im doing this from memory

88 y.o. hungarian lady, COPD, asthma, HTN, DM, arthritis, CRI. Home O2 3L, hx of a-fib and inferior MI 6 years ago (no stents). GERD, well controlled

Meds: oral hypoglycemics, albuterol IH, prevacid, advair, lasix, tylenol, ibuprofen, colace, coumadin (off x 5 days), other old person meds

CR 1.4, BUN 19.
Hgb 10
NSR currently
BP 190/80
doesn't speak english, and is HOH (sweet)
MP I, TMD ok, edentulous


in for a lap chole (can't remember why she was having it done) after being turned down by the surgeon multiple times. Apparently he was hassled into doing it

give her a couple hits off an albuterol IH preop. Thorough preo2, induce, sux, as I go to tube her her SaO2 drops to 80%, Easy intubation. + BBS/ETCO2. We use zemuron 30mg as our paralytic.

Initial peak pressures 33 on TV 500, RR 10, I:E 1:2, FiO2 80%, SaO2 100%
Insuffilation, trendelenberg, PP increase to 40, switch to PCV, get a TV of 500 with a PP 33.

3-5 min after trochar placement, peak pressures start increasing drastically, SaO2 quicky drops to 75%. hand bag, ask for deflation, which we get. bag feels really tight, peak pressures 50 with TV of 60. still has bilateral breath sounds, but very diminished. give a bunch more albuterol, still extremely tight.

Now peak pressures up to 60-70, delivering tidal volumes of 80-100 ml despite albuterol. ETT in the same place as intubation, not kinked, lung sounds still very diminished, slight wheezing, but otherwise clear.


whats going on and how do you fix it