Hello,
Thank you for your query at DoctorSpring.com
I understand your concern.
Seems that your father is in a bad condition.
What could have been the problem - at the very onset - is vague. Diabetic patients are prone for Tuberculosis and other bacterial infections that may cause fluids in lung. this is called pleural effusion, rather than pneumonia.
the above statement is a pure assumption of mine, and i cannot substantiate it, unless i have a chest xray of that time.
being a diabetic, the infection flared up, and over a period of time, it has increased so that it caused a condition called ARDS.
ARDS used to be a condition of high mortality, but now in centres with experience, the mortality is coming down.
Its not clear whether the ventilator oxygen setting is 50% or patients oxygen is 50% at present.
Proning is done late in the management, when conventional methods of ventilation fail to maintain saturation of oxygen. patient has to be kept prone for at least 16 hours a day, and till he improves. but you also mentioned that ventiator oxygen was reduced to 50%. does it mean that patients oxygen is improving?
You had mentioned that he was initially on support for blood pressure. how is his condition now? does he still require support?
How is his liver and kidneys doing?
Was an echo done? how is the right and left hearts doing?
How is his sugar levels at present? how is his sensorium? is he still under sedation and / or paralysis?
Have they done any culture from fluid, blood or lung secretions?
What was the initial procalcitonin level, and what is the present condition now?
I still do not consider it necessary that he has a viral infection at present as ARDS has enough other reasons to be present in him for the time being.
Can i know what all antibiotics he is on, what dose and dosing intervals?
How is the LUNG COMPLIANCE at present?
How is the secretions from the ventilator tube? did the doctor mention anything about trying to wean from ventilator / did he suggest to try ECMO?
Sorry for firing back a few questions. but that would help us to reply better.
In short, i do believe he is in ARDS, secondary to a bacterial infection and still on ventilator, oxygenation improving. if the treatment centre is experienced in treating ards, then he should be fine.
Regards
Dr. Jacob George P
MD,IDCCM, FCCP
Patient replied :
Hello Dr.
Thanks for your answer. Below are answers to some of the questions that I have information on. The main question I seek answer for is, does it feel we are in right direction treating the right underlying cause of ARDS? Is there anything commonly missed in this complex case? I want to be more assured of the underlying cause diagnosis. If it's chest infection, shouldn't it start receding by this time - it's been 4 days in ICU.
Will await your further response.
Clarification Answers (To best of my knowledge)
Ventilator Oxygen Setting is 50% in Prone position. Pressure setting in ventilator is 16.
Patients oxygen level (in the blood) improved on first 2 days and then is holding steady. But the doctors don't yet feel comfortable reducing ventilator settings.
Blood Pressure: Until yesterday blood pressure was maintained to 70-80/125-129. This was done using some medication - but I don't know which one or how much.
Liver and Kidney: Urine quantity passed is 40-60 ml per hour. We were told, every organ except Lungs is functioning fine.
Heart: Heart was functioning normal and rythm is steady. I have not seen echo or ECG myself, but I was assured of the saem.
Lung Secretions: Samples were taken and test done. It came positive for Adeno Virus and Influenza A. More detailed report is expected today. - Does it take this long for the report? I am doubtful of this diagnosis. It is entirely possible that underlying cause is different and infection is incidental. Please provide some insight.
I don't have enought information to answer the remaining questions. But I will try to find more today.
Looking forward for your response.
Thanks
Manish
Dear Manish,
Once a patient lands on a ventilator, it takes approximately 5- 15 days for the patient to improve. So I will not panic.
However it's these days, and our interventions that change the course of disease. We can do harm or benefit depending on expertise. I have a gut feeling that your present doctors do know their stuff.
ARDS is a condition where the body over reacts to an infection. So it lasts more than an infection does.
Virus to cause such infection is possible, though not that convincing. However I don't reckon them stopping antibiotics because we got virus isolated from sample.
So in short, I think it's reasonable for them to take time, your father seems to be stable, and recovering. It might take a few more days or a couple of weeks .
Wishing him a speedy recovery.
Dr. Jacob George P
MD IDCCM FCCP
Patient replied :
Thank you Dr. Jacob. It is a stressfull time and we are taking a day at a time. A few new developments listed below that I would like to share and get your opinion.
In the last two days
1) Doctors took fluid samples from the Lungs which came back sterile with no signs of an obvious infection. About 4 days back the Lung X-ray showed uniform opaqueness - which was thought to be indicative of viral infection.
2) A test of the Upper respiratory tract clearly has Influenza A (Adeno Virus confirmed and highly unlikely to be H1N1 or another dangerous state).
This is perplexing me.
1) What is the underlying cuase if it's not infection?? Doctors don't suspect fungal or allergen due to the season.
2) What if it's not ARDS but confused with something else - Is there something that can mimic ARDS?? Is there something that can be done to re-confirm this?
3) Also if it was infection due to Virus - he would have had it since 40+ days now.. shouldn't it go away?
4) Finally, what parameters are key markers of improvement in the patient ? We are able to ask the parameters from doctors and nurses regularly and it may help to guage progress and quality of attention to my father.
Thanks
Manish
Dear Manish,
ARDS is a broad term that stands for any x ray shadows causing low oxygen in blood. The usual initiating cause being an infection. Ards is a bodies response that has gone out of limit.
So your father can still have Ards, and no infection.
The good things are all other vital organs are doing well.
We assess the progress based on improvement in oxygenation, and lung compliance.
Lung compliance is proportional to the pressure needed to produce a good lung expansion. So if the pressure comes down from 16, it's a good sign.
We at present need to follow just th improvement in oxygenation, without other organs being damages, and Bp being stable.
So in short your father is having Ards, cause probably a lung infection, which has now settled. And if Ards also settles, everything will be fine.
Hope that helped.
Regards
Patient replied :
Hello, Dr. Jacob, Thank you very much for your patience on this topic.
Can you shed some light on the safety/risks of moving my Father from Kuwait to India via air in this condition? Is there a set of parameters that define a safer zone? Some doctors mentioned that with 60% oxygen via ventilator under about 8 PEEP would only add small extra risk on top of whatever risk he already has with ARDS during Air travel.
We want to have an option of getting him to a better facility if possible and currently restricted by the extra high risk of air travel.
Looking forward for your answer.
Thanks
Manish
Dear Manish,
Air travel should be possible, if your father is maintaining saturation in normal lying position, with peep less than ten, and oxygen requirement less than 60 PC. If any value is more, suggest air lifting with transport ecmo. Please ask if ecmo facility is possible there.
Hope it helps
Regards