Question

ear-old, 6-foot-tall man presented to the emergency department with a 2-0da A 45-y of fever and productive cough with copious amounts of brown spuay history hemodynamically stable with a blood pre showed a right middle lobe infiltrate, and his room air arterial blood gas (ABG) is as follows: pH 7.32; Paco2 32mmHg (HCOs) 18 mEq/i; (mEqL), and Pao2 78mm Hg. He was started on antibiotics and ssure of 130/87 mmHg. His chest radiograph admitted to the floor. Four hours later, the nurse calls you be cause she is concerned that he is doing worse. On your arrival at his room, his BP is 85/60mm Hg, his pulse is 120 beats min and his oxygen saturation, which had been 97% on 2L of oxygen via nasal cannula, is now 78% on a nonre breather mask. The patient is laying labored breathing with accessory muscle use and is less responsive than he was disp on admission. He is diaphoretic and is not able to talk. Lung examination reveals that he has crackles bilaterally in the bases posteriorly. You obtain a chest radiograph, which shows increasing bilateral, diffuse lung opacities. An ABG is done while he is on the nonrebreather mask, and it shows: pH 7.17; PaCO2 45 mm Hg; HCO3- 14mEqL; and Pa 58 mm Hg. 1. What should you do? Is there a role for CPAP or BiPAP in his management? What information regarding initial ventilator settings would you need to communicate to the physician? 2. 3. How does this mode work? 4. How do you choose the tidal volume? 5. On the basis of the information above, fill in the chart below: Setting Suggested Starting Value

Answer 1

1. The patient should be shifted to intensive care immediately and intubate him to initiate mechanical ventilation. This patient has difficulty in breathing and also decline in consciousness. Also his oxygenation and ventilation is becoming worse and mechanical ventilation is required.

2. The information regarding the mode of the ventilator and the settings to be communicated to the physician. Regarding setting the tidal volume , respiratory rates , FIO2 and PEEP need to be confirmed.

3. The mode which is set will help the patients to correct hypoxaemia. It allows an increased rate of inspired oxygen content which increases the mean airway pressure and improves ventilation to collapsed areas of the lung.

4. The tidal volume can be calculated according to the body weight of the individual. Usually the initial tidal volume chose is 8-10 ml /kg body weight of the patient, by using his height,the following formula can be used.

[ (Height in inches - 60) * 2.2 ] + 50

According to this formula, the patient's weight is 75 kg.

5. Tidal volume - 600 ml

Frequency - 16 bpm

Flow pattern - constant flow pattern

FIO2 - 1.0

PEEP - 5 cm H2O