2. CHIEF COMPLAINTS
• 37 year old male software employee by occupation was admitted
from ER to MICU with chief complaints of
• cough since 8days
• Fever since 5days
• Breathlessness since 3days
3. HISTORY OF PRESENTING ILLNESS
• Cough since 8days,insidious in onset, gradually progressive, not
associated with expectoration, chest pain, no diurnal,postural and
seasonal variation.
• Fever since 5days insidious in onset, gradually progressive,
continuous, low grade, subsided with medication, not associated with
chills and rigors, sweating, headache, rash.
• Shortness of breath since 3days insidious in onset MMRC grade 1
gradually progressed to grade IV, associated with wheeze.
• No history of orthopnea, PND, syncope, chest pain, palpitations.
4. Past history- No comorbidities / History of previous hospital admission
1yr back for covid pneumonia recovered and required minimal oxygen
support.
Family history- No similar complaints in family / no other relevant
history
Personal history- Consumes mixed diet , reduced appetite , disturbed
sleep due to SOB, bowel and bladder – regular and normal; Smoker – 5-
10 cigarettes/day for 10 years 10 pack years, occasional alcohol
intake.
5. • Patient initially took treatment on OPD basis for 3days with above
complaints.
• In view of worsening SOB he came to our hospital for further
management.
6. At ER
• Patient was tachypneic, tachycardic and restless at presentation
• HR- 132bpm
• BP- 126/78 mmHg
• Rr- 36/min
• SPO2- 78% on RA
• SPO2- 86% with NRBM mask with 15 litres O2 support.
7. ABG on 15 LIT O2 NRBM
• Patient was started on NIV support
• All routine investigations ( CBP, RFT, LFT, Sr ELECTROLYTES,
CXR, PT/INR) were sent from ER
• HRCT chest was done.
• Blood culture and sensitivity sent, patient wa started on
empirical antibiotics.
PH
PCO2
PO2
HCO3
LACTATES
P/F
9. AT MICU
• Patient was shifted to MICU on NIV support
• FiO2 – 1; PS-12cm H2O; PEEP- 6cm H2O
10. General physical examination
• A middle aged male conscious oriented to place person
• Class –I Obesity with BMI 34.5kg/m
• (weight -112kgs Height -180cms)
• No pallor/icterus/clubbing/lymphadenopathy/cyanosis/pedal edema.
11. • Pulse-132bpm checked in radial artery; regular; good volume; normal
character; no radio radial and radio femoral delay; all peripheral
pulses felt.
• BP- 140/85 mm hg measured in right arm supine position
• RR- 36 breaths /min, thoracoabdominal type with use of accessory
muscles of respiration
• Temperature- 101.4F( left axilla)
• SpO2- 88% on NIV
12. SYSTEMIC EXAMINATION
• RESPIRATORY SYSTEM
• Shape of chestwall- symmetrical
• Trachea – appears to be central
• Use of accessory muscles of respiration +
Apical impulse – not visualised due to obesity
• Auscultation- harsh vesicular breath sounds all over the lung fields;
B/L inspiratory crepitations Right > Left , polyphonic rhonchi+
13. • CVS: S1 S2 heard, no murmers
• P/A: Soft, non tender, liver and spleen not palpable, bowel sounds+
• CNS: conscious, oriented GCS – 15/15
B/L pupils mmractive to light; Tone : normal ; Power5/5
B/L plantor flexors.
Provisional diagnosis
Lower respiratory tract infection
B/L pneumonia
Impending respiratory failure
15. POCUS
• USG CHEST – Bilateral B profile with lung slide+
dynamic air bronchogram+ right upper lobe; no pleural
effusion
• 2DECHO- IVC 1.5cm, < 50% collapsibility; good LV function, No RWMA
• Patient continued to have tachypnea, tachycardia and using accessory
muscles of respiration.
16. • ABG was repeated after 1 hour on NIV
• Patient was in impending respiratory failure with no response to NIV
trial.
• Patient was intubated, sedation and muscle relaxants continued
• Mechanical ventilator settings
• MODE - VCV
FiO2 TV PEEP RR I:E
100 400 14 32 1:2
P/F 86
PH 7.31
PCO2 60
PO2 70
HCO3 26
17. VITALS POST INTUBATION
• HR – 124bpm; BP- 122/82 mmhg; SpO2 91% with FiO2- 100%
• ABG after 2hrs
• ET cultures, H1N1, Covid RT- PCR sent
• Invasive lines ( CVP; ARTERIAL LINE ) were secured
• Planned for prone ventilation
PH 7.37
PCO2 59
PCO2 68.6
HCO3 31
P/F 81
18. Proning session-1
• Firs session of proning done for 16hours.
• Patient was sedated and paralysed
• All pressure points secured
• No hemodynamic instability
• RT feeds started at 40ml/hour
• ABG after 8hours of proning with FiO2 90%
P/F 105
PH 7.36
PCO2 48.6
PO2 95.3
19. Day2-4
• Total 3 sessions of proning done
• Mechanical ventilation continued
MODE FiO2 TV PEEP RR I:E
PRVC 80 400ml 16 35 1:2
ABG DAY 1 DAY 2 DAY 3
P/F 105 125 109
PH 7.36 7.37 7.32
PCO2 48.6 52.9 56.9
PO2 95.1 74.8 87.5
HCO3 27 28.2 28
20. LAB VALUES
DAY 2 DAY 3 DAY 4
HB 15.1 14.7 13.7
TLC 3570 2950 5320
PC 1.8 1.9 2.5
S. Creatinine 0.6 0.7 0.6
Serum Na/K 142/3.8 142/4.3 146/4.6
21. • CXR- increase in B/L infiltrates
• V-V ECMO was planned as patient did not respond to 3 sessions of prone
ventilation
• Patient attenders were counselled regarding all the pros and cons of ECMO
and consent was taken.
• CTVS referral was given
• V-V ECMO initiated,(Right Femoral and Right IJV cannulated) with FIO2-
100% Sweep gas 6.6L/min; Blood flow 4.5L/min
• Heparin infusion was started, with target ACT of 180
• ACT repeated 2nd hourly and ABG 6th hourly
• RT feeds were continued at the rate of 75ml/hour
23. Before ECMO After ECMO
P/F 109 225
PH 7.32 7.52
PCO2 56.9 36
PO2 87.5 91
HCO3 28 29.4
24. • ET C/s was positive for Pseudomonas Aeruginosa
• Antibiotics were escalated
• Inj. Imipenem + cilastin was added
• Inj. Cefperazone + sulbactam was stopped
• BAL was done and samples were sent for culture sensitivity and
pneumonia film array panel
25. DAY 5-10
• H1N1 influenza A positive
• BAL samples positive for Acinetobacter baumanii,
• Pneumonia panel positive for Acinetobacter baumanii, pseudomonas
aeruginosa, Escherichia coli.
• Antibiotics were escalated according to the sensitivity
• TLC was 11,200 cells/ cumm
26. • ACT checked 4th hourly and titrated the heparin ( target ACT 180 –
220)
• ABG was done every 8th hourly
• APTT was monitored 12th hourly
• ECMO sweep gas flows were gradually titrated and reduced from (
6.5l/min on day 1 ECMO to 4.5l/min)
• Patiennt P/F ratios were around 150
• Lung transplant team referral was given
27. • CT Chest was done in view of refractory hypoxemia and difficulty to
wean off ECMO
• Bronchoscopy and bronchial toileting was done
• Thick mucopurulent secretions were seen in B/L lower lobes.
• BAL sample collected and mucolytic agent was instilled into
tracheobronchial tree.
28. • Percutaneous tracheostomy done in view of prolonged ventilator
support on day 9 of admission
P/F 185
PH 7.33
PCO2 42.9
PO2 73.9
HCO3 22.4
ABG
MODE FiO2 TV PEEP RR I:E
PRVC 40 400 16 30 1:2
MECHANICAL VENTILATOR SETTINGS
FiO2 RPM BLOOD FLOW SGF
100% 3210 4.5 L/ min 4.5 L/min
ECMO SETTINGS
29. DAY 6 DAY 8 DAY 10
HB 11 10.8 10.1
TLC 5860 4480 10490
PC 2.8 2.6 3.1
S. Creatinine 0.7 0.7 0.8
Serum Na/K 149/3.8 151/3.5 150/3.8
30. • Patient showed improvemt in lung meachanics and chest Xray
• He was conscious and obeying commands
• ECMO was weaned and SGF reduced to 4.5L/ min 2.5 L/ min 0
on day 15
• Patient was monitored overnight with SGF -0
31. DAY 16
• ABG before decannulation with SGF 0 L/ min
P/F 166
PH 7.45
PCO2 49.4
PO2 100
FiO2 TV PEEP RR 1:E
60 400 12 32 1:2
32. DAY 16
• SGF were 0 L/min for 17 hours
• P/F ratio- 166
• Patient was conscious, obeying and comfortable
• Patient was decannulated
33. DAY 16 - 25
• Patient was conscious,comfortable
• CXR was improving
• MV support was weaned to FIO2 40%
• Antibiotics were de-escalated; steroids stopped
• Chest and limb physiotherapy continued
• Mobilized to chair
• Patient was weaned to AVAPS support thermovent O2 support room air
• Patient was shifted to O2 room on Day 18 with TT
• Tracheostomy tube was decannulated on D-20
• Patient was discharged thereafter.
