A 68-year-old woman was admitted to the ICU with pneumonia and ...

[Marty]

A 68-year-old woman was admitted to the ICU with pneumonia and was intubated when she developed progressive hypoxemia. She has been on the ventilator for 5 days and has been toler-ating this therapy well.
 
  The patient has suddenly become severely agitated and appears to be fighting the ventilator. The ventilator's high pressure alarm is sounding continuously. The respiratory therapist disconnects the patient from the ventilator and begins manual ventilation with 100 oxygen and PEEP. The resuscitator bag is difficult to squeeze, breath sounds are present on the left with no adventitious sounds and absent on the right side, and percussion reveals hyperresonance over the right side. The most appropriate action to address this situation is which of the following?
  a. Pull the endotracheal tube back until bi-lateral breath sounds are heard.
  b. Administer a bronchodilator and suction the endotracheal tube.
  c. Extubate the patient and reintubate with a larger endotracheal tube.
  d. Insert a 14-gauge needle in the second in-tercostal space, midclavicular line, right side.

Question 2

At 1030 the respiratory therapist is called to the bedside of a patient being mechanically venti-lated with VC-IMV.
 
  The patient is a 55-kg female who has been intubated with a size 8 endotracheal tube. Currently, the ET tube is located 20 cm at the gum line. During spontaneous breathing, the patient shows lack of coordinated chest wall movement, and the respiratory therapist notes some retraction of the intercostal spaces. The respiratory therapist performs a system check. The current and past few patient-ventilator system checks reveal the following information:
  Time 0430 0640 0835 1030
  PIP (cm H2O) 28 31 34 41
  Pplateau (cm H2O) 18 21 19 20
  The most appropriate action to take in this situation is which of the following?
  a. Deflate the cuff and reposition the endo-tracheal tube.
  b. Request that the patient receive haloperi-dol and midazolam.
  c. Administer albuterol via an in-line me-tered-dose inhaler.
  d. Switch the mode to PC-IMV and increase the rate.

[jordangronback]

Answer to Question 1

ANS: D
If the endotracheal tube had slipped into the right mainstem bronchus, breath sounds would be heard on the right side and not on the left. The absence of breath sounds on the right side indi-cates that the endotracheal tube has not slipped into the right mainstem bronchus. No adventi-tious breath sounds are heard over the left lung, the patient has no history of bronchospasm, and no wheezing is heardthis essentially eliminates bronchospasm as the problem. The patient had been tolerating mechanical ventilation well for 5 days; therefore, the ET tube is not too small. The presence of auto-PEEP would cause hyperresonance to percussion bilaterally. The patient appar-ently has a pneumothorax on the right side, as evidenced by the absence of breath sounds and hyperresonance to percussion on that side.

Answer to Question 2

ANS: C
The lack of coordinated chest wall movement, the intercostal retractions, and the increased transairway pressure (seen at 1030) indicate bronchospasm. This can be confirmed by auscultat-ing the patient's chest. The patient should be suctioned before receiving the bronchodilator to remove any mucus. The sudden onset rules out an insidious increase in mucus. The ET tube is properly placed at the 20-cm mark and therefore does not require repositioning. This patient is not displaying any evidence of agitation, delirium, or anxiety; therefore, administration of haloperidol and midazolam is not appropriate in this situation. There is also no evidence of a need to change from volume to pressure control or to increase the set rate at this time.

[Marty]

TYSM

[flexer1n1]

Excellent