Thinking outside the square

Hi all, hope prac is going well.

I would like to relate the story of one patient I was treating this week, who was admitted with severe shortness of breath, due to an infective exacerbation of COPD. This patient had lung volume reduction surgery 6 years ago, and had developed increasing symptoms since Christmas.

This patient uses oxygen 24 hours per day, on 2l/min during the day, 1 l/min at night and up to 3 l/min on activity. Ambulation is with the aid of a 4WW. When I first saw the patient, his SpO2 was 94% on 31% FiO2. He had an upper chest breathing pattern and was using pursed lip breathing. He had just returned from the bathroom and sat down in a supported upper limb posture. His chest was clear on auscultation, but he was exhausted and was not keen to do anything.

The next day the doctors were trying to wean him off the oxygen, and when I went into see him he was lying down, and his sats were 85% on 24% FiO2. Again he had recently returned from the bathroom. In an attempt to make things easier for him I got him SOEB with his arm supported on the table, and spent the next 10 mins talking to him and trying to get him to relax. His sats climbed to 88%. I came back 90 mins later and he was still in this position, and his sats were at 94%. He felt much better.

I knew that the best thing for him to do was to get up and about in an attempt to improve his exercise tolerance, but he was desaturating when lying down. I thought about the best way to do this, and as he was comfortable with his upper limbs supported, I tried a pulpit frame. He had never used one before, but he was willing to give it a try. This also enabled him to rest leaning into the frame as required. He was on 28% FiO2.

When he got up and out of the room he desaturated to 83%, but leant into the frame and this quickly returned to 89%. After that he rested whenever he needed to, and didn’t desaturate beyond 87%. He managed to ambulate approx 50 metres, and felt better for it.

I was not hopeful of being able to do anything other than positioning this patient due to his severe dyspnoea. Thinking outside the square enabled him to be more comfortable walking, and he also managed to walk further than he thought was possible.

Dale.