ICU Cases · Mechanical ventilation
Hot case — worsening hypoxaemia and rising airway pressure on day 3
A CICM Second-Part hot case — the College's hallmark real-patient bedside encounter. The candidate synthesises a ventilated patient whose oxygenation and airway pressure have both deteriorated, examines at the bedside to localise the cause, presents a focused assessment, defends a management plan, and answers the examiner's probes.
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Candidate brief. Mr M, 64, intubated two days ago for severe pneumococcal pneumonia with ARDS (initial PaO2/FiO2 90). He has been ventilated on volume control, FiO2 0.6, PEEP 12, tidal volume 380 mL, with a plateau pressure around 26 cmH2O overnight. In the last two hours the saturation has fallen from 94% to 88% on the same settings, the peak airway pressure has risen from 30 to 42 cmH2O, and he is now tachycardic at 118/min with a blood pressure of 96/58 mmHg. The nurse asks you to come now.
[1]You have eight minutes to review the chart, examine the patient, and prepare a structured assessment before the examiner arrives.[4]
References5ShowHide
- [1]Brower RG, Matthay MA, Morris A, et al. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2000.PMID 10793162
- [2]Amato MBP, et al. Driving Pressure and Survival in the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2015.PMID 25693014
- [3]Gattinoni L, et al. Regional Physiology of ARDS. Critical Care, 2017.PMID 29297365
- [4]Bersten AD, Soni N (eds). Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
- [5]Marino PL. The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.