Case Study Report of Eddie: Acute Respiratory Failure with Underlying COPD

Today, approximately 10% of all intensive care unit admissions as well as almost one-quarter (24%) of all patients that require mechanical ventilation, are due to acute respiratory failure (Parcha et al., 2021). The purpose of this case study report is to provide an assessment of Eddie, a 50-year-old male recently admitted to the intensive care unit with acute respiratory failure. The case study report begins by providing a brief description of acute respiratory failure, including its pathophysiology, subtypes, causes, and diagnostic criteria. The next section provides a critical analysis of Eddie's presentation on admission to intensive care, linking it to pathophysiology, physical assessment findings, and diagnostic tests, to arrive at a diagnosis of Eddie's acute respiratory failure. In addition, the case study report evaluates and describes the ventilation-perfusion (V/Q) mismatch that was identified in Eddie's diagnosis. In addition, an interpretation of analysis of Eddie's arterial blood gas results and is followed by a discussion concerning two appropriate nursing assessments that would be indicated in Eddie's current condition, together with the physiological rationale, assessment technique, and expected findings. Finally, the case study report discusses the effectiveness of providing fluid to support Eddie's worsening hemodynamics and suggests other evidence-based management strategies that could be initiated to improve Eddie's condition.

Brief description of acute respiratory failure including pathophysiology, subtypes, causes and diagnostic criteria

Acute respiratory failure (ARF) refers to a state in which the respiratory system is unable to sustain adequate gas exchange at normal levels (Anesi et al., 2023). According to Gurka and Balk (2018), ARF is defined as the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient (p. 137). At present ARF is classified according to one of four general types as set forth in Table 1 below:

Table 1

Types of Acute Respiratory Failure

Type

Description

Type 1

Hypoxemic - PO2 < 50 mmHg on room air; usually seen in patients with acute pulmonary edema or acute lung injury because these disorders interfere with the lung's ability to oxygenate blood as it flows through the pulmonary vasculature.

Type 2

Hypercapnic/Ventilatory - PCO2 > 50 mmHg (if not a chronic CO2 retainer); this type of ARF is usually seen in patients with an increased work of breathing due to airflow obstruction or decreased respiratory system compliance, with decreased respiratory muscle power due to neuromuscular disease, or with central respiratory failure and decreased respiratory drive.

Type 3

Peri-operative - this type of ARF is generally a subset of type 1 failure but is sometimes considered separately because it is so common.

Type 4

Shock - secondary to cardiovascular instability.

Source: Adapted from Acute Respiratory Failure Overview (2023)

The causes of ARF include pulmonary diseases, non-pulmonary sepsis, viral or bacterial pneumonia, stroke, surgical complication, cardiogenic edema, cardiac arrest, and trauma (Ghale et al., 2022). The diagnostic criteria for ARF are: 1) pO2 less than 60 mm Hg (or room air oxygen saturation less than or equal to 90%); 2) pCO2 greater than 50 mm Hg with pH less than 7.35; and, 3) signs/symptoms of respiratory distress (Decaro, 2019).

Critical analysis of Eddie's current presentation on admission to intensive care linking to pathophysiology, critically analyse the physical assessment findings and diagnostic tests, and a diagnosis of Eddie's acute respiratory failure

Eddie's admission upon presentation to the intensive care unit suggests that he is suffering from acute respiratory failure, which is most likely caused by the worsening of his underlying COPD. In this regard, Gadre et al. (2018) report that, Chronic obstructive pulmonary disease is punctuated by recurrent exacerbations and a progressive decline in the patients functional status (p. 2). Likewise, Eddie's tachypnea, tachycardia, and decreased air entry bilaterally indicate the presence of airway obstruction and increased work of breathing and are indicative of ARF exacerbated by COPD. Moreover, the diagnostic tests that were administered to Eddie (pathology, chest X-ray and ECG) ruled out myocardial infarction as the cause of his chest pain and respiratory presentation. In addition, Eddies expiratory wheeze and fine crepitations that were identified to the lower bases further support the diagnosis of COPD exacerbation.

Although a myocardial infarction has been ruled out as the cause of Eddied chest pain as noted above, Magesh and Karthikeyan (2018) caution that, Clinically right ventricular myocardial infarction can be suspected when a patient with inferior wall myocardial infarction presents with elevated JVP, positive Kussmaul's sign, hypotension [and] right-sided third...

…and decreased cognitive function. It is therefore important to assess Eddie's mental status, including his level of consciousness, orientation, and ability to follow commands now and in the future.

Discussion concerning the effectiveness of providing fluid to support the worsening haemodynamics linking to the pathophysiology of Eddie's diagnosis

The medical team prescribed a 500 ml STAT fluid bolus of 0.9% sodium chloride to support Eddie's blood pressure; in the context of Eddie's diagnosis, the effectiveness of fluid resuscitation is limited. As previously discussed, Eddie's acute respiratory failure is characterized by V/Q mimatch, which results in poor oxygenation and impaired gas exchange. Fluid administration can further compromise gas exchange by increasing pulmonary capillary hydrostatic pressure, which can lead to pulmonary edema and exacerbate V/Q mismatch. Some alternative evidence-based management strategies for Eddie's condition include the following:

Bronchodilators and corticosteroids: Bronchodilators and corticosteroids can improve airway patency and reduce inflammation in patients with COPD which can improve gas exchange and reduce breathing workload (Roland, 2018). Here again, though, the use of these medications should be carefully monitored, as they can cause adverse effects, such as tachycardia, arrhythmias, and hyperglycemia.

Non-invasive ventilation (NIV): NIV, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), can improve gas exchange and can also reduce breathing workload in patients with acute respiratory failure. For instance, Kinnear (2023) notes that, CPAP is employed in patients with acute respiratory failure to correct hypoxemia. It permits a higher inspired oxygen content than other methods of oxygen supplementation, increases mean airway pressure, and will improve ventilation to collapsed areas of the lung (p. 337).

Conclusion

This case report provided an overview of acute respiratory failure, its pathophysiology, subtypes, causes, and diagnostic criteria. In addition, the case study report also provided a critical analysis of specific patient, Eddie's, presentation, including his physical assessment findings and diagnostic tests. These findings led to a diagnosis of acute respiratory failure and V/Q mismatch due to COPD exacerbation. The case study report also discussed priority nursing assessments and management strategies in the context of Eddie's diagnosis. Taken together, it is reasonable to conclude that the importance of early recognition and appropriate management of acute respiratory failure is essential in…