Question

Part 2 Directions: Answer the following questions below your scenario. Clearly identify to which question you are referring 12 points each). 1. Non-Invasive Scenarios: Use the following patient information to make recommendations for changing NIV settings. a. Initial settings: IPAP 14, EPAP 6, FIO2 0.70. Blood gas: pH 7.32, PaCo2 54 mmHg. PaO2 45mmHg, HCO3 29 mg/l b. Initial settings IPAP 15, EPAP 5, FIO2 0.30. Blood gas: pH 7.29, PaCO2 78 mmHg, PaO2 82 mmHg. HCO3 30 mg/L. C. Initial settings: IPAP 18, EPAP 8, FIO2 0.60. Blood gas: pH 7.36, PaCO2 79 mmHg. PaO2 50 mmHg. HCO3 37 mg/L 2. Adjusting Settings Scenarios: Use the following patient information to make recommendations for adjusting invasive ventilator settings. a. Patient: 45-year-old male, alcohol intoxication, (6'4", 275 lbs) Ventilator Settings: VC-CMV, VT 500 ml, Rate 15 breaths/min, FIO2 40%, PEEP 5 cmH2O, Flow 75 L/min Outputs: Rate 17 breaths/min, SpO2 93%, PIP 25 cmH20, Polat 21 cmH2O ABG: pH 7.33, PaCO2 49, PaO2 90, HCO3 25 b. Patient: 68-year-old female, ARDS (5'6", 152 lbs) Ventilator Settings: PC-CMV Paw (above PEEP) 15 cmH2O, Rate 24 breaths/min, FIO2 60%, PEEP 10 cmH2O, Ti 1.0 seconds Outputs: Rate 24 breaths/min, SpO2 86%, Spontaneous VT 360 mL ABG: pH 7.40, PaCo2 43, PaO2 45, HCO3 19 mEg/L 3. Weaning Scenario: Use the following patient information to make recommendations for liberation of mechanical ventilation a. Patient: 62-year-old male, Drug OD, (5'10", 235 lbs) Ventilator Settings: CPAP 6 PS 10 FIO2 0.4 Outputs: Rate 20 breaths/min, SpO2 95%, VT 450, VC 11, NIF-28 cmH2O

Answer 1

1.Non invasive scenarios:

a.IPAP 14,EPAP 6,FIO2-.70,BLOOD GAS;PH7.32,PACO2-54MMHG,PAO2 -45 MMHG,HCO3 -29 Meq/L

As the patient is still in respiratory acidosis due to hypercapnia: i suggest to increase positive pressure by increasing IPAP to 16 ,thus we will get a positive pressure of 10(Ipap-Epap).it will help to wash out the carbondioxide.Also due to persisting hypoxia fio2 to be increased to 100 percentage.

b.IPAP 15,EPAP 5,FIO2-.30,BLOOD GAS;PH7.29,PACO2-78MMHG,PAO2 -82 MMHG,HCO3 -30 Meq/L

As the patient is still in respiratory acidosis due to severe hypercapnia: i suggest to increase positive pressure by increasing IPAP to 16 ,thus we will get a positive pressure of 11(Ipap-Epap).it will help to wash out the carbondioxide. fio2 can be kept unchanged and keep monitoring pao2.

c.IPAP 18,EPAP 8,FIO2-.60,BLOOD GAS;PH7.36,PACO2-79MMHG,PAO2 -50 MMHG,HCO3 -37Meq/L

As the patient is still in partialy compensated respiratory acidosis : i suggest to increase positive pressure by increasing IPAP to 20 ,thus we will get a positive pressure of 12(Ipap-Epap).it will help to wash out the carbondioxide. fio2 has to be increased to .80.if the pco2 is not improving then consider for a invasive ventilation.

2.Adjusting setting scenarios:

a.In the first case patient is in Respiratory acidosis ,oxygenation is in acceptable range.The set breath in ventilator is 15 breaths and patient is breathing on 17 breaths.ventilator breath rate can be increased to 18 with some mild sedation as the patient is breathing above the set values.

b.In the second case of ARDS,only hypoxia is the concern-we can increase the fio2 to 80 percent and decrease the ventilator Respiratory rate to 22 breaths per minute(it permits more air exchange time for better oxygention0.

3.Weaning scenarios:

As all the paitents output parameters are acceptable except borderline oxygenation of 95%,i would suggest to reduce the pressure support 8 and cpap by 5 first then followed by oxygen titration to 0.3l and further abg is acceptable,go for extubation.