1. Indications for mechanical ventilation
A 32 year otherwise healthy female is admitted for dysuria and fever. She is admitted to the floor for IV antibiotics. A critical care consult is requested at 1AM because of low blood pressure. The resident orders a 3000 ml of NS in addition to appropriate antibiotics. The patient continues to be hypotensive despite the fluids and vasopressors, and is transferred to the ICU. She now complains of respiratory distress. She is still hypotensive and is in obvious significant distress. ABG shows a pH 7.45, pCO2 35, HCO3 22 and SaO2 of 95% on 40% FiO2. CXR shows bilateral infiltrates. Regarding her respiratory status, the next appropriate step is to:
A. Place her on 100% NRB
B. Obtain another ABG and CXR in 30–60 minutes to decide further course of action. Intubate if she shows significant hypoxemia or abnormal CXR.
C. Intubate and initiate mechanical ventilation immediately
D. Obtain another ABG and CXR in 30–60 minutes to decide further course of action. Intubate if she shows significant respiratory acidosis or abnormal CXR.
2. Initial Setup: Modes
A decision is made to intubate and place the above patient on mechanical ventilation. Which of the following ventilation modes would be your initial choice?
A. Assist Control
B. Synchronized Intermittent Mechanical Ventilation
C. Airway Pressure Release Ventilation
D. Pressure Control Ventilation (CPAP)
E. High Frequency Oscillatory Ventilation
3. Initial Setup: Settings
She weighs 100 kg and is 5’6” tall. The recommended tidal volume for her is:
A. 1000 ml
B. 750 ml
C. 600 ml
D. 360 ml
E. None of the above.
4. The initial PEEP, FiO2 and RR settings for her could be:
A. PEEP 0, FiO2 40%, RR 12
B. PEEP 5, FiO2 20%, RR 18
C. PEEP 15, FiO2 100%, RR 36
D. PEEP 5, FiO2 100%, RR 24
5. Ventilator Settings: Adjustments
The patient above is placed on a VT of 360, RR of 20, PEEP of 12 and FiO2 of 100%. Her SaO2 now is 72%. What do you do next?
A. Increase FiO2
B. Increase PEEP
C. Change to APRV
D. Change to PRVC
E. Increase Tidal Volumes
6. Ventilator Settings: Adjustments
Appropriate changes in PEEP are made. SaO2 has now come up to 78% and the patient appears uncomfortable. What do you do next?
A. Increase PEEP further
B. Sedate patient
C. Increase FiO2
D. Change mode to APRV
7. Ventilator Settings: Adjustments
Appropriate action is taken. Two hours later, her BP is 110/75, HR 98, RR 30/minute, her plateau pressure is 29, her peak airway pressure is 35, SaO2 is 94% but the ABGs show a pH of 7.25 with a pure respiratory acidosis. The next step is to:
A. Increase tidal volume
B. Decrease tidal volume
C. Decrease rate
D. Start an IV bicarbonate infusion to maintain a pH 7.35-7.45
E. Do nothing at this point
8. Ventilators: Troubleshooting
Appropriate steps are taken. Later in the day the nurse calls you because of high pressure alarms on the ventilator and decreased SaO2. You notice an obviously awake patient in distress. The immediate next steps will include all except:
A. Order a stat CXR and wait for the CXR before taking the next step
B. Remove patient from the ventilator and “manually bag the patient”
C. Sedate the patient to prevent asynchronous breathing and straining
D. Note the ease or difficulty in “bagging” the patient
E. Auscultate and percuss for symmetry
F. Note position of ET tube to look for migration
9. Ventilators: Troubleshooting
A 68 year male who was admitted for pneumonia is currently on mechanical ventilation (AC, VT 360, RR 12, PEEP 5, FiO2 55%). Patient is breathing at 26/minute. You are concerned about the significant respiratory alkalosis that this patient has. You will address this by making the following change:
A. Increase FiO2 to decrease the respiratory drive
B. Decrease respiratory rate
C. Decrease PEEP
D. Increase sensitivity for triggering the ventilator
E. None of the above
10. Ventilator: Modes
A 55 year male with advanced COPD presents with respiratory distress, cough, and fever. Physical examination shows a mild fever, bilateral wheezing, and respiratory distress. ABGs show PO2 50, pH 7.25, pCO2 60. He is awake and able to follow commands. Steroids and bronchodilators are started. It is appropriate to place the patient on:
A. Oxygen alone
B. Noninvasive mechanical ventilation
C. Invasive mechanical ventilation
11. Ventilators: Discontinuing
During weaning, a patient is found to have a VT of 400 cc and a RR of 20. The RSBI (Rapid Shallow Breathing Index) for this patient is:
A. 20
B. 8000
C. 50
D. Cannot be calculated based on the information available
12. Ventilation: Discontinuing
A 67 year female is admitted to the ICU for urosepsis and ARDS. On the fifth ICU day she is afebrile and appears awake and comfortable. She is on Zosyn, vancomycin, Lovenox, Nexium, dopamine (15mcg/kg/min), versed and Fentanyl. She is on AC, VT 360cc, PEEP 5, FiO2 35%, RR 16/min. Weaning parameters show a NIF of -65 and RSBI of 45.
A. Extubate patient
B. Do not extubate patient
13. Ventilation: Discontinuing
A 75 year old male is admitted with pneumonia and ARDS. On the sixth admission day, he is afebrile and appears awake and comfortable. He is on Zosyn, vancomycin, Lovenox, Nexium, Versed and Fentanyl. He is on AC, VT 340ml, FiO2 75%, RR 16/min, PEEP 12.5. Weaning parameters show a NIF of -75 and a RSBI of 44.
A. Extubate patient
B. Do not extubate patient
14. Ventilator: Discontinuing
A 34 year male with progressive GBS (bulbar) is intubated because of inability to protect airway and severe respiratory acidosis. Ten days later, his neurological condition has not deteriorated further and is unchanged otherwise. He is afebrile, awake and looks quite comfortable. He is hemodynamically stable, has a clear CXR, and has very good oxygenation.
A. Extubate patient
B. Do not extubate patient
15. Ventilator: Discontinuing
A 45 year male with aspiration pneumonia is admitted for respiratory failure. He is intubated and placed on mechanical ventilation. 7 days later, he is hemodynamically stable, off vasopressors, and has a SaO2 of 94% on a FiO2 of 35%. He tolerates PSV, PS 5cm and PEEP 5cm for 2 hours. Weaning parameters show a NIF of -55, VT of 200 ml and RR of 40.
A. Extubate patient
B. Do not extubate patient
16. Ventilator: Discontinuing
A 45 year male with cirrhosis is admitted for alcohol withdrawal and is intubated for airway protection. Three days later, he is no longer agitated. He is hemodynamically stable and the labs are all within normal limits. The Ativan drip that patient was on has been discontinued and he is unarousable. His SaO2 is 99%. He is on AC, VT 400 ml, RR 18/min, FiO2 25%, PEEP 5. Weaning parameters show a RSBI of 35.
A. Extubate patient
B. Do not extubate patient
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