Page 677 - Clinical Application of Mechanical Ventilation

Case Studies 643

The F O was reduced to 50% and the patient was continuously monitored by the
I
2
Reduce F I O 2 when PaO 2 SpO and SvO measurements.
is too high. 2 2
Respiratory Care Procedures

Based on the preadmission diagnosis of complicating pneumonia, the patient was
aggressively treated with frequent suctioning, with moderate amounts of cloudy
secretions removed.
Bronchopulmonary toilet was initiated, and the patient was immediately
started on bronchodilator therapy for wheezing, with 20 puffs of Proventil® via
a metered-dose inhaler (MDI) given inline through the ventilator circuit via
Aerochamber®, and he was frequently turned from side to side to help prevent
atelectasis.

NOTE: Clinical use and evaluation of lavage must be carefully considered; i.e., see
Pedersen, C. R. (2009). Endotracheal suctioning of the adult intubated patient--what is the
evidence? Intensive and Critical Care Nursing, 25(1), 21–30. Ackerman, M. H. (1993). The
effect of saline lavage prior to suctioning. Journal of Critical Care, 2(4), 326–330.

Weaning

Two days following surgery, the patient began to breathe spontaneously and he
was changed to SIMV in an attempt to wean him from the ventilator. Initially,
his frequency was decreased to 8/min, and all spontaneous breaths were aug-
mented by 10 cm H O of pressure support. He was able to initiate 20 breaths
2
above the set frequency and maintained a tidal volume of 400 to 600 mL at
this level of support. His ventilator tidal volume was set at 1,000 mL, and over
that time his PEEP was reduced to 5 cm H O and his F O was reduced to
2
I
2
40%. As his muscular effort improved (as evidence revealed that he was able to
maintain tidal volume at progressively lower pressure support settings), the tidal
volume increased for spontaneous breaths, and his pressure support was quickly
weaned to 6 cm H O. He remained at that level throughout the day without
2
signs of fatigue, hypoxemia, tachypnea, hypertension, desaturation, or evidence
of tachycardia.
That night he was placed on assist/control in an effort to rest the muscles of in-
spiration. Weaning began at six o’clock the next morning on CPAP with pressure
support of 12 cm H O, PEEP of 5 cm H O, and F O of 40%. Spontaneous pa-
2
2
I
2
rameters obtained 2 hours later revealed:
f 5 26 V 5 12.4 L V 5 0.47 L VC 5 1.09 L
E
T
MIP of 252 cm H 2 O MIP 5 252 cm H O f/V 5 55/min/L
and f/VT of ,100/min/L 2 T
correlate with weaning
success. Based on stable spontaneous parameters and improving clinical condition, he was
removed from the ventilator and allowed to breathe on a “T-piece” at 40% F O for
2
I
4 hours. Subsequent evaluations led to successful weaning and eventual extubation.
He was placed on a nasal cannula at 6 L/min where he continued to improve until
discharge.

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