3. “I didn’t give inhaled bronchodilators because he was so tachycardic.” Although tachycardia may be a side effect of inhaled bronchodilators, it is rarely if ever hemodynamically significant, and hemodynamic compromise is of secondary concern if respiratory failure is untreated (“B comes before C”).
4. “I thought the rule about giving too much oxygen is just for internists on the ward.” For reasons that remain contentious and poorly understood, some patients will develop worsened hypercapnic respiratory failure in the face of hyperoxia. We currently have no way of identifying which patients will develop this response. In the absence of a compelling argument in favor of hyperoxia, the prudent approach is to give no more oxygen than is necessary to achieve an SaO2 in the range of 88%–92%.
5. “His ABG didn’t indicate that he required intubation,” or the closely related “His pulse-ox was just fine until…” Numeric values may be deceptive, especially in the COPD patient, who may have striking and unpredictable abnormalities at baseline and even more so when acutely decompensated. Therefore, it is of paramount importance that decisions regarding airway management and aggressive management be based on integration of the overall clinical picture rather than one or two laboratory or monitoring values.
6. “I adjusted the ventilator to weight-appropriate settings.” Permissive hypercapnia is an effective strategy to maintain oxygenation while avoiding iatrogenic VILI. While it can be very uncomfortable to leave a patient at a pH of 7.20, carbon dioxide narcosis is no longer of concern once a patient is intubated, and the mild acidemia does not appear to be of clinical consequence.
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