A 62-year-old man with a history of congestive heart failure presents with severe respiratory distress and an oxygen saturation of 82%. When you auscultate the lungs, you hear widespread rales. He is conscious and alert, is able to follow simple commands, and can only speak in two- to three-word sentences at a time. You should:

The steps that must be taken with this 62-year-old man, who presents with congestive heart failure, severe respiratory distress and a saturation of 82%, aside from widespread crackling lung sounds, would be:

1. Place a CPAP device to increase the oxygenation capacity of the lungs by increasing the pressure of oxygen that enters the lungs and the volume of it. The respiratory distress, and the low saturation comes from the problems his lungs are having due to the congestive heart failure condition. Fluid in the lungs themselves due to the condition lower the lungs´ capacity to exchange oxygen with the air, and this also causes the low saturation. It means the blood is not getting enough molecules of oxygen per breath. The CPAP will increase the pressure of O2 and its availability in air, so the lungs can capture more.

2. Monitor blood pressure. It must be remembered that congestive heart failure means the heart is unable to pump enough blood to sustain the needs of the different tissues. As a result, the body responds to this defficiency through adaptive mechanisms and shock mechanisms that will not necessarily benefit the body. One such measure is increasing blood pressure to maximize the possibility of oxygen exchange between tissues and the blood. However, this pressure will further damage the tissues that have already been affected, especially lung tissues, and will exacerbate this patient´s situation.

3. Monitor all vital signs to determine improvement of the patient, or lack of it, to determine the next steps: probable use of oxygen by mask, probable need of intubation, and transfer to a hospital.