# Audible Fluid In Lungs



## LetItGo (Nov 6, 2017)

88 y/o male in nursing home with history of COPD and respiratory failure.  In respiratory failure upon our arrival.  Eyes open, mouth wide open, accessory muscles in use.  No verbal communication, only fixed focused gaze.  Slight eye movement towards me (can't even be certain) when I spoke his name.  SpO2 reads 67%.  Audible, without stethescope, fluid in lungs.  No history of CHF, lower extremities without edema.  We are told they gave him a DuoNeb approximately 10 minutes prior to our arrival.  Stated he was having some difficulty breathing all morning (current time 11:25am).  They also stated that he had vomited.  Communicated to incoming engine company to prepare for RSI.  Simultaneously placed EtCO2, non-rebreather and monitor and transferred to cot.  Respiratory rate was 25, pulse 124.  EtCO2 reads 31.  BP 152/74 automated cuff.  By the time we got to the ambulance (approximately 3 minutes), there was obvious change in mental status.  Color became grey, eyes open and rolled backwards.  RSI without difficulty and suction immediately.  Approximately 30cc of cloudy white liquid, not pink, not frothy, (Ensure????) was suctioned from the lungs. Color improved, SpO2 up to 97%.  Heart rate still tachycardic at 130, EtCO2 41.  BP 127/67.  I have been taught to intubate as a last resort in elderly patients with pulmonary disease, due to the dependence of the ventilator for respiratory drive.  I was reluctant to place this patient on CPAP due to the suspicion of foreign contents in his lungs.  Was I right in my thinking?  As it turns out, his mental status would not have allowed for CPAP.


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## luke_31 (Nov 6, 2017)

LetItGo said:


> 88 y/o male in nursing home with history of COPD and respiratory failure.  In respiratory failure upon our arrival.  Eyes open, mouth wide open, accessory muscles in use.  No verbal communication, only fixed focused gaze.  Slight eye movement towards me (can't even be certain) when I spoke his name.  SpO2 reads 67%.  Audible, without stethescope, fluid in lungs.  No history of CHF, lower extremities without edema.  We are told they gave him a DuoNeb approximately 10 minutes prior to our arrival.  Stated he was having some difficulty breathing all morning (current time 11:25am).  They also stated that he had vomited.  Communicated to incoming engine company to prepare for RSI.  Simultaneously placed EtCO2, non-rebreather and monitor and transferred to cot.  Respiratory rate was 25, pulse 124.  EtCO2 reads 31.  BP 152/74 automated cuff.  By the time we got to the ambulance (approximately 3 minutes), there was obvious change in mental status.  Color became grey, eyes open and rolled backwards.  RSI without difficulty and suction immediately.  Approximately 30cc of cloudy white liquid, not pink, not frothy, (Ensure????) was suctioned from the lungs. Color improved, SpO2 up to 97%.  Heart rate still tachycardic at 130, EtCO2 41.  BP 127/67.  I have been taught to intubate as a last resort in elderly patients with pulmonary disease, due to the dependence of the ventilator for respiratory drive.  I was reluctant to place this patient on CPAP due to the suspicion of foreign contents in his lungs.  Was I right in my thinking?  As it turns out, his mental status would not have allowed for CPAP.


It sounds like aspiration. You did right to intubate this patient. ALOC would have precluded use of CPAP and this patient was in obvious respiratory distress.


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## VFlutter (Nov 6, 2017)

Not saying you did anything wrong or that ALOC isn't a contraindication to CPAP in most protocols however to me it is a "soft" contraindication in these situations as long as you are monitoring the patient. Anecdotally, I have had many unresponsive patients on Bipap for an hour or two, sometimes much longer, as we had family discussions regarding end of life care. Deciding not to intubate is usually an "easier" decision than withdrawing care once they have been placed on the ventilator. Having said that it is easier to do that in the hospital and not always feasible in EMS, sometimes you just have to do what is indicated and worry about long term after the fact.


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## StCEMT (Nov 6, 2017)

Chase said:


> Not saying you did anything wrong or that ALOC isn't a contraindication to CPAP in most protocols however to me it is a "soft" contraindication in these situations as long as you are monitoring the patient. Anecdotally, I have had many unresponsive patients on Bipap for an hour or two, sometimes much longer, as we had family discussions regarding end of life care.


Since I don't have the greatest toolbox for intubation, I'd definitely have to toe the line a bit more with CPAP in this case. Fortunately, at the nursing homes I would most likely expect this from, it wouldn't be a long term thing.


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## ThadeusJ (Nov 7, 2017)

There are other reasons intubate besides providing mechanical ventilation; bronchial toilet being one of them.  Risk of aspiration is very high in this demographic, however the concern for not being able to extubate is very real.  This is a very tricky issue because even if the patient was a DNR (for example), does that mean that bronchial toilet cannot be performed and we allow the patient to drown on their dinner?  The role of CPAP here is (as stated above) controversial as there are arguments to its efficacy in cases such as these.  Personally I feel that although it may have bought time, it could have exacerbated the situation by making the aspiration worse (or caused more vomiting).  Tough call but it sounds like you thought the process through as opposed to performing recipe medical care.


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## RocketMedic (Nov 17, 2017)

I reckon early ventilators support with a BVM +Peep valve if possible would help, but this guy is fixin' to be intubated.


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