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To C-PAP? or not to C-PAP? (Part 1)

Posted Oct 23 2008 1:38pm
Aggressive management of respiratory problems is usually a pretty solid idea. Don't want it to go down hill on you and they can quickly. It used to be, when we had a failure patient that was in respiratory distress and they were getting tired we would bag this patient or nasally intubate them. Along with the NTG, Lasix and MS. Because we had to protect their airway and help them along when they get too tired. With the placement of C-PAP on our units that approach is starting to go away. If we can get to them before them get worn completely out, they can usually be turned around with medication and C-PAP. Here is the story of 2 patients. C-PAP or no? You decide.

Patient #1 (0400) : 90 y/o complaining of difficulty breathing increasing all day and into the night. Hx of HTN, Renal failure ( w/ dialysis), CHF, and other "heart problems". Pt is due for dialysis today w/ the last appointment being 2 days prior. Pt does not produce urine. Pt presents sitting on couch A&Ox3 but anxious, perrl, skin pink,w,d. pt is able to speak 3-4 word sentences and becomes more sob while talking. Pt has increased work of breathing. Vitals: RR-32 HR- 120 BP- 230/150 LS- clear in uppers A&P, crackles in bases A&P. No obvious edema in extremities. On 6L o2 pt sats are 90%. Sinus tach on the monitor w/ occasional multifocal PVCs. Pt denies cp, abd pain, weakness, dizziness, ha, n,v,d or fever. Due to living condition and placement of pt, pt has to ambulate onto porch. Pt becomes increasingly more sob with movement.

Patient #2 (0530): 78 y/o complaining of difficulty breathing increasing all day and into the night. Hx of HTN,CHF, DM, complete blindness, other "heart problems" and was released from hospital 24 hours ago after being in for pneumonia. Pt states that they were told not to take their lasix again until after the holiday weekend when they could call the doctor to have him advise on the dose. Pt has been without lasix for 24 hours. Pt presents lying on the bed, A&OX3, skin pink, w,d. Pt is able to speak full sentences but does become sob when speaking. Pt feels afebrile. Admits to productive cough unknown color. Vitals: RR-24 HR- 88 BP- 210/90 LS- Clear on the right upper and lower A&P, diminished on left in lower A&P, very little air movement heard in upper. No rales, rhonchi, wheezes heard. On RA pt sats are 87%. On monitor pt is in sinus rhythm w/o ectopy. Pt has rounded taught abdomen that they state is not normally that way. No abd pain. Edema noted in right hand and arm, small amount of pedal edema noted, non-pitting. Pt also denies cp, weakness, dizziness, ha, n,v,d or fever. Pt was able to be carried from bed to stretcher.

So how would you treat each patient? My response to both in a day or so.
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