One evening I got a call from one of my close friend regarding an emergency and critical case of a 67yr old man admitted in I.C.U., suffering from Acute Respiratory Distress Syndrome with Septicemia (Pneumonitis With UTI & ARF).
Patient was on ventilator since last 2 weeks due to difficult respiration but with no improvement. Relatives were informed by the attending physicians about the worsening condition of the patient. Relatives were very much worn out with the difficult situation and also because of the increasing cost (3lakhs already spent). When my friend realized the situation, advised them to visit my hospital as a last ray of hope. After consulting with me very same night he got the patients video along with his relatives for narrating the case.
Relatives explained that patient had h/o frequent high grade fever, profuse vomiting followed by severe weakness. Condition was further deteriorating and hence the patient was taken to the hospital where due to his critical condition was admitted to I.C.U.
Acute respiratory distress syndrome (ARDS), also known as respiratory distress syndrome (RDS) or adult respiratory distress syndrome is a serious reaction to various forms of injuries or acute infection to the lung. ARDS is a severe lung syndrome (not a disease) caused by a variety of direct and indirect issues. It is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. This condition is often fatal, usually requiring mechanical ventilation and admission to an intensive care unit. A less severe form is called acute lung injury (ALI).
Signs and symptoms
People usually present with shortness of breath, tachypnea leading to hypoxia providing less oxygen to the brain, occasionally causing confusion.
ARDS mostly occurs about 72 hours after the trigger, such as an injury (trauma, burns, aspiration, massive blood transfusion, drug/alcohol abuse) or an acute illness (infectious pneumonia, sepsis, acute pancreatitis).
ARDS is characterized by
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Acute onset
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Bilateral infiltrates on chest radiograph sparing costophrenic angles
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The PaO2:FiO2 ratios refers to the gradient between the inspired oxygen level and the oxygen that is present in the blood. The lower the ratio, the less inspired oxygen is getting into the blood.
To summarize and simplify, ARDS is an acute (rapid onset) syndrome (collection of symptoms) that affects the lungs widely and results in a severe oxygenation defect, but is not due to heart failure.
Cause
Three clinical settings account for 75% of ARDS cases :
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Sepsis syndrome - most important cause
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Severe multiple trauma
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Aspiration of saliva/gastric contents and it could also be a complication of pneumonia if left untreated known as aspiration pneumonia.
Diagnosis
An arterial blood gas analysis and chest X-ray allow formal diagnosis by the below mentioned criteria.
Any cardiogenic cause of pulmonary edema should be excluded.
Plain chest X-rays are sufficient to document bilateral alveolar infiltrates in the majority of cases. While CT scanning leads to more accurate images of the pulmonary parenchyma in ARDS, it has little utility in the clinical management of patients with ARDS, and remains largely a research tool.
Four main criteria for ARDS :
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Acute onset
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Chest X-Ray: Bilateral diffuse infiltrates of the lungs
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No cardiovascular lesion
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No evidence of left atrial hypertension: PaO2/FiO2 ratio equal to or less than 200 mmhg
To assess the severity of ARDS, the Murray scoring system is used, which takes into account the chest X-ray, the PaO2/FiO2 ratio, the positive end-expiratory pressure, and lung compliance.
Pathophysiology
ARDS is a clinical syndrome associated with a variety of pathological findings. These include pneumonia, eosinophilic pneumonia, cryptogenic organizing pneumonia, acute fibrinous organizing pneumonia, and diffuse alveolar damage (DAD). Of these, the pathology most commonly associated with ARDS is DAD.
Neutrophils and some T-lymphocytes quickly migrate into the inflamed lung parynchema and contribute in the amplification of the phenomenon.
Progression
If the underlying disease or injurious factor is not removed, the amount of inflammatory mediators released by the lungs in ARDS may result in a systemic inflammatory response syndrome (or sepsis if there is lung infection). The evolution towards shock and/or multiple organ failure follows paths analogous to the pathophysiology of sepsis.
Treatment
Acute respiratory distress syndrome is usually treated with mechanical ventilation in the Intensive Care Unit. Ventilation is usually delivered through oro-tracheal intubation, or tracheostomy whenever prolonged ventilation (≥2 weeks) is deemed inevitable.
Investigations :
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On examination - R/s - bilateral crepts rt. > lt.
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ABG : metabolic acidosis + hypoxia.
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Hb% : 10.7
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TLC : 15,800 /mm3
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Polymorph : Leucocytosis
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Platelets : 2,23,000
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Urine : 2+
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Pus cells : Plenty.
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Blood urea : 63
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Sr. create : 4.9
C/C :
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General weakness
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Vomiting,
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Recurrent fever and chills
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H/o Continuous cough with fever on and off
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Difficulty in deglutition.
Past History :
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Peptic ulcer in 1974 operated.
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Recurrent groin infections – ointment applied – suppression.
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Brain hemorrhage with paralysis of larynx & pharynx in 1998.
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Hypertension since 1998.
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Family History :
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Father : Ca of throat.
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Mother : expired of Ca
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Brother : Hypertension.
Personal History :
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Diet : Veg.
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Appetite : Good.
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Desire : Pungent++, Spicy, Oily+, Green veg., Milk & milk product, Sweets+++
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Aversion : fruits+++
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Thirst : Thirsty.
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Throat : Difficulty in deglutition.
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Abdomen : Distented feeling
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Bowel : Constipation (usually took Ayurvedic medicine for it), unsatisfactory stool.
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Skin : Recurrent skin eruption, h/o suppression
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Perspiration : Profuse, in armpit and back, staining yellow
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Sleep : feels sleepy during the day, drowsy, sleepless at night Lying on back.
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Thermals : HOT.
Mind :
1. Tell me about his childhood?
His native place is a small village in Karnataka. He has completed his education up to S.S.C.
Since childhood, he was short tempered. But had a twofold sort of behavior, like outside the home he was friendly, talkative, mixing, jovial and nice. But at home he used to trouble his parents a lot and was very irritable & quarrelsome. He was the 3rd amongst 4 brothers & 3 sisters. He had many friends and use to mix easily with others. Financially the family was weak.
2. What about his nature, now?
Even now, he is short-tempered having same dual behavior but after his illness he has became more irritable & nervous. He is quarrelsome and when angry will shout, scream, abuse and at times beat.
He has lot of negative thinking and feels that he is suffering from some incurable disease.
Many a times he pretends to be seriously ill to seek attention & sympathy of attendants.
He is very religious and believes in poojas and havans and in recent times has spent lot of money over it.
He nowadays most of the times seems sad and discontented. He has recently got a habit of playing lottery.
He usually doesn’t dress up properly and tidy i.e. his appearance is not very presentable.
He desires for a lavish, hi-fi living. He plans a lot for different things it but never executes.
He is jolly jesting and cheerful especially in the office and likes listening to old songs.
He has a fear of sudden noises as that of crackers, crossing road.
He likes spending money lavishly.
3. What are his worries?
His son added, “He is really worried about my future and that’s because I am not ready to get married.”
Remedy with Response of the case of Acute Respiratory Distress Syndrome with Septicemia (Pneumonitis With UTI & ARF)
Totality :
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Jolly jesting.
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Discontented.
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Forsaken feeling - relatives.
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Pessimist.
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Religious.
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Loss of presentation - ugly.
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Abusive.
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Extravagance.
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Greedy.
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Irritable .
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Desire: Sweet.
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Perspiration: Profuse.
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Quarrelsome.
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Sadness.
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H/o suppression of skin ailments.
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Pnemonitis : inflammation of lungs.
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THERMAL : HOT
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MIASM : SYPHILITIC.
Remedy Selected : SULPHUR 30.
Response :
The patient responded remarkably just after 10 days. The most amazing and important thing is that the continuous ventilator that he needed was totally removed as he was able to breathe normally. This was for the first time that the patient spoke; “ Now I am feeling good and I can breathe easily. ”
Patient was able to sit up in his bed with minimal support and was also able to stand for few seconds. In few days, the face became normal and gave a healthy look to the patient.
Further he progressed well and recovered fully.
He told in the follow up that he didn’t know what had happened to him and he thinks that he had just got up from a deep sleep.
D/D : The most answers got were. We can differentiate it :
ANTIMONIUM TARTARICUM :
It is a well-known remedy for such kind of Respiratory manifestation. It shows symptoms of marked respiratory insufficiency. This case was a perfect match for Pathological aspect. But as per our principles drug should be a match on physical, mental, particular along with pathological level to get a complete result which is not the case with this patient’s presentation.
LYCOPODIUM :
Lyco seems to be close to this case but it does not cover the extravagance untidy character of patient. Also the pace of disease development in this patient is very fast in contrast to the pace of Lycopodium which covers mostly slow developing pathology.