BIPAP is a wonderful invention
I recently treated an elderly man who was visiting from out of town, brought by ambulance for shortness of breath. He'd had some indigestion-like pain the previous day, and now at 2 am he was gasping for breath, his entire body heaving, unable to speak, his eyes alone revealing the terror he must have felt.
He had no known cardiac history, but he was taking antihypertensives. He had not previously documented "end of life" issues nor spoken about them with his family, but those who were present asked that we not take extreme measures, specifically intubation. He looked like he desperately needed assistance with his ventilation, because he was dying right in front of us all, drowning in his pulmonary edema.
His blood pressure was 200+/100+, with a heart rate of 130, sinus tachycardia with some lateral ST depression on the ECG, questionable borderline inferior elevation. Oxygen saturation by pulse oximetry was 88% initially, improving to 100% on a nonrebreather mask.
At the very least, this was a hypertensive crisis, perhaps complicated by myocardial infarction. I gave him an aspirin, intravenous enalapril, lasix, morphine, and topical nitropaste, and called for BIPAP. Because he couldn't relax enough to close his mouth, we used a full face mask, with inspiratory pressure of 12 and expiratory pressure of 5. His blood pressure improved, and he seemed a little less labored, but he was still terrified, trying to pull off the mask. He was making minimal urine, so I repeated the lasix (80mg each). My Cardiology consultant had arrived by this time, and recommended intravenous heparin as well. His troponin I was positive at 2.4.
He continued to be extremely anxious despite another morphine injection. Finally, I gave him one mg of versed, which put him to sleep, although he maintained his respiratory drive (thank God). His blood gas showed a pH of 7.2, with combined acidosis. He was uroseptic as well, perhaps precipitating the entire event, so he also got IV antibiotics. Looking back on it, I might have given a glycoprotein IIb/IIIa inhibitor as well. Early administration of that class of drug in the ER can be helpful in acute coronary syndromes.
Amazingly, the next day he was only on a nasal cannula, and he was discharged from the hospital 5 days later, back to baseline. Another BIPAP save.