A 45-year-old female (58-kg IBW) with a past medical history of ...

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A 45-year-old female (58-kg IBW) with a past medical history of asthma arrives at the emergen-cy department short of breath, anxious, diaphoretic, and unable to perform a peak expiratory flow measurement.
 
  She also has a combined acidosis. Breath sounds reveal the patient is not moving much air. The patient is intubated, stabilized, and transported to the ICU. The ventilator settings are: PC-CMV, f = 12/min, PIP = 30 cm H2O, FIO2 = 0.6, and PEEP = 3 cm H2O. The patient is sedated and paralyzed; the resulting ABGs are: pH 7.17, PaCO2 69.3 mm Hg, PaO2 90 mm Hg, and HCO3 21 mEq/L after continuous bronchodilator therapy. The respiratory rate is increased to 20/min, and the next ABG results are: pH 7.26, PaCO2 58 mm Hg, PaO2 96 mm Hg, and HCO3 22 mEq/L. The respiratory therapist should suggest which of the following at this time?
  a. Increase PIP to 38 cm H2O.
  b. Decrease PIP to 25 cm H2O.
  c. Continue with current therapy.
  d. Change to VC-CMV, f = 12/min, VT = 700 mL.

Question 2

A patient with an IBW of 68 kg is intubated and being mechanically ventilated with VC-CMV, f = 12/min, and VT = 470 mL.
 
  The patient has a combined respiratory rate of 25/min. The ABG results are: pH 7.56, PaCO2 26 mm Hg, and HCO3 22 mEq/L. The most appropriate action is to do which of the following?
  a. Decrease the set f to 8/min.
  b. Decrease the set VT to 300 mL.
  c. Sedate and paralyze the patient.
  d. Change the mode to VC-IMV.

[ebonylittles]

Answer to Question 1

ANS: C
The current therapy should be continued in an effort to prevent lung injury.

Answer to Question 2

ANS: D
The patient has ventilator-induced respiratory alkalosis, because the patient is triggering the ma-chine breaths each time there is a spontaneous effort. Decreasing the set f will not alter the rate at which the patient is assisting. Decreasing the set VT to 300 mL will most likely result in the pa-tient's breathing at a faster rate because of the low volume. The patient could be sedated and paralyzed. However, the patient is not demonstrating a need for this option (i.e., extreme agita-tion, increased WOB, and patient-ventilator asynchrony). Changing to the VC-SIMV mode will allow the patient to breathe spontaneously and not trigger a machine breath each time.

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Gracias!

[phuda]

TYSM