Why is my aunt having severe breathing problems?

Hello,

Welcome to icliniq.com.

I went through the reports and will try to analyze them to the best of my ability. First of all, her CT is clearly showing signs of interstitial lung disease (attachments removed to protect patient's identity), but there may be a superadded infection over it. Interstitial Lung Disease (ILD) comprises a group of lung diseases; some are easily treatable, and some are not. But a CT (computerized tomography) scan will not tell what kind of ILD it is.

For confirmation, a lung biopsy needs to be done. Your doctors have done a transbronchial biopsy. Kindly follow up on that report and let me know what it shows. I advise starting her on broad-spectrum antibiotics first to clear off the superadded infection. They might have done some blood culture, sputum culture, or BAL (bronchoalveolar lavage) culture, which will help in deciding which antibiotic is best. (If they have not done it, ask them to do it now.) Once the antibiotic course is completed (7 to 10 days), a repeat CT scan of the chest must be performed to confirm that the infection has been cleared, and then treatment for ILD should be initiated.

Treatment of ILD involves steroids and immunosuppressants, which can be very harmful in the presence of infection. That is the reason why the infection has to be treated first, and then later ILD treatment. I also advise you to do a total leukocyte count every alternate day and follow up with me with the report. Also, get sputum AFB (acid-fast bacillus) tests done thrice. Feel free to discuss or clarify anything.

I hope this helps.

Thank you.

Hello,

Welcome back to icliniq.com.

I am very sorry to hear that she had fits. I went through the files posted by you (attachments removed to protect the patient's identity).

What I will be telling you next is my personal opinion, and it may change from doctor to doctor. But if I were the treating doctor, I would have stopped Azuran. Azuran is an immunosuppressant that suppresses the body's immunity.

Though it is the right treatment for ILD, it will flare up the infection, and the infection will become nonresponsive to the antibiotic used. I am trying to search the contents of the antibiotic C-Bantum, which is mentioned in the treatment chart, but I am not able to get it.

I want to know the content of it. Her lung biopsy report is suggestive of bronchiolitis obliterans organizing pneumonia (BOOP), which is a form of ILD. Her other reports are also positive for Rheumatoid Arthritis.

This BOOP most of the time responds to steroids, and only in refractory cases are immunosuppressants required. My advice is to stop Azuran and give steroids as injections (she is getting them in the form of tablets).

Also, I advise you to stop Unicontin, as it can cause fits. The long-term outcome with proper steroid treatment for BOOP is good, so be positive. Revert with the contents of Injection C-Bantum, also her present condition in the form of pulse rate, BP (blood pressure), SPO2 (oxygen saturation), recent total leucocyte count, consciousness level, and respiratory rate. I pray for her speedy recovery.

I hope this helps.

Thank you.

Hi,

Welcome back to icliniq.com.

Thanks for the follow-up, and apologies for the delay. I think what medication is going on now is fine. Her SpO2 of 80% is low. It needs to be at least 90% or more. Ask your doctor to increase the amount of oxygen given to her. Also, ask them if they can put her on non-invasive ventilation (NIV), which will help her recover faster.

Her back pain might be because of stress and continuous lying posture, and Volini gel is fine for that. Also, Volini will not cause fits. If her Liver function test is normal, they can use Inj Paracetamol 1 gram 3 times a day for better pain relief. Also, ask your doctor to start chest physiotherapy and incentive spirometry. This will help in her speedy recovery.

I hope this helps.

Thank you.

Hello,

Welcome back to icliniq.com.

First of all, let me clarify that I advised Paracetamol for her back pain, not for the fever. Therefore, it can be used even if there is no fever as a painkiller, as Paracetamol is much safer than other pain medications. But I agree that if she is not in pain, then no need for Paracetamol. Second, she is very much dependent on oxygen.

Even a short period of discontinuation can lead to serious Hypoxia (low oxygen) and affect her badly. So she has to pass urine and motions in bed only (in a bedpan) and not to go to the washroom. This may be uncomfortable for her, but this is necessary. As said earlier, please ensure that NIV is given at least a few hours a day. Chest Physiotherapy two to three times a day. Incentive Spirometry every hour.

Also, ask your doctors to keep her in a Sitting or semi-sitting position always and not in a lying down position. Also, sometimes turning to one side (right or left), there will be an improvement in oxygen saturation. The nurses have to watch her SpO2 in the monitor when she turns to one side and see if there is any improvement or deterioration in SpO2.

If such a thing happens, she should be encouraged to be in that position as much as possible. I asked you to tell me the content of the antibiotic. Kindly let me know. Also, her recent Total Leucocyte Count, her recent ABG report, and her recent Chest X-ray. Kindly let me know her progress.

I hope this helps.

Thank you.

Hi,

Welcome back to icliniq.com.

Thanks for the follow-up.

First thing I want to tell you is that any person, if kept in ICU isolated from family members, will become irritable. Second, if the oxygen level in the blood is less patient can become irritable. Solution: frequent visits by family members ( but the hospital policy may not allow frequent visits, still request it).

Also, the sedation has to be given intermittently instead of continuous sedation. I saw her ABG report. Apart from Low oxygen levels, she is having a condition called HIGH ANION GAP METABOLIC ACIDOSIS. Ask your doctors to find out the cause of this. ( Kidney injury is a common cause ) and also ask them to correct it by giving Sodium Bicarbonate Injection so that her Blood PH is maintained between 7.35-7.45 (present ABG report showing PH=7.23).

Also, her TLC=33000 is extremely high. It means that her lung infection is not under control, and they need to escalate the antibiotic dose or change the antibiotic. I really need to know what Antibiotic she is on. If not already started, I advise starting INJ MEROPENEM for her. Also, if her serum Sodium level is very low ( 112.4 ), the normal is 135.

She needs to be started on INJ 3% Nacl slowly and correct her sodium level in two to three days. Looking at her present condition, it may take two to three days for her to become more alert and less irritable, and if she becomes less irritable, she can start eating food by mouth. Ask them to do Serum Sodium, Potassium TLC, every day. Also, ask them to increase the PEEP level and increase the duration of NIV.

I hope it helps.

Thank you.

Hi

Thanks for the follow-up.

First of all, very sorry, I did not know she was on invasive ventilation. Her blood counts are improving, which indeed is a good sign. Her oxygen saturation is also improving. But her heart rate is very high. It might be due to low oxygen or discomfort and pain due to the ventilator.

I advise starting fentanyl low-dose infusion if not yet started. I am happy with the ongoing antibiotics. Coming to ECMO. It is something similar to what we do dialysis for kidney failure. It has given good results when conventional treatments failed. But if the patient was on a ventilator for more than 1 week, then the outcomes are not that good.

Moreover, if you need to shift the patient, it may be risky to shift her as she is on high requirements. If ECMO is available in the present hospital, then I think you can go ahead. But in case you need to shift her to some other hospital, then wait for one more day, as she is showing improvement with the present treatment.

Thank you.

Hello,

Welcome back to icliniq.com.

Before going to the medical discussion, I would like to tell you to be positive and emotionally strong. It is your strength that will give her the strength to fight the disease. So be strong. Also, when you or any family member goes to see her, keep a smile on your face. Tell her that she is improving and will be fine in a few days.

First thing I want you to know is that everything is being given to her, and we just have to wait for her to recover. And don't feel that nothing is done for her main problem. She is getting medicines for that. Ok, so her parameters are looking good. The drop in TLC indicates that antibiotics are working well for her. But since her kidney function has deteriorated, the dose of antibiotics needs to be reduced accordingly. Swelling of the leg indicates that her nutrition is not adequate.

Mostly, her blood proteins have gone low, which suggests malnutrition. I advise doing a Serum Albumin level test and correcting it if it is low. Also, bluish discoloration indicates that blood is not reaching her toes properly. I advise doing or repeating a 2D Echo. I could not understand why they stopped the ventilator to do physiotherapy. I recommend not stopping the ventilator even for 1 second because that will push her back to her previous state. Continue ventilation and increase PEEP if feasible.

Coming to drop in platelet count its a complication of infection or a side effect of antibiotics or Azuran. Ask your doctors to monitor platelet count daily, and if it drops less than 30000, she needs to be transfused with platelets. I am not in favour of starting Cyclophosphamide. It is a dangerous drug, and that too in the face of kidney damage and low platelet count. I strongly do not recommend it. They can continue to use the same medications with the above-mentioned modification.

I advise you to ask your doctors to do an early tracheostomy for her and monitor her urine output. If her urine output drops significantly, she should also start dialysis. Also, ask your doctors about the possibility of a trial drug called Ulinastatin. It is not approved for ILD, but the sepsis part, which your sister is having, can be taken care of by it. Although there is insufficient data to prove its efficacy. Do ask or research about it.

Please let me know if I can help you further.

Thank you.

Hi,

Welcome back to icliniq.com.

First thing I want to say is that there is nothing that can give instant recovery. She is deteriorating, but still, hope is there. Now the main concern is her failing kidney. She needs to undergo dialysis at any cost. You can ask the doctors to start Ionotropes, which will raise her BP and help with dialysis. Using noradrenaline is a good option.

Also, her urea is very high. It means she is getting dehydrated. So her IV fluids have to be increased. Her platelets have improved. Was it because a platelet transfusion was given, or did it improve by itself? I hope her antibiotic dosage is given as per her creatinine level. She is maintaining SpO2 =90% thats Good.

But deterioration in the conscious level is not a good sign. I advise stopping all sedation and observing if there is any improvement in consciousness. If no improvement in consciousness, then she needs an EEG. As advised previously, get a tracheostomy done for her, and also, it is better to start parenteral nutrition. Kindly mention the ventilator settings also.

Also, I had mentioned to correct her METABOLIC ACIDOSIS, make sure that is done properly. Also, last time I was told to get a 2D ECHO scan to see her cardiac function. Do let me know what the scan shows. I could not find any attachment to your query. Kindly send me tomorrow's ABG report. Wishing her a speedy recovery.

I hope it helps.

Thank you.

Hello,

Welcome back to icliniq.com.

Went through the ABG report. Blood pH is very low. She needs Inj Sodium Bicarbonate 50-100ml. Also, her Blood Carbon Dioxide level is extremely high. That might be the cause of her Unconsciousness. I advise to increase the respiratory rate in ventilator.

Also, ask your respiratory physician to reduce the Inspiratory time and increase expiratory time ( There will be a parameter in the ventilator called I:E ratio. They have to reduce it ). I hope they are dialyzing her today. Revert with Ventilator settings, ABG report, Urine output, 2D ECHO report, and her vitals when you get time.

I hope it helps.

Thank you.

Hello,

Welcome back to icliniq.com.

You are most welcome. Please let me know if I can assist you further.

Thank you.