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65 years old male was brought to the casualty in unresponsive status and was intubated for the airway protection and respiratory failure. Patient was diagnosed to have hypoglycemia and was treated with 25% Dextrose. However, the patient didn’t bacome responsive even after correction of BSL. Arterial blood gas analysis showed very high CO2 levels of 104 and pH of 7.12 along with hypoxemia. Patient was connected to the ventilator and was ventilated on volume control pressure regulated mode with higher minute ventilation to wash-out CO2.

Once the patient was stabilised, the history obtained from the care taker was- the patient is bed ridden due to his obesity and was a retired engineer working in UK for many years. He smoked all his life and was alone all life. He had fever for 2 days and took antibiotic along with some pain killer as initial remedy from his GP at his previous home-visit. Patient had H/O progressive exertional dyspnea for long time and was attributed to the morbid obesity. He was never prescibed any inhalers or was not on any medicines for his lung condition. However, he was diabetic with controlled sugar levels on oral hypoglycemic drugs. He had received Ciprofloxacin as the antibiotic from his GP for respiratory tract infection, which must have contributed to his hypoglycemia on admission. His ECG showed sinus tachycardia nad no-specific ST-T changes.

On examination, We had 65 years overseas patient who was obese with bull-neck and puffed up from top to bottom. He was connected to the ventilator and needed high volumes for maintaing SpO2. His vitals were stabilised with BP of 110/60mmHg with infusion of Noradrenaline. He had heart rate of 112/min with no arrythmias. Chest was silent and air entry was minimal especialy at the bases. Patient had underwent coronary angioplasty 3 years before and was on stable medicines for his heart condition.

His CXR showed ill-defined patch in Lt. Lower zone and was adequately covered with Broad spectrum antibiotics, Inj. Piperacilin-Tazobactam and Inj. Clarithromycine. Patient was started with Inj.

LMWH for DVT prophylaxis and his cardiac medicines were continued. He was given Methylprednisolone for his Type II Respiratory failure.

On Day2, his parameters were normal and his ABG showed corrected acidosis with CO2 of 62 on PRVC mode with FiO2 of 60%. However, patient had persistent tachypnea and used to desaturate with weaning modes. He was subjected to CT-Thorax with contrast which revealed Chronic pulmnoary thrombus in Lt. Lower lobe pulmonary artery. Patient was hemodynamically stable and we could taper off his vasopressors and hence, was managed with Inj. LMWH in twice a day dosing.

The patient remained stable for 4-5 days and was conscious and was unable to wean with raised CO2 levels.

In summary, we had an obese patient with Type II respiratory failure, Diabetic, Ischemic Heart Disease, Cor-pulmonale, Lt. LL pneumonitis and Lt. LL pulmonary thromboembolism stuck on the ventilator. Although, patient’s general condition was improving, he used to get fatigue with weaning efforts. The danger of extubating the patient and putting on Non-invasive ventilation was discussed with the patient and an attempt of extubation was made with preparation for re-intubation if required.

The patient had large bulky tongue, short neck and raised CO2 levels and had history of witnessed apneas at night along with excessive daytime sleepiness. The possibility of Obstructive sleep apnea was beyond doubts and hence, the use of Long term NIV with auto and timed mode BiPAP was rrecommended. The patient tolerated the extubation and was comfortable with Auto-BiPAP despite high levls of CO2 of around 60-65. We accepted the lower saturations of 88% on low flow nasal oxygen. The patient was given Medroxyprogesterone acetate 20mg two times a day as a respiratory supplement. He was prescibed long term Inhaled Tiotropium along Formoterol and Inhaled steroid, Budesonide.

However, he had new onset fever with increasing cough in ICU and was diagnosed to have Hospital Acquired Seconday Infection with progressive infiltrate on chest X-Ray. He needed upgradation of injectable antibiotics to Meropenem and colistin combination along with aminoglycoside. His sputum revealed presence of Pseudomonas and antibiotics were continued as per the sensitivity pattern.
The patient was discharged on 11th day from the Hospital with Home-BiPAP AND HOME O2.

Diagnosis-Acute COPD exacerbation, Type II respiratory failure, Diabetes Mellitus, Cor-pulmonale, Ischemic heart disease, Lt.LL pneumonitis, Lt.LL pulmonary embolism, severe pulmonary hypertension, Hospital acquired pneumonia and probable, sleep apnea with Overlap syndrome.