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Idiopathic Pulmonary Fibrosis with Acute Respiratory Failure & Sepsis

By Debra Brown

Symptoms

This patient has been moved from the hospital setting to a rehabilitation facility for further care before she will be able to go home.

Because of the severe complications of her hospitalization she did need to be put on the ventilator.

The UTI, MRSA, and sepsis that this patient has at this time has caused complications of her IPF.

Treating the infections with the proper medications is the only way to make this patient have a better prognosis.

This patient’s respiratory symptoms are

SOB- decreased tolerance for activity

Shortness of breath during activity (this symptom lasts for months or years, and over time may also occur when at rest)

Scattered rhonchi throughout lungs with diminished breath sounds in the bases.

Chronic nonproductive cough- usually dry

Small amount of thick beige secretions when suctioned.

Scattered infiltrates in both lower lung fields

Chest pain (occasionally)

References

Jardins, T., & Burton, G. (2011). Clinical manifestation and assessment of respiratory disease. (p. 344). Maryland Heights, MS: Elsevier.

Pilbeam, S., & Cairo, J.M. (2006). Mechanical ventilation physiological and clinical applications. St. Louis, MS: Elsevier.

Chapman, J. & Brown, K. (2009). Egan’s Fundamentals of respiratory care. (pg. 533). St.

Louis, MS: Mosby Elsevier.

Patient Presentation

Medical History/Interview

This is a case of a 56 year old female that has a past history of being a chronic smoker for 30 years, she quit about a year ago and has developed Idiopathic Pulmonary Fibrosis (IPF) and is being treated for Acute Respiratory Failure (ARF), Methicillin Resistant Staphylococcus Aureus (MRSA) and sepsis.

This patient’s problem began when she came into the hospital presenting with shortness of breath.

The lungs are the region of the body that was first evaluated to access her problems.

On admission a chest x-ray was taken witch revealed infiltrates in both lower lung fields.

Medical History/Interview

http://www.coalitionforpf.org/cpf_rsrchrecent_news.php

http://www.ees.com/clinicians/specialties/thoracic?utm_source=google&utm_medium=cpc&utm_campaign=Clinician+-+Broad&utm_term=video%20thoracic%20surgery&utm_content=Specialties+-+VATS|mkwid|slmp5NqYd|pcrid|17399187331

Upon evaluation it was determined she was found with Idiopathic Pulmonary Fibrosis and candida glabrata urinary tract infection (UTI).

She is also being treated for Acute Respiratory Failure, MRSA, and sepsis.

This patient has had this problem before she has a past medical history of Idiopathic Pulmonary Fibrosis.

http://www.bing.com/images/search?q=UTI+Infection+Picture&qs=n&form=QBIR&pq=uti+infection+picture&sc=0-11&sp=-1&sk=

Symptoms

Her history of surgical procedures include:

Video-assisted thoracoscopic surgery (VATS)

Tracheostomy

Hernia repair

Hysterectomy

There is no documentation of her family’s history of illnesses.

This patient’s respiratory symptoms are

SOB- decreased tolerance for activity

Shortness of breath during activity (this symptom lasts for months or years, and over time may also occur when at rest)

Scattered rhonchi throughout lungs with diminished breath sounds in the bases.

Chronic nonproductive cough- usually dry

Small amount of thick beige secretions when suctioned.

Scattered infiltrates in both lower lung fields

Chest pain (occasionally)

http://www.coalitionforpf.org/cpf_rsrchrecent_news.php

Outline of Past Medical History

This patient has a past medical history of:

Idiopathic Pulmonary Fibrosis

Pulmonary Embolism

Hypertension

Gastroesophageal Reflux Disease (GERD) &

Coronary Artery Disease (CAD)

This patient has been moved from the hospital setting to a rehabilitation facility for further care before she will be able to go home.

Because of the severe complications of her hospitalization she did need to be put on the ventilator.

The UTI, MRSA, and sepsis that this patient has at this time has caused complications of her IPF.

Treating the infections with the proper medications is the only way to make this patient have a better prognosis.

Social and Environmental History

There is no documentation of this patient’s

Education level

Military experience

Occupational history

Hobbies and recreation activities

Recent travel

She lives at home with her husband

No documentation of her stresses or of any relationship problems.

Physical Examination

Initial Impression of this patient

She is awake, alert and oriented

Skin is warm and dry to touch, no rashes

Tracheostomy and peg noted

Shortness of breath noted

No cyanosis noted

No digital clubbing noted

No peripheral edema or venous distention noted

No distended neck veins

No enlarged/tender liver

Idiopathic Pulmonary Fibrosis with Acute Respiratory Failure and Sepsis

Chest

Facial expression is calm no painful expression noted

Inspiration and Expiration with out distress noted

No excessory muscle use noted

No nasal flaring noted

No JVD

Degree of comfort is normal

Chest movement symmetrical during inspiration and expiration

Sweat chloride- (< 39 mmol/L)

Value not given

Neck : No JVD

Heart: Normal PMI, regular rate and rhythm with normal S1 and S2, no murmur, rub, gallop

Abdomen- Soft, non-tender, non-distended, normal bowel sounds.  No hepatosplenomegaly, shows no signs of abnormality

Extremities –shows no digital clubbing or edema, no leg or hand edema; peripheral pulses normal

Laboratory Data

CBC

WBC - (3.8 – 11.0 K/mm3

9.0 K/mm3

RBC - (3.8 – 5.6 M/uL)

3.68 million/mm3 (low)

Differential – (11 – 18 g/dL)

HGB 9.5 g/dL (low)

Platelet count – (34 – 54%)

HCT 30% (low)

Blood Glucose – (70 – 110 mg/dL)

181 mg/dL (high)

BUN – (6 – 23 mg/ dL)

A blood urea nitrogen (BUN) test measures the amount of nitrogen in your blood that comes from the waste product urea. Urea is formed when protein is broken down in your body. It is made in the liver and removed from your body in urine.

A BUN test is done to tell how well your kidneys are working. If your kidneys are not able to remove urea from the blood normally, your BUN level increases. Heart failure, dehydration, certain medicines, intestinal bleeding, or a diet high in protein also can increase your BUN level. Liver disease or damage can decrease your BUN level, because urea is made in the liver. A decreased BUN level can occur normally in the second or third trimester of pregnancy.

Cardiac Enzyme – measures Creatine Phosphokinase (CPK) and Creatine Kinase (CK), and the proteins Troponin l (Tnl) and Troponin T (TnT) in the blood. (CPK – 24 – 195 U/L, CK - 0 – 3, Tnl – 0 – 0.1 ng/ml, and TnT – 0 – 0.2 ng/ml)

Value not given

Palpation and percussion

Auscultation

Bronchial breath sounds

Scattered rhonchi heard throughout lung fields with diminished breath sounds in bases.

By Debra Brown

Future RRT, CRT!

Creatinine – (0.6 – 1.5 mg/ dL)

Value not given

Serum creatinine

Adult males: 0.5–1.2 mg/dL*

Adult females: 0.4 – 1.1 mg/dL*

Children (up to 12 years of age): 0.0–0.7 mg/dL

Serum protein – (6.0 – 9.0 gm/dL) and albumin – (3.5 – 5.0 gm/dL)

Value not given

The normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.

Liver Enzymes Liver enzymes most commonly measured are alanine transaminase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT). ALT and AST are made in the liver where they participate in the metabolizing of amino acids and the production of proteins. ALT is found in the liver only, whereas AST is found in the liver and other organs. ALP is found in the bones, intestines, placenta, kidneys and the liver. ALP is responsible for the production of energy and the metabolism of phosphorus. GGT is exclusively found in the liver and helps with the delivery of oxygen to body tissues.

URINE VALUES

Color Straw

Specific Gravity 1.003 - 1.040

pH 4.6 - 8.0 Na 10 - 40 mEq/L

K Less than 8 mEq/L Cl Less than 8 mEq/L

Protein 1 - 15 mg/dL

Osmolality 80 - 1300 mOsm/L

Urine Bilirubin, Blood, Ketone, Leukocytes-Negative

Urine Nitrite Negative

RBC's 0-2/HPF WBC's 0-2/HPF

RBC Casts 0/HPF Urobilogen 0.2-1.0 Ehr U/dl

PTT – (32 – 45 seconds) and PT – (10 – 14 seconds)

Value not given

Partial thromboplastin time (PTT) is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems.

Chest Radiographs and Electrocardiography

Hospital Medications

Interpretation from radiologist or cardiologist

Chest x-ray shows infiltrates in both lower lung fields.

A routine chest x-ray may be used as a screening test. However, 5-15% of patients with significant scarring will have a normal chest x-ray, and IPF cannot be diagnosed from chest x-ray alone.

Apply interpretation to clinical assessment

Home Medications

Respiratory Lab data

The RT’s care of the patient consists of:

This female came to the hospital presenting with shortness of breath. On admission a chest x-ray was taken which revealed infiltrates in both lower lung fields. Upon evaluation it was determined she was in acute respiratory failure along with her chronic idiopathic pulmonary fibrosis and she was found with candida glabrata urinary tract infection (UTI).

ABG’s with interpretation

pH 7.38

PaCO2 59 mm Hg

PaO2 40 mm Hg

HCO3 34.9 mEq/L

Be 7.9.

This blood gas shows that she has compensated respiratory acidosis with sever hypoxemia.

PFT’s are not recorded.

Boehringer Ingelheim Completes Enrollment of Pivotal Phase III Studies for Nintedanib (BIBF 1120) in Idiopathic Pulmonary Fibrosis

IPF is a progressive and severely debilitating lung disease with a high mortality rate; there are no approved treatments in the United States

Boehringer Ingelheim Pharmaceuticals, Inc. announced that clinical trial enrollment has completed for two phase III studies evaluating the safety and efficacy of nintedanib (BIBF 1120), an investigational compound, in patients with idiopathic pulmonary fibrosis (IPF), being studied at a twice-daily oral dose. There are no approved treatments in the U.S. for IPF, a progressive and severely debilitating lung disease with a high mortality rate: approximately 60 percent of patients with IPF die from the disease within two to five years of diagnosis. IPF is characterized by inflammation and scarring of lung tissue, called fibrosis, and over time, the lungs lose their ability to take in and transfer oxygen into the bloodstream, and vital organs do not get enough oxygen. As a result, individuals with IPF experience shortness of breath and often have difficulty participating in everyday physical activities. Research indicates that IPF may affect approximately 100,000 Americans.

RT Interventions

This patient was placed on mechanical ventilation because of her past medical history. She came into the hospital with acute respiratory failure along with her chronic idiopathic pulmonary fibrosis and she was found with a candida glabrata urinary tract infection (UTI).

Because of her past difficulties she had a tracheostomy done to help her in her recovery.

She has an 8.0 Shiley cuffed tracheostomy tube with a cuff pressure of 30 mm H2O.

Learning Experience

What I learned from studying this patient is that Idiopathic Pulmonary Fibrosis is the most common idiopathic lung disease that causes scarring of lung tissues. It causes formation of fibrous tissue or lesions that has no known cause. It is a progressive inflammatory disease that presents with varying degrees of fibrosis. Death usually occurs within 4 to 10 years from diagnosis.

Pathophysiology

Pulmonary Fibrosis is a progressive inflammatory disease with varying degrees of fibrosis and, in severe cases, honeycombing. The precise cause is unknown.

Because this patient has acquired an UTI infection this has exacerbated her Idiopathic Pulmonary Fibrosis and has caused her to go into Respiratory Failure.

Outline of Past Medical History

This patient has a past medical history of:

Idiopathic Pulmonary Fibrosis

Pulmonary Embolism

Hypertension

Gastroesophageal Reflux Disease (GERD) &

Coronary Artery Disease (CAD)

Medical History/Interview

Upon evaluation it was determined she was found with Idiopathic Pulmonary Fibrosis and candida glabrata urinary tract infection (UTI).

She is also being treated for Acute Respiratory Failure, MRSA, and sepsis.

This patient has had this problem before she has a past medical history of Idiopathic Pulmonary Fibrosis.

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