You are on the NICU service and your attending asks you to see a patient with impending respiratory failure while he continues examining another patient. The patient is a 45 yo man who was being evaluated for Cushing’s syndrome and was found to have a pituitary adenoma. He underwent transsphenoidal hypophysectomy earlier in the day. He has a BMI of 39.
He was extubated in the OR and monitored in the PACU, where he received 2 IV doses of fentanyl for pain. He was transferred to the NICU because of sonorous breathing and mild somnolence. On arrival his O2 sat was 95%. When you see him, he appears drowsy, but is able to arouse to simple verbal command or tactile stimulus. He is now on high flow mask to maintain O2 sats >90%. His last dose of fentanyl was 6 hours ago.
On exam he is somnolent and intermittently snoring. Vitals are 150/90 HR 85 RR 9. Cardiac exam is normal but breath sounds are difficult to auscultate due to body habitus. ABG reveals pH 7.26 pCO 57mmHg and pO2 60mmHg.
You are considering how to improve his respiratory status and have a number of options in mind. Which of the following choices you are considering is the best?
1) Begin CPAP
2) Increase O2 to 100% NRB mask
3) Begin BiPAP
4) Perform awake fiberoptic intubation
Is there additional examination or other considerations that would help you make your decision?
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