tag:blogger.com,1999:blog-1474751880645498536.post8523620249300655423..comments2023-10-10T10:14:36.340-04:00Comments on Medical Evidence Blog: The Respiratory Rosenhan Experiment on Obese PatientsScott K. Aberegg, M.D., M.P.H.http://www.blogger.com/profile/17564774546019869201noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-1474751880645498536.post-56462115111177959422019-01-11T20:13:42.951-05:002019-01-11T20:13:42.951-05:00Here is a similar case reported in AJRCCM in Augus...Here is a similar case reported in AJRCCM in August 2018: https://www.atsjournals.org/doi/full/10.1164/rccm.201712-2411IMScott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-9358907191471666802018-04-23T16:25:45.668-04:002018-04-23T16:25:45.668-04:00An esteemed colleague and mentor emailed me this a...An esteemed colleague and mentor emailed me this anecdote:<br /><br />A 22 yo M weighing 600 # came to the ED c/o his scrotum swelling. To examine his scrotum the ED team had him lie down on a gurney, supine. Within about 5 minutes he had lost his sensorium. He was intubated and rocketed up to the MICU, where he was wide awake, with pH ~7.30 and PaCO2 ~75 mmHg. I asked him, “Lenny, do you sleep in a bed?” He nodded no. His mother, standing there with him, explained that he sleeps with his knees on the floor, his arms crossed over the side of the bed, and his head resting on his arms. We found a large, sturdy chair, had him get out of bed to the chair, and extubated him. He breathed just fine after extubation. <br /><br /> <br /><br />Some very obese patients have not been supine for years. They can’t breathe when they are supine, but our repertoire of body positions for patients is limited. <br /><br /> <br /><br />His whole body, including his scrotum, was swollen, anasarcic, from chronic cor pulmonale. We gave him a little O2 by nasal cannula and touched him with one dose of furosemide. The flood gates then opened and he peed out many, many gallons of urine. He lost 100 # of edema weight and went home a happy customer.<br />Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-3904513564722206932018-04-23T16:23:03.557-04:002018-04-23T16:23:03.557-04:00Thanks for this comment! In the past I have used p...Thanks for this comment! In the past I have used post-extubation CPAP to replace the PEEP. In this case, he was clearing his airway of blood and secretions post extubation on 6 liters NC, so we did not immediately apply it. After he had cleared the secretions and was sitting upright on nasal cannula, (negative pressure breathing) it was clear with SpO2 94% and RR 16 that he did not "need" the CPAP for positive pressure.<br /><br />I think that this guy was chronically hypoxemic for a long time - he was also polycythemic - and that the proverbial "bottom fell out" and he had to call 911 to his truck. Had he been on oxygen and maybe some diuretics, that would not have happened.<br /><br />I think that all obese patients are at grave risk of having their blood gasses misinterpreted, and so are all chronica respiratory failure patients. I was recently called to admit a patient with COPD for "hypercapnic respiratory failure" who had "become somnolent" in the ED from "CO2 narcosis". Her blood gas showed: 7.35/70/85/35. Totally compensated chronic respiratory acidosis. She had received a dose of morphine for abdominal pain - that was the cause of her somnolence. It is my position that very few physicians can properly interpret an ABG in the context of a specific clinical scenario, especially when respiratory drive is part of the equation.Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-40477401901396792172018-04-22T14:47:55.623-04:002018-04-22T14:47:55.623-04:00Very interesting scenario. I have seen these kinds...Very interesting scenario. I have seen these kinds of patients and they can be challenging - one has to take a small leap of faith at times. A couple things I was curious about: you say that the pt wasn't able to be weaned from his PEEP and FiO2 (presumably during spontaneously breathing trial)and yet you were able to extubate him to nasal cannula immediately afterwards. That doesn't make a lot of sense to me if you're diagnosis is that the pt has baseline obesity-induced atelectasis - but perhaps I missed something there. Also, you postulate that this pt has "chronic respiratory failure" that became clinically manifest. What, if anything did you/could you do to prevent such an episode from happening again? Or is this gentleman doomed for another intubation down the road with a predictably poor eventual outcome?<br />Thanks for your blog - I find it very interesting and well thought-out. CheersAnonymousnoreply@blogger.com