New Questions

Rafaela Schulz is a 28-year-old woman who developed acute-onset ascending paralysis over 48 hours, now completely paretic including loss of all cranial nerve motor function. She has a tracheostomy and is fully ventilator-dependent with no spontaneous respiratory efforts. Pupils are 3 mm bilaterally, minimally reactive, requiring pupillometry to confirm reactivity. The neurology team raises the question of neurological death determination.
Over subsequent weeks she shows partial neurological recovery with preserved vertical eye movements and voluntary eyelid closure but no limb or bulbar motor recovery. She is on assist-control ventilation and the ventilator displays 14 total breaths per minute against a set backup rate of 8. The esophageal pressure tracing is shown below. Several weeks later she has further recovery — she is awake, triggering comfortably, and breathing adequately on pressure support. She cannot tolerate a tracheostomy mask trial. The team partially deflates the cuff while maintaining positive pressure ventilation to allow her to phonate.

a) State the primary reason a positive apnea test in this patient cannot be used to diagnose neurological death (1 mark)

b) State two low-technology communication strategies applicable to this patient given her available motor repertoire of vertical eye movements and voluntary eyelid closure. (2 marks)

c) State the ventilator phenomenon demonstrated by the esophageal pressure tracing described and shown, and identify the single Pes finding that confirms this diagnosis. (2 marks)

d) State what P0.1 measures and identify its expected value in this patient (2 marks)

e) State two ventilator parameter adjustments that should be made to address the autotriggering, targeting its most common cause in this clinical context. (2 marks)

f) State two ventilator alarms expected to activate during partial cuff deflation on positive pressure ventilation and name the primary ventilator adjustment required to compensate for the intentional leak. (2 marks)

Grigor Brandt is a 69-year-old man with a size 6 cuffed tracheostomy following 28 days of mechanical ventilation for ARDS. He has been ventilator-independent for 72 hours. Cuff deflation is attempted and within 10 minutes he becomes tachypnoeic (RR 34), SpO2 drops to 88%, and copious secretions appear at the tracheostomy site. His voice is absent and he is unable to phonate with the cuff deflated.

a) List the four axes that must be systematically assessed when a patient does not tolerate cuff deflation. (2 marks)

b) State the most likely primary cause of cuff deflation failure in this patient and identify the management directed at this specific cause. (2 marks)

c) State what the absent phonation with cuff deflated suggests and name the investigation indicated to evaluate this finding. (1 mark)

d) State what a hemodynamic deterioration during cuff deflation would indicate and name the next step if this is the primary failure mechanism. (1 mark)

Three patients on the chronic ventilator ward each have different tracheostomy tube situations.
Patient A: a 58-year-old man on 16 hours per day of pressure support ventilation with copious thick secretions. His ventilator shows progressively rising peak pressures and reduced tidal volume alarms over 6 hours. Examination confirms the inner cannula is in situ and heavily coated with dried secretions.
Patient B: a 71-year-old woman who is ventilator-independent for 20 hours per day with adequate cough. Her team placed a fenestrated tube to facilitate phonation and decannulation planning. She develops a persistent granuloma at the fenestration site and secretions are difficult to clear as the suction catheter repeatedly diverts through the fenestration.
Patient C: a 44-year-old man who has been fully ventilator-independent for six weeks with strong cough, requiring suctioning only once daily, and is being prepared for decannulation with a size 8 cuffed single-lumen tube in situ.

a) State the cause of Patient A’s ventilator alarms and identify the specific advantage of inner cannula tubes that is relevant to his management. (2 marks)

b) State two complications of fenestrated tracheostomy tubes illustrated by Patient B’s course. (2 marks)

c) State the most appropriate tube change for Patient C at this stage and name one clinical advantage of this change. (2 marks)

Mirjam Flanagan is a 64-year-old woman with COPD who required mechanical ventilation for 24 days following severe pneumonia and has had a size 8 cuffed tracheostomy for 18 days.
Phase 1 (Week 4): She has been off invasive mechanical ventilation on tracheostomy mask oxygen, FiO2 0.35, SpO2 94%, suctioning required every 6 hours, haemodynamically stable. Cuff deflation is attempted and tolerated. She passes a finger occlusion test.
Phase 2 (Week 5): She has been downsized to a size 6 cuffed tube.
Phase 3 (Week 6): She is liberated from invasive ventilation. The team debates between a cap with cuff deflated, a speaking valve, and a high-flow tracheostomy adapter.

a) State why downsizing from a size 8 to a size 6 tube before adequate ventilator independence increases work of breathing and identify the physiologic mechanism. (2 marks)

b) State the prerequisite cuff condition for safe speaking valve use and identify the harm of using a speaking valve with the cuff inflated. (2 marks)

c) State the preferred approach for the Phase 3 trial (cap, speaking valve, high-flow) (1 mark)

d) State one criterion used to assess cough adequacy before proceeding to decannulation. (1 mark)

Piotr Banda is a 58-year-old man with severe ARDS who received 14 days of controlled mechanical ventilation with cisatracurium infusion and high-dose methylprednisolone for 12 days. On day 18 he is awake but fails every SBT within 20 minutes. Neurological exam shows proximal limb weakness with preserved distal sensation, absent deep tendon reflexes in the lower limbs, and facial muscle sparing. He has a tracheostomy. His cough effort on suctioning is weak and insufficient to mobilize secretions into the tracheostomy tube, resulting in worsening atelectasis on CXR.

a) State the clinical weakness pattern and identify one finding that distinguishes this presentation from pure steroid myopathy. (2 marks)

b) List four bedside measurements used to quantify respiratory muscle strength in a tracheostomized patient. (2 marks)

c) State two modifiable risk factors for ICUAW present in this patient’s course. (1 mark)

d) List three interventions to address the inadequate cough and secretion clearance in this patient. (2 marks)

Birgitta Volkov is a 71-year-old woman with morbid obesity (BMI 44), a short neck, and a non-palpable cricothyroid membrane who has been mechanically ventilated for 16 days. The team proceeds with bedside percutaneous tracheostomy. During the procedure the patient coughs violently, the bronchoscopist loses the airway view, and the tracheostomy tube is placed blindly and secured. SpO2 drops to 81%. Thirty minutes later SpO2 has recovered to 94% on FiO2 0.60 (previously 0.35), peak airway pressure is 38 cmH2O (previously 26), and bilateral breath sounds are equal with the tube in midline position. The RT is concerned about a false passage given the coughing, loss of view, and worsening hypoxaemia.

a) State two anatomical features of this patient representing relative contraindications to percutaneous over open tracheostomy. (2 marks)

b) State the two best methods to confirm endotracheal placement of the tracheostomy tube and name one additional confirmatory modality. (3 marks)

c) State the most likely cause of the post-procedure hypoxaemia and identify two findings that specifically argue against false passage. (3 marks)

Cormac Almeida is a 67-year-old man with hypertension and type 2 diabetes admitted with septic shock from pneumonia requiring 18 days of mechanical ventilation, deep sedation (RASS -3 to -4) throughout, and no physiotherapy due to staffing constraints. He received corticosteroids for vasopressor-refractory shock for 10 days. He is extubated on day 22. His wife reports he has not slept normally since extubation, seems confused at times, and cried unprovoked twice yesterday. On exam he cannot lift his arms against gravity.

a) State the syndrome this clinical picture represents. (1 mark)

b) State the three primary domains of this syndrome and classify each of this patient’s symptoms into the correct domain. (3 marks)

c) List four ICU risk factors for this syndrome present in this patient’s course. (2 marks)

d) State two ICU-based prevention strategies absent in this case supported by current evidence. (1 mark)

e) State two components of a structured post-ICU follow-up strategy for this patient and his wife. (1 mark)