain. For example, pulse,
temperature, chest percussion, breath sounds, blood
pressure, heart sounds, tracheal position, and capnometry,
etc.

17
 o These are the things that can literally be done/checked
at the patient’s bedside. After you’ve gone through the
choices, is there an emergency? If no, move on to the
basic lab tests.
• Basic Lab Tests – Now you can select any lab tests that are
necessary for this patient. Examples include ABG, CBC, 12-
lead EKG, Electrolytes, and/or Chest X-ray.
o These are your basic tests that still aren’t difficult to
perform but are only necessary if indicated for some
patients. Still no emergency? Move along to the special
tests.
• Special Tests – Now you can select any special test that is
indicated for the patient. These are very specific and should
only be selected if it’s necessary for this patient’s case.
Examples include lab tests like blood culture, PFTs, imaging
studies like MRIs, CT scans, bronchoscopy, ICP, hemodynamic
monitoring, and specific tests like sweat chloride test for CF,
Apgar score, V/Q scan, etc.
o These tests are very specific for specific patient
situations.

After making all necessary selections, you should interpret the

data and make proper decisions in the next section.

Exam Hint: There are a few options that you should Always
select when they are available. These are quick to obtain and
usually always helpful in identifying the patient’s problem.

Here are some examples: Color/general appearance, respiratory

rate, heart rate, SpO2, blood pressure (if the problem deals with
the heart), body temp (only if an infection is involved), level of
consciousness, breath sounds, and history of present illness.

You should only make selections if they are appropriate for the
situation at hand.

18
For example, you probably don’t need the check any PFT results
for a patient with ARDS.

Not every test should be selected for every patient. Only those that
are pertinent to their situation.

Here are some general tips in regard to Information Gathering:

• Select ABG to assess acid-base balance, oxygenation, or

ventilation.
• Assess the tracheal position to identify atelectasis or a
pneumothorax (Shifts away from the affected side for a
pneumothorax, and it shifts towards with atelectasis).
• Assess percussion to identify a pneumothorax or pneumonia.
• Select an MIP/NIF to assess respiratory muscle strength for
weaning.
• Select Vital Capacity to check respiratory muscle strength for
neurological disorders, and for weaning.
• Select the VE and RSBI to check for the adequacy of
ventilation for weaning.
• Assess the sputum to check for an infection.
• Select certain PFT tests to check to see if the disease is
obstructive or restrictive.
• Again, always select blood pressure for a patient that has a
cardiovascular disorder.
• Select only certain laboratory tests that would be necessary
for the patient’s specific situation. For example, you would
select to assess the WBC count if the patient has an infection.
That would be necessary in that situation.
• The same applies for x-rays and imaging tests. Only select
them when they would help diagnose the patient. For
example, a neck x-ray would be helpful to identify croup or
epiglottitis or to check for a foreign body aspiration.
• Select ICP for a patient with a head or brain injury.
• If the patient is unconscious, a Glasgow Coma Scale would be
necessary.

19
 • Never select Urinalysis. Just skip it unless you want to lose
points. J

These are only just a few tips that I wanted to share with you to
get the ideas flowing in your brain.

We will talk more about these in more detail in the Pathology and
Disease Management sections later on in this study guide.

Decision Making

After you have made your selections in the Information Gathering

section, you will then be directed to the Decision Making section.

This is where you must take what you know from the information
given and make the best possible decision for the patient.

Usually, you will be asked to select the best of 4–5 options.

Keep in mind, sometimes you will have to make the Best Available
selection if the most desired option is not listed.

Once you make the selection, it will usually say: “Physician Agrees.
Done.”

Exam Hint: However, it could possibly say, “Physician Disagrees.

Make another selection.”

Don’t Panic!

Just because it says this does not necessarily mean you are
wrong. Proceed to pick the next best option using the
information that you have available.

20
After you’ve made your decision, you will be taken to the next
scenario. You must then evaluate how the patient responded to
the decisions you previously made.

This pattern between Information Gathering and Decision Making

usually cycles back and forth about 4–5 times for each problem.

You take what they give you, gather the necessary information,
then make the best decision possible for the patient.

Boom, easy peasy!

I hope this simplifies things for you! It’s not as bad as people make
it out to be. You just have to take it one step at a time.

Here are some general tips in regard to Decision Making:

• Always select the Best option that is available to you, even

though the absolute correct answer may not be listed.
• Only select more than one choice if you’re prompted to do
so.
• Be sure to read all of the responses carefully.
• Don’t select any unfamiliar actions. If you do not know what it
means, it’s probably a bad idea to choose that one unless you
can 100% rule out the other choices.
• For wheezing, there could be 3 different causes that require 3
different selections. Recommend a bronchodilator for
bronchospasm. For wheezing with CHF, recommend
diuretics. A child could have wheezing caused by a foreign
body aspiration — in this case, you would recommend a
bronchoscopy.
• For stridor, you would recommend cool mist or racemic
epinephrine.
• If you found rhonchi or tactile fremitus, this means that there
are secretions in the large airways and the patient needs
bronchial hygiene therapy or suctioning.

21
 • A dull percussion note means that there is consolidation — in
this case, recommend lung expansion therapy.
• Does the patient have a weak cough? Then they likely can’t
cough out secretions properly. Recommend bronchial
hygiene therapy or suctioning.
• Is the patient’s secretions yellow, green, or colored? They
have an infection and you should recommend antibiotics.
• Do they have frothy secretions? If so, you automatically know
it’s pulmonary edema and you should recommend BiPAP.
• ABG interpretation is also important! You passed the TMC
Exam, so I know you already know how to do so. Here are
things to keep in mind when interpreting ABGs for the CSE:
o A really low pH with a high CO2 and normal HCO3
means acute ventilatory failure. Recommend
mechanical ventilation.
o A normal pH with high CO2 and high HCO3 means
chronic ventilatory failure. Recommend low-flow
oxygen and avoid intubation if possible.
o A high pH with a normal CO2 and a high HCO3 means
acute metabolic alkalosis. Recommend either
potassium or chloride, depending on whichever one is
low.
o A low pH with a normal CO2 and a low HCO3 means
acute metabolic acidosis. You should increase the
ventilation and treat the underlying cause.
• If the patient has a PaO2 > 60 on an FiO2 < 60%, this is
moderate hypoxemia (V/Q imbalance). You should
recommend oxygen therapy and treat the underlying
problem.
• If the patient has a PaO2 < 60 on an FiO2 > 60%, this is severe
hypoxemia (shunting). You should recommend oxygen
therapy with PEEP/CPAP and treat the underlying cause.

Again, these are just a few of the basic things I want you to
remember to get the juices flowing in your brain.

22
Not to worry, we’ll cover each of these tips in more detail in the
following sections of this study guide.

CSE Scoring
There will be a total of 22 problems on the exam that are selected
from 8 different categories.

(Two of the problems are pretested scenarios that are individually

scored based on the judgment of the NBRC committee. The total
points scored on these will be added to your results at the end.)

Each version of the exam will be different which means that each
version will have a minimum passing score. Of course, this is
decided by the testing committee for each exam.

Exam Hint: More than half of the total possible points will come
from the selections you make in the Information Gathering
sections.

That is why it’s a major focus throughout this study guide.

If your final score exceeds the minimum passing score, that

means you will have passed the exam.

On average, you will need to score roughly a 72% in order to pass

the CSE.

That doesn’t sound so bad, right?

Now let’s talk about the actual physical points that you can get for
each selection you make.

The scoring scale runs from –3 points up to 3 points. That’s right,

folks. You can earn up to 3 points or you can lose up to 3 points,
depending on the selections that you make.

23
 • Usually, there will be one best available answer that gives
maximum points. (+3)
o It is necessary for proper care and not doing it would
cause harm to the patient.
• You can earn (+2) points for selecting very important
information for good patient care.
• You can get (+1) for information that is helpful.
• You get 0 points for the selections you make that are neither
helpful nor harmful to the patient.

Now here’s where it gets dicey!

• You lose a point (–1) for selecting something that is

counterproductive.
• You lose two points (–2) for making a selection that is very
counterproductive.
• You lose three points (–3) for making a selection that is
detrimental to the patient.
o This includes any selection that could result in harming
the patient, or worse.

Obviously, it goes without saying, you want to make selections

that earn you points and avoid those that take points away!

And what you’re about to learn in the following sections will help
you do just that. J

24
Pathology & Disease Management

Now that you’ve made it this far in the study guide, you have a
good understanding of how the CSE is structured. You also know
exactly what you need to do to prepare for and pass the exam.

In this section, we’re going to put all the pieces together!

We’re going to cover the pathology of each and every disease that
you could possibly see on the exam, and we’re going to share with
you the ins and outs of how to manage each disease properly.

If you remember the chart that we provided earlier (on page 13)
where we listed out the categories. Now we’re going to take you
through each category and each disease that is listed so that you’ll
have all of the exact information you need in order to pass the
exam.

Does that sound good?

If so, let’s go ahead and dive right in!

25
COPD (Conservative)

As we mentioned earlier, there will be (4) total problems on the

CSE regarding COPD. Two regarding the management of
conservative COPD and two regarding critical care.

We’re going to cover them separately, so this section is about the

management of conservative COPD.

Chronic Obstructive Pulmonary Disease (COPD) is a chronic

airway disease with progressive airway obstruction that is
preventable and treatable, but it is not fully reversible.

The causes of COPD include:

• Cigarette/tobacco smoking
• Genetics
• Air pollution

In COPD, either Emphysema or Chronic Bronchitis can be present,

or both.

Exam Hint: Definitely know the difference between Emphysema

and Chronic Bronchitis, which are (of course) two types of
COPD.

Emphysema
Emphysema is a disease with irreversible destruction of the
alveolar walls which causes permanent enlargement of the air
spaces distal to the terminal bronchioles and the collapse of the
small airways.

Two characteristics of Emphysema are air trapping and

hyperinflation. (Pink Puffer)

26
Chronic Bronchitis
Chronic Bronchitis is a productive cough that lasts for at least 3
months in 2 successive years. (Blue Bloater)

There are some key characteristics that differentiate these two

from one another. We will cover those in the chart below.

Key differences between Emphysema and Chronic Bronchitis:

Emphysema Chronic Bronchitis

Appearance Pink Puffer (reddish Blue bloater
skin); thin and (cyanotic); stocky and
underweight; barrel overweight; peripheral
chest; Hoover’s sign. edema; JVD.
Cough Late; small amounts of Early; copious
sputum amounts of sputum
Breath Sounds Diminished with Rhonchi, crackles,
prolonged expiration wheezes
Respiratory Severe dyspnea; Less common use of
Pattern pursed-lip breathing; accessory muscles;
use of accessory Mild dyspnea.
muscles.
Chest Hyperresonant Normal
Percussion percussion note
Chest X-Ray Translucent lung fields; Translucent lung
flattened diaphragms; fields; flattened
hyperinflation; small diaphragms;
heart; increased prominent vessels;
retrosternal airspace; large heart.
increased A-P diameter.
ABG Results Acute alveolar Chronic respiratory
hyperventilation with acidosis (ventilatory
hypoxemia. In the failure) with moderate
severe stages, you will hypoxemia.

27
 see chronic ventilatory
failure.
Lung Volumes Increased RV and TLC Increased RV
Lung Increased Normal
Compliance
PFTs Decreased flowrates Decreased flowrates
and a Decreased DLCO and a Normal DLCO
Spirometry FEV1% < 70% after FEV1% < 70% after
Results bronchodilator bronchodilator
treatment treatment
CBC Increased RBC/Hb/Hct Increased RBC/Hb/Hct
in the late stages. in the early and late
stages.

Treatment for COPD

The goal for treating patients with COPD is to increase the
patient’s life expectancy and quality of life while decreasing the
number of COPD exacerbations and hospital visits.

Here are the general steps for treating COPD:

1. Smoking cessation
2. Disease management education
3. Pulmonary rehab
4. Avoid triggers and recurrent infections (like the flu and
pneumonia)

Treatment approaches for COPD:

Low-flow Oxygen – give a nasal cannula at 1–2 liters or an air

entrainment mask at 24–28%.

28
 • For home care COPD patients, consider recommending
oxygen conserving devices like a reservoir cannula or
transtracheal catheter.

Bronchodilator therapy
• You can give short-acting beta-agonists and anticholinergics
for acute exacerbations.
• Give long-acting beta-agonists with a long-acting
anticholinergic for long-term management use.
• Add inhaled steroids if the patient has frequent
exacerbations.

Noninvasive Positive Pressure Ventilation

• Consider BiPAP during an acute exacerbation of ventilatory
failure, if indicated. Remember, for the conservative
management of COPD, we want to try to avoid intubation if
possible.

Preventive care
• Instruct the patient to strive to live a healthy lifestyle. Also
recommend flu and pneumococcal vaccinations, as well as
exercise.

Exam Hint: For your COPD problems on the CSE, you may have
the options to select mucolytics and/or antibiotics as treatment
methods for COPD. These are wrong!

Neither of these are recommended to treat COPD, so keep that

in mind.

Now we’re going to cover Bronchiectasis as well, just in case you

see it on the CSE. Remember, it is part of the CBABE mnemonic
that represents the obstructive diseases.

29
CBABE: Cystic Fibrosis, Bronchiectasis, Asthma, Bronchitis
(Chronic), and Emphysema.

Bronchiectasis
Bronchiectasis is an abnormal condition of the bronchial tree
characterized by irreversible dilation and destruction of the
bronchial walls, frequently found in the lower lobes of one or both
lungs.

It results in impaired mucociliary clearance that causes the

accumulation of copious amounts of bronchial secretions.

Exam Hint: You can easily recognize Bronchiectasis if the

patient has chronic production of large quantities of purulent
sputum.

Approximately half of patients with Bronchiectasis stems from

Cystic Fibrosis.

What to look for (Information Gathering)

• Shortness of breath may be present with pursed-lip

breathing and use of the accessory muscles when breathing.
• The patient’s cough will reveal purulent foul smelling
sputum.
• The patient will have a barrel chest with an increased A-P
diameter.
• Their skin will be cyanotic and they will show digital clubbing
on the nail beds.
• Chest percussion will reveal a hyperresonant/tympanic note.
• Breath sounds will be diminished or possibly some wheezing.

30
Treatment for Bronchiectasis:

• Recommend bronchopulmonary hygiene to help with the

secretions.
• Also, recommend lung expansion therapy.
• If an infection is present, you can recommend antibiotics, of
course.
• Expectorants can help the patient cough out more of the
secretions.
• You can recommend sympathomimetic and
parasympatholytic aerosolized agents.
• Provide oxygen if hypoxemia is present.
• Provide mechanical ventilation for acute ventilatory failure.

Asthma
Now let’s talk about Asthma!

Asthma is a chronic obstructive disease in which your airways

narrow and cause episodes of wheezing and coughing.
• It is known as a reversible condition because the obstruction
can be reversed with certain drugs or stimuli.

Asthma episodes occur when the patient is exposed to certain

triggers, like cigarette smoke, pollen, dust, mold, etc.

Other causes include exercise, infections, cold air exposure, GERD,

stress, and chemical exposure.

Information Gathering

• As we mentioned, the episode will be caused by a specific

trigger. Recommend that the patient avoid such triggers in
the future.

31
 • The patient will show signs of dyspnea including chest
tightness, wheezing, pursed-lip breathing, tachypnea, usage
of accessory breathing muscles, cyanosis, and an increased
A-P chest diameter.
• Chest percussion would reveal a hyperresonant percussion
note.
• Breath sounds would reveal wheezing, or if the episode is
very severe, they will be diminished (little or no airflow).
• They patient will appear very anxious and diaphoretic. They
will have difficulty speaking due to shortness of breath.
• Their vital signs would show tachycardia and pulsus
paradoxus during severe episodes.
• Recommend a chest x-ray. It will reveal an increased A-P
diameter of the chest, as well as flattened diaphragms.
• Recommend an ABG. It will reveal acute hyperventilation
with hypoxemia in the initial stages. But as the episode gets
worse, it will shift into respiratory acidosis with hypoxemia.
• Their PFT results would reveal decreased flowrates and
normal DLCO.
• You may recommend a pre and post bronchodilator
treatment. Look for improvement on the post-treatment to
determine if the condition is reversible.

Decision Making (Treatment)

Treating asthma is different, depending on the state of the

patient. You will need to know to treat an acute asthma attack
different than you would the control of a long-term asthma
patient.

An acute episode will likely be a medical emergency! Remember,

on the CSE, whenever you have an emergency, you stop gathering
information and act right then to help the patient.

Let’s look at what you should recommend for asthma patients

that are have an acute attack/episode:

32
 • Provide oxygen for hypoxemia.
• Recommend short-acting bronchodilator treatments via
aerosol therapy as well as an anticholinergic. For example,
you could recommend albuterol or DuoNeb and Atrovent.
o If the patient’s breath sounds do not improve, consider
recommending continuous aerosol therapy.
• Recommend corticosteroids via oral or IV.
• Closely monitor the patient’s vital signs.
• Recommend intubation and mechanical ventilation for
ventilatory failure. Look specifically for rising PaCO2 levels and
a decreasing pH.

Now let’s discuss how to treat long-term asthma patients because,

obviously, it’s a little different.

• Recommend that the patient avoid their specific asthma

triggers.
• Recommend bronchodilators. You can recommend short-
acting, long-acting, and anticholinergics.
• Recommend inhaled corticosteroids.
• Recommend bronchopulmonary hygiene therapy.
• Monitor the patient’s peak flow. This helps measure the
degree of obstruction in the airways.

Moving right along — now let’s cover the second type of COPD
cases that you will see on the CSE — critical care.

33
COPD (Critical Care)

Now that we have covered the conservative management of

COPD, we will now discuss the how to manage COPD patients in
critical care.

This typically concerns patients who are experiencing an acute

exacerbation with a worsening respiratory status — in other
words, they are going into respiratory failure and you (the
Respiratory Therapist) are needed to intervene.

Signs and Symptoms

• Increased dyspnea
• Hypoxemia
• Tachycardia
• Tachypnea
• Increased cough and sputum production
• Change in sputum color or characteristics
• Use of accessory muscles
• Peripheral edema
• Wheezing and chest tightness
• Change in mental status

Information Gathering
You will need to gather the following test data for these patients.
Again, that is, if there isn’t an emergency.

• Vital signs
• SpO2
• Chest X-ray to assess the lungs imaging
• ABG to assess for impending respiratory failure
• Sputum culture and sensitivity (Only if the exacerbation is
believed to be caused by an infection; i.e. if the patient has a
fever).

34
 Exam Hint: They may ask you to obtain the spirometry results
for a patient having a severe COPD exacerbation.

You should remember that this is NOT necessary and would

provide little value at this time. That is because the patient is
most likely in critical condition and needs more immediate care.

Decision Making (Treatment)

Treatment for an acute exacerbation of COPD includes the
following:

Basic Treatment and Management

• Supplemental Oxygen – Maintain a PaO2 of 60–65 torr and an

SpO2 of 88–92%
• Administer (or increase) the beta-agonist dosages
• Administer inhaled anticholinergic medications (if it’s not
already being given)
• Recommend systemic steroids in addition to inhaled steroids
• Only recommend antibiotic therapy if the secretions are
purulent or colored, or if there is reason to suspect an
infection. Otherwise, do not recommend it.

If these treatments are effective, you will see the patient start to
improve.

Less wheezing, decreased chest tightness, decreased work of

breathing, heart rate back in the normal range, respiratory rate
back in the normal range, no use of accessory muscles, etc.

However... the patients who do not respond well to basic

treatment will need ventilatory support.

35
You’ll know because they will develop worsening respiratory
acidosis (decreasing pH, increasing CO2), increased fatigue, and a
decreased level on consciousness.

Exam Hint: In general, COPD patients tend to be very difficult to

wean from invasive mechanical ventilation. Therefore, unless it’s
contraindicated, NPPV is the preferred treatment.

If the patient is still deteriorating on NPPV, then obviously you

will want to recommend intubation and mechanical ventilation.

Initial Settings for NPPV

Let’s assume that you have decided that putting the patient on
BiPAP is now the best course of action. Here are some good initial
settings that you can use:

• IPAP of 10 cmH2O
• EPAP of 5 cmH2O
• Rate of 10
• Sufficient expiratory time to allow a complete exhalation (I:E
Ratio of 1:3)
• FiO2 of whatever is necessary to keep the SpO2 greater than
or equal to 90%

You can adjust these setting as necessary to reduce tachypnea

and the use of accessory muscles.

You will want to try to blow off as much CO2 as necessary to

increase the pH back into the normal range.

Remember, to increase ventilation, you increase the IPAP

pressure.

36
How to know when it’s time to intubate?

For the CSE, it’s critical that you understand when it’s necessary to
put the patient on BiPAP. Not only that, but also when you should
intubate and put the patient on the ventilator. Or… when to switch
the patient from BiPAP to the ventilator.

Let’s talk about that now! J

• It’s important to use ABGs to determine how to best treat the

patient.
• If the patient is deteriorating while on the BiPAP, that means
it’s time to initiate mechanical ventilation.
• You’ll know it’s time if the patient’s ABG results get worse
within the first 2 hours of being on NPPV.
o Or, if there is a lack of improvement in 4 hours on the
BiPAP, it’s time to switch.
• ALWAYS intubate and mechanically ventilate a patient in
severe respiratory acidosis!
o Severe acidosis = pH < 7.25 and a PaCO2 > 60 torr
• Look for severe hypoxemia.
o P/F ratio < 200
• Look for severe tachypnea. If the patient is breathing too fast,
you’ll need to recommend intubation.
o > 35 breaths per minute
• Other complications include: metabolic abnormalities, sepsis,
severe pneumonia, pulmonary embolism, barotrauma, and a
pleural effusion.

Contraindication for using NPPV

If any of these are present, it’s best to just skip BiPAP (NPPV) and
go straight to intubation and mechanical ventilation.

• Respiratory arrest

37
• Upper airway obstruction
• The patient is unable to protect the airway
• Unable to clear secretions
• High risk for aspiration
• Cardiac arrest or hemodynamic instability
• Mental status changes
• Active upper GI bleeding
• Facial surgery or trauma, because they will be unable to wear
the BiPAP mask
• Significant air leaks in the mask

38
Trauma Cases

Now we are going to cover the different types of trauma cases

that you should prepare to see on the CSE.

Here are a few things to keep in mind:

• The most important thing for you to remember with trauma

patients is to secure the airway.
• For trauma patients, provide 100% oxygen via a
nonrebreather, bag-valve mask, or an advanced airway.
• Trauma patients require rapid assessment to determine the
specific type of injury that they sustained in order to make
the proper treatment decision.

Let’s start by talking about chest trauma.

39
Chest Trauma

For the sake of this section, we will be referring to any type of

trauma to the chest wall.

• Penetrating chest trauma – most commonly caused by a

knife or gun shot wound. The injury can occur to any thoracic
structure.
o Bleeding can cause a Hemothorax.
o Air leakage will result in a Pneumothorax.
• Sucking chest wounds – they should be covered with a
dressing to prevent a tension pneumothorax and allow
adequate ventilation.

Exam Hint: The big thing to remember with chest trauma on

the CSE is that the patient will likely have a pneumothorax or
hemothorax.

So, when you get one of these cases on the exam, be looking for
the signs and symptoms of such.

Flail Chest – is the result of fracture of at least 3 or more adjacent

ribs, which will cause the thoracic cage to become unstable.
• Flail chest = Paradoxical chest movement

Information Gathering:
A patient with chest trauma will have the following assessment
results:

• Possible hemoptysis from cough.

• Bruising over the injured area on the chest.
• Paradoxical chest movement (flail chest from broken ribs)
• Tachycardia and hypertension are likely.
• The chest x-ray will reveal increased opacity from lung
compression.

40
 • ABG results will show acute alveolar hyperinflation with
hypoxemia.
• PFT results would show decreased volumes and capacities.
• Patients with a pulmonary contusion must be monitored
closely for worsening hypoxemia. Many of these patients
develop ARDS.
• If the patient has blood loss, recommend CBC, Hb, and Hct.

Exam Hint: Always recommend a chest x-ray for these patients!

HOWEVER…. If there are clear signs of a tension pneumothorax,

you do not want to recommend a chest x-ray at this time. This is
an emergency and you want to treat the issue NOW.

You should recommend immediate treatment via needle

decompression or thoracostomy (chest tube). THEN… you can
proceed with the chest x-ray.

Decision Making (Treatment)

As with every other case, this one is no different — you must take
the information that you have to make the best possible decision
for the patient.

• As we already discussed, provide 100% oxygen for hypoxemia.

• Provide mechanical ventilation (with PEEP) for apnea,
profound shock, ventilatory failure, and/or a compromised
airway.
• Provide analgesics for pain.
• Recommend hyperinflation therapy to prevent pneumonia.
• Severe cases may require surgical stabilization.
• Recommend bronchopulmonary hygiene.

41
Pneumothorax/Hemothorax

This information often goes hand in hand with the previous

section on chest trauma, but it’s just too important not to make it
into its own section.

Pneumothorax
A pneumothorax is the accumulation of gas or air in the pleural
space.

It is caused by a traumatic injury, like a penetrating chest injury,

for example. This will be an obvious indication of a pneumothorax
on the CSE.

Keep in mind, though, that a pneumothorax can occur

spontaneously as well. Meaning that it can just happen.

You will need to know the signs and symptoms in order to

diagnose the pneumothorax and treat the patient effectively.

Information Gathering:
A patient with a pneumothorax will display the following
assessment results:

• Sudden respiratory distress and increased work of breathing.

• Severe chest pain is likely.
• When assessing the chest, you will note that there is a
tracheal and/or mediastinal shift AWAY from the affected
side.
• There will be increased volume on the affected side as well as
bruising on the affected side.
• You will see decreased chest expansion on the affected side.
• The patient will likely be breathing fast (tachypnea).
• The patient may appear cyanotic.

42
 • Diagnostic chest percussion will reveal a hyperresonant
percussion note on the affected side.
• The patient’s breath sounds will be diminished or absent on
the affected side.
• The patient will have the following vital signs:
o For a small pneumothorax, the patient will be
tachycardic and hypertensive.
o For a large pneumothorax, the patient will be
bradycardic and hypotensive, with pulsus paradoxus.
• The chest x-ray will show hyperlucency with the absence of
vascular markings on the affected side. And as we said
earlier, it will show the trachea shifted away from the affected
side. It will also show a depressed diaphragm and lung
collapse.
• The patient will have the following ABG results:
o For a small pneumothorax, the results will show acute
alveolar hyperventilation with hypoxemia.
o For a large pneumothorax, the results will show acute
ventilatory failure with hypoxemia.
• If the patient is already on the ventilator, a sudden increase in
airway pressure or a decrease in tidal volume are signs that a
pneumothorax had developed.

Decision Making (Treatment)

• Give 100% oxygen.
• The treatment for a pneumothorax is a chest tube
(thoracostomy).
• If the patient in already on the ventilator, recommend
changing the settings to minimize peak inspiratory
pressures, i.e. decrease the PIP or lower the tidal volume.
• A tension pneumothorax may require needle aspiration if the
patient is unstable (they have bradycardia, hypotension, etc.).
• Provide mechanical ventilation with PEEP for patients with
ventilatory failure.

43
Now let’s talk about Hemothorax, which appears similar but is
slightly different.

Hemothorax

A Hemothorax is the accumulation of blood in the pleural space. It

is caused by a traumatic injury to the chest.

Information Gathering:
A patient with a pneumothorax will display the following:

• The patient will likely have severe chest pain.

• Their vital signs will show tachycardia and hypertension.
• Hemoptysis is possible.
• When assessing the chest, you will note that there is a
tracheal and/or mediastinal shift AWAY from the affected
side.
• The patient may be experiencing dyspnea and tachypnea.
• Diagnostic chest percussion will reveal a flat or dull
percussion note on the affected side.
o There will be decreased tactile and vocal fremitus.
• The patient’s breath sounds will be diminished or absent on
the affected side.
• The chest x-ray will show increased radiodensity, and it will
show the trachea shifted away from the affected side.
• The CBC would show reduced RBC, HB, and Hct due to
bleeding.

Decision Making (Treatment)

• Give 100% oxygen for hypoxemia.
• You will need to recommend a thoracentesis or chest tube in
order to drain the blood.

44
 • Recommend hyperinflation therapy after then chest tube
has been inserted.
• Recommend mechanical ventilation (with PEEP) for
ventilatory failure.

Exam Hint: The big thing to remember with chest trauma on

the CSE is that the patient will likely have a pneumothorax or
hemothorax.

So when you get one of these cases on the exam, be looking for
the signs and symptoms of such.

45
Burns/Smoke Inhalation

In this section, we will talk some about body surface burns, but
we’ll mostly talk about smoke inhalation because, as a Respiratory
Therapist, that is what you will be dealing with. Not to mention, it’s
what you are more likely to see on the CSE.

Smoke inhalation and burns can lead to complete airway

obstruction, so it’s a very serious issue. These injuries are typically
fire victims, firefighters, or those who have inhaled car exhaust.

Information Gathering:
• The patient’s secretions will be black and sooty, from the
smoke inhalation.
• They will likely have a fast breathing rate (tachypnea).

Exam Hint: On the CSE, if it states that the patient has a “Cherry
red” appearance, you should automatically suspect carbon
monoxide poisoning.

For CO poisoning, know to check COHb using a co-oximeter

instead of a regular ABG analyzer.

And always recommend Hyperbaric oxygen therapy (if it’s

available) for CO poisoning.

• The patient may be either alert, confused, or unresponsive.

• The patient may have pharyngeal swelling and edema (from
inhaling hot gases), and/or an altered voice.
• The patient’s vital signs will show tachycardia, hypertension,
and their SpO2 will be read falsely high is there is carbon
monoxide poisoning present.
• If the patient is unresponsive, you can assess sensorium and
coma level with the Glasgow Coma Scale.

46
 • Definitely recommend a chest x-ray. It may be normal in the
early stages but show ARDS (ground glass appearance) later
on.
• Monitor the patient’s SpO2 for hypoxemia and reevaluate
their airway and oxygenation status frequently.

Decision Making (Treatment)

• If the patient is in severe distress with stridor, then it likely
means that they have inhaled hot gases and are at risk of
upper airway obstruction. This is an emergency and you
should recommend intubation and mechanical ventilation in
this case.
• Always provide 100% oxygen for these patients.
Nonrebreather first, because it’s quick. Then recommend a
hyperbaric oxygen chamber (for CO poisoning) if it’s
available.
• Check the depth and percentage of body surface area that is
covered in burns. Cover the patient to prevent heat and fluid
loss.
• Recommend immediate insertion of an IV to provide and
monitor fluids and electrolytes.
• Recommend analgesics for pain.
• Monitor for signs of infection, but only recommend an
antibiotic if an infection is suspected or confirmed.
• Recommend an isolation room for the patient to decrease
the chances of infection.
• A bronchoscopy may be needed in order to evaluate the
upper airway (because it won’t show on a chest x-ray).
• Recommend mechanical ventilation for ventilatory failure.
• If bronchospasm is present, you can recommend aerosolized
bronchodilators, mucolytics, and anti-inflammatory agents.
You can also recommend bronchial hygiene and airway
clearance therapy.

47
ARDS

ARDS or acute respiratory distress syndrome is a respiratory

disorder characterized by noncardiogenic pulmonary edema that
causes respiratory insufficiency and results in refractory
hypoxemia and decreased lung compliance.

The causes of ARDS include:

Pneumonia, trauma, aspiration, sepsis, drug overdose, fluid

overload, inhalation of toxins, shock, burns, and pancreatitis.

Things to looks for with ARDS:

• An acute onset within 1 week and worsening respiratory

symptoms.
• Bilateral infiltrates/opacities (ground glass appearance) on
the chest x-ray.
• Pulmonary edema that is not due to heart failure or fluid
overload (noncardiogenic pulmonary edema).
• Refractory hypoxemia or severe oxygenation issues (P/F ratio
< 300 on a PEEP of 5 or more).

Information Gathering:
• The patient will show signs of respiratory distress (Tachypnea,
intercostal retractions, diaphoresis, cyanosis).
• Auscultation will reveal bronchial breath sounds or crackles.
• Vital signs will show tachycardia and hypertension and
severe hypoxemia is likely.
• Recommend an ABG to assess PaO2, P/F ratio, and the acid-
base balance. It will reveal refractory hypoxemia.
• The chest x-ray will show alveolar infiltrates with radiopacity
(white out) and a “honeycomb” or “ground glass”
appearance.
• A sputum culture may reveal that an infection is present. If
so, you know what to do — recommend antibiotics.

48
 • Recommend hemodynamic monitoring. It will likely reveal
an elevated PAP and a normal PCWP.

Decision Making (Treatment)

When treating patients with ARDS, it’s important to treat the
underlying cause. What caused the patient to get ARDS in the first
place? That’s what you treat!

For example, the patient had pneumonia that got worse and led
to ARDS. In this case, the underlying cause would be pneumonia.

What to recommend for ARDS:

• Always recommend oxygen therapy! Increase the FiO2 to as

high as 60%, then add PEEP. If the patient improves, you can
titrate the FiO2 first back down below 60%, then reduce the
PEEP.
• Use the ARDSNet ventilator protocol:
o ARDS patients need smaller tidal volumes. Lower the
tidal volume down to 6 mL/kg of IBW.
o Keep their plateau pressure < 30 cmH2O.
o Use the permissive hypercapnia technique. As long as
the pH can be maintained at or above 7.20, allow the
PaCO2 to rise.
• Recommend diuretics to prevent fluid overload.
• Again, closely monitor the patient’s hemodynamics.
• Consider placing the patient in the prone position for up to 16
hours to improve oxygenation.
• Consider using alternative modes of ventilation, such as:
HFOV, Inverse Ratio Ventilation (IRV), and Airway Pressure
Release Ventilation (APRV).
• As a rescue therapy, you can recommend pulmonary
vasodilators such as Inhaled Nitric Oxide (iNO).

49
What NOT to recommend for ARDS:

The following are considered ineffective therapies for ARDS

patients and should not be recommended:

• Beta agonists
• Corticosteroids
• N-acetylcysteine
• Surfactant therapy
• Use of a Pulmonary Artery (PA) catheter

50
Neuromuscular Disorders

In this section, we will focus on disorders that cause paralysis,

acute muscle weakness, and those that cause respiratory
insufficiency and failure.

Here’s what we’ll cover:

• Myasthenia Gravis
• Guillain-Barré Syndrome
• Drug Overdose
• Muscular Dystrophy
• Stroke
• Tetanus

Exam Hint: For patients with any disorder in this section you
should closely watch for ventilatory failure by monitoring the
following:
• Spontaneous Tidal Volume (VT)
• Vital Capacity (VC)
• Maximum Inspiratory Pressure (MIP)

Exam Hint: You will definitely have a case on the CSE where you
need to know the difference between Guillain-Barré Syndrome
and Myasthenia Gravis, so you must be able to differentiate the
two.

No worries, we’re going to show you how. J

51
Myasthenia Gravis

Myasthenia Gravis is a disorder that leads to muscle weakness of

the skeletal muscles, particularly the muscles of the face, throat,
and respiratory system.

Weakness and respiratory failure can occur rapidly as muscle

strength decreases with repetitive contraction against a load.

Exam Hint: Remember that Myasthenia Gravis is a Descending

Paralysis, meaning that it moves from Mind to Ground.

The paralysis starts in the brain and then spreads down

throughout the body.

You can use the ‘MG’ mnemonic to remember this and

differentiate it from Guillain-Barré Syndrome.

A Myasthenic Crisis is a severe episode of respiratory muscle

weakness and can be life-threatening.

It is commonly triggered by viral infections, surgery, childbirth,

emotional stress, febrile illnesses, temperature changes, and drug-
related issues.

Information Gathering:
• The patient may show a gradual onset of muscle weakness
and may have previous hospital admissions for Myasthenia
Gravis.

Exam Hint: On the CSE, a key sign to look for is ptosis, or

drooping eyelids. If you see a patient with this, you can
automatically think Myasthenia Gravis.

52
 • The patient has descending muscle weakness.
• The patient shows signs of dysphagia (difficulty swallowing).
• The patient has shallow breathing.
• The patient has diminished breath sounds.
• The patient will have decreased volumes (tidal volume, VC,
and MIP).

Exam Hint: A special test that you should always recommend for
a patient with Myasthenia Gravis is the Endrophonium
(Tensilon) Challenge Test.

Once you give the patient Tensilon, if their tidal volume, VC, MIP,
and muscle weakness improve, the drug is working and you can
give more of it.

If the patient gets worse after Tensilon is given, you can reverse
the effects of the drug by giving Atropine.

• The patient’s ABG results will show acute alveolar

hyperventilation with hypoxemia. Monitor the patient closely
for ventilatory failure.
• Recommend a blood test to check the patient’s antibodies.

Decision Making (Treatment)

• Closely monitor the patient’s vital signs, tidal volume, vital
capacity, and maximum inspiratory pressure. Recommend
intubation and mechanical ventilation if/when indicated.
• Give oxygen for hypoxemia.
• Recommend hyperinflation and pulmonary hygiene therapy.
• Recommend the following anticholinesterase drugs:
o Neostigmine
o Pyridostigmine
• You may also recommend Plasmapheresis or a Thymectomy.

53
Guillain-Barré Syndrome

Guillain-Barré Syndrome is a rare autoimmune disorder

characterized by lower extremity weakness that progresses to the
upper extremities and face.

It eventually may lead to flaccid paraplegia and marked

respiratory muscle weakness.

Exam Hint: Remember that Guillain-Barré Syndrome is an

Ascending Paralysis, meaning that it moves from the Ground to
the Brain.

The paralysis starts in the lower extremities (near the ground)

and then spreads up throughout the body (to the brain).

You can use the ‘GB’ mnemonic to remember this and

differentiate it from Myasthenia Gravis, which instead uses ‘MG’
(mind to ground).

Guillain-Barré Syndrome often follows viral or bacterial infections,

but the precise cause is unknown.

Information Gathering:
• The patient will have a febrile illness that is usually viral in
nature.
• The patient will have acute weakness that starts in the legs
and lower extremities (ascending paralysis).
• The patient’s breath sounds may be diminished with crackles
and rhonchi.
• The patient may show signs of dysphagia and loss of the gag
reflex.
• They will likely show signs of dyspnea and shallowing
breathing.

54
 • The patient will have decreased volumes (tidal volume, VC,
and MIP).

Exam Hint: A special test that you should always recommend for
a patient with Guillain-Barré Syndrome is the Lumbar Puncture
in order to gather cerebral spinal fluid.

• The patient’s ABG results will show acute alveolar

hyperventilation with hypoxemia. Monitor the patient closely
for ventilatory failure.

Decision Making (Treatment)

• Closely monitor the patient’s vital signs, tidal volume, vital
capacity, and maximum inspiratory pressure. Recommend
intubation and mechanical ventilation if/when indicated.
• Give oxygen for hypoxemia.
• Recommend hyperinflation and pulmonary hygiene therapy.
• Recommend Plasmapheresis in severe cases only.
• Other treatment modalities that you could possibly
recommend include: Anti-coagulant therapy, corticosteroids,
and physical rehabilitation therapy (during recovery).

55
Drug Overdose

A drug overdose is a harmful overuse of medication that exceed

the recommended medical dose. It can be accidental or
intentional.

There are literally thousands of different drugs, so it would be

impossible to cover them all here.

Instead, we’ll focus more on the general aspects of what a

Respiratory Therapist (you) should do in the real-life case of a drug
overdose. This will, of course, prepare you in case one of these
problems come up on your version of the CSE.

Information Gathering:
• In some cases, the patient may have shown signs of mental
illness, like depression or addiction.
• The patient will likely have slow and shallow respirations.
• If possible, try to determine what drug was ingested.
• The patient will have an altered or diminished level of
consciousness.
• Obtain an ABG to check the patient’s acid-base imbalances,
ventilatory and oxygenation status.
• Recommend drug toxicology and monitor the basic lab tests,
including the following:
o Serum electrolytes
o CO-oximetry (to check for carbon monoxide poisoning)
o EKG

Decision Making (Treatment)

• As a Respiratory Therapist, your first priority should be to
establish an artificial airway.
o Recommend intubation for those who are obtunded or
those who are at risk for aspiration.

56
 • Recommend mechanical ventilation for ventilatory failure.
• Provide oxygen for hypoxemia.

Exam Hint: Recommend Naloxone (Narcan) to reverse a

narcotic overdose.

If you get a drug overdose case on your version of the CSE, you
will most likely need to recommend Narcan.

• Recommend Acetylcysteine for an acetaminophen overdose.

• If the patient overdosed by orally ingesting drugs, you can
recommend a gastric lavage or activated charcoal.

57
Muscular Dystrophy

Muscular dystrophy refers to diseases that cause progressive

muscle weakness and loss.

This will eventually result in the inability to walk, swallowing

difficulty, respiratory muscle insufficiency, and respiratory failure.

This disease state occurs in different stages, which means that the
treatment varies according to whichever stage the patient is
currently in.

Information Gathering:
• If the patient is in the earlier stages, it would be a good idea
to obtain baseline respiratory function values (PFTs). This way
you can compare results as the patient progresses.
• You can recommend polysomnography (sleep study) to
assess the patient’s breathing while asleep.
• Of course, recommend a chest x-ray.

Decision Making (Treatment)

• Monitor the patient’s respiratory function (PFTs).
• Recommend immunizations and regular doctor visits.
• Provide airways clearance therapy, such as mechanical
insufflation-exsufflation.
• If the patient has sleep-disorder breathing, you should
recommend NPPV (BiPAP) at night while asleep.
o You should avoid CPAP in this case because it does not
overcome hypoventilation.
• Provide oxygen for hypoxemia.
• Recommend intubation and mechanical ventilation for
ventilatory failure.

58
Stroke

A stroke is a condition characterized by the sudden onset of a

neurologic deficit that results from the lack of blood flow to the
brain.

It results from vascular occlusion or hemorrhage.

The causes of a stroke include: Cerebral thrombi or emboli,

atherosclerosis, and hypertension.

Information Gathering:
• You may see that the patient has a decreased level on
consciousness (and they may need to be intubated).
• The patients may have loss of speech and motor skills.
• The patient’s respiratory pattern will exhibit Cheyne-stokes
respirations.
• You will want to recommend a CT scan and MRI of the brain,
as well as a cerebral angiogram.
• Be sure to monitor the intracranial pressure, because it may
be elevated.

Decision Making (Treatment)

• You can recommend the following drug therapy:
Vasodilators, Anticoagulation therapy, and thrombolytic
therapy.
• Recommend mechanical ventilation for ventilatory failure or
to help reduces the intracranial pressure.

59
Tetanus

Tetanus is a neuromuscular disorder that stems from bacteria

from a wound exposure or a puncture wound.

This one isn’t super-likely to be on the CSE, but it has been on

different versions in the past. That is why we want to briefly cover
it here for you.

Information Gathering:
• Look for the history of present illness. If there is some type of
wound involved or a penetrating wound, always be on the
lookout for tetanus.
• Lockjaw is a prime symptom.
• The patient may exhibit signs of dysphagia or an abnormal
gag reflex.
• Keep in mind, no lab or x-ray tests can diagnose this disorder.
However, the presence of serum antitoxin levels greater than
0.01 U/mL can help rule out the diagnosis of tetanus.

Decision Making (Treatment)

• Once tetanus is diagnosed, you should recommend the
administration of tetanus immunoglobulin.
• Keep a close monitor of the patient’s tidal volume, vital
capacity, and maximum inspiratory pressure.
• You can recommend an antibiotic to cease the spread of the
tetanus bacteria.
• Recommend intubation and mechanical ventilation for
ventilatory failure.

60
Cardiovascular Diseases

In this section, we will focus on disorders of the heart and

cardiovascular system that the NBRC expects you to know for the
CSE.

Here’s what we’ll cover:

• CHF
• Heart Attack
• Shock
• Coronary Artery Disease
• Cor Pulmonale
• Pulmonary Embolism

Exam Hint: Before we dive in, let’s discuss arrhythmias, which

are irregularities in the patient’s cardiac rhythm.

You will mostly likely see a patient which an arrhythmia on the

CSE, which is why we’re covering it now.

The causes may include: hypoxemia, ischemia, electrolyte

imbalances, and conduction disorders.

The different types include:

• PVC (Premature Ventricular Contraction) – treat with

oxygen.
• V-fib (Ventricular Fibrillation) – requires immediate
defibrillation.
• Pulseless V-tach (Ventricular Tachycardia without a pulse) –
requires immediate defibrillation.
• Atrial flutter – consider synchronized cardioversion.
• Atrial fibrillation – consider synchronized cardioversion.
• V-tach with a pulse – consider synchronized cardioversion.

61
To treat arrhythmias, anti-arrhythmic agents can be administered.

Exam Hint: We literally just discussed it, but I want to make sure
you remember this…

The ONLY (2) rhythms that require defibrillation are:

• Ventricular Fibrillation
• Pulseless Ventricular Tachycardia

Now, let’s dive into the cardiovascular diseases that you must
know for the CSE.

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Congestive Heart Failure

CHF occurs when the heart’s ability to pump blood is impaired

and does not meet the body’s metabolic needs.

Exam Hint: For the CSE, in general, you should always

remember that CHF and pulmonary edema go hand in hand.

(Cardiogenic Pulmonary Edema, that is.)

When you hear pulmonary edema — think CHF — and vice

versa.

Also for these, know that they are associated with fluid overload.

Cardiogenic Pulmonary Edema – when fluid from the pulmonary

vascular system accumulates in the alveoli of the lungs.

CHF is caused by:

• Myocardial Infarction
• Coronary Artery Disease
• Ischemic Heart Disease
• Hypertension
• Cardiomyopathy

Cardiogenic Pulmonary Edema is caused by things directly related

to CHF. However, Noncardiogenic Pulmonary Edema is caused by
and is related to ARDS.

Information Gathering:
• The history of present illness could happen suddenly, or there
could be a gradual onset.
• Of course, the secretions will be pink and frothy. When you
see this, automatically think CHF/pulmonary edema.

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Exam Hint: Orthopnea is labored breathing while lying flat.
When you see orthopnea, automatically think CHF/pulmonary
edema.

• The patient will likely have a fast breathing rate (tachypnea)

and they could appear cyanotic.
• The patient will have increased tactile and vocal fremitus.
• During auscultation, you will hear crackles and rhonchi.
• Look for signs of pedal edema (swelling and fluid
accumulation in the feet).
• Other signs of fluid overload that you may see include:
diaphoresis, jugular venous distention, tachycardia, and
increased anxiety levels.
• Of course, you should recommend a chest x-ray to access the
heart and chest. You will see fluffy opacities, butterfly or
batwing pattern, and Kerley B lines.
• Recommend a 12-lead EKG.
• Recommend serum electrolytes.
• Recommend an ABG. It will likely show respiratory alkalosis
with hypoxemia.
• PFT results would show reduced lung volumes with a normal
FEV1/FVC ratio.
• Hemodynamic monitoring would show an increased PCWP
and PAP.
• You can recommend an echocardiogram to further assess
the heart.
• Recommend cardiac biomarkers to assess for a heart attack.
• Recommend BNP (brain natriuretic peptide), which is a
hormone that is useful for diagnosing CHF.

Decision Making (Treatment)

• Restrict fluid because the patient is already fluid overloaded.
Also, definitely recommend diuretics (Lasix) in order to help
with fluid excretion.

64
• Provide oxygen for hypoxemia. These patient’s will most
likely need 100% O2.
• Closely monitor the patient’s vital signs — especially blood
pressure.
• Keep the patient positioned upright in the Fowler’s position,
because as we stated, they will have difficulty breathing
while lying flat, due to the fluid.
• Recommend positive inotropic agents, which help increase
the contractility of the heart. Examples are: Digitalis, Digoxin,
and Dopamine.
• Recommend NPPV (BiPAP/CPAP) to improve gas exchange
and to decreases venous return and ventricular preload.
• Recommend morphine or a benzodiazepine in order to
reduce anxiety.
• Recommend vasodilators and afterload reducing agents
such as: nitroglycerin, sodium nitroprusside, and ace
inhibitors.
• Recommend intubation and mechanical ventilation if the
patient develops severe respiratory acidosis while on NPPV.
o The patient will need PEEP.
• Recommend the electrolyte replacement of sodium and
potassium.

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Myocardial Infarction

A heart attack, or Myocardial Infarction, occurs when a portion of

the heart is deprived of oxygen due to blockage of a coronary
artery.

This causes irreversible damage to the heart muscle and sudden

death can occur.

Coronary Artery Disease is the narrowing or blockage of the

coronary arteries that is usually caused by atherosclerosis. This
reduces the blood flow to the myocardium which will cause
ischemia, angina, or an infarction.

Exam Hint: Angina, or chest pain, is dangerous when it’s

unstable and is a sign of impending failure.

For the CSE, in general, when you have a patient with angina, in
most cases, you should think heart attack. Just be sure that
there are other signs and symptoms as well to back up this
assumption.

The causes of a heart attack include: heart disease, hypertension,

and a thrombus or blockage.

Other risk factors include: diabetes, elevated LDL lipids,

hypertension, smoking, obesity, sedentary lifestyle, and a family
history of coronary artery disease.

Information Gathering:
• The patient will most likely (obviously) have chest pain. It’s
possible that the patient has a history of heart attacks in the
past.

66
 • The patient will likely show signs of shortness of breath and
tachypnea, with possible cyanosis. They may also appear
anxious and diaphoretic (sweaty).
• The patient will have hypertension and likely tachycardia.
• Their ABG results will display hypoxemia.
• When assessing the patient’s electrolytes, it’s key to look at
the potassium levels for a heart attack patient. They can be
increased or decreased.
• Definitely recommend an EKG. The results will likely show
arrhythmias.
o Look for ST-segment elevation, and also look for
significant Q waves.
• Recommend a test to check the patient’s cardiac enzymes.
You will see elevated troponin levels.

Decision Making (Treatment)

• ALWAYS… for a suspected heart attack patient, always
recommend 100% oxygen. A nonrebreather would be the first
and fastest option.
• Keep a close eye on the patient’s vital signs — specifically
their SpO2, EKG, and blood pressure.
• You can recommend Aspirin.
• Recommend anti-arrhythmic agents such as amiodarone
and atropine.
• You can recommend nitrates for chest pain.
• In order to maintain the patient’s blood pressure, you can
recommend fluid or vasopressors as needed.
• And remember… always defibrillate the patient if the EKG
shows V-fib or Pulseless V-tach.
• On discharge, you can recommend cardiac rehab and
smoking cessation.

Exam Hint: Remember MONA. Give Morphine for pain. Oxygen

for hypoxemia. Nitroglycerin. Aspirin.

67
Shock

Shock is a condition in which perfusion to the tissues and vital

organs is inadequate to meet metabolic needs. Life cannot be
sustained without adequate blood flow to the tissues.

There are (6) different types of shock to be familiar with:

• Cardiogenic shock – caused by heart failure.

• Hypovolemic shock – caused by decreased fluid levels.
• Neurogenic shock – caused by alterations in vascular smooth
muscle tone.
• Septic shock – caused by an infection.
• Traumatic shock – can be caused by both the loss of fluid
(blood) or by an infection.
• Anaphylactic shock – caused by an allergic reaction.

Information Gathering:
• The patient will likely have shortness of breath with
tachypnea and possible cyanosis.
• The patient may appear lethargic and unresponsive, dizzy,
sweaty, cold and clammy, with poor capillary refill.
• The patient’s vital signs will show hypoxemia, tachycardia,
hypotension, and likely hypothermia.
• The patient’s hemodynamics will show decreased volumes.
• Their urine output will be decreased as well.

Decision Making (Treatment)

• Give oxygen for hypoxemia.
• Initiate mechanical ventilation for ventilatory failure.
• Recommend atropine if the patient has significant
bradycardia.

68
• Monitor the patient’s fluid levels closely. Recommend IV
fluids for hypovolemia. Recommend vasopressors for
hypotension.
• Recommend Digitalis or Digoxin for heart failure.
• Recommend antibiotics if an infection is present (septic
shock).

69
Cor Pulmonale

Cor Pulmonale is another term for ‘right heart failure’. It is an

abnormal enlargement of the right ventricle as a result of disease
of the lungs or the pulmonary blood vessels.

It is caused by an increased workload to the right ventricle that is

caused by pulmonary hypertension.

Exam Hint: Cor Pulmonale is often caused by COPD and is

commonly seen in COPD patients.

Just something to keep in mind for the CSE.

Information Gathering:
• The patient likely has a history of COPD or chronic lung
disease.
• The patient will exhibit shortness of breath with an increased
AP diameter of the chest and chest pain.
• You will also likely note that the patient has distended
external jugular veins and peripheral edema.
• The patient’s hemodynamics with show an increased CVP.
• Their EKG will show right ventricular hypertrophy.

Decision Making (Treatment)

• Give oxygen for hypoxemia and closely monitor the patient’s
vital signs.
• Treat the underlying cause of — for example, COPD.
• For these patient’s, you should strive to lower the workload of
the right ventricle by decreasing the pulmonary artery
pressure.
• Recommend the following drug therapies: Digitalis,
Diuretics, and Pulmonary Vasodilators.

70
Pulmonary Embolism

A pulmonary embolism is a blockage in one of the pulmonary

arteries in the lungs that is caused by blood clots that travel to the
lungs from the legs or other parts of the body.

Exam Hint: A good thing to remember is that a pulmonary

embolism results in a deadspace condition. This means that
there is ventilation without perfusion.

So as air/oxygen goes through the lungs, the blood is not

properly picking up oxygen due to the embolism.

The causes include: recent surgery, fractures, blood clots, fat or air
emboli, and immobility.

Information Gathering:
• The patient may show signs of chest pain, dyspnea,
hemoptysis, tachypnea, and cyanosis.
• The patient will also likely appear anxious and diaphoretic.
• The patient’s breath sounds may have wheezing, crackles, or
a pleural friction rub.
• The patient will likely have a decreased blood pressure with
tachycardia, and a decreased cardiac output.
• The chest x-ray will likely appear normal, but it could show a
wedge-shaped infiltrate.
• Their ABG results will show respiratory alkalosis with
hypoxemia.
• Hemodynamics will show an increased PAP and CVP.
• Capnography would show a decreasing PECO2 with a normal
PaCO2.
• The VD/VT ratio will be increased.
• Recommend a CT scan.
• Recommend a V/Q scan.
• Recommend a pulmonary angiogram.

71
 • Recommend a d-Dimer test.

Exam Hint: For the CSE, you may get a case or situation such as
this in regard to a pulmonary embolism:

There is a postoperative patient with sudden dyspnea,

hemoptysis, chest pain, and tachycardia.

Know that these are the signs of a pulmonary embolism. The

key is that it happens suddenly.

Also remember to always recommend a d-Dimer test and

pulmonary angiography.

Decision Making (Treatment)

• Give oxygen for hypoxemia and closely monitor the patient’s
ABGs and vital signs.
• Recommend anticoagulation drugs such as heparin or
warfarin.
• Recommend analgesics for chest pain.
• Recommend positive inotropic agents (Digitalis, Digoxin) to
help maintain circulation.
• Recommend thrombolytic agents such as urokinase or
streptokinase.
• Recommend early movement or ambulation of the patient.
• Recommend the anti-embolism stockings to prevent blood
clots.

72
Pediatric Diseases

Whether you plan to work with kids some day or not, the CSE
takes place in “NBRC hospital.” And you know what that means…

It means that we have to play by their rules. There are some things
you must know about pediatric diseases and we’ll cover them in
this section.

Just a reminder, you will see (2) cases on pediatric diseases on the
CSE.

Not to worry — after you finish this section, you’ll be prepared to

ace this portion of the exam.

Here’s what we’ll cover in this section:

• Croup
• Epiglottitis
• Bronchiolitis
• Cystic Fibrosis
• Foreign Body Aspiration

But first and foremost, we’re going to learn the difference

between croup and epiglottitis.

Exam Hint: You are pretty much guaranteed to have either

croup and/or epiglottitis as one of your cases on the CSE. Most
people do.

This is why it’s critical that you understand how to differentiate

the two.

73
Croup and Epiglottitis

Croup

Croup, or Laryngotracheobronchitis, is a viral subglottic infection

of the upper airway, which obstructs breathing and causes an
inspiratory barking cough.

The infection causes swelling of subglottic tissue (below the vocal

cords) including the larynx, trachea, and larger bronchi.

Since it is a viral infection, it is often caused by Parainfluenza virus.

Exam Hint: Croup is associated with inspiratory stridor. So for

the CSE, when you see a child with inspiratory stridor, you
should automatically think and know that he or she has croup.

Epiglottitis

Epiglottitis is a bacterial supraglottic infection of the upper airway

that causes swelling above the glottis.

The swelling occurs above the vocal cords to the epiglottis,

aryepiglottic folds, and arytenoids.

Epiglottis is a life-threatening emergency! Death can occur if it is

not treated!

(We put this text in red to show emphasis so that you are more
likely to remember this. J )

Since epiglottitis is a bacterial infection, it is often caused by

Haemophilus influeza B.

74
It’s no secret that students have a difficult time distinguishing the
difference between these two diseases. So, to make it easier on
you, we compiled what you need to know in the tables below.

Information Gathering:

Croup Epiglottitis
• It has a gradual onset that • It has a sudden onset that
usually stems from a cold usually occurs within a
over 2-3 days. few hours. It is a medical
emergency!

• Their cough will be very • The cough will be muffled.

hoarse with a barking This is a distinguishing
sound and inspiratory factor because with croup,
stridor. there will be a barking
cough.
• Their breathing pattern • Their breathing pattern
will be fast (tachypnea) will also show tachypnea
with use of accessory with possible intercostal
muscle during breathing. retractions. Breath sounds
There may be signs of will be diminished and
cyanosis and diminished there may be signs of
breath sounds. Intercostal cyanosis.
retractions may be
present.

• Their vital signs will likely • Their vital signs will likely
show an increased heart show an increased heart
rate and blood pressure. rate and blood pressure,
and also a high fever.
• Recommend a lateral • Recommend a lateral
neck x-ray and look for the neck x-ray and look for the
“steeple sign.” “thumb sign.”

75
 • The swelling is below the • The swelling is above the
glottis. glottic.

• The ABG results will show • The ABG results will show
acute alveolar acute alveolar
hyperventilation with hyperventilation with
hypoxemia. hypoxemia.
• CBC results would show • CBC results would show
an elevated white blood an elevated white blood
count (due to the count (due to the
infection). infection).

Decision Making (Treatment)

Croup Epiglottitis
• Recommend close • Recommend close
monitoring of vital signs monitoring of vital signs
and ventilatory and and ventilatory and
oxygenation status. oxygenation status.
• Provide oxygen for • Provide oxygen for
hypoxemia. hypoxemia.

• Recommend antibiotics • Recommend antibiotics

for the infection. for the infection.

• Recommend a cool • As we stated already, this

aerosol mist for the is a medical emergency
stridor, and also and you should
recommend placing the recommend immediate
patient in a cool intubation and
environment. mechanical ventilation.

76
 • Recommend aerosolized • If the intubation attempt
racemic epinephrine. fails and it cannot be
• If repeated racemic accomplished, you can
treatments do not work, recommend a
you can recommend cricothyroidotomy or
Heliox therapy. emergency tracheotomy.
• Also, you can recommend • You can recommend to
corticosteroids for proceed with extubation
patients who do not when the child’s condition
respond to cool aerosol is stable, or when the
and racemic epinephrine swelling in the airway has
therapy. gone down.
• In severe cases, the child
will be very lethargic, have
marked inspiratory stridor,
and extreme use of
accessory muscles during
breathing.

• Recommend intubation
for ventilatory failure, or if
the patient is unable to
protect the airway.

Exam Hint: Again, this is one of the biggest distinguishing

factors that you should remember for the exam.

Epiglottitis is a medical emergency and requires immediate

intubation, whereas croup does not.

Croup occurs more gradually, where epiglottitis happens

suddenly.

77
Bronchiolitis

Bronchiolitis is a viral acute lower respiratory tract infection that

occurs in infants younger than 2 years old.

It is usually caused by RSV (Respiratory Syncytial Virus).

It results in inflammation in the bronchioles that causes edema

and excessive mucous production. This can lead to airway
obstruction, air trapping, and atelectasis.

Information Gathering:
• It usually starts as an upper respiratory tract infection and
then the symptoms and respiratory distress gets worse.
• It can be treated on an outpatient basis or may require
hospitalization.
• The patient will have an intermittent cough and a fast
breathing rate (tachypnea). Also, they may have intercostal
retractions as well.
o In severe cases, apnea may be present.
• On auscultation, you may hear wheezing, rhonchi, or
crackles.
• Vital signs will show tachycardia, hypertension, and fever.
• You can look at the appearance of the child and likely see
nasal discharge, cyanosis, grunting, nasal flaring, and
lethargy.
• A chest x-ray would show hyperinflation with consolidation.
• ABG results would show acute alveolar hyperventilation with
hypoxemia.

Decision Making (Treatment)

• Recommend hospitalization if their condition worsens. Or, if
there is severe respiratory distress, signs of cyanosis,
bradycardia, or periods of apnea.

78
• If the infant is hospitalized, recommend that they are placed
in droplet isolation to prevent the spread of the infection.
• Provide oxygen for hypoxemia.
• Perform nasal suctioning if indicated.
• Do NOT recommend routine bronchodilator therapy because
the wheezing in this case is due to edema, not
bronchospasm.
• Do not recommend corticosteroids, ribavirin, or antibiotics.
o Unless a bacterial infection is present, then you can
recommend antibiotics.
• Provide mechanical ventilation for impending or acute
ventilatory failure.
• Remember, only recommend hospitalization for severe cases.
Most cases can be treated at home with humidification and
oral decongestants.

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Cystic Fibrosis

Cystic Fibrosis is a genetic disorder that effects the exocrine

glands and causes chronic respiratory infections.

It causes abnormal electrolytes and water in and out of the

epithelial cells.

It is associated with:

• The accumulation of thick, viscous mucous in the lungs.

• Blocked passageways in the pancreas.
• Inhibition of the digestion of protein and fat.
• Deficiencies of vitamins A, D, E, and K.

Information Gathering:
• The signs of CF include: family history of CF, chronic cough
and sputum production, barrel chest, digital clubbing, and
recurring respiratory infections.
• The patient may be small in size. The condition causes a lack
of growth.
• They will have large amounts of thick, purulent secretions.
• They will show signs of dyspnea including tachypnea,
pursed-lip breathing, cyanosis, and the use of accessory
muscles during breathing.
• Their vital signs will show tachycardia and hypertension.
• The chest x-ray would show translucent lung fields and a
flattened diaphragm. You may also see an enlarged right
ventricle and areas of atelectasis.
• ABG results would show acute alveolar hyperventilation with
hypoxemia.
• There PFT values would show decreased flows (because it is
an obstructive disease).
• Their CBC results would show elevated hemoglobin and
hematocrit.

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 • A sputum gram stain would reveal Haemophilus influenzae,
Pseudomonas, or Staphylococcus aureus.

Exam Hint: On the CSE, if it is suspected that the patient has

cystic fibrosis, always recommend a Sweat Chloride Test.

The test is considered positive for CF if the level is > 60 mEq/L.

With that being said, if the case tells you that the patient has CF,
then there is no need to order the test, however.

Decision Making (Treatment)

• Recommend airway clearance therapy. Examples include:
postural drainage, chest percussion, PEP therapy, directed
cough, and high frequency chest wall compression (the vest).
• Recommend aerosol drug therapy. Give a bronchodilator
followed by mucolytics (Pulmozyme), followed by anti-
inflammatory agents.

Exam Hint: Recommend the appropriate inhaled antibiotics.

For CF patients, ALWAYS recommend ‘TOBI’ or Tobramycin.

• Give oxygen therapy for hypoxemia.

• Recommend digestive enzyme replacements.

Once the patient is stable, you can recommend the following:

• Annual flu immunizations.

• Recommend a diet high in fat and salt.
• Regular exercise regimens.
• Clinic visits every 2-3 months to assess basic tests.

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Foreign Body Aspiration

This section involves a medical emergency that occurs when a

child aspirates a foreign object causing an airway obstruction.

Most often occurs in children less than 3 years old and is the
leading cause of accidental deaths in infants and toddlers.

Exam Hint: Keep in mind that most organic foreign objects that
are aspirated (for example, food) are radiolucent, so they do not
show up on a chest x-ray.

However, the inorganic objects (like toys, coins, etc.) tend to be

radiopaque and can be seen on the chest x-ray.

Information Gathering:
• There may or may not be a choking event with the child. If
there is a complete airway obstruction, the child will be in
severe respiratory distress with a violent cough.
• They will possibly show signs of tachypnea, cyanosis, and
retractions.
• Their breath sounds may be absent on one side if there is a
complete obstruction. Also, you may hear unilateral
wheezing on the side of a partial obstruction.

Exam Hint: For the CSE, if you get a case that has a child with
unilateral wheezing — boom — you should automatically know
that they have aspirated a foreign object.

• As we stated before, the chest x-ray may or may not show the
aspirated object.
• Also, the chest x-ray may show air trapping, hyperinflation,
and unequal ventilation.

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Decision Making (Treatment)
• Of course, you should recommend that the object be
removed as soon as possible.
• You can recommend rigid bronchoscopy to remove the
object.
• If it still cannot be removed, you may need to recommend an
emergency cricothyroidotomy.
• After the object has been removed, it may be necessary for
you to recommend aerosolized bronchodilators or
corticosteroids if coughing or wheezing persists.
• Do not recommend antibiotics unless an infection is present.

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Neonatal Diseases

Again… whether or not you want to work with babies in the future,
you still have to know this information.

That is because, you will see (2) cases on the CSE regarding
neonatal diseases.

We’re going to cover what you need to know here in this section.

That includes:

• Delivery Room Management

• Apnea of Prematurity
• Meconium Aspiration
• Infant Respiratory Distress Syndrome
• Congenital Heart Defect
• Bronchopulmonary Dysplasia
• Congenital Diaphragmatic Hernia

Are you ready to get started with the neonatal diseases? If so, let’s
go ahead and dive right in.

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Delivery Room Management

As a Respiratory Therapist working in the NBRC hospital, you will

be called to the delivery room to assist with the delivery of a high-
risk infant.

The infant will most likely be less than 35 weeks gestation.

Information Gathering:
• Immediately after birth, you should assess the infant’s heart
rate, respiratory rate, muscle tone, color, and reflexes. And as
I’m sure you are aware, these are the parameters needed to
obtain an Apgar sore.
• You should perform an Apgar score 1 minute and 5 minutes
after delivery.

APGAR Scoring Chart

2 (good) 1 (bad) 0 (very bad)
Appearance Full body pink Body pink but blue
(color) extremities are
blue
Pulse > 100 < 100 No pulse
Grimace Coughing or Grimace No response
sneezing
Activity Active motion Some flexion No movement
of extremities
Respiratory Strong cry Weak cry No cry
effort

• When you repeat the Apgar score at 5 minutes, if it is less

than 7, you should repeat the assessment every 5 minutes for
up to 20 minutes.
• If the infant is cyanotic, provide oxygen for hypoxemia.

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 • You may or may not see this on the CSE. Just be familiar that
you can recommend the Silverman-Anderson scale to assess
the infant’s level of respiratory distress.

Decision Making (Treatment)

• Once you receive the Apgar score during the Information
Gathering section, the treatment for the neonate depends on
the score that they receive.
o A score of 0–3 is a medical emergency! You should
recommend resuscitation and CPR.
o If they receive a score of 4–6, you should stimulate and
warm the neonate. You may also need to provide
oxygen and assist with ventilation.
o If they receive a score of 7–10 and are crying and
breathing normally, there is no need for resuscitation.
Dry the infant, monitor, and provide routine care.
• For meconium stained babies, we will discuss how to treat
them below in the next section.

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Meconium Aspiration

Meconium Aspiration Syndrome is a condition where the fetus has

marked respiratory distress due to meconium stained amniotic
fluid.

It usually occurs in infants that are born at or beyond full term.

Information Gathering:
• Again, this condition is more common in post-term infants.
• The infant will show signs of respiratory distress, including
grunting, nasal flaring, retractions, tachypnea, cyanosis, and
possibly periods of apnea.
• The infant’s vital signs will show tachycardia and
hypertension.
• The infant will have a dark-green-ish appearance due to the
meconium (stool) stain.
• The infant’s breath sounds may reveal wheezing, rhonchi, or
crackles.
• Be sure to closely monitor the infant.
• The infant will likely have a low Apgar score.
• Recommend a chest x-ray. It will likely reveal some
atelectasis and/or consolidation.
• The ABG results would most likely show hypoxemia and/or
possibly metabolic acidosis.

Decision Making (Treatment)

• Do not recommend intubation just because the infant is
meconium stained. If they have a good respiratory effort,
muscle tone, and heart rate, there isn’t a need to intubate.
• Recommend a thorough suction of the nasopharynx and
oropharynx.

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 • However, if the infant has poor respiratory efforts, poor
muscle tone, and a heart rate less than 100 — you should
recommend intubation.
o In this case, intubate and suction the trachea
immediately.
• Recommend surfactant replacement therapy.
• Closely monitor vital signs and oxygenation status.
• Provide oxygen therapy for hypoxemia to maintain the PaO2
at 55–80 torr and the SpO2 at 88–95%.
• If mechanical ventilation is necessary, you can recommend
High-Frequency Oscillation Ventilation if it’s available.

Exam Hint: The key to succeeding with one of these Meconium

Aspiration Syndrome cases on the CSE is this:

Knowing when to recommend intubation and when not to.

Again, to make it simple for you — if the infant is crying with

good muscle tone, strong respirations, and a heart rate greater
than 100 — you do NOT need to intubate.

However, if the infant is not crying, has poor muscle tone, weak
respirations, and a heart rate less than 100 — you know what
this means — it’s a medical emergency and you should
recommend intubation immediately.

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Apnea of Prematurity

Apnea of Prematurity is a disorder that effects infants born less

than 37 weeks gestation that is caused by physiologic immaturity
of the respiratory control center in the CNS.

The earlier the infant is born and the lower the birth weight, the
higher the incidence of Apnea of Prematurity.

Information Gathering:
• The infant will be experiencing episodes of central apnea and
irregular breathing.
• Bradycardia is also likely in these infants.
• Cyanosis is possible.

Decision Making (Treatment)

• Recommend continuous apnea monitoring for respirations
and heart rate.
• Recommend continuous pulse oximetry to monitor for
hypoxemia during periods of apnea. And, of course, provide
oxygen therapy if hypoxemia is present.
• Recommend that the infant be cared for in the prone
position.
• Recommend intubation and mechanical ventilation if the
episodes get more frequent or longer.
• Recommend daily doses of methylxanthines (caffeine).
• If the infant still has regular periods of apnea but is still stable
and doesn’t require mechanical ventilation — you can
recommend nasal CPAP or high-flow nasal cannula.

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IRDS

IRDS, or Infant Respiratory Distress Syndrome, is a disease that is

common in premature infants because their lungs have not fully
developed yet.

Another name for this is Hyaline Membrane Disease.

Exam Hint: IRDS is associated with the lack of surfactant

production, which leads to atelectasis and hypoxemia.

So if you get a case on the CSE where you determine that the
infant has IRDS, you can immediately know that you should
recommend surfactant replacement therapy.

Information Gathering:
• For IRDS to be present, the infant will be born prematurely
(less than 37 weeks gestation) and a low birth weight of less
than 1,500 grams.
• They will likely have low Apgar scores.
• You may need to recommend to test the L:S ratio. It will likely
be less than 2:1.
• The infant will show signs of respiratory distress, including
cyanosis, retractions, grunting, nasal flaring, tachypnea, and
possible periods of apnea.
• The infant’s vital signs will show and increased heart rate and
blood pressure.
• For breath sounds, you will hear bronchial breath sounds, or
possibly crackles.
• Definitely recommend a chest x-ray. You will see a ‘ground
glass’ appearance with increased opacity and air
bronchograms.
• Definitely recommend an ABG. The results will show
respiratory acidosis with hypoxemia.

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Decision Making (Treatment)
• Recommend oxygen therapy for hypoxemia. You may need
to recommend nasal CPAP at 4–6 cmH2O.
o Strive to keep PaO2 between 50–70 torr and the SpO2
between 85–92%.
• As we stated before in the Exam Hint, you must recommend
surfactant replacement therapy because the infant will have
a deficiency.
o Just a reminder: surfactant can be administered and
directly instilled down the ET tube.
o Types of surfactant include:
§ Survanta (beractant)
§ Curosurf (poractant alfa)
§ Infasurf (calfactant)
• A high-flow nasal cannula at 1–6 L/min can be recommended
as an alternative to nasal CPAP.
• Recommend the maintenance of the infant’s neutral thermal
environment with an incubator or radiant warmer.
• Recommend intubation and mechanical ventilation if the
infant cannot maintain a pH greater than 7.25 while on nasal
CPAP.
o PEEP will most likely be necessary as well.

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Congenital Heart Defects

This section covers the Congenital Heart Defects that you need to
know for the CSE. Basically, this refers to structural abnormalities
of the heart that are present at birth.

The first (2) that are going to cover cause severe hypoxemia. They
are:

• Tetralogy of Fallot – is a combination of four congenital

abnormalities that affects normal blood flow through the
heart. The four defects include:
o Ventricular septal defect (VSD)
o Pulmonary valve stenosis
o Misplaced aorta
o Right ventricular hypertrophy
• Transposition of the Great Vessels – A heart defect where
there is an abnormal arrangement of the vessels. The aorta is
connected to the right ventricle, and the pulmonary artery is
connected to the left ventricle, which is the opposite of
normal.

Both of these cause right-to-left shunting with cyanosis and

hypoxemia and usually require surgery in order to correct the
defect.

Information Gathering:
• Respiratory distress will likely be present with labored
breathing and cyanosis.
• A heart murmur may be present and an abnormal heart rate.
• Definitely recommend a chest x-ray to assess the heart!
o Tetralogy of Fallot – the heart will be boot-shaped.
o Transposition of the Great Vessels – the heart will be
egg-shaped.
• Definitely recommend an echocardiogram. This is the most
important test to diagnose cardiac defects.

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 • Recommend pre and post-ductal ABG studies.

Other Heart Defects

Here are just a few other congenital heart defects that we want to
refresh your memory on, just to be safe.

Each of these defects leads to left-to-right shunting.

Patent Ductus Arteriosus – a condition where the ductus

arteriosus fails to close after birth.
• Early symptoms are uncommon, but in the first year of life
include increased work of breathing and poor weight gain.
• An uncorrected PDA may lead to congestive heart failure
with increasing age.

Truncus Arteriosus – a rare type of heart disease where the aorta

and pulmonary artery are combined into one vessel.

Coarctation of the Aorta – a defect where the aorta is constricted,

which leads to hypotension in the lower extremities and
hypertension in the upper extremities.

Atrial Septal Defect – a birth defect where there is a hole in the

wall that divides the atria.

Ventricular Septal Defect – a birth defect where there is a hole in

the wall that divides the ventricles.

Decision Making (Treatment)

• As I stated previously, these defects require surgery in order
to correct. So, you should recommend surgery once the
congenital heart defect is confirmed.
• Provide oxygen therapy for hypoxemia.

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• If the defect causes the infant to have low blood pressure or
low cardiac output, recommend a positive inotropic agent
like dopamine.
• You can recommend Prostaglandin E1 in order to maintain or
dilate a patent ductus arteriosus.
• Recommend intubation and mechanical ventilation for
ventilatory failure.

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Bronchopulmonary Dysplasia

Bronchopulmonary Dysplasia is a chronic lung disease that affects

mostly premature newborn infants and requires long-term need
for supplemental oxygen.

The cause of BPD is unknown, but it is associated with infant’s that

are born early and/or with a low birth weight.

It often requires mechanical ventilation with high concentrations

of oxygen.

Information Gathering:
• The infant will show signs of respiratory distress including
retractions, nasal flaring, grunting, abdominal distention, and
cyanosis.
• The infant will have an extremely fast breathing rate
(extreme tachypnea).
• Breath sounds will reveal crackles and expiratory wheezes.
• Vital signs will show tachycardia and hypertension.
• Recommend a chest x-ray. It will show decreased lung
volumes and atelectasis, and will often resemble IRDS.
• Recommend an ABG. The results will show respiratory
acidosis with hypoxemia.

Decision Making (Treatment)

• You will definitely need to recommend oxygen therapy.
Strive to use the lowest level possible to maintain the SpO2 in
the 88–92% range.
• You may need to recommend surfactant replacement
therapy.
• Recommend pulmonary hygiene.
• Monitor fluid levels closely.

95
• Recommend mechanical ventilation for ventilatory failure
and select a volume-control mode, as opposed to a pressure-
control mode.
• Wean the infant from the ventilator. It will be a slow process,
but strive to wean them to nasal CPAP.
• Bronchodilators may be helpful, so you can recommend
them if wheezing (bronchospasm) is present.

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Congenital Diaphragmatic Hernia

A Congenital Diaphragmatic Hernia occurs when the diaphragm

does not close completely during prenatal development.

This is a medical emergency!

Prompt surgical repair is imperative. Mortality rate is up to 40% if

the hernia isn’t treated properly within the first few hours.

Information Gathering:
• The infant will be in respiratory distress, including signs of
retractions, grunting, nasal flaring, and cyanosis.
• The respiratory rate will be extremely fast (extreme
tachypnea).
• Breath sounds will likely be absent on the affected side.
• The vital signs will show tachycardia and hypertension.
• The infant may have a barrel chest appearance due to some
air trapping.
• You should recommend a chest x-ray, and it will likely show
intestinal loops in the sternum due to the open diaphragm.
The heart and mediastinum will be shifted away from the
affected side. You will also likely see atelectasis or a total lung
collapse.
• ABG results will show respiratory acidosis with hypoxemia.

Decision Making (Treatment)

• As I said before, this is a medical emergency! Always
recommend surgery to repair the hernia.
• Once the diagnosis has been made, recommend the
insertion of an oral gastric tube to decrease gas in the bowel.
• Provide oxygen therapy for hypoxemia.
• Recommend that the infant be placed on the affected side.

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• Recommend intubation and mechanical ventilation. Do not
ventilate with a bag-valve mask.
o This infant would be a good candidate for high-
frequency oscillation ventilation.
• For severe cases, recommend ECMO.

98
Other Adult Medical Conditions

Almost to the end! You’ve done a great job focusing and retaining
the information thus far. Keep up the good work!

Now, we’re going to cover a few disorders that you may see on the
CSE that didn’t quite fit into the other sections.

I know, I know — it’s more information for you to learn.

BUT, as I said, I want you to be as prepared as possible. So, it would

be a disservice to you if I didn’t include them for you here.

Learning about these conditions now will do nothing but benefit

you, both for the CSE as well as your career as an RRT.

Here’s what we’ll cover in this section:

• Sleep Disorders
• Hypothermia
• Pneumonia
• AIDS
• Renal Failure
• Diabetes
• Thoracic Surgery
• Head Trauma
• Spinal Injury

Whoof! I know, it’s sounds like a lot. BUT… these conditions are
very straight-forward, and the sections are much shorter than the
others in this study guide.

You got this! Let’s go ahead and dive right in.

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Sleep Disorders

In this section, we will cover the disorders or dyssomnias that keep

patient’s from maintaining normal sleep. Particularly, I’m referring
to sleep apnea.

Sleep Apnea is a sleep disorder that can be diagnosed in patients

who have more than 5 episodes of apnea per hour while asleep in
a 6-hour period.
• Technically, a period of apnea is the cessation of breathing
for a period of at least 10 seconds.

Information Gathering:
Patient History
• Insomnia
• Snoring
• Frequent awakenings
• Morning headaches
• Hypertension
• Hyperthyroidism
• Morning dry mouth/sore throat
• Obesity
• Increased neck circumference
• More common in males
• Age > 50 years old
• ABG results would show chronic ventilatory failure
• PFT results would show decreased volumes

Exam Hint: You must know the difference between central and
obstructive sleep apnea.

Central Sleep Apnea – the absence of breathing as the result of

medullary depression that inhibits respiratory movement, which
becomes more pronounced during sleep.

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 • It occurs as a result of the failure of the brain to send signals
to the respiratory muscles.

Obstructive Sleep Apnea – it is characterized by occlusion of the

oropharyngeal airway with continued efforts to breathe.
• This is the most commonly encountered type of sleep apnea.

Mixed Sleep Apnea – as the name implies, it’s a mixture of central

and obstructive sleep apnea.

Exam Hint: For the Information Gathering or Decision Making

portion of the CSE, when you have a patient with sleep apnea,
ALWAYS recommend a sleep study.

Sleep Study (Polysomnography) – is a test used to diagnose sleep

disorders. You always want to recommend this for sleep apnea
patients.
• During the sleep study, in central sleep apnea, the patient
isn’t moving air because there is no effort to move air.
• In obstructive sleep apnea, the patient will not be moving
any air because of an obstruction, but you will see that they
did make a breathing effort to do so.

Apnea-Hypopnea Index – the average number of apneas and

hypopneas per hour of sleep.
• Normal is < 5 per hour
• Mild is 5–15 per hour
• Moderate is 16–30 per hour
• Severe is > 30 per hour

Decision Making (Treatment)

Central Sleep Apnea
• Noninvasive positive pressure ventilation is recommended.

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Obstructive Sleep Apnea
• CPAP is recommended. You may have to change or adjust
the mask/interface to make it comfortable for the patient.
o For example, you may have to recommend switching
from a full-face mask to a nasal mask.
• Weight loss for obese patients
• Improve sleep posture and avoid the supine position
• Provide oxygen therapy for hypoxemia
• Reconstructive surgery of the upper airway

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Hypothermia

Hypothermia is a medical emergency that occurs when the

patient has a dangerously low body temperature (Below 95° F).

It is usually caused by cold water immersion, or by prolonged

exposure to a cold environment.

Information Gathering:
• In most cases, this will be a medical emergency. You will
likely need to recommend immediate CPR.
• Recommend the measurement of the patient’s body
temperature.
• The patient will be extremely cold with shivering, confusion,
and cyanosis.
• Their vital signs will show bradycardia and bradypnea.
• Recommend an ABG. The results will likely show respiratory
acidosis with hypoxemia.
o Remember that when obtaining an ABG on a
hypothermic patient, the results will need to be
adjusted.
o Their pH will be falsely increased, and the PaCO2 and
PaO2 will be falsely decreased.
• Recommend EKG monitoring.
• Recommend a chest x-ray. It may show pneumonia or
pulmonary edema.

Decision Making (Treatment)

• Remove any wet or cold clothing and cover with warm
blankets to increase the body temperature.
• If the patient displays no signs of life, initiate CPR
immediately.
• Provide (warm) supplemental oxygen for hypoxemia.

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• Recommend intubation and mechanical ventilation for
ventilatory failure.
o Use a heated humidifier instead of an HME.
• Warm IV fluids can help increase the patient’s body
temperature.

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Pneumonia

Pneumonia is an infection that causes inflammation to the alveoli

in the lungs that leads to consolidation and atelectasis.

It is caused by bacteria, viruses, or aspiration.

It’s one of the most common diseases that you’ll deal with as a
Respiratory Therapist.

Information Gathering:
• The patient’s signs and symptoms will be like a cold or flu.
• The patient may experience shortness of breath with a
productive cough.
o Sputum may be colored which indicates an infection is
present.
• The patient’s chest appearance will show decreased
expansion and increased tactile fremitus.
• Their vital signs would show tachypnea, tachycardia,
hypertension, and likely a fever.
• Breath sounds would show crackles or bronchial breath
sounds.
• The diagnostic chest percussion note would be dull or flat.
• Recommend a chest x-ray. It will show consolidation,
atelectasis, air bronchograms, or possibly a pleural effusion.
• Recommend an ABG. The results would show respiratory
alkalosis (hyperventilation) with hypoxemia.
• PFT results would show decreased volumes.
• A CBC may show increased white blood cells with a bacterial
infection and decreased white blood cells with a viral
infection.
• You can recommend a sputum culture to access the
infection.

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Exam Hint: For the CSE, when you see a patient with
consolidation (fluid in the chest) — look for other signs too, of
course, but you can usually associate that with pneumonia.

Decision Making (Treatment)

• Give supplemental oxygen for hypoxemia.
• Recommend hyperinflation therapy as well as pulmonary
hygiene therapy.
• Recommend bedrest and adequate fluid intake.
• Recommend a thoracentesis to remove large amounts of
fluid (pleural effusion).
• Recommend antibiotics for the infection.
• Recommend intubation and mechanical ventilation for
ventilatory failure.
o Be sure to abide by the VAP protocol.

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AIDS

Although the percentages are small, there have been versions of

the CSE in the past to have a case about AIDS.

So, we will briefly cover a few important things about the disease
for you here.

AIDS, or Acquired Immune Deficiency Disorder, is essentially a

weakened immune system.

Information Gathering:
• The patient could have a history of drug abuse.
• The patient may appear pale in color and have weight loss.
• The patient will likely have a recurrent fever.
• Recommend the ELISA test to check for AIDS.
• You can recommend a bronchoscopy to obtain a biopsy to
check for AIDS.
• The patient may test positive for Pneumocystis carinii.

Exam Hint: Definitely know to recommend the ELISA test in

order to check for AIDS or HIV.

Decision Making (Treatment)

• Pneumocystis carinii can be treated with Pentamidine via
aerosol.
o Make sure the therapist administering the treatment
wears a mask.
• Recommend the use of standard precautions in order to
protect medical personal from acquiring the disorder.
• Blood culture tests would not be helpful. That is because,
Pneumocystis carinii cannot grow outside of the body.

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Renal Failure (Diabetes)

We’re going to briefly cover what you should look for if you were to
get a case on the CSE where the patient is in renal failure or
diabetes.

Information Gathering:
• Their respiratory pattern would display Kussmaul breathing.

Exam Hint: If you see a patient with Kussmaul breathing —

boom — automatically think renal failure.

• Auscultation may reveal crackles if CHF is present.

• The patient may be lethargic, confused, or even comatose.
• The patient may have pedal edema (fluid overload).
• Recommend an ABG. The results will show metabolic
acidosis.
• Their urine output will be decreased (<500 mL/day).
• Recommend to check their blood glucose level.
• Recommend to check their electrolytes.

Decision Making (Treatment)

• For diabetes, you should closely monitor their blood glucose
levels. Also, monitor their ABG results for ventilatory failure.
• For renal failure, you should closely monitor their fluid levels.
Also monitor their electrolytes and watch for signs of CHF.

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Thoracic Surgery

In this section, we will be referring to any type of surgical

procedure to the chest or thoracic cavity.

Examples include heart surgery, lung repairs, and tracheal repairs

etc.

Exam Hint: Remember the importance of hyperinflation therapy

both before and after surgery in order to prevent atelectasis.

Incentive spirometry, for example.

• Focus on preventing infection after surgery.

• Monitor the chest tubes and drainage systems.
• Recommend the use of a pillow for splinting when coughing.
• Monitor for post-surgery complications. Examples include:
o Decreased lung compliance
o Hypovolemic shock due to the loss of blood
o Subcutaneous emphysema
o Increased pressures on the ventilator
• If the patient was extubated and begins to deteriorate,
recommend that they be re-intubated and placed back on
mechanical ventilation.

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Head Trauma

In section, we’re going to cover injuries to the brain or skull.

Examples include traumatic brain injury, tumors, aneurysms,

seizures, and cerebrovascular accidents.

Information Gathering:
• The patient’s breathing pattern will show Cheyne-Stokes
breathing.
• Recommend continuous capnography to monitor for
hypercapnia.
• Recommend the Glasgow Coma Scale to assess the level of
consciousness (Severe is 8 or less).
• The patient’s pupillary response will likely be abnormal.

Exam Hint: On the CSE, if you get a case where the patient has
a Cheyne-Stokes breathing pattern — you should automatically
know the patient most likely has had a traumatic brain injury.

Decision Making (Treatment)

• Provide 100% oxygen. If using a mask, be sure to keep the
patient’s head/neck area stable until a spinal cord injury has
been ruled out.
• If the patient scores 8 or less on the Glasgow Coma Scale,
recommend immediate intubation and mechanical
ventilation.
• Recommend continuous monitoring of the patient’s blood
pressure.
• Closely monitor the patient’s intracranial pressure. Keep the
ICP less than 20 mm Hg (Normal is 5–10 mm Hg).
o Avoid hypercapnia.

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 o Keep PEEP levels to a minimum to reduce ICP.
o Recommend Mannitol to decrease the ICP.
• Recommend barbiturates for sedation.
• If the patient has seizures, recommend the drug Dilantin.

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Spinal Cord Injuries

This section refers to the injuries of the neck or spinal cord. These
often will be seen in motor vehicle accidents, falls, and other
accidents — possibly tumors, as well.

Information Gathering:
• Evaluate airway patency. If apnea is present, initiate manual
ventilation.
• Recommend basic labs like ABG, CBC, Hb & Hct, blood
lactate, and a toxicology screen.
• Recommend imaging scans like a CT scan and an MRI.
• The patient may have bruises over the affected area.
• You can recommend to check the patient’s respiratory
muscle function ONLY after they are stable. This includes
checking the vital capacity and MIP/NIF.

Decision Making (Treatment)

• Focus on keeping the spine and neck stable with as little
movement as possible.
• Provide oxygen therapy for hypoxemia.
• Focus on maintaining a patent airway.
o To intubate, you will need to use the modified jaw thrust
technique.
o Also, recommend using a flexible bronchoscope to
assist with intubation.
• Recommend a tracheostomy if the patient is likely to be
ventilator-dependent for a longer period of time.

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Normal Values

You’ve made it this far, which means that you’ve passed the TMC
Exam already. That tells me that you definitely already know your
normal values.

BUT….

They are still very important and you definitely need to know them
for the CSE as well. That is why we are including them again for
you here.

Go through the following charts a few times to refresh your

memory on these important normal values.

Patient Assessment Normal Values:

Patient Assessment Normal

Urine Output 40 mL/hour
Heart Rate 60 – 100 /min
Diagnostic Chest Percussion Resonant
Breath Sounds Vesicular
Heart Sounds S 1, S 2
Blood Pressure 120/80 mmHg
range: 90/60 – 140/90 mmHg
Intracranial Pressure 5 – 10 mmHg
Cerebral Perfusion Pressure 70 – 90 mmHg
Exhaled Carbon Monoxide < 7 for nonsmokers

Complete Blood Count (CBC) Normal

Red Blood Cells (RBC) 4 – 6 mill/mm3
Hemoglobin (Hb) 12 – 16 gm
Hematocrit (Hct) 40 – 50 %
White Blood Cells 5,000 – 10,000 per mm3

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Chemistry Normal
Potassium (K+) 4.0 mEq/L
range: 3.5 – 4.5 mEq/L
Sodium (Na+) 140 mEq/L
range: 135 – 145 mEq/L
Chloride (Cl-) 90 mEq/L
range: 80 – 100 mEq/L
Bicarb (HCO3-) 24 mEq/L
range: 22 – 26 mEq/L
Creatinine 0.7 – 1.3 mg/dL
Blood Pressure 120/80 mmHg
(range: 90/60 – 140/90 mmHg)
Blood Urea Nitrogen (BUN) 8 – 25 mg/dL

Coagulation Studies Normal

Clotting Time Up to 6 minutes
Platelet Count 150,000 – 400,000/mm3
Activated Partial 24 – 32 seconds
Thromboplastin Time
Prothrombin Time 12 – 15 seconds

Infant Assessment Normal

Term Infant 38 – 42 weeks
APGAR Score 7 - 10
Temperature 36.5 °C
Heart Rate 110 – 160/min
Respiratory Rate 30 – 60 breaths/min
Blood Pressure 60/40 mmHg
Birth Weight 3000 g
Dubowitz Score 40
Blood Glucose > 30 mg/dL
L/S Ratio 2:1 or higher

Cardiac Enzymes Normal

Troponin < 0.1 ng/mL
Brain Natriuretic Peptide (BNP) < 100 pg/mL

114
 Hemodynamic Monitoring Normal
Mean Arterial Pressure (MAP) 93 – 94 mmHg
Right Atrial Pressure (RAP) or 2 – 6 mmHg
Central Venous Pressure (CVP) 4 – 12 cmH2O
Right Ventricle Pressure 25/0 mmHg
Pulmonary Artery Pressure 25/8 mmHg
(PAP) Mean 13 – 14 mmHg
Pulmonary Capillary Pressure 8 – 10 mmHg
Pulmonary Capillary Wedge 4 – 12 mmHg
Pressure (PCWP)
Left Atrial Pressure 2 – 6 mmHg
Left Ventricle Pressure 120/0 mmHg
Cardiac Output 4 – 8 L/min
Pulse Pressure 40 mmHg
Systemic Vascular Resistance < 20 mmHg/L/min or
(SVR) 1600 dynes/sec/m-5
Pulmonary Vascular Resistance < 2.5 mmHg/L/min or
(PVR) 200 dynes/sec/cm-5
Cardiac Index 2.5 – 4 L/min/m2

Laryngoscope Blade Sizes Normal

Adult 3
Pediatric 2
Term Infant 1
Pre-Term Infant 0

ET Tube Sizes & Markings Normal

Pre-Term Infant 2. – 3.0 mm
Term Infant 3.0 – 3.5 mm
Adult Male 8.0 – 8.5 mm
Adult Female 7.0 – 7.5 mm
Oral Intubation 21 – 25 cm at the lip
Nasal Intubation 26 – 29 cm at the nares

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Monitoring Data Normal
Capnography 30 torr
3–5%
Pulse Oximetry 93 – 97 %
Carboxyhemoglobin (COHb) 0–1%
Cuff Pressure 20 – 25 mmHg
25 – 35 cmH2O

Blood Gas Normal Values:

Parameter Normal Value Acceptable Range
PCO2 40 torr 35 – 45 torr
PO2 97 torr 80 – 100 torr
pH 7.40 7.35 – 7.45
SO2 98% 95 – 100%
HCO3 24 mEq/L 22 – 26 mEq/L
BE 0 -2 – +2
Hb 14g 12 – 16g
CaO2 20 Vol% 17 – 20 Vol%
CvO2 12 – 16 Vol%

How to adjust therapy according to Blood Gas

Values:
PaCo2 Value Interpretation Response
35 – 45 torr Normal Ventilation You should not put
the patient on the
ventilator, or change
the vent. settings.
> 45 torr This indicates that You should initiate
the patient is not mechanical
ventilating. ventilation, or if they
are already on the
vent., you should

116
 increase their
current ventilation.
< 35 torr The patient is Don’t put the
hyperventilating patient on
mechanical
ventilation, or if they
are already on it;
decrease their
ventilation.

PaO2 Value Interpretation Response

80 – 100 torr Normal Maintain current
Oxygenation settings
< 80 The hypoxemia is You should increase
(with an FiO2 less caused by either the FiO2 up to 60%.
than 60%) poor ventilation or
V/Q Mismatch
< 80 Indicates a You should increase
(with an FiO2 shunt/refractory the PEEP or CPAP.
greater than 60%) hypoxemia is
present
> 100 Over-oxygenation You should
decrease the FiO2,
PEEP, or CPAP.

Pulmonary Diagnostic Testing Normal Values:

Calculations Normal
PAO2 Varies directly with the
patient’s FiO2 and PB
A-aDO2 Varies directly with the
patient’s FiO2
P/F Ratio ≥ 380 torr
CaO2 17 – 20 vol%
CvO2 12 – 16 vol%

117
C(a-v)O2 4 – 5 vol%
Cardiac Output (QT) 4 – 8 L/min
QS/QT 3–5%
SaO2 98 % or
95 – 100 %
Oxygen Index (OI) < 10
VD/VT Ratio 20 – 40 %

Arterial Blood Gases (Adult) Normal

PCO2 40 torr
range: 35 – 45 torr
PaO2 97 torr
range: 80 – 100 torr
pH 7.40
range: 7.35 – 7.45
HCO3- 22 – 26 mEq/L
BE -2 – +2

Newborn Arterial Blood Gases Normal

PaCO2 < 50 torr
PaO2 > 60 torr
pH > 7.30

PFTs Normal
Calibration Syringe 3.0 liters
Maximum Inspiratory Pressure 80 cmH2O
(MIP)
Maximum Expiratory Pressure 160 cmH2O
(MEP)

Typical Values Normal

VC 4.8 liters or
80 % of predicted or higher
FEV1 4.0 liters or
80 % of predicted or higher
FEV1/FVC 83 %

118
FEF200-1200 6.0 L/sec or
80 % of predicted or higher
FEF25-75% 4.7 L/sec or
80 % of predicted or higher

Peak Expiratory Flowrate (PEFR) 10 L/sec (600L/min) 80% of

predicted

Airway Resistance 0.6 – 2.4 cmH2O/L/sec

Compliance 60 – 100 mL/cmH2O

DLCO 25 mL CO/min/mmHg

Bedside Ventilatory Parameters:

Measurement Normal Acceptable Unacceptable

Vital Capacity 65 – 75 mL/kg ≥ 10 mL/kg < 10 mL/kg
(VC)
Respiratory 12 – 20 8 – 20 > 20 /min or
Rate breaths/min breaths/min < 8 /min
Minute 5 – 6 L/min < 10 L/min > 10 L/min
Ventilation (VE)
Maximum 80 cmH2O 20 cmH2O < 20 cmH2O
Inspiratory
Pressure (MIP)
or Negative
Inspiratory
Force (NIF)
Maximum 160 cmH2O 40 cmH2O < 40 cmH2O
Expiratory
Pressure (MEP)
Spontaneous 5 – 8 mL/kg ≥ 5 mL/kg < 5 mL/kg
Tidal Volume

119
Initial Settings for Mechanical Ventilation

Setting Value
Tidal volume 5 – 10 mL/kg of ideal body weight
Pressure ≤ 35 cmH2O
Respiratory rate 10 – 20 breaths/min
FiO2 40 – 60% (or set to the same level
prior to ventilation)
PEEP 2 – 6 cmH20

Initial Settings for Infant Mechanical Ventilation

Setting Value
Tidal volume 4 – 8 mL/kg
PIP 20 – 30 cmH2O
Respiratory rate 20 – 30 breaths/min
FiO2 40 – 60% (or set to the same level
prior to ventilation)
PEEP 2 – 4 cmH20

Mechanical Ventilation Normal Values

Typical Values Normal

Tidal Volume (VT) 5 – 8 mL/kg
Vital Capacity (VC) 65 – 75 mL/kg or
10 x VT
Respiratory Rate 12 – 20 breaths/min
Minute Ventilation (VE) 5 – 6 L/min
Maximum Inspiratory 80 cmH2O
Pressure (MIP)
Maximum Expiratory 160 cmH2O
Pressure (MEP)
Static Lung Compliance 60 – 100 mL/cmH2O
Mean Airway Pressure 5 – 10 cmH2O

120
Anatomic Deadspace 1 mL/pound of ideal body weight
Work of Breathing (WOB) 0.5 ± 0.2 J/L
1 Hz 60 cycles/min

121
Conclusion

You did it! You made it all the way to the end of the study guide!

Congratulations!
First and foremost, I want to congratulate you on this incredible
accomplishment.

Just by making it this far, that tells me you have what it takes to
become an amazing Respiratory Therapist.

And kudos to you!

But unfortunately…. your work here is not finished.

This study guide contains a lot of information that you really need
to truly know and understand in order to increase your chances of
passing the CSE.

And for most people (myself included), reading through this

information once is not going to be enough.

In order to truly learn this stuff, you’re most likely going to have to
read through it several times. I know I sure had to!

In all honesty, it does take time, but it’s a small price to pay in
regard to passing the exam and earning that exquisite RRT
credential that we all want so badly.

The good news it this…

You can do it!

No, seriously. I know you can do it. I know you can pass the exam! I
have 100% faith in your ability to do so.

122
Look at it this way.

Passing the CSE is like chopping down a tree…

And Abraham Lincoln said it best:

“Give me six hours to chop down a tree and I will spend the first
four sharpening the axe.”

You have the perfect tool to use to pass the exam. This study
guide is outlined with the exact information that you need to
know.

Now you just need to sharpen the axe.

You must read through this study guide again and again until
your axe is as sharp as possible.

Then, and only then, will you have no trouble chopping down the
tree and passing the exam!

It will most definitely be worth it in the end. And like I said, I know
you can do it!

Thank You!
Again, thank you so much for reading all the way to the end. And
thank you for choosing Respiratory Therapy Zone as your resource
to prepare for the exam.

Keep working and studying hard. All the work that you are putting
is now is going to pay off for you in a big way, I promise.

And most importantly — never give up on achieving whatever

goals you want to accomplish in life.

123
I look forward to hearing your success story after you pass the
exam and earn your RRT credential.

You got this. I wish you the best of luck and as always, breathe
easy my friend. J

124
Appendix A

Many students often ask me if I recommend that they use our

TMC Study Guide to prepare for the CSE as well.

And my answer is always, yes!

While your primary focus should be on the information in this CSE

Study Guide, it’s always helpful to revisit the topical content found
inside of our TMC Study Guide as well.

So, if you haven’t got your copy yet, I definitely highly recommend
it.

You can do so using the link below:

Click Here to Grab Your Copy Today!

125
References

1. Kacmarek, RM, Stoller, JK, Heur, AH. (2012) Egan’s Fundamentals

of Respiratory Care, 10th and 11th editions. Elsevier.

2. Cairo, JM. (2014) Mosby’s Respiratory Care Equipment. 9th

edition. Elsevier.

3. Cairo, JM. Pilbeam’s Mechanical Ventilation, Physiological and

Clinical Applications, 5th edition. Suanders/Elsevier, 2012.

4. Mottram, C. (2013) Ruppel’s Manual of Pulmonary Function

Testing. 10th edition. Elsevier.

5. Gardenhire, DS. (2012) Rau’s Respiratory Care Pharmacology. 8th

edition. Elsevier.

6. Walsh, BK, Czervinske, MP, DiBlasi, RM. (2010) Perinatal and

Pediatric Respiratory Care. 3rd edition. Saunders.

7. American Thoracic Society. (2005) Series ATS/ERS Task Force:

Standardization of Lung Function Testing. European Respiratory
Journal.

8. Heuer, Al. (2013) Wilkins’ Clinical Assessment in Respiratory Care,

7th edition. Saunders/Elsevier.

9. Sills. (2015) The Comprehensive Respiratory Therapist Exam

Review, 6th edition. Elsevier.

10. Bickley, LS, PG. (2013) Bates’ Guide to Physical Examination and
History Taking, 11th edition. Lippincott-Williams & Wikins.

11. Export Panel Report 3 (2012) Guidelines for the Diagnostics and
Management of Asthma, Full report.

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12. Des Jardins, T, & Burton, GG. (2010) Clinical Manifestations and
Assessment of Respiratory Disease. 6th edition. Elsevier.

13. Mazzoli, Andrew J (2015) Kettering National Seminars

Comprehensive Review. Study Guide.

14. Persing, H, G. (2015) Respiratory Care Exam Review, 4th edition.

Saunders. Elsevier.

15. Walsh, Brian K. (2014) Neonatal and Pediatric Respiratory Care,

4th edition. RRT. Elsevier.

16. Chang, David W. (2013) Clinical Application of Mechanical

Ventilation, 4th edition. Cengage Learning.

Copyright ã Respiratory Therapy Zone

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