A 68-year-old woman was admitted to the ICU with pneumonia and was intubated when she developed progressive hypoxemia. She has been on the ventilator for 5 days and has been toler-ating this therapy well.
The patient has suddenly become severely agitated and appears to be fighting the ventilator. The ventilator's high pressure alarm is sounding continuously. The respiratory therapist disconnects the patient from the ventilator and begins manual ventilation with 100 oxygen and PEEP. The resuscitator bag is difficult to squeeze, breath sounds are present on the left with no adventitious sounds and absent on the right side, and percussion reveals hyperresonance over the right side. The most appropriate action to address this situation is which of the following?
a. Pull the endotracheal tube back until bi-lateral breath sounds are heard.
b. Administer a bronchodilator and suction the endotracheal tube.
c. Extubate the patient and reintubate with a larger endotracheal tube.
d. Insert a 14-gauge needle in the second in-tercostal space, midclavicular line, right side.
Q. 2 At 1030 the respiratory therapist is called to the bedside of a patient being mechanically venti-lated with VC-IMV.
The patient is a 55-kg female who has been intubated with a size 8 endotracheal tube. Currently, the ET tube is located 20 cm at the gum line. During spontaneous breathing, the patient shows lack of coordinated chest wall movement, and the respiratory therapist notes some retraction of the intercostal spaces. The respiratory therapist performs a system check. The current and past few patient-ventilator system checks reveal the following information:
Time 0430 0640 0835 1030
PIP (cm H2O) 28 31 34 41
Pplateau (cm H2O) 18 21 19 20
The most appropriate action to take in this situation is which of the following?
a. Deflate the cuff and reposition the endo-tracheal tube.
b. Request that the patient receive haloperi-dol and midazolam.
c. Administer albuterol via an in-line me-tered-dose inhaler.
d. Switch the mode to PC-IMV and increase the rate.
Q. 3 The initial step in the management of patient-ventilator asynchrony is which of the following?
a. Lower the high pressure alarm setting.
b. Check the endotracheal tube cuff pressure.
c. Ventilate the patient with a manual resus-citator bag.
d. Check the low and high pressure alarm settings.
Q. 4 Removing a patient from a ventilator to ventilate manually can lead to which of the following? 1. Barotrauma 2. Lung derecruitment 3. Increased airway resistance 4. Ventilator-acquired pneumonia
a. 1, 2, and 3
b. 1, 2, and 4
c. 2, 3, and 4
d. 3 and 4
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