Martin,,, first and foremost,,, many thanks for your feedback,,, and whilst I was not expecting to be given the answers on a plate, I fully take on board your views on being able to apply clinical reasoning etc,,, (However, as I have not yet undertaken any clinical/hospital based practice, my clinical reasoning is somewhat limited at the present to information gleaned from lectures and relevant literature etc). Hence, the following are a list of ideas that I have been mulling over,,, but should you feel they are in any way inappropriate, or that I am completely on the wrong track, I would be grateful for any clues, hints and or guidance that you may be able to offer, so that I may once again plough through the relevant literature to gain a better understanding of this area.

Consequently, whilst I have concerns for this pt’s deteriorating ABG’s, (especially his currently borderline pO2 level),,, I would first want to attempt the following treatment plan,,, prior to advising the use of any invasive management (ventilation) has its own associated risk factors. Therefore,,,

as this pt’s ABG’s levels appear comparable with type 1 respiratory failure, I was also suspicious of ARDS due to the nature of this traumatic event (RTA) and associated timing of onset,,, Additionally, this pt’s pH level also suggests a borderline respiratory alkalosis,,,, however, sats/ABG’s may resolve if,,, (as you have stated,,, with I hope some satisfactory explanantion from myself),,, the following plan is successful?

1. Upping this pt’s FiO2 could help increase his sats,,, which may currently be reduced due to the pain associated with having to expand/contract his chest on breathing with broken ribs,,, which is probably why he may be breathing shallowly and thus impacting of his Respiratory Rate. (However, I am concerned that by increasing his FiO2 above the already administered 0.60, there will be a potential for nitrogen washout, which may further complicate his RLL collapse/atelectasis?)

2. By treating this pt’s pain (refer to MDT/pain team for appropriate analgesia – eg: PCA or as Bulger et al. (2004) suggests using an Epidural analgesia). Why?, because by reducing his level of pain, it may allow him to take slightly deeper breaths, thus reducing his work of breathing, respiratory and heart rates. Additionally, I would hope that this might help to increase his sats and even level out his ABG’s. (The MDT may also be able to administer meds to reduce/limit onset of infection/possible sepsis and thus help reduce his temp?)

3. As referenced by your good self, appropriate positioning for RLL collapse may also assist with the above complications; however, I would obviously want to include intermittent turning to prevent pressure sores etc. (Question: with appropriate pain management, could this patient be placed on the side that has the rib fractures or even a ¼ turn from supine in order to facilitate a better V/Q match?)

4. Whist I would possibly use supported ACBT, I might be inclined to use only light percs/vibs on the NON-fractured side, providing adequate pain management had been achieved. (Light percs/vibs would take into consideration any secondary changes that this pt’s osteoarthritis may have had on his skeletal system). However, I am also concerned that manual techs might be contraindicated due to the continuous shape of the thorax (thoracic ring) and thus any treatment applied to one area of the chest may ultimately affect the contra lateral side?

5. Although the crackles might suggest consolidation/retained sputum,,, I was also considering that they may be a factor associated with this pt having smoked 30 a day for the past 50 years,,, and thus difficult to remove,,, even if a neb or suctioning were utilised?

6. If none to the above help to stabilise this pt or his deteriorating sats/ABG’s continued, then I would have to suggest intubation,,, especially as Manual Hyperinflation appears contraindicated/precautionary due to his as yet un-drained pneumothorax? Settings for this invasive ventilation might possibly be SIMV (on volume / pressure control??), TV 450-500; a low PEEP of 5-10 (due to the still resolving pneumothorax); FiO2 0.60. (However, it is my understanding that it is not the job of a general PT to apply settings on invasive ventilation,,, and that the above figures will be dependant upon the pt’s size, statue and consideration or any baro/volu trauma that may be caused by this intervention,,, although, I would be interested in any feedback that you may suggest is applicable?) Obvioulsy, if invasive ventilation is undertaken, a pt’s normal positioning will alter due to associated physiological changes. On a positive point, this form of intervention will allow for easier application of suctioning (especially if a closed circuit airway is utilised).

7. Finally, passive mvt’s can help maintain ROM, as well as help the PT to recognise any onset of soft tissue shortening? Once the pt has stabilised though, more active mvt’s/X’s could possibly be introduced?