A 36-year-old female patient with a history of asthma is admitted to the ICU from the emergen-cy department. Her respirations are 30, very labored, with accessory muscle use and bilateral in-spiratory and expiratory wheezing.
There is bilateral hyperresonance during chest percussion. A blood gas taken in the ICU after 1 hour of continuous aerosolized albuterol (15 mg) reveals: pH 7.38, partial pressure of carbon di-oxide (PaCO2) 42 mm Hg, partial pressure of oxygen (PaO2) 53 mm Hg, oxygen saturation (SaO2) 88, bicarbonate (HCO3) 25 mEq/L with nasal cannula 6 L/min. The patient is 5'5 and weighs 135 lb. The most appropriate action at this time is which of the following?
a. Continue current therapy with 20 mg al-buterol and reassess in 1 hour.
b. Noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pres-sure (bilevel PAP), f = 12, inspiratory pos-itive airway pressure (IPAP) 28 cm H2O, expiratory positive airway pressure (EPAP) 3 cm H2O, fractional inspired ox-ygen (FIO2) 0.30
c. Intubate, use pressure-controlled continu-ous mandatory ventilation (PC-CMV), f = 8, peak inspiratory pressure (PIP) 28 cm H2O, TI 0.75 seconds, positive end-expiratory pressure (PEEP) 3 cm H2O, FIO2 1.0
d. Intubate, use volume-controlled continu-ous mandatory ventilation (VC-CMV), f = 12, tidal volume (VT) 600 mL, PF 40 L/min, PEEP 5 cm H2O, FIO2 0.60
Q. 2 During mechanical ventilation, a patient with a closed head injury develops the Cushing re-sponse. This may be immediately managed by using which of the following?
a. Pressure-controlled continuous mandatory ventilation (PC-CMV) with positive end- expiratory pressure (PEEP)
b. Sedation and paralysis
c. Permissive hypercapnia
d. Iatrogenic hyperventilation
Q. 3 Essential capabilities of an adult intensive care unit (ICU) ventilator include all of the following except:
a. expiratory pause.
b. pressure control modes.
c. flow rates up to 250 L/min.
d. respiratory rates up to 60 breaths/min.
Q. 4 Methods to minimize air trapping in mechanically ventilated patients include which of the fol-lowing?
a. Using a longer inspiratory time (TI)
b. Switching to pressure support ventilation (PSV)
c. Increasing inspiratory flow
d. Administering a mucolytic agent
Q. 5 A chronic obstructive pulmonary disease (COPD) patient with an ideal body weight of 65 kg is brought to the emergency department.
The patient is short of breath and using accessory muscles. Aerosolized bronchodilators are ad-ministered. The arterial blood gas reveals the following: pH 7.31, partial pressure of carbon diox-ide (PaCO2) 72 mm Hg, partial pressure of oxygen (PaO2) 88 mm Hg, oxygen saturation (SaO2) 90, bicarbonate (HCO3) 32 mEq/L on nasal cannula 2 L/min. The respiratory therapist should recommend which of the following at this time?
a. Intubate, volume-controlled continuous mandatory ventilation (VC-CMV) rate 15 breaths/min, tidal volume (VT) 650 mL, fractional inspired oxygen (FIO2) 0.50, positive end-expiratory pressure (PEEP) 6 cm H2O.
b. Noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pres-sure (bilevel PAP) rate 8 breaths/min, in-spiratory positive airway pressure (IPAP) 10 cm H2O, expiratory positive airway pressure (EPAP) 4 cm H2O.
c. Intubate, pressure-controlled intermittent mandatory ventilation (PC-IMV) rate 10 breaths/min, peak inspiratory pressure (PIP) 30 cm H2O, FIO2 0.60, PEEP 3 cm H2O.
d. Administer 30 oxygen via air entrain-ment mask and continuous bronchodilator therapy.
Q. 6 A 70-year-old, 61-inch-tall female patient was admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD).
After 12 hours of oxygen therapy, bronchodilator therapy, and intravenous corticosteroids, the patient began to show signs of clinical deterioration. Her chest X-ray revealed an enlarged heart and bilateral infiltrates. Her arterial blood gas shows acute on chronic respiratory failure. It is de-cided that this patient requires intubation and mechanical ventilation. The most appropriate ven-tilator settings for this patient include which of the following?
a. Volume-controlled continuous mandatory ventilation (VC-CMV) rate 15, VT 200 mL, FIO2 1.0, positive end-expiratory pressure (PEEP) 5 cm H2O
b. VC-CMV rate 12, VT 400 mL, FIO2 0.4, PEEP 3 cm H2O
c. Pressure-controlled intermittent mandato-ry ventilation (PC-IMV) rate 10, peak in-spiratory pressure (PIP) 30 cm H2O, FIO2 0.60, PEEP 3 cm H2O
d. PC-IMV rate 12, PIP 35 cm H2O, FIO2 0.30, PEEP 8 cm H2O
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