A 52-year-old male with a medical history of congestive heart failure and hypertension arrives in the emergency department because of an acute onset of dyspnea. The patient has pink frothy se-cretions at the mouth

A rapid physical assessment reveals a pulse of 128 beats/min, respiratory rate 28 breaths/min and labored, and blood pressure 82/56 mm Hg. Bilateral coarse crackles are heard in the lung bases. Arterial blood gas results on a 12 L/min nonrebreather mask are: pH 7.32, PaCO2 49 mm Hg, PaO2 50 mm Hg, arterial SaO2 74%. The most appropriate immediate action for this patient is which of the following?
a. Intubation and mechanical ventilation
b. Increase flow to the nonrebreather mask
c. Continuous positive airway pressure via mask
d. Nasotracheal suctioning and a high flow nasal cannula

ANS: A
This patient is hypoxemic with a nonrebreather mask and is also unable to move a sufficient amount of air. This is evidenced by the patient's partial pressure of oxygen in the arteries (PaO2) of 50 mm Hg and partial pressure of carbon dioxide in the arteries (PaCO2) of 49 mm Hg. Three out of the four oxygenation criteria are below the critical values. The pink frothy sputum is car-diogenic pulmonary edema and the hypotension is caused by cardiogenic shock. This is a medical emergency requiring intubation, mechanical ventilation, and positive end expiratory pressure (PEEP). Increasing the flow of oxygen to the nonrebreather, continuous positive airway pressure (CPAP) via mask, nasotracheal suctioning, and a high flow nasal cannula will not reverse this pa-tient's oxygenation or ventilation issues.