Mechanical Ventilation Questions

1. A 68-year-old man with a history of COPD (FEV1 and PaCO2 measured under
stable conditions of 550 mL and 58 mm Hg, respectively) is admitted with a 3-
day history of increasing cough, purulent sputum, and dyspnea. His only
medications are an inhaled beta-2 agonist and an inhaled anticholinergic agent.
The patient weights 65 kg. His temperature is 38.3 C, his respiratory rate is
28/min, he has an irregular heart rate of 120/min, and a blood pressure of 100/65
mm Hg. He is using his accessory muscles of respiration and appears anxious.
Heart sounds are diminished and breath sounds are decreased bilaterally. His
chest x-ray shows hyperinflation but no evidence of pneumonia, heart failure,
pneumonthorax, or rib fracture. Arterial blood gases drawn on 5 L/min of nasal
oxygen show a pH of 7.22, a PaCO
2
of 74, mm Hg and a PaO
2
of 92 mm Hg. The
ECG shows multifocal atrial tachycardia.

1a. All of the follow would be expected to lower his PaCO
2
except?
a. Reducing the FiO
2

b. Applying a continuous positive airway pressure (CPAP) mask
c. Applying noninvasive positive pressure ventilation (NIPPV)
d. Administering a benzodiazepine
e. Administering acetaminophen

1b. Which of the following is least likely to be contributing to the increased
PaCO
2
?
a. Increased resistive work of breathing
b. An inspiratory threshold load induced by autoPEEP
c. Pulmonary shunt
d. Mechanically disadvantaged respiratory muscles
e. Excessive dead space

1c. All of the following effects of NIPPV have been demonstrated in patients
with COPD except?
a. Increases personnel costs by roughly 50%
b. Reduces the frequency of pneumonia
c. Reduces mortality
d. Reduces the frequency of intubation
e. May reduce cardiac output










1d. Which of the following represents the best mode of ventilatory support in this
patient?
a. Intubation; volume assist-control ventilation; tidal volume of
approximately 12 mL/kg; respiratory rate of 8; no PEEP
b. Intubation; synchronized intermittent mandatory ventilation; adjust
to provide 50% of his required minute ventilation; PEEP 5 cm H
2
O
c. Intubation; pressure-control ventilation; IPAP 30 cm H
2
O; EPAP 5
cm H
2
O
d. NIPPV; pressure-support ventilation; IPAP 15 cm H
2
O; EPAP 5
cm H
2
O
e. NIPPV; pressure-support ventilation; IPAP 25 cm H
2
O; EPAP 0
cm H
2
O

Despite your management the patient fails to improve, but by evening you leave him
stabilized treated with bronchodilators; and intubated, on these settings : volume assist-
control; V
T
400 mL; RR 22; PEEP 2 cm H
2
O; FiO
2
0.4, and he is comfortable and
passive. You are next called at 2:00 AM because, while being moved onto a bedpan, the
patient became abruptly agitated, using all accessory muscles, and much more
tachycardic. The nurse reports that during hand-bagging the patient became comfortable
once again, but that upon returning him to the ventilator, he quickly became agitated. On
examination, you find that the patient is diaphoretic with symmetrical but diminished
breath sounds. He is working hard to breathe but the ventilator seems not to respond to
his efforts. A suction catheter can be passed readily down the ETT.

1e. Which of the following would be the most appropriate intervention?
a. Prescribe benzodiazepines
b. Prescribe benzodiazepines and a paralytic agent
c. Prescribe heparin, 80 U/kg, and request an urgent helical CT
angiogram
d. Increase the level of PEEP
e. Change from assist-control mode to pressure-support mode

2. A 23-year old woman is admitted following multiple gunshot wounds to the
abdomen. She is now s/p surgery to repair multiple bowel perforations and to
stanch hepatic hemorrhage. Her predicted body weight is 60kg. On examination
the BP is 115/70; HR 118, RR 16, and she is sedated and paralyzed. There are
diffuse crackles and her abdomen is firm and distended. Chest radiograph shows
small lungs and subtle, diffuse infiltrates. Ventilator settings are SIMV 16; V
T

0.8; PEEP 5 cm H
2
O, FiO
2
1.0; inspiratory flow rate 50 lpm; and the peak and
plateau airway pressures are 48 and 43 cm H
2
O, respectively, The PaO
2
is 67 mm
Hg; PaCO
2
41 mm Hg; pH 7.31.



2a. Which of the following ventilator adjustments should be made first?
a. Change the mode to volume assist-control
b. Lower the tidal volume and increase the rate
c. Change to pressure control with IPAP 40 cm H
2
O; EPAP 5 cm H
2
O
d. Raise the PEEP
e. Lower the FiO
2
to 0.6

2b. Which are most likely dominant contributors to the elevated peak airway
pressure?
a. The high inspiratory flow rate and elevated airway resistance
b. Pulmonary edema and the high FiO
2

c. The PEEP combined with acute lung injury
d. Occult autoPEEP and tidal volume
e. Acute lung injury and abdominal distension

2c. Which of the following have been shown in ARDS?
a. Use of lower PEEP is associated with enhanced survival.
b. Use of a liberal fluid strategy is associated with improved survival.
c. Use of steroids in the fibroproliferative phase is associated with
enhanced survival.
d. Permissive underfeeding increases ventilator-free days
e. ARDS mortality is decreasing

2d. Which of the following is least likely to improve her oxygenation
substantially?
a. Inverse ratio ventilation
b. Raising the tidal volume
c. Increased PEEP
d. Prone positioning
e. Administration of inhaled nitric oxide

3. Which combination of ventilator mode and end-inspiratory alveolar pressure is
represented in this flow and pressure waveform?


a. Volume control; Palv = 30
b. Pressure control; Palv = 30
c. Volume control; Palv = 40
d. Pressure control; Palv = 40
e. Pressure control; Palv = 25

4. A 32-year-old man with morbid obesity (420 lbs/191 kg) is admitted with
Fourniers gangrene of the perineum. Two days following debridement, he is
hemodynamically stable, alert, afebrile, and has VO
2
= 285 mL O
2
/min by
metabolic cart. CXR shows small but clear lungs. Ventilator settings are volume
assist-control; V
T
0.45; FiO
2
0.4; and PEEP 12 cm H
2
O. ABG shows PaO
2
71
mm Hg; PaCO
2
35 mm Hg; pH 7.42. His spontaneous tidal volume is 0.34; RR =
29 (f/V
T
= 85) but when PEEP < 12 cm H
2
O, his SpO
2
falls below 0.88.

Which of the following is indicated?
a. Extubate the patient
b. Begin albuterol nebulizer treatments
c. Sedate, reduce the V
T
and reassess daily
d. Change the enteral nutrition formula to reduce the respiratory quotient
e. Change to SIMV, then reduce the rate by 2 every 2 hour

5. Match the choice of tidal volume and patient activity with the flow and pressure
waveforms.

a. V
T
= 480 cc; active patient
b. V
T
= 480 cc; passive patient
c. V
T
= 680 cc; active patient
d. V
T
= 680 cc; passive patient