Respiratory Failure Patient Case Study


A 65-year-old man presents to the intensive care unit with increasing shortness of breath, cough, and fever for the last 2 days. He is diagnosed with right lower lobe pneumonia. He has a history of chronic obstructive lung disease and coronary artery disease. On examination, his temperature is 39.5 C; pulse, 120 beats per minute; respiratory rate, 40 breaths per minute; blood pressure, 70/30 mm Hg; and body mass index, 32.

Physical examination findings were consistent with severe sepsis with signs of impaired perfusion to the peripheries along with confusion and occasional combativeness. Oxygen saturation was 78% and patient was placed on 15 liters non-re-breather mask and his saturations improved to 88%. Arterial blood gas analysis shows a pH of 7.2 and a pCO2 of 70 mm Hg on 15 liters non-re-breather mask.


Which of the following is the most appropriate next step in management?

A. Bi-level positive airway pressure

B. Intubation and mechanical ventilation (Correct)

C. Continuous Positive Airway Pressure (CPAP)

D. High-flow humidified oxygen


Intubation and mechanical ventilation are the most appropriate next steps in management because the patient is in acute hypercapnic and hypoxemic respiratory failure in the setting of severe sepsis and underlying history of chronic obstructive lung disease. Hypotension and combativeness are contraindications for the use of noninvasive positive-pressure ventilation (NPPV) such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP). If there were no contraindications for NPPV, BPAP would have been the preferred approach due to his hypercapnia. High-flow humidified oxygen might help with oxygenation but may not help or even worsen his hypercapnia.


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