A. What is patient's mental status? A patient who has impaired mental status may be "tiring out" from breathing yet still have inadequate ventilation. Consider endotracheal intubation if there is not an immediate response to therapy.
B. What are patient's other vital signs? Is patient in shock? What is the volume status? Typically, patients with respiratory acidosis are both tachycardic and tachypneic in an effort to "blow off" excessive CO2. Bradycardia or bradypnea may represent a near-arrest situation requiring urgent intervention and possible endotracheal intubation. Shock exists when metabolic demands of the body are not being met; this leads to lactic acidosis (metabolic). Initial therapy should virtually always include fluid resuscitation to correct hypovolemia.
C. What are patient's oxygen saturation and PaO2 values? Although elevated PaCO2 is indicative of respiratory failure, inadequate oxygenation can more rapidly lead to cardiac arrest and requires immediate attention.
D. Are breath sounds inaudible, unequal, or absent? Patients without audible breath sounds may be so "tight" that they are unable to move air. In this situation, aerosolized medications may be ineffective because of inadequate delivery to distal bronchioles. Consider other modalities to deliver medications (IV or SQ). Be prepared for patient to "crash" quickly. Consider the possibility of a spontaneous pneumothorax when breath sounds are unequal or unilaterally absent.
E. What medications has patient received? Narcotics are a common cause of respiratory depression.
F. Does patient have a history or signs and symptoms consistent with sepsis or sepsis syndrome? Inadequate tissue perfusion secondary to septic shock can cause metabolic acidosis.
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