Question

MANAGE THIS PATIENT OBJECTIVE: Provide initial ventilator settings from the guidelines for patient management for any of the following patient conditions: chronic obstructive pulmonary disease (COPD). A 65-year-old man with a history of COPD is brought to the emergency department (ED) complaining of severe shortness of breath. The following information was obtained during an initial patient assessment. The SpO2 of 75% obtained while he was breathing room air is very low. Because pulse oximetry may be inaccurate in this range, an ABG was obtained. A 28% air-entrainment mask was placed on the patient. A sputum specimen is sent to the laboratory for culture and sensitivity testing. Initial Patient Assessment on Admission: History of COPD The patient is a retired salesman and lives at home with his wife. He has a 40-pack-per-year history of cigarette smoking. Mental Status • Alert and oriented but shows signs of fatigue • Speaks in halting sentences and appears to be catching his breath between efforts to talk Physical Appearance • Tall and thin • Barrel chest • Pale skin • Pitting edema of the ankles • Prolonged expiration through pursed lips with labored breathing • Sitting in a chair, leaning forward with his arms on the chair arms • Active use of the sternocleidomastoid muscles Vital Signs • f = 35 to 40 breaths/min • Heart rate = 135 beats/min • Blood pressure = 185/110 mm Hg • Temperature = 98.6° F Breath Sounds • Bilateral wheezes, crackles in the bases, hyperresonance to percussion bilaterally Cough • Weak, producing a moderate amount of thick, yellow secretions SpO2 • 75% on room air Chest Radiograph Increased bilateral radiolucency, flattened diaphragm, widened rib spaces; scattered infiltrates in both bases. The infiltrates in the lower lung fields and the production of thick yellow sputum suggest the presence of a respiratory infection, but the absence of an elevated temperature is confusing. (NOTE: Elderly patients, particularly those with chronic health problems, do not always develop a fever. If patients take aspirin or nonsteroidal or steroidal antiinflammatory medications, an elevated temperature may be masked.)The patient is given an aerosol treatment with albuterol by small-volume nebulizer followed by an aerosolized mucolytic. He does not tolerate the treatment well and is unable to take a deep breath or perform a breath-hold maneuver. His dyspnea persists. 1) His dyspnea persists. ABGs on an FIO2 of 0.28 are pHa = 7.24; PaCO2 = 97 mm Hg; PaO2 = 38 mm Hg; and HCO3 − = 41 mEq/L. The ABGs indicate chronic CO2 retention (elevated HCO3 − ) that has now progressed to an acute-on-chronic phase (elevated PaCO2 and low pH). VT=548ml, RR 35bpm, Calculate the:Show your work

1. Total Cycle time

2. I:E ratio

3. Ti

4. Te

5. The flow you need to get the desired I:E

Answer 1

1. The whole breath includes both the inspiration and expiration time along with any pauses in between. Dividing 60 second by the respiratory rate of a patint gives the total cycle time.For this patient 60 devided by the average respiratory rate ie, =1.58 seconds.

2. Inspiration Expiration Ratio is calculated from the total Cycle time in this case 1second for inspiration and 58 second for expiration( In normal it is 1: 3-4)

3. Ti- inspiratory time that is1 second for this patient

4. Te- Expirtory Time is 58 sec

5. I:E rato is 1:4