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Severe hypoxaemic respiratory failure from pneumonia — SCE Acute Medicine MCQ

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HardCritical Care MedicineSevere hypoxaemic respiratory failure from pneumoniaSCE Acute Medicine

A 60-year-old man with severe community-acquired pneumonia is on high-flow oxygen. RR is 38, SpO2 89% on FiO2 0.8, PaO2 is 7.2 kPa, PaCO2 4.4 kPa and lactate 2.1 mmol/L. Chest radiograph shows bilateral infiltrates and he is tiring. What is the most appropriate next step in management?

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Correct answer: D — Urgent critical care review for invasive ventilatory support

Severe hypoxaemic respiratory failure with high oxygen requirement, bilateral infiltrates and fatigue suggests evolving ARDS or severe pneumonia requiring critical care review. NIV is not routine for de novo hypoxaemic respiratory failure and may delay intubation in a tiring patient. Normal PaCO2 can be ominous when the respiratory rate is very high. The key is to recognise failing work of breathing, not just the gas number.

Reference: BTS oxygen guideline, Faculty of Intensive Care Medicine guidance