10 free AEMT practice questions: Pulmonary Disease Processes: Sorting the Dyspneic Patient

Loud wheezing heard across all lung fields: A loud wheeze means air is still getting through, so loudness does not measure how blocked the airways are. Wheezing only happens when air moves fast enough through narrowed airways to make sound. A chest that goes silent is the one heading toward arrest.

A heart rate of 124 after two treatments: Two nebulized bronchodilator treatments can raise the heart rate on their own, and hypoxia and the work of breathing can raise it too. With two possible causes, a rate of 124 cannot measure the airway by itself.

A respiratory rate of 30 breaths per minute: Thirty breaths a minute says nothing about how much air each breath moves. A patient taking 30 shallow breaths and a patient taking 30 effective breaths look the same on that number.

Flat on the back with the head turned: Flat on the back is the position that just made this patient worse. Lying flat lets the blood pooled in the legs and abdomen drain back toward a heart that is already full. Turning the head does nothing about where the fluid goes.

On the left side with the knees drawn up: The left side with the knees drawn up is a comfort position for abdominal pain. This patient's problem is a heart overwhelmed with fluid, and lying on the side takes none of that load off.

Flat with the legs raised above the heart: Raising the legs above the heart sends more blood back to the center of the body. A patient in shock who needs more blood returning to the heart would get this position. This patient already has too much volume coming back, and raising the legs sends even more of it to the lungs.

A patient whose lower airways are narrowed by bronchospasm: Bronchospasm is exactly what a nebulized bronchodilator treats. The smooth muscle is squeezing, and the drug relaxes the muscle. This patient's airway opens, and the question asks which patient's problem stays unchanged.

A patient whose airways are tightened by an allergic reaction: An allergic reaction has effects all over the body that albuterol will not fix. The airway tightening in an allergic reaction is still smooth muscle squeezing the lower airways. That muscle relaxes the same way it does in plain bronchospasm, so this patient's airway improves.

A patient wheezing during a chronic obstructive pulmonary disease flare: A COPD flare can look like the sickest patient in the group. The wheezing in a COPD flare comes from the same bronchospasm. How sick the patient is does not change what the drug acts on, so this airway still opens.

Leave the flow where it is, since a bag that empties shows the oxygen is being used: Some shrinking of the reservoir bag on each breath is normal. A bag that empties completely is a different finding. The flow ran out before the breath did, and this patient finished that breath on room air.

Switch to a simple face mask, which has no reservoir bag to empty: Changing devices makes sense when the one you have is failing. A simple face mask gives roughly 35 to 60 percent oxygen. That is less than the NRB was already giving this hypoxic patient.

Recheck the mask seal, since a leak at the cheeks is what empties the bag: A poor mask seal does lower the oxygen this patient gets, so checking the seal is never wasted. A leak at the cheeks lets room air in around the edges. The patient then pulls less from the bag, so the bag would empty more slowly, not faster. The seal is not what is emptying this bag.

Whether the saturation has fallen below 94% on room air: A saturation below 94% on room air is a reason to give oxygen, and a low saturation tells you the patient is in trouble. The saturation measures how well oxygen gets into the blood. The saturation does not tell you what is narrowing the airway, so it cannot tell you whether to nebulize.

Whether the wheeze is heard on inspiration or on expiration: A wheeze heard only on expiration versus on both inspiration and expiration does show how far the narrowing has progressed. A wheeze on both phases still does not tell you whether asthma or heart failure caused the narrowing. The nebulizer decision depends on that difference.

The loudness of the wheeze on auscultation: A louder wheeze sounds like it should mean worse obstruction. Loudness only reflects how much turbulent air is moving through the narrowed airway. A silent chest from near-total obstruction is more dangerous than a loud wheeze. Neither loudness nor silence tells you whether bronchospasm or fluid caused the narrowing.

A response to the oxygen that should be given more time: Oxygen does help, and giving a treatment time to work is usually wise. Here the saturation of 94% is the number that lags behind. Waiting on that number delays ventilation this child already needs.

A normal pause between episodes of increased effort: Children do tire and rally in waves, so watching for a pattern is reasonable. A quiet child who looks worse, with a respiratory rate that has fallen to 16, is not resting between episodes.

Improvement, since the work of breathing has come down: Less work of breathing is the goal of everything you are doing for this child. In a child, effort dropping while the appearance gets worse is exhaustion, never improvement.

The oxygen has taken effect and the sound will keep fading: Oxygen is the right thing to give, and oxygen does help this child. Oxygen does not shrink swelling in the upper airway. The saturation is still 89% with the oxygen running.

The swelling has come down and the patient is improving: Less noise would mean less swelling if the child also looked better. This child is limp and cyanotic. The stridor is quieter because airflow is being lost, not because the swelling went down.

The stridor has moved lower into the chest as a wheeze: Breath sounds can change as a child's condition changes. Stridor comes from a narrowed upper airway. Stridor does not move down into the chest and turn into a wheeze.

Asthma exacerbation: The lung sounds are clear and equal and the waveform shape is normal, so this is not asthma. Asthma gives wheezing, a long exhale, and a shark fin waveform. Asthma also tends to push the EtCO₂ up as the patient tires, not down.

Bacterial pneumonia: Pneumonia builds over a day or two with fever, a productive cough, and rhonchi or diminished sounds over one area. This difficulty breathing started suddenly, at rest. A pneumonia bad enough to drop the SpO₂ to 88% would be something you could hear with your stethoscope.

Cardiogenic pulmonary edema: happens when the left ventricle backs fluid up into the alveoli. Those patients have crackles that start at the bases, trouble breathing when lying flat, and often a history of heart failure. Fluid in the alveoli is loud, and clear, equal breath sounds rule pulmonary edema out here. The pleuritic pain and the recent surgery point to a clot instead.

Cardiogenic pulmonary edema: There is no jugular venous distention and no ankle swelling, and the abnormal sounds are on one side only. A failing left heart backs fluid into both lungs, with crackles in both bases, distended neck veins, and swollen ankles. Fluid backing up from the heart also does not cause a temperature of 102.4°F.

Pulmonary embolism: Three days of slow worsening and a cough with thick sputum do not come from a clot. A clot also does not explain the fever or the rhonchi in one lobe. Pulmonary embolism brings sudden trouble breathing with clear lungs, often with chest pain on each breath and a risk factor like recent immobility, surgery, or a known clot.

Asthma exacerbation: Rhonchi in one lower lobe with every other field clear cannot come from asthma, which tightens the airways all through the chest. Asthma also does not cause fever or thick, infected sputum.

The sensor has become disconnected: A disconnected sensor makes the waveform suddenly disappear. This waveform still has a clear shape with a flat plateau and a reading of 43. Exhaled gas has to reach a connected sensor to make that waveform.

The patient is now hypoventilating: Hypoventilation makes the EtCO₂ go up. This EtCO₂ went down, from 52 to 43. The patient is also moving more air now, speaking in longer sentences with less accessory muscle use.

Air trapping has become more severe: Worsening air trapping makes the waveform slope even more and pushes the plateau further out of reach. This waveform went back toward a rectangle. Worse trapping would also push the EtCO₂ up, and this number came down.