2008 Mechanical Ventilation Knowledge-Feedback

Background

The multiple choice examination was developed by Cox et al (Am J Resp Crit Care Med 2003;
167(1):32-38) and the results for US medical residents were reported in 2003. They found signifi-
cant gaps in knowledge of mechanical ventilation after these residents had completed their ICU rota-
tions. There were differences in the resident’s assessment of their knowledge and training and the
program director’s impression. The examination developed by Cox et al was used for this project to
assess knowledge of a broader range of physicians regarding mechanical ventilation in 2008. The
answers provided are based on a presentation developed at the University of Manitoba by Dr. Dean
Bell and are provided for individual education only. Images have been used from several sources and
are provided only to help illustrate why the answer selected is correct.

Case 1

A 64 year-old female with a history of COPD presents to the emergency room with increasing short-
ness of breath. At baseline she uses bronchodilators up to four times daily. Over the past week, her
exercise tolerance has been decreasing, and she is now dyspneic at rest despite frequent use of her
beta agonists. She reports a moderate cough with clear sputum.

On physical exam, she is in moderate respiratory distress but alert and appropriately responsive. Tem-
perature is 38 °C, heart rate (HR) 110, respiratory rate (RR) 28, and blood pressure (BP) 110/70 mm Hg.
She is using accessory muscles to breathe but can complete short sentences. Decreased breath sounds
are present bilaterally and prolonged expiration is noted. Heart sounds are distant but regular and the
abdomen is unremarkable.

A chest radiograph reveals hyperinflation and decreased lung markings throughout both lung fields.
An arterial blood gas (ABG) performed while the patient is on 2 liters O2 by nasal cannula reveals: pH
7.30, PaCO2 60mmHg, PaO2 58mmHg, SaO2 88%.

Case1 questions
In addition to close monitoring, which ONE of the following interventions would be MOST APPRO-
PRIATE at this time?

a) Increased supplemental oxygen with continuous beta agonist therapy

b) Continuous beta agonist therapy only

c) Intubation and mechanical ventilation

d) Noninvasive positive pressure ventilation (BiPAP)

Answer: D Noninvasive positive pressure ventilation (BiPAP)

This patient is the “poster child for Non invasive ventilation (NIV)!

Patient populations shown to benefit from NIV: COPD patients with acute respiratory failure (pH
<7.3 but >7.25 have greatest benefit)

Sinuff T, Keenan SP. J Crit Care 2004; 19(2): 82-91Keenan SP, Sinuff T, Cook DJ, Hill NS. Ann Int
Med 2003; 138:861-70

Feedback on Mechanical Ventilation 1

Benefits of NIV

• Reduced rate of endotracheal intubation

• Shorter hospital stay

• Decreased in-hospital mortality

Evidence based NIV indications

Respiratory failure following pulmonary resection (Liesching et al Chest 2003; 124:699-713; Aguilo
et al Chest 1997; 112:117-121)

Hypoxic respiratory failure in an immunosuppressed population (Antonelli et al JAMA 2000;

283:235-41; Hilbert et al N Engl J Med 2001; 344:481-87)

Cardiogenic pulmonary edema (Controversy resolved CPAP not safer than BiPAP) (Liesching et al
Chest 2003; 124:699-713 ; Nadar S et al Int J Cardiol 2005; 99:171-185)

Suggested
application of
NIV
Truwit JD, Bernard GR. N Engl J
Med 2004; 350:2512-15

Feedback on Mechanical Ventilation 2

During the course of her therapy, a decision is made to intubate the patient. After a 500-mL fluid
bolus, she is sedated and a 7.0 endotracheal tube is placed without difficulty. The CO2 indicator
reading is consistent with appropriate placement of the endotracheal tube. The patient is ventilated
at 25 breaths per minute by Ambu-bag. Immediately after intubation however, the blood pressure is
observed to be 70/40 mm Hg.

What ONE process is the MOST LIKELY cause of the hypotension?

a) Sepsis

b) Pneumothorax

c) Increased intrathoracic pressure (“auto-PEEP”)

d) Myocardial infarction

Answer: c) Increased intrathoracic pressure (“auto-PEEP”). The respira-

tory rate is fast and the patient has obstructive airways disease. This re-
sults in trapped intrathoracic gas and deceased venous return.

AutoPEEP can influence the patient’s ability to trigger the ventilator and result in increases in
work of breathing if the patient is interacting with the ventilator. AutoPEEP can also result in
poor patient/ventilator interaction and can result in missed breaths due to failure to trigger.

Feedback on Mechanical Ventilation 3

The MOST APPROPRIATE first intervention to improve the cardiovascular compromise would be
to:

a) Increase IV fluids

b) Place a 16-gauge needle in the left anterior second intercostal space

c) Stop bagging and allow the patient to exhale

d) Begin dopamine at 5 mcg/kg/minute

Answer c) Stop bagging and allow the patient to exhale

This will allow the trapped gas to escape and will improve venous return. AutoPEEP should be
considered in any patient with PEA arrest after intubation. Tidal volume and frequency of ventila-
tion need to be considered when patients with obstructive airways disease are intubated or when
high minute ventilation is provided. Even people with normal lungs can develop AutoPEEP if in-
adequate time for exhalation is provided while delivering a high minute ventilation.

The BP improves to 95/65. Which ONE of the following ventilator settings would be MOST AP-
PROPRIATE for this patient (60 kg)?

a) Volume assist-control with respiratory rate 22, tidal volume 400mL, PEEP 5 cm H2O, FIO2 1.0

b) Volume assist-control with respiratory rate 12, tidal volume 500mL, PEEP 5 cm H2O, FIO2 0.6

c) Volume assist-control with respiratory rate 20, tidal volume 700mL, PEEP 5 cm H2O, FIO2 0.6

d) Pressure assist-control ventilation with respiratory rate 15, inspiratory pressure of 25 cm H2O,
inspiratory to expiratory (I:E) ratio 1:1, PEEP 5 cm H2O, FIO2 1.0

Answer: b) Volume assist-control with respiratory rate 12, tidal volume

500mL, PEEP 5 cm H2O, FIO2 0.6
Principles of ventilation in patients with obstructive disease
• Increase the I: E ratio
• Slow rate (faster rate= less “E” time)
• Increased inspiratory flow (shorter “I“ time means longer “E” time!)
• Smaller tidal volumes (less to expire)
• Titrate oxygen to saturation >90-92%
• Try to reduce autoPEEP
• Longer “E” time (see above)
• Bronchodilators
• Bigger ETT
• Tolerate hypercapnia

Feedback on Mechanical Ventilation 4

In volume assist-control ventilation (not pressure regulated), if the respiratory rate is set at 16
breaths per minute and tidal volume 600 mL, what ONE statement is TRUE of the tidal volume
delivered if the patient’s measured respiratory rate is 22 breaths per minute?

a) 600 mL every breath

b) 600 mL during the 16 set breaths and the rest determined by patient effort

c) Tidal volume will be determined by patient effort each breath

d) Tidal volume will vary depending on lung compliance

Answer: a) 600 mL every breath

Assist control
• all demands from the patient trigger
the ENTIRE preset tidal volume.
• Preset volume given at regular intervals
if no patient interaction
• Trigger- Time or (if patient interacting)
pressure or flow
• Limit-Pressure
• Cycle-Volume

Feedback on Mechanical Ventilation 5

After 3 days of mechanical ventilation, the patient is awake, follows commands, and has an ade-
quate cough reflex. She is placed on continuous positive airway pressure (CPAP) of 5 cm H2O. After
one minute she has a respiratory rate of 20 and tidal volume of 300mL.

Of the following options, which ONE would be the MOST APPROPRIATE plan for the day regard-
ing mechanical ventilation?

a) Sedate the patient and resume volume assist control ventilation

b) Sedate the patient and begin pressure assist control ventilation

c) Begin a weaning trial with pressure support ventilation or a T-piece

d) Have the patient evaluated for tracheostomy

Answer: c) Begin a weaning trial with pressure support ventilation or a T-

piece
Can be useful to calculate the frequency/tidal volume ratio. In this case f/Vt ratio= 20/.3= 67

This is an encouraging number and should prompt a spontaneous breathing trial.

Evidence-based guidelines for weaning and discontinuing ventilatory support

• Chest 120 (6) December 2001, 375S-395S.

• Weaning from Mechanical Ventilation: The evidence from clinical research; Respir Care
December 2001, 46(12):1408-1415

• Criteria for weaning from mechanical ventilation. Summary, Evidence Report/Technology

Assessment http://www.ahrq.gov./clinic/mechsumm.htm

Review of Recommendations (Evidence-based guidelines for weaning and discontinuing ventilatory

support

Recommendation #2 Chest 120 (6) December 2001, 375S-395S.)

Patients receiving mechanical ventilation for respiratory failure should undergo a formal assess-
ment of discontinuation potential if there is:

1. Evidence that the underlying cause has improved

2. PaO2/FiO2 >150-200; PEEP < 5-8, and pH >7.25

3. Hemodynamic stability (no myocardial ischemia and no or only low dose vasopressors)

4. Ability to initiate an inspiratory effort

Some patients may be ready to attempt discontinuation before all the above are met!

Feedback on Mechanical Ventilation 6

Recommendation #3 Chest 120 (6) December 2001, 375S-395S.)

• Formal discontinuation assessments of mechanically ventilated patients should be per-

formed during spontaneous breathing.

• Criteria for SBT are respiratory pattern, adequacy of gas exchange, hemodynamic stabil-
ity, and subjective comfort.

• Tolerance of SBT of 30-120 min should prompt consideration of permanent ventilator

discontinuation.

• An initial brief trial of spontaneous breathing can be used to assess potential for formal
Spontaneous breathing trial (SBT).

• Frequency/tidal volume ratio should be assessed during initial brief trial

Weaning prediction- Dr. Martin Tobin’s take (Tobin MJ, Jubran A. Variable performance of
weaning-predictor tests: role of Bayes’ theorem and spectrum and test-referral bias. Intensive Care
Med 2006; 32(12):2002-12)

• Interpretation of a diagnostic test depends on PRE-TEST Probability of disease

• Testing gives us the most information when pre-test probability around 50%

• Most studies of weaning predictors have occurred in patients with pre-test probabilities of
75% or greater!

• First screening test- f/Vt ratio

• High sensitivity test needed- 0.9 or higher reported

• Works best if pre-test probability of weaning success around 50%

• Second test- T piece trial

• High specificity needed

• 15-20% reintubation rate reported after t-piece trial. True negative rate NOT known as
would have to extubate patients who fail trial

• Third test- extubation

Alternate approach- just do a spontaneous breathing trial (SBT)

• Efficacy and safety of SBT may make most predictors unnecessary

• SBT is the most direct way to assess patient’s performance.

• Unnecessary prolongation of failing SBT could precipitate muscle fatigue, hemodynamic

instablility, discomfort, or worsened gas exchange.

• No data showing SBT’s contribute to adverse outcomes if terminated promptly when failure
recognized.

Feedback on Mechanical Ventilation 7

How do you conduct a Spontaneous Breathing Trial?

• Initial Tobin study used a t-piece

• Subsequent trials have been done using the ventilator on CPAP or CPAP+PSV.

• My recommendation

• Do NOT do SBT with PSV or CPAP/PEEP applied

• Can do on ventilator with flow triggering BUT no PEEP, no PSV!

WHY? (Adapted from Tobin’s chapter on Weaning in his Text MECHANICAL VENTILATION)

• It is an oxymoron to refer to SBT with PS of 5-10 cm H2O as “unassisted”!

• No method has EVER been reliably shown to estimate the amount of PS needed to compen-
sate for ET resistance in individual patients.

• PSV application during SBT ignores known increase in resistance post extubation secondary
to airway edema/inflammation from ETT

Nathan et al. Chest 1993; 103:1215-19 Measured WOB in several conditions

• WOB higher with extubation than with ETT in 6/7 patients studied!

ETT resistance (Straus et al Am J Respir Crit Care Med 1998; 157:23-30)

• No difference in
Work of breathing
with extubation.
• Suggests any addi-
ton of PSV will
underestimate
WOB post extuba-
tion

Feedback on Mechanical Ventilation 8

PSV affects WOB-with and without ETT

Mehta et al Crit Care Med 2000; 28:1341-46

• PSV 5 underestimates post extubation WOB by 36%

• CPAP 5 underestimates WOB by 23%

Kuhlen et al Eur J Anesth 2003; 20:10-16

• 30 minute periods

• PSV 7 and PEEP 7

• ATC and PEEP 8

• PSV REDUCED WOB during SBT

Feedback on Mechanical Ventilation 9

Case 2

A 29-year-old (60kg) female is found unresponsive in a city park after ingesting an unknown sub-
stance. The patient is resuscitated and intubated in the field by EMS. On arrival to the ER, the pa-
tient’s temperature is 38.4°C, HR is 110, and BP is 130/78. Thick sputum is being suctioned from the
endotracheal tube. Lung exam reveals crackles in the right lower chest without wheezes. Heart sounds
are normal, and urine output is adequate. A chest radiograph shows a dense infiltrate in the right
lower lobe.

The patient is placed on synchronized intermittent mandatory ventilation (SIMV) with tidal volume
450 mL, set respiratory rate 16 breaths/minute, PEEP 5 cm H2O, and FiO2 0.40. On these settings, the
patient’s respiratory rate is measured at 30 breaths per minute. An arterial blood gas reveals: pH 7.45,
PaCO2 34 mm Hg, PaO2 50 mm Hg, and SaO2 83%. The FiO2 is increased to 1.0, and an ABG done 30
minutes later shows: pH 7.43, PaCO2 36 mm Hg, PaO2 55 mm Hg, and SaO2 89%. The patient’s meas-
ured respiratory rate is unchanged.

Case 2 Questions
The PRIMARY physiologic abnormality accounting for the hypoxemia is:

a) Excessive dead space ventilation

b) Low cardiac output

c) Intrapulmonary shunt

d) Hypoventilation

Answer: c) Intrapulmonary shunt Causes of hypoxemia

• Alveolar Hypoventilation ( Low VA )

100% O2
• Ventilation / Perfusion Mismatch

• Right to Left Shunts

• pulmonary
CO2 = 20 vol % CO2 = 14 vol % • cardiac

CO2 = 20 + 14 • Reduced Diffusion

2
= 17 vol %
• Low alveolar PAO2

• altitude
Response to oxygen differentiates shunt
from V/Q mismatch. Shunt is not improved • equipment failure
by oxygen. V/Q mismatch is.

Feedback on Mechanical Ventilation 10

Which ONE of the following is TRUE of synchronized intermittent mandatory ventilation (SIMV)?

a) The tidal volume of patient triggered breaths above the set rate is determined by the set tidal
volume

b) The tidal volume of patient triggered breaths above the set rate is determined by patient effort

c) The tidal volume of each breath is determined by patient effort

d) SIMV is a form of pressure-cycled ventilation

Answer: b) The tidal volume of patient triggered breaths above the set rate
is determined by patient effort
IMV=AC if no patient interaction with the ventilator- set tidal volume at regular intervals deter-
mined by the set rate.

When the patient starts to interact with the ventilator IMV differs from AC in that the spontane-
ous breaths on IMV are taken by the patient with no support from the ventilator. If the patient
makes a big effort they are rewarded with a big breath. If they take a small effort they get a small
breath. The “S” in SIMV means the machine attempts to synchronize a ventilator breath with a
patient effort.

Later that night, a nurse calls you over to examine the patient because her O2 saturation has
fallen over the past 5 minutes from 94 to 80% despite an increase in FiO2 to 1.0 (100% oxygen). You
notice that breath sounds are audible bilaterally but decreased symmetrically, and there is no
wheezing present. Peak airway pressure has increased to 65 cm H2O (from 40 cm H2O) but plateau
pressure is relatively unchanged at 25 cm H2O. Measured respiratory rate is now 42, her heart rate
is 110, and her BP is 150/85.

What ONE intervention would be MOST LIKELY to improve the physiologic process causing the
patient’s hypoxemia?

a) Emergent needle decompression of presumed pneumothorax

b) Emergent tissue plasminogen activator (tPA) followed by heparin

c) Suctioning followed by change of the endotracheal tube if no improvement

d) Bronchodilators followed by IV solumedrol

Answer: c) Suctioning followed by change of the endotracheal tube if no

improvement
This is the classic description of an obstructed endotracheal tube. A high airway pressure algo-
rithm needs to be rapidly performed to rule out problems with the ventilator, the endotracheal
tube and finally the patient.

Feedback on Mechanical Ventilation 11

Approach to high ventilator pressures in an intubated patient
• Remove from ventilator and ventilate manually with ambu bag

• Eliminates ventilator/tubing as causes

• If still hard to bag then check depth of ETT and pass suction catheter

• Looking for R Mainstem intubation or ETT obstruction

• If ETT obstructed-remove!

• If still hard to bag and ETT depth OK with easy passage of suction catheter, then problem is with
PATIENT

• bronchospasm, pneumothorax, low compliance, foreign body

After you perform the proper intervention, the patient stabilizes. Gradually over the next three days
her oxygenation improves. The patient is changed to pressure support ventilation with inspiratory
pressure of 20 cm H20 and PEEP of 5 cm H20.

Which ONE of the following is TRUE regarding the patient’s respiratory status on pressure sup-
port ventilation (PSV)?

a) Tidal volumes will be the same with each breath

b) Minute ventilation will be constant

c) Minute ventilation will vary according to her strength and effort

d) Inspiratory to expiratory (I:E) ratio is set by the physician

Answer: c) Minute ventilation will vary according to her strength and ef-
fort
No set rate or tidal volume on PSV- these vary with patient effort. PSV in a mode TRIGGERED by
patient effort (pressure or flow), LIMITED by pressure; and CYCLED by flow (usually when flow
drops to 25% of initial flow the ventilator cycles off to allow exhalation).

Feedback on Mechanical Ventilation 12

Case 3

A 56 year-old female with diabetes mellitus is brought to the emergency room with a 3-day history
of dysuria and low back pain. In the emergency room, she is obtunded and tachypneic. Her tem-
perature is 38.9°C, RR 28, HR 120, BP is 80/50, and her ideal weight is 60 kg. The patient has dry
mucous membranes and brisk capillary refill. Faint bilateral inspiratory crackles are heard on lung
exam, and the cardiac exam is significant only for tachycardia. Abdominal exam is unremarkable.
No pedal edema is seen. The white blood cell count is 13,000 per mL and urinalysis reveals
>100,000 WBCs with many bacteria. A chest radiograph demonstrates bilateral interstitial infil-
trates without effusions. An ABG taken while the patient is breathing 100% oxygen by facemask
reveals a pH of 7.30, PaCO2 25 mm Hg, PaO2 62 mm Hg, and SaO2 90%. As IV fluids and antibiotics
are begun, it is felt that ventilatory support is indicated.

Case 3 Questions
Which ONE of the following would be the MOST APPROPRIATE form of ventilatory support at
this time?

a) Noninvasive positive pressure ventilation (BiPAP) by face mask

b) Intubation and volume assist-control ventilation, respiratory rate 20, tidal volume 360 mL

c) Intubation and intermittent mandatory ventilation, respiratory rate 20, tidal volume 700 mL

d) Intubation and volume assist-control ventilation, respiratory rate 20, tidal volume 700 mL

Answer: b) Intubation and volume assist-control ventilation, respiratory

rate 20, tidal volume 360 mL
At the time of the Cox paper this was one of the poorly answered questions as the “lung protective
strategy” advocated by the ARDSnet trial (N Engl J Med 2000 342:1301-8) was not fully imple-
mented. Implementation has proceeded since then and more physicians should be aware of this
strategy. This patient has ARDS- acute onset, diffuse infiltrates on chest radiograph, poor PaO2/
FiO2 ratio (<200), and no evidence that the findings can be explained by hydrostatic (high pressure)
pulmonary edema. Ware LB, Matthay MA N Engl J Med 2000 342:1334-49

ARDSnet-Lung protective
ventilation

• Tidal volume 6 ml/kg PRE-

DICTED body weight
• Plateau pressure <30

Image from: Malhotra A. N Engl J Med 2007; 357:1113-20

Feedback on Mechanical Ventilation 13

ARDSnet results- ARR of 8.8% with low tidal volumes

from: N Engl J Med 2000 342:1301-8

On hospital Day 2, she is being managed on a volume assist-control mode of ventilation. Blood
pressure is 100/70 and HR is 90. While sedated, her peak airway pressures are 40 cm H2O and pla-
teau pressures are 24 cm H2O. On a FiO2 of 0.60 and PEEP of 5.0, an ABG reveals a pH 7.28, Pa-
CO2 36 mm Hg, PaO2 of 55 mm Hg, and SaO2 85%.

Which ONE of the following would be the MOST APPROPRIATE next measure?

a) Increase the FiO2 to 0.80

b) Increase the tidal volume by 100 mL from your initial setting

c) Increase the rate by 4 breaths per minute from your initial setting

d) Increase the PEEP to 10 cm H2O

Feedback on Mechanical Ventilation 14

Answer: d) Increase the PEEP to 10 cm H2O
Not meeting oxygenation objectives and plateau pressure still less than 30 cm. Even if plateau
pressure increased 5 cm H2O with addition of 5 cm H2O PEEP plateau pressure would still be <30.
PEEP would help recruit more lung and improve the FRC.

ARDSnet ventilation strategy N Engl J Med 2000 342:1301-8

• Reduce tidal volume to 6 ml/kg PREDICTED body weight

• Keep plateau pressure <30 cm H2O

• Study used ladder of PEEP/FiO2 combinations to keep SaO2>90

• Increase PEEP to 10 cm H2O would be next step on the ladder

• Study used weaning protocol (SBT)

Effect of PEEP on lung recruitment

Image from: Malhotra A. N Engl J Med 2007; 357:1113-20

Which ONE of the following interventions would PROLONG the expiratory phase (“E time”) of a
patient receiving volume assist-control mechanical ventilation?

a) Increase respiratory rate

b) Increase inspiratory flow rate

c) Increase PEEP

d) Increase tidal volume

Feedback on Mechanical Ventilation 15

Answer: b) Increase inspiratory flow rate
Higher inspiratory flow means a shorter inspiratory time (Ti) which must result in a longer expira-
tory time (Te).

Several days later in the patient’s course, she was being managed on pressure assist-control ventila-
tion with a respiratory rate of 18, a PEEP of 12 cm H2O and total inspiratory pressure 30 cm H2O.
The inspiratory to expiratory (I:E) ratio is 1:1. Initially on these settings, measured tidal volumes
averaged 400 mL. Two days later on the same settings, the measured tidal volumes now average 500
mL

Which ONE of the following is the MOST LIKELY explanation for the change in tidal volume?

a) Increased respiratory effort by the patient.

b) Increased lung compliance

c) Increased dead space ventilation

d) Air trapping leading to increased intrinsic PEEP (“auto-PEEP”).

Answer: b) Increased lung compliance

Overall condition is improving and the lung is “less stiff” or “more compliant”. This means for the
same applied pressure a larger volume can be accommodated.

Crs, eff = VT / (Pplat – PEEPTot)

PEEPTot = PEEPapplied + PEEPi

ignoring PEEPi can underestimate Crs by
100%

Normal: 0.06 – 1.0 L/cmH2O

ARDS: 0.035 L/cmH2O
COPD: 0.056 L/cmH2O

On Hospital Day 14, the patient is afebrile, hemodynamically stable, and has a central venous pres-
sure (CVP) of 12. She has been managed with volume assist-control ventilation for the past 7 days
and currently is receiving a tidal volume of 360 mL, respiratory rate of 24 breaths per minute,
PEEP of 15 cm H2O, and FiO2 0.5. An ABG at this time reveals: pH 7.35, PaCO2 50 mm Hg, PaO2 90
mm Hg, and SaO2 97%. Serum HCO3 is 27 mEq/L. Peak pressure is 48 cm H2O and plateau pres-
sure is 38 cm H2O.

Feedback on Mechanical Ventilation 16

Which ONE of the following would be the MOST APPROPRIATE intervention at this time?

a) Decrease PEEP

b) Begin an infusion of NaHCO3

c) Increase tidal volume

d) Give IV furosemide

Answer: a) Decrease PEEP

ARDSnet Goals

• Tidal volume 6 ml/kg PBW

• Plateau pressures <30 cm H2O

• PEEP/FiO2 ladder to avoid toxic FiO2

In this case oxygenation has improved but the pressure goals are not being met and the plateau
pressure is too high. A PEEP of 15 cm H2O is excessive for the current PaO2/FiO2 ratio. Reducing
PEEP by 8 cm H2O would reduce the plateau pressure to 30 cm H2O. The ARDSnet ladder of com-
binations of PEEP and FiO2 would also support lowering PEEP level.

On hospital Day 21, a tracheostomy is performed at the bedside without complication. That night,
after being turned during a bath, the peak pressure alarms on the ventilator are heard and a de-
creased SaO2 is noted on the monitor. On exam, the patient is in respiratory distress and is tachy-
cardic. The tracheostomy tube appears dislodged from its original position. Lung exam reveals lim-
ited breath sounds bilaterally without wheezes. The patients’ neck appears swollen, and the skin of
the neck and upper chest is crepitant to touch.

Which ONE of the following is the MOST APPROPRIATE immediate intervention?

a) Call for a stat portable chest radiograph

b) Place bilateral chest tubes

c) Attempt to replace the tracheostomy tube

d) Remove the tracheostomy tube and place an oral endotracheal tube

Answer: d) Remove the tracheostomy tube and place an oral endotracheal

tube
Fresh Trach
• Safest course is to intubate from above

• Risk of creating false passage with attempts to reinsert

• Reinsertion should only be attempted with direct vision

Feedback on Mechanical Ventilation 17

Case 4

A 35-year-old female (60 kg) with asthma is intubated on arrival to the ER for respiratory distress.
The ventilator mode is volume assist-control; settings are FiO2 0.6 (60% oxygen), tidal volume 500
mL, PEEP 5 cm H2O, set respiratory rate of 22 breaths/minute, inspiratory flow of 80 L/min. The
patient is heavily sedated and not breathing over the set rate. Fifteen minutes after intubation, an
ABG shows: pH 7.22, PaCO2 60 mm Hg, PaO2 85 mm Hg, and SaO2 95%. Peak inspiratory pressure
is 70 cm H2O and plateau pressure is 40 cm H2O. Her blood pressure is 85/60 and decreasing. The
heart rate has increased to 120 (from 95 earlier).

Case 4 questions
What SINGLE intervention would be MOST APPROPRIATE right now?

a) Decrease respiratory rate to 12 breaths per minute

b) Increase PEEP to 15 cm H2O

c) Increase tidal volume to 600 mL

d) Decrease FiO2 to 0.3 (30%)

Answer: a) Decrease respiratory rate to 12 breaths per minute

Need to lengthen the expiratory time for this patient with reactive airways disease. The current
settings do not give her adequate time to exhale and she is has AutoPEEP or dynamic hyperinfla-
tion with decreased venous return. The only choice of the 4 provided that would lengthen expira-
tion is to decrease the respiratory rate. All other choices will either WORSEN the situation (In-
creased PEEP, increased tidal volume) or effect no change (increased FiO2).

How would you quantify the amount of “auto-PEEP” present in a patient (who is sedated and para-
lyzed)?

a) Measure airway pressure during a 1.0-second pause at the end of inspiration (and subtract set
PEEP)

b) Measure airway pressure during a 1.0-second pause at the end of expiration (and subtract set
PEEP)

c) Subtract the plateau pressure from the peak inspiratory pressure

d) Multiply flow rate times the tidal volume

Answer: b) Measure airway pressure during a 1.0-second pause at the end

of expiration (and subtract set PEEP)

Feedback on Mechanical Ventilation 18

This is the classically described technique for measurement of autoPEEP and is illustrated in the
left diagram below. The diagram on the right shows an alternate technique that can be used.

On the morning of the second day of mechanical ventilation while heavily sedated, the patient’s
SaO2 decreases suddenly from 96 to 84% and her BP falls from 118/76 to 90/55. Peak airway pres-
sure has increased from 40 cm H2O to 75 cm H2O and the plateau pressure has increased from 28
cm H2O to 50 cm H2O. The patient remains sedated. On lung exam wheezes are present. Good air
movement is present on the left side, although somewhat decreased air movement is noted on the
right. Heart sounds are distant and regular.

Which ONE of the following is the MOST LIKELY explanation for this change in airway pres-
sures?

a) Occlusion of the endotracheal tube

b) Increased bronchospasm

c) Patient-ventilator asynchrony

d) Tension pneumothorax

Answer: d) Tension pneumothorax

Classic description! Both peak and plateau pressures affected, clinical signs supportive and hemo-
dynamic compromise. This patient needs urgent treatment of the tension pneumothorax.

Feedback on Mechanical Ventilation 19