A 76-Year-Old Man Is Brought to the Hospital from a Nursing

question 655

Multiple Choice

A 76-year-old man is brought to the hospital from a nursing home due to confusion, high-grade fever, and decreased oral intake.  Three days ago, he underwent cystoscopy with removal of a bladder polyp.  The patient has a history of benign prostate hyperplasia and recurrent urinary tract infections.  Other medical conditions include type 2 diabetes mellitus, hypertension, osteoarthritis, and gout.  On admission, the patient has respiratory failure requiring endotracheal intubation and mechanical ventilation.  He is resuscitated with intravenous normal saline and treated with broad-spectrum intravenous antibiotics.  Ventilator settings are as follows: tidal volume, 370 mL (6 mL/kg of ideal body weight) ; respiratory rate, 22/min; positive end-expiratory pressure, 5 mm Hg; and FiO₂, 70%.  Inspiratory plateau pressure is normal (<30 cm H₂O) .  Chest x-ray reveals extensive bilateral alveolar opacities.  The results of arterial blood gas analysis are as follows: Which of the following is the best next step in management of this patient?

• A)Increase FiO₂
• B)Increase positive end-expiratory pressure
• C)Increase respiratory rate
• D)Increase tidal volume
• E)Keep current respiratory settings

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