Skenario 2

Shortness of breath

Mr. Solomon is a 63-year old gentle man who has been under your care for a variety of
medical problems during the past 5 years. He has been treated for two myocardial infarctions,
hypertension, non-insulin dependent diabetes and stasis dermatitis of the left leg. He had an
aorto-coronary bypass one year ago.

Today he presents in the office with shortness of breath which has been progressive over the
past five days. He has, however, experienced episodes of shortness of breath during the past
four months, especially when exerting himself. He fatigues easily and has lost "all my energy
to do anything." He also complains of anorexia. Last night he awoke suddenly from sleep
because "I couldnt catch my breath" and developed a dry cough. The breathing problem
improved when he sat on the edge of his bed for an hour. He generally sleeps with two,
sometimes three pillows. He has not experienced chest pain, leg pain or fainting spells.

Examination in the office reveals an undernourished man who appears depressed and older
than his stated age. He is unkept and unshaven. His shoes are untied. His breathing is labored
and his lips have a blue tinge.

Vital Signs: Blood Pressure 98/82mmHg in the right arm; Heart Rate 110/min; Respiratory
Rate 26/min; Temperature 98F. Examination of the lungs reveals dullness to percussion in
both bases with decreased excursion of the diaphragms. Course rhonchi and moist,
inspiratory crackles are heard bilaterally in the lower lung fields.

Examination of the cardiovascular system: Neck veins are prominent and distended to the
mandible when the patient is sitting upright. The apical pulse is palpated in the 5ICS, left of
the MCL. S3 is palpable at the apex. S1 and S2 are diminished. S3 is heard at the apex. A
grade 3/6 holosytolic murmur is heard best at the apex; it radiated to the left axilla.

Examination of the abdomen: The anterior wall is round and soft. The liver edge is palpable
and tender. The spleen is not palpable. Examination of the extremities revealed diminished
peripheral pulses. There is an irregular pulse. There is pitting edema of both lower
extremities.

http://www.meddean.luc.edu/lumen/meded/mech/cases/case4/Case_f.htm

A 50-year-old male presented to the emergency room at night with complaints of paroxysmal
nocturnal dyspnea and worsening shortness of breath on exertion. He was an active tireless
estate agent till three months before, when he noticed shortness of breath on climbing the
stairs at the station. Then dyspnea developed during sleep at night since one week before, but
which was relieved soon by sitting up on the bed. However this night, the nocturnal dyspnea
was hardly relieved by sitting and more worsened, and he was transferred by the ambulance
car and admitted to this hospital. On examination, he was orthopnea condition. The
temperature was 36.4 centigrade, and the pulse rate 104 beats per minute, regular, the blood
pressure 170/100 mmHg, and the respiratory rate 25 per minute. The body height 179 cm, the
body weight 102.2 kg, and the body mass index 31.9 kg/m2 . Pulmonary course crackle was
audible bilaterally, and the third heart sound gallop was manifest. The chest X-ray film taken
after the emergency room treatment showed cardiothoracic ratio (CTR) 65% and the
interstitial edema pattern. Electrocardiogram was regular sinus tachycardia with T wave
inversion at leads I, aVL, V5 and V6, consistent with left ventricular hypertrophy.

International Journal of Anesthetics and Anesthesiology Case Report: Open

Access ClinMed International Library Citation: Kim C, Seino Y Sakamoto A (2017)
A Case Report: Adaptive Servo Ventilation for a Patient with Acute Heart Failure
and Central Sleep Apnea. Int J Anesthetic Anesthesiol 4:055.
doi.org/10.23937/2377-4630/4/1/1055 Received: December 02, 2016: Accepted:
January 16, 2017: Published: January 18, 2017 Copyright: 2017 Kim C, et al.
This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are
credited. Kim et al. Int J Anesthetic Anesthesiol 2017, 4:055 Volume 4 | Issue 1
ISSN: 2377-4630 DOI: 10.23937/2377-4630/4/1/1055 A Case Report: Adaptive
Servo Ventilation for a Patient with Acute Heart Failure and Central Sleep Apnea
Chol Kim, Yoshihiko Seino* and Atsuhiro Sakamoto Nippon Medical School Chiba
Hokusoh Hospital, Japan *Corresponding author: Yoshihiko Seino, MD, PhD,
Director of Hospital, Chair, Professor of Internal Medicine, Professor of
Cardiovascular Medicine, Nippon Medical School Chiba Hokusoh Hospital, Japan,
E-mail: y-seino@nms.ac.jp

Mr.ADwasa25yearoldstudentwhowasanactivefootballeruntiltendayspriortopresentationto
Cardia Heart Clinic (CHC), Kano, Nigeria, when he started having dyspnoea on exertion, which
progressed to dyspnoea at rest, associated with orthopnoea, paroxysmal nocturnal dyspnoea, easy
fatigability,abdominalandlegoedema,upperrightabdominaldiscomfort,easysatiety,andsubsequently
coughwithfrothysputum.Hedeniedhavingurinarysymptoms,fever,orothersymptoms.Priortohisself
referral to CHF, he had visited another clinic where a chest Xray, complete blood count, and renal
functionassessmentwerecarriedout.

Physicalexaminationrevealedayoungmaninmildrespiratorydistress.Therewerenoskeletalanomalies
ordigitalclubbing,andhewas1.76meterstallwithbodyweightof68 Kg.Hisaxillarybodytemperature
was37.1C,oxygensaturationonroomairwas91%,andhehadbilateralpittingpedaloedemaextending
totheshins.Hehadregularheartrateof104beats/minute,bloodpressureof100/80 mmHg,raisedjugular
venouspressure(approximately8cm),displacedapex,thirdheartsoundwithloudcomponentofsecond
heartsound,andgradeIVmitralregurgitationandgradeIIItricuspidregurgitationmurmurs.Therewere
bilateralbasalcrepitations,softandtenderhepatomegalyof12 cmbelowtherightcostalmargin,andmild
ascites.Otheraspectsofphysicalexaminationwerenotremarkable.

Chest Xray revealed cardiomegaly, pulmonary venous congestion, and minimal left pleural effusion.
Electrocardiogramshowedsinustachycardiawithbifascicularblock(completerightbundlebranchblock
plusleftposteriorhemiblock).Echocardiogram(seeFigures1and2)revealedabsentinteratrialseptum
(commonatrium)withdeformedmitralandtricuspidvalves(MVandTV,resp.),whichwereseverely
regurgitant.Therightventriclewasdilatedwithabasaldiameterof50 mm,butleftventricular(LV)end
diastolicdiameterwasnormal(39mm),andLVwashypercontractile(LVejectionfraction(LVEF)=
90%). His mean pulmonary artery systolic pressure was approximately 36.8 mmHg, consistent with
moderatepulmonaryhypertension.Thepulmonaryveinsandsuperiorvenawerenormallypositioned.The
pericardiumwasmildlythickenedwithmoderatepericardialeffusion(averageechofreespace=15.5 mm).
Fibrinstrandswerenotseenwithintheeffusion.Thecompletebloodcountshowedtotalwhitebloodcell
count of 11.6109/L, neutrophils = 8.3109/L, lymphocytes = 2.6109/L, haemoglobin = 16.3g/dL,
haematocrit=54.9%,andplatelets=522109/L.Serumcreatininewas92mol/L,andotherrenalfunction
parameterswereallnormal.

https://www.hindawi.com/journals/crim/2015/497891/