A 54-year-old man is admitted to the intensive care unit after being intubated for severe respiratory distress. He was witnessed aspirating gastric contents during a seizure 12 hours ago. Vital signs are blood pressure 90/60 mm Hg, pulse 112/min, and temperature 38.2°C (100.8°F). His height is 170 cm (5 ft 7 in) and weight is 75 kg (165 lb). A chest radiograph shows bilateral diffuse alveolar infiltrates without cardiomegaly. He is placed on mechanical ventilation. Current ventilator settings and arterial blood gas results are as follows:
| Ventilator Parameter | Value |
|---|---|
| Mode | Volume-controlled |
| Tidal volume | 650 mL |
| Respiratory rate | 14/min |
| FiO2 | 0.70 |
| PEEP | 5 cm H2O |
| Blood Gas Parameter | Value |
|---|---|
| pH | 7.25 |
| PaCO2 | 60 mm Hg |
| PaO2 | 52 mm Hg |
| HCO3- | 26 mEq/L |
Which of the following interventions are indicated in the management of this patient's respiratory failure? (Select all that apply)
- Decrease the tidal volume to 400 mLCevap
- Increase the positive end-expiratory pressure (PEEP)Cevap
- Increase the respiratory rateCevap
- DAdminister intravenous sodium bicarbonate
- EAdminister intravenous furosemide
Cevap
The indicated interventions are to decrease the tidal volume to 400 mL, increase the positive end-expiratory pressure (PEEP), and increase the respiratory rate.
This patient has severe acute respiratory distress syndrome (ARDS) following an aspiration event, defined by acute onset, bilateral infiltrates, a known clinical insult, and a ratio less than 100 mm Hg (here, ). Standard management requires a lung-protective ventilation strategy. This involves decreasing the tidal volume to mL/kg of predicted body weight (approximately 400 mL for a 66 kg male) to prevent alveolar overdistension and volutrauma. Because the patient is severely hypoxemic, increasing PEEP is necessary to recruit collapsed alveoli, decrease intrapulmonary shunting, and improve oxygenation. Finally, because decreasing the tidal volume will further lower minute ventilation and worsen the existing respiratory acidosis ( 60 mm Hg), the respiratory rate must be increased concurrently to facilitate clearance.
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The management of acute respiratory distress syndrome (ARDS) requires a lung-protective ventilation strategy involving low tidal volumes ( mL/kg of predicted body weight) to prevent volutrauma, increased PEEP to recruit alveoli and improve oxygenation, and an increased respiratory rate to maintain adequate minute ventilation for clearance.