Page 684 - Clinical Application of Mechanical Ventilation

650 Chapter 19

Her medical history also included chronic anemia (hemoglobin 8.7 g %, normal
An iron supplement 12 to 15 g %) and was on an iron supplement at the time. Her white blood cell
is used to increase the
3
3
oxygen-carrying capacity of (WBC) count was 21 3 10 (normal 3.2 to 9.8 3 10 ), hematocrit (HCT) 27%
hemoglobin.
(female average 42%) without evidence of blood loss. Blood pressure was 93/
59 mm Hg (normal 120/80 mm Hg), HR 114/min, and spontaneous respira-
tions were shallow and guarded at 20/min. Tenderness was noted across the
Hemoglobin, WBC, HCT, upper abdomen and the lower ribs without organomegaly or other masses present.
and blood pressure are all She was 4 months postpartum with gradual onset abdominal pain, progressive
outside normal limits.
dyspnea with a nonproductive cough, and was admitted to the hospital for further
evaluations.
The patient’s nonspecific symptoms led to a wide range of diagnostic tests for
Persistent hyperventila- her condition, which included lupus, mitral regurgitation, and pulmonary insuf-
tion (PaCO 2 31 mm Hg) with ficiency. Initial blood gases on room air were obtained in the emergency room,
moderate hypoxemia (PaO 2
67 mm Hg) could lead to the patient was admitted to the medical floor, and a sputum culture was ordered to
fatigue of respiratory muscles evaluate pathology concerning the respiratory tract.
if causes of hypoxemia are
not identified and treated The initial blood gases were as follows:
promptly.
pH 7.49
PaCO 2 31 mm Hg
PaO 2 67 mm Hg
-
HCO 22.7 mEq/L
3
Hb 8.4 g %
Mode Spontaneous
FO 2 21%
I
Her breath sounds were unremarkable but she was moderately fatigued and
continued to be short of breath. She was started on a nasal cannula at 2 L/min of
oxygen and was encouraged to deep-breathe and cough. At this point, the
patient was still able to adequately ventilate as evidenced by the PaCO of
2
31 mm Hg. However, her condition deteriorated during the course of her evalua-
tion and workup. Shortly thereafter, she developed intermittent wheezing for which
albuterol nebulizer treatments were administered.

Indications

Her blood gases continued to deteriorate and on day 6, she required a non-rebreather
Impending ventilatory mask at high oxygen flow to maintain her SpO above 90%. She showed signs of
2
failure typically shows in- impending ventilatory failure evidenced by the rising PaCO and acidotic pH on
creasing PaCO 2 and decreasing 2
pH and PaO 2 . subsequent blood gases. A chest radiograph showed areas of bibasilar atelectasis and
haziness with bilateral infiltrates. No pulmonary consolidation was noted. Postural
drainage and chest physiotherapy were started to help facilitate removal of secretions,
but she was too weak to generate a productive cough and unable to contribute to her
pulmonary care.

Postural drainage and Family members refused permission to obtain a diagnostic bronchoscopy or any
chest physiotherapy were attempts at percutaneous biopsies to evaluate lung pathology. Three days later, her
done to facilitate loosening
and removal of secretions. oxygen requirements had increased to the point where she required a heated nebu-
lizer analyzed at an F O of 95% bled into her non-rebreather mask at 15 L/min,
I
2

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