A 64-year-old female patient having an acute exacerbation of chronic obstructive pulmonary dis-ease (COPD) was admitted to the hospital yesterday

During rounds today the respiratory therapist finds the patient to be difficult to arouse and has the following physical findings: heart rate 102 beats/min, respiratory rate 23 breaths/min shallow and slightly labored, breath sounds are bilaterally decreased with rhonchi in both bases. The pa-tient has a frequent but weak cough. The respiratory therapist draws an ABG with the following results on a 2 L/min nasal cannula: pH 7.52, PaCO2 30 mm Hg, PaO2 45 mm Hg, SaO2 86%, HCO3? 24 m Eq/L. The most appropriate action is which of the following?
a. Intubate and mechanically ventilate.
b. Increase the nasal cannula to 4 L/min.
c. Administer incentive spirometry.
d. Begin noninvasive positive pressure venti-lation.

ANS: B
It would be inappropriate to intubate or use noninvasive positive pressure ventilation (NPPV) on this patient at this time because the patient is able to move air, as evidence by the partial pressure of carbon dioxide (PaCO2) of 30 mm Hg in the arteries. This patient might benefit from lung ex-pansion therapy. However, she would not be able to cooperate to perform the incentive spirome-try properly because she is difficult to arouse. The patient would benefit from an increase in ox-ygen therapy by increasing the nasal cannula flow to 4 L/min since her partial pressure of oxygen in the arteries (PaO2) is 45 mm Hg on 2 L/min nasal cannula. When the 2 L/min is estimated to be approximately 28% oxygen the PaO2/FIO2 is 161. This is a critical value. This patient would also benefit from bronchial hygiene therapy to mobilize the retained secretions.