每日一题_2022.07.11

A 55-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) requiring intubation is admitted to the ICU for a COPD exacerbation due to seasonal influenza. He becomes more fatigued throughout the evening and is intubated for severe respiratory distress despite optimal medical management and noninvasive positive pressure ventilation. Post-intubation, the first arterial blood gas analysis reveals: pH 7.20, partial arterial carbon dioxide pressure 65 mm Hg, partial arterial oxygen pressure 150 mm Hg on ventilator settings of assist control/volume control, rate 16 breaths/min, tidal volume 450 mL, positive end-expiratory pressure 5 cm H2O, fraction of inspired oxygen 40%. Respiratory rate is increased to 24 breaths/min to address the respiratory acidosis. One hour later, he has a pulseless electrical activity arrest. The respiratory therapist is having difficulty using the bag valve mask, and end- tidal carbon dioxide is less than 10 mm Hg with adequate chest compressions. There are no breath sounds over either lung field.

Which of the following is the most appropriate next step in management?

A. IV epinephrine, 1 mg

B. Bilateral needle thoracostomy

C. Venoarterial extracorporeal membrane oxygenation

D. Reintubation due to endotracheal tube dislodgement

E. Disconnection of the bag valve mask from the endotracheal tube​

答案解析：

管理用于重度慢性阻塞性肺疾病 (COPD) 加重的机械呼吸机可以是确保充分通气以防止危及生命的酸中毒和减轻可能产生的内在呼气末正压的危险水平之间取得良好的平衡。允许性高碳酸血症通常耐受良好。在这种情况下，增加呼吸频率以使血气正常化导致呼气时间减少。在患有严重 COPD 和呼气流量受限的患者中，由此产生的自动 PEEP 导致心血管衰竭。断开患者与呼吸机的连接并让其呼气可能导致自主循环恢复。在这种情况下，可以考虑进行双侧胸腔穿刺术，因为 COPD 患者发生气胸的可能性更高，但在这种情况下这种可能性较小。同样，肾上腺素是高级心脏生命支持的标准，但这并不能解决导致该患者心脏骤停的问题。可以考虑静脉动脉体外膜肺氧合，但首先尝试其他操作更为谨慎。最后，考虑到潮气末二氧化碳较低但仍然存在，气管插管不太可能移位。

正确答案：E