Question of the Week
For November 12, 2019
An 82-year-old man is brought to the emergency department with a 3-day history of increasing dyspnea, wheezing, purulent sputum, and cough. He also has a history of severe chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease.
On examination, the patient is afebrile, his blood pressure is 145/80 mm Hg, his heart rate is 115 beats per minute, his respiratory rate is 40 breaths per minute, and his oxygen saturation is 88% while receiving 3 liters of oxygen by nasal cannula. He is in respiratory distress, speaking in 1- to 2-word sentences and using accessory muscles and pursed lips to breathe. He has tachycardia with a regular rhythm, and his jugular venous pressure is not elevated. His breath sounds are diminished bilaterally with scattered expiratory wheezes.
An arterial blood gas sample reveals a pH of 7.15, a partial pressure of carbon dioxide of 100 mm Hg (reference range, 35–45) and a partial pressure of oxygen of 60 mm Hg (80–100).
The patient is intubated with initial ventilator settings of volume control with a respiratory rate of 25 breaths per minute, tidal volume of 6 mL/kg ideal body weight, positive end-expiratory pressure of 5 cm of water, and fraction of inspired oxygen of 100%.
Chest radiography after intubation reveals hyperinflated lungs with adequate endotracheal-tube position and no focal consolidation. On arrival to the intensive care unit 20 minutes later, the patient’s blood pressure is 74/43 mm Hg.
What is the best next step for this patient?