Question

Mr. C., age 68 with a history of COPD, presented in the emergency department 2 days ago febrile with a productive cough of large amounts of purulent sputum and in acute respiratory failure. He was diagnosed with community-acquired pneumonia and treated with antibiotics, hydration, aggressive pulmonary hygiene, and supplemental oxygen therapy. Although his oxygenation improved, he continued to be diaphoretic, using accessory muscles of respiration and complaining, "I am exhausted" and "I can't get enough air." Arterial blood gas revealed: pH 7.31, PaCO2 59 mm Hg, PaO2 89 mm Hg, SaO2 91%, HCO3 29 mEq/L. The decision was made to intubate and place him on mechanical ventilation with the following settings: assist control (AC) mode, tidal volume (VT) 625 mL, respiratory rate 16 breaths/min, FiO2 0.70, and 5 cm H2O of positive end-expiratory pressure (PEEP). He was transferred to the critical care unit.

Two days later, his presentation at 0500 is as follows:

• Ventilator settings: Mode AC, V_T625 mL, respiratory rate 12, FiO₂35, 5 cm H2O PEEP
• Total RR 16, peak inspiratory pressure (PIP) 22 mm Hg
• Moderate amounts sputum, rhonchi that clear with coughing, chest x-ray shows clearing pneumonia
• Negative inspiratory force ­-37 cm H₂O, spontaneous tidal volume 5 mL/kg, vital capacity (VC) 10 mL/kg, minute ventilation 10 L/min, rapid shallow breathing index of 37
• Temperature 99.0° F oral, heart rate 86 beats/min, blood pressure 132/84 mm Hg
• No vasopressor or inotropic agents, urinary output is good, NPO since admission.
• Alert and oriented to person, place and situation, hypervigilant and restless, has not slept well since admission

The team decides to perform a ventilator weaning trial. At 0620 Mr. C. is placed on 10 cm H₂O of pressure support with an FiO₂ 0.40.
Assessment at 0720 is as follows:

• Heart rate 108 beats/min
• Blood pressure 157/90 mm Hg
• Respiratory rate 36 breaths/min and labored
• SpO₂90%

He is diaphoretic and alternates between picking at his gown and falling asleep and needing to be aroused to stimulate breathing. He is placed back on the ventilator at the previous settings.
Late that morning, during rounds, Mr. C. is started on nutritional support via tube feeding and given trazodone at night for sleep. He is allowed a morning nap and has physical therapy that afternoon.

The following day he passes the pre-wean screening and is again placed on PS 5 above 5 cm H₂O PEEP. Assessment findings 30 minutes into the weaning trial are as follows:

• Heart rate 84 beats/min
• Blood pressure 120/76 mm Hg
• Respiratory rate 18 breaths/min, unlabored
• SpO₂96%

Mr. C. is calm, cooperative, and oriented, so the weaning trial is continued for 90 minutes. Arterial blood gas results were pH 7.34, PaCO₂ 48 mm Hg, PaO₂ 74 mm Hg, HCO₃ 24 mEq/L, and SaO₂ 95%. The decision was made to extubate, and the patient was discharged from the critical care unit the following day.

Please answer the following questions concerning Mr. C.

1. How long does a weaning the trial last?
2. Is Mr. C. tolerating weaning, and how do you know?
3. What interventions are indicated?

Answer 1

1. The term weaning is used to describe the gradual process of decreasing ventilator support.Spontaneous breathing trail assesses the patient's ability to breathe while receiving minimal or no ventilator support.Average time to ventilator liberation varies with the severity and type of illness or injury,but typically orange from 16 to 37 days after intubation for respiratory failure. If the patient failed to wean from ventilator dependence within 60 days. Once meeting the liberation criteria,a spontaneous breathing trail should be conducted before determining whether extubation can occur.Generally Spontaneous breathing test that is weaning trail period should last from 30 to 120 minutes. To start weaning patient want to meet liberation criteria that is. *Glasgow coma scale score should be 13 or more. *Oxygen saturation should be above that is SaO2more than 90% and PaO2 above 60 mm of hg. *PEEP should be in range of 5 to 8 cm of water. * Carbon dioxide level That is PaCO2 less than 69 mm of Hg. *Ph level should be more than 7.25 .

2. Mr.C is tolerating weaning. That can be determined by assessing extubation criteria. Mr. C meet the extubation criteria by given following values that PaO2 74 mm of hg , SaO2 95% , PaCO2 48 mm of hg, Ph range7.34. Patient was toleration ,oriented , cooperative and Calm. So we can do extubation after trial test of weaning.

3.*To do extubation first need to assess extubation criteria. *Make arrangements of Bi pap to support patient if needed partially . *Explain procedure if extubation for patient if patient was cooperative, it improve the chances of early recovery and give cooperation for care . * According to give Arterial blood gas levels of PaCO2 48mm of hg ,patient was in respiratory acidosis ,we need to provide Bi pap to reduce respiratory acidosis and need to administer Bicarbonate , so make arrangements for that. *Immediately after extubated advice patient to coughing to relieve from respiratory congestion. *Assess vital signs closely .