A 68-year-old woman was admitted to the ICU with pneumonia and was intubated when she developed progressive hypoxemia. She has been on the ventilator for 5 days and has been toler-ating this therapy well

The patient has suddenly become severely agitated and appears to be fighting the ventilator. The ventilator's high pressure alarm is sounding continuously. The respiratory therapist disconnects the patient from the ventilator and begins manual ventilation with 100% oxygen and PEEP. The resuscitator bag is difficult to squeeze, breath sounds are present on the left with no adventitious sounds and absent on the right side, and percussion reveals hyperresonance over the right side. The most appropriate action to address this situation is which of the following?
a. Pull the endotracheal tube back until bi-lateral breath sounds are heard.
b. Administer a bronchodilator and suction the endotracheal tube.
c. Extubate the patient and reintubate with a larger endotracheal tube.
d. Insert a 14-gauge needle in the second in-tercostal space, midclavicular line, right side.

ANS: D
If the endotracheal tube had slipped into the right mainstem bronchus, breath sounds would be heard on the right side and not on the left. The absence of breath sounds on the right side indi-cates that the endotracheal tube has not slipped into the right mainstem bronchus. No adventi-tious breath sounds are heard over the left lung, the patient has no history of bronchospasm, and no wheezing is heard—this essentially eliminates bronchospasm as the problem. The patient had been tolerating mechanical ventilation well for 5 days; therefore, the ET tube is not too small. The presence of auto-PEEP would cause hyperresonance to percussion bilaterally. The patient appar-ently has a pneumothorax on the right side, as evidenced by the absence of breath sounds and hyperresonance to percussion on that side.