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Q. My aunt has difficulty in breathing and attached her reports. Kindly suggest.

Answered by
Dr. Divakara P
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Dec 14, 2020

Hi,

I would first like to thank you for your services. Well things got started from last 10 days, my aunt was all fine and doing great back then but suddenly she got starting coughing slowly which then after next day became more and more coughing, we didn't took the cough seriously but after 2 or 3 days she said she is facing some breathing problems which doing work.

We were not sure why she was facing this and told her to relax and we felt the issue can be due to rainy season or can be due to humidity. But after 6 days she was facing real weekness and too much breathing problem, she can't even talk as if she talks she looses the breath. After all this we admitted her to a Hospital nearby and the Hospital doctors took some tests i.e Blood Tests, CT Scan, Bronchos Test, etc.

I have attached all reports with my question. The thing we are most concern is with the Doctors, it's been 8 days in hospital now but the doctors still didn't started any treatment. They said every report of her is clear so they can't even figure out the disease yet so results in no treatment. I thought to give a try to iCliniq to check if you guys can help somehow or can even tell us what to do next. She is day by day getting weak, and everyday she is facing with unconsciousness. Hope to hear from you soon.

#

HI

Thanks for posting your query.

I went through the reports and will try to analyse to the best of my capability . First of all her CT is clearly showing signs of Interstitial lung disease . ( I will not go into details of telling what it is ) but there may be super added Infection over it. Interstitial Lung disease ( ILD ) comprises of group of lung disease some are easily treatable some are not. But a CT 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 that report and let me know what it is showing . I advise to start her on Broad Spectrum antibiotics first to clear off the super added infection . They might have done some Blood Culture or Sputum culture or BAL culture which will help in deciding which antibiotic is best . ( If they have not done ask them to do now )

Once Antibiotic course is completed ( 7-10 days ) a repeat CT Chest has to be done to confirm that infection has been cleared and then treatment for ILD has to be started. Treatment of ILD involves steroids and Immuno suppressants which in presence of infection can be very harmful . That's the reason why Infection has to be treated first and then later ILD treatment. I also advise to do Total leucocyte Count Every alternate day and follow up me with the report. Also get Sputum AFB tets done thrice. Feel free to discuss or clarify anything .

Hi,

Thanks for getting back, your answer really gave us some hope as just today she started having fits, she got one attack just today morning. I spoke to the doctors they said currently they are providing her Broad Spectrum antibiotics and they already done the Culture test which shown Negative results. They also said while with the Spectrum Antibiotics they are providing her Steroids along the way so i think both all together is causing her problems in breathing, as she is now facing more trouble in breathing then she used to have.

Overall, i am seeing her going down day by day and we are loosing hope. Doctors itself supposedly seems uninterested they are just making money. It's been overall 9 days in Hospital and i see no improvement in her, only the downfall. We actually got very down yesterday when someone told us that this type of diseases are untreatable and she will be the same whole life with Support system like Nebulizers etc.

I really do thank you from deep inside to take a chance to reply us. I have therefore attached a Lung Biopsy report and course of actions that hospital took so far, pls check and reply soon. Thank You!

#

HI

Thanks for the follow up. Very sorry to know that she had fits. I went through the files posted by you . See what I will be telling you next is my personal opinion and it may change from doctor to doctor . But if I was the treating Doctor I would have done this. STOP AZURAN . Azuran is an Immunosupressant means it suppress the immunity of the body. Though it is the right treatment for ILD but it will flare up the infection and infection will become non responsive to the antibiotic used.

I am trying to search the contents of the antibiotic C-Bantum which is mentioned in the treatment chart but 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 case Immunosuprresants are required. My advise is to stop AZURAN , give steroids as Injections ( She is getting in the form of tablets ) Also I advise to stop Unicontin as it can cause Fits. The long term outcome with proper steroid treatment for BOOP is good so be positive. Revert back with the contents of Injection C-Bantum , also her present condition in the form of Pulse rate , BP , SPO2, Recent total leucocyte count , Conscious level , Respiratory rate. I pray for her speedy recovery .

Hi,

Thanks for replying back, your suggestions and diagnostics are really effective. We discussed further with the doctors and they told us this :

1. Pulse Rate : 98 /min

2. Blood Pressure : 110 / 60

3. SPO 2 : 80% (It was last checked at 11 Am)

I have also attached few more reports as well please take a look at them as well. Also, she is actually suffering from severe back pain what can be the cause for that. She sometimes also feel like vomiting, just today she said she is having some back pain so doctors put up Volini Gel on her back due to which she got unconscious and feel like vomiting.

Currently doctors have stopped giving AZURAN, for now they have started giving these :

1. Pirfenidone Tablets 200mg (1BD)

2. Medrol 16 mg (1BD)

3. Acetylcysteine 600 mg (1OD)

4. Sodium Valporate Injection 100mg/ml IV Infusion

It is a kind request please suggest some course of actions for her so that she can be treated well and little faster. She has shown no such improvements in all 9 days in hospital. Even my family members are expecting some fast recovery now, we are upset seeing her in same situation from last 15 days.

#

HI

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 ) this will help her to recover more 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 Incetive Spirometry . This will help in her speedy recovery .

Hi,

Thanks for getting back, we are following your instructions and doctors as well appreciated your advices and i would love to say that we can see some improvement with the patient but can’t say now as it will be too early to say it. I hope the medication will work as it is. My entire family is thanking you up! Alright, currently the doctors are giving 88% SPO2 as they said more can disable body to recover “Naturally”.

About the Paracetamol, the patient is sleeping and having no fever so they said giving paracetamol will be useless, but if she says that she is having pain again so they can start paracetamol. Let me tell you what happened last night, she actually is having loose motions so yesterday at night after going washroom taken by nurse and staff she went unconscious and Oxygen level dropped to 30 that’s why to have more Oxygen and Ventilator she has been transferred to ICU and we think she is showing some improvements now but not that are expected!

Can you please tell us what we can do to recover her better and atleast give her something so that she don’t feel weakness. She is so weak at the time that’s why she faints or gets fits by loosing her cool. Even she is so irritated, that i can’t even express. It maybe due to the pressure she went threw and going on. I am really thankful for your help and your knowledge is been appreciated by many here. Thanks

#

HI

Very thanks for your words , am Honored. First of all let me clarify you that I advised Paracetamol for her Back Pain and not for the fever , so it can be used even if there is no fever as a pain killer because Paracetamol is much safer than other pain medicines . But I agree if she is not in pain then no need of paracetamol . Second she is very much dependent on Oxygen .

Even 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 bedpan ) and not to go to washroom . This may be uncomfortable for her but this is necessary . As said earlier please Ensure that NIV is been given at least for few hours a day . Chest Physiotherapy 2-3 times a day . Incentive Spirometry every hour.

Also ask your doctors to keep her in Sitting or Semi sitting position always and not in lying down position. Also sometimes turning to one side ( right or left ) there will be improvement in oxygen saturation . The nurses have to watch her Spo2 in monitor when she turns to one side and see if there is any improvement or deterioration in Spo2 . If such thing happens she should be encouraged to be in that position as much as possible . I asked you to tell me the content of antibiotic . Kindly let me know . Also her recent Total Leucocyte Count , Her recent ABG report , her recent Chest X ray also . Kindly let me know her progress . WISHING HER A SPEEDY RECOVERY . :))

Thank you so much for your well wishes. She is not complaining of back pain so paracetamol is not been given. Ryle's tube feeding is given and catheterization has been done. NIV is already continued. Chest physiotherapy and incentive spirometry are not possible as the patient is on sedation. Position of patient is continuously changed to different sides from time to time.

Her oxygen saturation is 90%. She is kept on broad spectrum anti-biotics. Composition of anti-biotics is not known right now so we 'll provide you the details as soon as possible. TLC is 33000 and her ABG report and chest X-ray is been attached. The worst problem we are facing is her irritation, whenever she is awake after sleep she just gets irritated and takes out the oxygen tubes and ventilator tubes out of her mouth and hands which instantly drops her oxygen level but thank god today she did the same but she didn't faced fits and doctors gave her injection for sleep and instantly inserted tubes back.

Is their is any solution to make her calm? Also can you please be kind to tell us what ETA it takes to atleast recover her fully or atleast to some level so that she can start eating, talking! Thank you so much for your help and coordination. Looking forward for a positive respond . :))

#

HI

Thanks for the follow up. First thing I want to tell you is any person if kept in ICU isolated from family members will become Irritable . Second if oxygen level in blood is less patient can become irritable. Solution frequent visits by family members ( but the hospital policy may not allow frequent visits , still request for 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 for 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 coming to 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 to start INJ MEROPENEM for her. Also if her serum Sodium level is very low ( 112.4 ) Normal is 135 .

She needs to be started on INJ 3% Nacl slowly and correct her sodium level in 2-3 days. Looking at her present condition it may take 2-3 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 everyday . Also ask them to increase the PEEP level and increase the duration of NIV .

Hi, Really sorry for the delay response, today my day went while visiting some doctors in AIMS for suggestions for ECMO. I would be glad to tell you that your mail has been forwarded to the concerned doctor and he has changed management accordingly. Today's vitals/condition is as follows :

1. Heart rate is 148 .

2. RR is 28 .

3. BP is 116/71 .

4. SPO2 is 90 % .

5. Temperature is normal .

6. Urine output is adequate .

7. Ryle's tube feeding is continued .

She is conscious but irritable perhaps due to intubation and is on still intermittent sedation. She is on invasive ventilation . Today's TLC is 27000 which hopefully seems to be a positive sign, ABG is not available. INJ Merocrit and INJ Tecocin are being given as anti-biotics presently. Perhaps we would like to know if there is any role of ECMO presently .We are gratefully thankful for your help and coordination . Hoping and looking forward for a positive response . :)) Thank you again! Best Regards

#

Hi

Thanks for the follow up. First of all very sorry I didn't knew 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 ventilator. I advise to start 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 patient was on ventilator for more than 1 week then the outcomes is not that good. Moreover if you need to shift the patient it may be risky to shift patient as she is on high requirement. 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 present treatment.

Hi, Todays patient's condition / vitals / investigations available as of now are as follows :

1) Conscious but still on intermittent sedation

2) Pulse Rate : 127/min

3) Respiratory Rate : 31/min

4) BP is 106/60 mm of mercury

5) SPO2 : 88%

6) TLC : 19000

7) Platelets got reduced to 50000

8) Lower extremities are cold, Oedematous and Blueish toe nails .

9) Serum Cretenine is 3.4

10) Concerned doctor wants to give cyclo phosphamide along with previous treatment .

We are currently happy with the TLC drop but are very very concerned with her situation now, Platelets got dropped to very lower number also her kidney seems to be having some damage too. I literally cried while thinking about her today, Doctors said the TLC drop is good but the medicine should effect her main disease too. Main disease is ineffective of their medicines and it seems the side effects are damaging other organs too.

Just today, doctors noticed her toe nails got blueish so they decided to turn the ventilator off for a while and started some type of Physiotherapy but due to this her Oxygen level started and dropped by 80%. Then again they need to put her back on ventilator. I am really upset with all this, it's been 12 days in hospital now and i see her without improvement.

Tomorrow it's Raksha Bhandhan, it's a festival out here i can't expect any festival without her (Just getting emotional) Can you please suggest something please, your every recommendations is been followed up and we expect you are the one who can play a role of god in out case. Kindly suggest something that can actually overcome and situation and fix her as soon as possible. Also please mention the reason why her original disease is not been treated still and her platelets are going down. Have a wonderful day sir! Please help!

#

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

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

Mostly her blood proteins have gone low which suggests malnutrition. Iadvise to do Serum Albumin level test and correct it if its low. Also bluish discoloration indicates that blood is not reaching her toes properly. I advise to do or repeat 2D Echo. I couldnt understand why did they stop ventilator to do a physiotherapy.I recommend not to stop ventilator even for 1 second because that will push her back to 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 antibiotic or Azuran . Ask your doctors to monitor platelet count daily and if it drops less than 30000 she needs to be ttansfused platelet. I am not in favour of starting Cyclophosphamide . Its a dangerous drug and that too in the face of kidney damage and low platelet count I strongly dont recommend it .They can continue to use same medications with above mentioned modification.

I advise you ask your doctors to do an early tracheostomy for her and monitor her urine output. If in case her urine output drops significantly to start dialysis also. Also ask your doctors about the possibility of a trial drug called Ulinastatin . Its not approved for ILD but the sepsis part which your sister is having can be taken care by it. Although there is no sufficient data to proove its efficacy. Do ask or resrarch about it.

Hi, Today patient's condition/vitals/investigations available are as follows :-

1) Patient unconscious, mallard rashes present over face

2) Heart Rate : 131 per min

3) Pulse Rate : 89 per min

4) Respiratory Rate : 20 per min

5) Blood Pressure : 109/50 mm of hg

6) SPO2 : 90%

7) ABG. has been attached with the message.

8) Serum Cretinine : 5.8

9) Blood Urea : 238

10) Platelets : 87000

11) TLC : 26700

Today treating Respiratory Physician and Nephrologist has decided for slow dialysis for two hours but unfortunately due to sudden fall of BP dialysis stopped after one and half hour. Please suggest what else can be done for her instant recovery. Have a wonderful day!

#

Hi First thing I want to say is there is nothing which can give instant recovery.She is detereorating but still hope is there. Now 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 to do dialysis. Using noradrenaline is a good option. Also her urea is very high . It means she is getting dehydrated. So her IV fluids has to be increased. Her platelets have improved . Was it because platelet transfusion given or it improved by itself? I hope her antibiotics dosage are given as per her creatinine level. She is maintaining spo2 =90% thats Good.

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

Also I had mentioned to correct her METABOLIC ACIDOSIS make sure thats done properly. Also last time I told to get 2D ECHO scan to see her cardiac function .Do let me know what did the scan show. I couldnt find any attachment with your query. Kindly send me tomorrows ABG report. Wishing her speedy recovery.

Hi,

Apologies, these days my mind set aren't working properly. I have attached the report now. Regards

#

HI 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 expiaratory time ( There will be a parameter in Ventilator called I:E ratio. They have to reduce it ) I hope they are dialysis her today . Revert back with Ventilator settings , ABG report , Urine output , 2D ECHO report and her vitals when you get time.

Hi,

Thanks for your entire followup. Regards

#

Thanks Regards


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