Understanding Acute Respiratory Distress: A Case Study

The Patient and Assessment

Discuss about the Deep Seated Pathophysiology Associated Exacerbation of Asthma.

The current assignment focuses upon understanding the deep seated pathophysiology associated acute respiratory distress or failure. In this respect, developing a knowledge regarding the pathophysiology can help in the development of effective preventive measures as well as design a sound care plan. The pathophysiology here mainly focuses upon the aetiology and the causes of a disease. Therefore, understanding the pathophysiology helps in understanding the origin as well as identifies the genetic roots for the development of a disease within the patient population (Villar et al. 2014). It has been observed that most of the times the environment along with the genetic factors contributes towards the development of a disease (Khemani et al. 2015).  Therefore, a detailed knowledge of the pathophysiology helps to take into consideration all these factors and the different levels of expression produced by them.  In the current study, a particular case study has been taken into consideration. Based upon the conditions and the symptoms presented by the patient, the underlying pathophsyiology has been accessed.

Here, the patient is a 66 year old man Harry suffering from acute respiratory distress owing to which he had been admitted to the hospital. The respiratory distress emerged due to exacerbation of asthmatic conditions within the patient. As mentioned by Pediatric Acute Lung Injury Consensus Conference Group (2015), the falling of the SpO2 below 90% for longer periods of time could lead to medical emergency as the patient is unable to respire normally. In case the patient is left untreated for longer periods of time it could lead to respiratory failure and eventually death (Mac Sweeney and McAuley 2016). As mentioned by Lemiale  et al. (2015), with failure of the respiratory system, the neurological system will fail and the mental status of the patient deteriorates.

Here,   the patient Harry was diagnosed with PaO₂ less than 60 mm of Hg without elevated CO₂ level. In this respect, urgent resuscitation had to be provided to the patient, which involves airway control, ventilator management and stabilization of the circulation. In this respect, a therapeutic plan needs to be developed for the patient based on informed clinical and laboratory examination (Pediatric Acute Lung Injury Consensus Conference Group 2015). The laboratory examination confirmed exacerbation of asthma within the patient.  The tests which were conducted upon the patients were a chest x- ray followed by a sputum tests. The chest x-ray depicted shrunken alveoli which signified the presence of chronic respiratory distress within the patient, whereas the sputum test signified the presence of viral infection. The viral infection further worsened the asthmatic conditions of the patient (Lemiale et al. 2015).

Pathophysiology of Acute Respiratory Distress

The current health condition of the e patient could be further accessed with the help of an ABCDE approach. Here, A refers to Airway, B refers to breathing, C refers to circulation, D refers to disability and E refers to exposure. These could be accessed within the patient to understand the current health condition.

ABCDE assessment of patient condition

(Source: Author)

The patient is a 66 years man suffering from asthma and had a past history of smoking. The patient was a native of the Queensland region Australia and worked as a civil engineer in a construction unit. The habit of smoking along with the dust emitted from the factory further worsened the health condition of the patient.  Harry  reported that he had been prescribed by his  doctor a number of corticosteroids, which could be  inhaled  for relieving the conditions  of  asthma  within the patient.  Some of these medications are- fluticasone, budesonide, flunisolide, mometasone etc. The patient reported that he would often require the help of nebulizers for dealing with respiratory distress. The patient had been previously admitted to the hospital on several occasions owing to shortness of breath. Some of the medications which had been previously suggested to the patient are Salmeterol which are long acting beta agonists. These are known to open the airways in the patient. However, as argued by Frat et al.  (2015), the salmeterol may increase the severe asthma attack. Hence, the medicined need to be provided in combination with corticosteroids. Additionally, bronchodilators such as ipratropium have been seen to relax the airways and make breathing easier.

Therefore, some of the initial care plan which could be used to support the treatment and care of the patient were use of bronchodilators, corticosteroids inhalers. On initial admissions, some of the preliminary care strategies which could be provided to the patient are providing the patient with mechanical ventilation (Brochard et al. 2017). For the purpose of which an endotracheal tube could be placed through the mouth or the nose of the patient. Regular blood pressure should be monitored within the patient looking for orthostatic changes (Scaravilli et al. 2015). Blood tests could be performed for monitoring oxygen levels.

While understanding the pathophsyiology of a patient a number of ethical considerations need to be taken into consideration. For instance, at no stage during the study the exact details of the participants could be leaked out. For the public presentation of the study, the name of the participants needs to be changed as using the exact details of the participants could lead to legal breaches.

Management of Acute Respiratory Distress

Asthma is a common respiratory condition which is commonly characterised by shortness of breath or difficulty in breathing within the patient. Asthma is characterised by an increased sensitivity of the lower airways to irritants and allergens, which could lead to bronchospasm characterised by inflammation and narrowing of the arterioles (Bellani et al. 2016). Some of the associated asthmatic complications  which obstructs the normal passage of air through the lungs are-bronchospasm,  edema of  inner lining of the airways, increased  secretion of  mucous  which blocks the  small airways. The asthma patients usually suffer from periodic attacks, which are accompanied with very few or no signs and symptoms (Ranieri et al. 2016).

In this respect, a prolonged life threatening attack could lead to the development of status asthmaticus within the patient (Lee et al. 2015).  It is often characterise by a stage when the patients respond to neither oxygen nor medication. Under such conditions, the patients require immediate transport to the hospital. The respiratory distress often results in altered mental awareness within the patient. As suggested by Schmidt  et al. (2014), the upper respiratory tract infections are often accompanied by fever, allergic reactions such as sneezing, redness of eye, chests tightness running nose etc. It is often accompanied by tachycardia and tachypnea , where the tachycardia  resembles heart rate greater than 120 breaths per minute. In this respect, falling of the partial pressure of oxygen below 90% for prolonged periods of time could signify the need for immediate hospitalization, as it could lead to respiratory failure within the patient (Neto et al. 2015).

In the present scenario, the exacerbation of asthma leads to an acute respiratory failure within the patient. The failure of the respiratory   system could be referred to as a condition where adequate gas exchange cannot be maintained. As mentioned by Amato  et al. (2015), the patient looses the ability to ventilate adequately. Here, the respiratory failure could be divided into two significant types such as type 1 and type 2. The type 1 respiratory failure is defined by PaO₂ of 2. On the other hand, type 2 respiratory failure is defined by PaO₂ of 2  of >45  mm Hg. It has been seen that hypoxemia and hypercarbic conditions often co-exist. The type 1 respiratory failure can occur due to a number of causes such as – chronic bronchitis, pneumonia, pulmonary edema, pnemothorax and pneumoconiosis etc. On the other hand, the type 2 respiratory failure could be accounted to a number of causes such as – emphysema, asthma, pulmonary edema, infections caused by foreign bodies etc (Brochard et al. 2017).

Ethical Considerations

The respiratory failure could be further classified into acute respiratory failure and chronic respiratory failure.  It could be characterised by acute deterioration in an individual with significant hypercarbic respiratory failure. One of the most common causes of type 2 respiratory failure is pulmonary disorder (Neto et al. 2015). The hypoxemia that develops slowly over the years produces little effects within the patients. The diagnosis could be done by arterial blood gas analysis. The assessment of ph helps in measuring the degree of acute versus chronic respiratory failure (Frat et al. 2015). However, at any stage the falling of the partial pressure of oxygen below 90% should be taken as a pivotal sign.

Therefore, for management of the condition of the patient supplemental oxygen could be supplied via nasal prongs or venturi mask. Based upon the responses of the patient further treatment plan could be designed. The assessment needs to test the level of consciousness within the patient, checking the position of the respiratory drive as wrong positioning of the respiratory tract can further worsen the asthmatic exacerbations within the patient. Based upon the positive or negative response produced by the patient they could be further provided with non-invasive positive pressure ventilation (NIPPV) or mechanical ventilation.

The NIPPV gives positive pressure ventilation without endotracheal intubation. In this respect, a tightly fitted nasal mask could be used for transmitting positive pressure ventilation. It could help in reducing the complications associated with endotracheal tube insertion. The success of the method rests upon an intact respiratory drive along with sufficient cooperation from the patient. As suggested by Bellani  et al. (2016), NIPPV have been successfully used with patients suffering from hypoxemic respiratory failure.

The mechanical ventilations on the other hand respond favourably within the first 24 hours. As mentioned by Brochard  et al. (2017), the mechanical ventilations are found to be most effective when other supportive means fail to produce the same effect.  It   could be administered to the patient at a stage when conventional ventilation and noon-invasive ventilation have failed. Rapid  increase  in hypercapnia  , i.e. , elevated carbon dioxide  retention , tachypnoea  which recorded less than 35 breaths /min can  point towards the  use of mechanical ventilation.Since the    condition of the patient was worsened owing to viral infection, antibiotics  such as cefadroxil could be  provided to the patient.  This would in turn check further progression of the disease.

Conclusion

The current assignment focuses upon the aspect of pathophysiology identification and delivery of effective care and treatment to a patient suffering from acute respiratory failure. Here, the patient suffers from asthma which has worsened   leading to complications such as acute respiratory distress and failure within the patient.

Therefore, a number of effective assessment patterns have been discussed over here such as the ABCDE assessment. It helps in understanding the present symptoms expressed by the patient which could be further related with the underlying pathophysiology. In this respect, understanding the past history of the patient is also important in designing of an effective care Plan. The  pathophysiology have  been further  discussed  with reference  to the  interventions and methods  which could be  used for  treating the  conditions of the patient. Therefore, in order to reduce the incidences of acute respiratory failure it is important to know the underlying causes, which could be used to design  effective intervention  strategies.

References

Amato, M.B., Meade, M.O., Slutsky, A.S., Brochard, L., Costa, E.L., Schoenfeld, D.A., Stewart, T.E., Briel, M., Talmor, D., Mercat, A. and Richard, J.C.M., 2015. Driving pressure and survival in the acute respiratory distress syndrome. New England Journal of Medicine, 372(8), pp.747-755.

Bellani, G., Laffey, J.G., Pham, T., Fan, E., Brochard, L., Esteban, A., Gattinoni, L., Van Haren, F., Larsson, A., McAuley, D.F. and Ranieri, M., 2016. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. Jama, 315(8), pp.788-800.

Brochard, L., Slutsky, A. and Pesenti, A., 2017. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. American journal of respiratory and critical care medicine, 195(4), pp.438-442.

Brochard, L., Slutsky, A. and Pesenti, A., 2017. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. American journal of respiratory and critical care medicine, 195(4), pp.438-442.

Frat, J.P., Thille, A.W., Mercat, A., Girault, C., Ragot, S., Perbet, S., Prat, G., Boulain, T., Morawiec, E., Cottereau, A. and Devaquet, J., 2015. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. New England Journal of Medicine, 372(23), pp.2185-2196.

Khemani, R.G., Smith, L.S., Zimmerman, J.J., Erickson, S. and Pediatric Acute Lung Injury Consensus Conference Group, 2015. Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5_suppl), pp.S23-S40.

Lee, H.Y., Rhee, C.K. and Lee, J.W., 2015. Feasibility of high-flow nasal cannula oxygen therapy for acute respiratory failure in patients with hematologic malignancies: a retrospective single-center study. Journal of critical care, 30(4), pp.773-777.

Lemiale, V., Mokart, D., Resche-Rigon, M., Pène, F., Mayaux, J., Faucher, E., Nyunga, M., Girault, C., Perez, P., Guitton, C. and Ekpe, K., 2015. Effect of noninvasive ventilation vs oxygen therapy on mortality among immunocompromised patients with acute respiratory failure: a randomized clinical trial. Jama, 314(16), pp.1711-1719.

Lemiale, V., Resche-Rigon, M., Mokart, D., Pène, F., Rabbat, A., Kouatchet, A., Vincent, F., Bruneel, F., Nyunga, M., Lebert, C. and Perez, P., 2015. Acute respiratory failure in patients with hematological malignancies: outcomes according to initial ventilation strategy. A groupe de recherche respiratoire en réanimation onco-hématologique (Grrr-OH) study. Annals of intensive care, 5(1), p.28.

Mac Sweeney, R. and McAuley, D.F., 2016. Acute respiratory distress syndrome. The Lancet, 388(10058), pp.2416-2430.

Neto, A.S., Simonis, F.D., Barbas, C.S., Biehl, M., Determann, R.M., Elmer, J., Friedman, G., Gajic, O., Goldstein, J.N., Linko, R. and De Oliveira, R.P., 2015. Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome: a systematic review and individual patient data analysis. Critical care medicine, 43(10), pp.2155-2163.

Pediatric Acute Lung Injury Consensus Conference Group, 2015. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 16(5), p.428.

Ranieri, V.M., Suter, P.M., Tortorella, C., De Tullio, R., Dayer, J.M., Brienza, A., Bruno, F. and Slutsky, A.S., 2016. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. Jama, 282(1), pp.54-61.

Scaravilli, V., Grasselli, G., Castagna, L., Zanella, A., Isgrò, S., Lucchini, A., Patroniti, N., Bellani, G. and Pesenti, A., 2015. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study. Journal of critical care, 30(6), pp.1390-1394.

Schmidt, M., Bailey, M., Sheldrake, J., Hodgson, C., Aubron, C., Rycus, P.T., Scheinkestel, C., Cooper, D.J., Brodie, D., Pellegrino, V. and Combes, A., 2014. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. American journal of respiratory and critical care medicine, 189(11), pp.1374-1382.

Villar, J., Sulemanji, D. and Kacmarek, R.M., 2014. The acute respiratory distress syndrome: incidence and mortality, has it changed?. Current opinion in critical care, 20(1), pp.3-9.

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