Ventilatory failure after Pasteurella multocida pneumonia.

Abstract

Casereport A 62-year-old womanwasadmitted asanemergency with a seven-day history ofcoughproductive ofpurulent sputum. Twenty-four hoursbefore admission shehad becomeincreasingly breathless andtwohoursbefore admission shebecamedrowsy andlost consciousness. Shehadneverpreviously beenahospital inpatient but hadbeenseeninachest clinic 10years before because of exertional breathlessness. Pulmonary function testing at thattimeshowedmoderately severe airways obstruction (FEV,/FVC 09/24litres, predicted FEV,24+ 0-4litres andFVC 3-5+ 04litres). Shewasa life-long nonsmoker taking noregular medication. Onadmission shewascomatose, centrally cyanosed, and unresponsive topainful stimuli. Shewasclinically shocked with verypoorperipheral perfusion andbarely palpable peripheral pulses. Herapexbeat wasirregular with arate of160/minute andBP 100/50. Therespiratory ratewas 40/minute andshewasnoted tohaveaslight kyphosis, milddigital clubbing andbilateral mid-zone coarse crackles. Admission ECG confirmed atrial fibrillation witha ventricular reponsevarying between 150and 190/ minute while theinitial chest radiograph showedpatchy shadowing inbothupperzoneswithageneral reduction inpulmonary vascular markings. Theresident physician madeaclinical diagnosis ofleft ventricular failure and arterial blood gases taken10minutes after starting high flowoxygen treatment (6litres/minute vianasal cannulae) revealed anarterial Po2of10-4kPa(78mmHg),Pco2 11-7kPa(88mmHg),andhydrogen ion81mmol/l (pH709);shewasimmediately changed tolowflow oxygentherapy andphysiotherapy wasstarted. This yielded nosputum butrigid bronchoscopy produced large quantities ofpurulent secretion andthepatient's consciousness improved toa level whereshecouldspeak rationally butonlysingle wordswerepossible because of hersevere breathlessness. Post-bronchoscopy bloodgas