Name:
Harrison's Podclass - Episode 88- A 79-Year-Old with Pneumonia
Description:
Harrison's Podclass - Episode 88- A 79-Year-Old with Pneumonia
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T00H06M38S
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https://cadmoreoriginalmedia.blob.core.windows.net/6547732a-5993-4430-8bb4-cd4b78b7fa0b/Harrison%27s Podclass - Episode 88- A 79-Year-Old with Pneumon.mp3?sv=2019-02-02&sr=c&sig=o%2Bkt3iYeDkQ91IQ%2BrYr8pWMwLp0zrgJ7sEPjFTPRybo%3D&st=2024-05-05T22%3A58%3A28Z&se=2024-05-06T01%3A03%3A28Z&sp=r
Upload Date:
2022-06-12T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music] [Dr. Handy] Hi, welcome to Harrison's PodClass, where we discuss important concepts in internal medicine. I'm Cathy Handy. [Dr. Wiener] And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. [Dr. Handy] Welcome to episode 88, a 79-year-old with pneumonia. [Dr. Wiener] Hey Cathy, well today's case is a 79-year-old former IRS auditor who has advanced Alzheimer's disease.
As background, she was living at home with her eldest son and her daughter-in-law and despite notable decline over the past year she still had a good quality of life, including visiting with her great-grandchildren and her grandchildren, and she particularly enjoyed the Price is Right every day, starring Drew Carey. Because of her advanced disease, she developed aspiration pneumonia with sepsis and was admitted to the intensive care unit with sepsis.
[Dr. Handy] Okay, let's stop there for a moment. It sounds like she was a very high functioning woman who unfortunately had declined due to Alzheimer's disease over the last year but she was still enjoying a good quality of life. The cognitive changes of Alzheimer's disease tend to follow a characteristic pattern. They begin with memory impairment and progress to language and visuospatial deficits, and then that's followed by executive dysfunction.
In the end stages, people can become rigid, mute, they can have incontinence or be bedridden and oftentimes will need help with eating, and dressing, and toileting. Hyperactive tendon reflexes and myoclonic jerks can also occur. Unfortunately, aspiration is a common cause of death for patients with advanced Alzheimer's disease but other causes will include malnutrition, secondary infections, pulmonary emboli, or heart disease.
So keep going with the case. [Dr. Wiener] Okay. She was admitted to the ICU but unfortunately after four days of mechanical ventilation it was clear that her condition had only deteriorated. She was still requiring mechanical ventilation with an inspired oxygen tension of 70%. She was on vasopressors and she developed acute kidney injury. After a number of family meetings over those days, her son who was her designated medical decision maker made it clear that his mom had never wanted prolonged mechanical therapy, would not want dialysis, and if she was unable to enjoy the Price is Right would really not want to prolong her life.
He therefore requested that the team stop intensive care, in effect he said, I'd like you to withdraw care. [Dr. Handy] Quick comment about that, because this is one of my pet peeves when medical professionals use this but we should not use the expression withdrawal of care. Especially in this case, we're not withdrawing care, we're really transitioning her from intensive care to comfort care or palliative care.
[Dr. Wiener] That's a great point. Okay, so in this case, the patient was treated with fentanyl and midazolam intravenously. She was extubated and her NG tube was removed. The family was at the bedside. [Dr. Handy] Transitioning to comfort care is a common occurrence now in intensive care units, surprisingly more than 90% of Americans die without performance of cardiopulmonary resuscitation.
And that has changed dramatically over the last one to two decades as patients and families really better understand the limitations of intensive care and more conversations about goals of care occur, not only in the ICU setting but even more importantly in the outpatient setting with the primary care physician. Now that being said, when a family decides to transition to comfort care the treating care team of doctors, nurses, and respiratory therapists really must work together to ensure that the dying process will be comfortable for both the patient and the family.
[Dr. Wiener] Yeah. That's the context of this question because you are urgently called to the bedside 15 minutes after the patient is extubated because the patient's daughter-in-law is distraught. She states that her mother is drowning and struggling to breathe. When you enter the room you hear a gurgling noise that is coming from the accumulated secretions in the oropharynx. You suction the patient for liberal amounts of thin salivary secretions and reassure the daughter that you will make her mother as comfortable as possible.
Which of the following interventions may help with the treatment of this patient's oral secretions? And the options are, A. increase the infusion rate of fentanyl; B. nebulized N-acetylcysteine; C. pilocarpine drops; D. placement of a nasal trumpet and oral airway to allow easier access for aggressive suctioning; or E. a scopolamine patch.
[Dr. Handy] The issue of respiratory secretions is common and can be very distressing for family members. These sounds are sometimes referred to as a death rattle. I'm going to presume that the patient appears comfortable on fentanyl and midazolam and in fact is likely not responsive. [Dr. Wiener] Yes, that's exactly right. The patient appears comfortable but there are a lot of secretions.
[Dr. Handy] Right, so it's important to understand that fentanyl and midazolam which are a narcotic and a benzodiazepine are great for sedation, anxiolysis, pain, and dyspnea, but will have little or no effect on oropharyngeal or respiratory secretions. And remember, this woman's primary event was an aspiration pneumonia, so secretions are an issue. And further the secretions can produce or exacerbate agitation and labored breathing.
[Dr. Wiener] Okay. So which of those is the treatment though? [Dr. Handy] Treatments for excessive oropharyngeal secretions are primarily anticholinergic medications which would include scopolamine delivered either transdermally or intravenously. You could also use atropine or glycopyrrolate. [Dr. Wiener] Okay. So the answer above is E. a scopolamine patch. [Dr. Handy] Yes, that's what I would try next. Titrating the midazolam and fentanyl are important components to the comfort approach and may also help with dyspnea.
[Dr. Wiener] Okay. What about the other options quickly? [Dr. Handy] While placement of a nasal trumpet or oral airway may allow better access for suctioning of secretions, these can be very uncomfortable or even painful interventions. So these are typically discouraged in a palliative care situation. My experience is also that families prefer to see their loved ones without these types of devices.
N-acetylcysteine can be used as a mucolytic agent to thin lower respiratory secretions but it's seldom useful in a palliative or comfort situation. And pilocarpine is a cholinergic stimulant and will increase salivary production and secretions. So that's a bad idea in this case. [Dr. Wiener] Okay, so the teaching point in this case is that most deaths in the ICU are not unexpected and that a comfort care approach requires a multidisciplinary care that is sensitive to the patient and the family's needs.
Use of multiple medications that can enhance comfort are indicated in these situations. [Dr. Handy] And you can read more about this in Harrison's chapter on palliative and end of life care. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's PodClass is brought to you by McGraw Hill's AccessMedicine, the online medical resource that delivers the latest trusted content from the best minds and medicine.
Go to accessmedicine.com to learn more.