A 72-year-old male with a history of chronic obstructive pulmonary disease (COPD), hypertension and chronic atrial fibrillation presented to the Emergency Department (ED) at a Tertiary Medical Center in the northeastern region with shortness of breath. His vital signs showed a blood pressure (BP) of 146/80 mmHg, a heart rate of 96 beats per minute, a respiratory rate (RR) of 28 breaths per minute, an oxygen saturation of 82%, and a temperature 101.6°F. Physical assessment revealed an irregularly irregular heart rhythm, breath sounds with bilateral air entry, but diminished, a soft, non-tender abdomen and pulses palpable in all extremities.
Treatment and Response
The patient was quickly placed on BiPAP at IPAP 12 cmH2O/EPAP 5 cmH2O, and 100% FiO2. Following BiPAP initiation, the respiratory rate increased to 32 breaths per minute, while the oxygen saturation increased to 100% (Table 1).
Table 1: Initial Patient Treatment
Diagnostic testing included a chest x-ray revealing right lower lobe pneumonia and hyper-expanded lung fields. Laboratory testing results showed a white blood count (WBC) of 18k, and hemoglobin of 13.2 g/dL. The laboratory examination of arterial blood on BiPAP showed a pH of 7.18, a partial pressure of carbon dioxide (PaCO2) of 90 mmHg, and a partial pressure of oxygen (PaO2)of 170 mmHg. The patient was admitted to the pulmonary floor and pulmonary consultation was called. Additional testing of blood cultures and sputum cultures was performed. The patient was diagnosed with right lower lobe pneumonia with COPD exacerbation and started on levofloxacin 500 mg IV daily, solumedrol 40 mg IV q 8 hours, ipratropium bromide and albuterol sulfate 3mg-0.5mg/3mL q 6 hours, while home apixaban 5 mg PO BID and metoprolol 50 mg PO BID were maintained.
As the blood gas and patient’s condition was poor despite BiPAP support, the clinical team decided to transition to high velocity therapy (Vapotherm Precision Flow) at 30 liters/min and FiO2 at 100% and a repeat arterial blood gas (ABG) was ordered to be drawn in two hours. Within 10 minutes, the RR dropped to 20 breaths per minute and the patient was noted to be more comfortable. A repeat ABG two hours post initiation of high velocity therapy showed a pH of 7.30, a PaCO2 of 75 mmHg and a PaO2 of 280 mmHg ; FiO2 was then decreased to 50% (Table 2).
Table 2: Initiation of High Velocity Therapy
The 24 hour culture results showed the sputum culture was positive for Streptococcus Pneumoniae, and the blood culture was negative.
On Day 2 of admission, the patient clinically seemed to have improved, was less tachypneic with RR of 20 breaths per minute, a pulse rate of 76 beats per minute and BP of 132/76 mmHg, while the oxygen saturation was maintaining 100%. The ABG at this time showed a pH of 7.37, a PaCO2 of 66 mmHg, PaO2 of 150 mmHg, and the FiO2 was decreased to 30% while the high velocity therapy flow was decreased to 20 liters/min (Table 3).
Table 3: Day 2 of Patient Treatment
On admission Day 3, the patient continued to improve and was transitioned to nasal cannula oxygen at 2 liters/minute. The patient was discharged home the following day, Day 4 of hospitalization, with one more day of antibiotics, Medrol dose pack, a refill for home long-acting muscarinic antagonists (LAMA) and long-acting beta agonist (LABA) nebulizer medications and follow up scheduled with the pulmonologist in a week.
Years ago, this patient would likely have been intubated in the ED after failing BiPAP. However, in this case, Vapotherm’s high velocity therapy was able to provide sufficient ventilatory support for the patient as noted by the reduction in RR and improved blood gas. The use of the high velocity treatment allowed the patient to receive the necessary ventilatory support while receiving the treatment for pneumonia and COPD exacerbation. If the patient had been intubated, he would have been admitted to the ICU and depending on his course could have remained in the hospital for an average of 10 days. With the use of Vapotherm’s high velocity, he was admitted to the pulmonary floor and discharged in 5 days.