Week 9 Response 2

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Apr 3, 2024

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Week 9 Response 2 I agree with all of your differential diagnosis for this patient. There are some other diagnostic tests that you can use to diagnose the patient. A ProBNP can be used to differentiate between a CHF and COPD exacerbation. High levels of BNP in the bloodstream means that your heart is not pumping adequately and is in heart failure (National Library of Medicine, 2021a). In a normal person, there should only be small amounts in the blood. The higher the level of BNP in the blood, the more severe the heart failure is (National Library of Medicine, 2021a). I feel like this is one of the methods used to determine the difference between a CHF and COPD exacerbation. Another method to distinguish between the two would be an Echocardiogram. An Echocardiogram is a diagnostic test that is more detailed than an Xray and uses sound waves to create a moving picture of the heart (National Library of Medicine, 2021b). This test can determine which type of heart failure the patient is having and how their heart is functioning. This test is also used to diagnose HF by showing the pumping function of the heart, which is also called ejection fraction (National Library of Medicine, 2021b). There is a chance that the patient is experiencing both a CHF and COPD exacerbation at the same time. But I do feel as if these tests would be needed to rule out that statement. References National Library of Medicine. (2021a, March 4). Natriuretic Peptide Tests (BNP, NT-proBNP) . Medline Plus. Retrieved April 26, 2023, from https://medlineplus.gov/lab-tests/natriuretic-peptide-tests-bnp-nt-probnp/#:~:text=If %20your%20BNP%20or%20NT,being%20caused%20by%20heart%20failure. National Library of Medicine. (2021b, May 8). Heart failure - tests: MedlinePlus Medical Encyclopedia . Medline Plus. Retrieved April 26, 2023,

from https://medlineplus.gov/ency/patientinstructions/000366.htm#:~:text=An %20echocardiogram%20is%20the%20best,failure%20and%20guide%20your %20treatment Response 2 To answer your first question, I would intubate the patient and take him off BIPAP. My main reasoning for this is due to his secretions. You stated he was having moderate secretions, and with him being on BIPAP, he is more likely to aspirate on his secretions. The bilevel positive airway pressure (BIPAP) is a ventilator device that facilitate breathing for people suffering from breathing related problems. It is usually impossible to continue a BIPAP on a patient for too long, usually above 24-48hours as it may cause some problems such as pressure necrosis of the nasal skin and nutritional problems (Bowen, 2018). Therefore, when a patient on BIPAP fails to record any improvements within 1-2days, then there is need for a transition to intubation. The AC is the most appropriate ventilator to use for intubation of patients who were on BIPAP. The AC is essential as it facilitate the control of the important physiologic parameters that provide a good comfort for the patient. The initial ventilator setting starts with FiO2 of 100% and progressively titrated downwards with a guidance from ABG or Oximetry. Regardless of the peak, plateau or compliance pressure in the lungs, the tidal volume delivered by the ventilator will always be the same. The decision to use an AC ventilation further result to modification of two more parameter settings which include the respiratory rate for delivering breaths per minute(bpm) and the Positive End Expiratory Pressure (PEEP). These settings assure quality ventilations especially in respiratory and acidosis patients. In most diseases including Acute respiratory distress syndrome,

the use of Low tidal volume ventilation has been showed to be effective (Daniel et al., 2021). Therefore, starting a patient on low tidal volume of between 6 to 8 mL/Kg of ideal body weight facilitates reduction of ventilator induced lung injuries. The initial BIPAP settings for a patient usually begin from 8-10 but can reach to a maximum of 24 cmH2O in the case of inhalation. For exhalation purposes, the reading can start from 2-4 and a maximum of 20 cmH2O (Daniel et al., 2021). To facilitate the maintenance of the Bilevel air flow in BIPAP, the pressure of inhalation must be higher than the pressure of exhalation. References Bowen, J. (2018). Bipap Settings — Maimonides Emergency Medicine Residency. Maimonides Emergency Medicine Residency . https://www.maimonidesem.org/blog/bipap-settings Daniel, P., Mecklenburg, M., Massiah, C., Joseph, M. A., Wilson, C., Parmar, P., ... & Zehtabchi, S. (2021). Non-invasive positive pressure ventilation versus endotracheal intubation in treatment of COVID-19 patients requiring ventilatory support. The American journal of emergency medicine , 43 , 103-108. https://doi.org/10.1016/j.ajem.2021.01.068

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Week 9 Response 2

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