Emphysema
Patient Presentation:
S.H. is an 84 year old male presenting to the ED with shortness of breath, lethargy, and confusion after his live-in daughter found him unresponsive and “grey” in his bed at home this morning. When emergency crews arrived, the patient was arousable, with O2 saturation initially at 47%. Administration of oxygen via a non-rebreather mask brought the O2 saturation up to 69%. Vital signs upon admission to the ED: O2 sat 69%, BP: 106/75, RR 28, HR 110, T 97.9 orally. The patient has a pack a day for 50 years smoking history, known early emphysema, multiple myeloma in remission, high cholesterol, and healing stage 3 pressure sores on bilateral heels. The patient appeared very thin, with noted barrel shaped chest, consistent with patients with emphysema. This patient still smokes cigarettes every day.
Differential List:
Pneumonia, acute exacerbation of emphysema
Treatment:
Immediately the patient was placed on BiPAP and ABGs were drawn. As the patient’s oxygen saturation rose, the patient’s confusion diminished. A portable chest x-ray was done indicating hyperinflated lung fields, but no evidence of infiltrates. This ruled out pneumonia, leaving the health care team to strongly feel that this episode is an exacerbation and possible advancement of the patient’s emphysema. CBC indicated normal white cell count at 9.1 and anemia with hemoglobin and hematocrit at 9.7/27.9%. ABG results: pH 7.29, PaCO2: 55, HCO3 25, PaO2 58. These ABGs indicate uncompensated respiratory acidosis.
Often times pulmonary function tests are ordered for patients with emphysema. In this case, the MD decided against it. However pulmonary function tests typically assist the health care team in determining the severity of the patient’s emphysema. In an individual with emphysema, there will be a decrease in FEV1, a decrease in FVC, and an increase in FRC, RV, and TLC.
Outcome:
The patient was admitted to the hospital for monitoring for the next few days. The patient would require respiratory treatments around the clock including inhaled bronchodilators and inhaled corticosteroids, a regimen to be ordered by the patient’s pulmonologist. A social work consult was also written, as the patient will now require at home oxygen therapy. A wound consult was also ordered for evaluation and continued treatment of his bilateral stage 3 pressure sores on his heels. Smoking cessation counseling was also ordered.
Case created by Shannan Henry, 2011.