You go to monitor a patient and note that the patient is slightly uncomfortable. She is...

You go to monitor a patient and note that the patient is slightly uncomfortable. She is on Pressure Assist Control with the following settings: inspiratory pressure of 15cm H2O, PEEP 5 cm H2O, FIo2 .35, and an inspiratory time of 1.2 seconds. Upon careful examination you note that there is diaphragmatic activity prior to exhalation near the end of the breath.

Question 1: What is the primary problem or issue to be addressed?

Question 2: What can you do with the ventilator to make this patient more comfortable?

The nurse calls you in to the room of a patient with chronic obstructive pulmonary disease (COPD), who appears uncomfortable and is on the following settings: PS of 8 cm H2O, Peep 5 cm H2O, and Fio2 .30. His respiratory rate is 18 and his tidal volume is 600 mL (approximately 8 mL/kg ideal body weight). You also not that his inspiratory time is about 1.6 seconds.

Question 1: What is this issue a problem to be addressed?

Question 2: What can you do with the ventilator that could make this patient more comfortable?

Expert Solution

1A. Spontaneous breathing on the ventilator relates to protective effects on ventilator-induced diaphragmatic dysfunction, which is defined as the loss of diaphragmatic force-generating capacity specifically related to the use of passive mechanical ventilation. It is characterized by structural damage to muscle fibers from oxidative stress, mitochondrial dysfunction, and lipid accumulation as well as muscle atrophy.16 Atrophy from prolonged inactivity heavily affects the most active skeletal muscles and respiratory muscles are susceptible to disuse atrophy given their constant high activity levels.

1B. Change the settings of the ventilator to SIMV mode .

2A. When ventilating patients with COPD, a smaller VT, slow RR, high peak flow should be used with an aim to target normal pH and not PaCO2 (permissive hypercapnia). PEEP setting start at 5 cm H2O, and keep a watch at Pplat or PIP and haemodynamics.

2B. NPPV is widely accepted as the first choice of ventilator setting in a COPD patient.

Nightingale answered 2 years ago

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