Case Report: Mrs STS with

Respiratory Failure

Unggul Pribadi-GUP
SPV: dr. Yuddy Imowanto, SpEM, KEC
 Disclaimer

Case study was extracted from medical records and presenter was not
directly involved in patient care
 Table of contents

01 02
Introduction Case presentation

03 04
Discussion Conclusion
 Introduction

Background
Acute respiratory failure is the most
common indication for admission to
critical care. Appropriate management
requires the early recognition and
identification of precipitating factors,
understanding of the pathophysiology and
a systematic approach to assessing disease
severity. (Vasques et al., 2023)
Importance
Learning through case reports helps
reinforce concepts, particularly in
patient management, enabling the
selection of the best possible options
in emergency scenarios.

Vasques, F., Slattery, M., Srivastava, S., & Camporota, L. (2023). Management of acute respiratory failure.
Case presentation – patient dentity
Name : Mrs. STS
Age : 72 yrs
Presented to ER : 10th Oct 2023
MR number : 106106XX
 Case presentation - History of illness

Chief of complaint: decreased of consciousness since the evening

Recent history of illness : Decreased consciousness since the evening prior to hospital admission, unresponsive to verbal stimuli.
Experienced vomiting leading to choking. Shortness of breath for the past 2 weeks, worsening over the last 3 days, with DOE for
the past year and PND in the last 2 weeks. Intermittent fever for the past week. Approximately 2 kg weight loss over the course
of 2 weeks

Recent and Past medical history: History of discharge from Kanjuruhan Hospital 4 days ago, previously hospitalized for 2 weeks
with a history of ventilator placement. Past history of pulmonary TB completed treatment 5 years ago, currently has diabetes
(DM) but not on medication, uses Berotec when experiencing shortness of breath

Problems: DOC, SOB (DoE, PND), suspected pulmonary aspiration, fever, mechanical ventilation history, hospital admission
history, past pulmonary TB infection, DM without medication, COPD/Post TB obstructive airway disease
 Case presentation – Clinical findings

Triage zone Critical care zone Critical care zone Admitted to ICU
Case presentation - Diagnostic workup
Case presentation - Diagnostic workup

Problem: chronic respiratory acidosis, SOFA score 5

without bilirubin, hyponatremia, hypokalemia,
hypochloremia
Case presentation - Diagnostic workup
 Discussion – differential diagnosis

DOC Type 2 respiratory failure

SOB (DoE, PND) DoC dt hypercarbia encephalopathy
suspected pulmonary aspiration Sepsis – Pneumonia
Fever Acute on COPD
mechanical ventilation history Hyponatremia
hospital admission history
past pulmonary TB infection
DM without medication
COPD/Post TB obstructive airway disease
Ronchi
Severe distress breathing any other?
Leukocytosis – neutrophilia
Chronic respiratory acidosis
SOFA score 5 without bilirubin
Pneumonia based on chest Xray
Hyponatremia, hypokalemia, hypochloremia
 Case presentation – Clinical findings
Confirm diagnosis
and the cause

Management

Treat underlying Provide supportive

cause measure

Teng, C. M., Ling, G. E., & Mahadevan, M. (2022). Respiratory Failure, Acute. In S. Ooi, M. Low, & P. Manning (Eds.), Guide to The Essentials in Emergency Medicine (III, pp.
338–343).
Discussion – ventilation support for respiratory failure
 Discussion – ventilation support for respiratory failure
Oxygen supplementation to targeted SpO2 values of 94-98% for most patients and
88-92% for patients with chronic type 2 respiratory failure

HFNO: reduces mortality in hypoxaemic normocapnic respiratory failure, and meta-

analyses have shown that HFNO reduces the need for escalation of respiratory
support and intubation rates.

NIV: 2 modes: CPAP and BiPAP. the use of high pressures (e.g. CPAP >10 cmH2O,
inspiratory support >12-15 cmH2O) can be poorly tolerated

Vasques, F., Slattery, M., Srivastava, S., & Camporota, L. (2023). Management of acute respiratory failure.
Teng, C. M., Ling, G. E., & Mahadevan, M. (2022). Respiratory Failure, Acute. In S. Ooi, M. Low, & P. Manning (Eds.), Guide to The Essentials in Emergency Medicine (III, pp. 338–343).
Discussion – ventilation support for respiratory failure
‘Lung-protective’ mechanical ventilatory support: the goals of ventilation are to
maintain the PaO2 at 7.3-10.6 kPa (55-79.5 mmHg), and to accept a rise in PaCO2
(permissive hypercapnia) to enable low-volume ventilation if inspiratory pressures
reach 30 cmH2O

PEEP: The most common uses a PEEP scale depending on PaO2/FiO2, where the
lower the PaO2/FiO2, the higher the PEEP. A pragmatic initial approach using the
PaO2/FiO2 ratio would be to set a PEEP of 5-10 cmH2O for mild ARDS, 10-15
cmH2O for moderate ARDS and >15-20 cmH2O for severe ARDS
 Discussion – ventilation support for acute hypercapnic
respiratory failure
Pressure-targeted ventilators are the devices of choice for acute Worsening physiological parameters, particularly pH and
NIV (Grade B). respiratory rate (RR), indicate the need to change the
management strategy. This includes clinical review, change of
A full face mask (FFM) should usually be the first type of interface, adjustment of ventilator settings and considering
interface used (Grade D). proceeding to endotracheal intubation (Grade A).

NIV should be started when pH6.5 kPa persist or develop
despite optimal medical therapy (Grade A).
Severe acidosis alone does not preclude a trial of NIV in an
appropriate area with ready access to staff who can perform
safe endotracheal intubation (Grade B).
Advanced age alone should not preclude a trial of NIV (Grade
A).
IMV should be considered if there is persistent or deteriorating
acidosis despite attempts to optimise delivery of NIV (Grade
A).
Intubation should be performed in respiratory arrest or
periarrest unless there is rapid recovery from manual
ventilation/ provision of NIV (Grade D).

NIV can be discontinued when there has been normalisation of

pH and pCO2 and a general improvement in the patient’s
condition (Grade B).
Davidson, A. C., Banham, S., Elliott, M., Kennedy, D., Gelder, C., Glossop, A., Church, A. C., Creagh-Brown, B., Dodd, J. W., Felton, T., Foëx, B., Mansfield, L., McDonnell, L., Parker, R., Patterson, C. M., Sovani,
M., & Thomas, L. (2016). BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax, 71, ii1–ii35. https://doi.org/10.1136/thoraxjnl-2015-208209
 Discussion – status volume

Significance
Volume status assessment is a critical but
challenging clinical skill and is especially
important for the management of
patients in the emergency department

Kearney, D., Reisinger, N., & Lohani, S. (2022). Integrative Volume Status Assessment. POCUS Journal, 7(Kidney), 65–77. https://doi.org/10.24908/pocus.v7iKidney.15023
 Discussion – status volume

Kearney, D., Reisinger, N., & Lohani, S. (2022). Integrative Volume Status Assessment. POCUS Journal, 7(Kidney), 65–77. https://doi.org/10.24908/pocus.v7iKidney.15023
 Discussion – status volume

Kearney, D., Reisinger, N., & Lohani, S. (2022). Integrative Volume Status Assessment. POCUS Journal, 7(Kidney), 65–77. https://doi.org/10.24908/pocus.v7iKidney.15023
 Discussion – status volume

Kearney, D., Reisinger, N., & Lohani, S. (2022). Integrative Volume Status Assessment. POCUS Journal, 7(Kidney), 65–77. https://doi.org/10.24908/pocus.v7iKidney.15023
 Discussion – status volume

Kearney, D., Reisinger, N., & Lohani, S. (2022). Integrative Volume Status Assessment. POCUS Journal, 7(Kidney), 65–77. https://doi.org/10.24908/pocus.v7iKidney.15023
 Discussion – status volume

Kearney, D., Reisinger, N., & Lohani, S. (2022). Integrative Volume Status Assessment. POCUS Journal, 7(Kidney), 65–77. https://doi.org/10.24908/pocus.v7iKidney.15023
 Discussion – Hypercapnic encephalopathy

Scala, R. (2011). Hypercapnic encephalopathy syndrome: A new frontier for non-invasive ventilation? Respiratory Medicine, 105(8), 1109–1117. https://doi.org/10.1016/J.RMED.2011.02.004
 Conclusion
• The cause of altered mental status of Mrs. STS is most likely due
to hypercapnic encephalopathy
• High levels of PCO2 from BGA Mrs STS indicate type II
respiratory failure caused by chronic respiratory acidosis
• Emergency handling of type II respiratory failure using NIV is in
accordance with the guidelines
• POCUS is a very sensitive examination option in assessing patient
volume status
“Life is but a breath, appreciate
it before it dissipates”
- Anonymous
 Thanks
unggul.pribadi@gmail.com
unggulpribadi@student.ub.ac.id

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