CASE STUDY: GAS EXCHANGE
Z.Q., 74-year-old Hispanic male with Acute Respiratory Distress Syndrome Z.Q., 74-year-old Hispanic male, came to the emergency department (ED) 7 days ago with complaints of shortness of breath.
His wife stated that he had a history of hypertension, depression, and chronic obstructive pulmonary disease (COPD). The admission chest x-ray revealed dense consolidation of the left lower lobe. An arterial blood gas (ABG) at that time showed: pH 7.60, PaCO2 29 mm/Hg, HC03 32 mmol/L, and PaO2 75 mm/Hg. Z.Q. quickly deteriorated and subsequently was intubated. He has been in the intensive care unit for 3 days.
Z.Q. and wife have been married 45 years and live with a daughter and 2 grandchildren
Z.Q. and his wife speak both English and Spanish
Objective Data/ Physical Examination
Blood pressure 167/98, pulse 112, temperature 102.0° F, respirations 14, oxygen saturation 72%
Height 5 feet 6 inches, weight 75 kg
Patient localizes to endotracheal tube (ETT) and is intermittently aroused, making several attempts to pull ETT
Orally intubated #7.5 ETT, taped at 27 cm to lip
Volume cycled ventilator at FIO2 – 60%, in assist control mode of 14 breath per minute, tidal volume 450, positive end-expiratory pressure PEEP 5 cm H2O
Breath sounds decreased in bases with bilateral crackles that do not clear after suctioning
Brown/yellow secretions returned with suctioning
Peripheral pulses weak at 1/4 with capillary refill greater than 4 seconds
2+ pitting edema in the bilateral lower extremities
Newly Obtained Diagnostic Study Results
Arterial blood gas (ABG) pH 7.31, PaCO2 58 mm/Hg, HC03 28 mmol/L, PaO2 54 mm/Hg, EtCO2 38 mm/Hg
Chest x-ray reveals diffuse white out in middle and lower lobes; endotracheal tube present with tip well above the carina; left subclavian central venous catheter is located in the superior vena cava
CT scan reveals alveolar opacities with increasing effusions in the gravity-dependent areas of the lungs
1: Interpret Z.Q.’s latest set of ABGs.
2: After reviewing Z.Q’s ABG results, the physician increases the PEEP from 5 cm H2O to 8 cm H2O. Why would this be necessary and what is the expected outcome associated with this action?
3: What measures should be part of Z.Q.’s care to promote respiratory function and improve nutritional status?
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