Unit 3

Ventilator Initiation

Initial Settings

Ventilator Optimization

Pharmacology

Condition Specific Stabilization

100

What is the most important feature to consider when selecting a ventilator?

Clinician familiarity

100

The initial minute ventilation target for an adult patient receiving mechanical ventilation is approximately _________.

100 ml/kg/min

100

What is the calculation for driving pressure?

Plateau-total PEEP

100

You are preparing to intubate a patient and the RN tells you the patient's recent potassium was 6.1. What neuromuscular blocking agent would you recommend?

Rocuronium

100

A patient is intubated for status asthmaticus. When selecting a sedative agent, this medication may be considered due to additional respiratory effects beyond sedation.

Ketamine

200

Name 3 advantages of A/C-PC

Variable flow

Plateau pressure controlled

Sustained inspiratory pressure may result in more alveolar recruitment

Improved gas distribution

Lower PIP compared to VC w/ square wave form

200

If initiating a patient in PC, what initial inspiratory pressure should be set?

Range of 10-15 cm H₂O above PEEP

200

Two patients have a plateau pressure of 28 cm H₂O. Patient A has a PEEP of 5 and patient B has a PEEP of 15. Which has the lower driving pressure?

Patient B 28-15 = 13

Patient A 28-5 = 23

200

Name the reversal agents for:

-Rocuronium

-Benzodiazepines

-Opioids

-Rocuronium: Sugammadex

-Benzodiazepines: Flumazenil

-Opioids: Naloxone

200

Describe 3 ways severe metabolic acidosis contributes to hemodynamic instability.

•Reduction of left ventricular contractility (decreased stroke volume)

•Increased likelihood of cardiac arrhythmias

•Arterial vasodilation

•Decreased responsiveness to vasopressor medications

300

A patient with ARDS is placed on a mode designed to maintain alveolar recruitment by spending the majority of time at a high pressure with brief releases for ventilation. Identify the mode.

APRV

300

Which of the following ventilator settings would be MOST appropriate for a 5'5" female patient with ARDS?

a. PRVC 460, R-12, +8, 100%

b. VC 340, R-16, +8, 100%

c. SIMV-VC 340, R-16, +8, 100%

d. PRVC 400 R-16, +8, 100%

b. VC 340, R-16, +8, 100%

300

You increase PEEP from +8 to +12. Plateau pressure does not increase and oxygenation improves. What likely happened?

Lung recruitment?

300

A 58-year-old male with a BMI of 48 kg/m² presents with worsening shortness of breath and stridor. He has a history of head and neck cancer with a known upper airway mass. He is awake but becoming increasingly fatigued. Current assessment:

SpO₂ 92% on NRB, RR 32 breaths/min, Accessory muscle use present, Able to answer questions appropriately

Which of the following airway management strategies is MOST appropriate for this patient?

a. Perform RSI with induction agent and neuromuscular blockade followed by immediate intubation
b. Attempt NIV to avoid invasive airway placement
c. Perform awake fiberoptic intubation
d. Administer a paralytic first to improve visualization during intubation

c. Perform awake fiberoptic intubation

300

A patient with renal failure is intubated for respiratory failure. Assessment shows:

pH 7.12
PaCO₂ 25
HCO₃ 8
Na 140
Cl 105

Calculate the anion gap and identify if it is increased, decreased, or normal. Should bicarbonate be given?

140 - (105+8) = 27

Elevated anion gap

No, bicarbonate should not be administered. Correct the cause of high anion gap acidosis

400

A sedated and paralyzed patient is receiving mechanical ventilation. The patient is making no spontaneous effort and every breath is initiated by the ventilator. What type of ventilation is occurring?

Controlled ventilation

400

Which of the following ventilator settings would be MOST appropriate for a 6'0" male patient intubated for a stroke?

a. PC 15/+5, R-12, 100% (exhaled Vt: 475 mL)

b. PC 25/+5 R-12, 100% (exhaled Vt: 624 mL)

c. PC 15/+5 R-16, 100% (exhaled Vt: 475 mL)

d. PC 18/+5 R-12, 100% (exhaled Vt: 550 mL)

c. PC 15/+5 R-16, 100% (exhaled Vt: 475 mL)

400

What is the patient's driving pressure based on the image below?

Need a plateau pressure

< 15 because inspiratory flow is not equilibrating

400

A 72-year-old male with pneumonia requires intubation due to worsening respiratory failure. Prior to intubation, assessment shows:

BP: 80/47 (58), HR: 115, RR: 28, SpO₂ 90% on nonrebreather

Which induction agent would be MOST appropriate for this patient during RSI?

Etomidate: hemodynamically neutral

Avoid propofol here

400

A patient presents with renal failure and pulmonary edema:

pH 7.18
PaCO₂ 28 mmHg
HCO₃ 10 mEq/L
K⁺ 6.5 mEq/L
Creatinine 6.8 mg/dL
CXR: bilateral pulmonary edema

What therapy should be considered to correct the underlying problem?

Dialysis

500

Your patient is in PC 18/+8. Their tidal volume decreases from 450 to 250 mL. Give 3 possible causes.

Decreased compliance

Increased resistance

Decreased patient effort

500

A 5'8" male patient is admitted with septic shock. His vitals are as follows:

HR-115, RR- 36, BP- 110/56, SpO₂ - 98% on nonrebreather

ABG: 7.14/20/159/7

Which of the following initial ventilator settings would be MOST appropriate?

a. VC 410, R-16, +8, 100%

b. VC 550 R-14, +8, 100%

c. VC 410 R-20, +5 100%

d. VC 410, R-28, +5, 100%

500

You are performing a PEEP titration on your patient in VC. Which PEEP would you leave the patient on? Is your driving pressure goal met? If not, what ventilator adjustments could you make?

+12

At +14 BP was decreased 20%

Driving pressure 28-12 = 16, goal not met

Decrease tidal volume and increase RR to compensate

500

Your patient was recently intubated with Etomidate and Rocuronium and placed VC 320/16/+8/100%. Your vital signs are below, what would you recommend?

Start sedation, patient is paralyzed and not sedated

Etomidate 3 to 12 minute duration

Rocuronium 30 to 60 minutes duration

500

A patient with a traumatic brain injury is intubated for airway protection.

Current assessment:

ICP: 28 mmHg
BP: 130/75
Vent: VC VT 480 mL, RR 12, PEEP +5, FiO₂ 40%
ABG: 7.28 / 55 / 95 / 25

Why could the current ventilator strategy worsen the patient’s neurologic status?

Hypoventilation causing CO₂ retention

Increased PaCO2: cerebral vasodilation, increased cerebral blood volume, increased ICP