what will you do? - diffuse chronic lymphocystic leukemia..

[gpywwp]

hi all kindred spirits in cardiorespiratory physio!

just wondering if anyone of you has any comments/suggestions about this case:

58 year old woman who is a known case of diffuse chronic lymphocystic leukemia was admitted for community acquired pneumonia, was subsequently transferred to icu for intubation and ventilation after worsening abg results. cxr shows r middle and lower lobe consolidation, nursing staff reported viscous secretions, ph 7.41, pco2 38 torr, base excess -4, po2 99 torr, sao2 96.2% on simv 12 bpm, pressure support 14 cmh2o, peep 10 cmh2o, fio2 0.50. lightly sedated on dormicum. on blood transfusion. blood profile: hb 6.2, wbc 3.2, platelets 17K. haemodynamically, hr 122 bpm, bp 170/78 mmhg, cvp +12 mmhg.

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[MH123]

I haven't worked in ICU for a while, but I do work in oncology. Her gasses look okay. Given her low platelets and relatively low Hb, I would be tempted to monitor, and r/v daily the need for intervention. Also should sadly keep in mind that haem patients once ventiliated have a mortality rate of 90%'ish.

[gpywwp]

thanks mh. what i found challenging treating this patient was:
1) mh is contraindicated in view of her high peep
2) manual techniques such as percussion and vibration are limited because of the low platelets (she has multiple areas of spontaneous ecchymoses, probably just from nursing care and turning)
3) head down tilt gravity assisted drainage is poorly tolerated, as her bp is often on the high side.

nevertheless, i have persisted with modified gad (ie without head down tilt) and vibrations +++ (as gentle as i possibly can, considering that chest wall compliance is low with in the presence of high peep too) - at least 3-4 times within a 24 hour cycle. some resolution of cxr this morning during the round, but i wonder if it's really due to physio or just a natural progression from antibiotic therapy and ventilation.

:hat

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