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

HI

Thanks for posting your query.

I went through the reports and will try to analyze them to the best of my capability. First of all her CT is clearly showing signs of interstitial lung disease (attachments removed to protect patient's identity) but there may be superadded infection over it. Interstitial Lung disease (ILD) comprises a group of lung diseases some are easily treatable 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 super-added 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 ask them to do now). Once the antibiotic course is completed (7 to 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 can be very harmful in the presence of infection. That is the reason why infection has to be treated first and then later ILD treatment. I also advise you to do a total leucocyte count every alternate day and follow up with me with the report. Also, get sputum AFB (acid-fast bacillus) tets did thrice. Feel free to discuss or clarify anything.

HI

Thanks for the follow up. Very sorry to know that she had fits. I went through the files posted by you (attachments removed to protect the patient's identity). 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 stopped Azuran. Azuran is an immunosuppressant means which suppresses the immunity of the body. Though it is the right treatment for ILD but 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 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 immunosuprresants are required. My advice is to stop Azuran, and give steroids as injections (she is getting 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 back 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.

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

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 . :))

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

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 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 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 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.

Thanks Regards