While providing CPAP to a patient in severe respiratory distress, you note that his heart rate has increased by 20 beats/min and he is no longer following verbal commands. What should you do?

• A. Remove the CPAP device and ventilate him with a bag-valve mask.
• B. Decrease the amount of pressure that the CPAP device is delivering.
• C. Increase the amount of pressure that the CPAP device is delivering.
• D. Remove the CPAP device and apply oxygen by nonrebreathing mask.

Answer: (A)

When a patient on noninvasive ventilation deteriorates and can no longer protect their airway, you must discontinue the CPAP and secure ventilation with a bag-valve mask. The key here is airway protection: altered mental status and loss of command-following indicate a compromised airway and a risk of apnea or aspiration, so continuing CPAP, which does not guarantee airway protection, is unsafe. Switching to bag-valve mask ventilation allows you to provide controlled breaths, assess chest rise, and ensure adequate ventilation while you prepare for a definitive airway if needed. Decreasing or increasing CPAP wouldn’t address the airway protection issue, and a nonrebreathing mask can’t deliver breaths.