Acute Respiratory or Cardiac Failure

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Requirement

A case study of 2000 words on either shock, acute respiratory or cardiac failure
This assessment task enables you to deeply engage with the literature around the health status of an acutely ill patient. You must select a patient for the case study who has experienced either shock, acute respiratory or cardiac failureWrite a brief summary of the patient’s current health problem,
relevant history and any specific early management provided to address the primary problem prior to arriving in your ward if relevant. This should be sufficient to set the scene for the reader and should take up no more than one (1) to one and a half (1 ½) pages. At all times you must maintain patient confidentiality by assigning the person a pseudonym and abide by your organisations ethics policy on using patient information. Please note that no patient details are required and it is your interpretation of patient data that is examined. There is no need to include patient’s test results.
To facilitate demonstrating depth of knowledge related to complex care patients, critically analyse the related health problem (shock, or acute respiratory or cardiac failure) that the patient experienced using evidence based findings. The paper should focus upon detailed explanation of the underlying pathophysiology related to the presenting problems.
The paper should include an introduction that describes how the paper is organised. Include a conclusion that draws the key themes together.

Solution

Acute respiratory or cardiac failure

The current case study deals with analysis on the health issues faced by Mr. Jones. Mr. Jones has recently experienced Type 2 Respiratory Failure because of chronic bronchitis. In the current essay, the health issues of Mr. Jones along with his medical history and the associated pathophysiology will be discussed. The essay will include discussion on the medical history of the patient, along with the symptoms and the assessment findings. The key issues faced by Mr. Jones will be discussed in the essay at first. Next how the general pathophysiology of these patients relates to the particular patient will also be discussed in the essay. 
The patient, whose case is being studied in this essay, is being mentioned as ‘Mr. Jones’. Due to ethical reasons, the identity of the patient needs to be kept secret and so, here; he is being denoted in a different name. The risks of respiratory failure   increases with   chronic bronchitis Mr Jones is 45 years old male who has suffered from chronic bronchitis for last 2.5 years and it caused `Acute Type 2 Respiratory Failure. Mr. Jones has been admitted to ICU before 3 days. Extreme obesity is another problem that Mr. Jones has (McKenzie DK, 2018). 

Mr. Jones has been reported with rapid and shallow breathing. The lungs of the patient, which should be filled with air normally, were found filled with the fluid. In addition, he has been reported with poor ventilatory muscle function and secretions in the alveoli and also in the airways. Along with it, the chest wall of the patient was also found in abnormal condition. The patient has been reported with morbid obesity for last 4 years and used to have an average BMI of 42 kg/ m2. Morbid obesity of the patient also added to the chest wall abnormalities and caused failure (Galiè et al.2015). Other pathophysiologies of the respiratory failure include muscular dystrophies and obstruction of airways.
After being admitted to the Intensive Care Unit (ICU), Mr. Jones has undergone a chest X-Ray which revealed the fluid filled lungs. The chest X-Ray also indicated presence of Obesity Hypoventilation Syndrome. In case of obesity hypoventilation syndrome, the patients fail to breathe deeply because of their obesity and it increases the level of carbon dioxide in blood (Hillman et  al.2014). He was having problem due to rapid breathe. As the patient has a history of chronic bronchitis, Salbutamol, was administered. Salbutamol increases the airways immediately and makes breathing easier for the patient (Watkinson et al.2014). Clearly, it relieved the patient a lot from his pain. In addition he was also given with the supplementary oxygen to get rid of the breathing problem. The patients suffering from type 2 respiratory failure have higher amount of CO2 in their blood. The Arterial Blood Gas test (ABG test) provides the information on the amount of gas present in the blood (Lee et al.2016). So, for knowing the extent of hypercapnia, blood sample was collected from MR. Jones and was sent for laboratory test. The patient was found to have the PaCO2 of 55 mmHg. In normal situation, the PaCO2 level of an individual needs to be below 45 mmHg (Zhang et al.2016). So, finding of the assessment indicates that the patient has excess CO2 in blood. The PaO2 level of the patient was found as 70 mmHg. In normal condition, the PaO2 level of an individual remains above 75 mmHg (Lee et al.2016). So, it can be stated that the partial pressure of oxygen in Patient’s blood was lower than normal and so, he has hypoxeimia. The patients with both hypoxemia and type 2 respiratory failures are at greater risk and managing their health issues are more difficult. As in this case, the patient had both the issues, managing it was quite complex.

The patients suffering from Type 2 Respiratory failure often have a risk of degraded ventilator muscle function. As Mr. Jones, was facing serious breathing problems at the time of admission, it necessary to check whether he has been facing any issue due to reduced muscle function or not. The Maximum Inspiratory Pressure (MIP) is a test that measures muscle strength of an individual while breathing in the air (Czarna et al.2016). On the contrary, Maximum Expiratory Pressure (MEP) is another effective test to measure the strength of the muscle at the time of breathing out in forced and normal condition (Lee et al.2016). In case of Mr. Jones, both the tests were done. The best MIP value for male individuals above 40 years can be around 82.8 cms H2O. On the contrary, the best MEP value for male individuals above 40 years needs to be around 110 cms H2O. In case of the patient, Mr. Jones, both the values were found below the normal level indicating the reduced lungs muscle strength. 
Considering all the discussions, the Type2 Respiratory failure can be considered as a state when the body cannot eliminate the CO2 generated by it and as a result, the patients start having a CO2 buildup with the body. Type 2 Respiratory Failure can be easily indicated by an increased PaCO2 level (Mazzuco et al.2015). Lack of alveolar ventilation is a common cause of Type 2 Respiratory failure. However, the issue may be generated as an effect of chronic bronchitis also.
 In case of the patient, chronic bronchitis and morbid obesity both caused the respiratory failure. In case of bronchitis, the patient experiences inflammation of the bronchiole tube which carry air to the lungs. A patient suffering from bronchitis often has sticky, thickened and discolored mucus. In case of chronic bronchitis the patient may have a mucus build-up within the bronchiolar tube (Moxon & Lee, 2015). It prevents the tubes to carry adequate air into the lungs. The patients suffering from chronic bronchitis tend to generate huge amount of mucus. The bronchitis also reduces the lungs area available for gas exchange. It causes hypercapnia within the patient. 
 In case of Mr. Jones, the problem of hypoxemia and hypercapnia alleviated because of his morbid obesity. The patient with morbid obesity experiences problems to breathe deeply. It reduces the level of oxygen into the body and increases the CO2 level. The people with obesity usually have a body mass index (BMI) of more than 30 kg/m2.
The obesity and the pulmonary mechanism are linked closely. Excessive increase in weight and the BMI has severe negative impact on the pulmonary mechanics (Fuster et al.2016). The higher weight and higher BMI reduces the lung volumes. It leads to development of a highly restrictive ventilatory pattern. As a result , the area available for gas exchange also reduces in case of obese people. It results in the abnormalities in the oxygen and CO2 level within the body. It can be stated that obesity increases the risk of type 2 respiratory failure in the body.

The longitudinal and the cross sectional studies of lungs indicate that increase in the BMI reduces the forced expiratory volume within 1 second (FEV1) (Fuster et al.2016). The forced vital capacity (FVC) and forced residual capacity (FRC) are two other measures that provide idea on the lungs capacity (Kaw et al.2016). Along with it, the total lungs capacity (TLC) and residual volume (RV) also decreases due to morbid obesity. As Mr. Jones has previously diagnosed with morbid obesity (BMI>40 kg/m2), his respiratory problem was heightened and excessive weight made the situation more complex.

The obese individuals have more tendencies to have respiratory issues than the normal individuals (Fuster et al.2016). The researches on respiratory muscle oxygen consumption during ventilation among obese people indicate that such people require higher amount of oxygen than the lean people. In case of Mr. Jones, the obesity increased demand of oxygen within the body. On the contrary, due to mucus build up in the bronchiole tubes, he was not able to intake the adequate amount of oxygen. Lack of breathing in sufficient oxygen caused hypoxemia within his body. However, the intensity of the problem was higher due to increased demand of oxygen by him.
To avoid the pulmonary issues, the respiratory muscles play a significant role. The functionalities of the respiratory muscle tend to degrade with the increase in weight. The pattern of decrease in muscle function among the obese people is almost similar to the pattern as in case of Chronic Obstructive Pulmonary Disease (COPD) (Fuster et al.2016). As Mr. Jones has both morbid obesity and chronic bronchitis, the functionalities of his respiratory muscles reduced significantly. The effects of both the health issues were reflected by the lower MIP and lower MEP. The obese people experience significant reduction in the overall fat free mass (Martin-Rodriguez et al.2016). It also increases the additional requirement of oxygen by the obese patients. As these patients require higher amount of oxygen, their sensation for the breathlessness also becomes more and more intense. Obesity creates extra workload on the respiratory muscles for breathing in and it reduces the efficiency of the muscles gradually (Kaw et al.2016). Therefore, the patients star facing problems to breathe in and out adequate amount of oxygen and CO2 and the problem gets intensified with time as the muscle strength reduces gradually. For Mr. Jones the morbid obesity increased the demand of oxygen within the body significantly while the functions and strength of the muscles reduced to a great extent due to increased workload on them. Both the issues combined together, increased the intensity of breathing problems.

Not only the excess weight, the COPDs like chronic bronchitis also have several negative effects on the muscle function of the lungs. In case of COPD, the capacity of diaphragms to create adequate diaphragm pressure reduces due to inflammation (Martin-Rodriguez et al.2016). This situation is mechanically unfavorable for the lungs muscle, as in the absence of adequate diaphragm pressure the muscles have to work harder to execute the normal breathing function (Kaw et al.2016). As Mr. Jones has chronic bronchitis, one type of COPD, his lungs muscles have to put extra effort to keep the breathing functions normal. In addition, the changes in a diaphragm pressure, is often compensated by the increase in neural drive and change in the diaphragm shape. In addition, the chest wall also starts to adapt the changes in bodily functions. In case of Mr. Jones , the abnormalities in the chest wall were identified in the X-Ray. It can be stated that the issues in chest wall was an effect of the chronic bronchitis he is suffering for several years. Finally, the muscle fiber also changes in order to adjust with the physical issues. The high inspiratory need of the COPD patient often relates with the indorsing of lower coastal margin (Martin-Rodriguez et al.2016). The central drive remains low in case of COPD patients. The lack of adequate central drive, leads to ventilator failure among the patients (Czarna et al.2016). As the situation continued for several years, now the functionalities of the muscles reduced significantly and it contributed to the respiratory failure of Mr. Jones. In addition, the decreased central drive added to the risk of ventilator failure. Therefore, long history of COPD leads to lung and chest wall impairment among the patients. The similar effects have been found in Mr. Jones also as he had been suffering from chronic bronchitis for several years. 
The discussion in the essay indicates that the patient Mr. Jones has chronic bronchitis and morbid obesity for past few years. The COPD diseases like chronic bronchitis create restriction in the airways to lungs and increase the chance of hypoxemia. The bronchitis also reduces the lung muscle strength and the available lung volume for gas exchange. It enhances the risk of hypercapnia among the patient. In case of Mt. Jones, both the chronic bronchitis and morbid obesity created an unfavorable situation for the respiratory mechanism and caused type 2 respiratory failure.

References:

• Czarna, A., Sakairi, Y., Matsuda, A., Hatzistergos, K. E., Liu, X., Luciani, M., ... & Camp, P. C. (2016). Lung Stem Cells and Chronic Obstructive Pulmonary Disease.

• Fuster, J. J., Ouchi, N., Gokce, N., & Walsh, K. (2016). Obesity-induced changes in adipose tissue microenvironment and their impact on cardiovascular disease. Circulation research, 118(11), 1786-1807.

• Galiè, N., Humbert, M., Vachiery, J. L., Gibbs, S., Lang, I., Torbicki, A., ... & Ghofrani, A. (2015). 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European heart journal, 37(1), 67-119.

• Hillman, D., Singh, B., McArdle, N., & Eastwood, P. (2014). Relationships between ventilatory impairment, sleep hypoventilation and type 2 respiratory failure. Respirology, 19(8), 1106-1116.

• Kaw, R., Bhateja, P., y Mar, H. P., Hernandez, A. V., Ramaswamy, A., Deshpande, A., & Aboussouan, L. S. (2016). Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest, 149(1), 84-91.

• Lee, P., Innes, E., Qian, J., Chen, C., & Ng, A. T. (2016). Mortality Outcomes Of Long-Term Domiciliary Non-Invasive Ventilation In Stable Chronic Obstructive Pulmonary Disease With Chronic Type 2 Respiratory Failure. In A41. THE SPECTRUM COPD CARE: FROM IDENTIFICATION TO POLICY (pp. A1513-A1513). American Thoracic Society.

• Martin-Rodriguez, E., Guillen-Grima, F., Martí, A., & Brugos-Larumbe, A. (2015). Comorbidity associated with obesity in a large population: The APNA study. Obesity research & clinical practice, 9(5), 435-447.

• Mazzuco, A., Medeiros, W. M., Sperling, M. P. R., de Souza, A. S., Alencar, M. C. N., Arbex, F. F., ... & Borghi-Silva, A. (2015). Relationship between linear and nonlinear dynamics of heart rate and impairment of lung function in COPD patients. International journal of chronic obstructive pulmonary disease, 10, 1651.

• McKenzie DK, e. (2018). Respiratory muscle function and activation in chronic obstructive pulmonary disease. - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 19 April 2018, from https://www.ncbi.nlm.nih.gov/pubmed/19390004

• Moxon, A., & Lee, G. (2015). Non-invasive ventilation in the emergency department for patients in type II respiratory failure due to COPD exacerbations. International emergency nursing, 23(3), 232-236.

• Watkinson, P., Collins, G., Gerry, S., Malycha, J., Pimentel, M., Prytherch, D., ... & Smith, G. (2018). External validation of the National Early Warning Score 2 (NEWS2) prediction of in-hospital death in patients with type II respiratory failure: a multi-centre database study [protocol].

• Zhang, J. R., Fu, H., Li, S. L., & Guo, C. F. (2016). Assessment of blood gas parameters and the degree of inflammation in noninvasive positive pressure ventilation combined with aminophylline treatment of COPD complicated with type II respiratory failure. Journal of Hainan Medical University, 22(20), 60-64.