CAN WE STAY AWAY FROM
TRACHEA AND MANAGE RESP.
DISTRESS IN EMERGENCY???
Case details, evaluated and managed
(NIV) Dept. Emergency medicine and trauma,
Kamineni institute of medical sciences
Dr. M.S.Devijan
Post Graduate
Emergency Medicine
Kamineni Institute Of Medical Sciences
CASE I
• A 45yr old male known case of
Chronic kidney disease on
dialysis(CKD stage-5) came with chief
complaints of
• Swelling of feet
3days
• Decreased urinary out put
3days
• Shortness of breath
6hrs
History of present illness
• Swelling of feet
•Sudden onset
•B/L
•Progressed till knee
•Pitting type of odema
•Aggravates on walking and relieves by
rest
• Decrease urinary output
•Reduce urinary flow for 2days
•No H/O burning micturition , pain in
abdomen , pain during micturition
•No H/O fever
• Shortness of breath
•Sudden onset
•Progressed from grade I to grade III in
6Hrs(NYHA)
•Aggravates on working , lying down
•Relived by sitting posture
•H/O orthopnea present
•Not relieved by his regular medications
•No H/O of seasonal or diurnal
variations
•No H/O atopy , allergies
• Negative H/O
•No H/O of fever , cough, cold, wheeze
•No H/O of chest pain, palpitations,
syncope attacks
•No H/O jaundice,pruritis
Past history
• K/C/O chronic kidney disease on
maintenance hemodialysis, missed his last
cycle posted 2days back
• H/O similar attacks previously
• Hypertensive :on medications
• No H/O DM , asthma , tuberculosis , thyriod
disorders
Personal history
• Diet
• Appetite
• Sleep
• Bowel
• Bladder
• Addictions
: mixed
: decreased
: disturbed
: normal
: oliguria
: alcoholic
• Family H/O : no history of familial
disorders
• Drug H/O
: no H/O any drug allergy
 Analgesic abuse for joint
pain relief
 Tab.Clonidine 0.1µgm TID
for hypertension
Gen.examination
• Patient is thin built and poor nourished
• Vitals
•Pulse : 100 bpm regular, high volume,
normal character, no radio-radio / radio-femoral
delay
•Blood pressure : 170/100 mm Hg
Right arm supine
•Resp. rate
: 26 cpm regular, rapid
shallow breathing use of
accessory muscles present
•Afebrile
•Pain
:absent
•Et CO2
:26 mm Hg
Gen.examination
• Pallor
• Icterus
• Cyanosis
• Clubbing
• Odema
: present
:absent
:absent
:absent
:present
• Cardio vascular : JVP elevated
apex beat 5th ICS (3cm)
lateral to mid clavicular line
S1 and S2 heard,no murmur
• AV fistula left forearm (functioning)
Systemic examination
• Respiratory
• Inspection: trachea central in position, symmetrical
chest expansion equal on both sides,
use of accessory group muscles
Palpation: all inspectory findings confirmed
vocal fremitus equal on both sides
• Percussion : resonant note in all areas
• Auscultation: AEBE , NVBS breath sounds heard in
all areas
B/L basal fine crepitation present
vocal resonance equal on both sides
• P/A : soft non tender, no guarding or rigidity
mild hepatomegaly tender.
• Central nervous system
no focal neurological defect
no gait abnormalities
no cranial nerves palsy
no movement disorders
Provisional Diagnosis
• Cardiogenic pulmonary edema
• Non cardiogenic pulmonary
edema
• Investigations:
Complete blood picture
Complete urine examination
renal function test
Ultrasonography
Arterial blood gas analysis
chest x ray
Lab investigations
• CBP: Hb : 7.8 gm/dl
TC : 9000 /cu.mm(DC: N-78, L-20,E-2,M-0,B-0)
platelet count:1.6 lakhs/cu mm
normocytic normochromic anemia
• CUE :pale yellow color,clear,acidic,bile salts
and bile pigments absent, no amorphous
deposits
albumin : +++
sugar : nil
pus cells:5-6 epithelial cells :2-6 RBC : nil
Lab investigation cont
• Blood urea
: 159 mg/dl
• Serum creatinine: 9 mg/dl
• Serum electrolytes :Na:136 mmol/L
K :5.2 mmol/L
Cl :100 mmol/L
• USG : grade III renal parenchymal
disease
kidney size:right 6× � ��
left 7 ×6 cm
Lab investigation cont
• Arterial blood gas analysis(FiO2 0.2%)
pH
pCO2
pO2
HCO3
: 7.3
:27 mm of Hg
:75 mm of Hg
:15 mm of Hg
2DEcho : normal ejection fraction
no RWMA
left ventricular hypertrophy
ECG
Diagnosis
• Acute pulmonary edema of chronic
kidney disease
• Left ventricular dysfunction
Treatment in ER
• In order to reduce his respiratory distress he was kept
on NON INVASIVE VENTILATION until he could be
taken up for emergency dialysis
• BiPAP(Bi level postive airway pressure)
•IPAP : 12 cm of H2O
•EPAP : 5 cm of H2O
•Back up rate : 10 breaths
•Trigger : low
•For 4hrs
Outcome
• Patient improved symptomatically.
• Respiratory distress decreased
• vitals : pulse :98 bpm
respiratory rate : 18 cpm
ABG :
pH
: 7.3
pCO2
:36 mm of Hg
pO2
:90 mm of Hg
HCO3
:15 mEq/L
Patient was taken for dialysis
CASE II
• A female patient of age 50yr came
with chief complaints of
•Giddiness
2 days
•Vomiting
1 day
•Swelling of lower limbs
1 day
• Giddiness
•Sudden onset since 2 day
•Not associated with trauma
•Not associated with any drugs
•Not associated with deafness or ear
discharge
•No H/O aggravating or relieving with
head position
• Vomiting
•Non projectile , non billious in nature
•Not associated with abdominal pain
•Not associated with diarrhea or
constipation
•Not H/O head ache
• Swelling of limbs
•B/L and pitting of type of edema
•Graded till knee
•Associated with exertion dyspnea
•No H/O chest pain,
palpitations,syncopal attacks
•No H/0 reduced urinary flow or
burning micturition
•No H/O jaundice
• Past H/O : K/C/O Type 2 Diabetes
K/C/O Hypertension
K/C/O Vertibulobasilar Insufficiency
H/O episodes of Exertional Dyspnea
• Personal history:
•Diet :mixed
•Appetite : normal
•Sleep : disturbed
•Bowel and bladder : regular
•Addictions : chews tobacco
• Drug H/O : no known drug allergies
Inj.H.Mixtard Insulin (30/70)
for DM 12U – 6U
Tab. Telmesartan 40mg OD
for HTN
• Gynic H/O : hysterectomy was done
no H/O white discharge
• On Day 2 of admission she developed
dyspnea
•Sudden onset
•progressed grade IV (NYHA)
•H/O cough( productive) occasionally
•H/O exertion dyspnea in past
•No H/O chest pain, palpitations
,syncope
•No H/O puffiness of face, oliguria
•No H/O jaundice,pruritis.
General examination
Patient is obese and with respiratory distress
O2 at 6 lit/min VPD( poly mask )
• Pulse : 110 bpm regular, normal volume, normal
character no radio-radio / radio-femoral delay
• Blood pressure : 180/110 mm Hg left arm supine
• Resp. rate
: 28 cpm regular,
rapid shallow breathing
use of accessory muscles present
• Afebrile
• Pain
• Et CO2
:absent
:26 mm hg
Systemic examination
• Respiratory
• Inspection: trachea central in position, symmetrical
chest expansion equal on both sides
use of accessory group muscles present
• Palpation: all inspectory findings confirmed
vocal fremitus increased on RT side
• Percussion : dull note on RT infra mammary,
infra axillary,infra scapular..
• Auscultation: air entry decreased on RT side, NVBS
breath sounds heard in all other areas
B/L basal creptations present
vocal resonance increased on RT side
• CNS : GCS 15/15
higher motor function normal
no motor or sensory lesions
gait and co ordination normal
• Cardio vascular :JVP increased 7 cm
apex beat 5th ICS lateral to
mid clavicular line
S1 and S2 heard, no murmur
• P/A
: soft, tender hepatomegaly
Provisional Diagnosis
• Cardiogenic pulmonary odema
• B/L Pneumonia with effusion
• ALI(??ARDS)
• Investigations:
Complete blood picture
Complete urine examination
FBS/PPBS
renal function test
Arterial blood gas analysis
chest x ray
Ultrasonography
2D Echo
Lab investigations
CBP:
Hb : 9.8 gm/dl
TC : 9000 /cu.mm(DC: N-70, L-24,E-3,M-3,B-0)
platelet count:1.9 lakhs/cu mm
normocytic normochromic anemia
CUE :pale yellow color,clear,acidic,bile salts
and bile pigments absent,no amorphos
deposits
albumin : +++
sugar : ++++
pus cells:5-6 epithelial cells :2-6 RBC : nil
FBS :140mg/dl
PPBS :300mg/dl
Lab investigations cont
• Blood urea
: 45 mg/dl
• Serum creatinine: 1.2 mg/dl
• Serum electrolytes:Na:131 mmol/L
K :4.2 mmol/L
Cl :99 mmol/L
• USG : grade I renal parenchymal disease
mild hepatomegaly,
fatty changes present in liver
Lab investigations
• Arterial blood gas analysis(FiO2 0.2%)
pH
: 7.47
pCO2
:27 mm of Hg
pO2
:75 mm of Hg
HCO3
:20 mm of Hg
• 2D Echo : Ejection fraction : 45%
LV dysfunction present
ECG
Diagnosis
• Acute Pulmonary Edema Due To
Left Ventricular Failure
Right Lower Lobe Consolidation
Treatment
• Patient was opted for NON INVASIVE
VENTILATION as the pulmonary edema
was not responding to regular diuretics
• CPAP (Continuous Positive Airway
Pressure) :
•Pressure at 5 cm of H20
•Back up rate of 12 bpm
•Duration 6hrs daily
• Medical therapy:
•Inj.Azithromycin 500mg IV od
•Tab.telmesartan 80 mg od
•Inj.H.Mixtard (30/70) S/C 12U-6U
•Tab.Vertin 8mg BD
•Tab.Atorvas 20 mg H/S
•Inj.frusemide 80 mg IV BD
Day 2
Day 3
Outcome
• Patient improved symptomatically.
• Respiratory distress decreased
• vitals : pulse :98 bpm
respiratory rate : 18 cpm
ABG :
pH
: 7.46
pCO2
:40 mm of Hg
pO2
:102 mm of Hg
HCO3
:22 mEq/L
Patient was referred for Angiography
CASE III
• A male patient of age 55yrs came to
ER with chief complaints of
•Fever
1day
•Shortness of breath 3Hrs
•Wheeze
3Hrs
History of present illness
• Fever
• Sudden onset
• High grade fever
• Intermittent in nature
• Associated with chills and rigors
• Relived with medication
• No H/O change in color of sputum
• No H/O head ache,vomiting,body pains
• No H/O ear pain and ear discharge
• No H/O abdominal pain, diarrhea
,constipation
• No H/O burning micturition
• Shortness of breath
• Sudden onset
• Progressed from grade I to grade IV in
4Hrs(MRMC)
• H/O wheezing present
• H/O Aggravates on working, lying down
• Relived by sitting posture
• H/O orthopnea present
• H/O of seasonal variation (+), aggravates on
cold exposure
• H/O cough occasionally
• Negative H/O
•No H/O of fever, cold
•No H/O atopic , allergies
•No H/O of chest pain, pedal edema
palpitations, syncope attacks
•No H/O PND
•Not relieved by his regular medications
•No H/O jaundice,pruritis
•No H/O puffiness of face,oliguria
Past history
• K/C/O Chronic Obstructive Pulmonary
Disease
• H/O similar attacks previously
• Hypertensive :on medications
• No H/O DM , tuberculosis , thyroid
disorders,epilepsy,CVA,CAD.
Personal history
• Diet
• Appetite
• Sleep
• Bowel
• Bladder
• Addictions
: mixed
: decreased
: disturbed
: normal
: normal
: smoker 2pac/day
since 25yrs
non alcoholic
• Family H/O : no history of familial
disorders
• Occupational H/O : agriculture
• Drug H/O
: no H/O any drug allergy
Tab.Deriphylline 100mg OD
Tab.Ramipril
10mg OD
Gen.examination
• Patient is well built and well nourished
• Vitals
• Pulse: 100 bpm regular, normal volume, normal
character no radio-radio / radio-femoral delay
• Blood pressure : 170/100 mm Hg left arm supine
• Resp. rate
: 26 cpm regular, prolonged
expiratory phase use of accessory muscles
present, pursing of lips present
• Temp
:100 F
• Pain
: absent
• Et CO2
: 35 mm Hg
Gen.examination
• Pallor
• Icterus
• Cyanosis
• Clubbing
• Odema
: absent
:absent
:absent
:present
:absent
Systemic examination
• Respiratory
• Inspection: trachea central in position, barrel
shaped chest, expansion equal on both sides,
use of accessory group muscles present
• Palpation: all inspectory findings confirmed
vocal fremitus equal on both sides
• Percussion : resonant note in all areas
• Auscultation: AEBE, Bronchial breath sounds
heard in all areas, no added sounds
Vocal resonance equal on both sides
• Cardio vascular : JVP normal
apex beat absent
S1 and S2 heard, no murmur
• P/A : soft non tender, no guarding or rigidity
no organomegaly
• Central nervous system : GCS 15/15
higher motor function normal
no motor or sensory lesions
gait and co ordination normal
Provisional Diagnosis
• Acute exacerbation of COPD
• Bronchial asthma
• Investigations:
Complete blood picture
Complete urine examination
Renal function test
Arterial blood gas analysis
chest x ray
Ultrasonography
2D Echo
Lab investigations
CBP: Hb :14 g/dl
TC :11,000 /cu.mm(DC:N-80, L-2,E-3,M-1,B-0)
platelet count:2 lakhs/cu mm
normocytic normochromic
CUE :pale yellow color,clear,acidic,bile salts
and bile pigments absent,
no amorphos deposits
albumin : nil
sugar : nil
pus cells:2-3 epithelial cells :1-2 RBC : nil
Lab investigation cont
• Blood urea
: 32 mg/dl
• Serum creatinine: 0.8 mg/dl
• Serum electrolytes:Na:136 mmol/L
K :3.6 mmol/L
Cl :100 mmol/L
• USG :normal study
• 2DEcho:ejection fraction :65%
no LV dysfunction
no RWMA
• Arterial blood gas analysis
•pH
•pCO2
•pO2
•HCO3
•sO2
:7.21
: 65 mm Hg
:78 mm Hg
:26 mEq/L
:89%
ECG
Treatment
• Medical treatment:
• Propped up position
• O2 inhalation 6lit/min with VPD
(poly mask)
• Neb.levosalbutamol and Ipratropium bromide
respule every 2Hrly
• Neb.Budesonide respule every 2Hrly
• Inj .Hydrocortisone 100mg IV stat
• Tab.Doxyphlline 200mg BD
• Inj.ceftriaxone 1gm IV BD
• Tab.Paracetamol 500mg TID
ABG & NIV SETTINGS
Admission
2Hrs after
4hrs
6hrs
pH
7.21
7.26
7.32
7.35
pCO2
65 mm Hg
60 mm Hg
54 mm Hg
50 mm Hg
pO2
78 mm Hg
90 mmHg
90 mm Hg
94 mmHg
HCO3
26 mEq/L
25 mEq/L
27 mEq/L
26 mEq/l
sO2
89%
90%
94%
96%
BiPAP
IPAP : 12 cm
EPAP : 6 cm
IPAP : 12cm
EPAP : 6cm
IPAP : 10cm
EPAP:5cm
IPAP : 10cm
EPAP : 5cm
• After 6 Hrs patient resp. rate came down and distress was relived.
• Patient was supported NIV for 2hrs and gradually weaned off
• Vitals were stable:
Resp.rate :20 cpm,normal pattern
•
Arterial blood gas analysis
• pH
:7.42
• pCO2
: 48mm Hg
• pO2
:95mm Hg
• HCO3
:26 mEq/L
• sO2
:98%