DOCSLIB.ORG

The Natural History of a Patient with COVID-19 Pneumonia and Silent Hypoxemia

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Natural History of a Patient with COVID-19 Pneumonia and Silent Hypoxemia CASE IN POINT The Natural History of a Patient With COVID-19 Pneumonia and Silent Hypoxemia Nicholas Hornstein, MD; Gilad M. Jaffe, MD; Kelley Chuang, MD; Jaime Betancourt, MD; and Guy W. Soo Hoo, MD A patient who declined all interventions, including oxygen, and recovered highlights the importance of treating the individual instead of clinical markers and provides a time course for recovery from pneumonia and severe hypoxemia. Author affiliations n less than a year, COVID-19 has infected benefit in those patients with COVID-19 can be found at the nearly 100 million people worldwide and who require oxygen or mechanical venti- end of the article. caused more than 2 million deaths and lation, but their impact on the progression Correspondence: I Guy Soo Hoo counting. Although the infection fatality of respiratory failure and need for intuba- ([email protected]) rate is estimated to be 1% and the case fa- tion are undetermined. tality rate between 2% and 3%, COVID-19 There also are reports of patients who Fed Pract. 2021;38(4). Published online has had a disproportionate effect on the report no signs of respiratory distress or April 12, 2021 older population and those with comorbidi- dyspnea with their COVID-19 pneumo- doi:10.12788/fp.0100 ties. Some of these findings are mirrored in nia despite profound hypoxemia or high the US Department of Veterans Affairs (VA) oxygen requirements. Various terms, in- population, which has seen a higher case cluding silent hypoxemia or happy hy- fatality rate.1-4 poxia, are descriptive of the demeanor of As a respiratory tract infection, the these patients, and treatment has invari- most dreaded presentation is severe pneu- ably included oxygen.15,16 Nevertheless, monia with acute hypoxemia, which may low oxygen measurements have generally rapidly deteriorate to acute respiratory dis- prompted higher levels of supplemental tress syndrome (ARDS) and respiratory oxygen or more invasive therapies. failure.5-7 This possibility has led to early Treatment rendered may obscure intubation strategies aimed at preempting the trajectory of response, which is im- this rapid deterioration and minimizing portant to understand to better posi- viral exposure to health care workers. In- tion options for invasive therapies and tubation rates have varied widely with ex- other therapeutics. We recently encoun- tremes of 6 to 88%.8,9 tered a patient with a course of illness However, this early intubation strategy that represented the natural history of has waned as some of the rationale behind COVID-19 pneumonia with low oxygen its endorsement has been called into ques- levels (referred to as hypoxemia for con- tion. Early intubation bypasses alternatives sistency) that highlighted several issues of to intubation; high-flow nasal cannula ox- management. ygen, noninvasive ventilation, and awake proning are all effective maneuvers in the Case Presentation appropriate patient.10,11 The use of first- A 62-year-old undomiciled woman with line high-flow nasal cannula oxygen and morbid obesity, prediabetes mellitus, long- noninvasive ventilation has been widely standing schizophrenia, and bipolar disor- reported. Reports of first-line use of high- der presented to our facility for evaluation of flow nasal cannula oxygen has not dem- dry cough and need for tuberculosis clear- onstrated inferior outcomes, nor has the ance for admittance to a shelter. She ap- timing of intubation, suggesting a signifi- peared comfortable and was afebrile with cant portion of patients could benefit from blood pressure 111/74 mm Hg, heart rate a trial of therapy and eventually avoid in- 82 beats per minute. Her respiratory rate tubation.11-14 Other therapies, such as sys- was 18 breaths per minute, but the pulse ox- temic corticosteroids, confer a mortality imetry showed oxygen saturation of 70 to 184 • FEDERAL PRACTITIONER • APRIL 2021 mdedge.com/fedprac 75% on room air at rest. A chest FIGURE 1 Admission and Discharge Chest X-rays X-ray showed bibasilar infiltrates (Figure 1), and a rapid COVID-19 nasopharyngeal polymerase chain reaction (PCR) test returned pos- itive, confirmed by a second PCR test. Baseline inflammatory mark- ers were elevated (Figure 2). In ad- dition, the serum interleukin-6 also was elevated to 66.1 pg/mL (nor- mal < 5.0), erythrocyte sedimenta- tion rate elevated to 69 mm/h, but serum procalcitonin was essen- A, On admission, findings were consistent with COVID-19 pneumonia, including bibasilar infil- tially normal (0.22 ng/mL; normal trates. B, Prior to discharge, improvement of infiltrates can be seen. < 20 ng/mL) as was the serum lac- FIGURE 2 Trends in Peripheral Capillary Oxygen Saturation and tate (1.4 mmol/L). Inflammatory Markers The patient was admitted to the intensive care unit (ICU) for Oxygen Saturation Lactate Dehydrogenase close monitoring in anticipation of the possibility of decompensation 90 400 based on her age, hypoxia, and el- 17 80 U/L 200 evated inflammatory markers. Be- Percent sides a subsequent low-grade fever 70 0 (100.4 oF) and lymphopenia (man- 0 10 20 30 0 10 20 30 ual count 550/uL), she remained Days Days clinically unchanged. Throughout D-Dimer C-Reactive Protein her hospitalization, she maintained 15 20 a persistent psychotic delusion that 10 she did not have COVID-19, refus- 10 ug/mL ing all medical interventions, in- 5 mg/dL cluding a peripheral IV line and 0 0 0 10 20 30 0 10 20 30 supplemental oxygen for the en- Days Days tire duration. Extensive efforts to identify family or a surrogate deci- Ferritin Lymphocytes sion maker were unsuccessful. After 1,500 consultation with Psychiatry, Bio- 2,000 1,000 Ethics, and hospital leadership, ng/mL the patient was deemed to lack 500 cell/uL 1,000 decision-making capacity regard- 0 10 20 30 0 10 20 30 ing treatment or disposition and Days Days was placed on a psychiatric hold. Lowest recorded awake daily peripheral capillary oxygen saturation and inflammatory markers However, since any interventions gathered during hospitalization showed profound hypoxemia and inflammation. Dotted lines indicate upper limits of normal (lower limit in case of lymphocytes). Not included: elevated against her will would require se- interleukin-6 (66.1 pg/mL [normal < 5.0]) and negative procalcitonin. dation, IV access, and potentially increase the risk of nosocomial COVID-19 transmission, she was allowed in the low 80% range, but on day 12, read- to remain untreated and was closely moni- ings were > 90% and remained > 90% for tored for symptoms of worsening respiratory the remainder of her hospitalization. There- failure. fore, shortly after hospital day 12, she was Over the next 2 weeks, her hypoxemia, in- clinically stable for discharge from acute flammatory markers, and the infiltrates on care to a subacute facility, but this required imaging resolved (Figure 2). The lowest daily documentation of the clearance of her viral awake room air pulse oximetry readings are infection. She refused to undergo a subse- reported, initially with consistent readings quent nasopharyngeal swab but allowed an mdedge.com/fedprac APRIL 2021 • FEDERAL PRACTITIONER • 185 COVID-19 Pneumonia TABLE 1 Pulse Oximetry PaO2 Conversion well tolerated in a variety of conditions. A common example are patients with chronic Pulse Partial Pressure of O2 Oximetry, % Under Ideal Circumstances, mm Hg obstructive pulmonary disease. Long-term mortality benefits of continuous supplemen- 90 60 tal oxygen are well established in specific populations, but the threshold for correc- 85 50 tion in the acute setting remains a case-by- case decision. This decision is complex and 80 44 is based on more than an absolute number or the amount of oxygen required to achieve a 75 40 threshold level of oxygenation. The PaO2/FIO2 (fraction of inspired oxy- oropharyngeal COVID-19 PCR swab, which gen) is a common measure used to address was negative. She remained stable and severity of disease and oxygen requirements. unchanged for the remainder of her It also has been used to define the sever- hospitalization, awaiting identification of ity of ARDS, but the ratio is based on intu- a receiving facility and was able to be dis- bated and mechanically ventilated patients charged to transitional housing on day 38. and may not translate well to those not on assisted ventilation. Treatment with supple- DISCUSSION mental oxygen also involves entrained air The initial reports of COVID-19 pneumo- with associated imprecision in oxygen deliv- nia focused on ARDS and respiratory failure e r y. 18 For this discussion, the patient’s admis- requiring mechanical ventilation with less sion PaO2/FIO2 on room air would have been emphasis on those with lower severity of ill- between 190 and 260. Coupled with the bi- ness. This was heightened by health care lateral infiltrates on imaging, there was justi- systems that were overwhelmed with large fied concern for progression to severe ARDS. number of patients while faced with lim- Her presentation would have met most of ited supplies and equipment. Given the the epidemiologic criteria used in initial case risk to patients and providers of crash in- finding for severe COVID-19 cases, including tubations, some recommended early intu- a blood oxygen saturation ≤ 93%, PaO2/FIO2 bation strategies.3 However, the natural < 300 with infiltrates involving close to if not history of COVID-19 pneumonia and the exceeding 50% of the lung. threshold for intubation of these patients With COVID-19 pneumonia, the patho- remain poorly defined despite the cre- logic injury to the alveoli resembles that of ation of prognostic tools.17 This patient’s any viral pneumonia with recruitment of pre- persistent hypoxemia and elevated in- dominantly lymphocytic inflammatory cells flammatory markers certainly met mark- that fill the alveoli, derangements in ventila- ers of disease associated with a high risk of tion/perfusion mismatch as the core mech- progression.
Load more

Recommended publications
  • Approach to Cyanosis in a Neonate.Pdf
    PedsCases Podcast Scripts This podcast can be accessed at www.pedscases.com, Apple Podcasting, Spotify, or your favourite podcasting app. Approach to Cyanosis in a Neonate Developed by Michelle Fric and Dr. Georgeta Apostol for PedsCases.com. June 29, 2020 Introduction Hello, and welcome to this pedscases podcast on an approach to cyanosis in a neonate. My name is Michelle Fric and I am a fourth-year medical student at the University of Alberta. This podcast was made in collaboration with Dr. Georgeta Apostol, a general pediatrician at the Royal Alexandra Hospital Pediatrics Clinic in Edmonton, Alberta. Cyanosis refers to a bluish discoloration of the skin or mucous membranes and is a common finding in newborns. It is a clinical manifestation of the desaturation of arterial or capillary blood and may indicate serious hemodynamic instability. It is important to have an approach to cyanosis, as it can be your only sign of a life-threatening illness. The goal of this podcast is to develop this approach to a cyanotic newborn with a focus on these can’t miss diagnoses. After listening to this podcast, the learner should be able to: 1. Define cyanosis 2. Assess and recognize a cyanotic infant 3. Develop a differential diagnosis 4. Identify immediate investigations and management for a cyanotic infant Background Cyanosis can be further broken down into peripheral and central cyanosis. It is important to distinguish these as it can help you to formulate a differential diagnosis and identify cases that are life-threatening. Peripheral cyanosis affects the distal extremities resulting in blue color of the hands and feet, while the rest of the body remains pinkish and well perfused.
    [Show full text]
  • Asphyxia Neonatorum
    CLINICAL REVIEW Asphyxia Neonatorum Raul C. Banagale, MD, and Steven M. Donn, MD Ann Arbor, Michigan Various biochemical and structural changes affecting the newborn’s well­ being develop as a result of perinatal asphyxia. Central nervous system ab­ normalities are frequent complications with high mortality and morbidity. Cardiac compromise may lead to dysrhythmias and cardiogenic shock. Coagulopathy in the form of disseminated intravascular coagulation or mas­ sive pulmonary hemorrhage are potentially lethal complications. Necrotizing enterocolitis, acute renal failure, and endocrine problems affecting fluid elec­ trolyte balance are likely to occur. Even the adrenal glands and pancreas are vulnerable to perinatal oxygen deprivation. The best form of management appears to be anticipation, early identification, and prevention of potential obstetrical-neonatal problems. Every effort should be made to carry out ef­ fective resuscitation measures on the depressed infant at the time of delivery. erinatal asphyxia produces a wide diversity of in­ molecules brought into the alveoli inadequately com­ Pjury in the newborn. Severe birth asphyxia, evi­ pensate for the uptake by the blood, causing decreases denced by Apgar scores of three or less at one minute, in alveolar oxygen pressure (P02), arterial P02 (Pa02) develops not only in the preterm but also in the term and arterial oxygen saturation. Correspondingly, arte­ and post-term infant. The knowledge encompassing rial carbon dioxide pressure (PaC02) rises because the the causes, detection, diagnosis, and management of insufficient ventilation cannot expel the volume of the clinical entities resulting from perinatal oxygen carbon dioxide that is added to the alveoli by the pul­ deprivation has been further enriched by investigators monary capillary blood.
    [Show full text]
  • Clinical Management of Severe Acute Respiratory Infections When Novel Coronavirus Is Suspected: What to Do and What Not to Do
    INTERIM GUIDANCE DOCUMENT Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do Introduction 2 Section 1. Early recognition and management 3 Section 2. Management of severe respiratory distress, hypoxemia and ARDS 6 Section 3. Management of septic shock 8 Section 4. Prevention of complications 9 References 10 Acknowledgements 12 Introduction The emergence of novel coronavirus in 2012 (see http://www.who.int/csr/disease/coronavirus_infections/en/index. html for the latest updates) has presented challenges for clinical management. Pneumonia has been the most common clinical presentation; five patients developed Acute Respira- tory Distress Syndrome (ARDS). Renal failure, pericarditis and disseminated intravascular coagulation (DIC) have also occurred. Our knowledge of the clinical features of coronavirus infection is limited and no virus-specific preven- tion or treatment (e.g. vaccine or antiviral drugs) is available. Thus, this interim guidance document aims to help clinicians with supportive management of patients who have acute respiratory failure and septic shock as a consequence of severe infection. Because other complications have been seen (renal failure, pericarditis, DIC, as above) clinicians should monitor for the development of these and other complications of severe infection and treat them according to local management guidelines. As all confirmed cases reported to date have occurred in adults, this document focuses on the care of adolescents and adults. Paediatric considerations will be added later. This document will be updated as more information becomes available and after the revised Surviving Sepsis Campaign Guidelines are published later this year (1). This document is for clinicians taking care of critically ill patients with severe acute respiratory infec- tion (SARI).
    [Show full text]
  • Respiratory and Gastrointestinal Involvement in Birth Asphyxia
    Academic Journal of Pediatrics & Neonatology ISSN 2474-7521 Research Article Acad J Ped Neonatol Volume 6 Issue 4 - May 2018 Copyright © All rights are reserved by Dr Rohit Vohra DOI: 10.19080/AJPN.2018.06.555751 Respiratory and Gastrointestinal Involvement in Birth Asphyxia Rohit Vohra1*, Vivek Singh2, Minakshi Bansal3 and Divyank Pathak4 1Senior resident, Sir Ganga Ram Hospital, India 2Junior Resident, Pravara Institute of Medical Sciences, India 3Fellow pediatrichematology, Sir Ganga Ram Hospital, India 4Resident, Pravara Institute of Medical Sciences, India Submission: December 01, 2017; Published: May 14, 2018 *Corresponding author: Dr Rohit Vohra, Senior resident, Sir Ganga Ram Hospital, 22/2A Tilaknagar, New Delhi-110018, India, Tel: 9717995787; Email: Abstract Background: The healthy fetus or newborn is equipped with a range of adaptive, strategies to reduce overall oxygen consumption and protect vital organs such as the heart and brain during asphyxia. Acute injury occurs when the severity of asphyxia exceeds the capacity of the system to maintain cellular metabolism within vulnerable regions. Impairment in oxygen delivery damage all organ system including pulmonary and gastrointestinal tract. The pulmonary effects of asphyxia include increased pulmonary vascular resistance, pulmonary hemorrhage, pulmonary edema secondary to cardiac failure, and possibly failure of surfactant production with secondary hyaline membrane disease (acute respiratory distress syndrome).Gastrointestinal damage might include injury to the bowel wall, which can be mucosal or full thickness and even involve perforation Material and methods: This is a prospective observational hospital based study carried out on 152 asphyxiated neonates admitted in NICU of Rural Medical College of Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra from September 2013 to August 2015.
    [Show full text]
  • Chronic Hypoxemia in the Newborn Lamb: Cardiovascular, Hematopoietic, and Growth Adaptations
    003 1-3998/85/19 10-l004$02.00/0 PEDIATRIC RESEARCH Val. 19, No. 10, 1985 Copyright O 1985 International Pediatric Research Foundation, Inc. Printed in U.S. A. Chronic Hypoxemia in the Newborn Lamb: Cardiovascular, Hematopoietic, and Growth Adaptations DAVID TEITEL, DANIEL SIDI,' DANIEL BERNSTEIN, MICHAEL A. HEYMANN, AND ABRAHAM M. RUDOLPH Cardiovascular Research Institute and the Departments of Pediatrics, Physiology, and Obstetrics, Gynecology and Reproductive Sciences, University of California, Sun Francisco, California 94143 ABSTRAm. We have created a model of chronic hypox- developed a model of a common cyanotic heart lesion to assess emia in the newborn lamb by decreasing pulmonary blood some of its cardiovascular and metabolic effects on the newborn flow in the presence of an atrial septal defect. Via a left lamb. lateral thoracotomy, we place an inflatable balloon around Several authors have studied acute hypoxemia in the devel- the pulmonary artery and perform an atrial septostomy oping organism and elucidated its effects on general cardiovas- under direct vision. We also insert several vascular cathe- cular function (1-3), regional blood flow (1, 4, 5), metabolic ters and place an electromagnetic flow transducer around activity (6, 7), and course of decompensation (1). The effects of the ascending aorta. Three days after surgery, we inflated sympathetic blockade (8, 9) and decreasing Hb oxygen affinity the balloon in 11 lambs such that arterial oxygen saturation (10, 11) on the response to acute hypoxemia have also been decreased to 60 to 75%. Studies were performed on these addressed. Few studies have been performed on the chronically lambs twice weekly and weekly on 12 normoxemic lambs.
    [Show full text]
  • Pathophysiology and Treatment of Cheyne-Stokes Respiration Thorax: First Published As 10.1136/Thx.53.6.514 on 1 June 1998
    514 Thorax 1998;53:514–518 Pathophysiology and treatment of Cheyne-Stokes respiration Thorax: first published as 10.1136/thx.53.6.514 on 1 June 1998. Downloaded from M T Naughton Cheyne-Stokes respiration is a disorder charac- results from hyperventilation, prolonged circu- terised by recurrent central apnoeas during lation time, and reduced blood gas buVering sleep alternating with a crescendo-decrescendo capacity.21 pattern of tidal volume.12 It is often observed in patients with congestive heart failure, usually HYPERVENTILATION during stages 1 and 2 non-REM sleep when Hyperventilation, the common pathophysi- ventilation is under chemical-metabolic ological feature of all forms of periodic breath- 2 control. Patients with Cheyne-Stokes respira- ing, causes PaCO2 levels to fall below the tion usually present with the symptoms of apnoeic threshold triggering a central apnoea. orthopnoea, paroxysmal nocturnal dyspnoea, Once the peripheral chemoreceptors sense an excessive daytime sleepiness and witnessed apnoea related rise in the PaCO2 level above the apnoeas in the setting of congestive heart apnoea threshold, hyperventilation recurs driv- 13 failure. Excessive weight and snoring may be ing the PaCO2 level below the apnoea threshold absent. Approximately 50% of patients with once again.2 symptomatic congestive heart failure have Increased central hypercapnic ventilatory sleep apnoea, mainly of the Cheyne-Stokes responsiveness has been reported to occur in respiration variety.4-6 As congestive heart failure Cheyne-Stokes respiration with congestive occurs in 1% of the adult population and dou- heart failure22 and in other forms of periodic bles in prevalence for each decade beyond 60 breathing in subjects without congestive heart years,7 Cheyne-Stokes respiration is common failure—namely, idiopathic non-hypercapnic but often left unrecognised.
    [Show full text]
  • Respiratory Failure Diagnosis Coding
    RESPIRATORY FAILURE DIAGNOSIS CODING Action Plans are designed to cover topic areas that impact coding, have been the frequent source of errors by coders and usually affect DRG assignments. They are meant to expand your learning, clinical and coding knowledge base. INTRODUCTION Please refer to the reading assignments below. You may wish to print this document. You can use your encoder to read the Coding Clinics and/or bookmark those you find helpful. Be sure to read all of the information provided in the links. You are required to take a quiz after reading the assigned documents, clinical information and the Coding Clinic information below. The quiz will test you on clinical information, coding scenarios and sequencing rules. Watch this video on basics of “What is respiration?” https://www.youtube.com/watch?v=hc1YtXc_84A (3:28) WHAT IS RESPIRATORY FAILURE? Acute respiratory failure (ARF) is a respiratory dysfunction resulting in abnormalities of tissue oxygenation or carbon dioxide elimination that is severe enough to threaten and impair vital organ functions. There are many causes of acute respiratory failure to include acute exacerbation of COPD, CHF, asthma, pneumonia, pneumothorax, pulmonary embolus, trauma to the chest, drug or alcohol overdose, myocardial infarction and neuromuscular disorders. The photo on the next page can be accessed at the link. This link also has complete information on respiratory failure. Please read the information contained on this website link by NIH. 1 http://www.nhlbi.nih.gov/health/health-topics/topics/rf/causes.html
    [Show full text]
  • The Pathophysiology of 'Happy' Hypoxemia in COVID-19
    Dhont et al. Respiratory Research (2020) 21:198 https://doi.org/10.1186/s12931-020-01462-5 REVIEW Open Access The pathophysiology of ‘happy’ hypoxemia in COVID-19 Sebastiaan Dhont1* , Eric Derom1,2, Eva Van Braeckel1,2, Pieter Depuydt1,3 and Bart N. Lambrecht1,2,4 Abstract The novel coronavirus disease 2019 (COVID-19) pandemic is a global crisis, challenging healthcare systems worldwide. Many patients present with a remarkable disconnect in rest between profound hypoxemia yet without proportional signs of respiratory distress (i.e. happy hypoxemia) and rapid deterioration can occur. This particular clinical presentation in COVID-19 patients contrasts with the experience of physicians usually treating critically ill patients in respiratory failure and ensuring timely referral to the intensive care unit can, therefore, be challenging. A thorough understanding of the pathophysiological determinants of respiratory drive and hypoxemia may promote a more complete comprehension of a patient’sclinical presentation and management. Preserved oxygen saturation despite low partial pressure of oxygen in arterial blood samples occur, due to leftward shift of the oxyhemoglobin dissociation curve induced by hypoxemia-driven hyperventilation as well as possible direct viral interactions with hemoglobin. Ventilation-perfusion mismatch, ranging from shunts to alveolar dead space ventilation, is the central hallmark and offers various therapeutic targets. Keywords: COVID-19, SARS-CoV-2, Respiratory failure, Hypoxemia, Dyspnea, Gas exchange Take home message COVID-19, little is known about its impact on lung This review describes the pathophysiological abnormal- pathophysiology. COVID-19 has a wide spectrum of ities in COVID-19 that might explain the disconnect be- clinical severity, data classifies cases as mild (81%), se- tween the severity of hypoxemia and the relatively mild vere (14%), or critical (5%) [1–3].
    [Show full text]
  • Long-Lasting Effect of Prolonged Hypoxemia After Birth on the Immediate Ventilatory Response to Changes in Arterial Partial Pressure of Oxygen in Young Lambs1
    003 1-3998/93/3406-082 1 $03.00/0 PEDIATRIC RESEARCH Vol. 34. No. 6. 1993 Copyright O 1993 International Pediatric Research Foundation. Inc. Printed in U.S.A. Long-Lasting Effect of Prolonged Hypoxemia after Birth on the Immediate Ventilatory Response to Changes in Arterial Partial Pressure of Oxygen in Young Lambs1 Deparrrnenrs of Pediarrics and Prevenrive Medicine, Vanderbilr University School of Medicine. Nashville, Tennessee 37232-2585 ABSTRACT. The effect of prolonged hypoxemia (H) after The immediate ventilatory response to hypoxia and hyperoxia birth on the evolution of the ventilatory response to changes is principally mediated by the peripheral chemoreceptors located in arterial partial pressure of 02was determined in un- in the CB (1-3). The magnitude of this response is proportional anesthetized, awake lambs. H was induced for 12 d after to the strength of 02-sensitive chemoreceptors and is abolished birth in seven lambs through exposure to 0.10 fraction of inspired O2 (Fi02). Five control (C) lambs were kept in by CB denervation (2-4). The role of CB in the ventilatory 0.21 Fi02.The ventilatory response (percent increase from regulation in utero, at the time of relative hypoxemia and hyper- baseline) to acute hypoxia was tested with 0.14 FiOl and capnia, still remains unresolved and controversial (5, 6). Recent 0.10 Fi02. The tonic activity of the peripheral chemore- studies have indicated that the peripheral chemoreceptors are ceptors was assessed by the transient pure oxygen inhala- responsive to changes in oxygen tension during fetal life (7-9), tion test (Dejours' test). The occlusion technique was used although the respiratory response to hypoxemia in the fetus is to measure the baseline neuromuscular drive of breathing.
    [Show full text]
  • CASE REPORT Persistent Hiccups As a Rare Presenting
    UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health Title Persistent Hiccups as a Rare Presenting Symptom of Pulmonary Embolism Permalink https://escholarship.org/uc/item/6mn9685q Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 13(6) ISSN 1936-900X Authors Hassen, Getaw worku Singh, Mona Milkha Kalantari, Hossein et al. Publication Date 2012 DOI 10.5811/westjem.2012.4.6894 License https://creativecommons.org/licenses/by-nc/4.0/ 4.0 Peer reviewed eScholarship.org Powered by the California Digital Library University of California CASE REPORT Persistent Hiccups as a Rare Presenting Symptom of Pulmonary Embolism Getaw worku Hassen, MD, PhD New York Medical College, Metropolitan Hospital Center, Department of Emergency Mona Milkha Singh, MD Medicine, Westchester County, New York Hossein Kalantari, MD Selamawit Yemane-Merriwether, MD Steven Ferrante, PA Ronald Shaw, MD Supervising Section Editor: Rick A. McPheeters, DO Submission history: Submitted September 13, 2011; Revision received March 23, 2012; Accepted April 2, 2012 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2012.4.6894 Pulmonary embolism (PE) is a life-threatening condition that may present as dyspnea, chest pain, cough or hemoptysis, but often occurs without symptoms. It is not typically associated with hiccups. Hiccups are generally self-limiting benign contractions of the diaphragm that may be associated with medications or food but may also be symptomatic of serious disease when persistent. We report 3 cases of PE presenting as persistent hiccups. [West J Emerg Med. 2012;13(6):479-483] INTRODUCTION esophagitis, gastric volvulus) and cardiac conditions Pulmonary embolism (PE) is a potentially lethal (myocardial infarction, pacemaker lead injury).7, 9, 12, 14-17 condition that can be difficult to diagnose.
    [Show full text]
  • This Poster I It's Designed Large the Placeho Formatted Fo Placeholder
    IS IT TIME TO TAKE THE “O” OUT OF “M.O.N.A.”? UNIVERSITY OF MARYLAND BALTIMORE WASHINGTON MEDICAL CENTER GLEN BURNIE, MD Printing: Felicia Caughlin, RN, Cassie Johnson, RN, & Asisat Popoola, RN This poster is 48” wide by 36” high. It’s designed to be printed on a PURPOSE METHODS RECOMMENDATIONS large To assess the use of supplemental oxygen during a Databases: Cochrane Review, CINAHL, Medline myocardial infarction in patients with oxygen Apply oxygen based on patient saturation above 95% without supplemental Search terms: Oxygen toxicity, acute coronary syndrome, chest pain management, myocardial infarction, oxygen, oxygen saturation. oxygen. cost of oxygen usage Customizing the Content: . Current UM BWMC guideline is to place The placeholders in this Limits: Less than 5 years since publication, randomized monitored patients experience chest pain on 4L controlled studies, systematic reviews BACKGROUND of supplemental oxygen (2L for COPD formatted for you. patients). All evidence was appraised using the Johns Hopkins placeholders to add text, or click According to UMBWMC’s current Chest Pain Nursing Evidence-Based Practice appraisal tools. There is no benefit of supplemental oxygen in an icon to add a table, chart, Management of the Monitored Patient normoxemic (O2Saturation >95%) patients. guidelines, the RN is to apply oxygen in the RESULTS SmartArt graphic, picture or event of a myocardial infarction regardless of multimedia file. patient oxygen saturation Study Level of Evidence Results Limitations Implement guideline change. Cabello et Level 1A No clear effect of oxygen on Three studies reviewed had . UMMS U web-based and in-service training al, 2016 Systematic Review infarct size.
    [Show full text]
  • Guidance for the Distribution of Pulse Oximeters to Patients at Increased Risk for Severe COVID-19
    Guidance for the Distribution of Pulse Oximeters to Patients at Increased Risk for Severe COVID-19 The New York City Department of Health and Mental Hygiene (NYC Health Department) will facilitate the distribution of pulse oximeters to hospitals and outpatient providers that predominantly serve populations disproportionately impacted by COVID-19, including those with medical comorbidities and sociodemographic factors that put them at increased risk for poor outcomes. This document provides guidance for the use of home pulse oximetry to facilitate enhanced home monitoring of patients who are at higher risk for moderate to severe COVID-19 illness. Background Although most cases of COVID-19 are mild, the clinical status of some patients can deteriorate rapidly, particularly in the second week of illness. There are also reports of COVID-19 patients who develop silent hypoxemia, when blood oxygen saturation levels are exceedingly low despite patients not exhibiting shortness of breath or other symptoms of respiratory distress, leading to dangerous delays in care. Risk factors for this specific clinical course have not yet been identified, but providers can take steps to identify a clinical decline promptly so care can be escalated early. Home self-monitoring of peripheral pulse oxygen saturation (SpO2) can be a useful tool to support the ongoing evaluation and care of individuals exhibiting COVID-19 symptoms that are at 1 increased risk for severe illness. In a NorthShore University Health System study,0F 50% of patients discharged with pulse oximeters returned to the emergency department when SpO2 was found to be below 92% (per clinical instructions). These patients were admitted even though they did not perceive their symptoms to be worse.
    [Show full text]