Reza

But if you are worried that the patient has a right-to-left shunt, adding intrathoracic pressure may worsen that shunt.

And so I'd sit back and say, hold on, what is my indication for using BiPAP right now over high flow nasal cannula?

And the main use of BiPAP in hypoxemic respiratory failure is to use it in patients who have pulmonary edema.

I think the case for pulmonary edema in this patient is weak enough that I would say, hold on, what benefit am I actually getting from the BiPAP in this situation?

And I don't think there is any benefit.

So I would start to think, hmm, can we switch over to high flow nasal cannula because there's a small and increasingly measurable chance that this patient's extra intrathoracic pressure may be actually part of the vicious cycle that they're in.

And let me offload that pressure.

So potentially, if they are shunting right to left,

that I remove that extra gradient for that to happen.

And in the room, I'd be really, really curious about one thing, which is this patient's probably, as all patients with BiPAP, sitting right up.

And one powerful clue to the presence of a right-to-left shunting is position-dependent shunting.

And so what I'm thinking I might do is, hey, let's get you on hyphal nasal cannula, get the BiPAP off.

And then let's see how you do when you lie down.

Because if you feel better and your O2 set improves when you lie down, gosh, I'm definitely going to get that CT with contrast to look for shunting, as you alluded to, Prof. Rez.

But then I'm calling the cardiology fellow and say, hey, I think we need a really, really high quality echo in this kind of acute situation.

Is there pathological shunting going on?

That was a lot, but yeah, go for it, please.

Oh, my gosh, Professor, I feel like, you know, we get to do so many of these fun cases.

I think I have not been this discombobulated in quite some time.

You know, I feel like there's so many possibilities.