Organ weight loss. A two week history of

Organ failure case study question 1The male patient first presents with complaints of a dry cough, blood in sputum, fever, sweating and weight loss. A two week history of a dry cough and fever suggests that it is an acute cough, which usually manifests with respiratory infection. Sweating, haemoptysis and unexplained weight loss are all common clinical sign of lung cancer, pneumonia and tuberculosis.On the examination, his respiratory rate is 28/min ie. hyperventilation, suggesting that he is suffering from a condition that cause insufficient oxygen delivered to the blood. On ABG results, his PaO2 is very low. The saturation of haemoglobin with oxygen (SO2) is also lower than the normal range. This could be caused by obstruction in the airway or ventilation-perfusion mismatch, where shunting has occur. Since he is not hypoventilating, which usually causes hypoxemia, the problem might lie within the lung where the lung is well profused but not well ventilated. There is also a rise in blood pressure where the heart pumping force has increased to compensate for the low oxygen saturation in blood being delivered to rest of the body. From the information provided by ABG, the patient is suffering from type 1 respiratory failure. It is clearly seen that he has dyspnoea because he is using his accessory muscle to breath, suggesting forced respiration probably cause by disturbance of ventilation, gas exchange or ventilation-perfusion mismatch. Clubbing of finger can manifest in patients with hypoxia condition where there is insufficient oxygen delivered to the tissue.Information social history, he does not have a fixed home to live, suggest that the environment he is living now has some influence to his condition. The patient has a history of smoking, chronic alcoholism and drug abuse, all these contained substances are injurious to pulmonary tissue; these factors contribute to the respiratory failure.With all this information taken into account, our differential diagnosis is: (1) Pulmonary infection, for example pneumonia, upon first admission to the hospital; (2)Chronic Obstructive Pulmonary Disease (COPD) which is the obstruction of the airway; (3) Acute Respiratory Distress Syndrome (ARDS) resulting from injury to the alveolocapillary membrane that leads to severe pulmonary oedema- in this case more prominent in left lung; (4) Lung cancerAll these condition manifest the common clinical symptoms such asdyspnoea, hyperventilating, cough, blood in sputum, and finger clubbing.fQuestion 2: What investigations will you perform?1)      Blood testing and Microbiological testsA number of respiratory conditions and diseases can be diagnosed with the aid of blood testing. A full blood count should be ordered, as well as Renal function tests, Liver function tests and Tropinin tests. To rule out a pulmonary embolism, a D-dimer test could be carried out. Tumour marker tests would test for lung cancer (CEA, CYFRA 21-1, NSE) and malignant mesothelioma (mesothelin, fibulin, osteopontin). The blood can be tested for Alpha-1 Antitrypsin Deficiency, which is a common genetic risk factor for COPD. Diminished air entry bilaterally was noted, suggesting fluid in the lungs. Pleural effusion would be diagnosed by the presence of proteins, LDH, cholesterol in the pleural fluid.  Urinary Antigen tests can be carried out to diagnose certain respiratory infections.2)   Sputum Culture A Gram’s staining is used to determine if the patient is suffering from pneumonia and if so what the cause is, which will allow more effective treatment. This test may also help determine if the patient has lung cancer.3)      SpirometryThis would be used to determine if the patient is suffering from COPD. Spirometry will measure the patient’s Vital Capacity (FVC), Forced Expiratory Volume in 1 second (FEV1), Tidal Volume and inspiratory and expiratory reserve volumes. If the patient has COPD, he will have a low FEV1 while his FVC will be close to normal and the FEV1/FVC ratio will be less than 70%.4)      A chest X-rayA chest X-ray would allow the structural aspects of the thorax to be visualised and interpreted non-subjectively and would aid in advising further investigations if an abnormality was observed. This would help distinguish between COPD, Pneumonia and ARDS, which are the three main possibilities for his diagnosis. The X-Ray will show any emphysema, consolidation in pneumonia, abnormalities such as tumours, fluid, or dilation of the bronchial tree.5)   A CT scanA computed tomography scan would allow the anatomical features of the thorax to be seen and analysed in more detail. It can be performed with intravenous contrast enhancement, which could be used to diagnose or rule out a suspected pulmonary embolism. A CT-PET scan would identify areas of high glucose uptake (cancerous tumours). This would also aid in staging lung cancer, and in determining if the cancer was benign or malignant. Question 3 What are your initial plans to provide respiratory support?It is necessary to commence supportive care prior to a definitive diagnosis as this buys more time for the patient. His respiratory rate is above normal, 28/min as opposed to 12/min. Given his elevated breathing rate and PaO2 of 55 mm Hg it is likely he is experiencing hypoxia. Hypoxia can lead to a decline in organ function if left untreated so it is extremely important to reduce this oxygen deficit to best manage the patient. Oxygenation Oxygenation should be the first step in respiratory support. We would treat the patient with oxygen to try to bring his breathing rate back to normal and his oxygen saturation levels to 92%. Oxygen can be provided via a face mask, nasal prongs or a cannula. Oxygen should be initially provided at a high level and then adjusted using the results of a second ABG. Heliox could also be administered to reduce turbulent flow if there was a suspicion of airway obstruction or narrowing. The patients PC02 is not elevated but the patient should still be monitored for signs of CO2 narcosis as they are receiving oxygen therapy. Pulmonary oxygen toxicity is also something that needs to be looked out for so to reduce the likelihood of this we would administer an FiO2 of less than 0.6 We should look for improvement within 1 hour.PhysiotherapyPhysical therapy is an essential part of the support plan for patients with respiratory problems. Postural drainage is important to help clear secretions from the airways. This involves getting the patient into positions that will make it easier for mucus to drain. Patients with resistant hypoxemia may benefit from being turned prone. The improvement in oxygenation is a result of the normalization of the lung’s pleural pressure gradients.Continual MonitoringThe patient should be closely monitored for any signs of deterioration or improvement. SpO2, heart rate and blood pressure  should be continuously monitored and ABG values obtained at regular intervals.Question 4: What support might you consider now?Mechanical ventilation can be used to improve oxygenation and to assist with breathing, especially since use of accessory muscles of breathing may indicate increased Work of Breathing.  High Flow Oxygen Therapy may be used and if the patient is still hypoxemic then assisted ventilation with non-invasive positive pressure ventilation (CPAP) may be used. By recruiting underventilated alveoli CPAP may help to ameliorate the bilateral diminished air entry.  As gastric distension is a possibility the patient must be cooperative, have the ability to protect their airway, breathe on their own and cough effectively to clear secretions.There is a danger that the patient could develop Type II respiratory failure whilst receiving this support, which would be indicated by rising PaCO2. If this happens and the patient starts to lose consciousness, then endotracheal intubation and ventilation may become necessary. CRP levels would be checked and CXRs performed in order to monitor the progression of the disease and inflammation as treatment proceeds. It may be necessary to provide analgesia for pleuritic chest pain, e.g. paracetamol 1g/6h or NSAID. Renal output should still be monitored. There would be a continuous process of monitoring, looking at ECG, blood pressure and O2 saturations, with close observations for any deteriorations. If there are any deteriorations, then the patient would need advanced ICU management with effective communication with the ICU team. To minimise the risk of ventilator-induced lung injury, low tidal volumes would be used.Question 5: Is the repeat ABG better or worse than the initial ABG? Patient’s A repeat ABG is worse than the initial. His PaO2 levels have improved slightly from 55mmHg to 65mmHg, he is still hypoxic.His PaCO2 has increased from 35mmHg to 53mmHg, increasing hypercapnia. What concerns you most about it and why? The increasing PaCO2 is the most concerning and strongly suggest he has progressed from Type One to Type Two Respiratory Failure. This associated with hypoxia, hypercapnia. The hypercapnia is associated with acidosis and CO2 narcosis, which can ultimately lead to drowsiness and coma. What intervention is he likely to need? The interventions to consider now for this patient are Bipap or possibly mechanical ventilation in the ICU.If patient remains unresponsive to supplemental O2 delivery, he might need to be intubated and invasive ventilator support in the ICU. An IV line should be set up and delivery of antibiotics if he has been diagnosed with an infection. Administer steroids or bronchodilators depending on the diagnosis. Ultimately treatment will depend on the result of the earlier investigations.An arterial line should also be inserted to take blood readings every half hour to monitor his condition until it begins to improve.


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