13th January 2024

A patient with known COPD is admitted with a 4-day history of productive cough, fever and breathlessness.

A patient with known COPD is admitted with a 4-day history of productive cough, fever and breathlessness. He is given a trial of nebulisers, IV hydrocortisone and IV antibiotics. 

CXR is shown below.

Serial ABG results are as follows:

ABG on admission (on 0.6 Fᵢ02)

Repeat ABG after initial management (on 0.45 FᵢO2)

He is now more confused with a flapping tremor in both his hands. NIV is considered the next best option. 

What possible contraindication will be a hindrance to using NIV?

Select the SINGLE most appropriate option from the list below. Select ONE option only.