An elderly patient with worsening COPD presents to the Emergency Department (ED) with fatigue and altered level of consciousness (ALOC). Upon assessment the nurse finds SpO2 saturation of 87%, and ABG: pH 7.21, CO2 of 75, and HCO3 of 24. Which immediate intervention is BEST?
Call respiratory for an Albuterol breathing treatment.
Place on BiPap machine.
Put on oxygen 1L via Nasal Cannula.
Have them breathe into a paper bag.
The Correct Answer is B
Choice A rationale
Albuterol is a short-acting beta-2 adrenergic agonist, primarily causing bronchodilation by stimulating beta-2 receptors in bronchial smooth muscle, leading to cyclic AMP production and muscle relaxation. While beneficial for bronchospasm, it does not directly address the severe hypercapnia and respiratory acidosis indicated by the patient's ABG (pH 7.21, CO2 75), which suggests significant ventilatory failure beyond simple bronchodilation.
Choice B rationale
BiPAP (Bilevel Positive Airway Pressure) provides non-invasive ventilatory support, delivering inspiratory and expiratory positive airway pressure. This improves alveolar ventilation by increasing tidal volume and reducing the work of breathing, effectively decreasing the elevated CO2 (75 mmHg, normal range 35-45 mmHg) and improving the acidotic pH (7.21, normal range 7.35-7.45) in a patient with acute hypercapnic respiratory failure exacerbated by COPD.
Choice C rationale
Administering oxygen via nasal cannula at 1 L/min may worsen hypercapnia in COPD patients with chronic CO2 retention, due to the blunting of hypoxic drive. Their primary respiratory stimulus is hypoxia, and providing supplemental oxygen can suppress this drive, further depressing ventilation and exacerbating CO2 retention, which is already dangerously high at 75 mmHg. The SpO2 of 87% (normal range 95-100%) indicates hypoxemia, but the primary issue is ventilatory failure.
Choice D rationale
Breathing into a paper bag increases the rebreathing of exhaled CO2, which is a therapeutic intervention for hyperventilation and respiratory alkalosis. In this patient, the ABG shows significant respiratory acidosis (pH 7.21, CO2 75 mmHg), meaning they are retaining too much CO2. Therefore, increasing CO2 rebreathing would exacerbate the already severe hypercapnia and acidosis, leading to further decompensation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Respiratory acidosis is characterized by a low pH and an elevated PaCO2. In this scenario, the pH is elevated (7.57), indicating alkalosis, and the PaCO2 (37 mmHg) is within the normal range, not elevated. Therefore, this option is inconsistent with the provided ABG results.
Choice B rationale
Metabolic acidosis is characterized by a low pH and a low bicarbonate level. The patient's pH is elevated (7.57), signifying alkalosis, and the bicarbonate (30 mEq/L) is elevated. These findings contradict the definition of metabolic acidosis.
Choice C rationale
The pH of 7.57 is significantly elevated, indicating alkalosis. The bicarbonate (HCO3) level of 30 mEq/L is elevated above the normal range (22-26 mEq/L), which directly accounts for the alkalosis. The PaCO2 of 37 mmHg is within the normal range (35-45 mmHg), indicating no respiratory compensation has occurred. This complete lack of respiratory compensation points to uncompensated metabolic alkalosis. The loss of gastric acid through the NGT contributes to this condition.
Choice D rationale
Respiratory acidosis is characterized by a low pH and an elevated PaCO2. Here, the pH is high (alkalotic) and the PaCO2 is within normal limits. Thus, this option does not match the observed blood gas values.
Correct Answer is A
Explanation
Choice A rationale
The non-rebreather mask delivers the highest possible fraction of inspired oxygen (FiO2) among conventional oxygen delivery devices, often reaching 85-90%. This high concentration is achieved by a one-way valve system that prevents exhaled air from mixing with the inspired oxygen and a reservoir bag that stores a high concentration of oxygen. This mechanism minimizes room air entrainment, maximizing oxygen delivery to the patient's respiratory system.
Choice B rationale
A non-rebreather mask is designed to deliver high concentrations of oxygen and prevent rebreathing of exhaled gases, including carbon dioxide. The one-way valves direct exhaled air out of the mask, ensuring that the patient inhales nearly pure oxygen from the reservoir bag, thereby minimizing CO2 retention, not increasing it. This physiological effect ensures efficient gas exchange.
Choice C rationale
While a simple mask may appear less complex in its physical design, its operation still requires proper fitting and flow rate adjustment for effective oxygen delivery. The perceived simplicity does not outweigh the significant physiological advantage of a non-rebreather mask in delivering higher oxygen concentrations, which is the primary goal of oxygen therapy.
Choice D rationale
Non-rebreather masks, due to their tight seal and large reservoir bag, can exacerbate feelings of claustrophobia in some patients. Similarly, the mask's design might induce or worsen nausea in individuals prone to it, making simpler face masks or nasal cannulas often more tolerable options for these patient populations. Patient comfort and tolerance are crucial considerations in oxygen therapy.
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