A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD), requiring prior..

A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD), requiring prior intubation, and active tobacco use presents to the emergency department with shortness of breath. He states that over the last 24 hours, he has had increasing difficulty breathing. He denies fevers or chills at home and is not aware of any sick contacts. His initial vitals are temperature of 99.4 F, hear rate 90/min, blood pressure 130/80 mm Hg, respiratory rate 22/min, and SpO2 95%. On examination, he appears to have a mild increase in work of breathing. He is noted to have scattered wheezing

A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD), requiring prior intubation, and active tobacco use presents to the emergency department with shortness of breath. He states that over the last 24 hours, he has had increasing difficulty breathing. He denies fevers or chills at home and is not aware of any sick contacts. His initial vitals are temperature of 99.4 F, hear rate 90/min, blood pressure 130/80 mm Hg, respiratory rate 22/min, and SpO2 95%. On examination, he appears to have a mild increase in work of breathing. He is noted to have scattered wheezing throughout both lung fields. He is started on albuterol nebulizers and IV steroids. Three hours into his emergency room stay you are called to the bedside as the patient appears to be in more distress. His vitals demonstrate temperature of 99.8, HR 125, BP 120/70 with an RR of 35 and SpO2 90%. On examination, the patient is using accessory muscles, and his lung examination is notable for poor air movement with no wheezing. An arterial blood gas is performed pH 7.28, PCO2 50, and PaO2 65. A chest x-ray is performed and demonstrates hyperinflation of both lung fields with no infiltrate. He is intubated for hypoxemic respiratory failure and is subsequently paralyzed with a neuromuscular blocker secondary to ventilator dyssynchrony. He arrives to the ICU ventilated, with an FiO2 of 0.8, PEEP 10, RR 30, and TV 420 mL/kg (the patient weighs 70 kg). His arterial blood gas demonstrates a pH 7.29/PCO2 50/PaO2 200. His blood pressure upon arrival to the ICU is 80/50 mm Hg. 1. What would be the next step in management? A. Increase his tidal volumes B. Increase his PEEP from 10 to 15 C. Decrease the respiratory rate D. Increase the inspiratory time

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