because a lot of the problems with our equipment can be fixed by increasing the flow and if you're going to guess anyway that's a pretty good way to hedge your bets now if that's not there a guess is a guess is a guess you have a 25% chance the point is don't leave anything blank on that okay so you're going to track your time your uh time on this and then when you're done and you submit it you're going to get instant feedback okay so let's talk about these cut scores and I'm going to take it from from the very very bottom so you take the test and you score um 85 out of 140 do you see how you're just shy of that lower cut score that means you're going to end up having to take the test again all right what we're shooting for is for you to be at the very least getting 86 right so anywhere from 86 to 91 is a lower level cut score what that means say you will carry the CRT credential all right but to be eligible to take the rrt exam you're going to have to test again and hit the upper level cut score all right what we are shooting for what you want to do is to take this test one time and score 92 correct out of 140 now I think percentage wise y'all can check me that's around like a 66 or 67% now minimum grade in School most schools have a minimal standard of anywhere from 70 to 75% that's hopefully because you're going to hold to that standard in school and to get a 6668 on the exam is not going to be that big of a deal so that's why your programs are holding you to that minimum percentage score for all of your classes all right just a few other questions or uh comments about the TMC you're gonna have recall questions application questions and Analysis questions so I'm going to use the potassium a a theme of potassium for all of these if I asked you what the normal range of pottassium is you would tell me three and a half to five or somewhere around that depending on the reference uh the textbook you used that's an example of a simple recall question just be able to recall facts figures specific information all right so on the TMC they're about 33 recall questions which is not that many there are more application questions which is taking what you know and relating it to something that's new or something that's changing for example if we drew a blood gas on a patient and that patient had a metabolic alkalosis and the question asked you which of the following could be a contributing factor you look down there there and one of the answers is a low potassium okay do you see how that's still a question about potassium but it's taking a blood gas and relating it to pottassium all right so application questions there are 66 of those and then we have analysis questions which I typically call these the critical thinking questions that you're taking a lot of information you're putting it together to figure out what is going on or what need to do or what you need to suggest okay so let's say we have a patient come into the emergency department they're short of breath um they're having frequent pac's on the monitor they also have when you draw a blood gas a metabolic alkalosis and now the question is which of the following would you suggest to figure out the underlying cost well if you add all of that stuff up potassium can cause that so what test do you need to suggest to look at the potassium you need a set of electrolytes right so that's putting all of that together every one of those questions was about potassium they were just deeper questions but the point I really want to make is you can't memorize your way through this test only 33 are recall questions the vast majority over a hundred of these questions out of 140 are going to be how things work together how things put together you have to understand what you're doing not just memorize and we're going to work on some of that stuff over the next two days making sure you understand some of the big principles they talk about all right once you hit that upper level threshold you're ready to take the Clinical Simulation exam there are 22 exams that you're going to take has anybody taken a full set of clinical simulations set for 20 or 22 simulations some of you have some of you are like okay it's hard okay just the fact of setting and testing through simulation after simulation after simulation and you would think okay 22 simulation that's 22 patients some of these simulations have four or five patients mixed in with them so just the fact of going over test after test after test is kind of a a mental game okay it it's just it it takes a specific mindset for these so what I want you to think of is that these scenarios are supposed to flow like real patient cases you've all had clinicals some of you may be working right now when you're taking a clinical stimulation I want you in your mind's eye to think about yourself at the bedside with the patient that'll help you okay so because it's based on how things ought to operate at the hospital if you were doing it the correct textbook way okay it's a branching logic format all also what that means is you get to Choose Your Own Adventure on these clinical simulations and there are Pathways that are 100% correct based off the person that wrote the simulation there are Pathways that you can go down that you won't get perfect points but there's a lot of different ways to do things right so you'll still get enough points to pass and then there are going to P be Pathways choices you make that will not give you a passing grade on that simulation one of the things that I really want you to know and people don't think about this very much is how these are scored now unfortunately can everybody see the board okay unfortunately you don't get to see the software that's running when you take this test but here's what's going on there there are they're tracking numbers they're tracking um your score they're tracking minimal passing and they're tracking the maximum score okay and each simulation all the way through the 20 you're tested on has scores in all of these categories so let's say you get to the first Clinical Simulation and it is a COPD patient with pneumonia and you've talked about that in school a lot you've seen it in clinical practice a lot your score is 20 minimum passing was 15 maximum was 20 and you got all the points you passed this one but here's what really matters minimum passing was five you got five points over that this is now like a savings account that you can draw from if you go negative okay so you're feeling pretty good about the first one you roll into the second one it's congestive heart failure and y'all talked about that all the time and you you're really really comfortable about that you score 18 minimum was 15 maximum was 20 okay you weren't perfect and we're not looking per for Perfection on these exams we're looking for competency we're looking for passing okay minimum passing here was 15 so you passed and you got an additional three points so now you have eight and you're feeling really good and you're starting to settle into it and you test faster but oops the third one for my students I would say if it's a neonatal one that's the ones they kind of get all freaked out about a little bit and it's uncomfortable for them I'll say you get to the third one it's a neonatal one and you're going a little too fast and you make some bobbles minimum passing was 15 you made 13 maximum was 20 okay you didn't pass this one you don't have to you do not have to pass all of these clinical simulations because of these points over here you fell shy by two all right that means you got six left now I can't tell you how many you can fail I don't know it depends on how well you do on all the other ones but what I can tell you is if you hit a Clinical Simulation that just goes the wrong way and you you've had those right those of you that you've practiced you click and you get a physician agree and then you're like oh my gosh and you click again and you get another physician disagree and then you're just either ticked off or panicked and you just get click happy and you just start clicking anything don't do that don't do that but if you do poorly on one you feel like you do portly on one all is not lost okay you just need to kind of clear your mind get up move around a little bit come back into it because I have seen score reports where people have failed four or five out of the 20 and still made a passing score what matters if the minimal passing is uh 270 it doesn't matter that the maximum passing is 500 if you made a 271 you have pass the clinical Sim it is that Baseline score that matters a combination of information gathering decision making okay all right so coming back to the slides real quick we're going to practice clinical simulations we're going to try to end with two today start with two tomorrow end with two tomorrow so we're going to take them together and I'm going to help walk you through all right you got four hours to take all those 22 clinical simulations track it you want to be done by six every hour if you're done by six every hour you'll definitely be done by the last um that last hour of it all right so mbrc Matrix that's who writes the test they tell us as instructor what's going to be on the test that's the Matrix your instructors teach you based off of this Matrix because our first primary goal is to make sure you're credentials and a very close second is to make sure you're confident in clinical practice so we use the Matrix this review is also Matrix based and I could show you that but I don't know that it matters I think what matters is that you know where your weaknesses are so you can study those places and if we use that table I think you're going to have a better idea of where you need to study than worrying about tying things to The Matrix because the Matrix is very broad like if you miss a question it could be covered in like three or four places in The Matrix and it's really hard to tell where you need to focus in but I think looking at it by chapter is going to help you a little bit more all right test prep strategies I know you know these but they're worth going over again because what you're doing between these two tests is you're spending about almost $400 to take these two two different exams 390 that's if you take it once so you want to use every possible test prep strategy because it's not just knowledge based it's how you approach the exam also so you got to study there's no getting around that don't cram the night before relax don't be the one in the parking lot at the testing center cramming whatever you're cramming that's a lot of stress to put on yourself so try not to do that take as many practice exams as possible now my students only pay attention to that bullet they don't pay to the one underneath okay the practice exams tell you where you're weak you study your weakness before you test again if all you're doing is taking practice test after practice test after practice test without studying between you're hoping you're memorizing questions that are going to be on the exam it's a secured exam you're not going to memorize a question that's on the exam okay so make sure you study sh up your knowledge base all right going to a testing center make sure you know where it's located okay so and take account if you're testing in the morning wherever you're going to wherever your testing center is located pay attemp attention to the traffic flow we test our students have to go to Fort Worth that's the closest place there's a lot of rush hour traffic in the morning and so if they're testing at 9: they have to take that into account you don't want to be late because if you're more than 15 minutes late they don't have to let you test and you lose your money and according to the nbrc policy to retest you're paying for it again so don't be late all right now when I made this slide I made this slide like you were going to test in the morning because that's what I would do okay here's what I'm going to say test when you are me mentally at your best I am a morning person I think best in the mornings but if you're somebody that's a night out and you don't go to bed until 300 or 4 don't test at 9:00 in the morning test in the afternoon test wherever you are physically at your best but the B the the what I'm wanting you to know eat before you go fuel your brain studies show test performan is better when you've eaten okay so make sure you eat again don't cram try to relax the night before sleep good get a good night sleep but don't do anything different okay don't think I need to make sure I sleep really good so I'm going to take a couple of badril because they they help me sleep a little bit better you don't want to wake up groggy and and and cloudy headed and not being able to test so avoid sleeping pills unless you take them all of the time okay keep doing with to your body what you do to your body don't introduce anything EXT extra um again eat min minimize caffeine okay I'm a two cup of coffee person in the morning when I test I'm drinking two cups of coffee it's what I do every day but if you have never had an energy drink in your life this is not the morning to drink one okay because you're going to sit down in front of that computer and you are going to be nervous and you're going to be a little shaky don't put anything in your system that adds to that because you will not be able to think clearly if all you can do is kind of shake all right all right questions about the test itself before we get into the review all right then before we actually start going over the test I want to make a chart I am and so pull a piece of paper out divide it in half I am a firm believer if you understand your disease processes and you know where they are happening it makes a lot of difference um in figuring out things like mechanical ventilation compliance and resistance FTS will become super super simple if you at least have a division and and and a knowledge of where the disease processes are located so let me show you what I mean all right as respiratory therapist we typically take care of patients that their disease process or disorder falls into two primary categories right those that have obstruction okay so obstructive disease processes and those that have restriction do you know everybody teaches different so some some portions of the country doesn't don't do this but is there an acronym that you learned to know all the obstructive diseases okay I'm seeing some head nods so that acronym was cbab right right okay good all right let's just lay them all out so we can can look at them real quick cystic fibrosis bronie eases asthma bronchitis and we're meaning The Chronic form not acute bronchitis that anybody can get in the winter time but chronic bronchitis and empyema okay now you notice on this chart I don't have COPD right but I really do COPD include chronic bronchitis and osma so you're going to see COPD a lot on your credential in exams that could mean chronic bronchitis that could mean osma most commonly a patient has both of them existing in their chest at the same time okay so these by and large are the main obstructive diseases that you're going to see on your exam now I want to ignore enyma for just a minute and I'm going to ask you about these top four cystic fibrosis bronchiectasis asthma and and and chronic bronchitis if I were to ask you where in the lungs they are where in the lungs are these diseases or disorders where do they take place I'll tell you the three places you got three choices in the airway in the alvioli or in the pulmonary capillary bed because that's that's really the only place lung disease can manifest in those three spots so if we're talking about these diseases these disorders they are categorized as Airway disorders okay all of these let's keep emphasing out for just a minute all of these when you learned about them all of those anatomic alterations all the changes that made this disease process what they were happened in the airway they are Airway disorders okay these don't happen in the alviola region empyema does have an alveolar component but it's distal Airway and alveolar weakening so that means the littlest of little Airways are compromised so we still classify empyema as an airway disorder and all Airway disorders are obstructive in nature we okay here this is really important because I'm going to build on this throughout these two days okay to get these straight I'm going to swing into mechanical ventilation right off of this okay so are we okay with the obstructed side okay good deal empys oh hang on just a second um one of the things I'm also bad about is watching the chat while I'm doing all this too so Miranda I just so you say you asked what empyema was empyema is defined as distal Airway or alveolar weakening but it is still classified as an obstructive disorder or an airway disorder because it affects the distal Airways as well okay restrictive disorders so I tell my students when we're first learning things and we don't have our disease class until their second semester of the program but we still talk about all of these things in their first semester with patient assessment so when we start out with restrictions I tell them I want you to remember the A's in P okay so one of the A's I start with an a I end with an A okay so this first a is atelectasis all right then I'm going to start with the piece um pneumonia pulmonary edema Numa thorax plural diffusion and ards okay so these are not all of the restrictive disorders but these are some of the biggies that come up all the time on the exam so let's just look at this if you if you had to tell me what atelectasis was if your hand was an alviola show me with your hands what adelus this is yep alveolar collapse right incomplete expansion okay pneumonia is when the alvioli is filled with pus and cellular debris from an infection pulmonary edema is when the Alvi is filled with fluid either heart related or non-heart related cardiogenic or non-cardiogenic anuma thorax so anuma thorax is air in the plural space right but when you get all that pressure in the plural space What happens to the underlying alvioli they collapse don't they which is atelectasis so in Num thorax while it is in the plural space still compromises the alveoli same with the plural affusion that's fluid in the plural space that fluid Bears down on those alveoli the alveoli collapse okay and then ards well it's not necessarily always it doesn't start out in the alvioli it's an intital lung disease it increases the AC membrane of the Li so basically if I asked you where all of these disorders or disease states are where are they in the alvioli right so a lot of times we say if something's not sea bab and we know all of C bab is in the airway then more than likely it's a restrictive disorder and all of your restrictive disorders compromise the alvioli so do you see how just easy everything about diseases has gotten okay the only other place that there can be a problem in the lung is in the pulmonary capillary bed and really about the only disease States disorders that you're worried about there are pulmonary imoli a blood clot an air embolism a fat embolism or pulmonary hypertension okay so I'm I'm going to come back to this a lot over the next couple of days and say okay where in the lung is that because if we know where it is we can figure out what the assessment findings are we can understand how to treat it because if somebody says a patient had with a numa thorax will a numa thorax whee well no a whee is caused by a narrow Airway and somebody that has a num thorax is going to wee because there's nothing wrong with their Airway it's that plural space in the collapse of the alviola does that make sense okay so we're going to use this again so kind of keep that out with you we may have to redraw it and just call it obstructive and restriction and remember these because I'm going to build on this okay so how you feel anybody have any questions all right is it making sense how's my speed good okay do you need a break or are we ready to go into the testing okay we'll go into a few questions on the test maybe go about 25 more minutes 30 minutes or so and then all right so I did see somebody saying that they didn't receive any attachments at all um I'm not sure who that that was so um when we go to a break next time before you get off talk to me and let me see what's going on and I'll get Gary to resend those with with the attachments okay all right so we are on uh the multiple choice exam practice exam number one all right I'm just kind of kind of roll let's look at the top of this because I told you that this was in BRC uh Matrix based so if you look at this all of these questions when you look at the nbrc Matrix should fall under patient data and specifically how to evaluate data in the patient record okay again I don't know that anybody's probably going to go back to the Matrix we as as instructors do but you as students what we're going to do each question we are going to classify it on that chart all right so here we go so number one this is going to be kind of weird I'm going to use my hands to explain this then I'm going to put it on the chart all right the following data has been obtained from a ventilator patient on volume control ventilation and a title volume of 600 and when we scroll down here we're looking at really the differences over a three-hour time period between Peak and Plateau let's just talk about these pressures because the the nbrc is going to ask questions about compliance and resistance quite a bit they can ask the question based off differences in pressure the actual formula for compliance and resistance and then they're always going to tie it into a disease process okay so everybody's done your your patient ventilator checks right that you've gone in and you've checked your assessor patient and you've assessed the ventilator and one of the two main pressures that you should be looking at are your peaking your platto pressures so the peak pressure is generated when the vent pushes en tial volume into the lungs it takes a specific pressure to push it in that is the peak inspiratory pressure but you as the therapist when that breath gets into the lung you can make the patient hold their breath and look at that pressure on that breath hold an inspiratory pause or an inspiratory hold that is the plateau pressure now watch my hands because this makes a lot of sense Peak and Plateau PE Peak should always be higher than Plateau all right these are got on the or these are obtained on the same machine breath so Peak if you've done it right will be higher than Plateau if it's not you've goofed up okay you can't defy the laws of phys laws of physics say that that Peak has to be higher than Plateau all right the peak pressure tells us about the airway and the alviola together the plateau pressure tells us about the alveoli by itself so let me tell show you what I mean so back at this chart if an asmatic is on the vent and they have a bronchospasm you know they're having they're in active bronchospasm they have a lot of inflammation inflammation that Airway gets small right what happens to the peak inspiratory pressure as that Airway gets smaller what just show me with your fingers up or down which way does it go Peak inspiratory pressure during an asthma attack Peak inspiratory pressure is rice okay now different patient that's on the vent all of a sudden they blow a numa their lung collapses that Peak pressure is going to rise all right so see how Peak pressure Rises as both of these worsen Peak pressure in and of itself doesn't tell us much of anything except there is or isn't a problem okay all right what really begins to tell us where the problem is in the lung and that's what we need to figure out where is the problem in the lung is that Plateau pressure Plateau pressure will always tell you about the Alvi all right so I'm going to write that down here so this is the alveoli this is the plateau pressure we're looking at and then up here up here I'm going to put pip because pit tells us about both plat tells us just about the Alvi are we good there all right so now let's say we have a person that's on the vent we're monitoring peek and plateaus these numbers should be pretty close together okay the person's Plateau remember that's alviola as Alvi get worse the plateau pressure is going to rise so let's say this person starts developing a pneumonia those Plateau pressures are going to rise those Plateau pressures when they rise will push up the peak pressure also so if the problem is in the Alvi the peak and Plateau are going to rise together that Plateau is pushing up the peak does that make sense all right so if both of the pressures are rising your problems in the alveola they're Rising together okay but sometimes we have an instance catch this terminology because the board exams like to use this terminology that the peak pressure Rises independently of the plateau okay so if this tells us about the Alvi is anything changing with the alveoli if this pressure staying the same uhuh nothing's wrong with the alveoli but the peak is rising in independently if it's not in the alveola where is it probably going to be in the airway so if you're monitoring these pressures and the peak pressure is rising but the plateau pressure is staying the same you have an airway problem going on okay so just looking at these two pressures we can start identifying where the problem is because this problem might need a breathing treatment this Airway problem okay had auses doesn't need a breathing treatment because how Beal won't fix that does it so it tells us about how we treat the problem also by looking at these numbers okay so you do know well I we you're GNA have to know the formulas okay and I know we've gotten we've got these cool ventilators that they do these calculations for us you are going to have to do these calculations on the exam okay so let's talk about these calculations we have Dynamic compliance okay so Dynamic compliance uses the PIP so let me just erase this again all right so here's the formula for dynamic compliance I'm give myself a little bit more room and I'm drawing it right between the two because Dynamic compliance will decrease with both of the these problems all right Dynamic compliance is title volume divided by hip minus peep I know that's hard to see but tital volume divided by Peak inspiratory pressure minus Peak normal Dynamic compliance is 30 to 40 MLS per centimeter of water pressure all right so if this compliance is abnormally low the problem can be in the airway or in the aoli peak doesn't tell us where the problem is it only tells us that there is a problem so a low Dynamic compliance just tells us there's a problem it really doesn't tell us where the problem is okay it's when we use that Plateau pressure that plateau tow pressure tells us about the Alvi and that is the static compliance okay so static compliance is calculated as tital volume divided by Plateau pressure minus peep okay the normal value there is 60 to 100 MLS per ctim of water pressure so now if I calculate something and the the static compliance comes out to 30 that's super low but static tells me about the Alvi so I know I have an alveolar disorder going on okay now we also said that when that Peak pressure Rose independently when the difference between these two pressure gets bigger it's an airway problem well that's your formula for Airway resistance okay Airway resistance is PIP minus plat isn't that what we did with our hands the difference between the two pip minus plat when that difference is Big it's an airway problem pip minus plat divided by flow that flow has to be in liters per second all right now a normal Airway your Airway my Airway assuming that we don't have an obstructive lung disorder normal natural Airways are 6 to 2.4 cmers of water pressure per liter per second if we put an ET tube in place that's automatically going to create a little bit of resistance uh tracheostomy tube will create a little bit of resistance so on the board exams it when you calculate this on a person on a vent it's going to be higher okay what is important is the trend of things to Trend it over time because if it's changing over time and the airway stays the same size like they have the same ET tube in place the person's having a problem with their natural Airway creating Airway resistance all right so how does this feel I know it just got busy with all of that but do you see how it helps separates where the problem is in the lung is that helpful all right let's turn it around and look at this question so this right here will take care of every compliance and resistant question that they're going to ask you on the exam if you know how to do this if you know how to do your calculations and then you know the normal values and what abnormal values indicate Okay so we've done these three vent checks on this question and you notice looking at the peak and Plateau they are rising together okayy just answer my question first they're Rising together where is the problem if they're Rising together where in the airway or S sorry where in the lung is of problems not Airway alveoli alveoli so this is an alvioli problem but the question is really asking which of the following statements regarding these data is true was in the alveola problem obviously our static lung compliance is going to decrease right so the answer for one is a okay and I know this might have been a very simple question but I wanted to make sure we got all of compliance taken care of and we don't have to do it anym all right if you missed this question that little chart we've got that you've got beside you I want you to make a hash mark in Chapter 11 because this lines up with chapter 11 and then just because we all learn different let's go to the PowerPoint okay this says the same thing this top formula is dynamic compliance okay title volume divided by pit minus peep static compliance is title volume divided by plao minus Peep and we talked about these pressure changes when plao pressure increases with no change in volume lung compliance decreases okay and then when Pip increases with no change in title volume or Plateau pressure we have an airway problem all right so that takes care of number one we're moving on to number two while assessing a sleep study therapist notes a 40 second period where the respiratory rate was 20 so the chest is moving and the oral and Naser themister tracings were flat so they're measuring flow at the nose and chest wall movement so the chest is moving but there's no flow there's no air movement at the airway and so which of the following conditions is most likely present hopefully you know that that's obstructive apnea okay so two is a let's just look at some pictures real quick to make sure because I may ask you a question in in word format just like that one or they may just throw up a a a miniature sleep study okay and this is busy and you don't need it all really you just need to look at how the rib cage and abdomen are moving so do you see how this patient's taking attempting to pull in air but yet no flow is there so that means there's probably some that that soft tissue obstruction in the back of their throat they're trying to breathe but air can't move past that soft tissue obstructive it is obstruction okay obstructive sleep apnea compared to Central sleep sleep apnea Central sleep apnea there's no flow at the nose because the patient isn't even attempting to breathe okay so Central sleep apnea is a disorder usually from the brain sending a signal to the body to breathe okay so if the chest is moving but there's no flow it's obstructive if the chest is not moving and there's no flow it's Central sleep apnea so number two was a and on your chart if you missed it put a hash mark in chapter 12 all right number three a patient is experiencing cardiac arhythmia and muscle weakness you draw an AVG the patient is in metabolic alkalosis which of the following is most appropriate value to assess at this time and hopefully when we were going over the different types of questions you already know the answer to this right and it's potassium so a few things about electrolytes remember you're not a nephologist okay they're not going to give you just tons of electrolyte stuff and ask you to keep it all straight because it can get confusing you need to know the values for your big ones okay sodium chloride pottassium they have a tendency to ask about potassium a lot and the reason why is that it's such a small range of normal three and a half to five anything outside of that range will wreak havoc on the body so they tend to ask a lot of questions about hypokalemia Which is less than three and a half mil equivalents per liter typically that happens from um excessive diuretic therapy vomiting a lot of vomiting okay excessive vomiting excessive diarrhea severe trauma like burn injuries where a person's losing lots of fluid okay anytime potassium is abnormal you're going to experience heart aryas okay so cardiac arithm is Pac pvc's VTEC here's the deal they're not going to throw up something on the monitor that is excessive premature atrial contractions and say hey identify this but if you look at the monitor and you're like I don't know what that rhythm is it is not a normal sinus rhythm chances are you might need to look at the electrolytes to see if the potassium's screwed up some other things that happen the patient can has skeletal muscle weakness because electrolytes control our skeletal muscles but the diaphragm being that skeletal muscle if this goes on long enough a person actually can have respiratory failure ventilatory failure as a result of it all right so EKG changes can happen and muscle failure so number three is D and if you miss it put a hash mark in chapter three all right pfts show a hands who loves pfds no no okay oh look somebody's like me me I like them too most people don't my students hate them I even teach the class and they still hate them I don't know so we're going to drill this down really really basic okay so still coming back obstructive restrictive okay I'm not putting the disease processes there because we're good with that right C bab and the A's in peace over there um all right obstructive disorders if we think about what's going on with all of those disease process processes the problems in the airway and it makes the airway smaller a patient can breathe in just fine their inspiratory flow is just fine with an obstructive disorder it's the expiratory flow that has a problem you know like if I don't know if you live in a highly populated place but you know you have an interstate there it has four lanes and then all of a sudden it Narrows down to to one lane and all that traffic has to go through that smaller smaller passage and it all backs up right it can't go they cannot come out at the same flow rate same kind of thing with the airway as it gets smaller all that flow can't come out as fast it just doesn't happen so we're always looking for patterns okay so a pattern on a PFT for obstructive disease states are decreased expiratory flows all right so everybody in that goes in for a PFT everybody typically gets this test at the very beginning the forced vital capacity maneuver this is a test you take a great big huge deep breath in you blow it out as hard and as fast and as long as you can at least six seconds okay this test measures expiratory flow rates okay and the common flows you're going to see are the peak expiratory flow rate the fev1 which really tells you how much of that volume's coming out in one second but it's a flow um you're also going to see the FF 200 to 12200 and the FF 25% to 75% okay so a real PFT is going to have a lot of other flows in these but these are the ones that you want to focus on for your credentialing exam but these are all expor flows and anybody that's obstructive these flows will be decreased okay now I want to make a differentiation between these two because they look similar ffs but the subscripted numbers are different so if we're just comparing the numbers FF 200 to 1200 200 is a much larger number than 25 okay this is how you remember this measures flows in the large Airways okay where is ff25 25 is a much smaller number than 200 it's small that tells you about flows in the smaller Airways so if on the Sams they say something about small Airway disorder order okay it's often picked up here one of the places it's going to be picked up at all but you're going to see really remarkable changes here and when they say small Airway they're talking about the smallest Airways so what they're really talking about is empyema okay okay so I'm going to tell you the trick I'm gonna tell you the trick right here this is what you do with every single PFT you encounter on the exam so you know you get to a PFT and you see all those numbers and you're like oh my God I don't even know where to start I'm telling you what to do you take that fvc they give you a numerical value and you take the fe1 they give you a numerical value you go feev or um fe1 divided by fvc they probably already have this math done for you okay if this number is is less than 70% your patient has an obstructive disorder without a doubt without a doubt so when you get to that PFT and you have all those numbers it's a pre- and postbronchodilator study just look at the pre-study take the fe1 divided by the fvc see if they've done the math for you if it's less than 70 it's a cab cab is going on and they have an obstructive disorder okay now we can go a little further with this and you know this if a COPD patient takes a breath in and they can't get it out where is that air it's trapped in their chest right which is why you see that big old barrel chest well we can do lung volume testing to see how much trap gas they have and so this is another pattern on a PFT all right so not only will we have decreased expiratory flows that we diagnose with that fe1 divided by FEC of less than 70% these patients will also have increased volumes like if you're air trapped your residual volume is going to be increased because you've got all that trapped gas and if your residual volume is increased that's going to increase your F FRC and if F FRC is increased that's going to increase your TLC that makes sense now I'm not going to say every question they ask you is about an obstructive disease process but a lot are and the questions can be answered just with this knowledge right here okay so this is what you're looking at as far as p patterns for obstructive disorders let's go to restrictive these are Alvar diseases right there's nothing wrong with the airway so these patients will have normal expat flows there's nothing wrong with their Airway so that fe1 divided by fvc is going to be greater than 70 that just means they don't have an obstruction okay but what is different here SP what is different here is their alveoli are stiff they have atelectasis or pneumonia or ards or something going on well pulmonary fibrosis that they're alval I can't take on volume well if they can't take on volume because they're so stiff that residual volume is going to be decreased and if residual volume is decreased r c is going to be decreased then if that's decreased TLC is going to be decreased that's all that's all there is to restrictive diseases okay as far as piy so does that Mak sense so let me give you a scenario and let's see see if it works you have a patient that comes into the PFT lab all right Force vital capacity is the first test they're doing you've got all these different numbers that have come back where do you start what two values do you need talk to me guys talk to me fv1 and FC you take the F1 divided by the FEC it'll probably already be done for you you do that calculation though and it's 40% what do you know without a doubt it is Def M it's an obstructive disorder and more than likely if you go back and look at all these flows they're going to be decreased and if they do lung volume testing you're going to see an increase in the residual volume F FRC and TLC okay you're working in the pulmonary function lab next patient comes in they start out with a force vital capacity maneuver you look at the fe1 divided by FEC and that's 80% what do you know for sure restrictive yeah we like to say that right you know it's not obstructive you know it's not obstructive we need to check for restriction absolutely but don't forget there are normal patients okay and every once in a while they'll throw a normal patient on the exam because you're looking for abnormalities and you think I can't be normal but it can okay so don't overlook that all that fe1 divided by FEC all that tells you is if there's an obstruction or not so if that value is greater than 70 you know you don't have an obstruction that's all you know you need to test for a restriction all right and then if you have decreased volumes then you got an alveolar disease process going on okay all right one step further just one step further dlco diffusion capacity of the loan for carbon monoxide they use carbon monoxide because the hemoglobin it passes over the AC membrane and is taken up by the hemoglobin the same way that oxygen is okay normal dlco value is 25 and I always get right here and I'm like I don't remember the units of measurement but the normal value 25 okay normal values 25 dlco is decreased in any Alvar disease process as the alveolar disease process worsens dlco decreases so all of our restrictive lung diseases any restrictive lung disease as it worsens that AC membrane is getting thicker so if you have a dlco if you have decrease volumes normal flows and a dlco of let's say 12 it's an alveolar disease process okay I'm still talking about alveolar disease processes let me just back me up one it is kind of the same chart I just have the disease States on it okay of cbate which one of these disorders is an alveol or disorder also okay osma okay any alveolar disorder will have a decreased dlco so as osma worsens that dlco is decreased actually this is one of the ways they differentiate in the in the pulmonary lab between chronic bronchitis and osma is this dlco it's the differ differentiation of that those two disease processes but the reason the dlco decreases in osma is because in empyema you get a lot of blbs and bullly you know instead of those nice little grape like clusters of the lung you get one big old B baggy alvioli you lose surface area and when you lose surface area you can't exchange oxygen as easily so dcos will be decreased in nyma too that any better just remember with a PFT you're going to start with the um with the fe1 divided by FEC to know if it's obstructive let's go one more with the obstructive if somebody's got an obstructive obstruction don't we want to know if we can reverse it is a breathing treatment going to work for them okay so there's a formula for this also and you use the fv1 so it's post fe1 minus pre F1 okay and a lot of times we want to memorize this but if you understand it it makes sense when we give a breathing treatment they should be able to blow out more air right so we're just seeing how much more air they can blow out by looking at their end results and comparing it to their beginning results post minus pre and then we're going to divide it by pre F1 where we started and that turns it into a percentage if you do Post minus PR divided PR and it's greater than 12% that is clinically significant they have a reversible Airway obstruction okay if you do this and it's 6% that's not clinically it's not statistically significant it's not categorized as reversible that's be greater than 12% to be classified as a reverse reversible Airway obstruction okay so all of this work we've got all of pfts done though okay we're actually on number four you got these pfts and you got all these numbers right you got the actual the predicted and the percent of predicted what we really want is what the patient is actually doing okay got all these numbers what we really need is the fe1 divided by FEC there it is 48% we know that's an obstructive disease process without a doubt you can look at all these other things and it follows that pattern and then it asks you which disorder is it consistent with and you look at those the only obstructive disease state is empyema so do you see why separating like this makes pfts just a little bit easier so makes a difference to know where the the problem is all right so if you missed four that goes into chapter 16 in on that chart and I just want to give you the words because some people if you see the words it just clicks better this is everything we put on the chart though so this is an obstructive disorder we said decrease flows like the fe1 and the FF 2575 and those two other ones I gave and if they can't get the air out it's trapped so you're going to have an increase in RV F FRC and TLC and we said we needed that F1 divided by FEC if it's less than 70 that will indicate that obstructive disease process that's all that tells you is that they're obstructed does that's that's all you know it's at and then we we listed the obstructive diseases restrictive lung diseases they had normal flows because there's nothing wrong with their Airway decreased volumes and capacity so RV F FRC and TLC and here's some of the ones we put on the chart but pulmonary fibrosis it's not cab it's not a pulmonary embolism so it has to be an alveolar disorder kyphoscoliosis is an abnormality of the spine which keeps the life from inflating well so kyos scoliosis causes atelectasis is which is why it's why it's listed like that and then how do you know if it's reversible a 12% or more increase in the F1 or fvc um so here's the formula that I just gave you using the fe1 now I've taken a lot of practice exams from the nbrc from other companies I have never on an entry L exam seen any other way to diagnose a reversible disorder other than this formula right here okay so you can use a force vital capacity also if it increases by more than 200 mls it's considered reversible but the only time I've ever seen this one used is when I took my special my credentialing specialty exams for my pulmonary functions okay so if I were a betting girl it's going to be this formula if they want you to to diagnose a reversible eror way obstruction okay I'm sorry um you were saying um if you got that last question wrong to put it Market under the chapter Which chapter 16 thank you okay this might be a good place to stop let's take we've been going a little bit more than an hour let's take how do you feel do you need a 10-minute break let's take a 10-minute break and then we're going to push through to the end of this test okay so 10 minutes see in a bit oh wait um wait wait wait somebody somebody somebody uh if you don't didn't get the attachments stay on and talk to me