LUNG FIBROSIS

LUNG FIBROSIS 

Case presentation 

At the date of 11 dec .A patient with age 34 year old female called yasmin alnabulse with weight of 77 KJ arrive to emergency at 10.00 pm as case of SBO shortness of breath which make her shortness of breath ,dyspnea and fatigue and cyanosis face and tachypnia with tachycardia tachypnic breath with difficult to speak a full words without take a complete shallow and rapid breath with no obvious allergy to any food or medication .
Pt was pregnant in the 14 weeks complaint from vaginal secretions and upnormal swelling in the vaginal cavity as past Midecal history from she was young that diagnosed as hypertrophic labia that made some fluid and upnormal vaginal secretions and she admitted before to the emergency complaint of chest pain and shortness of breath with parallel swelling and distention chest with cyanosis face.
complaint shortness of breath make her fatigue and cyanosis face and hyperventilation with tachycardia tachypnic breath with difficult to speak a full words without take a complete shallow and rapid breath with chest pain radiated to heart and and lossing of appetite which her husband said that she has obvious decrease in eating routine in home which make her lose some of her weight. She addmited to emergency after transported via ambulance as suddenly SOB . pt was conscious oriented by* 3 with 15 GCS in semisetting position with difficult of getting enough air entry over the time and decrease mental status for patient with checked vital signs v/s as nurse measured was at upnormal level of
Tachypnia with 34 breath/min by asset chest raise and recoil
Tachycardia 110 /min when she connected to the monitor
Hypertension with 141/89 mmhg S/D when measured .
O2 sat was with 85% by pulse oxemetry use for measuring under NRB Mask .
And the test of blood
VBG'S
ABG'S
URINE TEST
LFT. KFT
Kidney function test
Show results from the laboratory of bad general conditions and episodes of palpitations of SOB .and CT show that pt started to c/o generalized Edema +4 low albumin by lab test with normal thyroid by TFT
T3
T4
TSH IS low
History of patient from family from husband that the pt his wife was working in the oil refinery company in the section where she may exposure to a dust from
Occupational and environmental factors
Long-term exposure to a number of toxins and pollutants can damage her lungs. These include some toxic chemicals and materials like silica. Also, she was tend to smoke in ceremony and wasn't routinely smoker . And her husband said: she was admitted to hospital in the previous year as SOB in the same symptoms and after she has treated with oxygen supply by non rebreather mask at 10 L/min and nebulizer of salbutamol and dexamethasone and discharge with take a permission and advised by doctor to decrease smoking and find alternative job away from toxic material and gas and to take a daily inhaler (may be was ventolin)as a bronchodilator inhalation and duaritic tablets and omeprazole tablet and amoclan (amoxicillin) forte as antibiotics tablet, but she still in the same routine and occupational environment and stopped her drugs after she got better without medical direction. One day after feeling shortness of breath admitted to emergency and she was in bad condition so she transfer now to ICU and after chest X_ray and Imaging of chest and blood lab test and past history doctor diagnosed her case as idiopathic pulmonary fibrosis IPF .which developed in the last days into tensionpneumothorax in right lung result of hyperinflamation of air sacs that make some of them blowout their content treated by inserted a chest tube between 4th and 5th intrrcostal space (ICS) and now pt on bipape ventilator device at rate of 20/12 under medical nurse care after pleurdesis procedure.



The assessment and clinical
investigations and clinical findings 

(subjective )Pt female 34 years old oriented by 3 with GCS of 15 . Said i have a chist pain with shortness of breath radiated to my heart and felt a pain while moving or coughing with dry cough .
complaint shortness of breath make her fatigue and cyanosis face and hyperventilation with tachycardia tachypnic breath with difficult to speak a full words without take a complete shallow and rapid breath with losing appetite make her weight being lose .Pregnant( in 14 weeks ) which make her shortness of breath ,dyspnea and fatigue and cyanosis face and tachypnia with tachycardia tachypnic breath with no obvious allergy to any food or medication.
(Objective)pt was conscious oriented by* 3 with 15 GCS in semisetting position with difficult of getting enough air entry increase in supine specifically at night and decrease (provocations ) at semisetting over the time and decrease mental status for patient with checked vital signs v/s as nurse measured was at upnormal level of
Tachypnia with 34 breath/min with shallow ,rapid, by asset chest raise and recoil
Tachycardia 110 /min when she connected to the monitor
Hypertension with 141/89 mmhg S/D when measured .
Temperature at 37.4
O2 sat was with 85% by pulse oxemetry use for measuring under non_rebreather mask .
And the test of blood
VBG'S ,ABG'S with CBC and Chemistry test , URINE TEST (after she had a Foley's tube inserted by nurse),LFT,KFT
Kidney function test
Show results from the laboratory of bad general conditions and episodes of palpitations of SOB .and CT show that pt started to c/o generalized Edema +4 low albumin by lab test with normal thyroid by TFT ,T3 ,T4, but with slightly TSH IS low and other investigation for chest x_ray and a check of CVS by ECG .pt at first was connected to NRB mask then after get worse after change into pneumothorax (in addition treated by inserted a needle between 4th and 5th ICS ) she ventilated via bipap mask on 20/12 . And the results were at these evidence from laboratory
ABG in emergency:
Ph 7.33
Paco2 51 %
O2 sat 84%
Hco3 37.7 %
Po2 51.1%
Pt with normal head with out any deformity or lacerations or contusion or any DCAPBTLSTIC head without any fracture with no signs to to racon eye or CSF drainage out of eye or ear like rihnorrhea or ottorihea with no battle signs or any destination in mastoid process with slightly pale and cyanosis face colour with semi hyperthermal to feel by palm of hand with normal eye contact to 4 quadrant and reacted to light with normal neck movements no stiffness or any (dcapbtls ) no JVD 's .
Parallel chest to inspection and destention in right lung from the pneumothorax at right side make some of paradoxical movement while inhalation. No any deformity or trumatic signs in the chest no any DCAPBTLSTIC in the chest use intercostal muscle and extra neck muscles .palpitation with pain in chest in the right lung increase with movement while breathing. There are some abnormal sounds heared by stethoscope like scatered wheezes over the right lung and some fluid puple like crackle while inhalation. The left lung is resonance to percussion and the right filled with air is hyper resonance . Heart rate is tachy with rapid irregular to auscultate with obvious s1 and s2 sounds with abnormal ECG with qrs in small space indicating a tachycardia with different distance and st segment straight without depression or elevated in II and III with v1 and v2 conductive delay show result of sinus tachycardia of abnormal ECG pattern with rounded p wave and p , t wave in normal height wave .
Soft abdomen to palpat and rounded from normal pregnant with no any DCAPBTLSTIC or umbilical swelling with no pain to palpation and normal bowel sounds to auscultate pelvic is stable and move with no pain or stiffness with no sound of while pushing it inward and upward with no joint friction or fracture with freely moving .
Some upnormal vaginal secretions from hypertrophy of labia with last diagnoses by nurse inspection.
Lower extremities and upper all are free from any DCAPBTLSTIC and PMS of pulse and motor and sense are intact with normal capillary refill with less than 2 seconds. But doctor found a small mass under her shoulder 5*5 nontender fill wih accumulation of fluid. And she start complain of
Bloatness after inserting a chest tube with posture free of any DCAPBTLSTIC with increase space when tectle fremetus test and increase vibration sense when lt tested in physical lung tests.




Differential diagnosis 

Signs of shortness of breath and difficult breaths with pain radiated into the heart with decrease of mental status make and fatigue and nausea and vomiting with sweating with increasing in heart rate 110 /min and blood pressure 141/89 some doubt about myocardial infarction but it roled out because there is no any pain in back or posture and pain stay in chest and don't radiated to left arm or back and heart sounds heared by s1 and s2 with just a normal sound by auscultation and lab test show low level of INR 0.9 and normal rang of pt and ptt with final result of
s1 and s2 sounds with abnormal ECG with qrs in small space indicating a tachycardia with different distance and st segment straight without depression or elevated in II and III with v1 and v2 conductive delay show result of sinus tachycardia of abnormal ECG pattern with rounded p wave and p , t wave in normal height wave .so heart attack roled out doubt.

DKA some doubt of hyperglycemic ketosis may be make pt feel the signs of acidosis when increase cough and kissmual breathing and and increase in paco2 in blood with dyspnea and irregular tachycardia and physical weakness with slightly higher heat with palm sensation but the doubt of dka roled out because pt have pt state has a history of respiratory distress and pt no longer had a hyperglycemic state before and dka developed from DM type one but pt have no history of diabetes before and his appetite is loss regardless dka that has a polyphagia and polydipsia and polyuria that's pt have indicated that she no longer had these signs and lab test make a judgement to role dka becouse of normal glocouse 5.94 in normal range
And k wirh level of 4.2 with normal range olso pt swelling normal with out fruity taste or acetone like breath.

UTI .some signs of may be make pt feel the signs of acidosis when increase cough and kissmual breathing and and increase in paco2 in blood with dyspnea and irregular tachycardia and physical weakness with slightly higher heat with palm sensation and increase of blood pressure and nausea and vomiting and decrease appetite and difficult to breathe on other hand,pt can urinate with out any problems and there is no pain in abdomen or in pelvic like flank pain and abdomen is soft with no detention .also , the blood CBC test show the normal rang of WBC 7.1 (10^3) these roles the doubt of viral infections and the colour of urine is normal with no bloody urine or small particles in urine.




Pathology

History of patient from family from husband that the pt his wife was working in the oil refinery company in the section where she may exposure to a dust from
Occupational and environmental factors
Long-term exposure to a number of toxins and pollutants can damage her lungs. These include some toxic chemicals and materials like silica. when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it more difficult for your lungs to work properly. As pulmonary fibrosisworsens, you become progressively more short of breathand the PF is affecte the paranchemal and functional unit of lung alveoli in complicated mechanisms
When human exposure to a toxic material or smoking heavily or gas or viral infections get into his respiratory tract then goblet cell starts his own job to secretion lubricant to imrove the ability to immune system to catch these foreign body but when thes chemicals espouse and effect the body routinely these make the allergy reaction in the alveoli make it hypersensitive so it begins reacted as a reflex for these effects make it hyperinflamation so these may make an tearing in it's paranchemal unite that make internal alveoli bleeding that's stimulate body to fix it by an coagulation and fiberinogynesis or called as myofibroplast that characterized by accumulation of leukocytes followed by progressive fibrosis and subsequent loss of air space when air sacs become inflammed and thicker so Currently, pulmonary fibrosis is regarded as a disease caused by repeated subclinical injury leading to epithelial damage and subsequent destruction of the alveolar-capillary basement membrane. This process initiates the infiltration of fibrotic cells and the activation of (myo)fibroblasts. In pulmonary fibrosis the normal resolution of inflammatory and mesenchymal cells through apoptosis and phagocytosis is dysregulated. This results in the destruction of the normal lung architecture and loss of function. And the reasone in details for unproperiorate tearing fixing is duo to he major elements involved in induction and progression of fibrosis. a) The onset of fibrosis is characterised by both injury and susceptibility to the formation of progressive fibrosis. Many different injurious agents have been identified that lead to epithelial and endothelial damage, vascular leak and fibrin clot formation. b) This is followed by an abnormal repair process characterised by an abnormal re-epithelialisation, abundance of myofibroblasts and the formation of a collagen matrix. c) The process proceeds to excessive matrix formation leading to architectural distortion and finally death. ECM: extracellular matrix; AEC: alveolar epithelial cell.so some of these alveoli lose its own function and other still inflamed and thick that make pt chest expansion by effort and fatigue to fill thise alveoli with air and result of tachypnic breath with rapid and shallow and make difficult in gas exchange with alveoli and blood stream that make the blood more acidic and the compensated system start to work to balance that by buffer and equalize blood by Hco3 base so labe test get low o2 sat with high paco2 amount and as stimulation to sympathetic system the body activates B1 heart tend to increase in pumping to push more blood and increase oxygenation.





Treatment and drugs ........

Last :

admitted to hospital in the previous year as SOB in the same symptoms and after she has treated with oxygen supply by non rebreather mask at 10 L/min and nebulizer of salbutamol filled with 1ml salbutamol and 2 ml normal saline and dexamethasone iv and discharge with take a permission and advised by doctor to decrease smoking and find alternative job away from toxic material and gas and to take a daily inhaler (may be was ventolin)as a bronchodilator inhalation and duaritic tablets and omeprazole to prevent her Gi tract ,tablet .and amoclan (amoxicillin) forte as antibiotics table as prevention for microbial organisms.

Thise period:
She changed from nonrebreather mask at 10 L ber min into a bipap on ventilator at 20/12 after she has a surgery procedure for chest tube doctor anesthesia give morphine infusion 10mg and lidocaine 10ml iv .
Treatment and ICU drugs and effect
Hydrocortisone as a class of gloucocortecosteroids and antiinflamatory to decrease histamine release and make a type if opening bronchial tract . Iv 100 defuse by 2 ml N/S .to decrease swelling and inflammation.

Salbutamol in nebulizer as a bronchodilator work on B2 sympathetic agonist in nublzer with 1ml an 2ml normal saline.

Ipratropum (albuterol) parasympathetic antagonists and anti colinergic drug make brounchodilation by relax the muscle with just 0.5 mg .

Lasix every morning at 2 ampule with 20 mg =40 mg as duaritic to decrease polmanary edema and increase urinate and decrease BP.

Perfalgan as a sedative for mild to moderate pain and antipyratic to decrease fever . Iv infusion 10 mg /ml

Folic acid give 5 mg each day converted into folate by the body, is used as a dietary supplement and in food fortification as it is more stable during processing and storage. 

Vitamin B 1 tablet 235 mg oraly ber day

Omeprazole 20 mg to prevent gi ulcers and prevent GI .
Doctor said if pt can't be devastating by treatment she will admit to a procedure of trachestomy in next month' at albasheer hospital. Amman .she is dead....

Written by:

Mr.Ahmad Alqayem 

Instructor : 

Dr. Nehaya alshiyab 

PHD IN NURSING 

Jordan university of science and technology 

JUST

All referance for my case study ;

https://www.physio-pedia.com/Pulmonary_Fibrosis


"lung FIBROSIS - الباحث العلمي من Google" https://scholar.google.com/scholar?hl=ar&as_sdt=0%2C5&q=lung+FIBROSIS+&btnG=#d=gs_qabs&u=%23p%3DBesQceU0tbkJ


"Sildenafil for treatment of lung fibrosis and pulmonary hypertension: a randomised controlled trial - ScienceDirect" https://www.sciencedirect.com/science/article/abs/pii/S0140673602110245

"Developmental pathways in the pathogenesis of lung fibrosis - ScienceDirect" https://www.sciencedirect.com/science/article/abs/pii/S0098299718300712


"Pulmonary fibrosis - Symptoms and causes - Mayo Clinic" https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/symptoms-causes/syc-20353690




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