Amnah al-lail

A 74-year-old causation male with a diagnosis of pulmonary emphysema ,he was seen in the emergency department with a complaint of shortness of breath .

He stated he become increasingly more difficult of breathing in cold weather.

He related that in his usual state of health , he was able to move freely about his home and yard and enjoyed his hoppy of grading ,but now was unable to do either.

Sleeping in the bed had become such a problem that for the pervious two nights he slept setting back in his easy chair.

His normal sputum production of about a table-spoon per day had increased to about ¼ cup a day and change to yellow in color .

He gained 6 lb in the past 4 days .

He stated that he had smoked two packs per day for 40 years, and had tried unsuccessfully to quit after his diagnosis or emphysema was made .He now smokes a half pack per day .

His medication include albuterol via metered does inhaler (MDI).

Physical examination

the patient is a mildly obese male , Wight 100 kg , high 72in moderately severe respiratory distress, setting on the edge of the bed leaning forward supporting his weight with his palms and breathing through pursed lip

Vital signs

Heart rate: 124/min

Blood pressure : 150/90

Respiratory rate: 28/min

Temperature : 100.5 f

HEENT: some cyanosis in the lip .Neck: trachea in midline , no masses ,

strider , lymphoadenopathy , there is marked use of accessory muscles of the neck with mild jugular venous distension

Chest: the anterior posterior diameter of the chest is increased with a deep suprasternal notch and some paradoxical motion of the abdomen . Decreased tactile fremitus

Heart: sounds are distant with no irregularity in rate of rhythm noted

Lungs: bilaterally diminished with scattered expiratory wheezing bibasilar rhonchi , and a prolonged expiratory phase

Extremities: slight digital cyanosis with +2 pitting edema in both ankles

Initial assessment and treatment

In the emergency room , a portable chest radiography and arterial bloods with co-oximetery were obtained , the patient was placed on a 2 l/min nasal cannula and given an aerosol treatment with 2.5 mg albutrol sulfate in NC .

ABG

PH: 7.32paCO2 : 70 mm HgpaO2 : 44 mm HgHCO3: 35 mEq/LBE: +6SaO2 : 85%Hb : 16g/dl

X-RAY:

The chest radiograph revealed evidence of hyperinflation ,an increase in vascular marking. And an infiltrated in the RLL.

The patient was the started on the following regimen .supplemental oxygen at 2 L/min by nasal cannula ,nebulized albutrol sulfate , 2.5 mg ,furosemide ,40 mg. The patient was also started on a prophylactic broad –spectrum antibiotic . The report on the gram stain showed numerous gram-positive diplococci

Over the next hour : the patient's respiratory status continued to

deteriorated despite intervention . Respiratory rate rose to 36/min and paradoxical

movement motion become more pronounced . increasing PaCO2 from the first blood gas are

indicative of increasing ventilatory fatigue . So,

Impending respiratory failure must be assumed

Initial Settings:

On the basic of clinical and laboratory data , a decision was made to assist the patient ventilation.

The patient put on NPPV” bilevel positive airway pressure (bilevel PAP ) “as initiated via nasal mask . The IPAP and EPAP levels were titrated to 15/5 resulting in a Spo2 endpoint of around 90%

Settings:

Mode spontaneousIPAP 15 cmH2oEPAP 5 cmH2oSup. O2 2 L/min

The patient was poorly complaint with therapy, removing the mask at regular intervals, complaining of not begging able to get enough air. after 1 hour ,an arterial blood gas was obtained and revealed the following:

ABG:

PH 7.25PaCO2 80 mm HgPa O2 56 mm HgHCO3 34 mEq/LBE +3SaO2 89%Hb 16 g/dl

On the basis of the worsening ventilatory failure despite non invasive ventalitory support, the patient was intubated with a size 8.5 endotracheal tube , and flow-trigger MV

Was initiated on the following setting:

Mode: CMVVt: 750 mlRR: 10/minPIF: 55l/min ,resulting in an I:E ratio = 1:4FiO2: 0.40PEEP: 5 cm H2OFlow trigger: 2 L/min

After 30 min, an arterial blood gas was obtained are revealed the following:

PH: 7.36PaCO2: 65 mm Hg

88 mm Hg :PO2HCO3: 36 mEq/LSaO2: 96%Hb : 16g/dl

On the basis of the blood gas an order was written to titrate the patient's FiO2>= 92% . No other change were made to the ventilator parameters .albutrol orders were changed to MDI,8 puffs in-line Q4H . The patient was suctioned prn for moderate amounts of thick pale yellow secretion

Patient Monitoring:

Over the course of the next 72 hours the patient was rested on the ventilator and treated appropriately for his pneumonia and right heart failure . The patient remained alert and cooperative with his care.

A chest radiography done on day three ICU admission demonstrated clearing of the pneumonic process in the RLL.

serum theophylline levels were monitored daily ,average 9 mcg/ml (5-15).

The ventilator setting were adjust appropriately and currently are:

Mode: SIMVVt : 750 mlRR: 6PIF : 55L/min , resulting in an I:E = 1:4FiO2: 0.35PEEP : 5 cm H2OPSV : 7 cm H2OFlow trigger : 2 l/min

Spontaneous parameters:

Spont.f 12Spont.Vt 550 mlVC 2.21 LMIP -36 cm H2O

The arterial blood gas drawn on ventilator setting shows:

PH: 7.39PaCO2: 57 mm HgPaO2 : 74 mm HgHCO3: 34 mEq/lSaO2 : 94%Hb : 15.5 g/dl

Patient Management:

The patient vital signs have normalized and along with ventilator care, fluid status was normalized

bronchodilator therapy was continued to relive brinchospazim and promote mucociliary clearance .

Antibiotics therapy was continued and adjust on the basis of the culture and sensitivity report.

Secretion volume and consistency have decreased and color has changed from yellow to white

Weaning:

He was placed in the spontaneous breathing mode (CPAP) at an FiO2 of 0.35 with a pressure support at 5 cm H2O and CPAP of 5 cm H2O .After 4 hours spontaneous ventilatory parameters were measured and an arterial gas was obtained.

:The result are as following

F 18Vt 525 ml

f/Vt 34/min/l “f/Vt ratio<100/min/l is predictive of weaning

success ”VC 2.85 lMIP -44 cm H2OPH 7.38PaCO2 59 mm HgPaO2 68 mm HgHCO3 34 mEq/l

:complication

On the basis of the patients clinical condition and diagnostic results . he was extubated and placed on 2 L/min O2 via nasal cannula .He was moved to the medical floor later that day . and was subsequently discharge 2 days later after being enrolled in the hospital outpatient rehabilitation program

Thank you;(

Amnah Al-lail