ABG Challenge - October, 2016

20 Oct 2016

An 83-year-old female is admitted to the ED for shortness of breath and change in affect. She has a history of congestive heart failure and COPD. Currently, she has rapid, shallow respirations and is minimally alert. Breath sounds are very decreased throughout. She has an occasional weak, nonproductive cough.

Blood gas data (drawn while the patient is breathing room air):

pH 7.07
PaCO2 96 mmHg
HCO3 27 mEq
PaO2 54 mmHg
SaO2 68%
Hgb 9.7 g/dL
electrolytes within normal limits

1. What is the interpretation of these data?

2. How do you explain the SaO2 being as low as it is?

3. How would you treat this patient?

Answer to ABG Challenge Two

The data indicates a partially compensated metabolic acidosis with overcorrected hypoxemia. The patient is experiencing an episode of diabetic ketoacidosis and will need to be treated accordingly.


Respiratory Update Corner - Oct, 2016 (part 1)

4 Oct 2016

Greetings and welcome to the second edition of my blog. Just a reminder that I would welcome questions, comments, or any other kind of feedback that would help to improve the blog and make it more interactive. You may contact me directly at professorbillsblog@yahoo.com.

Okay, let’s look at a few items that caught my attention in the past month or so:

1) Let’s start off with an item that’s been in the mainstream news quite a bit lately, what the news people are calling the opioid overdose epidemic. I know from the news and from talking with people that this has hit Ohio hard. However, I just read some data published by the ACCP, covering the years 2009 to 2015 from 44 states. The data showed that ICU admissions for opioid overdoses increased 150%. In addition, ICU deaths due to these overdoses have roughly doubled.

The studies show more troubling statistics which you can read in many publications. Obviously, this is a very serious problem. These overdoses tie up valuable resources, including ICU beds, mechanical ventilators, and skilled clinicians (e.g. intensivists, critical care nurses, and respiratory therapists). Also involved are first responders.

Clearly this is a problem that needs to be addressed at many levels, and it is being addressed. Has your hospital system and/or intensive care unit been affected?


Respiratory Update Corner - Oct, 2016 (part 2)

4 Oct 2016

2) A Cochrane review, conducted by investigators from the UK suggests that the addition of vitamin D supplements to standard asthma medication can lead to fewer severe asthma attacks in patients with mild to moderate asthma. The review looked at a total of nine double-blind, placebo-controlled trials that involved 435 children and 658 adults with predominantly mild to moderate asthma.

Apparently, vitamin D has an anti-inflammatory effect on the lungs and induces innate antimicrobial mechanisms. Clearly, more studies are needed, especially in children. However, it was noted that a significant number of people are vitamin D deficient so this may prove to be a promising approach to treating asthmatics.

3) Potentially good news for people who like red wine (or red grapes): I just read a review of a study that showed a component of red grapes/wine can potentially help control inflammation induced by a bacterial pathogen often linked to upper respiratory tract diseases (this includes asthma and COPD).

The component is called resveratrol which is a compound that apparently acts like an antioxidant. This is very preliminary research but, again, another interesting therapeutic avenue.

4) A small study conducted in Kansas City demonstrated that children with asthma can be treated just as effectively via telemedicine as they can with in-person visits to an allergist. Using RNs or RTs and digital equipment (e.g. stethoscopes) on site, the allergist was able to assess and prescribe.

I have been reading quite a bit about the potential for telemedicine over the past year or so, both in outpatient care and in hospitals. It is encouraging to see this kind of data. I believe these data are particularly useful to RTs (my bias).

5) A study out of the UK showed that once-daily treatment with the combo drug Breo Ellipta (ICS flucticasone, LABA vilanterol) resulted in a significant reduction in COPD exacerbations when compared with ‘usual care.’ This was a very large study enrolling patients in seventy-five general practices.

While the results (a significant reduction in exacerbations and relatively few adverse effects over the trial period) appear promising, the study noted that the patients were not blinded and that the study was sponsored by the drug’s manufacturer (Glaxo Smith Kline). Still, the data do demonstrate the potential efficacy of once-daily combo drugs in managing COPD.

As I indicated in my first post, any inhaled medication is only as effective as the patient’s ability to use and pay for it.

6) A study recently reported in the Annals of the American Thoracic Society indicates that a majority of survey respondents believe that patients in the ICU have poor quality of sleep. This is hardly news, as many previous studies have demonstrated the same result. Any clinician who has spent a night working in a busy ICU knows this to be true. Unfortunately, lack of quality sleep could lead to potentially negative outcomes (e.g. delirium, delayed liberation from mechanical ventilation, etc.).

Although I have seen this problem reported over and over, I have seen (at least in the literature) very few suggestions for improvement. The survey cited above also indicated that some of the respondents are working with ‘sleep-promoting’ protocols; however, these protocols were not described.

Is this an issue in your ICU and, if so, how is it being addressed?

7) As a follow up to the above, although it has been frequently reported that ICU patients are at risk for developing delirium, a recent study has indicated that clinicians don’t always get sufficient training in delirium screening or recognition.

This is a problem that obviously needs to be addressed. Do you feel adequately prepared to recognize and treat delirium in your ICU?

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