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Tim Op’t Holt, EdD, RRT, AE-‐C, FAARC
Case 1: Wheezing in an Adult � A 56 year-old male presents to his family physician 2 weeks
after having been hospitalized for 8 days with a presenting complaint of shortness of breath.
� Upon admission to the hospital, his SpO2 was 88% on room air. He was treated with antibiotics, oral corticosteroids, oxygen per protocol, and bronchodilator therapy.
� At the office, he states, “I feel better.”
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Case 1: Wheezing in an Adult � The patient’s medical history is positive for hypertension,
hypercholesterolemia, and obesity. He claims to have had asthma as a child. He takes metoprolol (Toprol XR) and simvistatin (Lipitor) and uses an albuterol inhaler (Ventolin HFA). He reports allergies to cats, pollen, and mold. He’s had no surgeries or other hospitalizations.
Case 1: Wheezing in an Adult � Presently, his vital signs are within normal limits. His blood
pressure is controlled on metoprolol. HEENT: normocephalic, PERRLA. CV: no murmurs or gallop, normal S1 and S2. Chest: slight increase in AP diameter, equal fremitus, resonant to percussion, faint wheeze, BS distant. GU/GI noncontributory, obese abdomen. Extremities noncontributory.
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Case 1: Wheezing in an Adult • The therapist in the office obtains pre- and post-bronchodilator
spirometry, results are:
• He reports daily wheezing, twice a week nightly awakenings with cough, once daily use of his albuterol MDI, and minor limitation to activity.
Pred Pre % pred Post % pred % change
FVC (L) 5.2 3.53 68 3.68 70.7 4.2
FEV1 (L) 4.2 2.34 55 2.64 62.8 12.8
FEV1/FVC 80 66% 71.7%
Case 1: Wheezing in an Adult: Differen6al Diagnoses
Asthma? COPD? History of allergies Cough during exacerbation Dyspnea uncommon Age onset varies Reversible spirometry
History of smoking Chronic productive cough Progressive dyspnea Onset in or later than 5th decade Partially or irreversible spirometry
Important facts to determine the pathophysiology: Our pa6ent has a history of allergies, childhood asthma, a cough and dyspnea during his hospitaliza6on, and has reversible obstruc6on on his PFT (increased FEV1 by 300 mL and > 12%)
Asthma!
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Case 1: Ini6al Plan of Care The plan of care from the primary care physician includes:
� Albuterol MDI use PRN � Fluticasone/Salmeterol 100/50 BID � Follow-up in 3 weeks � RT to teach/review device use
Case 1: Recommended Plan of Care – Albuterol MDI use PRN – Fluticasone/Salmeterol 250/50 BID – RT to teach/review device use – Determine personal best peak flow monitoring and peak flow diary – Discuss environmental control – Complete a written asthma action plan with symptom and peak flow monitoring – Flu vaccine – Follow-up in 3 weeks
Consistent with EPR-3 guidelines, this patient with severe persistent asthma should be on step 3 (a higher dose of ICS/LABA) with asthma education, peak flow monitoring, and a written asthma action plan.
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Case 2: Wheezing in an Adult • A 66 year-old female presents to her family physician 2
weeks after having been hospitalized for 8 days with a presenting complaint of shortness of breath.
• Upon admission to the hospital, her SpO2 was 88% on room air. She was treated with antibiotics, oral corticosteroids, oxygen per protocol, and bronchodilator therapy.
• At the office, she states, “I’m short of breath.”
Case 2: Wheezing in an Adult � The patient’s medical history is positive for hypertension, and
hypercholesterolemia. She has smoked cigarettes, up to 2 ppd, since she was 18. She takes metoprolol (Toprol XR) and simvistatin (Lipitor) and uses an albuterol/ipratropium inhaler (Combivent), up to 4x daily. She has allergies to codeine. She’s had no surgeries, but has been hospitalized twice before for pneumonia.
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Case 2: Wheezing in an Adult • Presently, her vital signs are significant for a respiratory rate
of 28 breaths/min. Her blood pressure is controlled on an ACE inhibitor. HEENT: normocephalic, PERRLA.
• CV: no murmurs or gallop, normal S1 and S2. • Chest: increased AP diameter, equal fremitus, hyperresonant
to percussion, faint wheeze, BS distant. Pursed-lip breathing and use of accessory muscles.
• GU/GI noncontributory. • Extremities: 1+ pitting edema in ankles
Case 2: Wheezing in an Adult The therapist in the office obtains pre- and post-bronchodilator spirometry, results are:
Pred Pre % pred Post % pred % change
FVC 3.54 3.00 85 3.05 86.1 1.7
FEV1 2.83 1.98 69.9 2.01 71.0 1.5
FEV1/FVC .66 65.9
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Case 2: Wheezing in an Adult: Differen6al Diagnoses Asthma? COPD?
History of allergies Cough during exacerbation Dyspnea uncommon except in exacerbation Age onset varies, often in childhood Reversible spirometry
History of smoking Chronic productive cough Progressive dyspnea Pedal edema Onset in or later than 5th decade Partially or irreversible spirometry
Important facts contribu6ng to this pathophysiology: Our pa6ent has up to a 96 pack-‐year history of smoking, chronic cough and dyspnea pedal edema, and irreversible obstruc6on on her PFT (increased FEV1 by only 30 mL and 1.5%)
Moderate COPD by GOLD guidelines!
Case 2: Ini6al Plan of Care The plan of care from the primary care physician includes:
� Albuterol/ipratropium MDI use PRN � Fluticasone/Salmeterol 250/50 BID � Told to quit smoking � Follow-up in 3 weeks � RT to teach/review device use
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Case 2: Recommended Plan of Care • Albuterol/ipratropium MDI PRN • Tiotropium bromide 17 µg (1 inhalation) each morning • Salmeterol 50 µg (1 inhalation) BID • Flu and pneumonia vaccinations • COPD education • Medication and device education • Referral to pulmonary rehabilitation and smoking cessation program • Follow-up in 3 weeks This is consistent with the GOLD guidelines for a patient with moderate COPD.
Case 3: Numbness and Weak Legs A 25-year-old figure skater was admitted to an emergency department with a presenting complaint of tingling, burning and finally numbness and weakness in her legs over 2 days. She was visibly upset, thinking that she was “having a stroke.” She had a history of a “cold” for a few days two weeks earlier, but it resolved.
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Case 3: Numbness and Weak Legs � S: “I’m so scared” � O: afebrile, respiratory rate 28 breaths/minute, pulse 112
beats/minute; BP 124/76 mmHg, SpO2 on room air 99%, weight 65 kg; HEENT unremarkable; Chest: clear; CV unremarkable, tachycardia; GU/GI noncontributory N-M: numbness, weakness, paresthesia bilaterally in the lower extremities Extremities: no edema
Case 3: Numbness and Weak Legs O: progressive decrease in forced vital capacity, maximum
inspiratory pressure, -20 cm H2O Electrodiagnostic study showed progressive ascending paralysis
What is the pathophysiolgic process?
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Case 3: Numbness and Weak Legs Important findings include: � Paresthesia, numbness, weakness of recent onset � A decrease in maximum inspiratory pressure � Progressive ascending paralysis
Over the next day: � Progressive decrease in FVC, dysphagia, and an ABG
indicating acute ventilatory failure
Case 3: Numbness and Weak Legs: Differen6al Diagnoses
Myasthenia Gravis Guillain-‐Barré Syndrome* Chronic muscle fatigue Diplopia Ptosis Weakness brought on by repetitive motion Difficulty with stair-‐climbing and lifting objects Increased ACh receptor antibodies in blood Positive response to the edrophonium test Positive ice pack test Improved, then relapse of ptosis after 20-‐30 minutes of sleep CT or MRI demonstrating thymoma
Leg muscle weakness Tingling, burning shock-‐like sensations Paresthesia Lower back, buttock and leg pain Absent deep tendon reflexes Drooling Difficulty with speech, chewing and swallowing “ascending paralysis” Elevated CSF protein (>500mg/dL) without an increased lymphocyte count
Abnormal electromyography
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Case 3: Ini6al Plan of Care • Noninvasive ventilation • IPAP 15 cm H2O • EPAP 5 cm H2O • FiO2 .4 • ABG after 30 minutes The patient’s respiratory distress continued and she began to gag on secretions. Her ABG showed progressive hypercapnic respiratory failure.
Case 3: Recommended Plan of Care • Intubate with 8mm ETT • Initial ventilator parameters
– VC-CMV/.4/800 mL/8 bpm/+5 cm H2O – Peak flow 60 L/min – Decelerating flow pattern
• Frequent turning & suction PRN
Patients with N-M disease often need to be intubated for airway protection, require CMV, and demand a higher VT and flow to breathe comfortably. Tracheobronchial hygiene is important for airway patency.
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Case 4: Clickit, or Through the Windshield • A 17-year-old male football player was on his way home after
the game Friday night when a deer ran in front of his pickup. He slammed on the brakes, hit the deer, and because he failed to wear his seatbelt, was propelled through the windshield, landing 15 feet from the wreckage.
• Paramedics at the scene intubated and manually ventilated the victim, applied a cervical collar, started a large-bore IV, covered his abdominal and head wounds, and transported him to the university medical center.
Case 4: Clickit, or Through the Windshield Upon admission PE revealed: • S: unresponsive • O: VS temperature 37°C, pulse 142 beats/minute, resps 12 by bag, BP
146/90 mmHg, SpO2 98%. • HEENT: pupils responsive, blood coming from right ear, laceration to
right temple • CV: tachycardia • Chest: absent breath sounds on the right • GU/GI: abdominal laceration on the right • Extremities: broken right humerus and femur
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Case 4: Clickit, or Through the Windshield A: closed head injury, forehead laceration, right pneumothorax,
broken ribs on right, liver laceration, broken right femur and humerus.
P: chest radiograph, limb radiographs, head CT, chest tube insertion on right, to OR for suturing of head laceration and orthopedic repairs, exploratory lap and repair of liver laceration
Case 4: Clickit, or Through the Windshield � Transferred to the ICU receiving
mechanical ventilation � Several periods of hypotension
require 15 L of blood, blood products, saline and vasoconstrictors
� The next afternoon, as the patient begins to respond, his respiratory rate increases to 36/minute
� CXR reveals bilateral basilar infiltrates*.
* Example of bilateral basilar infiltrates
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Case 4: Ini6al Plan of Care • Following surgery, the
therapist makes the following ventilator settings: • Mode: pressure regulated
volume control • FiO2 1.0 • Target VT 8 mL/kg • Mandatory rate 12 breath/min • PEEP 5 cm H2O • ABGs WNL
• That afternoon, along with the increase in respiratory rate:
• PIP had risen to 40 cm H2O • ABGs reveal: 7.38/42/58 on
PRVC/.6/8 mL/kg/15 bpm/+12 cm H2O PEEP
Case 4: Clickit, or Through the Windshield Clinical data reveals: � P/F= 97 � CVP=22 mmHg � PCWP=14 mmHg � PAP=25/14 mmHg
Is this : � Heart failure? � Iatrogenic fluid overload? � Nosocomial pneumonia? � ARDS?
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Case 4: Clickit, or Through the Windshield Differential Diagnoses: Heart Failure Iatrogenic Fluid
Overload Nosocomial Pneumonia
ARDS*
History of heart failure PCWP > 18 mmHg Enlarged heart and pulmonary edema on CXR Distended neck veins Peripheral edema Basilar crackles
Large volume of fluid replacement Increased CVP, PCWP, PAP Distended neck veins Pulmonary edema Basilar crackles
New infiltrates 24-‐48 hrs after intubation Leukocytosis Fever Purulent mucus Lobar infiltrates and air bronchograms Bronchial breath sounds
Predisposing condition* PCWP <18 mmHg* P/F < 200* Bilateral infiltrates*
Case 4: Recommended Plan of Care � Decrease VT to 5 mL/kg
� PIP decreased to 28 cm H2O � Increase PEEP to 15 cm H2O � Increase mandatory rate to 18 bpm � Provide “lung protection” Resulted in: � ABGs: 7.36/48/75
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Summary � Try to have a history of the patient’s recent activities � Obtain HOPI � Obtain a physical examination or read the PE � Determine the outcomes of current therapy � Know the differential diagnoses � Have a knowledge of guidelines pertaining to the diagnosis
(ERP-3, GOLD, ARDSNET)
