A patient with severe COPD is receiving mechanical ventilation. ABG VALUES shows Ph: 7.24 pCO2 68mmhg pO2 72mmhg. Waveform shows prolonged expiratory phase without touching normal before the next breath suddenly becomes hypotensive and tachycardic. Which ventilator adjustment will the nurse make immediately?

1. A

   Increase PEEP to 12 cm H2O

2. B

   Increase FiO2 to 100%

3. C

   Decrease respiratory rate to allow longer expiratory time

4. D

   Increase tidal volume to 600 mL

Appeared in: NORCET-11 Prelims

Explanation

• COPD patients on mechanical ventilation are at risk for air trapping (auto-PEEP) due to prolonged expiratory time constants.
• Waveform not returning to baseline before the next breath indicates incomplete exhalation and dynamic hyperinflation.
• Sudden hypotension and tachycardia are signs of increased intrathoracic pressure from trapped air, reducing venous return.
• Decreasing respiratory rate allows more time for expiration, reducing air trapping and improving hemodynamics.
• This is the immediate and most effective ventilator adjustment in this scenario.

Why Other Options Were Wrong

• Option A: Increasing PEEP in a COPD patient with air trapping will worsen hyperinflation and further decrease venous return, increasing the risk of barotrauma and hypotension.
• Option B: Increasing FiO2 to 100 percent may temporarily improve oxygenation but does not address the underlying problem of air trapping and dynamic hyperinflation.
• Option D: Increasing tidal volume will increase minute ventilation but also worsen air trapping and hyperinflation in obstructive lung disease.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Immediate ventilator adjustment for dynamic hyperinflation (auto-PEEP) in COPD helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Nurses must recognize signs of dynamic hyperinflation (auto-PEEP) in ventilated COPD patients to prevent life-threatening complications.
• Immediate ventilator adjustment can reverse hypotension and tachycardia caused by decreased venous return.
• What if? If the patient had hypoxemia without signs of air trapping, increasing PEEP or FiO2 might be considered instead.

How to Approach the Question

• Identify the clinical scenario: COPD, mechanical ventilation, ABG with respiratory acidosis, and waveform findings.
• Recognize the significance of the waveform not returning to baseline: indicates air trapping (auto-PEEP).
• Link sudden hypotension and tachycardia to dynamic hyperinflation and decreased venous return.
• Eliminate options that worsen air trapping (increased PEEP, increased tidal volume).
• Select the intervention that increases expiratory time: decrease respiratory rate.

Concept Tested & Keywords

• Concept Tested: Immediate ventilator adjustment for dynamic hyperinflation (auto-PEEP) in COPD
• Stem keywords: COPD, mechanical ventilation, ABG, prolonged expiratory phase, hypotension, tachycardia
• Lead-in keywords: immediately, ventilator adjustment
• Clinical cues: Waveform shows prolonged expiratory phase without returning to baseline
• Clinical cues: Sudden hypotension and tachycardia

Question ID

QahB3vmnAsU4EVpldlQW6D

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 2 p. 211-213

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 667-669