A 59-year-old patient is in severe respiratory distress in the emergency department. The patient is being treated for congestive heart failure and pulmonary edema
Vital signs are pulse 98 beats/min, respiratory rate 23 breaths/min, and BP 138/98 mm Hg. The patient's ABG results on a nonrebreather mask are as follows: pH 7.35; partial PaCO2 45 mm Hg; PaO2 49 mm Hg; SaO2 79%; and HCO3? 24 mEq/L. The respiratory therapy that is most appropri-ate at this time is which of the following?
a. 6 L/min nasal cannula
b. 50% air entrainment mask
c. Mask continuous positive airway pressure (CPAP) with 100% oxygen
d. Intubate and mechanically ventilate
ANS: C
This patient's oxygenation is not responding well to the nonrebreather mask. This is indicative of refractory hypoxemia. The next step in the treatment of a patient with congestive heart failure (CHF) who is moving air would be to use a continuous positive airway pressure (CPAP) mask with supplemental oxygen. CPAP is very effective in the treatment of hypoxemia caused by heart failure. It can relieve some of the vascular congestion, reduce the patient's work of breath-ing, and improve gas exchange. This patient is not quite a candidate for intubation and mechani-cal ventilation because he is still moving air as evidenced by his partial pressure of carbon dioxide in the arteries (PaCO2) of 45 mm Hg. Both the nasal cannula and air entrainment mask, in this case, are a step backward in the management of this patient.
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