Page 697 - Clinical Application of Mechanical Ventilation

Case Studies 663

atelectasis and improve alveolar ventilation as evidenced by a declining PaO on his
2
morning blood gas. These revealed the following:
pH 7.43
PaCO 2 35 mm Hg
PaO 2 57 mm Hg
SaO 2 87%
-
HCO 22.5 mEq/L
3
Mode A/C
f 14/min
V T 500 mL
F O 2 60%
I
PEEP 8 cm H O
2
The patient’s PEEP was subsequently increased to 10 cm H O without cardiac or
2
hemodynamic compromise. F O was decreased to 50% because of improving SpO
I
2
2
values. Follow-up ABGs revealed:
pH 7.45
PaCO 2 35 mm Hg
PaO 2 132 mm Hg
SaO 2 97%
-
HCO 23.5 mEq/L
3
Mode A/C
f 14/min
V T 500 mL
F O 2 50%
I
PEEP 10 cm H O
2
The F O was again lowered to 40% and he remained stable for the next 2 days.
I
2
Key Medications

On day 4 of mechanical ventilation, a persistent low-grade fever and thick tena-
cious secretions necessitated initiation of vigorous pulmonary toilet. Albuterol with
Mucomyst via a small-volume nebulizer was administered Q4 hours for wheezing
given inline with the ventilator circuit. Postural drainage and percussion were done
to the lower lobes. Bronchoalveolar lavage with 4 mL of 10% Mucomyst, 0.5 mL of
0.5% albuterol, and 5 mL of normal saline facilitated suction of moderate to large
amounts of thick secretions
Gradual clearing of retained secretions and atelectasis became evident by follow-
up chest radiographs. These management strategies in pulmonary toilet were con-
Each week of muscle tinued for the remainder of the ventilatory period.
immobility requires 4 weeks Immobility was a major factor in the patient’s clinical deterioration. Extensive
of rehabilitation of his dimin-
ished muscle mass. physical therapy was begun with range of motion and activity as tolerated. However,
extreme pain made these sessions almost unbearable to the patient.

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