A 72-year-old male patient (height 6'2, weight 95 kg) with a ...

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A 72-year-old male patient (height 6'2, weight 95 kg) with a history of congestive heart failure (CHF) presents to the emergency department complaining of shortness of breath and inability to lie down to sleep.
 
  Physical assessment reveals a very anxious patient with a pulse of 140, respirations 32, and la-bored with diaphoresis. Breath sounds are decreased with bibasilar coarse crackles. The patient has a productive cough of pink frothy secretions. The patient is placed on a nonrebreather mask and the resulting arterial blood gases (ABG) show: pH 7.25, partial pressure of carbon dioxide (PaCO2) 55 mm Hg, partial pressure of oxygen (PaO2) 54 mm Hg, oxygen saturation (SaO2) 86, bicarbonate (HCO3) 24 mEq/L. The most appropriate immediate action to take includes which of the following?
  a. Face mask continuous positive airway pressure (CPAP) 10 cm H2O
  b. Intubate, volume-controlled continuous mandatory ventilation (VC-CMV), respir-atory frequency (f) 20, tidal volume (VT) 810 mL, positive end-expiratory pressure (PEEP) 8 cm H2O, fractional inspired ox-ygen (FIO2) 1.0
  c. Intubate, volume-controlled intermittent mandatory ventilation (VC-IMV), f 6, VT 425 mL, PEEP 10 cm H2O, FIO2 0.80
  d. Noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pres-sure (bilevel PAP), inspiratory positive airway pressure (IPAP) 15 cm H2O, expir-atory positive airway pressure (EPAP) 5 cm H2O, FIO2 0.60

Question 2

A male patient who is 5'10 and weighs 190 lb arrives at the hospital having suffered a closed head injury in a motor vehicle accident.
 
  The patient is unconscious and a computer tomogram of the head reveals an intracranial bleed. The patient receives an intracranial pressure (ICP) monitor following neurosurgery. Initial venti-lator settings should include which of the following?
  a. Volume-controlled continuous mandatory ventilation (VC-CMV), respiratory fre-quency (f) 15 breaths/min, tidal volume (VT) 750 mL, positive end-expiratory pressure (PEEP) 5 cm H2O, fractional in-spired oxygen (FIO2) 1.0
  b. Pressure-controlled continuous mandatory ventilation (PC-CMV), f 15 breaths/min, peak inspiratory pressure (PIP) 35 cm H2O, PEEP 10 cm H2O, FIO2 1.0
  c. Volume-controlled intermittent mandatory ventilation (VC-IMV), f 6 breaths/min, VT 300 mL, pressure support (PS) 10 cm H2O, PEEP 5 cm H2O, FIO2 0.50
  d. Pressure-controlled intermittent mandato-ry ventilation (PC-IMV), f 12 breaths/min, PIP 20 cm H2O, PS 10 cm H2O, PEEP 5 cm H2O, FIO2 0.40

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Answer to Question 1

ANS: D
The patient is suffering from cardiogenic pulmonary edema from congestive heart failure (CHF) and has both hypercapnic and hypoxemic respiratory failure. The use of noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pressure (bilevel PAP) while waiting for pharmacological treatment to take effect would be appropriate. Face mask continuous positive airway pressure (CPAP) may not provide enough support to allow the patient to reduce the par-tial pressure of carbon dioxide (PaCO2). Although intubation is a more aggressive alternative, the choices provided are not within the guidelines for ventilation of patients with CHF. These guide-lines include a tidal volume (VT) between 8 and 12 mL/kg. That would be between 405 and 648 mL. This eliminates the answer with 810 mL tidal volume. The fractional inspired oxygen (FIO2) initially should be 1.0; this eliminates the choice with 0.80.

Answer to Question 2

ANS: A
The initial settings for a closed head injury patient include pressure-controlled (PC) or vol-ume-controlled (VC) continuous mandatory ventilation (CMV), tidal volumes between 8 and 12 mL/kg, respiratory frequency (f) 15-20 breaths/min, positive end- expiratory pressure (PEEP) 0-5 cm H2O with caution and higher only if there is severe hypoxemia, and fractional inspired oxy-gen (FIO2) 1.0 to start and titrate to keep partial pressure of oxygen (PaO2) between 70 and 100 mm Hg. This eliminates both intermittent mandatory ventilation (IMV) choices. The PC-CMV choice has a peak inspiratory pressure (PIP) and PEEP that are too high for this type of patient because it would increase intracranial pressure (ICP). Choice A fits within the guideline for ventilation of the closed head injury patient.