Nonivasive Ventilation: Update on Uses for the Critically Ill (original) (raw)

The triage nurse calls you to the resuscitation room and you see a morbidly obese male who is gasping for air and is cool, pale and diaphoretic. He has nasal flaring, pursed lip breathing, speaking in 1-2 word sentences, and rales to the apices. He is tripoding. EMS was unable to get intravenous access. BP is 240/160. EMS gave nitroglycerin sublingual but couldn't give lasix secondary to lack of iv access. You realize that attempting tracheal intubation on this patient is a recipe for disaster. You have used noninvasive ventilation (NIV) for your patients with chronic obstructive pulmonary disease (COPD), but you haven't tried it on patients with acute cardiogenic pulmonary edema (ACPE). You page the respiratory therapist to bring the noninvasive ventilator. You pray that the (NIV) will help the patient hang on so that he does not need a difficult tracheal intubation. The respiratory therapist asks whether you want bi-level positive airway pressure (BiPAP) or continuous airway pressure (CPAP). You are not sure, so you ask the respiratory therapist which modality she believes is best. She mentions CPAP, but wants to know what pressure to deliver. Again you defer to her knowledge and she replies, " 10 cm H 2 0 ". Finally, she wants to know whether you prefer a nasal mask, a face mask or a helmet. You reply. " Whatever you think is best is fine with me. " You promise yourself that you will review NIV in detail the moment you get some down time, most likely after this patient has been stabilized.

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