Page 650 - Clinical Application of Mechanical Ventilation

616 Chapter 19

CASE 1: COPD

INTRODuCTION

A 74-year-old Caucasian male with a diagnosis of pulmonary emphysema, made
The inability to breathe six years prior, was seen in the emergency department with a complaint of shortness
comfortably unless in an
upright position is called of breath. He has had respiratory problems on and off since diagnosis, including
orthopnea and is a common two hospital admissions, each of several days duration. He stated he caught a cold
clinical sign of pulmonary
artery congestion or conges- the previous week that moved down into his chest, and since that time breathing has
tive heart failure. become increasingly more difficult. He related that in his usual state of health, he was
able to move freely about his home and yard and enjoyed his hobby of gardening,
but now was unable to do either. Sleeping in bed had become such a problem that
for the previous two nights he slept sitting back in his easy chair. His normal sputum
Sudden weight gain
with dependent edema in a production of about a tablespoon per day had increased to about 1/4 cup a day
COPD patient is a sign of cor and had turned from white to yellow in color. He gained 6 lb in the past 4 days and
pulmonale.
noticed that his ankles were swollen by the end of the day. When questioned about his
smoking history, he stated that he had smoked two packs per day for 40 years, and
had tried unsuccessfully to quit after his diagnosis of emphysema was made. He now
smokes a half pack per day of a “lighter” brand. His home medications include an
albuterol metered-dose inhaler (MDI), 1 to 2 puffs every 2 to 6 hours, as needed.

Physical Examination

General. The patient is a mildly obese male, weight 100 kg, height 72 in., in mod-
erately severe respiratory distress, sitting on the edge of the bed leaning forward
supporting his weight with his palms and breathing through pursed lips.

Vital Signs. Heart rate 124/min, blood pressure 150/90 mm Hg, frequency 28/min,
and temperature 100.5°F.
HEENT. Some cyanosis of the lips, otherwise unremarkable.

Neck. Trachea in the midline, no masses, stridor, lymphadenopathy, or thyromegaly.
Carotid pulses 11 without bruit. There is marked use of accessory muscles of the
neck with mild jugular venous distention.

Chest. The anteroposterior diameter of the chest is increased with a deep supraster-
Paradoxical motion of the nal notch and some paradoxical motion of the abdomen. Decreased tactile fremitus
abdomen during ventilation is
an indication of diaphrag- and absent point of maximal impulse (PMI) are noted with hyper-resonance to
matic muscle fatigue. percussion bilaterally.

Heart. Sounds are distant with no irregularity in rate or rhythm noted; no gallops
or murmurs.

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