The Real-World Boards: Question #44
Set it, don't forget it (the ventilator, that is)
These are the Real-World Boards. As in the real world, there is often no “right” answer, and you are only competing against yourself. Upgrade to the Lifelong Learner level for full access to all the questions and unlimited CME credits with an included Learner+ account.
A 67-year-old man with severe COPD is admitted to the ICU with hypercapnic respiratory failure, presumed to be from an acute exacerbation of COPD. He is intubated and mechanically ventilated with the following settings:
Volume assist-control, tidal volume 450 mL (6.5 mL/kg predicted body weight)
Respiratory rate 24/min
FiO₂ 40%
PEEP 8 cm H₂O
Peak inspiratory pressure is 42 cm H₂O, and plateau pressure is 22 cm H₂O.
Over the next 24 hours, the patient becomes increasingly tachypneic and appears to be “fighting” the ventilator despite adequate sedation. The ventilator frequently fails to trigger despite obvious inspiratory effort. Blood pressure remains stable, but heart rate has increased from 95 to 110.
An end-expiratory hold maneuver demonstrates a total PEEP of 17 cm H₂O. When you evaluate the patient, the respiratory therapist has already disconnected and reconnected the ventilator circuit after a brief period of manual bag ventilation.
