12-15-2007, 01:02 PM
A 60-year-old male with chronic obstructive pulmonary disease is brought to the emergency department
with altered consciousness. His family reports a 2-day history of increasing shortness of breath that
requires nebulized albuterol every 2 h. In addition, the patient has had increasing sputum production
with a change in the sputum color from white to green. On presentation, the patient was breathing eight
times per minute and was unarousable. Initial arterial blood gas revealed a pH of 6.98, a PaCO2 of 110
mmHg, and a PaO2 of 100 mmHg while the patient was on a nonrebreather mask. The patient is
emergently intubated and brought to the intensive care unit. The initial ventilatory settings are as
follows:
Mode Assist control
Rate 12 breaths/min
Tidal volume 500 mL
PEEP 0 cmH2O
FIO2 0.5
Initially, the patient does well with improvement in arterial blood gases (ABG) to pH 7.20, a PaCO2 of 82
mmHg, and a PaO2 of 215 mmHg. You are called emergently to the patient's bedside 2 h later to deal
with hypotension. The patient currently is breathing 14 times per minute, but his oxygen saturation has
decreased from 100% to 84%. Blood pressure is 66/42. Heart rate is 130 beats/min with sinus
tachycardia. Temperature is 38.2°C (100.8°F). The patient is sedated, and his respirations do not appear
labored. Breath sounds are markedly decreased on the right side with tracheal deviation to the left. The
patient has thready peripheral pulses and is cool to touch. You notice that the patient's peak inspiratory
pressure has risen from 40 cmH2O to more than 75 cmH2O. What is the most important next step in
stabilizing this patient?
A. Disconnect the patient from the ventilator to relieve intrinsic positive end-expiratory pressure (PEEP).
B. Perform deep suctioning to relieve mucus plugging.
C. Initiate fluid resuscitation and vasopressor support for sepsis syndrome.
D. Insert a large-bore needle into the right pleural space to relieve a pneumothorax.
E. Administer a paralytic agent because the patient's decompensation can be attributed to dyssynchrony
with mechanical ventilation.
with altered consciousness. His family reports a 2-day history of increasing shortness of breath that
requires nebulized albuterol every 2 h. In addition, the patient has had increasing sputum production
with a change in the sputum color from white to green. On presentation, the patient was breathing eight
times per minute and was unarousable. Initial arterial blood gas revealed a pH of 6.98, a PaCO2 of 110
mmHg, and a PaO2 of 100 mmHg while the patient was on a nonrebreather mask. The patient is
emergently intubated and brought to the intensive care unit. The initial ventilatory settings are as
follows:
Mode Assist control
Rate 12 breaths/min
Tidal volume 500 mL
PEEP 0 cmH2O
FIO2 0.5
Initially, the patient does well with improvement in arterial blood gases (ABG) to pH 7.20, a PaCO2 of 82
mmHg, and a PaO2 of 215 mmHg. You are called emergently to the patient's bedside 2 h later to deal
with hypotension. The patient currently is breathing 14 times per minute, but his oxygen saturation has
decreased from 100% to 84%. Blood pressure is 66/42. Heart rate is 130 beats/min with sinus
tachycardia. Temperature is 38.2°C (100.8°F). The patient is sedated, and his respirations do not appear
labored. Breath sounds are markedly decreased on the right side with tracheal deviation to the left. The
patient has thready peripheral pulses and is cool to touch. You notice that the patient's peak inspiratory
pressure has risen from 40 cmH2O to more than 75 cmH2O. What is the most important next step in
stabilizing this patient?
A. Disconnect the patient from the ventilator to relieve intrinsic positive end-expiratory pressure (PEEP).
B. Perform deep suctioning to relieve mucus plugging.
C. Initiate fluid resuscitation and vasopressor support for sepsis syndrome.
D. Insert a large-bore needle into the right pleural space to relieve a pneumothorax.
E. Administer a paralytic agent because the patient's decompensation can be attributed to dyssynchrony
with mechanical ventilation.