CASE REPORT |
https://doi.org/10.4103/ijrc.ijrc_53_22 |
COVID-19-Induced Acute Respiratory Distress Syndrome and Challenges Faced in Management of Young Morbidly Obese Patient
Department of Critical Care Unit, Apollo Speciality Hospitals, Chennai, Tamil Nadu, India
E-mail: joshuaselvakumar89@gmail.com
Abstract
In 2020, the World Health Organization described the SARS-CoV-2 virus (severe acute respiratory distress syndrome [ARDS]) for the first time. Millions of people were affected by the COVID virus worldwide, and many of them lost their lives too. Our center was also one health-care center that has played a significant role in managing severe ARDS patients secondary to COVID-19 infection. We want to outline the challenges faced by the respiratory therapist in managing a 24-year-old morbidly obese young male with severe ARDS due to COVID-19.
Keywords: Acute respiratory distress syndrome in COVID-19 pneumonia, lung-protective ventilation, morbid obesity, prone ventilation
How to cite this article: David J, Ebenezer R, Kumar P. COVID-19-induced acute respiratory distress syndrome and challenges faced in management of young morbidly obese patient. Indian J Respir Care 2022;11:267-9.
Received: 11-03-2022
Revised: 02-06-2022
Accepted: 07-06-2022
Published: 28-07-2022
INTRODUCTION
Morbid obesity is a condition in which body mass index (BMI is the weight [Kg]/height [m] 2) is >40. Morbidly obese people are at high risk for COVID acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. ARDS is associated with the shunt mechanism in which fluid collects in the lung's air sacs, leading to the mismatch of ventilation/perfusion. COVID-19-induced ARDS was a novel combination where the patient came with different disease presentations. Managing an obese patient with COVID-19 ARDS was a challenge for a respiratory therapist due to the novelty of the disease and obesity. In this case, we describe the course of treatment of the patient and the challenges faced by reverse transcription (RT) while managing the patient.
CASE REPORT
A 24-year-old patient with “morbid obesity” (weight of 120 kg and height of 170 cm with BMI of 41) and vaccinated with two doses of COVID vaccine presented with fever, chills, cough, vomiting, shortness of breath for 6 days, and 4 days later developed three episodes of hemoptysis. COVID rapid antigen was tested “positive” and computed tomography of the chest had a severity score of 17/25. COVID reverse transcription-polymerase chain reaction was also positive. With these symptoms, he was treated initially outside the hospital and in view of worsening hypoxia was brought to our center. Initially, he was started with O2 through nonrebreather mask and high-frequency nasal oxygenation SpO2 of 85% in FiO2 of 95%, respiratory rate of 40/min with respiratory oxygenation index of 2.24. As his oxygen requirement was progressively increasing with increased work of breathing, the patient was started on noninvasive positive-pressure ventilation (NIPPV). In view of the worsening respiratory distress, despite NIPPV [RR-50/min; Spo2-86%, and P/F ratio <150 and chest X-ray showing poor compliance as depicted in Figure 1], the patient was intubated with an 8-sized endotracheal tube (ET) and initiated on mechanical ventilation. Insertion of ET tube was confirmed by five-point auscultation and end-tidal carbon dioxide later by chest X-ray and connected him to a mechanical ventilator. Initial settings were set based on “low-tidal-volume ventilation and high positive end-expiratory pressure (PEEP) strategy”[1] as per the ARDSnet protocol and target plateau pressure (Pplat) of <30 cmH2o. The patient was started with sedatives and neuromuscular blockers. Resistance was observed while placing a Foley catheter; therefore, suprapubic catheter was inserted. After other causes for possible worsening in oxygenation were ruled out and hypoxemia persists despite the above strategy, the patient was proned. The first proning lasted for 17 h. The patient was supined after 17 h. Chest X-ray was obtained as depicted in Figure 2. Postproning, there was an improvement in oxygenation but later hypoxia worsened; hence, the patient was reproned for 24 h. An arterial blood gas was drawn after the second session where oxygenation was better. The patient was clinically improving (chest x-ray as depicted in Figure 3). The patient was weaned from neuromuscular blockers and sedatives then weaned to spontaneous mode of ventilation (i.e., pressure support ventilation [PSV]) over the next 2 days and pressures were weaned gradually. The patient tolerated PSV trial; therefore, he was extubated to NIPPV. He was tolerating well on NIPPV and gradually weaned to bilevel positive airway pressure, and subsequently, nasal cannula over the next 2-3 days. As a RT, volume incentive spirometry was taught and monitored each hour and mobilized out of bed, chest percussions were also performed. The patient remained hemodynamically stable and was later moved to the ward to be discharged home.
DISCUSSION
ARDS is a life-threatening manifestation occurring in sick COVID patients.[2] Patients with severe ARDS secondary to COVID-19 were associated with a longer need for mechanical ventilation compared with non-COVID ARDS.[3]
Endotracheal intubation and mechanical ventilation had been a key tool for COVID ARDS early in the disease. Although the course of treatment was usual, the respiratory therapist faced certain challenges. First, the patient was obese, with a short neck, limited neck movements, double chin, and large abdomen. Hence, “rapid airway management positioner” was employed and the airway was secured. Cormack-Lehane grade of “2a” was visualized (partial view of cords).
With the worsening hypoxia and ARDS, the patient required intubation and ventilation. The procedure was successful but was challenging considering the anatomical limitations.[4] As the patient required ARDS ventilation, tidal volumes were based on his ideal body weight for “low-tidal-volume and high PEEP ventilation” [Figure 4] protocol to prevent volutrauma. Lung protective strategies were used to prevent barotrauma.
The next challenge that was faced was resistance while insertion of Foley catheter. However, this challenge was overcome by the insertion of the suprapubic catheter[5] which is a known alternative to Foley, is comfortable, and easier to change.
Figure 1: Chest X-ray before proning
Figure 2: Bedside CXR after the first proning. Slight improvement in aerated zones of the lung. CXR = Chest X-ray
Figure 3: Bedside CXR after the second proning. Aerated lung zones are increasing further ventilation resulting in improved oxygenation. CXR = Chest X-ray
The patient needed prone ventilation due to increasing respiratory failure. Prone ventilation is one of the rescue methods to improve oxygenation in patients with severe ARDS. Proning a morbidly obese patient is challenging and fraught with complications. Proning with suprapubic catheter was the next challenge, however, considering the extent of hypoxia went ahead with prone ventilation with all precautionary measures and complete supervision of a respiratory therapist.
Figure 4: Depiction of “low-tidal-volume and high PEEP ventilation” with plateau pressure depiction. Note: Actual settings of patient
Proning was performed by “double sheet” technique (i.e., pillows were placed in the chest and pelvis and above the pillow, a sheet was used to cover patients head to toe and by rolling both the sheets proning was done). A catheter was carefully handled, whereas proning and a person was dedicated to hold and focus only on the suprapubic catheter, hence workforce requirement was high for pronation. Similarly, two prone and two supine sessions were performed along with suprapubic catheter safely. During the entire ventilation period (both in supine and prone position), plateau pressure was kept <30 cmH2O and driving pressure <15 cmH2O with target PaO2 of >60 mmHg at the least Fio2 possible.
Postextubation risk of derecruitment is likely a possible complication and this patient had a history suggestive of obstructive sleep apnea. Hence, we electively decided to extubate the patient to NIPPV and he tolerated extubation to NIPPV very well which was gradually weaned.
Despite these challenges, we are able to effectively position and ventilate the patient who eventually overcame COVID-19-induced ARDS and go home. The patient was vaccinated which may have had a positive effect as COVID-19 vaccine trials have shown that the efficacy of vaccines appears to be similar among people with or without obesity.[6] Therefore, vaccination plays an important role in preventing COVID ARDS in all age groups of people.
CONCLUSION
We would like to conclude that proning patient with a suprapubic catheter seems challenging but it is safe and efficient in all age categories of patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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REFERENCES
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