Answer
The need for intubation can be established quickly at the bedside by asking the patient to hold the nebulizer in his or her hand. If the patient becomes so sleepy that the nebulizer starts to fall away, consider intubation regardless of PCO2 level. The cause of increased CO2 production is not decreased respiratory drive but probably reversal of hypoxic arterial vasoconstriction in areas of less-ventilated lung tissue, which increases the extent of ventilation/perfusion defects and thus CO2. "Stated another way, there is probably no single value for arterial PCO2, pH, or PO2 that by itself constitutes an indication for [intermittent positive pressure ventilation (IPPV)]." [7]
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