After one hour on NIV the patient's pH is 7.26. How do you proceed?

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Accepted Answer

A persistent pH of 7.26 after one hour suggests inadequate response to NIV and ongoing ventilatory failure. First I would reassess the basics clinically — level of consciousness, respiratory effort, mask fit, patient–ventilator synchrony and haemodynamic stability — and ensure NIV settings are optimised, increasing inspiratory pressure if tolerated. If despite optimisation there is persistent acidosis or deterioration, I would urgently involve ICU to consider invasive ventilation. At this stage it is essential to clarify escalation status based on comorbidities, baseline function and the patient's previously expressed wishes. Indications for intubation would include worsening acidosis, reduced consciousness, haemodynamic instability or inability to tolerate NIV.

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