Mr. Birmingham, a 38-year-old gentleman presents to ED at 0300 hrs with acute shortness of breath since midnight. Complains of right sided-pleuritic chest pain and persistent productive cough. Talking in words, audible wheeze, appears dyspneic, tripoding. Multiple admissions for breathlessness previously.
Appears unwell
Past Medical History: Late onset asthma, smoker 50 pack year, Eczema.
Medications: budesonide at 320 μg + formoterol at 9 μg b.i.d. combination and T. Prednisolone 30 mg/day for the last 5 months, Seretide 2 puffs in the morning, Ventolin 2 puffs QID PRN when SOB. Uses Ventolin everyday.
Airway. - Patent
Breathing. - Spontaneous, RR-38/mt, SPO2-77% RA, decreased lung sounds right lower lobe, bilateral diffuse high-pitched wheeze inspiratory and expiratory
Circulation- Appears flushed in face and neck, BP-136/92 mmHg, HR- 122/mt, dry mucous
membranes, soft murmur over mitral area
Disability - GCS-14 E4V4M6, not oriented to time, place or person, PEARL- 3mm
Exposure - Needed support to walk from waiting room to bed space. Unable to lie supine, tripoding.
Temperature 39.2 deg Celsius. Abdomen soft, no organomegaly, peripheries cold, centrally warm. Nil edema.
Fluids - Unable to tolerate oral fluids, NBM for now
Glucose - BGL-6.0 mmol/L
INVESTIGATION
Bloods- WCC: 22.0x10⁹/L with 38% neutrophils, 8% lymphocytes, 18 % monocytes and 35% bands; C-Reactive Protein: 119 mg/L; Serum sodium:125 mmol/L, potassium: 3 mmol/L, chloride : 91 mmol/L, bicarbonate: 21 mmol/L, blood urea nitrogen: 14.0 mmol/L, serum creatinine : 120 μmol/L, CXR: No collapse or consolidation, upper lobe diversion.
2D transthoracic ECHO of the heart showed normal valves and an ejection fraction of 65% with a normal left ventricular end-diastolic pressure and normal left atrial size. Elevated pulmonary artery systolic pressure suggesting possible right heart strain.
Unable to perform Spirometry. Spirometry last year- FEV1 1.25, FVC-2.23, FEV1/FVC 0.56
Arterial blood gas (ABG) analysis performed on room air : pH 7.16, PaCO2 120 mm Hg, PaO2 49 mm Hg, lactate 4.5 mmol/L
Additional Information: Sputum cultures showed moderate growth of Pasteurella multocida.
Diagnosis: Hypoxemic Respiratory Failure secondary to acute exacerbation of asthma
A MET call was made at 0400hrs Explain THREE high priority interventions OR the pharmacological actions of TWO drugs that could be used to improve the patient’s clinical condition. provide references.
Explain THREE high priority interventions OR the pharmacological actions of TWO drugs that could be used to improve the patient’s clinical condition. provide references.
