Page 719 - Clinical Application of Mechanical Ventilation

Case Studies 685

Discussion

This case demonstrates one of the clinical indications for the use of nocturnal ven-
tilation. F.W. was a COPD patient with hypercapnia and cor pulmonale. Is it also
possible that F.W. suffered from a sleep disorder? Maybe; however, no sleep studies
were ever done. F.W. qualified for nocturnal ventilation based on her PaCO levels
2
at the time of discharge from the hospital. Her pulmonary function studies indi-
cated severe obstructive disease and poor diffusion capacity. Because of her obesity,
F.W. also dealt with hypoventilation. The nocturnal ventilator assisted to overcome
the chest wall compliance and pressure placed on the diaphragm by her large abdo-
men, thereby increasing volumes when F.W. was in supine position.
Without nocturnal ventilation, home oxygen, bronchodilator therapies via nebu-
lizer, and oral medications, F.W. would probably have had numerous physician vis-
its and even hospital stays. In fact, she has avoided ER visits and hospital admissions
for over 1 year. The home therapy allowed her greater independence and helped her
‘feel better;’ therefore improving her quality of life. It is the responsibility of every
home care provider to adequately assess patients, make sound clinical decisions, and
report findings to the physician in a timely manner.
In this case the RCP quickly responded to signs and symptoms of hypercapnia and
impending cardiac insufficiency. The pressure on the nocturnal ventilator was increased
to improve minute ventilation and oxygenation, and the physician was consulted to
increase Lasix to eliminate pulmonary vascular congestion due to heart failure.

CASE 16: END-OF-LIFE SEDATION

ON MECHANICAL VENTILATION

INTRODuCTION

Mr. P.P. was a 66-year-old male with COPD and a smoking history of 80-pack years.
About two years ago the patient noted a grayish patch on his tongue but did not
immediately seek medical attention. He continued to smoke and use spitless tobacco.
About five months ago the patient sought medical help after he developed the fol-
lowing symptoms: 1) a feeling that something was caught in the throat, 2) difficulty
chewing or swallowing, 3) difficulty pronouncing words, and 4) numbness of the
tongue.

Diagnosis and Initial Medications

Assessment and testing revealed oral squamous carcinoma of parts of the tongue
and floor of the mouth which had metastasized to the cervical lymph nodes. He

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