An elderly female smoker is unable to speak, has cold clammy skin, and her head rests on her chest. Her SpO2 is 78% on home oxygen at 3 L/min. What should you do first?

• A. Assist her ventilations with a BVM
• B. Increase oxygen to 6 L/min
• C. Administer oxygen by nonrebreather mask
• D. Get her inhaler if she has one

Answer: (A)

The key idea is immediate ventilatory support when breathing is inadequate and oxygenation is severely compromised. Because the patient cannot speak, is cool and clammy, and has a SpO2 of 78% on home oxygen, she is in respiratory failure with significant hypoxemia. A bag-valve-mask (BVM) ventilatory assist delivers both air and high concentrations of oxygen, actively moving air into and out of the lungs and raising oxygen delivery to the blood. This directly addresses the deficient ventilation and oxygenation.

Simply increasing the oxygen flow or using a nonrebreather mask relies on the patient’s own breathing and won’t provide breaths for someone who isn’t ventilating well, which is insufficient here. An inhaler might help if bronchospasm were the sole issue, but it won’t restore ventilation in a patient with respiratory failure and severe hypoxemia. So the first action is to assist ventilations with a BVM to stabilize her breathing and improve oxygenation.