Final answer:
The patient with a pH of 7.29, PaCO2 of 66, PaO2 of 56, and HCO3 of 30 demonstrates respiratory acidosis, likely due to COPD. The best initial management includes NPPV via Face Mask to assist breathing, with cautious oxygen supplementation via nasal cannula at 2L/min and possibly I.V. Steroids for underlying reactive airway components.
Step-by-step explanation:
The patient presented in the emergency department (ED) with an arterial blood gas (ABG) indicating a pH of 7.29, a PaCO2 of 66, a PaO2 of 56, and an HCO3 of 30. The chest x-ray (CXR) suggests hyperinflation of the lungs with flattened diaphragms and hyperlucency at the apices, which are typical signs of obstructive lung disease such as chronic obstructive pulmonary disease (COPD). Based on the ABG results and CXR, the patient is in respiratory acidosis due to hypoventilation, a common issue in COPD exacerbations, leading to the retention of CO2.
Given the information, the recommendation for the BEST initial management should aim to improve ventilation and correct the acidosis. Noninvasive positive pressure ventilation (NPPV) via Face Mask could be beneficial, as it can assist the patient's breathing and help decrease the PaCO2 levels, alleviating the acidosis while avoiding the potential complications of invasive mechanical ventilation. Oxygen therapy, such as through a nasal cannula at 2L/min, can also be provided but cautiously, to prevent worsening hypercapnia and to avoid suppressing the patient's respiratory drive if they are CO2 retainers. Intubation and pressure-control ventilation should be considered if NPPV is ineffective or if the patient's respiratory status deteriorates. I.V. Steroids may be useful if the patient has an underlying reactive component like in acute asthma exacerbation, but as a supportive measure in combination with other respiratory interventions. It is critical to regularly re-evaluate the patient's status, as changes in their clinical condition may require escalation or de-escalation of therapy.