A 68-year-old female admitted for congestive heart failure is in respiratory distress and is being seen by the hospital's medical emergency team in her regular room

The patient is in obvious respiratory distress and is immediately placed on a nonrebreather mask. Physical assessment reveals: pulse 138 and thready; respiratory rate 30, shallow and labored; temperature 37° C; blood pressure 110/68. Breath sounds are bilaterally decreased with coarse crackles on inspiration. EKG shows normal sinus rhythm with widened cardiac output (QT) in-terval and an occasional irregular beat. No coughing is noted. The arterial blood gas on the non-rebreather mask is: pH 7.34; PCO2 46 mm Hg; partial pressure of oxygen in the arteries (PaO2) is 52 mm Hg; oxygen saturation is 86%; bicarbonate (HCO3?) is 24 mEq/L. The patient is diapho-retic. The most appropriate ventilator mode to manage this patient initially is which of the fol-lowing?
a. Noninvasive positive pressure ventilation (NIV)
b. Airway pressure release ventilation (APRV)
c. Volume-controlled intermittent mandatory ventilation (VC-IMV)
d. Pressure-controlled intermittent mandato-ry ventilation (PC-IMV)

ANS: A
This patient is in impending respiratory failure due to a congestive heart failure (CHF) exacerba-tion. The arterial blood gas (ABG) also reveals mild hypercapnia and severe hypoxemia. With the proper treatment this exacerbation could be reversed fairly quickly. Noninvasive positive pressure ventilation (NIV), in the form of bilevel positive airway pressure, is appropriate because of this. All the other choices require intubation. If the NIV doesn't work to decrease the patient's respir-atory failure then intubation would be the next step.