Mr. Q., age 72 with a history of COPD, presented in the emergency department 2 days ago febrile with a productive cough of large amounts of purulent sputum and in acute respiratory distress. He was diagnosed with community-acquired pneumonia and treated with antibiotics, hydration, aggressive pulmonary hygiene, and supplemental oxygen therapy. Although his overall oxygenation improved, he continued to be diaphoretic, using accessory respiratory muscles of respiration and complaining, “I am exhausted” and “I can’t get enough air.” Arterial blood gas revealed: pH 7.30, PaCO2 58 mm Hg, PaO2 87 mm Hg, SaO2 91%, HCO3 29 mEq/L. The decision was made to intubate and place him on mechanical ventilation with the following settings: assist control (AC) mode, tidal volume (VT) 625 mL, respiratory rate 16 breaths/min, FiO2 0.70, and 5 cm H2O of positive end-expiratory pressure (PEEP). He was transferred to the critical care unit.
Two days later, his presentation at 0500 is as follows:
Ventilator settings: Mode AC, VT625 mL, respiratory rate 12, FiO235, 5 cm H2O PEEP
Total RR 16, peak inspiratory pressure (PIP) 22 mm Hg
Moderate amounts sputum, rhonchi that clear with coughing, chest x-ray shows clearing bilateral lower love pneumonia
Negative inspiratory force -37 cm H2O, spontaneous tidal volume 5 mL/kg, vital capacity (VC) 10 mL/kg, minute ventilation 10 L/min, rapid shallow breathing index of 37
Temperature 99.0° F oral, heart rate 86 beats/min, blood pressure 132/84 mm Hg
No vasopressor or inotropic agents, urinary output is good, NPO since admission.
Alert and oriented to person, place and situation, hypervigilant and restless, has not slept well since admission
The team decides to perform a ventilator weaning trial. At 0620 Mr. Q. is placed on 10 cm H2O of pressure support with an FiO2 0.40.
Assessment at 0720 is as follows:
Heart rate 108 beats/min
Blood pressure 157/90 mm Hg
Respiratory rate 36 breaths/min and labored
He is diaphoretic and alternates between picking at his gown and falling asleep and needing to be aroused to stimulate breathing. He is placed back on the ventilator at the previous settings.
Late that morning, during rounds, Mr. Q. is started on nutritional support via tube feeding and given trazodone at night for sleep. He is allowed a morning nap and has physical therapy that afternoon.
The following day he passes the pre-wean screening and is again placed on PS 5 above 5 cm H2O PEEP. Assessment findings 30 minutes into the weaning trial are as follows:
Heart rate 84 beats/min
Blood pressure 120/76 mm Hg
Respiratory rate 18 breaths/min, unlabored
Mr. Q. is calm, cooperative, and oriented, so the weaning trial is continued for 90 minutes. Arterial blood gas results were pH 7.34, PaCO2 48 mm Hg, PaO2 74 mm Hg, HCO3 24 mEq/L, and SaO2 95%. The decision was made to extubate, and the patient was discharged from the critical care unit the following day.
Please answer the following questions concerning Mr. Q,
What is your analysis of Mr. Q’s first arterial blood gas? What factors contribute to these results?
What do the measures of negative inspiratory force, spontaneous tidal volume, vital capacity, minute ventilation, and rapid shallow breathing index assess?
What other parameters should/could be assessed as part of the initial wean screen?
Why is pressure support the mode used for the weaning trial, and why is pressure support more consistent than other modes?
How long does a weaning the trial last?
Is Mr. Q. tolerating weaning, and how do you know?
What interventions are indicated?
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