Respiratory Failure & Mechanical Ventilation

Post CABG surgery with ARDS. The surgeon thinks that he is doing protective lung strategy and does not see anything wrong with the settings. What do you think I should tell him?

66 year old, 16 days after COVID-19 on mechanical ventilation with FiO2 of 65% and PEEP of 12 who developed hypoxemia, hypotension, and increased ventilator peak pressures.

An inspiratory hold revealed an increase in the plateau pressure indicating a low lung or chest wall compliance. Breath sounds were decreased on the right side.

Stat chest X-ray revealed tension pneumothorax on the right side.

Chest tube was emergently inserted on the right side with re-exapnsion of the lung.

Flow over time and flow/volume loop showing inspiratory and exploratory oscillations due to secretions in the airways. As air passes by secretions in the airway, tiny flow and pressure changes occur. These tiny changes produce a saw tooth pattern during inhalation and exhalation

Capnography is very good monitor tool for critically ill patients. It has shown great potential in several conditions and procedures in critical care medicine. Literature exists for its use in cardiopulmonary resuscitation, intubation for confirmation of ETT placement, resuscitation of critically ill patients with sepsis, monitoring response to treatment in patients with respiratory distress (specifically COPD, CHF, and asthma), pulmonary embolism, and procedural sedation.

The above capnography graph shows evidence of mild obstruction in addition to waves of incomplete exhalations as they are interrupted with inspiratory efforts due to a high respiratory drive of the patient. Not the corresponding early inspiratory efforts on the pressure and volume scalars of the same patien.