Cairo: Pilbeam's Mechanical Ventilation, 6th Edition

Chapter 04: Establishing the Need for Mechanical Ventilation

WorkBook Answer Key

KEY TERMS CROSSWORD PUZZLE

CHAPTER REVIEW QUESTIONS

1. To maintain homeostasis.
2. (a) Support or manipulate pulmonary gas exchange: alveolar ventilation—achieve eucapnic
ventilation or allow permissive hypercapnia and alveolar oxygenation—maintain adequate
oxygen delivery; (b) increase lung volumes: prevent or treat atelectasis with adequate end-
inspiratory lung inflation and restore and maintain an adequate FRC; and (c) reduce work of
breathing.
3. (a) Reverse acute respiratory failure, (b) reverse respiratory distress, (c) reverse hypoxemia,
(d) prevent or reverse atelectasis and maintain FRC, (e) reverse respiratory muscle fatigue, (f)
permit sedation and/or paralysis, (g) reduce systemic or myocardial oxygen consumption, and (h)

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WorkBook Answer Key 4-2

minimize associated complications and reduce mortality.

4. (a) Tachypnea; (b) nasal flaring; (c) diaphoresis; (d) accessory muscle use; (e) retractions of
suprasternal, supraclavicular, and intercostal spaces; (f) paradoxical or abnormal movement of
the thorax and abdomen; (g) abnormal breath sounds; (h) tachycardia; (i) arrhythmia; and (j)
hypotension.
5. Acute respiratory failure (ARF)
6. (a) A PaO2 below the predicted normal range for the patient’s age under ambient conditions, (b)
a PaCO2 greater than 50 mm Hg and rising, and (c) a falling pH of 7.25 or lower.
7. (a) An acute life-threatening or vital organ-threatening tissue hypoxia. Hypoxemic respiratory
failure is a result of severe ventilation/perfusion mismatching. It can also occur with diffusion
defects, right-to-left shunting, alveolar hypoventilation, aging, and inadequate inspired oxygen.
(b) Acute hypercapnic respiratory failure, or acute ventilatory failure, occurs when a person
cannot achieve adequate ventilation to maintain a normal PaCO2. Disorders that can lead to this
are central nervous system disorders, neuromuscular disorders, or disorders that increase the
work of breathing.
8. Oxygen and PEEP/CPAP
9. Respiratory muscles, thoracic cage, and nerves and nerve centers that control ventilation.
10. (a) Brain or brainstem lesions, such as stroke, head or neck trauma, cerebral hemorrhage, or
spinal cord injury; (b) depressant drugs; (c) hypothyroidism; (d) central sleep apnea; and (e)
inappropriate oxygen therapy.
11. (any of the following) (1) Myasthenia gravis, (2) Guillain-Barré syndrome, (3) poliomyelitis,
(4) muscular dystrophy, (5) amyotrophic lateral sclerosis, (6) tetanus, and (7) botulism.
12. Flail chest, rib fracture, kyphoscoliosis, and obesity
13. Asthma, emphysema, chronic bronchitis, croup, acute epiglottitis, and acute bronchitis
14. Level of consciousness, presence of cyanosis and/or diaphoresis, respiratory rate, heart rate,
blood pressure, SpO2, and temperature
15.
HYPOXEMIA
Mild to Moderate Severe
Respiratory findings Tachypnea Tachypnea
Dyspnea Dyspnea
Paleness Cyanosis
Cardiovascular findings Tachycardia Tachycardia (eventually
Mild hypertension bradycardia, arrhythmias)
Peripheral Hypertension (eventually
vasoconstriction hypotension)
Neurologic findings Restlessness Somnolence
Disorientation Confusion
Headaches Delirium
Lethargy Blurred vision
Tunnel vision
Loss of coordination
Impaired judgment
Slowed reaction time
Manic-depressive activity
Loss of consciousness

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WorkBook Answer Key 4-3

Coma
HYPERCAPNIA
Mild to Moderate Severe
Respiratory findings Tachypnea Tachypnea (eventually bradypnea)
Dyspnea
Cardiovascular findings Tachycardia Tachycardia
Hypertension Hypertension (eventually
Vasodilation hypotension)
Neurologic findings Headaches Hallucinations
Drowsiness Hypomania
Dizziness Convulsions
Confusion Loss of consciousness (eventually
coma)
Signs Sweating
Skin redness
16. (a) Use of supplemental oxygen therapy, (b) maintenance of a patent airway, and (c)
continuous monitoring of oxygenation and ventilatory status with pulse oximetry and ABGs.
17. (a) Cheyne-Stokes breathing and (b) Biot’s breathing
18. Every 2-4 hours
19. (a) Vital capacity equal to or less than 10-15 mL/kg and (b) a maximum inspiratory pressure
between 0 and -20 cm H2O.
20. Respiratory muscle fatigue
21. (a) Tachypnea, (b) increased depth of respiration, and (c) paradoxical breathing
22. -50 to -100 cm H2O
23. Negative inspiratory force (NIF)
24. 20
25. 65-75 mL/kg
26. 10 L/min
27. FEV1, less than 10 mL/kg
28. Peak expiratory flow rate, less than 75-100 L/min
29. PaCO2
30. 0.3, 0.4, and greater than 0.6
31. (a) Pulmonary thromboemboli, (b) pulmonary vascular injury, and (c) regional hypoperfusion
32.
Measurement Normal Range Critical Value
P(A-a)O2 2-30 mm Hg on room air Greater than 450 mm Hg on
supplemental oxygen
PaO2/PAO2 0.75-0.95 Less than 0.15
PaO2/FIO2 475 Less than 200
33. Intubate and mechanically ventilate the patient.
34. PaO2 and SpO2
35. The following blood gas results:
Criteria Normal Values Critical Value
Ventilation*
pH 7.35-7.45 <7.25
Arterial partial pressure of carbon 35-45 >55 and rising

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WorkBook Answer Key 4-4

dioxide (PaCO2) (mm Hg)

Dead space to tidal volume ratio (VD/VT) 0.3-0.4 >0.6
†
Oxygenation
Arterial partial pressure of oxygen 80-100 <70 (on O2 >0.6)
(PaO2) (mm Hg)
Alveolar-to-arterial oxygen difference 3-30 >450 (on O2)
P(A-a)O2 (mm Hg)
Ratio of arterial to alveolar PO2 0.75 <0.15
(PaO2/PAO2)
PaO2/FIO2 475 <200
36. Intubation is contraindicated when it is contrary to the patient’s wishes, medically pointless,
or futile.
37. (a) Respiratory rate >25 breaths/min, (b) moderate to severe acidosis (pH 7.25-7.30 and
PaCO2 45-60 mm Hg), and (c) moderate to severe dyspnea with the use of accessory muscles and
paradoxical breathing pattern
38. Or (any of the following) (1) Respiratory arrest, (2) cardiac arrest, (3) non-respiratory organ
failure, (4) upper airway obstruction, (5) inability to protect the airway and/or high risk of
aspiration, (6) inability to clear secretions, and (7) facial/head surgery or trauma.
39. This patient is hypoxemic with a non-rebreather mask, and is unable to move an adequate
amount of air. The pink, frothy sputum is an indicator of pulmonary edema, and the hypotension
is due to cardiogenic shock. This is a medical emergency, and the patient requires intubation,
mechanical ventilation, and PEEP.
40. Oxygen therapy would be most appropriate for this patient. If the patient wishes further
intervention, arterial blood gas evaluations and other diagnostic tests may be performed.
41. Aggressive bronchodilator therapy (continuous), corticosteroids, oxygen therapy, and close
monitoring of this patient are required. If the bronchospasm does not respond to aggressive
therapy, intubation and mechanical ventilation may be necessary.
42. This patient requires oxygen and bronchodilator therapy. The patient’s PaCO2 reveals that he
is able to move air and therefore does not require mechanical ventilation at this time.
43. This patient is developing acute respiratory failure and meets some of the criteria for
mechanical ventilatory support (pH, 7.21; PaCO2 >55 and rising PaO2; FIO2 <200). This patient
should be intubated, and mechanical ventilatory support should be started. This patient’s head
trauma makes NPPV an absolute contraindication.
44. CaO2 = [Hb × 1.34 × SaO2] + [PaO2 × 0.003]
= [12 × 1.34 × 0.91] + [59 × 0.003]
= 14.63 + 0.18
= 14.81 vol%
45. CaO2 = [Hb × 1.34 × SaO2] + [PaO2 × 0.003]
= [8 × 1.34 × 0.9] + [58 × 0.003]
= 9.65 + 0.17
= 9.82 vol%
46. CaO2 = [Hb × 1.34 × SaO2] + [PaO2 × 0.003]
= [17 × 1.34 × 0.79] + [48 × 0.003]
= 18.00 + 0.14
= 18.14 vol%
47. PAO2 = [FIO2 (Pb - PH2O)] - [PaCO2/R] = [0.7 (760 - 47)] - [48/0.8]

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WorkBook Answer Key 4-5

= [0.7 × 713] - 60 = 499 - 60 = 439 mm Hg

PaO2 = 50 mm Hg
PAO2 - PaO2 = 439 - 50 = 389 mm Hg
48. PaO2/PAO2 = 50 mm Hg/439 mm Hg = 0.11
Of the oxygen available to the alveolus, only 11% is getting into the artery. Yes, 0.11 is a critical
value.
49. PaO2/FIO2 = 50 mm Hg/0.70 = 71.43. Yes, this is a critical value; it indicates the need for
mechanical ventilatory support.
50. PAO2 = [FIO2 (Pb - PH2O)] - [PaCO2/R] = [0.21 (760 - 47)] - [55/0.8]
PAO2 = 150 - 69 = 81 mm Hg; PAO2 - PaO2 = 81 - 51 = 30 mm Hg. This value is within the
normal range.
51. PaO2/PAO2 = 51 mm Hg/81 mm Hg = 0.63. This is not a critical value.
52. PaO2/FIO2 = 51/0.21 = 243. This is not a critical value.

CRITICAL THINKING QUESTIONS

1. A rapid physical assessment of a trauma patient should include, but is not limited to checking
for a patent airway, respirations, chest auscultation, patient appearance, pulse, blood pressure,
temperature, SpO2, chest inspection, chest palpation, chest percussion, and patient sensorium.
2. The diagnostic evaluations that should be done to assess the need for mechanical ventilation
include arterial blood gases, chest X-ray, and pulse oximetry.
3. The patient would be very anxious looking, flushed and sweating, in a tripod position (i.e.,
leaning forward braced on elbows or hands), using accessory muscles, and cyanotic or pale.
4. The patient requiring oxygen therapy only presents with hypoxic respiratory failure, as
evidenced by a PaO2 below the predicted normal for the patient’s age. This patient will have a
normal PaCO2. A patient requiring mechanical ventilation will have both hypoxic respiratory
failure and hypercapnic respiratory failure.

CASE STUDIES

Case Study 1

1. Hypoxemia is likely the cause of the patient’s tachycardia. Anxiety may also be a contributing
factor.
2. The patient’s PaO2 of 48 mm Hg on 40% oxygen and the PaO2/FIO2 value of 120 are critical.
However, both the P(A-a)O2 and PaO2/PAO2 are outside the normal range but not at critical levels.
3. This patient is presenting with an acute asthma episode. At the onset of an asthma episode, the
patient hyperventilates. A normal PaCO2 in this situation indicates a severe episode (stage III)
and impending respiratory failure.
4. Continuous bronchodilator therapy would be appropriate. Additional medications could
include magnesium sulfate and steroids. However, if little or no improvement is seen, ventilatory
support will be necessary.

Case Study 2

1. The patient’s oxygenation status is not at a critical level. The alveolar-arterial oxygen gradient
is wider than normal, 42.5 mm Hg, but not critical. The arterial/alveolar PO2, at 0.59, is lower

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WorkBook Answer Key 4-6

than normal but also not critical. The PaO2/FIO2 is lower than normal but not critical.
2. The patient’s pH and PaCO2 are both within normal limits. The patient is not weak enough to
require mechanical ventilatory intervention at this time.
3. The patient should be closely monitored for acute ventilatory failure by measuring the
maximum inspiratory pressure and/or vital capacity and also by evaluating the arterial blood
gases for PaCO2 changes. Medical treatment of myasthenia gravis includes an anticholinesterase
medication. The patient may benefit from low-flow oxygen, about 2 L/min by nasal cannula.

Case Study 3

1. The alveolar-arterial oxygen gradient is increased (315 mm Hg) but not critical. However, the
PaO2 (41 mm Hg), the PaO2/PAO2 (0.13), and the PaO2/FIO2 (68) indicate severe hypoxemic
respiratory failure.
2. The PaCO2 is markedly elevated, and the pH is very low. This is an indication that the patient
is in acute ventilatory failure.
3. This patient requires intubation, based on the deteriorating arterial blood gas values.

NBRC-STYLE QUESTIONS

1. D
2. C
3. D
4. D
5. C
6. C
7. C
8. B
9. B
10. A

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