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HLT-RESP80-08 · Lesson 2 · 180 clock hours · field

General Care and Pulmonary Function Rotations

Objective. The student will independently set up and administer prescribed oxygen therapy, aerosol medication treatments, and incentive spirometry, and will correctly perform or assist with spirometry and pulse oximetry testing on general-care patients under preceptor supervision.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

General Care and Pulmonary Function Rotations

This rotation places you at the bedside and in the pulmonary function laboratory, where you will carry out the most common respiratory therapy tasks ordered for general-care patients. Every encounter is a real patient, so accuracy, safety, and professionalism are not optional—they define you as a clinician.

Oxygen Therapy: Principles and Safe Delivery

Supplemental oxygen corrects or prevents hypoxemia. Your goal is to meet the prescribed SpO₂ target—no more, no less. Excessive oxygen in patients who retain carbon dioxide (such as some patients with severe COPD) can blunt the hypoxic drive and worsen ventilation; unnecessarily high FiO₂ can also cause absorption atelectasis and oxygen toxicity over time.

Common delivery devices and their approximate FiO₂ ranges at standard flows:

Setup steps for every oxygen device: (1) Verify the order and identify the patient using two identifiers. (2) Select the correct device for the prescribed FiO₂ or flow. (3) Attach to the flow meter or blender; confirm the source is oxygen, not air. (4) Set the prescribed flow or FiO₂. (5) Apply the device comfortably; check for skin irritation, especially around the ears and nose. (6) Measure SpO₂ after allowing time to equilibrate; document the result and your titration rationale in the clinical log. (7) Educate the patient not to remove the device.

Aerosol Medication Treatments

Aerosol delivery gets medication directly to the airways with fewer systemic effects than oral or IV routes. Your two main tools are the small-volume nebulizer (SVN) and the metered-dose inhaler (MDI) with spacer.

SVN procedure: Pour the prescribed medication and diluent into the nebulizer cup. Attach the mouthpiece or mask. Drive with oxygen or compressed air at the flow that produces a steady mist (typically 6–8 L/min, but follow manufacturer and institutional guidance). Instruct the patient to breathe slowly and deeply through the mouth; treatment ends when sputtering begins. Assess breath sounds, SpO₂, and/or peak flow before and after; document findings and patient response.

MDI with spacer procedure: Shake the inhaler, attach it to the spacer, and have the patient exhale to functional residual capacity. The patient then seals lips around the spacer mouthpiece, activates one puff, and inhales slowly over 3–5 seconds, then holds the breath for up to 10 seconds. Wait at least one minute between puffs when multiple puffs are ordered. Coach technique actively—most patients need correction. Document breath sounds and response.

Patient education is a required part of every aerosol encounter. A patient who leaves without understanding the purpose of the medication and correct technique is a patient at risk of readmission.

Safety: Always confirm the right drug, dose, route, patient, time, and reason before any administration. Report any adverse responses—tachycardia, bronchospasm, tremor, or worsening dyspnea—immediately and document them.

Incentive Spirometry

Incentive spirometry promotes sustained maximal inspiration to prevent or reverse atelectasis, particularly post-operatively. Instruct the patient to exhale normally, seal the lips around the mouthpiece, then inhale as slowly and deeply as possible while watching the flow indicator. The goal is to sustain the effort for 3–5 seconds. The prescribed volume target should be based on the patient's pre-operative or predicted value. Encourage 10 repetitions each waking hour. Assess and document effort, achieved volumes, and breath sounds.

Spirometry and Pulse Oximetry in the Pulmonary Function Lab

Spirometry measures how much air a patient can move and how fast. The critical maneuver is the forced vital capacity (FVC), from which FEV₁ (volume exhaled in the first second) and the FEV₁/FVC ratio are derived. These values classify obstruction versus restriction.

Follow ATS/ERS Standardization of Spirometry criteria for every session:

1. Calibrate the spirometer with a 3-liter calibration syringe at the start of each day and verify it meets the accuracy standard before testing patients.

2. Position the patient seated upright with feet flat on the floor; apply a noseclip.

3. Coach the patient: inhale maximally, blast the air out as hard and fast as possible, keep blowing until the curve plateaus (at least 6 seconds for most adults).

4. Acceptability criteria: the maneuver must have a good start (back-extrapolated volume within standard limits), no cough in the first second, no leak, and a satisfactory end-of-test.

5. Reproducibility: the two largest acceptable FVC values must agree within the standard threshold, and the same for FEV₁.

6. Print and label the flow-volume loop with patient name, date, technician ID, and whether each maneuver was acceptable or usable.

Interpretation is the supervising therapist's or physician's responsibility; your role is producing high-quality, standardized maneuvers.

Pulse oximetry during PFT testing monitors for desaturation. Apply the probe before testing, document baseline SpO₂, and alert the supervising therapist if SpO₂ drops significantly during or after the maneuver.

Safety and Scope of Practice Reminders

Key terms10

SpO₂Peripheral oxygen saturation measured non-invasively by pulse oximetry, expressed as a percentage; used to guide oxygen titration.
FiO₂Fraction of inspired oxygen; the proportion of oxygen in the gas the patient inhales, ranging from 0.21 (room air) to 1.0 (pure oxygen).
High-Flow Nasal Cannula (HFNC)A device that delivers heated, humidified oxygen-air blends at high flow rates (up to 60 L/min), allowing precise FiO₂ and reducing air entrainment.
FEV₁Forced expiratory volume in one second; the volume of air exhaled in the first second of a maximal forced expiration; a key index of airflow obstruction.
FVCForced vital capacity; the total volume of air expelled during a maximal forced expiration from full inspiration; used with FEV₁ to classify lung function patterns.
ATS/ERS StandardsGuidelines published jointly by the American Thoracic Society and European Respiratory Society that define acceptability and reproducibility criteria for spirometry maneuvers.
Small-Volume Nebulizer (SVN)A device that converts liquid medication into a fine aerosol mist driven by compressed gas, allowing inhalation of bronchodilators, corticosteroids, or other drugs.
Incentive SpirometryA technique using a flow- or volume-based device to encourage sustained maximal inspiratory effort, used to prevent or treat atelectasis.
Flow-Volume LoopA graphical display of airflow plotted against lung volume during a forced expiratory and inspiratory maneuver; the shape helps characterize obstructive, restrictive, or upper-airway conditions.
Calibration SyringeA precision 3-liter syringe used daily to verify that a diagnostic spirometer is measuring volume accurately within acceptable tolerances.

Worked examples4

1. A patient is prescribed oxygen to maintain SpO₂ 92–95%. At room air the SpO₂ is 87%. You apply a nasal cannula at 2 L/min; after 5 minutes SpO₂ is 90%. You increase to 4 L/min; after 5 minutes SpO₂ is 94%. What do you document as your titration rationale, and is the target met?
  1. Step 1 – Identify the prescribed SpO₂ target: 92–95%.
  2. Step 2 – Record baseline SpO₂ on room air: 87% (below target).
  3. Step 3 – Apply nasal cannula at 2 L/min; reassess after equilibration: SpO₂ = 90%. Still below the lower limit of 92%; titration is needed.
  4. Step 4 – Increase flow to 4 L/min; reassess after equilibration: SpO₂ = 94%. This falls within the 92–95% target range.
  5. Step 5 – Document in the clinical log: patient started at SpO₂ 87% on room air; 2 L/min nasal cannula yielded 90% (below target); flow increased to 4 L/min achieving SpO₂ 94%, within prescribed range. Device and flow confirmed and left in place.
Answer: The target is met at 4 L/min nasal cannula with SpO₂ of 94%. The clinical log entry must include baseline SpO₂, each flow rate tried, the resulting SpO₂ at each setting, the rationale for each adjustment, and the final confirmed setting.
2. During spirometry calibration, you inject the 3-liter syringe into the spirometer and the device reads 2.88 liters. The ATS/ERS accuracy standard requires the measured volume to be within ±3.5% of the true volume. Does this spirometer pass or fail calibration?
  1. Step 1 – Identify the allowable error: ±3.5% of 3.00 L.
  2. Step 2 – Calculate the allowable deviation: 3.00 × 0.035 = 0.105 L.
  3. Step 3 – Determine the acceptable range: 3.00 – 0.105 = 2.895 L (lower limit); 3.00 + 0.105 = 3.105 L (upper limit). Acceptable range: 2.895–3.105 L.
  4. Step 4 – Compare the measured value (2.88 L) to the acceptable range: 2.88 < 2.895.
  5. Step 5 – Conclusion: 2.88 L is below the lower limit of 2.895 L, so the spirometer fails calibration.
Answer: The spirometer fails calibration. A reading of 2.88 L falls outside the acceptable range of 2.895–3.105 L. Do not test patients; troubleshoot the device, recheck the syringe seal, and repeat calibration. If it fails again, remove the device from service and notify the supervisor.
3. A patient's spirometry results show FVC = 3.20 L (predicted 4.00 L) and FEV₁ = 2.75 L (predicted 3.20 L). Calculate the FEV₁/FVC ratio and FVC % predicted to help the supervising therapist classify the pattern.
  1. Step 1 – Calculate FEV₁/FVC ratio: 2.75 ÷ 3.20 = 0.859, or approximately 86%.
  2. Step 2 – Calculate FVC % predicted: (3.20 ÷ 4.00) × 100 = 80%.
  3. Step 3 – Interpret (for the supervising therapist's use): FEV₁/FVC of 86% is above the commonly used threshold of 70% (or the lower limit of normal), suggesting obstruction is not present. FVC % predicted of 80% is at the boundary commonly used to define a restrictive pattern.
  4. Step 4 – Your role: print the flow-volume loop, label it correctly, and present these calculated values to the supervising therapist for final interpretation.
Answer: FEV₁/FVC = 86%; FVC % predicted = 80%. The pattern does not show obstruction; the reduced FVC may suggest restriction, but clinical context and full lung volume testing are needed for a definitive classification—that assessment belongs to the supervising therapist.
4. You are setting up a non-rebreather mask. The flow meter is set to 10 L/min. Before applying the mask, you occlude the exhalation port with your thumb and watch the reservoir bag. It deflates completely with each breath in your test. What is the problem and what do you do?
  1. Step 1 – Identify the finding: the bag collapses completely, meaning flow is insufficient to keep the bag at least one-third to one-half full before the patient's next inspiration.
  2. Step 2 – Recognize the risk: if the bag collapses during inspiration, the patient will entrain room air through the one-way valves or around the mask, dramatically lowering FiO₂—potentially unsafe.
  3. Step 3 – Corrective action: increase the flow rate until the bag remains at least one-third to one-half inflated at end-inspiration (typically 10–15 L/min, but titrate to the bag volume).
  4. Step 4 – Verify: re-occlude the port, confirm the bag maintains adequate volume. If the bag still collapses at maximum allowable flow, check for leaks in the bag or tubing.
Answer: The flow is too low for the patient's inspiratory demand. Increase the flow until the reservoir bag stays at least one-third full at all times. Document the adjustment. A fully collapsing bag on a non-rebreather is a patient safety concern that must be corrected before applying the device.
In class: Perform a minimum of 30 documented oxygen-delivery setups (nasal cannula, simple mask, non-rebreather, high-flow nasal cannula) across varied patients, adjusting flow rates to achieve prescribed SpO₂ targets and recording titration rationale in the clinical log each time. · Administer prescribed small-volume nebulizer and metered-dose inhaler treatments—including patient education on proper technique—for at least 25 encounters; after each treatment, assess and document breath sounds, peak flow or SpO₂ change, and patient response. · Under direct supervision in the pulmonary function lab, position patients, calibrate the spirometer per ATS/ERS standards, coach patients through acceptable maneuvers, and print and label flow-volume loops for therapist interpretation on at least ten test sessions.
Materials: Oxygen delivery devices (cannula, masks, HFNC system), small-volume nebulizers, MDIs with spacers, incentive spirometers, pulse oximeters, calibrated diagnostic spirometer, ATS/ERS Standardization of Spirometry guidelines, clinical log
Check: Preceptor rates each oxygen, aerosol, and spirometry encounter on the program's 4-point clinical skills rubric (1 = unsafe, 2 = needs cuing, 3 = competent with minimal cuing, 4 = independent); student must achieve an average rating of 3 or higher across all encounters in this rotation to proceed; encounters rated 1 require immediate remediation and repeat demonstration.

Practice check7

Answer each question, then check it. Nothing is recorded; this is your own practice.

Therapeutic Procedures
1. A post-surgical patient receiving 2 L/min via nasal cannula has an SpO₂ of 89%. The order reads 'titrate oxygen to maintain SpO₂ 92–96%.' Which is the most appropriate immediate action?
Patient Education and Communication
2. A patient using a metered-dose inhaler with a spacer exhales, seals the mouthpiece, activates the puffer, and immediately removes the spacer and inhales rapidly through the nose. What error did the patient make?
Diagnostic Testing
3. During spirometry calibration, you inject a 3-liter syringe and the spirometer reads 3.12 liters. Given that ATS/ERS allows ±3.5% of the known volume, does this device pass or fail?
Therapeutic Procedures
4. A patient with a known history of significant CO₂ retention requires supplemental oxygen. Which statement best reflects safe oxygen administration for this patient?
Therapeutic Procedures
5. After administering an SVN bronchodilator treatment, which assessment finding would most directly indicate a therapeutic response?
Therapeutic Procedures
6. A patient's pre-treatment peak flow is 240 L/min. After an SVN bronchodilator treatment, the peak flow is 300 L/min. Which conclusion is most appropriate to document?
Diagnostic Testing
7. During a spirometry session, the supervising therapist asks you to assess maneuver reproducibility. The patient's two largest acceptable FVC values are 3.40 L and 3.18 L. Which statement is correct?
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