A 36-year-old woman comes to the emergency department because of worsening shortness of breath and cough for 4 days. Her medical problems include rheumatoid arthritis, interstitial lung disease on home oxygen, and pulmonary hypertension. Her trachea is cannulated because of respiratory distress and central venous access is obtained. In the intensive care unit, her temperature is 37.2 C (99 F), blood pressure is 99/67 mm Hg, and pulse is 120 /min. The patient's pulse oximetry shows 100% on assist control mode with tidal volumes of 300 mL, respiratory rate of 20/min, fraction of inspired oxygen (FiO₂) of 100%, and positive end-expiratory pressure (PEEP) of 5 cm H₂O. Examination reveals right-sided crackles and decreased breath sounds on the left. Heart sounds are regular with a loud second heart sound. The abdomen is soft and non-tender. Examination shows no peripheral edema. Laboratory values are as follows: A chest radiograph is performed. Which of the following is the most appropriate next step in management?

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11ec193a_9717_ce54_853d_05447f0df97d_MD0002_00 The patient's chest radiograph reveals diffuse interstitial prominence and right mainstem bronchus intubation. The endotracheal tube must be withdrawn for proper positioning. Ideal positioning of the tip is 2 to 6 cm from the carina to allow for migration with head movement. When the neck is flexed, the end of the endotracheal tube migrates toward the carina. Positioning can be confirmed by bilateral auscultation, observation of chest wall movement, and insertion depth (21 cm for women and 23 cm for men, measured at the corner of the mouth). A one-time chest radiograph is required after intubation to confirm placement. Studies have shown similar mortality, ICU length of stay, and mechanical ventilation duration with chest radiographs obtained on an as-needed basis as compared to daily. (Choice A) Increasing the PEEP is not necessary in a patient with adequate oxygenation. (Choice B) Increasing the tidal volume will not address the mainstem intubation. (Choice C) Loss of lung markings on the affected side (radiolucency) can signify a pneumothorax, which requires chest tube placement. However, this patient's x-ray reveals lung markings and is not consistent with pneumothorax. (Choice E) Suctioning would be beneficial in a patient with a mucus plug and atelectasis, which would appear as opacification and loss of lung volume on chest radiograph. This is not present in this image. Educational objective: Proper positioning of the endotracheal tube can be confirmed by auscultation, observation, and insertion depth. A chest radiograph is required to confirm placement. __________ References: Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. (http://www.ncbi.nlm.nih.gov/pubmed/21062875)

A 36-Year-Old Woman Comes to the Emergency Department Because of Worsening