Page 651 - Clinical Application of Mechanical Ventilation

Case Studies 617

Lungs. Bilaterally diminished with scattered expiratory wheezing, bibasilar rhonchi,
and a prolonged expiratory phase.

Abdomen. Mild hepatomegaly, paradoxical movement with breathing, otherwise
unremarkable.

Extremities. Slight digital cyanosis with 12 pitting edema in both ankles.

Initial Assessment and Treatment

In the emergency room, a portable chest radiograph and arterial blood gas with
co-oximetry were obtained, the patient was placed on a 2 L/min of oxygen via nasal
cannula and given an aerosol treatment with 2.5 mg albuterol sulfate in NS. Room
air blood gas results revealed:
pH 7.32
PaCO 2 70 mm Hg
PaO 2 44 mm Hg
-
HCO 35 mEq/L
3
BE 16
SaO 2 80%
Hb 16 g/dL
HBCO 3%

The chest radiograph revealed evidence of hyperinflation, an increase in vascu-
Acute-on-chronic lar markings, and infiltrates in the RLL. Because of the patient’s clinical condition,
ventilatory failure in the COPD
patient requires immediate chest radiograph findings, and the abnormal blood gases (acute ventilator failure
medical attention. superimposed on chronic ventilatory failure), the patient was transferred immedi-
ately to the medical intensive care unit (ICU) for further evaluation and treatment.
The patient was then started on the following regimen: supplemental oxygen at
Aminophylline 2 L/min by nasal cannula, nebulized albuterol sulfate, 2.5 mg in NS Q2H, 2.5 mg/kg
(theophylline) may help to
improve diaphragmatic func- loading dose of aminophylline over 30 min, followed by a maintenance dose of
tion in the COPD patient. 0.5 mg/kg per hour IV (titrated according to serum levels), furosemide, 40 mg, IV
push, and methylprednisolone, 120 mg IV, Q6H. Sputum for Gram stain and culture
was obtained and sent to the lab. The patient was also started on a prophylactic
Corticosteroids are broad-spectrum antibiotic. The report on the Gram stain came back later and showed
only useful in the treatment
of COPD if the patient has numerous gram-positive diplococci.
evidence of reversible
airway disease.
Indications

Over the next hour, the patient’s respiratory status continued to deteriorate despite
intervention. Respiratory frequency rose to 36/min and paradoxical abdominal
motion became more pronounced. The rising frequency in conjunction with the
abdominal paradox and the increasing PaCO from the first blood gas are indica-
2
tive of increasing ventilatory fatigue. Impending acute ventilatory failure must be
assumed.

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