1. High flow oxygen therapy 를 적용한 2 가지 증례 호흡기내과 R 2 박재훈, R 4 유정선 / Prof. 박명재 2013.03.14 MGR

2. CASE 1

3. 17319093 박 O 복 (F/95) adm. : 13. 2. 14 Chief Complaint –Cough o/s> 내원 3 일전 Present illness –95/F, HTN, CKD, old CVA, Alzheimer’s disease, both knee OA 로 본 원 IE(pf. 오승준 ) opd f/u 하며 요양원 가료 중인 자, 내원 3 일전부터 cough, sputum, fever 있으며 내원 당일 generalized weakness 심해 져 f/e 및 management 위해 외래 경유 입원함 History

4. Past Medical History DM/HTN/TBc/Hepatitis(-/+/-/-) –Previous stroke Hx(+) : Cb infarcion Rt. MCA severe stenosis(2004) Op Hx(+) –Both knee op(30 여년전, 타병원 ) –PTGBD, ERCP & EPBD d/t CBD stone(‘10) Medication ( 본원 IE opd – 2012.12.24) –Aceclofenac, Tamsulosin, Propiverine –Metoclopramide, Mg oxide, Atorvastatin –Amlodipine + Valsartan –Donepezil, Olanzapine –Pantoprazole, Soxinase, Mucolase

5. Personal History Alcohol/Smoking(-/-) Family History Non-specific

6. Review of System (1) 1. General Generalized weakness(+) Fever(-) Chill(-) Myalgia(-)Weight change(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) Itching(-) 3. HEENT Headache(-) Visual disturbance(-) Otalgia(-) Otorrhea(-)PND(-)Nasal obstruction(-) Rhinorrhea(-)Sore throat(-)Swallowing difficulty(-) 4. Respiratory Dyspnea(+) Cough(+)Sputum(+)Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-)DOE(-) Palpitation(-)

7. 6. Abdominal A/N/V/D/C(-/-/-/-/-) Dysphagia(-) Bowel habit change(-) Abd. Pain(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) Nocturia(-) 8. Musculoskeletal Pain(-) Swelling(-) Tenderness(-) Backpain(-) Myalgia(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) Review of System (2)

8. Physical Examination (1) Height : 150 cm Weight : 60 kg BMI : 26.7 kg/m 2 Vital Sign : 140/70 mmHg - 74/min - 20/min – 36.5 ℃ 1. General appearance Alert consciousness Acutely-ill looking appearance 2. Head & neck Normocephaly, LN enlargement(-), Neck vein engorgement(-) 3. E/ENT Isocoric pupil c PLR(++/++) Pale conjunctiva, clear sclera Pharyngeal injection(-), PTH(-/-)

9. Physical Examination (2) 4. Chest Symmetric chest expansion Coarse breathing Sound with rale and wheezing Regular Heart Beat without ⓜ 5. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness(-), Rebound Tenderness(-) Palpable mass(-), Hepatomegaly(-) 6. Back&extremities CVA Td(-/-) Pretibial pitting edema(-/-) Pressure sore(-) 7. Motor, sensory : intact

10. Initial Lab Finding 1.CBC/DC 27,590 / ㎕ – 6.3 g/ ㎗ – 20.2 % - 445,000 / ㎕ (seg : 92.6%) aPTT 44.8 sec PT INR 1.29 % 2.Chemistry TB 0.23 mg/ ㎗ BUN/Cr39 / 2.0 mg/dL Protein/Albumin6.6 / 3.3 g/ ㎗ Na/K/Cl 136 / 5.1 / 107 mEq/L AST/ALT19 / 15 U/L Ca/P/Mg 7.5 / 4.6 / 3.4 mg/dL ALP/rGT156 / 44 U/L Uric acid6.4 mg/dL CRP 27.41 mg/dL 3.U/A RBC 0~1 /HPF WBC 2~4 /HPF

11. Initial Chest AP(’13.02.14)

12. Initial ECG(‘13.02.14)

13. #1. Pneumonia, hypoxia #2. Acute on CKD #3. Anemia #4. known old CVA #5. known HTN #6. known Alzheimer’s dementia Initial Problem Lists

14. #1. Pneumonia r/o Tb, r/o influenza Diagnostic Plan> Blood, sputum culture Pneumonia study(Mycoplasma, Chlamydia, urine pneumococcal) Tb real-time PCR, Influenza A& B Therapeutic Plan> Antibiotics(pip/taz + levofloxacin) Nebulizer(ventolin, pulmicort) Methylprednisolone 125mg iv High flow oxygen Initial Assessment and Plan

15. #2. Acute on CKD Diagnostic Plan> Random urine Na, Cr, BUN, serum/urine osmolarity Therapeutic Plan> Hydration #3. Anemia Diagnostic Plan> Anemia study(PB smear, reticulocyte count, occult blood, TIBC, serum iron Vit.B12, folic acid, ferritin), abdominal sono Therapeutic Plan> Hydration, pRBC transfusion #4. old CVA #5. HTN #6. Alzheimer’s dementia Therapeutic Plan> NPO 해제 후 Self medication 재개 Initial Assessment and Plan

16. #1. Pneumonia S> –Mild fever(+) : 37.5, Cough, Yellowish sputum O> –Hypoxia – ABGA : 7.363 – 33.0 – 54.5 – 84.4%(at Reservoir O2 15L) –Sputum cx.(2/14) : Klebsiella pneumoniae –Chest CT(2/28) : Pneumonia on LLL, both pleural effusion with pulmonary edema A> –Acute hypoxic respiratory failure d/t pneumonia P> –High flow oxygen(LPM 14L/min, FiO2 80%) inhalation start –Antibiotics : axon+clarithromycin  pip/taz + levofloxacin –Methylprednisolone 125mg iv qd start Progression Note

17. Chest CT(‘13.02.28)

18. 2/142/182/202/222/242/262/283/02 3/04 MPD 125mg (2/15~18) Pip/taz(2/14~27) 2/16 Clinical Course 14LPM FiO2 0.8 Levofloxacin(2/14~) MPD 62.5mg (2/19~20) MPD 31.25mg (2/21) 14LPM FiO2 0.7 14LPM FiO2 0.6 10LPM FiO2 0.4 4  1 VNP0.5 VNPR.A pO2 54.5 at R.M 15L

19. #2. Acute on CKD S&O> –BUN/Cr 39/2.0 (eGFR 24.65) –Abd sono(2/26) : CKD of Rt. kidney A> –Acute on CKD, intrinsic type(FeNa 1.67%, FeBUN 56.41%) P> –Hydration –BUN/Cr f/u Progression Note

20. #3. Anemia S> –Hematochezia(2/19) O> –PB smear : normocytic, normochromic –Reticulocyte index : 0.6 A> –Anemia of chronic disease(Hypoproliferative) P> –pRBC transfusion –PPI –Treatment of underlying disease Progression Note

21. 2/142/182/202/222/242/262/283/02 3/04 Pip/taz(2/14~27) 2/16 Clinical Course pRBC transfusion (2/14~16) Levofloxacin(2/14~) Hematochezia PPI(pantoprazole iv)

22. #1. Pneumonia #2. Acute on CKD #3. Anemia of chronic disease #4. known old CVA #5. known HTN #6. known Alzheimer’s dementia Final Diagnosis

23. CASE 2

24. 12320492 허 O 준 (M/34) adm. : 13. 1. 14 Chief Complaint –Cough o/s> 내원 5 일전 Present illness –34/M, DM, HTN 으로 local po med 중인 자, 내원 5 일전부터 cough, sputum, fever 있어 local clinic 에서 po med 하였으나 증상 호전없고 내원 당일 dyspnea 동반되어 f/e 및 management 위해 응급실 경유 입원 History

25. Past Medical History DM/HTN/TBc/Hepatitis(+/+/-/-) –DM : 내원 수개월 전 HbA1c 7.7%, no po medication –HTN : 6 개월 전 진단, Norvasc 5mg qd, Candesartan qd Op Hx(-)

26. Personal History Alcohol(+) : 주 1 회 소주 2 병 Smoking(-) Family History Non-specific

27. Review of System (1) 1. General Gen. weakness(-) Fever(+) Chilling(+) Sweating(+) Myalgia(-)Weight change(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) Itching(-) 3. HEENT Headache(-) Visual disturbance(-) Otalgia(-) Otorrhea(-)PND(-)Nasal obstruction(-) Rhinorrhea(-)Sore throat(-)Swallowing difficulty(-) 4. Respiratory Dyspnea(+) Cough(+)Sputum(+)Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-)DOE(+) Palpitation(-)

28. 6. Abdominal A/N/V/D/C(+/+/+/-/-) Dysphagia(-) Bowel habit change(-) Abd. Pain(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) Nocturia(-) 8. Musculoskeletal Pain(-) Swelling(-) Tenderness(-) Backpain(-) Myalgia(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) Review of System (2)

29. Physical Examination (1) Height : 172 cm Weight : 125 kg BMI : 42.3 kg/m 2 Vital Sign : 110/70 mmHg - 96/min - 22/min – 36.5 ℃ 1. General appearance Alert consciousness Acutely-ill looking appearance 2. Head & neck Normocephaly, LN enlargement(-), Neck vein engorgement(-) 3. E/ENT Isocoric pupil c PLR(++/++) Pink conjunctiva, clear sclera Pharyngeal injection(-), PTH(-/-)

30. Physical Examination (2) 4. Chest Symmetric chest expansion Fine crackle on BLL Regular Heart Beat without ⓜ 5. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness(-), Rebound Tenderness(-) Palpable mass(-), Hepatomegaly(-) 6. Back&extremities CVA Td(-/-) Pretibial pitting edema(-/-) Pressure sore(-) 7. Motor, sensory : intact

31. Initial Lab Finding 1.CBC/DC 52,30 / ㎕ – 15.6 g/ ㎗ – 43.9 % - 121,000 / ㎕ (seg : 80.7%) aPTT 46.9 sec PT INR 0.93 % 2.Chemistry TB/DB 0.34/0.17 mg/ ㎗ BUN/Cr21 / 1.3 mg/dL Protein/Albumin6.7 / 4.0 g/ ㎗ Na/K/Cl 137 / 3.4 / 96 mEq/L AST/ALT151 / 157 U/L Ca/P/Mg 7.2 / 4.2 / 2.1 mg/dL ALP/rGT69 / 207 U/L Uric acid6.7 mg/dL CRP 16.39 mg/dL CK/CK-Mb/TnI 1476/10.0/0.12 3.UA RBC 2~4 /HPF WBC 2~4 /HPF

32. Initial Chest PA(’13.01.14)

33. Initial ECG(‘13.01.14)

34. #1. Pneumonia #2. Rhabdomyolysis #3. ARF #4. LFT elevation #5. known DM #6. known HTN Initial Problem Lists

35. #1. Pneumonia Diagnostic Plan> Blood, sputum culture Pneumonia study(Mycoplasma, Chlamydia, urine pneumococcal) Chest CT Therapeutic Plan> Antibiotics(levofloxacin) Nebulizer(ventolin, Mucomyst) Initial Assessment and Plan

36. #2. Rhabdomyolysis Therapeutic Plan> Hydration #3. ARF Diagnostic Plan> Random urine Na, Cr, BUN, serum/urine osmolarity Therapeutic Plan> Hydration #4. LFT elevation Diagnostic Plan> Abd US Therapeutic Plan> Hydration #5. DM #6. HTN Therapeutic Plan> NPO 해제 후 medication 유지 Initial Assessment and Plan

37. #1. Pneumonia S> –Mild fever(+) : 37.3, cough, sputum O> –ABGA : 7.413 – 33.2 – 51.6 – 86.0%(at Reservoir O2 15L) –HRCT(1/15) : Multifocal pneumonia, r/o malignancy –Bronchoscopy(1/16) : diffuse alveolar hemorrhage A> –Pneumonia –Alveolar hemorrhage P> –ICU 전동 (HD #3, 1/16) –Antibiotics : levofloxacin + azithromycin  levofloxacin + meropenem + teicoplanin –Steroid pulse therapy –High flow oxygen(LPM 17L/min, FiO2 90%) inhalation start Progression Note

38. HRCT(‘13.01.15)

39. Bronchoscopy(‘13.01.16)

40. 1/141/161/171/181/19 1/21 MPD pulse therapy (1/16~18) Levofloxacin(1/14~) 1/15 Clinical Course(HD#1~#8) Venturi FiO2 0.5 Azithromycin(1/16~18) 17LPM FiO2 0.9 30LPM FiO2 0.9 20LPM FiO2 0.7 Meropenem+Teicoplanin(1/18~) 14LPM FiO2 0.4 2L VNP 1/20 Reservoir 15L Adm ICU 일반 병실 pO2 51.6 at RM 15L

41. f/u HRCT(‘13.01.23)

42. #2. Rhabdomyolysis S&O> –CK 1476(1/14)  2485(1/16)  477(1/18)  321(1/24)  141(1/26) A> –Rhabdomyolysis P> –Hydration #3. ARF S&O> –BUN/Cr 21/1.3(eGFR 67.31)  15/0.8(eGFR 117.88) A> –ARF, prerenal type(FeNa 0.03%, FeBUN 20.1%) P> –Hydration –BUN/Cr f/u Progression Note

43. #4. LFT elevation S&O> –Abd sono(1/14) : fatty liver –AST/ALT 151/157  34/87 A> –Fatty liver P> –Hydration, hepatotonics #5. DM P> –Po medication (Amaryl Mex SR 2/500mg 2T qd) #6. HTN P> –Po medication (Exforge 10/160mg 1T qd) Progression Note

44. 1/141/181/201/221/24 1/26 MPD pulse therapy (1/16~18) Levofloxacin(1/14~) 1/16 Clinical Course Venturi FiO2 0.5 Azithromycin(1/16~18) 17LPM FiO2 0.9 30LPM FiO2 0.9 20LPM FiO2 0.7 Meropenem+Teicoplanin(1/18~) Adm ICU 일반 병실 D/C 14LPM FiO2 0.4 2L VNPR.A

45. F/U chest PA(‘13.03.11)

46. #1. Multifocal pneumonia #2. Rhabdomyolysis-resolved state #3. ARF #4. Fatty liver #5. DM #6. HTN #7. Alveoloar hemorrhage Final Diagnosis