A 72-year-old male patient (height 6'2", weight 95 kg) with a history of congestive heart failure (CHF) presents to the emergency department complaining of shortness of breath and inability to lie down to sleep

Question

Physical assessment reveals a very anxious patient with a pulse of 140, respirations 32, and la-bored with diaphoresis. Breath sounds are decreased with bibasilar coarse crackles. The patient has a productive cough of pink frothy secretions. The patient is placed on a nonrebreather mask and the resulting arterial blood gases (ABG) show: pH 7.25, partial pressure of carbon dioxide (PaCO2) 55 mm Hg, partial pressure of oxygen (PaO2) 54 mm Hg, oxygen saturation (SaO2) 86%, bicarbonate (HCO3?) 24 mEq/L. The most appropriate immediate action to take includes which of the following?
a. Face mask continuous positive airway pressure (CPAP) 10 cm H2O
b. Intubate, volume-controlled continuous mandatory ventilation (VC-CMV), respir-atory frequency (f) 20, tidal volume (VT) 810 mL, positive end-expiratory pressure (PEEP) 8 cm H2O, fractional inspired ox-ygen (FIO2) 1.0
c. Intubate, volume-controlled intermittent mandatory ventilation (VC-IMV), f 6, VT 425 mL, PEEP 10 cm H2O, FIO2 0.80
d. Noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pres-sure (bilevel PAP), inspiratory positive airway pressure (IPAP) 15 cm H2O, expir-atory positive airway pressure (EPAP) 5 cm H2O, FIO2 0.60

Answer 1

ANS: D
The patient is suffering from cardiogenic pulmonary edema from congestive heart failure (CHF) and has both hypercapnic and hypoxemic respiratory failure. The use of noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pressure (bilevel PAP) while waiting for pharmacological treatment to take effect would be appropriate. Face mask continuous positive airway pressure (CPAP) may not provide enough support to allow the patient to reduce the par-tial pressure of carbon dioxide (PaCO2). Although intubation is a more aggressive alternative, the choices provided are not within the guidelines for ventilation of patients with CHF. These guide-lines include a tidal volume (VT) between 8 and 12 mL/kg. That would be between 405 and 648 mL. This eliminates the answer with 810 mL tidal volume. The fractional inspired oxygen (FIO2) initially should be 1.0; this eliminates the choice with 0.80.