9/30/2017

1

A CLINICAL CASE STUDY

MANJU DANIEL, PHD, MSN, APN, FNP-BCMA VANESSA MABAZZA, BSN, RN, CCRN, CNRN

NORTHERN ILLINOIS UNIVERSITY

Patient casePatient Information:Name: OCAge: 63Gender: Female

Chief Complaint:“Feeling terribly weak for the past 24 hours.”

History of present illness (HPI) Resident of skilled nursing facility Morbidly obeseMultiple chronic health conditions Staff found patient to be too sleepyDifficult for staff to wake her up for meals

and ADLS x 1 day Refused CPAP intermittently in last 48 hours

for C/O of suffocation Episodes of snoring, gasping, and apneaCh use of 02 at 2-3 L PRN (current 4 L, O2

sat- 86%)

9/30/2017

2

Past Medical History: COPD OSA Chronic respiratory failure Hypertension, CHF Anemia, Hyperlipidemia Chronic renal failure (baseline

creatinine 1.5) GERD

Past Surgical History:Total abdominal hysterectomy bilateral salphingo-oophorectomy (TAHBSO)

Other Pertinent History Social Tobacco: Former smoker. Alcohol and Illicit Drugs : No

Preventive: Up to date with vaccination Bed-bound uses bariatric bed Exercise: None

Allergies: NKDA

Current medications COPD:

Fluticasone Propionate 250mcg 1 puff inhale orally every 12 hours

Duoneb every 6 hours PRN Saline nasal spray solution 0.65%- 2 sprays in

both nostrils TID PRN CHF:

Furosemide 40mg dailyMetolazone 5mg daily

CHF/HTN: Metoprolol succinate 25mg daily

9/30/2017

3

Current medications Anemia:

Ferrous Sulfate TID; Folic Acid daily Vitamin B12 deficiency:

Monthly Cyanocobalamin 1000mcg/mL IM Hyperlipidemia:

Atorvastatin (Lipitor) 20mg daily Constipation:

Colace BID, Miralax Powder daily GERD:

Omeprazole 20 mg daily Other: CRF and D/T diuretics

Kcl 20meq daily

Review of SystemsGeneral:Fatigue, malaise, weak & sleepy

Respiratory: Dyspnea with minimal exertion 02 at 4L O2 via NC during the day CPAP mask at bedtime & during

daytime for naps

Review of Systems (cont.)Cardiovascular: bilateral pedal edema (legs felt

heavy)Musculoskeletal: Generalized weakness Limited ROM on bilateral lower

extremities due to obesity Bed-bound

Hematologic: reports anemiaGenitourinary: NocturiaOther body systems- No concerns

9/30/2017

4

Vital SignsBP:124/70; T: 97.6F; HR: 72; RR: 31O2 sat: 86% on 4L O2 via nasal

cannula Pain = denies

Height: 5 feet 2 inches (157 cm)Weight: 502 lbsBMI: 91.8 (obese)

Physical ExamGeneral Survey: morbidly obese,

normotensive, calm, appears drowsy and mildly short of breath when talking , on 4L oxygen via nasal cannula, A&O x 2 (name & place only)

Skin: pale pink, warm, normal turgor

Nails: nailbeds pale pink, capillary refill <2 seconds, no clubbing

Mouth: lips and oral mucosa moist and pale pink

Physical Exam (Cont.)Chest/Lungs:

Respirations regular, tachypnea, symmetrical chest expansion

Increased work of breathing with use of accessory muscles

Diminished at bases bilaterally

Vasculature: +1 bilateral pedal edema

9/30/2017

5

Physical Exam (cont.)Abdomen:obese but unremarkable

Musculoskeletal:BUE: good strength 5/5 BLE: 3/5 strength D/T increased habitus. BUE- ROM: no limitation BLE- ROM: mild limitation D/T increased

habitus Other body systems: unremarkable

DIFFERENTIAL DIAGNOSES?

LABS/DIAGNOSTICS?

Differential Diagnosis: Acute on Chronic Respiratory Failure

SUPPORT REFUTE

• Morbid obesity• H/O CHF (stable)• OSA• GERD• H/O chronic respiratory failure• Drowsiness, fatigue, & weakness• Home use of O2: 4LPM via NC• CPAP- intermittent refusal x 48h• hypoxia• Diminished bibasilar lung sounds• SOB • tachypnea• Dyspnea with exertion• A& O x 2 (name and place)

• (-) cough • (-) wheezing• (-) cyanosis• (-) tachycardia• (-) crackles

9/30/2017

6

Differential Diagnosis: Obesity Hypoventilation Syndrome

SUPPORT REFUTE

• Obesity• Sleep apnea• CPAP- intermittent refusal x 48 Hr• Tiredness• Fatigue• Sleepiness• Dyspnea with exertion• (+) snoring• (+) gasping during sleep• Nocturia• Confusion: A& O x 2 (name and place)• Signs of right-sided heart failure such as

BLE edema, tiredness

• (-) headache• (-) personality or

mood changes• (-) cyanosis

(Downey III et al., 2017)

Differential Diagnosis: Acute on Chronic Heart Failure

SUPPORT REFUTE

• Hypertension• Hyperlipidemia• H/O CHF• OSA• Fatigue• Weakness• Dyspnea with exertion• Nocturia• Bilateral pedal edema

• (-) change in appetite (usually decreased)

• (-) crackles • (-) JVD• (-) tachycardia• (-) anxiety

(Dumitru, Baker, Windle, & Ooi, 2016)

Differential Diagnosis: COPD Exacerbation

SUPPORT REFUTE

• Former smoker• GERD• H/O CHF• Fatigue• SOB with exertion• Home use of O2: 4LPM via

NC• CPAP • Dyspnea with exertion: use

of accessory muscles • tachypnea• Sedentary lifestyle

• (-) family history• (-) digital clubbing• (-) wheezing• (-) cough• (-) rhonchi

(Mosenifar et al., 2016)

9/30/2017

7

Differential Diagnosis: Community-Acquired Pneumonia (CAP)

SUPPORT REFUTE

• (+) Comorbid factors• confusion• (+) Dyspnea with

exertion• (+) Fatigue• Tachypnea• malaise• Skilled nursing facility

resident

(Baer et al., 20114)

• (-) cough • (-) fever• (-) sore throat• (-) rales• (-) change in appetite• (-) increase tactile

fremitus • (-) symptoms of

pneumonia/infection

Complete Blood Count (CBC)Component Resulted Value Standard Range

RBCs 3.4 4.2-5.4/CMMHgb 10.3 12-16 g/dLHct 33.2% 37-47%RBC indices

MCV 97.8 80-100 flMCH 30.2 27.0-34.0 pgMCHC 30.9% 32.0-36.0 g/dL (or 32%-36%)RDW 15% 11.3-14.8%

WBCNeutrophilsLymphocytesMonocytesEosinophilsBasophils

78007025520

5000-10,000/mm3 or 5-10 SI units55-70%20-40%

2-8%1-4%

0.5-1.0%

Reticulocyte Count

1% 0.5-2%

Platelet count 182 150,000-400,000/mm3 or 150-400 SI units

(Pagana, Pagana, & Pagana, 2015)

Comprehensive Metabolic Panel (CMP)Result Normal

Albumin 3.5 3.5 – 5 g/dL

Alkaline Phosphatase 61 30 – 120 units/L

Alanine Aminotransferase (ALT) 33 4 – 36 units/L

Aspartate Aminotransferase (AST) 18 0 – 35 units/L

Blood Urea Nitrogen (BUN) 45 10 – 20 mg/dL

Calcium (Ca) 9.5 9.0 – 10.5 mg/dL

Chloride (Cl) 92 98 – 106 mEq/L

Carbon Dioxide (CO2) 41 23 – 30 mEq/L

Creatinine 1.90 0.6 – 1.2 mg/L

(Pagana et al., 2015)

9/30/2017

8

CMP (cont.)Result Normal

Globulin 3.1 2 - 3.4 g/dL

Glucose 89 70 – 110 mg/dL

Potassium (K) 4.9 3.5 – 5.0 mEq/L

Sodium (Na) 143 136 – 145 mEq/L

Total Bilirubin 0.7 0.3 – 1.0 mg/dL

Total Protein 6.6 6.4 – 8.3 g/dL

eGFR 32 87 – 107 mL/min (female)

Anion Gap 10 8 – 16 mEq/L (if potassium is not used in

the calculation)(Pagana et al., 2015)

Brain Natriuretic Peptide (BNP) –Result: 2509 (< 100pg/mL)

Troponin I –Result: 0.016 (< 0.03 ng/mL)

Electrocardiogram (EKG) –Normal sinus rhythm, Rate 70, normal intervals2D Echo -

Result: enlarged RV & LV indicating mild diastolic dysfunction, EF = 50%, no wall motion abnormality

Chest X-ray –Mild cardiomegaly and pulmonary vascular congestion

Impression: Mild CHFU/A–Unremarkable

(Pagana et al., 2015)

Other labs

Arterial Blood Gas (ABG) –with BiPap FiO2 40%, inspiratory pressure 10.0/ expiratory pressure 5.0

pH = 7.30 (7.35-7.45)pCO2 = 83 (35-45 mmHg)pO2 = 126 (80-100 mmHg)HCO3 = 37 (21-28 mEq/L)O2 saturation = 98 (95%-100%)Base excess = 13.5 (-2.0– +2.0 mEq/L)Total hemoglobin = 9.9 (11.7-17.7 g/dL)Oxyhemoglobin = 96.9 (85%-100%)Carboxyhemoglobin = 2.2 (0.0–1.5%)Methemoglobin = 0.3 (0.0–1.5%)

(Pagana et al., 2015)

9/30/2017

9

Final Diagnosis:

Acute on Chronic Respiratory Failure

r/t

Obesity Hypoventilation Syndrome (OHS)

aka

Pickwickian Syndrome

Obesity Hypoventilation Syndrome (OHS) OHS is characterized by: Obesity (31% prevalence) Day time hypoventilation (difficulty getting rid of

carbon dioxide) OSADaytime symptoms:

Sleepiness Lack of energy Breathlessness

Nighttime symptoms: Loud and frequent snoring during sleep And/or breathing pauses

(Dabal and Bahammam, 2009)

OHS (cont.1) In this case, main contributing factors: Obesity Poorly managed OSA R/T Obesity Refusal to wear CPAP as recommended

OHS patients may have: Apnea and sleep hypoventilation with

hypercapnia

Although responsive but c/o dyspnea, fatigue, weakness, drowsiness, and confusion are indications that she was experiencing anAcute hypercapnic respiratory failure

(Dabal and Bahammam, 2009)

9/30/2017

10

OHS (cont.2)

Acute hypercapnic respiratory failure is further validated by:CMP result- elevated CO2ABG results- respiratory acidosis

Low pH Elevated pCO2 Elevated carboxy- hemoglobin levels

OHS (cont. 3)

Evidence: even transient reductions of ventilation in OSA can produce acute hypercapnia during the

period of low ventilation Evidence: OSA- not directly attributed to

underlying cardio-respiratory disease So less contributing existing conditions were: COPD H/O chronic respiratory failure

(Dabal and Bahammam, 2009)

(Kaynar et al., 2016; National Heart, Lung, and Blood Institute, 2011)

OHS- Respiratory Failure (cont. 3)

9/30/2017

11

Pathophysiology of OHS Etiology: Exact cause is not known, however

- No correct signals by brain for effective breathing- Fat-producing hormones resulting to ineffective breathing- Extra weight placed on chest makes breathing more difficult

Daytime hypoventilation leads to: Reduced sensitivity to rising levels of PaCO2 Leptin resistance Interaction between the two leads to OHS

Obesity puts extra mechanical load on respiratory system : Leading to its restriction and subsequent respiratory

failure(Dabal and Bahammam, 2009) (Kaynar et al., 2016; National Heart, Lung, and Blood Institute, 2011)

Pathophysiology of OHS Respiratory failure can:

Either result in reduced capacity for ventilation Or result from an increased demand for

ventilation Both

3 processes in respiration: Transfer of O2 across alveolus Transport of oxygen to tissues Removal of CO2 from blood into the alveolus to be

exhaled

(Dabal and Bahammam, 2009) (Kaynar et al., 2016; National Heart, Lung, and Blood Institute, 2011)

Hypoxemic (O2 failure) RF :• From V/Q mismatch and shunt

• These processes results to widening of the alveolar-arterial PO2 gradient

• VQ mismatch is the most common cause of hypoxemia

• Shunt is the persistence of hypoxemia despite 100% O2 inhalation.

Hypercapnic (ventilatory failure) RF: • When PaCO2 increases due to

decrease in ventilation > 4-6L/min.

(Kaynar et al., 2016; National Heart, Lung, and Blood Institute, 2011)

9/30/2017

12

OHS Management In this case- RF was mainly because of

hypoventilation (Obesity hypoventilation syndrome (OHS)

Hypercapnia Hypoxemia

Main treatment focus: A. Noninvasive ventilation (NIV)

positive pressure ventilation CPAP (continuous positive airway pressure) BIPAP (bi-level positive airway pressure)Properly fit mask: adequate effect

NIV recommended if: Resp. acidosis with arterial blood Ph <7.35 OR PaC02

> 45mm of Hg Persistent hypoxemia with supplemental 02

OHS Management B. Controlled oxygen therapy

Long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure increases survival in patients with severe resting hypoxemia

02 is recommended if with arterial hypoxemia (SP02 less than 88% or Pa02 <55 mmHg)

Target saturation of 88% to 92% in acute hypercapnic respiratory failure (nasal cannula or mask)

Titrate to keep it SP02 >90% with health provider being aware of changes

C. Weight loss management (a future intervention) Bariatric surgery such as gastric bypass

OHS management (Cont.)In this case, BiPap settings were changed to FiO2 35%, inspiratory pressure 12.0/ expiratory pressure 8.0.

Repeat ABGs were: pH = 7.38 (7.35-7.45) pCO2 = 71 (35-45 mmHg) pO2 = 77 (80-100 mmHg) HCO3 = 28 (21-28 mEq/L) O2 saturation = 96 (95%-100%) Base excess = 1.5 (-2.0–2.0 mEq/L) Total hemoglobin = 10.4 (11.7-17.7 g/dL) Oxyhemoglobin = 95.9 (85%-100%) Carboxyhemoglobin = 1.0 (0.0–1.5%) Methemoglobin = 0.3 (0.0–1.5%)

(Pagana et al., 2015)

9/30/2017

13

Other: GOLD 2017 Guidelines for COPD Classification Severity per airflow limitation (Spriometrically)

Gold 1 (Mild): FEV1 > 80% of predicted Gold 2 (Moderate): 50% < FEV1 <80% of predicted Gold 3 (Severe): 30% < FEV1 <50% of predicted Gold 4 (Very severe): FEV1 <30% of predicted

Modified British Medical Research Council (mMRC): per Dyspnea Grade 0: Breathless with strenuous exercise Grade 1: Breathless when hurrying or walking up a slight hill Grade 2: Breathless makes walk slower than same age

people or have to stop for breath when walking on own pace Grade 3: stop for breath when walking about 100 meters or

after a few minutes Grade 4: Too breathless to leave house, when dressing or

undressing

CAT Assessment: scale of 0-40 (based on cough, chest tightness, breathlessness, activity tolerance and sleep)

GOLD Guidelines: COPD Pharmacological Management

2017 Global Initiative for Chronic Obstructive Lung Disease, Inc

Class A- Bronchodilator, SABA PRN or on a regular basis (LABA preferred over SABA)Class B- LAMA or LABA and if Persistent symptoms- bothClass C- LAMA, if further Exacerbation- (LAMA & LABA) or

(LAMA & ICS) Class D-Same as C; if Persistent and exacerbation- triple: LAMA, LABA, & ICS); Further exacerbation: if FEV₁ < 50%-consider Roflumilast (dalirespt- PDE4 inhibitor); if smoker -consider macrolide2017 Global Initiative for Chronic Obstructive Lung Disease, Inc

GOLD Guidelines: COPD Management (Cont.) Bronchodilators

Beta agonists-SABA( Albuterol, Proair)LABA (Salmeterol, Formoterol, Olodaterol, Brovana)

LABA is preferred over SABA unless occasional dyspnea Maintenance therapy: switching to LABA

recommended SABA with SAMA- as initial bronchodilators to treat an

acute exacerbation; Combination superior compared to either medication alone

Anti-muscarinic drugs SAMA (Atrovent)- more in duoneb (atrovent and

albuterol) LAMA (Spiriva , Tudorza, Ellipta)- Mod, severe, very

severe Methyxanthine (Theophylline)- controversy about

exact effect and increased side effect profile

9/30/2017

14

GOLD 2017: Anti-inflammatory agents ICS Corticosteroids: In combination with LABA

Moderate, Severe, very severe COPD Advair (salmateorol & fluticasone) Symbicort (formoterol & budesonide)Improve lung function; Reduce exacerbation

Systemic corticosteroids: Oral Prednisone

Acute management of exacerbations of COPD

Not in chronic daily treatment in COPD Improve lung function (FEV1)Shorten recovery time Duration of therapy no more than 5-7 days

GOLD 2017: Anti-inflammatory agents (Cont.) Phosphodiesterase-4 (PDE4) inhibitors:

(Roflumilast or daliresp) Severe, very severe COPD & h/o

exacerbationsReduces moderate and severe exacerbations For maintenance along with ICS in

combination with LABA

Antibiotics – Macrolides (azithromycin and erythromycin)Regular use of macrolide antibiotics may

reduce exacerbation over one yearRisk of drug resistance Hearing impairment

GOLD 2017 Guidelines: COPD Management (Cont.) Oxygen Therapy

With severe chronic resting hypoxemia- long-term oxygen therapy is recommended (( sa02 <88% or Pa02 <55)

Titrate to keep it SP02 >90% Stable COPD with resting or exercise-induced moderate

desaturation, long-term oxygen should not be prescribed routinely

Non invasive ventilation CPAP/BIPAP In exacerbation of COPD COPD with severe chronic hypercapnia (our patient) COPD with acute respiratory failure

Interventional treatments Lung volume reduction Lung transplantation

Other: Pneumococcal vaccine AND manage GERD

9/30/2017

15

COPD Management for OC In her case of mild COPD- plan was to:Discontinue Fluticasone Inhaler

250mcg, 1 puff every 12 hours

Started Symbicort (formoterol & budesonide), 2 inhalations every 12 hours, according to GOLD Guidelines

To continue Duoneb every 6 hours PRN for shortness of breath

Management of other conditions: Problem: Acute on Chronic Heart Failure

Continue: Metolazone, increased furosemide to 40 mg BID (40 mg IV q 12h for 2 days), metoprolol

Problem: Acute on Chronic Renal Failure Patient voiding adequately H/o chronic renal failure with baseline creatinine of

1.5. Current elevated BUN at 45 and creatinine at 1.9. Nephro consult, goal to bring her creatinine back

to her baseline by increasing lasix to 40mg BID Discontinue KCL due to normal level & elevated

creatinine. Problem: Anemia

Iron deficiency- Continue TID Feso4 TID and daily folic acid

Vitamin B12 deficiency – continue monthly cyanocobalamin injections

Patient Education Avoiding risk factors for respiratory failure and COPD

exacerbation (tobacco cessation in smokers; avoid second hand smoke).

Early recognition and early treatment initiation to prevent complications of respiratory failure

Risks of O2 toxicity and CO2 narcosis Encourage use of incentive spirometer. Pulmonary rehab

helps decrease severity and improve quality of life. Routine physical activity - 150 min of moderate-intensity

aerobic activity per week

Proper technique for inhaler and proper mask fit Proper posture- e.g. sitting posture with a forward-leaning

Stress lifelong adherence to treatment plan Coping strategies, social support and counseling Prepare for emergencies (Kaynar et al., 2016; National Heart, Lung, and Blood Institute, 2011; Rafiq et al., 2015)

9/30/2017

16

Follow-Up To use an inter-disciplinary approach Follow-up with PCP RT management Consult with pulmonary specialist Consult with nephrologist for renal failure

management Consult with cardiologist for management of

CHF Consult PT and OT for rehabilitation. Serial lab tests for comparison and to see

improvement (CBC, BMP, BNP 2 days after IV lasix ). (Kaynar et al., 2016; National Heart, Lung, and Blood Institute, 2011)

References Agency for Healthcare Research and Quality. (2016). BTS/ICS guideline for

the ventilatory management of acute hypercapnic respiratory failure in adults. Retrieved from https://www.guideline.gov/summaries/summary/50176/btsics-guideline-for-the-ventilatory-management-of-acute-hypercapnic-respiratory-failure-in-adults?q=Acute+respiratory+failure

American Thoracic Society.(2014). Obesity hypoventilation syndrome. American Respiratory Critical Care Journal,189, p15-p16.

Baer, S. L., Colombo, R. A., Vazquez, J. A., Talavera, F., Sanders, C. V., & Bronze, M. S. (2016). Community-acquired pneumonia (CAP). Retrieved from http://emedicine.medscape.com/article/234240-overview#showall

Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

Downey III, R., Gold, P. M., Rowley, J. A., Wickramasinghe, H., Talavera, F., Ouellette, D. R., & Mosenifar, Z. (2017). Obstructive sleep apnea. Retrieved from http://emedicine.medscape.com/article/295807-overview#showall

Dumitru, I., Baker, M. M., Windle, M. L., & Ooi, H. H. (2016). Heart failure. Retrieved from http://emedicine.medscape.com/article/163062-overview#showall

References (cont.) Global Initiative for Chronic Obstructive Lung Disease, Inc.(2017). Pocket guide to COPD diagnosis,

management, and prevention: A guide for health care professionals. Retrieved from www.goldcopd.org

Healthy People 2020. (2017). Respiratory diseases. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/respiratory-diseases

Kaynar, A. M., Sharma, S., & Pinsky, M. R. (2016). Respiratory failure. Retrieved from http://emedicine.medscape.com/article/167981-overview#showall

Lexicomp. (2016). Lexicomp clinical suite [Mobile application software]. Retrieved from http://webstore.lexi.com/Store/Bundled-Software-Packages/Lexi-ClinicalSuite

Medline Plus. (2016). RBC indices. Retrieved from https://medlineplus.gov /ency/article/003648.htm Mosenifar, Z., Harrington, A., Nikhanj, N. S., Kamangar, N., Windle, M. L., & Oppenheimer, J. J.

(2016). Chronic obstructive pulmonary disease (COPD). Retrieved from http://emedicine.medscape.com/article/297664-overview#showall

National Heart, Lung, and Blood Institute. (2011). What is respiratory failure? Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/rf

Pagana, K. D., Pagana, T. J., & Pagana, T. N. (2015). Mosby’s diagnostic and laboratory test reference (12th ed.). St. Louis, MO: Mosby.

Rafiq, M., Proctor, A., McDermott, C., & Shaw, P. (2015). Screening for respiratory failure in ALS using clinical questioning, respiratory function tests and transcutaneous carbon dioxide: Which is the better tool? Journal of Neurology, Neurosurgery & Psychiatry, 86(11), e4.54. Retrieved from http://jnnp.bmj.com/content/86/11/e4.54

Shetty, S. (2015). Obesity hypoventilation syndrome. Current Pulmonary Reports,4(1), 42–55. doi:10.1007/s13665-015-0108-

9/30/2017

17

Thank you!