60-year old male was admitted to the emergency department complaining of persistent chest pain and a persistent dry cough. The chest pain was noted to be pleuritic in nature and persisted for weeks prior to admission. On the day of admission, the patient complained of acute onset of dyspnea. He was found to be tachypneic and cyanotic with a respiratory rate of 36. Exam revealed crackles on the right and diminished breath sounds on the left. She was transferred to the closest hospital where she was emergently intubated and transferred to regional medical center.
Lab Values
WBC 11,000/mm3 with 38% neutrophils, 8%S lymphocytes, 18% monocytes and 35% bands
Platelet count was 187,000/mm3
Hematocrit 33%
Serum Sodium 122 mmol/L, potassium 4 mmol/L, chloride 90 mmol/L, bicarbonate 21 mmol/L, BUN 14 mg/dl, serum creatinine 0.6 mg/dl and anion gap of 14.
Arterial Blood Gas prior to intubation
pH- 7.48; PaCO2 28 mmHg; PaO2 48 mmHg
Hospital course
He was initially admitted to the general floor for observation, provided supplemental oxygen along with updraft treatments but was later transferred to ICU with hypoxemic respiratory failure. He was intubated and place on a mechanical ventilation in A/C mode.
Time | Rate | Exh. Tidal Volume | FIO2 | PEEP | pH | pCO2 | pO2 | PIP | Plat |
10:13 | 29 | 445 | .60 | 10 | 7.47 | 37 | 88 | 28 | 24 |
16:16 | 34 | 440 | .60 | 10 | 7.46 | 35 | 85 | 33 | 29 |
17:30 | 36 | 438 | .60 | 10 | 7.45 | 34 | 75 | 36 | 31 |
20:28 | 40 | 435 | .60 | 10 | 7.49 | 30 | 59 | 45 | 41 |
Instructions:
- How would you describe the physiologic changes noted in this case study?
- Provide a comparison of two different ventilator strategies/modes that can be used to address the clinical condition.
- What recommendation would you make to a physician? Why? (be sure that you utilize the Berlin definition of ARDS in your response)
- What literature supports your recommendations?
- What other adjunct strategies might be used to support lung protection?v