9/30/2017 1 A CLINICAL CASE STUDY MANJU DANIEL, PHD, MSN, APN, FNP-BC MA VANESSA MABAZZA, BSN, RN, CCRN, CNRN NORTHERN ILLINOIS UNIVERSITY Patient case Patient Information: Name: OC Age: 63 Gender: Female Chief Complaint: “Feeling terribly weak for the past 24 hours.” History of present illness (HPI) Resident of skilled nursing facility Morbidly obese Multiple chronic health conditions Staff found patient to be too sleepy Difficult 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 apnea Ch use of 02 at 2-3 L PRN (current 4 L, O2 sat- 86%)
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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%)
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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
Increased work of breathing with use of accessory muscles
Diminished at bases bilaterally
Vasculature: +1 bilateral pedal edema
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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)
• 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
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)
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OHS (cont.2)
Acute hypercapnic respiratory failure is further validated by:CMP result- elevated CO2ABG results- respiratory acidosis
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)
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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)
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OHS Management In this case- RF was mainly because of
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.
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
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)
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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-