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William French, MA, RRT
Lakeland Community College, Kirtland, OH
www.lakeland.cc.oh.us/index.htm
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INTRODUCTION
JH is a 67 year old male transferred from
the acute care hospital to a skilled nursing facility because
of failure to wean from ventilatory support. He was in the
hospital for three weeks prior to transfer because of an exacerbation
of COPD and CHF, leading to ventilatory failure. JH has a
long history of both COPD and CHF. Upon admission to the hospital,
he was 70" (177.8 cm) tall and weighed 140 lbs. (64 Kg).
CASE
PRESENTATION
In the hospital, JH was placed on a Puritan-Bennett 7200
for ventilatory support. Three days prior to transfer, he
had a tracheostomy performed and a #8 Shiley trach tube inserted.
Upon transfer the patient was on the following ventilator
settings:
| Mode |
SIMV |
Rate |
6 bpm |
| Tidal
Volume |
600 mL |
Peak
Flow |
60 Lpm (decelerating
pattern) |
| FIO2 |
.35 |
Pressure
Support |
+10 cmH2O |
| Humidity |
HME |
|
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The patient was admitted to the transitional
unit of the skilled nursing facility and placed on a Lifecare
PLV 102 with the following settings:
| Mode |
SIMV |
Rate |
6 bpm |
| Tidal
Volume |
600 mL |
Peak
Flow |
60 Lpm |
| O2
bleed in |
4 Lpm |
|
|
Once the patient was stabilized on these
settings, it was noted that he had a spontaneous respiratory
rate of 12 to 14 breaths per minute and a spontaneous tidal
volume of 200 to 300 mL. He appeared to be comfortable and
required occasional tracheal suctioning for moderate amounts
of thick pale yellow sputum. His SpO2 stabilized
at 95%.
Six hours after admission, the following
arterial blood gas data were obtained:
| pH |
7.43 |
PaO2 |
68 mmHg |
| PaCO2 |
52 mmHg |
SaO2 |
94% |
| HCO3- |
36 mEq |
Hgb |
14.6 gm |
Two days later, the respiratory therapist
notes a significant increase in the patient's apparent work
of breathing. His temperature was 38.2 degrees Celsius. A
chest x-ray showed an infiltrate in the right base. There
was a noted increase in sputum production. In response to
this change in the patient's condition, he was placed on antibiotics
and started on vigorous bronchial hygiene. His SpO2
remained between 92% and 95% on the same ventilator settings.
However, because of the apparent pneumonia and increase in
respiratory work, it was decided to change from SIMV to assist/control.
The ventilator rate was set at 10; however, the patient consistently
triggered the ventilator at 14 to 18 bpm. Within fifteen minutes
of assist/control, the SpO2 dropped from 94% to
85%. There was no other noticeable change in the patient's
condition. In response, the patient's oxygen bleed in was
increased to 6 Lpm; this resulted in a SpO2 of
93%.
Two days later, the patient's pneumonia
began to resolve and the patient was restored to SIMV at the
original settings. Fifteen minutes after the change in mode,
the SpO2 went up to 97%.
Within three weeks of admission to
the skilled nursing facility, the patient was successfully
weaned completely from ventilatory support and was eventually
decannulated and sent home.
DISCUSSION
What are the mechanisms that contributed
to the successful wean? What might have caused the episode?
Do you think the staff recognized and managed the case appropriately?
Post your thoughts or ask other questions related to this
case.
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