Case study(Cardiopulmonary)

A 35-year-old known asthmatic man has just been admitted to the medical ward with a 2day history of fever, cough productive of sputum and left-sided chest pain.

PMH: asthmatic;

DH: salbutamol and beclothemasone via metered dose inhalers;

SH: computer programmer lives with wife;

O/E:

·         Temperature 39°C;

·         Tachypneic RR 30, SOBAR talking in clipped sentences, shallow breaths;

·         Auscultation: reduced breath sounds bi-basally, inspiratory crackles left lower lobe, faint monophonic expiratory wheeze left lower lobe; •

·         CXR: Patchy white shadowing LL zone;

·         ABGs: (FiO2 0.4) pH 7.48, PCO2 4.4, PO2 10.5, HCO3–25 BE -1.

What pathophysiology can be identified?

What are the underlying causal factors?

Physiotherapy treatment

CASE STUDY  SOLUTION

What pathophysiology can be identified?

• ·      Acid-base disturbance: respiratory alkalosis with hypoxemia.
• ·         Airflow limitation: expiratory wheeze.
• ·         Impaired gas exchange: hypoxemia.
• ·         Probable infection: pyrexia, productive of sputum, CXR shadowing.
• ·         Impaired tracheobronchial clearance: retained secretions.
• ·         Pain: pleuritic chest pain.
• ·         Reduced lung volume: Reduced basal BS on auscultation ?bi-basal atelectasis on CXR, altered respiratory pattern.

What are the underlying causal factors?

• ·   Acid-base disturbance: hypoxemia secondary to pulmonary infiltrate, probable infection, producing V/Q mismatch. RR raised to compensate for hypoxemia producing a fall in CO2. Renal compensation has not occurred.
• ·  Airflow limitation: local airway inflammation producing narrowing or sputum-related obstruction.
• ·   Impaired gas exchange: large pulmonary infiltrate producing an area of low V/Q ‘wasted perfusion’. Patient is unable to compensate for this by increasing RR. Collapse of lung units distal to site of infection will contribute to ongoing hypoxemia.
• ·         Infection: probable respiratory infection, microorganism as yet unknown.
• ·         Pain: pleuritis secondary to probable infection.
• ·         Reduced lung volume: Reduced VT secondary to pain. Atelectasis of lung units distal to site of infection.

Physiotherapy treatment

• ·         Acid-base disturbance: Positioning to relieve SOB, breathing control to normalize RR. Oxygen therapy (prescribed by doctor) optimize delivery with correct device, humidification.
• ·         Airflow limitation: bronchodilator therapy, nebulized rather than MDI (prescribed by doctor).
• ·         Impaired gaseous exchange: position patient to maximize V/Q.
• ·         Probable infection: if possible send sputum specimen for cytology.
• ·  Impaired tracheobronchial clearance: positioning to relieve SOB, mucociliary clearance techniques: ACBT +/–manual techniques, GAP.
• ·         Pain: TNS, analgesia (prescribed by doctor).
• ·      Reduced lung volume: adjunct to increase VT and assist expectoration, e.g. IPPB, adjunct to increase FRC and assist re-expansion of atelectasis, e.g. CPAP. NB caution should be exercised in acute stage to reduce risk of further air trapping. Advise patient on positioning to improve lung volumes and promote early mobilization.