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Morbid Obesity, Difficulty Breathing, Drowsiness
September 21, 2003
DIAGNOSIS Morbid Obesity, Difficulty Breathing, Drowsiness By LISA SANDERS, M.D. 1. Symptoms The weekend quiet of the I.C.U. was broken by the familiar loud series of beeps and buzzes. The respiratory therapist looked at her watch. ''He's not going to make it for even 10 minutes today.'' She strode quickly into the room. A young man lay in the bed surrounded by equipment. His face gleamed with sweat; his large abdomen heaved. A monitor showed that his heart was beating rapidly. His breaths were fast and harsh-sounding as he struggled to get air through the ''trach'' -- the white plastic tube that protruded from his throat. His wife looked up at us, tired, worried. The respiratory therapist moved quickly to reattach the man to the ventilator, which immediately took over his breathing. We had been trying, once again, to see if the young man could be weaned from the vent -- if he could breathe without the help of the machine on which he had depended since he came to the hospital a few weeks earlier. ''I can't breathe,'' he whispered the day he arrived at the emergency room. He'd had a cold and a cough, but now he felt out of breath. ''Like I ran up the stairs,'' he gasped, ''but all the time.'' He had no fevers, no chills; just a headache and this difficulty breathing. And he was tired, really tired. He hadn't slept well for several months. But these last few days, he couldn't stay awake. ''I couldn't even drive here today,'' he admitted softly. He was just 23 years old. He had no doctor -- he didn't think he needed one. He worked as a mechanic and lived with his wife and new son. As he told his story to the medical team, his eyes closed. The young E.R. doctor shook his shoulder. ''I'm sorry,'' he stammered. ''I just can't stay awake.'' The patient was quite obese. He was average height, maybe 5-foot-7, but he probably weighed 350 pounds. He had curly dark hair and a sweet face, round and smooth. His plaid, short-sleeved shirt was drenched with sweat. 2. Investigation On examination, his heart was beating rapidly, and he breathed with quick, noisy breaths. Despite his effort, the meter on his finger showed that the oxygen in his blood was low, at 88 percent (100 percent is normal). His lungs were clear at the top two-thirds but silent at the bases: was it an infection or just his size that kept him from breathing deeply? Blood tests suggested that it was an infection, and a chest X-ray confirmed that he had pneumonia in both lungs. A third test explained his unusual sleepiness. It showed that the patient had high levels of carbon dioxide in his blood. Normally, you breathe in oxygen and breathe out carbon dioxide. Elevated levels of carbon dioxide make you sleepy. Our patient had what is quaintly called Pickwickian syndrome, so named after a character in Charles Dickens's ''Pickwick Papers.'' Those with this syndrome, like Joe, the character in the book, and like our own patient, are obese and, because of that, can't clear their lungs of carbon dioxide. Also known as obesity hypoventilation syndrome, it was first described in the medical literature in the 1950's and is now a widely recognized complication of morbid obesity. It was clear to us that the pneumonia was making his Pickwickian syndrome worse. His body was working hard to fight the infection. But the harder the body works, the more carbon dioxide it makes, so the sleepier the patient became. If his pneumonia didn't resolve quickly, he would need a ventilator to help him breathe. Sure enough, after two days, he was intubated. Slowly, with the help of antibiotics and the ventilator, he came through a terrible pneumonia. His fever came down, his blood pressure came up and finally his lungs began to clear. But now it seemed his recovery was at a standstill. He should have been able to come off the ventilator. Yet he couldn't. Moreover, he continued to run a low-grade fever. Clearly, something else was going on. That morning on rounds, we considered the possibilities. Infection was certainly the most likely cause of his fever, but his lungs were working better. Did he now have another infection? If so, where? Or could it be something else? Drugs can cause a fever as part of an allergic type of reaction, and he was on many. Tumors can as well, though we had no reason to think that this young man had a tumor. Blood clots are always a risk in those who have extended illnesses. Although our patient had been on blood thinners throughout his hospital stay to prevent these clots, they remained a possibility. Finally there was atelectasis, a partial collapse of the lung. This is a common concern in hospitalized patients whose immobility and pain discourage them from taking the deep breaths that keep lungs working well. Still, atelectasis didn't usually cause a fever like the one our patient had. First we looked for infection. A CT scan confirmed that his pneumonia was better. His white-cell count was back to normal. There was no evidence of a new infection in his chest or abdomen. The CT scans would have shown if he had a tumor or a clot in either. He didn't. Could this be a drug fever? We changed his antibiotics and stopped as many other medicines as we could. The fever persisted. Meanwhile, the family was confused and concerned. His wife spent every morning at her husband's bedside before going to work in the afternoon. Finally she asked the question she dreaded, ''Is he going to die?'' I didn't know what to say. I didn't think he was going to die, but I didn't know why he wasn't getting better. 3. Resolution Later that week, a new pulmonologist joined the team. He reviewed the thick chart. He examined the patient. Finally he made his recommendation: ''Keep the patient upright as much as possible.'' The patient, like most in the I.C.U., lay almost flat on his back. His point was that this position allowed the weight of his large abdomen and chest to compress his lungs and diaphragm. A recent study had suggested that sitting upright could combat this collapse. It seemed so very unlikely that something as simple as position could make any significant improvement on this very sick patient. But it was worth a try. The young man began to improve almost immediately. His fever stopped after 48 hours. He was more alert and was able to communicate with his wife with gestures and notes. Most important, when we tried again to take him off the vent, he was able to breathe on his own for almost an hour. He would have to practice breathing on his own before he could come off the machine for good, but this was a start. There is a tendency in medicine to focus on the data about the patient -- the vital signs, the monitors, the labs -- rather than on the patient himself. We look after patients without looking at them. Thus, this patient's obesity -- an essential reason he came into the I.C.U. -- was almost forgotten as we tried to get him out. Doctors are really only beginning to appreciate the ways obesity can affect a patient. The patient's recovery was slow but steady. After another week in the I.C.U., he was transferred to a rehabilitation center, where he spent a couple of months. That was five years ago. These days, he rarely thinks of his hospital stay. When I called him recently, an awkward pause told me that he had no recollection of the time we spent together. He's back at work. He has lost weight, though he'd still be classified as obese in a doctor's office. But he doesn't see his new doctors much. ''I'm healthy now, and that's what counts.'' Lisa Sanders is an internist and is on the faculty at the Yale University School of Medicine. ******* -- Steve º¤º°`°º¤ø,¸¸,ø¤º°`°º¤º Steve Chaney Remove "Vegetus." to get my real email address See the soc.singles HALL OF STUPID: http://member.newsguy.com/~gunhed/hallofstupid "If only sheep could cook, we wouldn't need women at all! 8)" - Dizzy, Message-ID: "Outside of this group, I don't remember hearing anyone in RL say that fat people are worthless." - some anonymous coward admitting the truth, Message-ID: "I watched The Accused last night with Jodie Foster. Tough movie. I was wondering what people felt as to whether or not they feel she deserved what happened to her." - Brenda Lee Ehmka, Message-ID: "Jade, your whole existence is spent trying to find people you can justify vetting your rage toward thorugh all forms of harassment. Do you realize that?" - Sunny, on Jade's life in a nutshell |
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Morbid Obesity, Difficulty Breathing, Drowsiness
Steve Chaney, aka Papa Gunnykins ® wrote:
|| September 21, 2003 || DIAGNOSIS || Morbid Obesity, Difficulty Breathing, Drowsiness || By LISA SANDERS, M.D. || || || 1. Symptoms || The weekend quiet of the I.C.U. was broken by the familiar loud || series of beeps and buzzes. The respiratory therapist looked at her || watch. ''He's not going to make it for even 10 minutes today.'' She || strode quickly into the room. A young man lay in the bed surrounded || by equipment. His face gleamed with sweat; his large abdomen heaved. || A monitor showed that his heart was beating rapidly. His breaths || were fast and harsh-sounding as he struggled to get air through the || ''trach'' -- the white plastic tube that protruded from his throat. || His wife looked up at us, tired, worried. || || The respiratory therapist moved quickly to reattach the man to the || ventilator, which immediately took over his breathing. We had been || trying, once again, to see if the young man could be weaned from the || vent -- if he could breathe without the help of the machine on which || he had depended since he came to the hospital a few weeks earlier. || || ''I can't breathe,'' he whispered the day he arrived at the || emergency room. He'd had a cold and a cough, but now he felt out of || breath. ''Like I ran up the stairs,'' he gasped, ''but all the || time.'' He had no fevers, no chills; just a headache and this || difficulty breathing. And he was tired, really tired. He hadn't || slept well for several months. But these last few days, he couldn't || stay awake. ''I couldn't even drive here today,'' he admitted softly. || || He was just 23 years old. He had no doctor -- he didn't think he || needed one. He worked as a mechanic and lived with his wife and new || son. As he told his story to the medical team, his eyes closed. The || young E.R. doctor shook his shoulder. ''I'm sorry,'' he stammered. || ''I just can't stay awake.'' || || The patient was quite obese. He was average height, maybe 5-foot-7, || but he probably weighed 350 pounds. He had curly dark hair and a || sweet face, round and smooth. His plaid, short-sleeved shirt was || drenched with sweat. || || 2. Investigation || On examination, his heart was beating rapidly, and he breathed with || quick, noisy breaths. Despite his effort, the meter on his finger || showed that the oxygen in his blood was low, at 88 percent (100 || percent is normal). His lungs were clear at the top two-thirds but || silent at the bases: was it an infection or just his size that kept || him from breathing deeply? Blood tests suggested that it was an || infection, and a chest X-ray confirmed that he had pneumonia in both || lungs. || || A third test explained his unusual sleepiness. It showed that the || patient had high levels of carbon dioxide in his blood. Normally, || you breathe in oxygen and breathe out carbon dioxide. Elevated || levels of carbon dioxide make you sleepy. Our patient had what is || quaintly called Pickwickian syndrome, so named after a character in || Charles Dickens's ''Pickwick Papers.'' Those with this syndrome, || like Joe, the character in the book, and like our own patient, are || obese and, because of that, can't clear their lungs of carbon || dioxide. Also known as obesity hypoventilation syndrome, it was || first described in the medical literature in the 1950's and is now a || widely recognized complication of morbid obesity. || || It was clear to us that the pneumonia was making his Pickwickian || syndrome worse. His body was working hard to fight the infection. || But the harder the body works, the more carbon dioxide it makes, so || the sleepier the patient became. If his pneumonia didn't resolve || quickly, he would need a ventilator to help him breathe. Sure || enough, after two days, he was intubated. || || Slowly, with the help of antibiotics and the ventilator, he came || through a terrible pneumonia. His fever came down, his blood || pressure came up and finally his lungs began to clear. But now it || seemed his recovery was at a standstill. He should have been able to || come off the ventilator. Yet he couldn't. Moreover, he continued to || run a low-grade fever. Clearly, something else was going on. That || morning on rounds, we considered the possibilities. || || Infection was certainly the most likely cause of his fever, but his || lungs were working better. Did he now have another infection? If so, || where? Or could it be something else? Drugs can cause a fever as || part of an allergic type of reaction, and he was on many. Tumors can || as well, though we had no reason to think that this young man had a || tumor. Blood clots are always a risk in those who have extended || illnesses. Although our patient had been on blood thinners || throughout his hospital stay to prevent these clots, they remained a || possibility. Finally there was atelectasis, a partial collapse of || the lung. This is a common concern in hospitalized patients whose || immobility and pain discourage them from taking the deep breaths || that keep lungs working well. Still, atelectasis didn't usually || cause a fever like the one our patient had. || || First we looked for infection. A CT scan confirmed that his || pneumonia was better. His white-cell count was back to normal. There || was no evidence of a new infection in his chest or abdomen. The CT || scans would have shown if he had a tumor or a clot in either. He || didn't. Could this be a drug fever? We changed his antibiotics and || stopped as many other medicines as we could. The fever persisted. || || Meanwhile, the family was confused and concerned. His wife spent || every morning at her husband's bedside before going to work in the || afternoon. Finally she asked the question she dreaded, ''Is he going || to die?'' I didn't know what to say. I didn't think he was going to || die, but I didn't know why he wasn't getting better. || || 3. Resolution || Later that week, a new pulmonologist joined the team. He reviewed || the thick chart. He examined the patient. Finally he made his || recommendation: ''Keep the patient upright as much as possible.'' || The patient, like most in the I.C.U., lay almost flat on his back. || His point was that this position allowed the weight of his large || abdomen and chest to compress his lungs and diaphragm. A recent || study had suggested that sitting upright could combat this collapse. || It seemed so very unlikely that something as simple as position || could make any significant improvement on this very sick patient. || But it was worth a try. || || The young man began to improve almost immediately. His fever stopped || after 48 hours. He was more alert and was able to communicate with || his wife with gestures and notes. Most important, when we tried || again to take him off the vent, he was able to breathe on his own || for almost an hour. He would have to practice breathing on his own || before he could come off the machine for good, but this was a start. || || There is a tendency in medicine to focus on the data about the || patient -- the vital signs, the monitors, the labs -- rather than on || the patient himself. We look after patients without looking at them. || Thus, this patient's obesity -- an essential reason he came into the || I.C.U. -- was almost forgotten as we tried to get him out. Doctors || are really only beginning to appreciate the ways obesity can affect || a patient. || || The patient's recovery was slow but steady. After another week in the || I.C.U., he was transferred to a rehabilitation center, where he || spent a couple of months. That was five years ago. These days, he || rarely thinks of his hospital stay. When I called him recently, an || awkward pause told me that he had no recollection of the time we || spent together. He's back at work. He has lost weight, though he'd || still be classified as obese in a doctor's office. But he doesn't || see his new doctors much. ''I'm healthy now, and that's what || counts.'' || || Lisa Sanders is an internist and is on the faculty at the Yale || University School of Medicine. || || ******* || || -- Steve || º¤º°`°º¤ø,¸¸,ø¤º°`°º¤º || Steve Chaney || || Remove "Vegetus." to get my real email address || See the soc.singles HALL OF STUPID: || http://member.newsguy.com/~gunhed/hallofstupid || "If only sheep could cook, we wouldn't need women at all! 8)" - || Dizzy, Message-ID: || "Outside of this group, I don't remember hearing anyone in RL say || that fat people are worthless." - some anonymous coward admitting || the truth, Message-ID: || "I watched The || Accused last night with Jodie Foster. Tough movie. I was wondering || what people felt as to whether or not they feel she deserved what || happened to her." - Brenda Lee Ehmka, Message-ID: || "Jade, your whole existence is || spent trying to find people you can justify vetting your rage toward || thorugh all forms of harassment. Do you realize that?" - Sunny, on || Jade's life in a nutshell what is your point with this one? Thanks for the free advertising for my profession of Respiratory Therapist. Orthopnea (dyspnea in certain positions) is a component of COPD also. positioning is an integral part of caring for any patient. Of course, sitting up allow freer movement of the diaphragm, and anyone who is overweight knows the SOB that comes with having a large abdomen, it is like being 10.5 months pregnant. I would wager that this patient has obstructive sleep apnea for his large size also, that can cause your Co2 to rise as well as causing poor sleep that results in sleepiness, lack of energy and lethargy but just posting an article doesn't seem to me to be very helpful. I see children with this type of thing going on a few times per year. `140 lbs at 4 yrs old, eating everything in sight, enabling parents (usually mothers, sorry ladies but it's true) then the have breathing problems so are kept out of physical activities and that just compounds the problem, Last year we had an 8 yr old with really bad asthma compounded by obesity and Developmental delays, he had a bad asthma attack and the outlying hospital couldn't control his behavior so they snowed him and intubated him and once his body got a break from trying to ventilate and oxygenate that big body, it couldn't do it anymore. He was ventilator dependent with a tracheostomy for many months, he was on our med-surg floor eventually and we slowly weaned him off the ventilator, they had to watch his diet so closely because he would sneak food or mom would sneak him food, they used food as a reward, it was really sad. He got decannulated about a month ago, he is smaller but not much. they had to move him out of his parents house and into his aunt's so that he wouldn't die. I could cite many of these cases, Steve Chaney but what is your point? -- Lori 220/149/135 LC since 1/17/03 Sept Challenge 155/150 http://community.webshots.com/user/lorismiller Back to Curves 6/30/03 |
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