Page 693 - Clinical Application of Mechanical Ventilation

Case Studies 659

Vital signs revealed: heart rate 76/min, temperature 38°C, blood pressure 120/74
mm Hg. The patient tolerated two trials of CPAP/PS at previous settings for 2 hours
each time. Breath sounds were markedly decreased in both lower lobes. Patient was
very anxious, restless, and had difficulty sleeping at night. He was started on Ativan
for his anxiety. A feeding tube was ordered and placed for total nutrition.
(Day 5) He was rested overnight on CMV. Spontaneous parameters were: V 12.9
E
L, V 720 mL, f 18/min, MIP 229 cm H O, and VC of 3.4 L. Patient had a repeat
T
2
endoscopy and was heavily sedated. A CPAP/PS trial was done before the patient
was sedated. The spontaneous frequency was between 15/min and 17/min and the
spontaneous tidal volume was in the low 400 mL range. Patient’s vital signs were:
heart rate 73/min, temperature 36.8°C, and blood pressure 120/59 mm Hg. The
patient’s endoscopy biopsy was positive for cytomegalovirus and he was started on
Ganciclovir and Prilosec.
Ganciclovir is an antiviral (Day 6) The patient was again rested on CMV overnight. He was only able to
medication used to treat or
prevent cytomegalovirus tolerate partial spontaneous parameters and the results were: MIP 228 cm H O
2
infections. Trade names and VC of 1.1 L. The patient tolerated 90 min on CPAP/PS before he was extremely
are Cytovene and Cymevene.
short of breath and exhibited an increased work of breathing with marked accessory
muscle use. The patient’s daily chest radiograph showed increasing bilateral infil-
trates consistent with pneumonia/aspiration and the presence of barium in the left
lower lobe. The patient had bilateral lower lobe rhonchi and was being suctioned for
copious amounts of light-yellow secretions. The patient also spiked a temperature to
39°C. Pulmonary consultation was obtained at this time.

Patient Monitoring

The patient’s spontaneous breathing parameters from Day 2 through Day 6 are
summarized as follows. On Day 6, the patient could perform only part of the
breathing parameters.

The overall breathing pa- Day V (L) V (mL) f (/min) MIP (cm H O) VC (L)
E
T
2
rameters are not satisfactory
for a weaning attempt. 2 9.7 660 15 224 2.08
3 7.8 720 12 212 4.02
4 9.9 550 18 226 3.0
5 12.9 720 18 229 3.4

6 N/A N/A N/A 228 1.1
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Weaning

This patient was eventually weaned from mechanical ventilation after 25 days. He
was weaned by using SIMV ventilation to build up his respiratory muscle strength
before weaning to CPAP/PS again. The PS level was much higher than with previ-
ous attempts. The PS level was gradually weaned down each day as the patient’s

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