6. Answer: B

Rationale:

Patient discomfort and agitation causes “Patient Ventilator Dys-synchrony,” reducing the effective ventilation. Appropriate sedation improves ventilation in these patients. Paralysis may be required briefly early on for some of these patients.

7. Answer: E

Rationale:

The concept of “permissive hypercapnia” is important to recognize. Except for patients who have an increased intracranial pressure, pregnant patients and those with unstable arrhythmias or severe hemodynamic instability, most patients tolerate a relatively high PCO₂ and a relatively low pH quite well. In fact, permissive hypercapnia would be preferable in patients who do not have the contraindications above, and are hard to ventilate because the risks of baro/volu trauma in these patients far outweigh the benefits, if any, of normalizing the pH and PCO₂. It is not clear as to what the target pH should be in these patients. Most of these patients tolerate a pH as low as 7.2 or 7.25 quite well. pH is probably a better parameter to watch than the pCO₂.

8. Answer: A

Rationale:

Refer to the section titled “troubleshooting”. Bottom line, don’t wait for CXR to rule out tube malposition or tension pneumothorax. Your patient may be dead by the time you get the CXR.

9. Answer: E

Rationale:

Every time a patient is on AC and triggers the ventilator, the ventilator delivers the full tidal volume. So if the patient is over-breathing the ventilator, decreasing the backup/set rate will have no impact on the final respiratory rate and the minute ventilation. The two ways to decrease the minute ventilation would be either to decrease the sensitivity so that the patient cannot trigger the ventilator, or to decrease the respiratory drive of the patient by sedating her/him. Decreasing sensitivity of ventilator triggering will work but is uncomfortable. So sedation is the way to go for this patient.

10. Answer: B

Rationale:

This patient needs mechanical ventilation because of respiratory failure. Noninvasive ventilation would be the ventilation of choice because it reduces mortality, ICU stay and the need for invasive ventilation in these patients as long as the patient is awake and cooperative, the mask can be placed on the face/nose, and the patient can be monitored closely for clinical improvement/deterioration. These patients should be in the ICU and should be re-evaluated in no more than 30–60 minutes later to decide if invasive ventilation is needed.

“BIPAP” is the ventilation mode to use. This is actually a PSV (Pressure Support Ventilation) with PEEP. So if you place the patient on “BIPAP 10/5”, in essence, the patient is on a PEEP of 5 and Pressure Support of 5. The PEEP improves oxygenation and the PS drives tidal volumes. BIPAP 10/5 or 12/6 are reasonable initial settings.

11. Answer: C

Rationale:

RSBI is the ratio of the RR and VT (in liters). So here, the RSBI is 20/0.4 = 50. RSBI is low when the patient is breathing slowly and has high tidal volumes. It is high when patient is “panting.” RSBI less than 100 predicts a greater likelihood of success than when the RSBI is high. RSBI is not the only criterion that should be used to assess eligibility for extubation.

Other weaning parameters include

1. Negative Inspiratory Force (NIF) of better (more negative) than -20,
   
2. Forced Vital Capacity > 10 mg/Kg Ideal body weight,
   
3. Spontaneous minute volume < 10 l/min,
   
4. Spontaneous respiratory rate < 25/minute and
   
5. Spontaneous V_T of > 5 ml/Kg IBW.

12. Answer: B

Rationale:

Patients with hemodynamic should not be extubated. Ongoing need for vasopressors in this patient disqualifies her for extubation.

13. Answer: B

Rationale:

Patients should have acceptable oxygenation and reasonable low PEEP and FiO₂ requirements before extubation. This patient needs too high a PEEP and FiO₂ to be extubated successfully. Patients needing a PEEP of > 5 and a FiO₂ of more than 40% should in general not be extubated.

14. Answer: B

Rationale:

The underlying condition that formed the basis for intubation/ventilation for this patient should have reversed for you to consider extubation. This is not so in this patient.

15. Answer: B

Rationale:

RSBI is too high for this extubation to be successful.

16. Answer: B

Rationale:

Patients need to be awake, responsive, and able to protect the airway and clear secretions for the extubation to be successful. This patient does not meet those criteria.

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