Case Study 1 Jane was a preterm

Case Study 1 Jane was a preterm neonate born at 28 weeks’ gestation, weighing 1.3 kg at birth. She was born by spontaneous vaginal delivery. Her mother received a course of antenatal steroids on admission to hospital to enhance surfactant maturation and to reduce the severity of respiratory distress syndrome (RDS). The neonate was vigorous at birth, spontaneously breathing, and required no resuscitation efforts except for some stimulation and prevention of heat loss. She was placed on nasal CPAP with a pressure of 5 cm H2O and FiO2 of 0.35 to maintain an oxygen saturation between 89% and 93%. Her initial arterial blood gas (ABG) revealed the following: pH 7.32, PaO2 62 mm Hg, CO2 45 mm Hg, bicarbonate 23 mEq, and base excess mEq/L. However, 6 hours later, the neonate started to have increased work of breathing with tachypnea, chest retractions, and nasal flaring and an increasing oxygen requirement. The ABG showed a respiratory acidosis pH 7.24, PaO2 57 mm Hg, CO2 63 mm Hg, bicarbonate 21 mEq/L, and base excess 3. Therefore, the noninvasive ventilation was initiated at a PIP of 12 cm H2O and a PEEP of 7 cm H2O. With minimal improvement after an hour and worsening respiratory status, the patient was intubated. Mechanical ventilation was initiated on the following settings: SIMV PIP 24 cm H2O, PEEP 6 cm H2O, I-time 0.35 seconds, and a rate of 60 breaths per minute. She remained stable on this mode through the night. Weaning was initiated on day 2 of invasive ventilatory support. On day 4 the ventilator settings were weaned to SIMV PIP 18 cm H2O, PEEP 4 cm H2O, I-time 0.35 seconds, and a rate of 20 breaths per minute. The measured VT was 4 to 6 mL/kg; spontaneous breathing rate was 50 to 60 breaths per minute and synchronized with the mechanical breath delivery. She was weaned to CPAP and extubated on day 6. 1. Why was a trial of biphasic positive pressure ventilation worthwhile for this patient? What was the rationale for initiating noninvasive ventilation? 2. What ventilator changes would you recommend if the blood gas postintubation was pH 7.50, PaO2 80 mm Hg, CO2 32 mm Hg, bicarbonate 19 mEq/L, and base excess -3? 3. What change in ventilation strategy might you consider if the initial setting of SIMV PIP 24, PEEP 6, I-time 0.35, and a rate of 60 produced a blood gas classified as a respiratory acidosis?

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