Answer for question 4.11 Debbie, Kalra, Buendia, Wang got it right. This patient has progressive exacerbation of COPD that is not responding to therapy with bronchodilators, corticosteroids, and antibiotics. Noninvasive positive-pressure ventilation is the most appropriate next step for a patient with severe dyspnea, respiratory rate ≥25 beats per minute, or pCO2 between 45 and 60 (SOE=A). Noninvasive positive-pressure ventilation can reduce the rate of intubation and length of stay in patients with pCO2 as high as 80 mmHg. A variety of protocols can be used. One approach is to initiate therapy with a bilevel device set to an inspiratory positive pressure of 8–12 cm H2O and expiratory positive pressure of 4 cm H2O, with the inspiratory and expiratory positive pressure increased in increments of 2 cm H2O based on patient response, tolerance, and arterial blood gas results (obtained pretreatment, at 1 and 4 hours after initiating therapy, and then as needed). Supplemental oxygen ≤4 L/min can be administered as needed to keep O2 saturation >90%. There should be continuous monitoring of O2 saturation, pulse, respiratory rate, and blood pressure. Relative contraindications to use of noninvasive positive-pressure ventilation include altered mental status (Glasgow coma scale
Posted on: Fri, 09 Aug 2013 01:58:46 +0000
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