Mechnical ventilation Questions/CCM Board review

8/10/2019 Mechnical ventilation Questions/CCM Board review

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Mechanical Ventilation Questions

1. A 68-year-old man with a history of COPD (FEV1 and PaCO2 measured under

stable conditions of 550 mL and 58 mm Hg, respectively) is admitted with a 3-day history of increasing cough, purulent sputum, and dyspnea. His only

medications are an inhaled beta-2 agonist and an inhaled anticholinergic agent.The patient weights 65 kg. His temperature is 38.3 C, his respiratory rate is

28/min, he has an irregular heart rate of 120/min, and a blood pressure of 100/65mm Hg. He is using his accessory muscles of respiration and appears anxious.

Heart sounds are diminished and breath sounds are decreased bilaterally. Hischest x-ray shows hyperinflation but no evidence of pneumonia, heart failure,

pneumonthorax, or rib fracture. Arterial blood gases drawn on 5 L/min of nasaloxygen show a pH of 7.22, a PaCO2of 74, mm Hg and a PaO2of 92 mm Hg. The

ECG shows multifocal atrial tachycardia.

1a. All of the follow would be expected to lower his PaCO2 except?a. Reducing the FiO2

b. Applying a continuous positive airway pressure (CPAP) maskc. Applying noninvasive positive pressure ventilation (NIPPV)

d. Administering a benzodiazepinee.

Administering acetaminophen

1b. Which of the following is least likely to be contributing to the increased

PaCO2?a. Increased resistive work of breathing

b.

An inspiratory threshold load induced by autoPEEPc. Pulmonary shunt

d. Mechanically disadvantaged respiratory musclese. Excessive dead space

1c. All of the following effects of NIPPV have been demonstrated in patients

with COPD except?a. Increases personnel costs by roughly 50%b. Reduces the frequency of pneumonia

c. Reduces mortalityd. Reduces the frequency of intubation

e.

May reduce cardiac output


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1d. Which of the following represents the best mode of ventilatory support in this

patient?

a.

Intubation; volume assist-control ventilation; tidal volume ofapproximately 12 mL/kg; respiratory rate of 8; no PEEPb. Intubation; synchronized intermittent mandatory ventilation; adjust

to provide 50% of his required minute ventilation; PEEP 5 cm H2Oc. Intubation; pressure-control ventilation; IPAP 30 cm H2O; EPAP 5

cm H2Od. NIPPV; pressure-support ventilation; IPAP 15 cm H2O; EPAP 5

cm H2Oe. NIPPV; pressure-support ventilation; IPAP 25 cm H2O; EPAP 0

cm H2O

Despite your management the patient fails to improve, but by evening you leave himstabilized treated with bronchodilators; and intubated, on these settings : volume assist-

control; VT400 mL; RR 22; PEEP 2 cm H2O; FiO20.4, and he is comfortable andpassive. You are next called at 2:00 AM because, while being moved onto a bedpan, the

patient became abruptly agitated, using all accessory muscles, and much moretachycardic. The nurse reports that during hand-bagging the patient became comfortable

once again, but that upon returning him to the ventilator, he quickly became agitated. Onexamination, you find that the patient is diaphoretic with symmetrical but diminished

breath sounds. He is working hard to breathe but the ventilator seems not to respond tohis efforts. A suction catheter can be passed readily down the ETT.

1e. Which of the following would be the most appropriate intervention?a.

Prescribe benzodiazepinesb. Prescribe benzodiazepines and a paralytic agent

c. Prescribe heparin, 80 U/kg, and request an urgent helical CTangiogram

d. Increase the level of PEEPe. Change from assist-control mode to pressure-support mode

2. A 23-year old woman is admitted following multiple gunshot wounds to the

abdomen. She is now s/p surgery to repair multiple bowel perforations and tostanch hepatic hemorrhage. Her predicted body weight is 60kg. On examination

the BP is 115/70; HR 118, RR 16, and she is sedated and paralyzed. There arediffuse crackles and her abdomen is firm and distended. Chest radiograph shows

small lungs and subtle, diffuse infiltrates. Ventilator settings are SIMV 16; VT0.8; PEEP 5 cm H2O, FiO21.0; inspiratory flow rate 50 lpm; and the peak and

plateau airway pressures are 48 and 43 cm H2O, respectively, The PaO2is 67 mmHg; PaCO241 mm Hg; pH 7.31.


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2a. Which of the following ventilator adjustments should be made first?

a. Change the mode to volume assist-controlb. Lower the tidal volume and increase the rate

c. Change to pressure control with IPAP 40 cm H2O; EPAP 5 cm H2O

d.

Raise the PEEPe. Lower the FiO2to 0.6

2b. Which are most likely dominant contributors to the elevated peak airwaypressure?

a. The high inspiratory flow rate and elevated airway resistanceb. Pulmonary edema and the high FiO2

c. The PEEP combined with acute lung injuryd. Occult autoPEEP and tidal volume

e. Acute lung injury and abdominal distension

2c. Which of the following have been shown in ARDS?a. Use of lower PEEP is associated with enhanced survival.

b. Use of a liberal fluid strategy is associated with improved survival.c. Use of steroids in the fibroproliferative phase is associated with

enhanced survival.d. Permissive underfeeding increases ventilator-free days

e. ARDS mortality is decreasing

2d. Which of the following is least likely to improve her oxygenationsubstantially?

a. Inverse ratio ventilation

b.

Raising the tidal volumec.

Increased PEEPd. Prone positioning

e. Administration of inhaled nitric oxide

3. Which combination of ventilator mode and end-inspiratory alveolar pressure isrepresented in this flow and pressure waveform?


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a. Volume control; Palv = 30

b. Pressure control; Palv = 30c. Volume control; Palv = 40

d. Pressure control; Palv = 40

e. Pressure control; Palv = 25

4. A 32-year-old man with morbid obesity (420 lbs/191 kg) is admitted with

Fourniers gangrene of the perineum. Two days following debridement, he ishemodynamically stable, alert, afebrile, and has VO2= 285 mL O2/min by

metabolic cart. CXR shows small but clear lungs. Ventilator settings are volumeassist-control; VT0.45; FiO20.4; and PEEP 12 cm H2O. ABG shows PaO271

mm Hg; PaCO235 mm Hg; pH 7.42. His spontaneous tidal volume is 0.34; RR =29 (f/VT= 85) but when PEEP < 12 cm H2O, his SpO2falls below 0.88.

Which of the following is indicated?

a.

Extubate the patientb. Begin albuterol nebulizer treatments

c. Sedate, reduce the VTand reassess dailyd. Change the enteral nutrition formula to reduce the respiratory quotient

e.

Change to SIMV, then reduce the rate by 2 every 2 hour

5. Match the choice of tidal volume and patient activity with the flow and pressurewaveforms.

a. VT= 480 cc; active patient

b. VT= 480 cc; passive patient

c. VT= 680 cc; active patientd. VT= 680 cc; passive patient

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Mechnical ventilation Questions/CCM Board review