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Respiratory Software
Adult Self-Evaluation Clinical Simulations
New for 2016
Updated to the 2015 Matrix
& Current Standards of Therapy

Each Adult Self-Evaluation Clinical Simulation features the following:
  • Format closely follows the computerized credentialing clinical simulations.  For teaching purposes, the adult clinical simulations contain more sections than the actual credentialing clinical simulations (each adult clinical simulation contains a minimum of 15 sections on the optimal path).
  • A detailed score report that includes the IG score, DM score, IG + DM score, proficiency score, efficiency score, errors of omission score, errors of commission score, and overall competence score.
  • After the user has seen his/her score report, he/she will have the opportunity to print the score report and (if you have set the program to teach mode) to review each section of the simulation to view the correct responses and compare them to his/her responses.
  • While viewing responses, the user is provided an explanation that identifies the rationale behind the correct response(s).
  • Use the Respiratory Administrator to set teach / test mode, passwords, and view users and scores.

Note: these programs are for institution purchase only.

View Screen Shots


ACS-01: Acquired Immune Deficiency Syndrome (AIDS) - This clinical simulation evolves around the management of a HIV-positive 50-year-old male who presents to the emergency department with complaints of dyspnea at rest, dry cough, and chest discomfort. Decisions relative to clinical and laboratory assessment, oxygen administration, chest x-ray and CT scan evaluation, sputum induction, bronchoscopy assistance and monitoring, pharmacology, chest x-ray interpretation of a pneumothorax, and placement of a chest tube are required.

ACS-02: Adult Respiratory Distress Syndrome (ARDS) - This clinical simulation evolves around the management of a 47-year-old female patient with acute pancreatitis complicated by sepsis and acute respiratory distress syndrome (ARDS). Decisions relative to clinical and laboratory assessment, bronchodilator therapy administration and assessment, intubation and initiation of volume control ventilation (VCV), adjustment of ventilator parameters, patient-ventilator assessment, ventilator graphic waveform interpretation, calculating optimal PEEP, initiating pressure control ventilation (PCV), setting initial PCV parameters, and pathophysiology are required.

ACS-03: Adult Transport - This clinical simulation evolves around the management of a 60-year-old female patient who was involved in a motor vehicle accident. The patient requires air transport from a suburban hospital to a Level I trauma center. Decisions relative to clinical and laboratory assessment, ensuring appropriate flight equipment is functioning and available, monitoring the patient while in-flight, initiating manual ventilation, troubleshooting the oxygen delivery system, attempting endotracheal intubation, performing an emergency cricothyrotomy, selecting an endotracheal tube for placement into the tracheal opening, repositioning the endotracheal tube, and ECG rhythm interpretation are required.

ACS-04: Aspiration Pneumonitis - This clinical simulation evolves around the management of a 32-year-old male who was training to be a fire eater when he accidentally aspirates some unknown liquids he had used for this purpose. Decisions relative to clinical and laboratory assessment, pathophysiology, aerosol therapy, pharmacology, oxygen administration, patient-ventilator assessment and troubleshooting, adjustment of ventilator settings, endotracheal suctioning, obtaining weaning parameters, weaning from mechanical ventilation, and extubation are required.

ACS-05: Asthma - This clinical simulation evolves around the management of a 27-year-old female who develops occupational asthma secondary to employment at a spray paint factory. Decisions relative to clinical and laboratory assessment, oxygen administration, adjustment of the oxygen delivery device, aerosol therapy, pharmacology, intubation and mechanical ventilation, setting ventilator parameters, pulmonary function and methacholine challenge testing and interpretation, pathophysiology, asthma action plan, and patient education are required.

ACS-06: Bronchiectasis - This clinical simulation evolves around the management of a 42-year-old male who presents with shortness of breath, persistent cough, and hemoptysis. Decisions relative to clinical and laboratory assessment, pathophysiology, pharmacology, mucolytic and bronchodilator therapy administration and assessment, chest physiotherapy, patient monitoring, pulmonary function testing and interpretation are required.

ACS-07: Bronchogenic Carcinoma - This clinical simulation evolves around the management of a 51-year-old female who has been referred by her family physician for increased fatigue, dyspnea on exertion, and a persistent dry cough. Decisions relative to clinical and laboratory assessment, chest x-ray and CT scan evaluation, pulmonary function testing and interpretation, bronchoscopy, pharmacology, double lumen endotracheal tube recommendation for left upper lobe lobectomy procedure, initiation of pressure controlled ventilation, patient-ventilator system evaluation, adjustment of ventilator parameters, patient-ventilator troubleshooting, and medical ethics are required.

ACS-08: Carbon Monoxide Poisoning - This clinical simulation evolves around the management of a 19-year-old male who was brought to the emergency department after being found unconscious lying next to his car in an enclosed garage. Decisions relative to clinical and laboratory assessment, diagnosis, manual ventilation initiation and adjustment, endotracheal tube troubleshooting, initiation of volume-controlled mechanical ventilation and setting initial ventilator parameters, recommending hyperbaric oxygen therapy, replacing the air in the cuff of the endotracheal tube with normal saline prior to hyperbaric oxygen therapy, switching to time-cycled ventilation and setting initial ventilator parameters prior to hyperbaric oxygen therapy, patient assessment during hyperbaric oxygen therapy, titrating the FIO2 following hyperbaric oxygen therapy, calculating new FIO2, and weaning are required.

ACS-09: Cardiac Tamponade - This clinical simulation evolves around the management of a 65-year-old female who develops cardiac tamponade following CABG surgery. Decisions relative to clinical and laboratory assessment, oxygen therapy, diagnosis, recommending pericardiocentesis, patient stabilization, manual ventilation, rapid sequence intubation, correction of right main stem intubation, extubation due to herniated cuff, re-intubation, initiation of mechanical ventilation and setting initial ventilator parameters, ventilator troubleshooting, ECG rhythm interpretation, and initiation of high-quality CPR are required.

ACS-10: Cardiopulmonary Resuscitation - This clinical simulation evolves around the management of a 30-year-old male who requires high-quality CPR following a motor vehicle accident. Decisions relative to clinical and laboratory assessment, administering whole blood, initiating manual ventilation and external cardiac compressions, selecting an appropriately sized endotracheal tube, ECG rhythm interpretation (PEA, sinus bradycardia, PVC), administering medications during cardiopulmonary resuscitation (epinephrine, atropine, lidocaine), mechanical ventilation initiation and assessment, recognizing the signs and symptoms of pulmonary embolism, and recommending CT pulmonary angiogram are required.

ACS-11: Chest Trauma / Diaphragmatic Rupture - This clinical simulation evolves around the management of a 61-year-old woman who sustains a diaphragmatic rupture following a fall down a flight of stairs. Decisions relative to clinical and laboratory assessment, oxygen administration, initiation of mechanical ventilation, setting and changing ventilatory parameters, ventilator troubleshooting, adjustment of PEEP and titration of FIO2, ECG rhythm interpretation, and medications to correct the ECG rhythm disturbance are required.

ACS-12: Chest Trauma / Double Lumen Endotracheal Tube - This clinical simulation evolves around the management of a 35-year-old male who sustains left-sided lung injury following a 30 foot fall. Decisions relative to clinical and laboratory assessment, chest x-ray interpretation of a pneumothorax, chest tube insertion, action to take when accidental dislodgment of the chest tube occurs, precautions pertaining to a chest tube, endotracheal intubation and initiation of mechanical ventilation, setting initial ventilator parameters, patient-ventilator assessment, recommending placement of a double lumen endotracheal tube with differential lung ventilation due to deteriorating gas exchange and persistent air loss from the left chest, recommending dual capnography, and interpretation of the bronchial and tracheal lumen capnograms are required.

ACS-13: Chest Trauma / Flail Chest - This clinical simulation evolves around the management of a 42-year-old male who sustains severe trauma to the left side of his chest following a bicycling accident. Decisions relative to clinical and laboratory assessment, fluid resuscitation, chest drain insertion, intubation and setting initial ventilatory parameters, low pressure alarm troubleshooting, extubation and re-intubation, ventilatory parameter adjustment, weaning from mechanical ventilation, noninvasive positive pressure ventilation (NPPV) for subsequent respiratory distress, and initial settings for NPPV are required.

ACS-14: Chest Trauma / Gunshot Wound - This clinical simulation evolves around the management of a 23-year-old female who sustains a gunshot wound to the chest. Decisions relative to clinical and laboratory assessment, bronchodilator therapy, pressure-controlled ventilatory parameter adjustments, PEEP therapy adjustments, initiation of inverse ratio ventilation, ventilator waveform troubleshooting, spontaneous weaning trial, weaning monitoring and adjustment, tracheal suctioning, and adjustments in oxygen therapy are required.

ACS-15: Chest Trauma / MVA - This clinical simulation evolves around the management of a 62-year-old male who sustains blunt chest trauma following a motor vehicle accident. Decisions relative to clinical and laboratory assessment, chest x-ray interpretation of a right-sided hemothorax, placement of a right-sided chest drain, recommending intubation, interpreting the results of an esophageal detector device, initiating manual ventilation, recommending initial ventilator settings, recommending decelerating waveform over constant waveform, adjusting ventilator settings based on arterial blood gas analysis, patient-ventilator assessment and troubleshooting, interpreting an ECG rhythm (ventricular fibrillation), and recommending defibrillation are required.

ACS-16: Chronic Bronchitis - This clinical simulation evolves around the management of a 56-year-old male who presents with increasing dyspnea and hemoptysis. Decisions relative to clinical and laboratory assessment, bronchodilator therapy, recommending bronchoscopy, patient assessment during bronchoscopy, medication regimen, PEP therapy, spirometry interpretation, treatment goals, and final diagnosis are required.

ACS-17: Congestive Heart Failure - This clinical simulation evolves around the management of a 78-year-old male who presents with increasing breathlessness. Decisions relative to clinical and laboratory assessment, diagnosis, oxygen therapy, initiating NPPV and setting initial parameters, adjusting NPPV to maintain oxygenation and ventilation, troubleshooting NPPV due to eye irritation, recommending corrective therapy for nose redness and irritation, nasotracheal suctioning, insertion of a nasopharyngeal airway, corrective action for nasopharyngeal airway obstruction, and initiation of mask CPAP are required.

ACS-18: Consolidative Pneumonia - This clinical simulation evolves around the management of a 64-year-old female who presents with a one week history of malaise, fever, and intermittent headaches. Decisions relative to clinical and laboratory assessment, chest x-ray interpretation, diagnosis, initiation and adjustment of oxygen therapy, oxygen flowmeter troubleshooting, initiation of PEP therapy, initiation of bronchodilator therapy, initiation and adjustment of CPAP therapy, and initiation of incentive spirometry upon clinical improvement are required.

ACS-19: COPD / Critical Care Management - This clinical simulation evolves around the management of a 71-year-old woman with COPD who presents for follow-up care after completing a 2-week course of oral antibiotics for community acquired pneumonia. Decisions relative to clinical and laboratory assessment, oxygen therapy, chest x-ray interpretation, recommending thoracentesis, assisting with the thoracentesis procedure, initiation of NPPV, intubation and initiation of mechanical ventilation, patient/ventilator systems check, ECG rhythm interpretation (ventricular tachycardia, ventricular fibrillation), defibrillation, initiation of high-quality CPR, and high pressure alarm troubleshooting are required.

ACS-20: COPD / Home Care with TTO - This clinical simulation evolves around the management of a 72-year-old male with COPD. Decisions relative to clinical and laboratory assessment, weaning from mechanical ventilation, extubation, discharge planning regarding home oxygen and bronchodilators, educating patient on correct use of oxygen, transtracheal oxygen initiation due to noncompliance of wearing nasal prongs, x-ray interpretation of correct placement of transtracheal catheter, educating the patient in the care and cleaning of the catheter, cautions of use of the transtracheal catheter, troubleshooting when the catheter is accidentally dislodged, supplies needed for reinserting the catheter, recommending repeat x-rays after placement of the catheter, and educating the patient regarding mucous balls is required.

ACS-21: COPD / Infection Control - This clinical simulation evolves around the management of a 69-year-old female with a long history of COPD who had recently suffered from a cold and who now presents to the ED complaining of a fever, weakness, chest pain and a cough. Decisions relative to clinical and laboratory assessment, initiation of oxygen therapy, chest x-ray and arterial blood gas interpretation, diagnosis of current clinical condition, initiation of bronchodilator therapy and PEP therapy, switching the mode of bronchodilator therapy, discontinuing respiratory treatment as needed, infection control instruction, appropriate hand washing advise, instructing the patient regarding the warning signs of infection, and instructing the patient on common irritants and avoidance of irritants are required.

ACS-22: COPD / Mechanical Ventilation - This clinical simulation evolves around the management of a 59-year-old male who is admitted to the ICU with a preliminary diagnosis of acute respiratory failure secondary to COPD, CHF, and pneumonia. Decisions relative to clinical and laboratory assessment, initiation of mechanical ventilation and setting initial ventilatory parameters, adjustment of ventilatory parameters, recognition and correction of auto-PEEP, administering bronchodilators and performing endotracheal suctioning, correction of a high pressure alarm situation, recommending placement of a tracheostomy tube when failure to wean is evident, and transferring the patient to a skilled nursing facility with continued ventilator management and monitoring with a home ventilator are required.

ACS-23: COPD / Pre-Postoperative Management - This clinical simulation evolves around the management of a 66-year-old male with severe COPD who is scheduled to have lung volume reduction surgery (LVRS). The patient requires pre-operative assessment and post-operative management. Decisions relative to clinical and laboratory assessment, pulmonary function testing, arterial blood gas analysis, chest x-ray interpretation, recommendations for pre-operative management and rehabilitation, initiation and adjustment of oxygen therapy following surgery, initiation of universal isolation precautions due to the presence of resistant Staphylococcus aureus, assessing and determining the cause of increased respiratory distress, diagnosing the presence of an acute pulmonary embolism, initiation of and setting initial parameters for noninvasive positive pressure ventilation (NPPV), troubleshooting patient dyssynchrony with the NPPV, switching to pressure-controlled ventilation (PCV), and setting initial pressure control parameters are required.

ACS-24: COPD / Pulmonary Function & Exercise Testing - This clinical simulation evolves around the management of a 57 year-old male who is admitted for diagnosis and treatment of acute dyspnea and chest tightness. Decisions relative to clinical and laboratory assessment, bronchoscopy to remove impacted mucous plugs, oxygen therapy, bronchodilator therapy, PEP therapy, incentive spirometry, evaluation of acute respiratory distress, initiation of NPPV and setting initial parameters, adjustment of NPPV parameters, obtaining pulmonary function and exercise tolerance tests, and interpreting the results of the tests are required.

ACS-25: COPD / Pulmonary Rehabilitation - This clinical simulation evolves around the management of a 74-year-old retired shipyard laborer with a 50+ pack-years smoking history who presents with a chronic cough and increasing dyspnea during exertion. Decisions relative to clinical and laboratory assessment, pulmonary function interpretation, chest x-ray and arterial blood gas interpretations, obtaining and assessing pulmonary history data, monitoring and recording a 6-minute walking test, implementing a pulmonary rehabilitation and home care program, recommending components to include in the pulmonary rehabilitation program, recommending respiratory therapeutic intervention for use in the home, oxygen concentrator use and maintenance, troubleshooting the oxygen concentrator, and what to do when a patient continues to smoke while using the oxygen concentrator are required.

ACS-26: Coronary Artery Disease - This clinical simulation evolves around the management of a 71-year-old male with a history of coronary artery disease who is admitted to the ED with complaints of dyspnea, palpitations, and nonspecific chest tightness. Decisions relative to clinical and laboratory assessment, oxygen therapy, administration of IV fluids and vasopressors for hypotension, recognizing the signs of pulmonary air embolism and taking corrective action, initiation of manual ventilation, intubation, interpreting the indicator color of a colorimetric end-tidal carbon dioxide detector, initiation of mechanical ventilation and adjustment of ventilator parameters, and troubleshooting the patient/ventilator system when the patient is dyssynchronous with the ventilator are required.

ACS-27: Cystic Fibrosis - This clinical simulation evolves around the management of a 27-year-old male with cystic fibrosis who has been admitted for increasing respiratory distress. Decisions relative to clinical and laboratory assessment, chest x-ray interpretation, concurrent diagnosis of P. aeruginosa lung infection and bronchiectasis, initiation and adjustment of oxygen therapy, initiation of aerosolized antibiotic therapy, initiation of IPV, discontinuing IPV due to intolerance and switching to high frequency chest wall oscillation (HFCWO) via the vest system, monitoring and evaluating the patient during HFCWO, initiation of dornase alpha (Pulmozyme), assessment for increasing shortness of breath, initiation of bronchodilator therapy, discontinuing oxygen therapy and instructing the patient in the order that respiratory treatments should be administered upon discharge from the hospital are required.

ACS-28: Drug Overdose - This clinical simulation evolves around the management of a 29-year-old female who has overdosed on prescription medications. Decisions relative to clinical and laboratory assessment, pharmacologic sedation for combativeness, intubation and initiation of mechanical ventilation, setting and adjusting ventilator parameters, administering sodium bicarbonate for worsening metabolic acidosis, assessing for the cause of a fever and elevated white blood cell count, diagnosing pneumonia, interpreting ventilator graphic waveform for active exhalation and taking corrective action, and initiating weaning from mechanical ventilation are required.

ACS-29: Guillain-Barre Syndrome - This clinical simulation evolves around the management of a 27-year-old pregnant female admitted with a diagnosis of pneumonia, upper respiratory infection, and progressive lower extremity weakness. Decisions relative to clinical and laboratory assessment, diagnosis of Guillain-Barre Syndrome, ventilatory parameter monitoring, supportive care and respiratory therapeutic intervention, intubation, initiation and adjustment of mechanical ventilation, adjustment of sensitivity to correct ventilator auto-cycling, insertion of an arterial line, insertion of a tracheostomy tube, endotracheal suctioning, and weaning from mechanical ventilation are required.

ACS-30: Head Injury - This clinical simulation evolves around the management of a 32-year-old female who was swimming at the local quarry when she did a forward flip into the water, striking her head on some submerged rocks. Decisions relative to clinical and laboratory assessment, intubation and manual ventilation, chest x-ray interpretation of a malpositioned endotracheal tube, repositioning the endotracheal tube, initiation of mechanical ventilation, adjustment of ventilator parameters, ventilator graphic waveform interpretation of an endotracheal tube cuff leak, continuing sedation, implementing PEEP therapy for atelectasis, ECG rhythm interpretation and corrective action for the ECG disturbance, evaluation of a low pressure limit alarm activation, evaluation of a dislodged endotracheal tube, and obtaining weaning parameters are required.

ACS-31: Hypothermia - This clinical simulation evolves around the management of an intubated and mechanically ventilated 22-year-old male with severe hypothermia and frostbite. Decisions relative to clinical and laboratory assessment, adjustment of ventilator parameters, recognition of asystole and taking corrective action, checking the manual resuscitator bag for proper function, administering CPR drugs, reinstituting mechanical ventilation following ECG rhythm conversion, troubleshooting the cause for the activation of the low inspired gas temperature alarm, adjusting the inspired gas temperature following the return of normal body temperature, titrating the FIO2 to maintain adequate oxygenation, weaning from mechanical ventilation and evaluating weaning parameters, extubating and administering supplemental oxygen, respiratory monitoring following extubation, and chest x-ray interpretation of pneumonia are required.

ACS-32: Kyphoscoliosis - This clinical simulation evolves around the management of a 59-year-old female with severe, deforming kyphoscoliosis who presents to the respiratory clinic for evaluation of a 1-week history of increasing dyspnea at rest. Decisions relative to pulmonary function testing and interpretation, arterial blood gas analysis, chest x-ray interpretation, clinical and laboratory assessment, admitting the patient to the hospital, oxygen therapy administration, initiating mask BiPAP for respiratory insufficiency, adjusting BiPAP parameters, intubation for respiratory failure, initiation of mechanical ventilation and adjusting ventilator settings, correction of an I:E ratio alarm activation, incrementing PEEP when faced with refractory hypoxemia, and diagnosing adult respiratory distress syndrome are required.

ACS-33: Lung Abscess - This clinical simulation evolves around the management of a 21-year-old male who presents with fever and a productive cough that is purulent, blood-streaked, and foul-smelling. Decisions relative to clinical and laboratory assessment, oxygen therapy, bronchodilator therapy, chest x-ray interpretation, obtaining a CT scan of the chest, diagnosis of lung abscess, adjusting ventilator parameters, endotracheal suctioning, obtaining and interpreting spontaneous respiratory parameters, weaning from mechanical ventilation, extubation, administering racemic epinephrine for post-extubation stridor, and re-intubating for increasing inspiratory stridor and respiratory distress are required.

ACS-34: Muscular Dystrophy - This clinical simulation evolves around the management of a 61-year-old female with adult-onset of muscular dystrophy who presents with generalized muscle weakness and lethargy. Decisions relative to clinical and laboratory assessment, intubation, assessment of the endotracheal tube cuff pressure, extubation and re-intubation, setting initial ventilator parameters, assessment of the patient/ventilator system, adjustment of ventilator parameters, chest x-ray interpretation of a right-sided pneumothorax, placement of a right-sided chest tube, obtaining arterial blood gases after patient stabilization, and diagnosis of aspiration pneumonia are required.

ACS-35: Myasthenia Gravis - This clinical simulation evolves around the management of a 39-year-old male with ventilatory failure secondary to acute exacerbation of myasthenia gravis. Decisions relative to clinical and laboratory assessment, patient/tracheostomy/ventilator assessment, initiation of weaning from mechanical ventilation, ventilator mode and parameter adjustment, resuming previous ventilator settings when failure to wean is evident, re-attempting weaning from mechanical ventilation, attempting a T-piece trial, switching to a trach collar, oxygen concentration adjustments, assessing for respiratory distress, tracheal suctioning, obtaining a chest x-ray, initiating IPV, and recommending tracheal suctioning prior to initiating IPV treatments are required.

ACS-36: Near Drowning - This clinical simulation evolves around the management of a 44-year-old male victim of a near drowning accident. Decisions relative to clinical and laboratory assessment, intubation, initiation of volume-control mechanical ventilation, adjustment of ventilator parameters, troubleshooting a high pressure alarm activation, endotracheal suctioning, administration of bronchodilator therapy, patient/ventilator evaluation, diagnosis of adult respiratory distress syndrome, ventilator graphic waveform interpretation, switching to pressure-control ventilation when faced with increasing peak inspiratory pressures during volume-control ventilation, setting initial pressure-control parameters, adjusting pressure-control ventilator parameters, and re-attempting volume-control ventilation when the patient's condition improves are required.

ACS-37: Organ Donor - This clinical simulation evolves around the management of an intubated and mechanically ventilated 31-year-old female admitted with massive head injuries and a broken neck following a fall from a ladder, who subsequently becomes an organ donor following brain death. Decisions relative to clinical and laboratory assessment, head injury precautions, patient/ventilator evaluation, troubleshooting and correcting an endotracheal tube cuff leak, administering a precordial thump for witnessed ventricular tachycardia, manually ventilating and initiating cardiac compressions following the onset of asystole, obtaining arterial blood gases during high-quality CPR and taking corrective action for hypoventilation, administering IV atropine for hypotensive bradycardia, re-instituting mechanical ventilation following high-quality CPR, evaluating confirmatory tests for brain death, performing an apnea test, monitoring and evaluation during the apnea test, reporting the results of the apnea test, and maintaining full supportive care and mechanical ventilation while waiting for organ procurement are required.

ACS-38: Postoperative Cardiac Surgery - This clinical simulation evolves around the management of a 72-year-old male admitted with severe chest pain and shortness of breath. Decisions relative to clinical and laboratory assessment, adjustment of oxygen therapy, recognition of unifocal PVCs and administering IV lidocaine, suggesting ventilator parameter changes when faced with inappropriate physician orders following CABG surgery, adjustment of ventilator parameters based on arterial blood gas analysis, performing endotracheal suctioning, initiating weaning from mechanical ventilation, recognition and treatment of cardiac tamponade, re-instituting weaning when the patient's condition stabilizes, assessing tolerance to weaning, obtaining spontaneous respiratory parameters, extubating and initiating supplemental oxygen, initiating incentive spirometry, monitoring and evaluating during the initial incentive spirometry treatment, and teaching the patient how to splint his incision with a pillow when he coughs are required.

ACS-39: Postoperative Thoracic Surgery - This clinical simulation evolves around the management of a 57-year-old male who underwent right pneumonectomy and subsequently develops bronchopleural fistula. Decisions relative to clinical and laboratory assessment, interpretation of a post-pneumonectomy chest x-ray, initiation and adjustment of oxygen therapy, diagnosis of bronchopleural fistula with empyema, placement of a right-sided intercostal drainage tube, initiation of and administering aerosol albuterol, initiation of and adjustment of pressure control ventilation parameters, weaning from pressure control ventilation, extubation and administering supplemental oxygen, assessment for respiratory distress post-extubation, initiation of NPPV, and troubleshooting the system pressure of the NPPV device are required.

ACS-40: Pulmonary Fibrosis - This clinical simulation evolves around the management of a 54-year-old male who presents with exertional dyspnea and a persistent, non-productive cough who subsequently is diagnosed with pulmonary fibrosis secondary to chronic inhalation of a herbicide. Decisions relative to clinical and laboratory assessment, interpretation of blood gas results, recommending a CT scan of the chest for further evaluation of the chest, obtaining and interpreting pulmonary function values, assessing for the cause of respiratory distress following video-assisted thoracic surgery (VATS) lung biopsy, chest x-ray evaluation of a misplaced chest tube, taking corrective action regarding the misplaced chest tube, taking corrective action regarding a dislodged endotracheal tube, initiating BiPAP, setting initial parameters, adjusting parameters, and troubleshooting the BiPAP unit are required.

ACS-41: Pulmonary Hypertension - This clinical simulation evolves around the management of a 36-year-old female with a history of right atrial septal defect who presents with increasing cyanosis, edema of the legs, and dyspnea on exertion. Decisions relative to clinical and laboratory assessment, diagnosis of pulmonary hypertension with right-to-left shunting, intubation and initiation of mechanical ventilation, adjustment of ventilator parameters, troubleshooting the cause for the high pressure alarm activation, administration of inhaled nitric oxide, initiation of a spontaneous breathing trial, assessment and evaluation during the spontaneous breathing trial, extubation and initiation of supplemental oxygen, adjustment of the oxygen concentration following extubation, re-intubation and re-institution of mechanical ventilation following a generalized seizure with decreasing consciousness, and adjustment of ventilator parameters following re-intubation are required.

ACS-42: Sarcoidosis - This clinical simulation evolves around the management of a 29-year-old female diagnosed with sarcoidosis who subsequently develops small cell carcinoma of the left lower lobe requiring left lower lobe wedge resection. Decisions relative to clinical and laboratory assessment, assessment for respiratory distress, intubation and initiation of mechanical ventilation, adjustment of ventilatory parameters, assessment for post-operative atelectasis, fiberoptic bronchoscopy with removal of an impacted mucous plug, weaning and discontinuation of mechanical ventilation, extubation, and initiation of incentive spirometry treatments are required.

ACS-43: Severe Acute Respiratory Syndrome - This clinical simulation evolves around the management of a middle-aged business man who develops ventilatory failure secondary to severe acute respiratory syndrome (SARS). Decisions relative to clinical and laboratory assessment, mechanical ventilation assessment and management, chest x-ray interpretation to determine the position of the endotracheal tube, placing the patient in the prone position for severe hypoxemia, recommending an anticoagulant for deep venous thrombosis, placement of a right-sided chest tube to correct a right-sided pneumothorax, switching to pressure-control ventilation when faced with rising plateau pressures and setting initial parameters, interpretation of ventilator waveforms - kinked endotracheal tube and then resolution after re-intubation are required.

ACS-44: Sleep Apnea - This clinical simulation evolves around the management of a 42-year-old male with obstructive sleep apnea (OSA) secondary to weight gain and enlarged nasal turbinates. Decisions relative to clinical and laboratory assessment, monitored overnight sleep study via polysomnography (PSG), monitoring and assessment during PSG, interpretation of PSG results, second overnight sleep study via PSG with CPAP titration, setting optimal CPAP pressure during CPAP titration, strategies utilized in encouraging the patient to comply with CPAP therapy, strategies utilized in reducing and/or controlling OSA, pharmacological agents used to promote daytime wakefulness, recommending turbinate reduction, and performing a tracheotomy with insertion of a tracheostomy tube when all measures to control OSA have failed are required.

ACS-45: Smoke Inhalation / Thermal Burns - This clinical simulation evolves around the management of a 24-year-old female admitted to the trauma center after being trapped in a burning building at her place of work. Decisions relative to clinical and laboratory assessment, intubation, initiation of pressure-control ventilation, assessment and adjustment of the ventilator parameters, diagnostic bronchoscopy to assess the severity of smoke inhalation and thermal burns, chest x-ray interpretation and diagnosis of adult respiratory distress syndrome, initiation of inhaled nitric oxide, assessment and treatment for pulmonary infection, and recommending a tracheotomy with insertion of a tracheostomy tube for long-term mechanical ventilation are required.

ACS-46: Spinal Cord Injury - This clinical simulation evolves around the management of a 28-year-old army specialist who has a spinal cord injury following a wrestling accident. Decisions relative to clinical and laboratory assessment, oxygen therapy, manual ventilation and nasotracheal intubation via fiberoptic bronchoscopy, ECG rhythm interpretation with correction of a bradyarrhythmia, initiation of mechanical ventilation and adjustment of ventilatory parameters, patient/ventilator troubleshooting, assessment for respiratory distress, chest x-ray interpretation, fiberoptic bronchoscopy with removal of an impacted mucous plug, ventilator and airway equipment necessary for home mechanical ventilation and airway management, and adjustment of ventilatory parameters following discharge are required.

ACS-47: Status Asthmaticus - This clinical simulation evolves around the management of a 34-year-old female with status asthmaticus. Decisions relative to clinical and laboratory assessment, oxygen and bronchodilator management, patient assessment during a trial of NPPV, endotracheal intubation, initiation and adjustment of mechanical ventilation, implementation of a plateau pressure based strategy with permissive hypercapnia, initiation of bronchial hygiene therapy, ventilator troubleshooting, and weaning from mechanical ventilation are required.

ACS-48: Tetanus - This clinical simulation evolves around the management of a 65-year-old female who develops tetanus following a traumatic knee laceration. Decisions relative to clinical and laboratory assessment, initiation and adjustment of oxygen therapy, nasal intubation, initiation and adjustment of mechanical ventilation, patient/ventilator systems check, endotracheal suctioning, administering a paralytic agent, tracheotomy with insertion of a tracheostomy tube, and weaning from mechanical ventilation are required.

ACS-49: Traumatic Asphyxia - This clinical simulation evolves around the management of a 24-year-old male who sustains a crushing neck injury and subsequently develops ventilator associated pneumonia. Decisions relative to clinical and laboratory assessment, securing an airway via emergent cricothyroidotomy, confirming correct placement of a tracheostomy tube following cricothyroidotomy, initiation of mechanical ventilation, administering fluid and vasopressor support, ventilator parameter adjustments, ventilator waveform interpretation, assessing for the cause of respiratory distress, administering IV antibiotics, and initiating aggressive bronchial hygiene are required.

ACS-50: Tuberculosis - This clinical simulation evolves around the management of a 41-year-old male admitted to the hospital to rule out tuberculosis. Decisions relative to clinical and laboratory assessment, implementing AFB precautions, obtaining an induced sputum sample, initiation of oxygen therapy, initiating CPAP therapy, adjustment of CPAP parameters, intubation and initiation of mechanical ventilation, initiation of capnography with waveform interpretation, and weaning from mechanical ventilation are required.

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