Questions: The physician admitted the patient to the respiratory intensive care unit (ICU) to be monitored closely. His vital capacity was 3500 mL on admission but decreased to 700 mL during the subsequent 48 hours. During this time, he also developed mild difficulties in swallowing. Shortly after this development, the pulse oximeter alarm sounded and the physician was notified. Because the physician anticipated that the patient would require respiratory assistance for several weeks, a tracheostomy was performed using local anesthesia, and the patient was connected to a ventilator with an FIO2 of 0.3, intermittent mandatory ventilation (IMV) rate 12 / min, VT 0.8 L, and pressure support ventilation (PSV) mode. Twenty minutes later, his blood gas values were pH 7.43, PaCO2 38, HCO3- 23, PaO2 104, and SaO2 97%. The respiratory care practitioner entered a SOAP in the patient's chart. Based on these clinical data, how would you SOAP this patient?

To SOAP this patient, we will follow the SOAP format, which stands for Subjective, Objective, Assessment, and Plan. This format is commonly used in medical documentation to organize patient information and clinical decision-making.

Subjective:

• The patient was admitted to the respiratory ICU due to a significant decrease in vital capacity from 3500 mL to 700 mL over 48 hours.
• The patient developed mild difficulties in swallowing, indicating potential neuromuscular involvement or respiratory muscle weakness.

Objective:

• Vital capacity decreased significantly, indicating respiratory muscle weakness.
• A tracheostomy was performed, and the patient was placed on a ventilator with specific settings: $\mathrm{FIO}_{2}$ of 0.3, IMV rate of 12/min, $\mathrm{V}_{\mathrm{T}}$ of 0.8 L, and PSV mode.
• Blood gas values 20 minutes post-ventilation: pH 7.43, $\mathrm{PaCO}_{2}$ 38 mmHg, $\mathrm{HCO}_{3}^-$ 23 mEq/L, $\mathrm{PaO}_{2}$ 104 mmHg, and $\mathrm{SaO}_{2}$ 97%.

Assessment:

• The patient is experiencing acute respiratory failure, likely due to neuromuscular weakness, as evidenced by the decreased vital capacity and difficulty swallowing.
• The blood gas values indicate adequate ventilation and oxygenation with a slightly alkalotic pH, normal $\mathrm{PaCO}_{2}$, and elevated $\mathrm{PaO}_{2}$, suggesting effective ventilatory support.

Plan:

• Continue monitoring the patient's respiratory status closely, including vital capacity and blood gas values.
• Maintain current ventilator settings as they are providing adequate support.
• Investigate the underlying cause of the neuromuscular weakness and swallowing difficulties, which may include neurological evaluation and further diagnostic testing.
• Provide supportive care, including nutritional support and physical therapy, to address swallowing difficulties and prevent complications.
• Reassess the need for ventilatory support regularly and adjust settings as necessary based on the patient's clinical progress.

In summary, the patient is being effectively managed on ventilatory support following a significant decline in respiratory function, with plans to investigate the underlying cause and provide comprehensive supportive care.