Pneumoniua/Breathing Treatment

[explenture]

Patient's chief complaint is difficulty breathing.

Dib the same evening we saw him. Fire had him on 10L o2 pt. said breathing was better. Pt. had pneumonia in February. Hear rales and crackles thru scope gurling audible aurally. Pt. has emphysemea, not on home 02, only meds are an inhaler. He has been eating normally but urination frequency has increased, stated every half hour the nite before.

A: Besides DIB he has no chest pain, regular but tachycardic pulse, no other complaints except fluid on lungs.

RX: Did a 12 lead which was benign, pt. is tachycardic @ 120 to 130. Decreased o2 to 4 lpm on NC, still breathing good with normal effort, rate 16-18. Did a saline lock. Here's the rub....did not do breathing treatment. Senior partner says I should have.

Rationale for not doing it was A. breathing improvement on 02 B. Fluid on lungs and increased urination would not seem to be helped by breathing treatment C. Tachycardia....yes perhaps caused by breathing, but also did not want to risk an increase in HR with an 81 year old. At ER a 12 lead was ordered but no breathing treatment was done.

What is the correct call treatment or no?

[Katiebug]

Based on info here, I believe I would have done an albuterol or duoneb updraft. My reasoning is this: the tachycardia seems to be caused by inadequate O2/CO2 exchange in the alveoli. Perhaps if resperations were improved, tachycardia would be relieved.

I wasn't there, you were. Seems that you got the pt to the hospital in good shape. That's the main thing.

[RomeViking09]

Based on your info here is what I would have done, take from it what you will:

VS q 10 min (HR, BP, RR, SpO2, 3-Lead ECG), O2 @ 15 Lpm NRB, IV, 12-lead, Albuterol & Atrovent Breathing Treatment, maybe call for orders for Solu-Medrol or another respiratory steroid. I would not worry about the tachycardia with a clean 12-lead as the most likely cause is the DIB. I would be ready to treat the tachycardia if no improvement or the rate goes past 150. Our local protocol says to give the A&A if DIB and with those lung sounds unless HR is greater than 150.

Did you treat the Tachycardia?

[VentMedic]

For patients with known respiratory problems, we treat the lungs and monitor the HR as we are sorting out the other signs or symptoms. If you don't fix the respiratory stuff, the heart will continue to work harder. Albuterol and Atrovent would both have been indicated with a previous history of COPD. I also would not have worried about that "hypoxic drive" thing and give the patient some O2.

What was the BP? What the patient also on a diuretic? What was his BGL? Steroids recently? Were the crackles localized to one lobe or multiple? What type of inhaler? Long Acting, Short Acting, Steriod, Mast cell inhibitor? How many puffs? Definitely want to know how many puffs if it was a LABA.

PNA vs CHF with exacerbation of COPD. Rarely are these patients just one simple disease process to treat.

Did they do a BNP at the hospital? Lactate level?

Don't get too excited about the calm respiratory effort. With some older COPD patients it is the calm before the storm as their CO2 is rising from impending failure...not the O2 being given.

Edited April 20, 2009 by VentMedic

[explenture]

Based on your info here is what I would have done, take from it what you will:

VS q 10 min (HR, BP, RR, SpO2, 3-Lead ECG), O2 @ 15 Lpm NRB, IV, 12-lead, Albuterol & Atrovent Breathing Treatment, maybe call for orders for Solu-Medrol or another respiratory steroid. I would not worry about the tachycardia with a clean 12-lead as the most likely cause is the DIB. I would be ready to treat the tachycardia if no improvement or the rate goes past 150. Our local protocol says to give the A&A if DIB and with those lung sounds unless HR is greater than 150.

Did you treat the Tachycardia?

Did not treat the tachycardia.

For patients with known respiratory problems, we treat the lungs and monitor the HR as we are sorting out the other signs or symptoms. If you don't fix the respiratory stuff, the heart will continue to work harder. Albuterol and Atrovent would both have been indicated with a previous history of COPD. I also would not have worried about that "hypoxic drive" thing and give the patient some O2.

What was the BP? What the patient also on a diuretic? What was his BGL? Steroids recently? Were the crackles localized to one lobe or multiple? What type of inhaler? Long Acting, Short Acting, Steriod, Mast cell inhibitor? How many puffs? Definitely want to know how many puffs if it was a LABA.

PNA vs CHF with exacerbation of COPD. Rarely are these patients just one simple disease process to treat.

Did they do a BNP at the hospital? Lactate level?

Don't get too excited about the calm respiratory effort. With some older COPD patients it is the calm before the storm as their CO2 is rising from impending failure...not the O2 being given.

1. BP 150/90 2. Patient not on diuretic. 3. bGL 120. 4. No steroids. 5. Crackles were in all lung fields. 6. Had albuterol and atrovent inhalers 7. As to CHF no diagnosis and no lower extremity edeme. 8. Don't know about BNP or lactate level

So far I think I have learned that giving a breathing treatment would have been in effect treating the tachycardia.

[nick Hoffman]

Patient's chief complaint is difficulty breathing.

Dib the same evening we saw him. Fire had him on 10L o2 pt. said breathing was better. Pt. had pneumonia in February. Hear rales and crackles thru scope gurling audible aurally. Pt. has emphysemea, not on home 02, only meds are an inhaler. He has been eating normally but urination frequency has increased, stated every half hour the nite before.

A: Besides DIB he has no chest pain, regular but tachycardic pulse, no other complaints except fluid on lungs.

RX: Did a 12 lead which was benign, pt. is tachycardic @ 120 to 130. Decreased o2 to 4 lpm on NC, still breathing good with normal effort, rate 16-18. Did a saline lock. Here's the rub....did not do breathing treatment. Senior partner says I should have.

Rationale for not doing it was A. breathing improvement on 02 B. Fluid on lungs and increased urination would not seem to be helped by breathing treatment C. Tachycardia....yes perhaps caused by breathing, but also did not want to risk an increase in HR with an 81 year old. At ER a 12 lead was ordered but no breathing treatment was done.

What is the correct call treatment or no?

CPAP- Pressurize the lungs to free up the alveoli. I think you did alright considering the O2 helped improve his breathing efforts. But I deff would have hooked up the CPAP.

[Katiebug]

CPAP- Pressurize the lungs to free up the alveoli. I think you did alright considering the O2 helped improve his breathing efforts. But I deff would have hooked up the CPAP.

CPAP as a field tx is something we are just getting into here. They are talking about nixing Furosemide for tx of CHF and using CPAP instead. Probably would have been a good idea for this guy if available. Since we don't do it yet, I didn't think of it.

[explenture]

We have CPAP, but this guy was not close to CPAP per our protocol.

CPAP- Pressurize the lungs to free up the alveoli. I think you did alright considering the O2 helped improve his breathing efforts. But I deff would have hooked up the CPAP.

[HERBIE1]

Tough call. If someone has pneumonia, you may actually thicken up their secretions with albuterol, as you would with a diuretic and make things worse. CPAP would be a good idea if available. The tachycardia could be from hypoxemia or from the infectious process. Unless you are working with the patient long term, I wouldn't worry about knocking out their respiratory drive- that generally takes far longer than we ever spend with a patient. Crank up the o2 and like you said, it was helping.

[VentMedic]

Tough call. If someone has pneumonia, you may actually thicken up their secretions with albuterol, as you would with a diuretic and make things worse.

Are you thinking about Atrovent?

Still, one Atrovent tx will not thicken anything very much. It is when we are giving it q4 hours for several days that we start to worry. Albuterol (or some bronchodilator) is required for mucolytics such as Mycomyst.

explenture

We have CPAP, but this guy was not close to CPAP per our protocol.

Yes, more education is needed to where clinical judgement can be used instead of following the recipe book.

I would not be too keen on lasix for this patient.

As to CHF no diagnosis and no lower extremity edeme. 8. Don't know about BNP or lactate level

Which is why a BNP is used in the hospital along with a CXR and other data from the physical assessment/history. Not everything is "textbook".

Edited April 21, 2009 by VentMedic