18 Oct A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O.

A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required?

a. The arterial line shows a blood pressure of 90/46.

b. The pulmonary artery pressure (PAP) is decreased.

c. The cardiac monitor shows a heart rate of 58 beats/min.

d. The pulmonary artery wedge pressure (PAWP) is increased.                                 

Question 2          A 40 year-old. 6-foot tall man has been inpatient on the step down unit for the past 2 days. He was admitted for fever and cough with production of yellow sputum. His admission blood pressure was 128/72 and initial chest x-ray showed a left lower lobe infiltrate. His ABG on room air showed: pH 7.31, PCO2 30, PO2 78, HCO3 17. He was started on antibiotics and progress notes from he past two days indicate improvement in his condition.

The APRN is called by the nurse because of worsening of the patients condition. 

On your arrival to the room, vitals signs are. BP. 86/60 P 118  RR 38  oxygen saturation on a non-rebreather mask is 78% (this am it was 97% on 2L per NC). The patient is laboring to breath with accessory muscle use. He is less responsive, diaphoretic, and is speaking in short sentences. Repeat chest x-ray shows bilateral diffuse lung opacities. ABG on the non-rebreather mask show: pH 7.18, PCO2 47, PO2 56, HCO3 13.

The decision to intubate the patient is made. What initial ventilator settings would you order?                                  

Question 3          A patient is admitted to the ICU with severe necrotizing pancreatitis. Three hours after admission his oxygen saturations decreased and he was intubated for hypoxia. Initially his oxygen saturation improved to 94% on FiO2 of 50% but over the past two hours his FiO2 has been increased to 70% and his saturation is 89%. The patient is on 5 cm H2O of PEEP.

His current ABG shows pH 7.34, pCO2 36, PO2 61, HCO3 21 on an FIO2 of 80%. The patient’s repeat chest x-ray shows diffuse bilateral opacities in a pattern consistent with pulmonary edema. An echo earlier today was read as normal.

What can you do to improve his oxygenation?                                  

Question 4          A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side.

What management steps should you institute at this point?                                       

Question 5          A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side.

What do static and peek pressures represent on the ventilator?                                              

Question 6          A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side.

Where do you think the problem lies with this particular patient?                                            

Question 7          A 34 year ole email who weights 96 kg (211 lbs.) and is 165 cm (5 ft. 6 inches) tall has chest trauma due to a motorcycle accident. The patient has just been intubated, sedated and paralyzed with morphine sulfate and pancuronium bromide. What initial ventilator settings are appropriate for this patient?                                             

Question 8          A 58 year-old man with a history of COPD presents to the emergency room with a two day history of increasing shortness of breath that started after a recent viral infection. His current oxygen saturation is 87% on room air. He is able to speak one to two words at a time and is working hard to breath. On exam, he has diffuse wheezes and a prolonged expiratory phase. His chest x-ray reveals changes consistent with COPD but no new focal infiltrates. An arterial blood gas (ABG) is done and shows pH 7.15, PCO2 57, PO2 61, HCO3 24.

What are the indications for initiating mechanical ventilation?                                    

Question 9          The APRN is notified that an intubated patients endotracheal tube (ET) was marked at 21 cm and is not at the 24 cm line. The patient appears anxious and restless. What action should the APRN take?                    

Question 10        A patient with COPD is on a spontaneous breathing protocol. His heart rate is 98 beats /minute, oxygen saturation is 93%, respiratory rate is 32 breaths /minute, and spontaneous tidal volume is 500 ml.  

Should the trial be continued at this time?