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IMAI second-level learning programme for district clinicians working at hospitals in limited-resource settings

Facilitator guide:

Management of the severely ill patient with septic shock

or respiratory distress

This training course is based on guidelines in the IMAI District Clinician Manual: Hospital Care

for Adolescents and Adults

June 2014

Integrated Management of Adolescent and Adult Illness (IMAI)

IMAI second-level learning programme for district clinicians

working at hospitals in limited-resource settings

Facilitator training guide:

Management of the severely ill patient with septic shock or

respiratory distress

This training course is based on guidelines in the IMAI District Clinician Manual: Hospital Care for Adolescents and Adults

June 2014

Produced by IMAI-IMCI Alliance for WHO HSE/PED

Comments to: [email protected] [email protected]

mailto:[email protected]�

Development of the Quick Check+ training curriculum was supported by funding from the government of USA (DOD DTRA) and the Government of Japan through grants to WHO/HSE/ Pandemic and Epidemic Diseases ( PED) (project manager Nikki Shindo) , with the support of WHO regional office for Africa (Francis Kasolo, Benido Impouma) and the WHO country offices in affected countries. Produced by the IMAI-IMCI Alliance. Design and illustrations: Robert Thatcher

Table of Contents

Introduction ........................................................................................................................ 1

Chapter 1: Caring for severely ill patients ....................................................................... 2

DRILL 1-1: Oxygen .................................................................................................................... 4 DRILL 1-2: Fluids ....................................................................................................................... 5 DRILL 1-3: Urine output ............................................................................................................. 5 DRILL 1-4: Fix the physiology .................................................................................................... 6 DRILL 1-5: Monitoring ................................................................................................................ 7 Assessment questions: Caring for the severely ill patient ......................................................... 14

Chapter 2: Managing patients in septic shock .............................................................. 16

DRILL 2-1: Management of septic shock initial two hours ........................................................ 22 DRILL 2-2: Vasopressors ......................................................................................................... 26 DRILL 2-3: Managing septic shock 2–6 hours .......................................................................... 27 DRILL 2-4: Management of septic shock 6–24 hours ............................................................... 29 DRILL 2-5: Fluid management in patient with septic shock....................................................... 31 Assessment questions: Septic shock ....................................................................................... 32

Chapter 3: Managing patients in severe respiratory distress ...................................... 35

DRILL 3-1: Management of severe respiratory distress first two hours ..................................... 44 DRILL 3-2: Management of fluids in patient with severe respiratory distress ............................ 45 DRILL 3-3: Managing severe respiratory distress 2–6 hours ................................................... 47 DRILL 3-4: Managing severe respiratory distress 6–24 hours .................................................. 49 DRILL 3-5: Managing severe respiratory distress post-resuscitation ........................................ 50 DRILL 3-6: Wheezing ............................................................................................................... 57 Assessment questions: Severe respiratory distress ................................................................. 67 Practice cases .......................................................................................................................... 68

Appendix 1 ....................................................................................................................... 74

1 – Introduction Partic ipan t manua l: Management o f the pa tien t with s evere res p ira to ry d is tres s o r s ep tic s hock

Introduction to management of the severely ill patient with severe respiratory distress or septic shock (Part 2 of the Quick Check training)

This course builds on the Quick Check Essentials: Triage and Emergency Treatments (QC) training course, which is a prerequisite to this course. It is geared for nurses and with district clinician support to provide further management for patients who are severely ill. The focus in this course is on severely ill patients with respiratory distress and/or septic shock; however, principles learned in the course will help in managing all patients who are severely ill. This training assumes that participants can do the Quick Check assessment and can provide first-line emergency treatments. The district clinician has been called, and the clinical team now needs to provide further urgent medical management. It is recommended that this part of the training programme is done in tandem with the first part of the Quick Check training, as covered in the 4-day training course. Summary guide for severe respiratory distress and shock chapters

Chapters

Methods

Time planned

Time Spent

Notes

1 Caring for the the severely ill patient

- Facilitator-led discussions in the classroom

- Group exercises - Clinical scenarios using

expert patient trainers and monitoring form

- Skill stations - Practical session in the

hospital

2 Managing the patient in septic shock

- Facilitator-led discussions in the classroom




hospital

3

Managing the patient in severe respiratory distress

- Facilitator-led discussion in the classroom




hospital

Fac ilita to r gu ide : Management o f the pa tien t with s evere res p ira to ry d is tres s o r s ep tic s hock Chapter 1 – 1

Chapter 1: Caring for severely ill patients

IF DOING THE 4-DAY COMBINED COURSE, YOU WILL SKIP SOME SECTIONS OF THIS LEARNING UNIT Expected duration for combined course Nurses- 60 minutes Doctors/Clinical officers-40 minutes

Duration: 1 hour and 15 minutes Materials: -IMAI district clinician manual -Participant manual: Management of the severely ill patient with severe respiratory distress or septic shock -Blank flipchart/markers -Extra blank monitoring forms (2 per participant) Wallcharts: -Quick Check -Oxygen Poster -Monitoring form (if available) Preparation: -Post wall charts -Copy enough monitoring forms for class

Chapter Overview: • Course introduction and overview • Brief review of Quick Check and emergency treatments • Knowledge of basic principles of medical management of

severely ill patients • How to provide good nursing care • How to monitor patients who are severely ill and record on the

monitoring form Learning Objectives: 1. Learn how to care for severely ill patients 2. Recognise abnormal physiology 3. Record and respond 4. Use the severely ill patient monitoring form Content Methods Time Introduction to Part 2 Explanation, Review,

Discussion, DRILL 10 minutes

General principles for caring for the severely ill patient

Explanation, Discussion, DRILL, EXERCISE

45 minutes

Nursing care for the severely ill patient

Explanation, Discussion 10 minutes

Assessment questions Written 10 minutes

2 – Chapte r 1 Partic ipan t manua l: Management o f the pa tien t with s evere res p ira to ry d is tres s o r s ep tic s hock

Chapter 1: Caring for severely ill patients

Learning objectives 1. Learn how to care for severely ill patients.

2. Recognize abnormal physiology.

3. Record and respond.

4. Use the severely ill patient monitoring form.

Introduction Severely ill patients suffer from acute, life-threatening problems such as severe pneumonia, septic shock from an overwhelming infection, or massive haemorrhage. Recognizing severely ill patients is challenging in a busy district hospital. However, identifying and treating these patients early will often greatly improve their chances of survival. These patients may present with symptoms at triage, or deteriorate while admitted to the hospital. As you have learned, the Quick Check system can be used to identify severely ill patients who require rapid evaluation and treatment. You will now be learning to use the relevant sections of the DCM to develop a differential diagnosis and guide further management. As always, these recommendations are meant to be used in conjunction with sound clinical reasoning and existing local guidelines in your hospital.

In this learning unit, you will learn about the general principles used to care for all severely ill patients. We will then cover specific clinical conditions such as septic shock and severe respiratory distress. Caring for severely ill patients requires a team approach as multiple tasks need to occur simultaneously. These tasks include frequently checking and recording vital signs, administering fluids or medications, carrying out necessary procedures, checking laboratory results and refining the differential diagnosis. Using an organized approach is useful for managing these complicated cases. Clear communication between team members is essential to deliver quality care.

When managing severely ill patients:

1. Recognize severe illness. 2. Fix abnormal physiology (i.e. low blood pressure, hypoxia). 3. Treat infections. 4. Monitor and record vital signs. 5. Respond as appropriate.

Other priorities include keeping the patient comfortable and safe, preventing complications, respecting patient dignity, communicating frequently with the patient, patient’s family members, and other staff members.

The mortality of severely ill patients is high and some patients may not improve, despite appropriate treatment. Preserve the dignity and comfort of patients and their families in these difficult situations.


Quickly review the Quick Check, emergency, and urgent treatments using the wall chart. Point out the specific sections in the IMAI manual to help guide your development of a differential diagnosis and definitive management. Explain that in Part 2 of this course, they will focus on caring for severely ill patients and on the specific management of sepsis and severe respiratory distress. Ask participants what are the general principles that they have observed that are common to all severely ill patients. Write some of their answers on the flipchart. Have participants read this page to themselves or aloud if time permits. Otherwise, highlight the key teaching points.

KEY TEACHING POINTS

By this time, emergency treatments have been given and the district clinician (DC) should have been called for help

o All vitals including pulse oximetry have been checked and labs have been sent.

o You may have already initiated some urgent treatments.

o In some facilities, the DC may not be available for several hours. If the DC is not available, the nurse should begin to use the following sections to help guide initial management.

o While the patient is being treated to “fix the physiology,” it is essential that the health-care worker is continuing to look for the underlying diagnosis and give disease-specific treatment.

o Remember to use standard precautions (wash hands for all patient care, wear gloves if there is potential contact with blood or body fluids, e.g. inserting IV, drawing labs).

General principles for caring for the severely ill patient • Discuss the key points in medical management of the severely ill patient, and write these

words on the flipchart. • Discuss the limitations when caring for severely ill patients. Some patients may not

improve despite appropriate treatment.

KEY TEACHING POINTS

o Recognize severe illness.

o Fix abnormal physiology (i.e. low blood pressure, hypoxia).

o Treat infections.

o Monitor and record vital signs.

o Respond as appropriate.

o Keep patient comfortable and safe.

o Respect patient dignity.

o Communicate with the patient, the family, and other staff.


RECOGNIZE SEVERE ILLNESS Severe illness is a general term used to describe any acutely ill patient with a life-threatening condition. Consider any patient with a Quick Check emergency sign as severely ill. Severely ill patients include those who require medical attention as well as those who require surgery. A severely ill patient can also develop more than one life-threatening condition at the same time. When you see a severely ill patient, immediately administer first-line emergency treatments and call the senior clinician for help. Once patients are diagnosed as severely ill, they require careful and frequent monitoring. In this learning unit you will learn how to use a recommended patient monitoring system. You can use this monitoring system to recognize changes in a patient’s condition, and determine what steps you should take to treat the patient.

FIX THE PHYSIOLOGY Respond to signs of abnormal physiology with appropriate treatments. Treatments include providing fluids or oxygen, and treating fever. These interventions prevent organ damage and support the patient through their illness. Ultimately an assessment and treatment of the underlying cause is required.

These recommendations are not meant to replace clinical reasoning or existing guidelines based on local epidemiology. For example, in a patient with known congestive heart failure you may choose to use more caution when giving IV fluids. In a patient with suspected dengue, you may choose to use existing country guidelines on the management of dengue instead.

Treat abnormal respiratory physiology

In the Quick Check you learned how to give oxygen and titrate flow. Some severely ill patients will not need oxygen. A patient with sepsis from a urinary tract infection for example, may not have respiratory distress or hypoxia. If you measure the oxygen saturation and it is >90% (in pregnancy oxygen saturation should be 92–95%), it is not necessary to administer supplemental oxygen. However, these patients must be monitored every 30–60 minutes for the first four to six hours to ensure they do not develop delayed hypoxia. If you are unable to carefully monitor these patients due to staff shortages, start them on oxygen until you can monitor them more closely or their condition improves. Remember, if a patient on oxygen is deteriorating, first check the equipment to make sure it is working correctly.

If hypoxia (SpO2<90%), increasing RR, or worsening respiratory distress:

• Give oxygen and titrate to SpO2 of 90%. • Assess for and treat fluid overload. • If wheezing give salbutamol.

Review what you learned in the Quick Check regarding the titration of oxygen by practicing the drill below.


RECOGNIZE

Write the word, “Recognize” on the flipchart. Now ask participant what is important to watch for in caring for the severely ill patient. Ask the participants to define severe illness, and describe some severely ill patients that they have treated.

KEY TEACHING POINTS Recognize

o Severe illness is a general term used to describe any acutely ill patient with a life-threatening condition.

o General principles and recommendations for treatment are provided. However, every clinical situation is different, and it is important to always use sound judgement and clinical reasoning.

Fix the physiology Ask participants if they have heard the phrase “fix the physiology.” Even if they have not, ask them to explain what they think it means and have them try to give examples. Explain that “Fix the physiology” means to correct the problem first by bringing the body as close to its normal functioning state as possible, such as giving fluids to improve a low blood pressure or oxygen to a person who is hypoxic. Emphasize that anytime a patient is given an intervention (start oxygen, change flow rate, give IVF bolus), they must reassess the patient and document the patient’s response. To explain this phrase, give the following EXAMPLES to the participants.

EXAMPLES 1) If you had a patient with BP 80/40, pulse 126 and no urine output in 2 hours, how would you

fix the physiology? ANSWER: give bolus of NS or LR. 2) If you had a patient with severe respiratory distress, RR 42, SpO2 88%, how would you fix

the physiology? ANSWER: give oxygen.

3) If you had a pregnant female in severe respiratory distress, what would be the goal oxygen saturation for her? ANSWER: 92-95%

Treat abnormal respiratory physiology Show oxygen poster and review titration of oxygen (SKIP THIS IF DOING 4 DAY COMBINED COURSE) Have participants say aloud the management steps they would take if a patient on oxygen suddenly deteriorated. Have participants do the DRILL 1-2: OXYGEN and then go through the answers with them.


DRILL 1-1: Oxygen

Treat abnormal circulatory physiology In addition to monitoring BP, pulse, and mental status, monitor urine output to assess perfusion. When you first start treating the patient, vital signs should be monitored every 30 minutes. Once the patient is stable, check vital signs every 60 minutes and reassess how the patient is responding to any new treatments. Urine output of 0.5–1 ml/kg/h indicates adequate perfusion to the vital organs (heart, lungs, kidney, and brain). Family members can be enlisted to measure urine output. If you cannot measure urine output, try to monitor and record whether the patient is urinating and the frequency of urination. If signs of poor perfusion such as BP decreasing, pulse increasing, or urine output is low: • Give IV fluid bolus. • Assess for other causes of shock such as blood loss or anaphylaxis. Immediately after delivering a bolus of IV fluid:

Check to see if the BP has increased and the HR decreased.

If BP remains low: • Check IV tubing and site. • Repeat fluid bolus. • Look for ongoing blood loss. • Reassess and continue looking for other causes of shock. If blood pressure remains low (SBP<90) after appropriate fluid resuscitation, consider vasopressors. • If a patient remains in shock and has clinical signs of poor perfusion (low BP, low urine

output, altered level of consciousness) after appropriate IV fluid treatments, consider the use of vasopressor medications to temporarily support the circulation. Vasopressors have significant side-effects, and should be only be used in patients who have not responded to appropriate IV fluids or blood.

Specific recommendations for the administration of fluid to patients with severe respiratory distress or septic shock are covered later in this learning unit.

Go around the room and take turns answering the questions aloud. 1. A patient is on oxygen at 5 litres via nasal cannula. They have been stable for over 30 minutes. You

check the oxygen saturation and it is 94%. What would you do next? Titrate oxygen flow down to 3-4 L via nasal cannula and observe for response. Recheck pulse oximetry in 15 minutes.

2. A patient is on oxygen at five litres via nasal cannula. The patient’s respiratory rate is increasing and the patient is now having retractions. What would you do next? Increase oxygen flow to 6-10 litres via face mask. Check equipment.

3. A patient is admitted to the ward with a cellulitis and the following vital signs: RR 24 PR 122 BP 80/40 T 39.0 Sat 96% on Room Air. Would you start this patient on supplemental oxygen? How often would you monitor the patient’s oxygen saturation? No. Monitor the oxygen saturation every 30-60 minutes until stable.

4. A patient is admitted to the ward with pneumonia. The patient’s initial measured oxygen saturation is 92%. Would you start this patient on supplemental oxygen? How often would you monitor the patient’s oxygen saturation? What would you do if the next measured oxygen saturation was 88%? No. Monitor the oxygen saturation every 30-60 minutes until stable. If saturation decreased to 88%, start oxygen at 5 L via NC.


Treat abnormal circulatory physiology Explain that the rate of fluid administration will depend on the likely diagnosis. Inform participants that they will learn to use the fluid tables in order to administer and monitor response to fluids given for septic shock and respiratory distress in the next two chapters.

KEY TEACHING POINTS

o After the bolus of IV fluid is given, immediately check to see if the BP has increased and the HR has decreased.

o Failure to respond or only a transient response should prompt a check of whether there is: • an equipment problem (e.g. IV line extravasation or blockage) • wrong diagnosis – reassess and consider other diagnoses (e.g. on-going bleeding,

cardiogenic shock).

o Monitor urine output – measure if feasible; if not, record when the patient urinates. • Normal urine output is a sign that the kidneys are receiving adequate blood flow. • Aim for urine output of at least 0.5-1 cc/kg/h.

o If urine output is not adequate, consider increasing the rate of fluid administration.

o Family members can help in measuring urine output. If it is not feasible to measure urine output at your facility, ask the family to inform you when the patient is urinating so that it can be recorded.

o Consider vasopressor medication if the blood pressure remains low after the patient has received 2-3 litres of intravenous fluids.


DRILL 1-2: Fluids Go around the room and take turns answering the questions aloud. 1. A patient is admitted to the ward with septic shock from peritonitis. The patient has

received one litre of lactated ringers. The blood pressure is now 80/40. What would you do next to manage circulation? When would you check the blood pressure next? Give a second bolus of IVF. In 30 minutes, or after fluid bolus has finished infusing- whichever comes first.

2. A patient is admitted to the ward with pneumonia and severe respiratory distress. The blood pressure is 110/60 after receiving 500 ml of normal saline. What would you do next to manage the circulation? How often would you monitor the blood pressure? Continue fluids at 1 ml/kg/hour IV or orally. Monitor BP every 30 minutes until stable.

3. A patient is admitted to the ward with sepsis and a urinary tract infection. The patient was given a one litre bolus of normal saline. The repeat blood pressure is 70/30. You check the IV site and notice that the intravenous fluids are infusing into the right arm, which is now swollen and tender. What would you do next? Assume that the IV is out of place and the fluids have gone into the skin tissue. Replace the IV and give IVF bolus through the new IV. Remove the old IV.

4. A patient is admitted to the ward following a fall and complains of abdominal pain. Over the next hour the abdomen becomes distended and very tender. The patient has received two litres of normal saline and the blood pressure is now 80/40. What would you do next?

Arrange for blood transfusion and transfer to the operating theatre.

DRILL 11-3: Urine output Go around the room and take turns answering the questions aloud. 1. You are taking care of a patient in septic shock who is 55 kg. After one hour, what is the

minimum urine output that the patient should have? 27.5-55 cc

2. You are taking care of a patient who is 70 kg. After 6 hours you measure the urine output and find the patient has made 70 cc of urine. Is this urine output adequate? The blood pressure is 80/40. What would you do next? No. The patient should have made at least 210 cc of urine in 6 hours. Give bolus of IVF or increase oral fluid intake.


Ask participants to do DRILL 1-2: FLUIDS and then go through the answers with them. The specifics of management will be discussed in the other chapters. Use these questions to discuss general principles and what they normally do at their facilities.

Ask participants to do DRILL 1-3: URINE OUTPUT and then go through the answers with them.


DRILL 1-4: Fix the physiology Respond to the physiological problem in the patient. Go around the room and answer aloud what would you do next.

1. No urine output for 2 hours and BP 80/40

Give bolus of IV fluid

2. Difficulty breathing and RR 40

Titrate oxygen

3. Cold extremities, BP 79/40, and pulse 130

Give bolus of IV fluid

4. SpO2 88% Titrate oxygen

5. Wheezing and in respiratory distress

Give salbutamol

6. BP 70/30 after receiving a 1 litre bolus of NS

Give another bolus of IV fluid

TREAT INFECTION Early treatment with antimicrobials (antibiotics, antimalarials, antivirals) can save the lives of severely ill patients. For patients in septic shock, IV antibiotics should be given as soon as possible, within one hour of arrival at the hospital. Empirical, broad-spectrum antibiotics should be administered early in the course of treatment. Once more information is gathered and you have a more firm diagnosis, change the antimicrobials based on the likely source of infection. The choice of antibiotics should be determined by national guidelines and local resistance patterns.


Ask participants to do DRILL 1-4: FIX THE PHYSIOLOGY and then go through the answers with them. TREAT INFECTION Explain that antimicrobials (antibiotics, antimalarials and antivirals) should be given early to severely ill patients with suspected infection so that they have the best chance of improving their outcome. Emphasize that it is an IMAI benchmark to give IV antibiotics to patients in septic shock within 1 hour of arrival at the hospital.


MONITOR – RECORD – RESPOND The clinical condition of severely ill patients may change very rapidly or slowly deteriorate. Regular and frequent monitoring using a patient flow chart to record the data, will help you recognize changing patterns in the patient’s condition, take action, call for help, and determine the need for additional treatments. Severely ill patients should be cared for in a common area close to the nursing station where they are under frequent observation.

In the first 6 hours, monitor the following initially every 30 minutes, then every 60 minutes once the patient is stable: • systolic blood pressure (normal: systolic >90) • heart rate (normal: 60 –100) • respiratory rate (normal: 12 to 16) • SpO2 (normal: >95%, give oxygen if < 90%) • mental status (use AVPU scale: alert, responding to voice, responding to pain,

unresponsive).

Monitor the following every 6 hours: • temperature (normal 36–38°C) • urine output (normal >30 ml/hour) • physical examination of the respiratory and cardiovascular systems.

If you recognize a patient who is deteriorating, respond, treat, and call the senior clinician for help. When assessing the patient after any intervention, always look for the following: • Is the BP decreasing? Is the pulse increasing? • Is the SpO2 decreasing or the RR increasing? Is there worsening respiratory distress? • Is the urine output adequate? • Is the patient becoming more confused or less responsive?

DRILL 1-5: Monitoring Go around the room and each person say aloud: 1. During the initial management of a severely ill patient, what should be monitored every

30 minutes? Pulse, BP, RR, oxygen saturation, mental status

2. During the initial management of a severely ill patient, what should be monitored every 6 hours? Temperature, urine output, physical exam (lungs, cardiac, abdomen, peripheral circulation, oedema)


MONITOR Explain that regular monitoring of vital signs on a flow chart helps to detect patterns in the patient’s condition. Ask participants how often they think a severely ill patient should be monitored and what may be standard at their hospitals. Write what should be monitored and how often on the flipchart

KEY TEACHING POINTS Monitor o For first 6 hours, review what should be monitored every 30 minutes initially, then every

60 minutes:

o Review what should be monitored every 6 hours.

Ask participants to do DRILL 1-5: MONITORING. Go around the room and have each person say the answer aloud.


Severe illness monitoring form The following monitoring form on pages 15-1, has been developed to help you monitor severely ill patients. This form gives you quick access to important information. You can track the patient’s progress, easily review the patient’s status at any moment, and communicate with other staff about your patient’s clinical condition. With this form you will have access to the patient’s most recent vital signs, laboratory results, medication list, and drug allergies. This information can ensure continuity of care for your patient and reduce provider error. If you go off your shift, the next provider will know exactly what your patient needs based on the information in this form. On the back of the monitoring form you will find benchmarks for best practices. As you care for your patient, use this form to check off the benchmarks as you achieve them. These forms can be used for quality improvement initiatives and continuing medical education of staff.

You will find a sample monitoring form on the next two pages. Fill in the form using the numbered guidelines below. 1. Fill in the patient’s name, age, sex, patient clinic number, admission date and time. 2. Fill in the working diagnosis. 3. Fill in investigations. Circle the appropriate tests, if sent, and record the results. 4. For all women check if pregnant and, if so, note expected date of delivery (EDD). 5. Record any history of drug allergy and type of reaction. 6. Record the time of day at each monitoring point, starting with the time of arrival. The form

specifies time monitoring intervals in minutes, starting at time 0. Alternatively, if the patient monitoring form is started after a patient has already been admitted, record the time of day at the start of the resuscitation.

7. Record the following clinical parameters every 30 minutes until stable, then every 60 minutes: • SpO2 • systolic BP in mmHg • pulse • respiratory rate per minute • consciousness level – use AVPU scale: Alert – Responds to Voice – Responds to Pain

– Unresponsive. If trauma patient, fill in an initial Glasgow Coma Scale; repeat if head injury.

8. Record the following every 6 hours in column corresponding to time since arrival: • temperature in degrees Celsius • urine output in ml per hour. Record volume if Foley catheter used. If not, just enter

checkmark () if noted. • repeat glucose and haemoglobin if initial values abnormal.

9. Record results of glucose, haemoglobin. 10. Exam – record findings of patient examination. 11. Assess – record clinical assessment of major problems plus likely or differential diagnosis. 12. Response – indicate which treatment was given and at what time. 13. Initials – always write your initials after recording patient information. 14. Any additional notes – document any additional information about clinical history,

examination, interventions, and response as necessary to communicate clinical course to other health workers.

15. Benchmarks achieved – these are a targeted list of interventions that should be completed within certain time frames. They serve as markers of delivering high-quality care to severely ill patients. For example, a patient with septic shock should be given empirical antimicrobials within 1 hour. Using a checklist like this can help health workers to deliver high-quality care.


SEVERE ILLNESS MONITORING FORM How to use the severe illness monitoring form Review the severe illness monitoring form in the manual (or on the wallchart if available). This form will be used later for exercises. Spend more time with nursing group in this section.

KEY TEACHING POINTS

o Use the form for severely ill patients as soon as you start caring for the patient.

o For example, the form may be started in the emergency ward but then continue it in the hospital ward when the patient is moved there.

o The monitoring form allows for communication with other clinical staff between shifts and will help prevent errors.

Go through all the steps in using the form. Give the participants an opportunity to ask questions. Review the benchmarks.

9 – Chapter 1 Participant training manual: Management of the patient with severe respiratory distress or septic shock

Severe illness monitoring form (first six hours) Name: Patient No.: Birth date: ___/___/___ Age: Sex: M / F Admission date: Admission time: Diagnosis: Circle if test

sent and record result:

Electrolytes _______________________ Urine dipstick _________________ Malaria ________ AFB _______ Blood culture _______ Gram stain _______ CXR _________ Other _________________________________________________________

Pregnant: Yes/No EDD: Allergies: Time of day Monitoring

interval (minutes) from arrival or start

0 30 60 (1 hr)

90 120 (2 hrs)

150 180 (3 hrs)

210 240 (4 hrs)

270 300 (5 hrs)

330 360 (6 hrs)

390

Q30 – 60 min (until normal)

SpO2 Heart rate Systolic BP Respiratory rate Conscious level (AVPU)

Q1 – 6 hours, repeat if abnormal

Temperature (°C) Glucose Urine output* Haemoglobin

Exam Assess Response Fluids

(type, rate)

Oxygen (method, flow)

Salbutamol Vasopressor (type, rate)

Glucose Antibiotics Antimalarial Antiviral Furosemide Blood Other

Clinician (initials)

Facilitator guide: Management of the patient with severe respiratory distress or septic shock Chapter 1 – 9


Severe illness monitoring form (hours 7–24)* Name: Patient No.: Birth date: ___/___/___ Age: Sex: M / F Time of transfer: Ward: Diagnosis:

Circle if sent and record result:

Electrolytes _______________________ Urine dipstick _________________

Malaria ________ AFB _______ Blood culture _______ Gram stain _______ CXR _________ Other _________________________________________________________

Pregnant: Yes/No EDD: Allergies: Time of day Monitoring interval

(hours) 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Q 1 hour if SBP<90 or if on pressors, otherwise Q 2 hours

SpO2 Heart rate Systolic BP Respiratory rate Conscious level (AVPU)

Q 6 hours Urine output* Temperature (°C)

Repeat if initial value abnormal

Glucose Haemoglobin

Exam

Assess

Response Fluids (type, rate)

Oxygen (method, flow)

Salbutamol Vasopressor (type, rate)

Glucose Antibiotics Antimalarial Antiviral Furosemide Blood Other

Clinician (initials) *Use AVPU to record level consciousness: Alert – Responds to Voice – Responds to Pain – Unresponsive. For urine output, record volume if foley or just √ if noted.



Additional notes (please note any changes from standard protocol).

If severe respiratory distress, suspect pneumonia, or acute lung injury, within 30 minutes: Oxygen started SpO2 measured IV started If wheezing, salbutamol given Appropriate infection control Within 1 hour: Broad-spectrum antibiotics If malaria possible, antimalarial

given If influenza possible, antiviral

given

If acute pulmonary oedema, within 30 minutes: Oxygen started SpO2 measured Furosemide 20 mg IV given If hypertensive, isosorbide

dinitrate given If ischaemia (chest pain), aspirin

given If wheezing, within 30 minutes: Salbutamol given If asthma/COPD, steroid given

If shock, within 30 minutes: IV line and rapid fluids started 1000 ml fluid bolus given Within 1 hour, if fever or suspect septic shock: Antibiotics given If malaria possible, antimalarial

given If influenza possible, antiviral

given Within first 2 hours: 3 litres IV fluids given

If altered level of consciousness/convulsing: Oxygen started Oxygen saturation measured Recovery position Glucose checked and given If convulsing, diazepam given If convulsing and pregnant,

magnesium sulphate given If trauma, within 30 minutes: Oxygen started Oxygen saturation measured Spine immobilized until clear If shock, IV line and rapid fluid

bolus If shock, surgical consult Hb and type and cross sent

BENCHMARKS – circle the relevant condition(s), then check if achieved



Activity: Practice filling out the monitoring form

Directions: Work in groups of two or three. Read the scenarios and practise filling out the form. Use the scenario number as the patient number and today’s date/time for the admission date/time. 1. Mary S. Is a 34 year-old female with cough, fever and shortness of breath. Her son

said that she has had a rash on sulfa drugs. She is six months pregnant. Her chest X-ray shows bilateral patchy consolidations. Blood culture is pending. Mary S. Is alert. Initial vitals: temperature 39°C HR 120 BP: 80/60 RR40 SpO2 84%.

2. John B is a 60 year-old male who is brought in by family because he has been confused, feverish and very weak. Based on the Quick Check, he has cold hands with a delayed capillary refill. His pulse is faint. His BP is 70/40 and HR 130. Initial 1000 ml bolus of IV NS was started. Other initial vitals: temperature 40°C, RR 25 and SpO2 90% on room air. Blood sugar is 110. Repeat vitals after 30 minutes: HR 120 BP 80/50 RR 30 SpO2 89%, and John B is still confused.

General nursing care for the severely ill patient Keep patient under close observation

• In the emergency department and on the ward, place the patient close to the nurses’ station so that the staff can always see the patient or in an area designated for critically ill patients where they can be continuously observed.

• If the hospital is very busy, it may be necessary to enlist the help of family and caregivers to help watch the patient.

Prevent complications (pressure ulcers, skin breakdown, infections, deep venous thrombosis)

• Alternate the position of the patient so that he/she does not get pressure sores. • Check IV cannula daily, and replace if there are local signs of inflammation/infection. • Remove IV when it is no longer required. • Change to oral fluids and antimicrobials as soon as possible. • Initiate DVT prophylaxis as needed.

Nutrition for the severely ill patient Early attention to nutrition is important for a patient’s improvement and continued health. Once the patient has stabilized, start feeding the patient orally. Ideally oral feeding should occur within the first two days. Remember to assess the patient for aspiration before feeding. Coughing or spitting with feeds is a sign of aspiration. Patients should always be sitting in the upright position for feeds.


Ask participants to do Class Activity. Then go through the forms with them.

NURSING CARE FOR THE SEVERELY ILL PATIENT (SKIP THIS SECTION IF DOING 4-DAY COMBINED COURSE; HAVE PARTICIPANTS READ AT HOME). Keep the patient under close observation.

KEY TEACHING POINTS

o Do not leave critically ill patients alone.

o Critically ill patients should be where they can be continuously observed – close to the nurse’s station or in an area designated for critically ill patients.

o If the hospital is very busy, it may be necessary to enlist the help of family and caregivers to help watch the patient.

o Patients can develop complications such as venous thromboembolism and pressure ulcers quickly from lying in bed.

o Early attention to nutrition is important for the patient to improve.

Families and caregivers Ask participants what activities they could ask families to help with if the hospital staff is limited. Discuss the importance of involving family members (decision-making, simple tasks such as measuring urine output, positioning patient, informing staff).


There are some patients who may not be able to take food orally, such as a patient with a gastrointestinal disorder (severe pancreatitis) or who recently had gastrointestinal surgery (ileus), or who cannot safely swallow due to a risk of aspiration (altered mental status, severely short of breath or severely unwell, on-going vomiting). For those that cannot safely swallow, use a nasogastric tube to deliver feeds. • Give pureed foods through the nasogastric tube. • Give small amount initially, 20–40 ml/hour. • Monitor NG aspirates to check for absorption. • Increase rate of feeding as tolerated. • Sit patient upright even when getting NG feeds to avoid aspiration. All other patients should be provided with solid foods. Most patients have decreased appetites, so small frequent meals are better tolerated. In general give patients foods that are easy to digest such as mashed vegetables and soups. Also provide oral rehydration solution (ORS) and clean, boiled water.

Keep patient comfortable Patients who have altered levels of consciousness, or who are unconscious, can still experience pain and anxiety. Since they cannot tell you they are in pain, look for other signs: • Check for tachycardia, diaphoresis, anxiety, elevated blood pressure. • Treat pain. • Cover with blanket if patient cold. • Treat fever with antipyretic.

Respect patient privacy

• Keep the patient covered. • Do not discuss confidential patient information in front of others.

Families and caregivers

• If hospital staff is limited, families can be trained to carry out simple tasks such as measuring urine output, informing staff when IV fluids need to be replaced, and helping to position the patient.

Families and caregivers should be involved in the decisions surrounding their loved one and kept informed of the situation.

Limiting therapy and palliative care Many patients with critical illness will die. Maintain their comfort and dignity, and support the family through this period. When you run out of treatment options the focus of care should be on providing comfort. Where possible, this decision should be made by a senior clinician after discussion with the family.


Limitations of care • Ask participants to discuss as a group the limitations of care, how to talk to families when care

is futile, and how to handle their staff when a severely ill patient dies.

GROUP DISCUSSION (5 minutes): ASK: What methods do you use to talk to families who are under stress over the illness of their loved one? Discuss futile care and how to talk to family members when the situation is futile. ASK: What do you tell patients’ families when you know that the situation is futile?


Summary of severely ill patients Caring for severely ill patients requires a team approach, frequent monitoring, and timely response to clinical changes: Recognize changes in clinical condition, vital signs, abnormal diagnostic results. Record findings on severely ill patient monitoring form. Respond to abnormal physiology. Treat infection. Prevent complications. Start nutrition early. Keep patient under close observation. Keep patient comfortable. Respect patient privacy. Communicate with patient and family.

Assessment questions: Caring for the severely ill patient

Directions: Answer all the questions in the space provided. 1. What initial treatment would you give a patient with low blood pressure and no

urine output? Bolus of IV fluid

2. At minimum, how often should you measure the blood pressure in an unstable

severely ill patient? Every 30 minutes

3. At minimum, during the first 6 hours, how often should you record a physical exam in a

severely ill patient? 6 hours

4. A patient with respiratory distress and a measured oxygen saturation of 88% should be started on oxygen. True or False? True


Now ask the participants to answer the Assessment questions: Caring for the severely ill patient.


5. If you were caring for a patient on oxygen who seemed to be having increased difficulty breathing or decreasing oxygen saturation, you should first check the equipment to make sure that oxygen is flowing to the patient. True or False? True

6. For a 60 kg female, what is the minimum acceptable urine output that should be produced in 1 hour? 30-60 cc

7. List three things which should be done when caring for severely ill patients to ensure

their comfort or dignity? - Control pain - Control temperature (make sure patient is not too hot or too cold) - Alternate the position of the patient so that s/he does not get pressure sores - Respect patient privacy

8. List two reasons why a severely ill patient may not be able to take food or fluid orally?

-Severe respiratory distress -Altered mental status

9. The following patients are seen in a district hospital. Circle the patients who should be

cared for using the severe illness monitoring form: (a, c, e) a. A 54 year-old female with pneumonia and an oxygen saturation of 82% on

room air. b. A 24 year-old male with fever, cough, and congestion for two days, who is speaking

in full sentences and has an oxygen saturation of 98%. c. A 36 year-old male with severe abdominal pain and a blood pressure of 70/30. d. A 16 year-old female with fever and painful urination, and a blood pressure of

110/60. e. A 26 year-old male who complains of feeling weak, appears very pale, and has

a BP of 85/40.

Facilitator guide: Management of the patient with severe respiratory distress or septic shock Chapter 2–15

Chapter 2: Managing patients in septic shock

Duration: 1 hour 30 minutes Materials: -Blank flipchart/markers -Blank monitoring forms Wallcharts: -Quick Check -Monitoring form (if available) -Shock and severe respiratory distress tables (if available) -Oxygen therapy Preparation: -Review corresponding section in manual

Chapter Overview: • Knowledge of the different types of shock • Recognition and management of septic shock • How to monitor patients with septic shock and record on

monitoring form • What steps to take if patient with septic shock has abnormal signs

and/or laboratory results Learning Objectives: 1. Understand the types of shock. 2. Recognize septic shock. 3. Fix the physiology. 4. Treat the infection. 5. Use the severely ill patient monitoring form to monitor patients

with septic shock. 6. Respond to abnormal signs and laboratory results.

Content Methods Time Recognize shock Theory, Discussion 15 minutes

Recognize septic shock

Explanation, Discussion

10 minutes

Septic shock: first 2 hours

Explanation, Discussion, DRILL

20 minutes

Septic shock: 2-6 hours

Explanation, DRILL 10 minutes

Septic shock: 6-24 hours


Septic shock: Post-resuscitation

Explanation, DRILL, Case Scenario

15 minutes

Assessment questions

Written 10 minutes

Fac ilita to r gu ide : Management o f the pa tien t with s evere res p ira to ry d is tres s o r s ep tic s hock Chapte r 2 – 15.5

Chapter 2: Managing patients in septic shock

Learning objectives 1. Understand the types of shock.

2. Recognize septic shock.

3. Fix the physiology of patients in septic shock.

4. Treat the infection.

5. Use the severely ill patient form to monitor patients with septic shock.

6. Respond to abnormal signs and laboratory results.

Introduction Shock is a general term used to describe the clinical condition when a decrease in blood pressure results in inadequate perfusion (blood flow) and oxygen delivery to vital organs. This lack of blood flow causes cell death in the organs such as brain, heart, kidneys and gut. .

Patients in shock require rapid recognition and treatment to prevent further morbidity and mortality. Using the Quick Check you can see that patients in shock will often present with emergency signs of circulation, and other emergency or priority signs. Most often these patients will present with low blood pressure and fast pulse. Use the severely ill patient monitoring form when caring for patients with shock.

The first step is quickly recognizing a patient with shock. As you support the patient during the acute phase of shock, you will also be searching for and treating the underlying cause of shock. There are different types of shock:

• Septic shock results from an overwhelming infection. • Hypovolemic shock results from severe dehydration or fluid loss (diarrhoea).

• Cardiogenic shock results from cardiac failure.

• Anaphylactic shock results from a severe allergic reaction. • Haemorrhagic shock results from severe, acute blood loss.

• Neurogenic shock, which is less common, results from acute spinal injury.

Common signs of shock include: • Low BP (SBP<90) • Fast pulse • Pallor or cold extremities • Decreased capillary refill

• Dizziness or inability to stand • Decreased urine output (less than 30 ml/hour) • Difficulty breathing • Impaired consciousness, lethargy, agitation,

and confusion.


Recognize shock Ask participants to define shock.

KEY TEACHING POINTS: Shock means a decrease in blood pressure with inadequate blood flow and inadequate oxygenation of the vital organs. Shock is a clinical entity – but not a final diagnosis.

Ask participants to name the different types of shock. Write the 5 types of shock on the flipchart. Now, discuss what may cause these types of shock and add to flipchart.

GROUP DISCUSSION (5 minutes) Ask the participants to give examples of what may cause the types of shock and what signs and symptoms they would expect to see. The following are possible examples:

TYPE OF SHOCK

CAUSES HISTORY EXAM

Septic Urosepsis, pneumonia, influenza, malaria

- fever, HA, neck pain, sore throat, cough, back pain, abdominal pain, diarrhoea, pain with urination, painful joints, vaginal or penile discharge, skin wound?

- HIV? Diabetes?

- neck stiffness, photophobia, pharyngitis, abnormal breath sounds, abdominal tenderness, skin erythema, skin fluctuance, inflamed joints, penile or vaginal discharge

Haemorrhagic Trauma, ruptured ectopic pregnancy, GI bleed, postpartum haemorrhage

- recent trauma or recent surgery?

- vomiting blood, vaginal bleeding, bloody stools?

- current or recent pregnancy?

- visible active bleeding - tender and rigid abdomen - decreased breath sounds

Hypovolaemic Severe diarrhoea - watery diarrhoea? - poor appetite and

decreased oral intake?

- dry mucous membranes - sunken eyes - tenting of skin

Anaphylactic Allergen (e.g. latex, nuts, medications)

- obvious exposure to a precipitant such as an allergen (medication, foods or insect bite)?

- skin rash, facial swelling or wheezing, airway oedema

Cardiogenic Acute myocardial infarction, cardiomyopathy from alcoholism, cardiomyopathy from HIV, valvular disease

- worsening shortness of breath when lying flat, chest pain, or lower extremity oedema?

- history of congestive heart failure, rheumatic heart disease, ischemic heart disease?

- heart murmur, crackles or rales, lower extremity oedema, enlarged liver,

distended neck veins

Neurogenic Acute spinal cord injury

-recent trauma to spine?

-hypotension, slow pulse, abnormal reflexes and muscle tone, and warm, dry skin

List the general signs of shock.


When presented with a patient in shock, quickly identify the type of shock and treat accordingly.

Type of shock Signs and symptoms

Septic • temperature dysregulation • infective symptoms • sepsis can present as “hot shock“ (bounding pulse,

warm hands) or “cold shock“ (vasoconstriction, cold extremities)

Hypovolaemia • history of diarrhoea and vomiting • dehydration • burns • pancreatitis

Cardiogenic • older patient • known cardiac history • chest pain and difficult breathing, sweaty

Anaphylactic • very sudden onset angioedema and wheezing • new medication or known allergy

Haemorrhagic • trauma • bleeding (internal or external) • pregnancy complications

Neurogenic • -history of trauma to spine • -abnormal reflexes and tone • -urinary incontinence or retention

Take a history

• What are the main symptoms? • Is there any history of preceding symptoms such as vomiting and diarrhoea, abdominal

pain, or fever? • How quickly did the symptoms develop? If sudden onset, were there any obvious

precipitants such as possible exposure to an allergen or poison? • Is there a history of trauma? • What is the past medical and surgical history? • Is the patient pregnant?

Perform a focused examination to identify likely cause

• Look for signs of bleeding: Rigid tender abdomen suggesting internal bleeding, vaginal bleeding, vomiting blood, external bleeding from trauma, bleeding from mucosa suggesting clotting disorder or viral hemorrhagic fever. Remember to always use standard precautions when examining patients.

• Look for signs of severe dehydration: Dry mucus membranes, sunken eyes, decreased skin turgor, confusion, and decreased urine output.

• Look for signs of sepsis: Fever, local signs of infection, and confusion. • Look for signs of anaphylaxis: Rash, stridor, wheezing, and facial swelling. • Look for signs of cardiac disease: Distended neck veins, cardiac murmur, lower

extremity oedema, lung rales or crackles.


Explain that performing a thorough history and physical exam can help to determine the cause of shock. Discuss what questions should be asked to obtain a thorough history. Add this to the flipchart for the different types of shock (see table above).

KEY TEACHING POINTS: History Ask specifically about:

Predominant symptoms – what are the main symptoms and do they suggest localization to a particular bodily system, i.e. lungs or heart?

History of any preceding illness (e.g. diarrhoea and vomiting, abdominal pain, fevers);

Onset – when did the symptoms start?

Pre-existing disease (especially HIV, diabetes, cardiac disease)

Recent surgery

Current or recent pregnancy

Now, discuss what they should check on an exam and what pertinent findings may be found in a patient in each type of shock to flipchart (see table above)

KEY TEACHING POINTS: Physical exam

Check vital signs: BP, HR, RR, Temp, SpO2

Look for signs of shock • signs of anaphylaxis (rash, stridor, wheeze) • signs of sepsis (fever, local signs of infection) • signs of bleeding (rigid abdomen, vomiting blood, vaginal bleeding) • signs of cardiac disease (distended neck veins, cardiac murmur)


Develop a differential diagnosis While gathering information, begin to develop a differential diagnosis to determine the need for further investigations and treatment. Take a few minutes to review the differential diagnosis table for shock in the DCM, Section 3.1. How many of these conditions do you frequently see in your hospital?

Send urgent investigations When a severely ill patient is identified with shock, several laboratory and diagnostic investigations should be sent for immediately. These diagnostic investigations are based on a wide initial differential diagnosis. Often, you will need to begin treatments without the final diagnosis or you may need to treat the patient for more than one life-threatening condition. Do not delay ongoing, life-saving, treatments if results are not available.

Initial investigations may include:

• blood glucose • haemoglobin • pregnancy test for woman of childbearing years • if available

o BUN and creatinine o electrolytes.

If you suspect septic shock, try to identify the source of infection. Initial investigations may include:

• urine dipstick or microscopy • malaria screen • AFB smear and culture of sputum • chest X-ray • blood culture and gram stain • lumbar puncture • stool culture.

Treat for suspected diagnosis while supporting the patient

• “Fix the physiology” to continue support of the patient through the acute phase of the illness (i.e. give oxygen, fluids).

• If the underlying source of the shock is determined, treat the specific cause.

Septic shock If an overwhelming infection is not treated immediately a patient can develop septic shock. Patients with compromised immune systems, particularly those with HIV and diabetes are at increased risk of developing septic shock. The risk of death from infection increases dramatically when the patient develops septic shock, and early treatment saves lives. Using the algorithms in the DCM, we will now review in detail the acute management of patients with septic shock. These are general recommendations for the treatment of septic shock. As you go through this chapter, refer frequently to the algorithms provided for the management of septic shock and severe respiratory distress. Take a few minutes before you get started to review these algorithms as a group.


Give the participants 1-2 minutes to review the differential diagnosis table for shock in the DCM Section 3.1.

KEY TEACHING POINTS:

Investigations should not delay delivery of supportive treatments and empirical antibiotics.

Review the possible investigations and diagnostic tests.

Ask the participants to suggest what they may be looking for with each test, and how the results may make a diagnosis more or less likely.


If a specific diagnosis is made (pneumonia, dengue shock syndrome, etc.), use established local guidelines for treating the syndromes. Refer to table 3.1-16 of the DCM for the modified management of septic shock associated with specific infections. Remember to always use standard precautions and infection control measures.

Benchmarks are defined as standards of achievement or excellence. As timely management is extremely important in patients with septic shock, benchmarks for specified time points have been established. You should try to achieve these benchmarks as soon as you recognize that someone is in shock. We will review these benchmarks throughout this learning unit.

Benchmarks for treatment of septic shock Record the following clinical parameters every 30 minutes until stable, then every 60 minutes: • SpO2 • systolic BP in mmHg • pulse • respiratory rate per minute • consciousness level – use AVPU scale: Alert – Responds to Voice – Responds to Pain

– Unresponsive. If trauma patient, fill in an initial Glasgow Coma Scale; repeat if head injury.

Record the following every 6 hours: • temperature in degrees Celsius • urine output in ml per hour. Record volume if Foley catheter used. If not, just enter

checkmark () if noted. • repeat glucose and haemoglobin if initial values abnormal.

First 2 hours

RECOGNIZE The clinical diagnosis of severe sepsis or septic shock is defined as follows:

Suspected infection, plus

Hypotension (systolic blood pressure <90 mmHg), plus

One or more of the following: o pulse>100 beats per minute o respiratory rate >24 o abnormal temperature (<36oC or >38oC). It is important to note that the diagnosis does not require a fever to be present. A low temperature is also a cause for including a patient in the diagnosis.


Review the benchmarks for the treatment of septic shock. Ask participants to define septic shock. Write the definition of severe sepsis or septic shock on the flipchart. Ask participants with what Quick Check emergency signs a patient with septic shock may present. Ask them what actions will have been taken in the Quick Check for these patients (Answer: oxygen and IVF.) Explain that these actions would start to “fix the physiology.” Provide participants with a general understanding of the physiology of septic shock. In particular, they should know what to look for on exam that may be a sign of early shock.

KEY TEACHING POINTS Physiology of septic shock A patient goes into septic shock when they get an overwhelming infection (from any source – urine, lungs, skin, or abdomen).

The body’s immune system tries to fight the infection by releasing inflammatory cells that release many substances into the circulation.

Some of these substances cause blood vessels to dilate and to leak fluid, which results in hypovolaemia and low blood pressure, or shock.

As part of this immune response, the patient will often also develop a fever.

As the shock worsens, end organs such as the kidneys, GI tract, and the brain will not get adequate oxygenation because of low perfusion. Cells around the body start to function abnormally and eventually die.

If you think about what happens in septic shock, it will explain some of the symptoms commonly seen.

• low blood pressure (dilatation of veins) • fever (immune response) • increased respiratory rate (from metabolic abnormalities or infection in the lung) • confusion or lethargy (end-organ involvement of brain) • decreased urine output (end-organ involvement of kidneys) – will see increased

creatinine on labs • increased difficulty breathing (end-organ involvement of lungs) • mottling or bluish discoloration of extremities (end-organ involvement of skin) • abdominal tenderness (bowel ischemia) • wide-spread bleeding or blood clots (coagulation cascade, platelets) – will see low

platelet count or increased PT/PTT.


FIX THE PHYSIOLOGY Titrate oxygen to SpO2

Patients with severe sepsis and septic shock are at risk of developing severe respiratory distress and hypoxia. Supplemental oxygen treatment is not needed if the SpO2 is initially above 90%. However, these patients must be monitored closely for the initial 6 hours, as respiratory distress and hypoxia can develop over time.

Check SpO2 every 30 minutes. o If the SpO2 is below 90%, then give oxygen and titrate to keep the SpO2 above 90%.

Fluids

o After initial bolus of 1000 ml, continue rapid fluids LR or NS at 20 ml/kg/hour – up to 60 ml/kg within first 2 hours.

During the Quick Check, any patient with emergency signs of circulation should have received one litre of crystalloid fluid (NS or LR) as a first-line emergency treatment. Now, if you suspect septic shock, the patient should continue to be given IV crystalloid fluid for resuscitation. To guide fluid administration as these questions:

• Is the patient still in shock? • What is the time interval (the recommendations are based on time from the start of

resuscitation)? • What is the patient’s estimated weight? The goal is to administer one litre of IV crystalloid fluid within initial 30 minutes AND up to 60 ml/kg by the end of hour 2 (this includes the initial one litre bolus given during the Quick Check). Only use lactated ringers (LR) or normal saline (NS) for fluid resuscitation. Do not use D5W or ½ NS. If a patient is also hypoglycaemic, you can treat with IV dextrose as a bolus, but usually you should not add dextrose to the resuscitation fluids.

TREAT THE INFECTION In a severely ill patient with septic shock, it is important to initially treat for all possible sources of infection, even if laboratory and diagnostic results are not yet available. For example, in a patient with suspected septic shock due to suspected pneumonia you may initially treat for bacterial pneumonia, malaria (if in endemic area), and influenza (if during influenza season or a pandemic). It may be several days or sometimes even weeks, before a specific microbiological diagnosis can be made. These severely ill patients will rapidly deteriorate if not treated quickly. The goal is to administer antimicrobials to a patient in septic shock within the first hour of treatment.

Weight-based fluid Target volume Small patient/

adolescent (30kg) Medium patient (50kg)

Large patient (≥70kg)

Initial bolus 20ml/kg 500ml 1000ml 1500ml Fluid target between 1-2 hours (20-40ml/kg)

500-1000ml 1000-2000ml 1500-3000ml

Maintainence fluids (2ml/kg/h)

60ml/h 100ml/h 140ml/h


Now give the participants the following brief scenario.

CLINICAL SCENARIO A patient recognized to be in septic shock was given 2 litres of LR. The patient then improved and the BP increased to 110/60. After 30 minutes, you recheck the blood pressure, and it is now again 85/40. What would you do now? ANSWER: Give bolus LR/NS 20 ml/kg and reassess.

TREAT THE INFECTION

Show the Shock table in the Participant manual and on the wallchart, if available. Show the “TREAT THE INFECTION” box. Emphasize the importance of early antibiotic treatment.

KEY TEACHING POINTS Oxygen Measure SpO2 in all patients with septic shock during the Quick Check and then every 30 minutes.

• If SpO2 >90%, oxygen is not needed. • Monitor these patients closely in the initial 6 hours for the development of respiratory

distress and hypoxia. • If SpO2 <90%, give oxygen to keep the SpO2 above 90%.

Fluids During the Quick Check, the patient with shock received 1 litre of NS or LR.

• 3 questions need to be answered to determine fluid treatment for septic shock: − Is the patient still in shock? − What is the time interval since treatment began? − What is the patient’s estimated weight?

• If the patient is in septic shock in the first 2 hours: − If the patient is still in shock, a second fluid bolus is recommended in Quick Check

(this is approximately crystalloid fluids at 20 ml/kg/hr). − Give a maximum of 60 ml/kg over 2 hours (this includes the initial 1 litre given

during the QC). − Do not use D5W or ½ NS, only NS or LR!

• If patient also hypoglycaemic, give bolus of IV dextrose. − Do not add dextrose into the resuscitation fluids.

The goals are to administer 1 litre of IV crystalloid fluid within initial 30 minutes AND up to 60 ml/kg by the end of hour 2 (this is about 3.6 litres over 2 hours for a 60kg person).


Antibiotics Studies have shown that the slightest delay in treating a patient with septic shock may increase the patient’s chances of death. During the Quick Check, you generally would have administered empirical antibiotics as an urgent treatment. Make sure this treatment has been given. o Choice of antibiotics depends of presence of focal signs of infection, local patterns of

disease, and availability of antibiotics. o If you suspect severe community acquired pneumonia, refer to local guidelines.

Common choices include ceftriaxone (1 gram daily) or ampicillin plus gentamicin (if community acquired pneumonia is suspected, add either a macrolide or respiratory fluroquinolone).

o Limit fluroquinolone use if alternative antibiotics are available, if TB is suspected, or if treating a pregnant patient.

Antimalarials when appropriate If you suspect severe malaria as possible cause of shock, give antimalarials immediately. Malaria smears should be sent to evaluate and repeated if necessary, but antimalarials should not be delayed in cases of severe malaria.

Antiviral if suspect influenza If influenza is suspected as cause of septic shock during influenza season or an influenza pandemic, treat the patient with appropriate antiviral immediately in accordance with recommendations for your hospital. Do not delay treatment to wait for viral testing results.

Identify source and control the infection During this time, make sure that laboratory and other diagnostic tests have been sent. This may include blood cultures, malarial smear, chest X-rays, sputum for AFB and where available molecular testing for TB. Consider TB, especially in persons living with HIV. Always use universal precautions, and take appropriate infection control measures. If there is an infection that needs surgery or debridement such as empyema, necrotizing soft tissue infection or acute appendicitis, then consult a surgeon immediately. If a specific diagnosis is made, such as pneumonia, dengue shock syndrome or malaria, you may choose to use established national or international guidelines.

MONITOR – RECORD Frequent and systematic clinical assessments should include a review of vital signs, physical examination findings and key laboratories. Record these findings on the severely ill patient monitoring form.

Every 30 minutes until stable then every 1 hour: • SBP • pulse • respiratory rate • SpO2 • mental status (AVPU) • JVP, auscultate for crackles (rales)

Check results of emergency laboratory: • if haemoglobin <7 mg/dl (Hct <20) consider

transfusion • if glucose <3 mmol/l (54 mg/dl) then give D50 25–

50 ml(see Quick Check page 19)


MONITOR, RECORD AND RESPOND Show the Shock table again, and now show the “MONITOR and RECORD, AND RESPOND” boxes.

KEY TEACHING POINTS Monitor Conduct frequent and systematic clinical assessments.

Includes: review of vital signs, physical examination findings, and key laboratories

Record and Respond Record on severely ill patient monitoring form.

Respond rapidly to changes or new abnormalities. • Example: If your patient with septic shock develops worsening respiratory distress,

then check SpO2 and start oxygen therapy.

KEY TEACHING POINTS

Give antimicrobials to treat all possible causes of infection • Do not wait for laboratory results of blood cultures, malaria smears, or influenza tests

in the severely ill patient if waiting for test results will result in any delay in treatment. • Empirical treatment is indicated for the severely ill patient. In patients who are stable

and not severely ill, it may be advised to wait for test results prior to beginning treatment.

Antibiotics • Studies have shown that each moment’s delay may increase the patient’s chances of

death. • Ensure that empirical antibiotics have been given during the Quick Check, as

indicated. The goal is to administer antimicrobials within the 1st hour of treatment.

Antimalarials when appropriate • If you suspect severe malaria, give antimalarials immediately.

Antiviral if suspect influenza based on existing regional or national recommendations.

Consider TB especially in PLHIV

Identify and control the infection • Send other laboratory/diagnostic tests to identify the cause of infection during this

time. • Examples: blood cultures, malarial smear, chest X-rays, or sputum for AFB • However, do not wait for the results to treat. • Consult a surgeon immediately if there is an infection that needs surgical removal or

debridement, e.g. empyema, necrotizing soft tissue infection, or acute appendicitis. • Use established national or international guidelines as agreed upon for specific

diagnosis, e.g. pneumonia, dengue shock syndrome, or malaria.

Review the benchmark box in the patient monitoring form.


RESPOND You should respond rapidly and appropriately to changes, new abnormalities, or diagnostic test results. If your patient with septic shock develops worsening respiratory distress (increasing RR, decreasing SpO2): • Titrate oxygen and check oxygen supply. • If wheezing give patient salbutamol. • If elevated JVP or increasing crackles suspect fluid overload. Slow down rate of fluid

administration and call for help. If still in shock (SBP<90) the patient may need to be started on vasopressors to support their circulation.

DRILL 2-1: Management of septic shock initial two hours

You are caring for a patient and suspect septic shock. 1. During the Quick Check your patient was found to have emergency signs of circulation.

You suspect septic shock. What is the clinical definition of septic shock in the IMAI DCM? Hypotension (SBP<90) AND 1 or more of the following: HR>100 RR>24 Abnormal temperature (<36 or >38) AND Suspected infection

2. Your patient has been given one litre of crystalloid fluid and the BP is 80/40. What type of IV fluids would you now give to the patient and at what rate? Second 1 L bolus of LR or NS (approximately 20 ml/kg/hour)

3. How much fluid should the patient in septic shock have received after two hours of appropriate treatment? Up to 60 ml/kg

4. According to the IMAI benchmarks, antibiotics should be administered to patients in septic shock within one hour. True or False? True

5. Patients with septic shock infected with HIV and TB are at high risk of clinical deterioration and death. True or False? True

6. List at least 3 laboratory or diagnostic tests that can be sent to evaluate for a source of infection? Blood cultures and Gram stain, malaria smear,-sputum for AFB, urinalysis, lumbar puncture, chest X-ray, stool culture


Have participants do the DRILL2-1: Management of septic shock initial two hours.


2-6 hours

RECOGNIZE Re-assess the patient and recognize if the patient is responding to treatment. Reconsider your diagnosis of septic shock if the patient is worsening.

o Is the patient still in shock? If so, is there another cause other than suspected septic shock? Is there any evidence of active blood loss?

o Look at the results of any diagnostic tests that are now available. What is the etiology of septic shock? Does the patient require drainage or debridement of an infection?

FIX THE PHYSIOLOGY Oxygen It is often during this timeframe, that patients in septic shock may begin to develop severe respiratory distress and hypoxia. Hypoxia can result from a primary infection of the lungs, fluid overload, or injury to the lungs from the overwhelming infection. o Check SpO2 every 30 minutes. o Give oxygen, if needed, titrate to SpO2 ≥90%.

Fluids Early fluid treatment for patients with septic shock is a key intervention that saves lives. By the end of the second hour the patient should have received up to 60 ml/kg of IV crystalloid fluid. For a 70 kg person this would be about 4.2 litres. Further management of fluid must continue, but the rate of fluid administration is dependent on the patient’s condition. Continue to monitor the patient frequently over this time period. Assess for adequate perfusion using clinical indicators and urine output to determine whether the patient is still in shock.

If shock has improved (SBP >90): o give IV crystalloid fluid (NS or LR) at rate of 2 ml/kg/hr.

If shock persists (SBP <90): o give IV crystalloid (NS or LR) at rate of 5–10 ml/kg/hour o consider starting vasopressors to support circulation (consult with senior physician).

Vasopressors Despite appropriate initial treatment, there may be patients who do not respond and continue to have low blood pressure at the end of the second hour of management. If a patient remains in shock and has clinical signs of poor perfusion (low BP, low urine output, altered level of consciousness) after early, aggressive IV fluid treatments, and antibiotics, consider the use of vasopressor medications to temporarily support circulation. Vasopressors work by vasoconstriction and increasing the contractility of the heart. Examples of vasopressor medications include epinephrine (adrenaline) and dopamine.

The decision to use vasopressors should be made by a senior clinician.


• Show the Shock table: 2-6 hours in the Participant manual and on wall chart (if available) and point to the “RECOGNIZE” box.

RECOGNIZE

KEY TEACHING POINTS ASK: Is the patient still in shock? If so, is there another cause? Active blood loss?

• Reconsider diagnosis if the patient is not responding to fluid boluses. What is aetiology of septic shock? Does the source need drainage or debridement?

• Check results of initial laboratory tests; results may assist in determining aetiology. • Show the Shock table again and point to the “FIX THE PHYSIOLOGY” box. FIX THE PHYSIOLOGY

KEY TEACHING POINTS Oxygen

• Continue to check SpO2 every 30 minutes during the 2–6 hour time frame • Patients with severe sepsis and septic shock are at risk to develop severe respiratory

distress and hypoxia. Fluids

• By the end of the 2nd hour, patient should have received up to 60 ml/kg of IV crystalloid fluid.

• For a 70 kg person this would be about 4.2 litres.

• If shock persists (SBP < 90): • Give IV crystalloid (NS or LR) at rate of 5-10 ml/kg/hr through end of hour 6. • Consider vasopressors (see below).

• If shock is resolved (SBP > 90): • Give IV crystalloid fluid (NS or LR) at rate of 2 ml/kg/hr.

Vasopressors ***At this point provide participants with the vasopressor handout that updates their manual on current Uganda DCM-includes updated instructions to mix vasopressors, vasopressor tables and drills

o Start vasopressors in patients who remain in shock (SBP<90) and have signs/symptoms of low perfusion (decreased urine output, altered mental status) by the end of the 2nd hour. • Decision should be made by a senior clinician • Patient will not improve on vasopressors alone if they have not been adequately

resuscitated and given antimicrobials. • Use short term only; these drugs have dangerous side-effects if not used correctly


A patient who has not been adequately fluid-resuscitated and treated with antimicrobials for the underlying cause of the septic shock will not improve on vasopressors. Vasopressor medications are meant for short-term use only to support a patient during an acute illness, and have dangerous side-effects if not used correctly.

Side-effects of vasopressors include tissue necrosis if the IV infiltrates, arrhythmias, and ischemia to organs (skin, gut, kidneys). You should use the minimum dose possible to maintain the blood pressure (target SBP of 90). Give vasopressors carefully by intravenous infusion and dose the medication based on the patient’s weight.

o Always dilute vasopressor medication and give by infusion at a strictly controlled rate.

o When preparing these drugs for infusion, have a colleague double check that all safety steps have been taken and the concentration and infusion rate is correct. Read the ampoule label 3 times to confirm the concentration before mixing.

o If administered through a peripheral vein, use the largest vein possible. o Do not use the blood pressure cuff on the same arm through which the medication is

infusing. o Use a metal gate-clamp in the IV rather than the integral roller device. The roller can

become loose and deliver the medication at the incorrect rate. o Inspect infusion site regularly to avoid leaking of the medication into the tissues. o Monitor patients frequently, continuous monitoring is preferred if available. o If unable to continuously monitor, then initially monitor the BP and HR at least every

five minutes until patient is at a stable infusion rate. Use the table below to determine the appropriate dose and rate of infusion.

Mixing the correct concentration of vasopressor medication

How to give vasopressor by peripheral infusion

Vasopressor Peripheral epinephrine infusion Peripheral dopamine infusion (preferred for shock in severe malaria)

Commonly available concentrations

1 amp = 1 mg epinephrine (adrenaline) in 1 ml*

1 amp = 200 mg dopamine in 5 ml*

Target infusion concentration

10 micrograms per ml 1000 micrograms per ml

Mixing procedure to create target infusion concentration

Use: 2 amps in 200 ml normal saline** OR 10 amps in 1000 ml normal saline**

Use: 1 amp dopamine in 200 ml normal saline** OR 5 amps dopamine in 1000 ml normal saline**

Epinephrine Dopamine

Dose rate*** 0.05 micrograms/ kg/minute

0.2 micrograms/kg/minute for very hypotensive

10 micrograms/ kg/minute



Infusion rate (ml/hour)**** Patient weight (kg)

50 kg 15 ml/hour 60 ml/hour 30 ml/hour 45 ml/hour 60 ml/hour 60 kg 18 ml/hour 72 ml/hour 36 ml/hour 54 ml/hour 72 ml/hour 70 kg 21 ml/hour 84 ml/hour 42 ml/hour 63 ml/hour 84 ml/hour

* 1 milligram (mg) is equal to 1000 micrograms (mcg). ** Read ampoule label 3 times to confirm concentration before mixing. *** Desired dose rate is weight based. **** Infusion rate is commonly presented per hour Infusion rate = desired dose rate/concentration of the infusion.


Using vasopressors Review how to administer vasopressors and use the vasopressor table. Discuss side-effects of vasopressor and important considerations.

KEY TEACHING POINTS

Participants should understand that vasopressors should only be used as a temporary medication in severely ill patients while waiting for other treatments to work.

The side-effects of vasopressors include tissue necrosis if IV infiltrates, arrhythmias, ischemia to organs (skin, gut, kidneys).

Use minimum possible dose to maintain SBP of 90.

Review the list of important considerations when administering vasopressors. Allow participants time to ask questions and discuss any difficulties when using these medications in their hospital settings.

Review the vasopressor table and explain how to determine appropriate dose. Write all calculations on the flipchart.

KEY TEACHING POINTS Mixing the correct concentration of medication (ideally should be done by pharmacist). Write on flipchart: Remember that 1 mg=1000 micrograms. The usual concentrations are:

• one amp epinephrine = 1 mg epinephrine (adrenaline) in 1 ml • one amp dopamine = 200 mg dopamine in 5 ml.

Epinephrine target infusion concentration of 10 micrograms per ml • mix 2 amps in 200 ml of (D5W, NS, LR) or • mix 5 amps in 500 ml of (D5W, NS, LR) or • mix 10 amps in 1000 ml of (D5W, NS, LR)

Dopamine target infusion concentration of 1000 micrograms per ml • mix 1 amp in 200 ml of (D5W, NS, LR) or • mix 2.5 amps in 500 ml of (D5W, NS, LR) or • mix 5 amps in 1000 ml of (D5W, NS, LR)

Explain how to determine correct infusion and go through example. The desired dose rate is weight-based. First choose the row in the tables which matches the patient’s weight, then choose the dose rate (start with the lowest). The infusion rate is commonly presented per hour but is monitored by setting the drip rate. The drip factor of the set determines if there are 10, 20 or 60 drops/ml. Based on the set you are using, choose the drip rate for the desire dose. For example, in a 40 kg patient with a drip set that provides 10 drops/ml, to start dopamine at the lowest infusion rate of 12 ml/hour, you would provide just 2 drops per minute.


Titration of vasopressors: o Use the lowest infusion rate possible to support the blood pressure

o epinephrine start at 0.05 micrograms/kg/min o dopamine start at 10 micrograms/kg/min.

o Initially, monitor the pulse every minute and the BP every 2-5 minutes, or continuously if available.

o Continue to monitor the BP continuously or every 2–3 minutes until the patient has stabilized.

o If after 10 minutes the SBP is still <90, increase the infusion rate. o Titrate the dose in small increments:

o epinephrine-titrate dose in 0.05 microgram/kg/min increments to a maximum dose of 0.2 micrograms/kg/min

o dopamine-titrate the dose in 2 microgram/kg/min increments up to a maximum dose of 20 micrograms/kg/min.

o Recheck the patient in 30 minutes. If the blood pressure and perfusion is improving, gradually decrease the infusion rate to keep the SBP>90 and adequate perfusion.

o Continue to administer intravenous fluids to patients who are receiving vasopressors.

Stop the infusion if: o The drip has infiltrated the tissues. o There is skin blanching. o The patient develops an irregular pulse, arrhythmia, or dangerous tachycardia. o The patient develops severe pain or swelling at the infusion site. Example A 60 kg female in septic shock has a blood pressure of 80/40 and no urine output, after receiving almost four litres of normal saline. The senior clinician decides to start vasopressors. The clinician orders an infusion of epinephrine (adrenaline) at a target infusion concentration of 10 micrograms per ml, and an initial dose rate of 0.05 micrograms/kg/minute. Ideally, the clinician should be at the bedside to monitor the patient when vasopressors are started.

Step 1: Get the epinephrine and read the label three times, to check the ampoule concentration.

Step 2: If the concentration of epinephrine is 1 mg epinephrine in 1 ml, mix two ampoules in 200 ml of normal saline. Alternatively, mix 10 amps in 1000 ml of normal saline if you suspect the patient will require the vasopressor for a longer period of time.

Step 3: Estimate the weight of the patient.

Step 4: Determine the desired dose rate for infusion. For a 60 kg patient, for a dose rate of 0.05 micrograms/kg/min, infuse the medication at 18 ml/hour.

Step 5: Check the patient immediately after the infusion is started to make sure the medication has not infiltrated.

Step 6: Observe the patient. Monitor the pulse and blood pressure continuously if a monitor is available. If continuous monitoring is not available check the pulse and BP every two to three minutes until the patient is at a stable infusion rate.


Explain how to titrate the vasopressors.

KEY TEACHING POINTS

Use the lowest infusion rate possible to support the blood pressure.

Titrate the dose in small increments • epinephrine – titrate dose in 0.05 microgram/kg/min increments to a

maximum dose of 0.2 micrograms/kg/min • dopamine – titrate the dose in 2-5 microgram/kg/min increments up to a maximum

dose of 20 micrograms/kg/min. Recheck the patient in 30 minutes. If the blood pressure and perfusion is improving gradually, decrease the infusion rate to keep the SBP>90 and adequate perfusion. Continue to administer intravenous fluids to patients who are receiving vasopressors.

Explain when to stop the infusion.

KEY TEACHING POINTS Stop infusion if: The drip has infiltrated the tissues (e.g. severe pain or swelling at the infusion site).

There is skin blanching.

The patient develops an irregular pulse, arrhythmia, or dangerous tachycardia.

Review the example together as a group, and go through the six steps.

Example calculation of vasopressor infusion rate for tables if participants need further explanation:

-using epinephrine starting dose rate

50 kg person X (0.05mcg/kgXmin)X (60min/1 hr)X (1 ml/10 mcg)= 15 ml/hr

15ml/hr X (1hr/60min) X DF 10 drops/ml (based on set that is being used) =2.5 drops/minute


DRILL 2-2: Vasopressors Use the table above from the DCM to help you. 1. You want to prepare a dilution of 10 micrograms of epinephrine per ml. Use the

vasopressor table and list two ways to correctly mix the dilution? 2 amps in 200 ml normal saline or 5 amps in 500 ml normal saline or 10 amps in 1000 ml normal saline

2. You want to prepare a dilution of 1000 micrograms of dopamine per ml. Use the vasopressor table above and list two ways to correctly mix the dilution? 1 amp dopamine in 200 ml normal saline or 2.5 amps in 500 ml normal saline or 5 amps dopamine in 1000 ml normal saline

3. You are asked to start an infusion of epinephrine on a 60 kg female because the blood pressure has remained low after three litres of normal saline have infused. The blood pressure is now 80/40 and you would like to start the infusion at 0.05 micrograms/kg/minute. Using a dilution of 10 micrograms/ml describe how you would mix the correct dilution and at what rate per hour you would infuse the medication. Mix 5 amps in 500 ml normal saline, or 10 amps in 1000 ml normal saline. Start infusion at 18 ml/hr.

4. Despite starting the epinephrine, the blood pressure has remained low and you are asked to increase the infusion. How fast would you run the infusion? Increase infusion to 36 ml/hr *for answers 5-8 see next page

TREAT THE INFECTION Between hours 2–6, results from laboratory tests may be available to assist you in determining the cause of septic shock. Continue broad-spectrum antibiotics until a senior clinician can make changes to the antibiotic orders based on focal signs of infection or laboratory results.

MONITOR – RECORD – RESPOND Carry out frequent and systematic clinical assessments and include a review of vital signs, physical examination findings and key laboratories. Respond rapidly and appropriately to changes or new abnormalities. o Check vital signs every 30 minutes (BP, HR, RR, SpO2, AVPU). o Check urine output. o Examine the patient. Has the mental status changed? Look for evidence of the

development of pulmonary oedema (elevated jugular venous distension, crackles). o If evidence of pulmonary oedema, slow down the fluids and call the senior clinician for

help.


Tell participants to do DRILL 2-2: VASOPRESSORS. Then go through the answers with them. For answers 5-7 in Drill 2-2: 5. 7 drops/min, 28 drops/min 6. Epinephrine 0.2 mcg/kg/min, dopamine 20 mcg/kg/min 7. Start titrating drip down since improving, 10 mcg/kg/min 8. 72 drops/min TREAT THE INFECTION

Show the Shock table again, and now show the “TREAT THE INFECTION” box.

KEY TEACHING POINTS

Check laboratory results; they may help in determining the cause of septic shock.

Continue with broad spectrum antibiotics until a senior clinician makes changes based on focal signs of infection.

MONITOR, RECORD, AND RESPOND Show the Shock table again, and now show the “MONITOR, RECORD, AND RESPOND” box.


o Recheck Hb if initial value abnormal. Refer to local guidelines regarding blood transfusion protocols.

o Recheck glucose, if initial value abnormal.

DRILL 2-3: Managing septic shock 2–6 hours You are caring for a patient with septic shock. After two hours of appropriate fluid therapy, your patient remains in shock with a blood pressure of 80/40.

1. What type of intravenous fluid would you administer? Crystalloid (NS or LR)

2. What rate would you administer the fluid?

5-10 mL/kg/hr 3. How long would you continue fluid at this rate?

Until end of hour 6 4. Would you start vasopressors?

Yes 5. List two reasons to stop the infusion of a vasopressor medication?

Any 2 of the following: - Drip has infilitrated the tissues - There is skin blanching - Patient develops an irregular pulse, arrhythmia, or dangerous tachycardia - Patient develops severe pain or swelling at the infusion site.

6. The patient is started on a dopamine infusion. When the medication is initially started,

how often should the HR and BP be assessed? Continuously if possible; otherwise every 2-5 minutes until patient stable

7. The SBP rises above 90 mmHg and your patient is on epinephrine (adrenaline) at 0.2

mcg/kg/min, how would you adjust the vasopressor rate (use vasopressor table to help determine correct answer)? Decrease to 0.15 micrograms/kg/minute

8. The SBP is above 90 mmHg for one hour. Your patient is not currently on vasopressors.

How would you adjust the fluid administration rate? Decrease IV NS or LR to 2 mL/kg/hr


Have participants do the DRILL 2-3: Septic shock 2-6 hours. Participants will need to refer to the vasopressor table in their manual for this drill.


6-24 HOURS

RECOGNIZE Continue to assess the patient and recognize if the patient is responding to treatment. Reconsider the diagnosis if the patient is not responding and the blood pressure remains low. At 6-24 hours often you will have some results available to determine the source of infection, including if the patient requires surgery.

FIX THE PHYSIOLOGY Oxygen During the 6–24 hour time frame, continue to monitor for the development of severe respiratory distress and hypoxia. Titrate oxygen for SpO2 ≥90%. If the SpO2 has been stable and above 90%, then monitor every two hours or when the patient’s condition changes.

Fluids Depending on the rate of fluid administration between 2-6 hours, by the end of hour 6 a 70 kg person would have received between 5 and 7 litres of IV crystalloid fluid. At the onset of the seventh hour, continue fluids but decrease the rate to 2 ml/kg/hr in all patients regardless if the patient remains in shock or not.

Vasopressors As discussed before, vasopressors are intended to be used only temporarily.

If shock has improved (SBP >90): o titrate the vasopressors (decrease rate) and eventually off. If shock persists (SBP <90): o titrate vasopressors (increase rate).

TREAT THE INFECTION

Between hours 6–24, additional results from diagnostic tests may assist you in determining cause of septic shock. Continue with broad-spectrum antimicrobials until a senior clinician makes changes based on focal signs of infection: o give additional antimicrobials if indicated based on suspected source of infection o drain or debride infections, if indicated o give next dose of antimicrobials when indicated.

Fac ilita to r gu ide : Management o f the pa tien t with s evere res p ira to ry d is tres s o r s ep tic s hock Chapte r 2 – 28

Show the Shock table: Post-resuscitation, and point to the relevant box as the points are discussed.

KEY TEACHING POINTS

RECOGNIZE • Is the patient still in shock? If so, is there another cause? Active blood loss?

− If yes, reconsider the diagnosis. • What is aetiology of septic shock?

− Check laboratory results to help determine aetiology. FIX THE PHYSIOLOGY

• If SpO2 has been stable and >90%, then monitor every 2 hours or when patient develops a change in any clinical parameter.

• A 70 kg person would have received 5.6 to 7.0 litres IVF by the end of the 6th hour of management (depending on rate chosen between hours 2–6). At the onset of the 7th hour, decrease IV crystalloid fluid rate to 2 ml/kg/hr in all patients regardless of whether shock is present or not. Ask participants to calculate the following:

• At what rate would a 50 kg person who is still in shock receive IVF after 7 hours of management? At what rate would a 100 kg person in shock receive IVF after 7 hours of management? What would the rate for IVF be for the same 100 kg person whose blood pressure is now improved at hour 7 and the patient is no longer in shock?

• ANSWER: 2 ml/kg/hr for all patients at 6–24 hours, regardless of whether shock is present or not.

• Titrate vasopressors as needed TREAT THE INFECTION

• Continue with broad spectrum antibiotics until a senior clinician makes changes based on focal signs of infection. − Give second dose of antimicrobials. − Drain or debride infections, if indicated. Obtain surgical consultation, if needed.

Write on flip chart: Summary of fluids from 0-24 hours 0-2 hours up to 60 ml/kg/hr 2-6 hours 5-10 ml/kg/hr 7-24hours 2 ml/kg/hr


MONITOR – RECORD – RESPOND Continue to carry out frequent and systematic clinical assessments and include a review of vital signs, physical examination findings and key laboratories. Respond rapidly and appropriately to changes or new abnormalities.

o Check vital signs, mental status, and evaluate for the development of pulmonary oedema every 1–2 hours.

o Every 6 hours: o monitor urine output o recheck Hb, if previously abnormal, suspect ongoing haemorrhage, or after a blood

transfusion o recheck blood glucose if previously abnormal result was treated.

o Despite all treatments, some patients with septic shock may not be improving. Make sure to communicate clearly with the family during this difficult situation.

DRILL 2-4: Management of septic shock 6–24 hours

You are caring for a patient in septic shock. After 6 hours your patient remains in shock and is on a peripheral epinephrine infusion at 0.05 mcg/kg/min.

1. What type of fluid would you administer and at what rate? IV NS or LR at 2 mL/Kg/hr

2. If the blood pressure is now 80/40, how would you adjust the vasopressor infusion (use vasopressor table to help)? Increase to 0.1 mcg/kg/min

3. How often would you measure the blood pressure in this patient? 2-5 minutes while vasopressor being titrated

4. The patient was given a dose of an antibiotic on arrival to the hospital, eight hours ago. The antibiotic is scheduled to be given every eight hours. You still do not know the definite source of infection in your patient. Should you give the second dose of antibiotic, yes or no? YES

5. Your patient is developing worsening respiratory distress. The previous oxygen saturation had been 98% on room air so the patient is not currently on oxygen, but the oxygen saturation is now dropping and it is 90%. What actions would you take? Would you start the patient on oxygen? - Consider fluid overload, call district clinician - YES


Ask participants to do the DRILL 2-4: Septic shock 6-24 hours. Participants will need to refer to the vasopressor table in their manual for this drill.

KEY TEACHING POINTS

Continue to monitor vital signs, conduct focal physical exams and check for key laboratories. Monitor for the development of pulmonary oedema. Review the clinical exam findings of pulmonary oedema.

• If SBP >90, then check vital signs every 2 hrs. • If SBP<90 or on pressors, then check vital signs every hour.

Record findings on the monitoring form and respond rapidly and appropriately to changes or new abnormalities.


POST-RESUSCITATION

RECOGNIZE In the post-resuscitation period, it is important to determine the etiology of the septic shock and determine the specific treatment course for the infection. o When possible, narrow antimicrobial coverage and determine length of treatment. o Use IMAI DCM for disease-specific treatment guidance.

FIX THE PHYSIOLOGY Oxygen During the post-resuscitation period, continue to monitor the SpO2and titrate the oxygen. However, if the SpO2 has been stable and above 90%, then monitor every 8 hours or when patient develops a change in any clinical parameter.

Fluids In the post resuscitation period, start patients who are improving and recovering their appetite on oral fluids while IV crystalloid continues at 2 ml/kg/hr. Once the patient is taking sufficient fluids orally, discontinue intravenous fluids.

TREAT THE INFECTION Continue with a full course of antimicrobial treatment as determined by the senior clinician. Switch to oral antimicrobials when possible.

NUTRITION As discussed in the previous chapter, nutrition therapy is important in the recovery of severely ill patients. Once shock is treated, it is safe to begin to feed patients orally. Most patients lose their appetite when ill, and may find soft foods and oral fluids easier to tolerate. Small frequent meals are often tolerated better. Before feeding a patient assess their aspiration risk. Does your patient have altered consciousness, severe respiratory distress or ongoing vomiting? o If so, consider NG feeding using pureed foods. o Give a small amount initially, such as 20–40 ml/hour and monitor NG aspirates to

check for absorption. o Increase the rate of feeding as tolerated.

MONITOR – RECORD – RESPOND Check the patient’s vital signs every eight hours and record. Remember to watch for the development of complications. Turn patients frequently to prevent the development of bedsores. If your patient develops respiratory distress during the course of their illness, be prepared to treat them immediately. Measure the SpO2 and start and oxygen therapy. The next chapter will guide you through the management of patients with severe respiratory distress.


Show the Shock table: Post-resuscitation, and point to the relevant box as the section is discussed.

KEY TEACHING POINTS 1. Recognize 2. When possible, narrow antimicrobial coverage (i.e. give antibiotic that will treat the

infection with the greatest specificity) and determine length of treatment. Use IMAI DCM for disease-specific treatment guidance.

3. Fix the physiology 4. Patients who are stable on oxygen should be monitored every 8 hours, or with any

clinical change. 5. Start oral fluids if the patient is able to tolerate oral intake. Discontinue IVF when

patient is taking full oral fluids 6. Treat the infection 7. Continue antibiotics for full course. Change to oral antibiotics when indicated. 8. Nutrition 9. Before feeding a patient assess the risk of aspiration. 10. Does your patient have altered consciousness, severe respiratory distress, or on-

going vomiting? o If so, consider NG feeding using pureed foods.

11. Give small amount initially, such as 20–40 ml/hour and monitor NG aspirates to check for absorption.

12. Increase rate of feeding as tolerated. 13. Monitor, record, and respond 14. Check vital signs every 8 hours (BP, HR, RR, SpO2, AVPU), then daily once stable.

Watch for the development of pulmonary oedema.


We have now reviewed the management of patients in septic shock. Practice your management of fluids for patients in septic shock with the following drill.

DRILL 2-5: Fluid management in patient with septic shock

How would you manage the fluids? What type of fluid and at what rate? Calculate based on patient’s weight.

1. 22 year-old 70 kg male arrives at the hospital with weakness and fever. Temp 39°C BP 80/40 HR 120 RR 26. Give 1000 ml bolus of LR or NS.

2. 36 year-old 60 kg female with septic shock. After 30 minutes the patient has received a 1000 ml NS bolus. You recheck the vital signs: BP 70/30 HR 110 RR 22. Give 20 ml/kg/hr (1200 ml) up to 60 ml/kg (3600 ml) in 2 hours.

3. 18 year-old 65 kg male with septic shock. After two hours the patient has received 3 litres LR. You recheck the vital signs: BP 60/40 HR 122 RR 28. Continue IV NS or LR at 5-10 ml/kg/hr and start vasopressors.

4. 55 year-old 60 kg female with septic shock. After two hours the patient has received three litres LR. You recheck the vital signs: BP 110/60 HR 105 RR 22 Continue fluids at 2 ml/kg/hr (120 ml).

5. 37 year-old 55 kg female with septic shock. The patient has received two litres LR since arrival 4 hours ago. The BP had initially improved to 100/60 after the first one litre bolus and had been stable for past 3 hours. When you recheck the patient, the vital signs are now: BP 70/30 HR 130 RR 26. Give 1 L (or 20 ml/kg-1100 ml) bolus of NS or LR.


Have participants do the DRILL 2-5: Fluid management in patients with septic shock.


Summary of septic shock Recognize septic shock • suspected infection, plus • hypotension (systolic blood pressure <90 mmHg), plus One or more of the following: o pulse>100 beats per minute o respiratory rate >24 o abnormal temperature (<36oC or >38oC). Fix the physiology • Monitor SpO2, give and titrate oxygen to target SpO2 of 90% • Give early and aggressive IV fluid resuscitation in the first six hours • Use vasopressors only after two hours of resuscitation if SBP remains <90. Treat the infection • Give early empiric antibiotics, antimalarials (endemic areas) and antivirals (when

appropriate) • Obtain surgical consultation for drainage or debridement of infection, if needed. Monitor – record – respond to abnormal signs and laboratory results

• Reassess patient frequently, every 30 minutes initially • Look for changes in vital signs, urine output, laboratories and physical examination • Record all clinical information on the patient monitoring form • Use clinical reasoning to process information and guide further management.



Assessment questions: Septic shock

1. What are the clinical criteria for severe sepsis and septic shock?

1. Hypotension (systolic blood pressure < 90 mmHg) AND 2. 1 or more of the following: o heart Rate > 110 bpm o respiratory Rate > 24 o abnormal temperature (<36oC or >38 (orally) oC)

AND 3. Suspected infection

2. During the first two hours, how often should you monitor the vital signs for a patient in septic shock? Every 30 minutes

3. List four tests that you may consider that may help to recognize the source of infection for a patient in septic shock? Urine dipstick Malaria screen AFB smear of sputum Chest x-ray Gram stain Blood culture

4. You should wait for blood culture results to come back, before starting antibiotics on a patient in septic shock. True or False False

5. If the respiratory function of a patient in septic shock is worsening, list two things that you would check for? Check equipment Check for fluid overload Check for wheezing Reconsider diagnosis

6. What type of fluid should be used for resuscitation for a patient in septic shock? Normal Saline or Lactated Ringers

7. How much intravenous fluid should a patient in septic shock receive in the first two hours of management? 60 ml/kg


Ask the participants to answer the Assessment questions: Septic shock. Next, have participants work on the Practice cases.

Directions: Divide participants into groups work through the practice cases. Based on time available, you may complete one or two cases now, or during the practical sessions. Materials Cases are in participant’s training manuals. Blank patient monitoring forms (2 per participant). See Training Tools Package/Non-reusable folder/Patient monitoring form. White board and dry erase markers. Preparation 1. Distribute cases and patient monitoring forms to participants. 2. Have a white board available to do calculations, and to review answers to the questions. 3. Have at least one copy of the IMAI DCM. 4. Hang the Quick Check wall chart for reference. 5. Hang laminated patient monitoring form poster. Process 1. Divide the group into 4-5 participants (one facilitator for each group). 2. Leave the group to work on one entire case at a time, then review. 3. Return to group and start to review the case. Allow participants to discuss their answers

and their thought processes. 4. Keep an open environment for learning and allow participants to comment on cases, ask

questions and think out loud. 5. As the facilitator, be prepared to answer questions, clarify misunderstandings, and confirm

correct answers.


Practice cases: Get together in small groups and discuss how you would manage these patients.

1. A 35 year-old female presents with fever, chills, abdominal pain. She has had these symptoms for three days. The patient is not pregnant. On exam she is lethargic and confused, and her extremities are cool with weak peripheral pulses.

Pulse: 123 BP: 70/30 RR: 33 T: 40°C SpO2: 95% on room air • What initial actions need to be taken to stabilize the patient?

- Monitor airway and breathing - Give 1000 ml bolus of LR or NS, and then continue IV fluids up to 60 ml/kg in first 2 hrs - Give empirical antimicrobials

• What is the differential diagnosis? - Urinary tract infection, appendicitis, cholecystitis, malaria, meningitis, diverticulitis,

influenza, pneumonia (may include others) • What laboratory or diagnostic evaluations would you initially order?

- Blood glucose, haemoglobin, pregnancy test, BUN/creatinine, electrolytes, urine dipstick and microscopy, malaria screen, chest X-ray (if cough or suspicion of respiratory infection), blood culture and Gram stain, lumbar puncture, stool culture (if diarrhoea).

• What do you think is the source of infection? What antibiotics would you prescribe? - The most likely source is in the abdomen. Initially should prescribe broad spectrum

antibiotics such as ceftriaxone, until there is a source of infection identified. May consider additional coverage for malaria and influenza depending on the risk of infection.

• What challenges would you face caring for this patient at your hospital? - Answers may include limited staff, limited IV fluids, limited antibiotics, limited diagnostic

testing

2. A 32 year-old male with known HIV and recently diagnosed with TB presents with generalized weakness and fever. The CD4 count is unknown and the patient is not currently taking any medications. On exam the patient is weak and complains of headache, vomiting, diarrhoea, and a productive cough. You notice thrush in the patient’s mouth. The patient has no meningismus, the lungs have bilateral wheezing, and the heart is regular. The abdomen is soft and non-tender.

Pulse: 122 BP: 82/40 RR 36 T: 38.5°C SpO2: 87% on room air • What initial actions need to be taken to stabilize the patient?

- Place on oxygen 5 L via NC - Give 1000 ml bolus of NS or LR, and then continue fluids up to 60 ml/kg in first 2 hours

• What is the differential diagnosis? - Gastroenteritis, bacterial pneumonia, PCP pneumonia, malaria, urinary tract infection,

tuberculosis, meningitis, influenza (may include others) • What laboratory or diagnostic evaluations would you initially order?

- Blood glucose, haemoglobin, pregnancy test, BUN/creatinine, electrolytes, urine dipstick and microscopy, malaria screen, Chest Xray (if cough or suspicion of respiratory infection), AFB smear and sputum for culture, blood culture and Gram stain, lumbar puncture, stool culture (if diarrhoea).

• What do you think is the source of infection? What antibiotics would you prescribe? - The most likely source is pulmonary, however patient should initially be broadly

covered with an antibiotic such as ceftriaxone until the source of infection is identified. May consider additional coverage for PCP pneumonia. Would also consider coverage for malaria and influenza if there is a risk of infection

• What challenges would you face caring for this patient at y.our hospital? • Answers may include limited staff, limited IV fluids, limited antibiotics, limited diagnostics.

Facilitator guide: Management of the patient with severe respiratory distress or septic shock

Chapter 3: Managing patients in severe respiratory distress

Duration: 1 hour 45 minutes Materials: -Blank flipchart/markers -Blank monitoring forms Wallcharts: -Quick Check -Monitoring form (if available) -Oxygen therapy -Shock and severe respiratory distress table (if available) Preparation: -Review corresponding section in Participant training manual

Chapter Overview: • Recognition of severe respiratory distress. • Management of patients with severe respiratory distress. • How to monitor patients with severe respiratory distress, record on

monitoring form and respond to abnormal findings. Learning Objectives: • Review initial management of patients with severe respiratory distress. • Develop a differential diagnosis of severe respiratory distress. • Manage patients with severe pneumonia and/or acute lung injury. • Manage patients with severe bronchospasm. • Manage patients with acute pulmonary oedema. • Monitor patients with severe respiratory distress using patient

monitoring form.

Content Methods Time Introduction to severe respiratory distress

Theory, Discussion 10 minutes

Severe respiratory distress: first 2 hours

Explanation, Discussion, DRILLS

15 minutes

Severe respiratory distress: 2-6 hours


Severe respiratory distress: 6-24 hours


Severe respiratory distress: Post-Resuscitation

Explanation, DRILL, Case scenario

10 minutes

Management of severe bronchospasm

Explanation, DRILL, Case Scenario

10 minutes

Management of acute pulmonary oedema

Explanation, DRiLL, Case Scenario

15 minutes

Assessment questions

Written 10 minutes


Chapter 3: Managing patients in severe respiratory

distress Learning objectives 1. Review initial management of patients with severe respiratory distress.

2. Develop a differential diagnosis of severe respiratory distress.

3. Manage patients with severe pneumonia and/or acute lung injury.

4. Manage patients with severe bronchospasm.

5. Manage patients with acute pulmonary oedema.

6. Monitor patients with severe respiratory distress using patient monitoring form.

Introduction Using the Quick Check you learned to rapidly screen patients for emergency signs and give emergency first-line treatments including treatment of any rapidly reversible causes. Patients presenting with Quick Check emergency signs of airway or breathing, and who do not rapidly improve with emergency treatments, have severe respiratory distress. They will require ongoing resuscitation, management, and monitoring. Patients may present with severe respiratory distress from a primary problem in the lungs such as pneumonia, or from a secondary cause such as sepsis or head injury. If untreated, the patient may develop respiratory failure which can lead to death. It is very important to recognize patients with severe respiratory distress and to treat them early.

If any of the following signs and symptoms are present, consider the patient to be in severe respiratory distress: o very fast or very slow respiratory rate o use of accessory muscles to breath (neck, intercostal, or abdominal) o inability to speak in full sentences due to respiratory distress o central cyanosis o respiratory distress with depressed level of consciousness (confusion, lethargy,

agitation) o SpO2 less than 90%.

Infection control!

• Use standard precautions for all patients (see DCM p. 39). When managing the airway, using nebulized drugs or advanced airway measures, perform hand hygiene and wear personal protective equipment (gloves, gowns, eye protection, mask, particulate respirator as indicated).

• If suspect acute respiratory disease, promote cough etiquette, separate from other patients, and use particulate respirator.


Introduction to severe respiratory distress Ask the participants to make a differential diagnosis for severe respiratory distress. Make a list on the flipchart. Now point out reversible causes for severe respiratory distress on the list created by participants.

Examples of reversible causes for severe respiratory distress

Choking and upper airways obstruction

Anaphylaxis

Pneumothorax

Pneumonia

Acute heart failure

Opioid overdose, organophosphate poisoning

Severe bronchospasm (asthma, chronic obstructive pulmonary disease (COPD))

KEY TEACHING POINTS

o Patient has severe respiratory distress if any impairment in ventilation or oxygenation, and any of the following are present: • very fast or very slow respiratory rate • use of accessory muscles to breathe • inability to speak in full sentences secondary to distress • central cyanosis • depressed level of consciousness • SpO2 less than 90%.

o Patients with severe respiratory distress are working harder than normal for every breath.

o If the cause of the respiratory distress remains untreated, eventually the patient can tire and develop respiratory failure

o Respiratory failure is the inability to carry out adequate gas exchange, which can then lead to hypoxemia (low blood oxygen), respiratory acidosis, multi-organ failure, and death.

o Respiratory distress develops if any part of the respiratory system is not functioning normally: • respiratory system problem, e.g. viral pneumonia in the airways, botulism affecting

respiratory muscles, blood vessel clot in the lung • cardiac problem, e.g. heart failure, which can lead to respiratory distress with fluid

overload on the lungs • systemic disease, e.g. sarcoidosis, AIDS • acidosis, e.g. severe sepsis, when patients compensate by exhaling more carbon

dioxide leading to respiratory distress

Emphasize infection control precautions. Discuss some special precautions that may need to be taken when patients present with respiratory complaints.


While supporting the patient with lifesaving first-line emergency and urgent treatments, try to identify the cause of severe respiratory distress and treat accordingly.

Refer to the table in the DCM for the detailed differential diagnosis of respiratory distress (3.2-25-3.2-27). Below is a table that can be used to help you quickly remember the causes of severe respiratory distress. Categories of severe respiratory distress

Severe respiratory distress – consider DDx in these categories

Respiratory Cardiac Blood Drug toxicity

Common Pneumonia bacterial influenza PCP

Pleural effusion

COPD

Asthma

Pulmonary oedema (acute heart failure)

Anaemia Opioid

Organo-phosphate

Less common

Pulmonary embolism

*Pneumothorax

Acute lung injury (malaria, severe sepsis, TB)

*Tamponade (traumatic, malignancy, TB)

Acidosis (malaria, diabetic ketoacidosis)

ART (lactic acidosis)

* Although not common, these conditions need to be identified rapidly because they require an urgent therapeutic procedure.

Take a history: o What are the main symptoms? When did the symptoms start? o Are there symptoms suggesting infection: Fever, chills, cough, body aches, headache,

or other systemic signs? o Are there symptoms suggesting TB: History of TB, weight loss, night sweats,

productive cough? o Are there symptoms suggesting an allergic reaction: Rash, facial swelling, difficulty

swallowing, allergen exposure? o Are there symptoms suggesting heart failure: Difficulty lying down, shortness of breath

with exertion, swelling of legs? o Are there symptoms suggesting a myocardial infarction: Chest pain, sweating, or

nausea? o Are there symptoms or medical history suggesting a blood clot (pulmonary embolus):

Recent surgery, history of cancer, swelling of one leg, pleuritic chest pain, or hemoptysis?

o Are there symptoms suggesting severe anaemia: Bleeding, pallor, or shortness of breath with exertion?

o Is there a history of aspiration? o Is there a history of recent trauma, snake-bite, fire or smoke inhalation?


Explain the four categories of severe respiratory distress. Write on flipchart.

KEY TEACHING POINTS

4 categories: respiratory, cardiac, blood, drug toxicity

Common respiratory: pneumonia, pleural effusion, COPD, asthma

Common cardiac: pulmonary oedema

Common blood: anaemia

Common drug toxicity: opioid and organophosphate

Discuss important features of taking the history. Also point out Section 3.2.1 in DCM.


o Is there a suspected drug ingestion or overdose? o Is there a significant medical history which can lead to respiratory distress: ischemic

heart disease, rheumatic heart disease, heart failure or cardiomyopathy, asthma or chronic obstructive pulmonary disease COPD, HIV, hypertension, diabetes, or neuromuscular disease?

o Is there a current or recent pregnancy? o Does the patient smoke?

Perform a focused examination to identify likely cause: o Check vital signs BP, HR, RR, Temperature, SpO2, AVPU

Look/listen for: o Signs of upper airway obstruction

o stridor or hoarse voice o swelling of the face, lips, or tongue.

o Signs of respiratory distress o cyanosis o fast, shallow, or laboured breathing very o retractions, use of accessory muscles, or nasal flaring o unable to speak in full sentences without pausing to catch breath o agitated, confused, unconscious, or uncooperative.

o Signs of fluid overload (pulmonary oedema) o unable to lie flat, sitting forward to breathe easier o elevated jugular venous pressure o peripheral oedema o abdomen distended or tender o liver enlarged.

o Signs of anaemia o pallor

o Signs of acute bronchospasm o wheezing, rhonchi, prolonged exhalation.

o Signs of effusion or consolidation (pneumonia) o dullness to percussion of lungs o decreased breath sounds.

o Signs of chest trauma (rib fractures, pneumothorax, haemothorax) o abnormal chest wall movements o crepitus or crackling under the skin.

o Signs of tension pneumothorax o trachea deviated to one side o decreased breath sounds.


Discuss important features of the physical exam.


o Signs of pericardial effusion

o heart sounds muffled, rub. o Signs of cardiac disease

o fast HR or irregular HR or heart murmur. o Signs of poisoning or intoxication

o pupils constricted or dilated. o Signs of blood clot

o unilateral calf or leg swelling or calf tenderness.

Develop a differential diagnosis

While gathering information, begin to develop a differential diagnosis to determine the need for further investigations and treatments. Take a few minutes to review the differential diagnosis table for respiratory distress in the DCM section 3.2. (DCM 3.2-25 – 3.2-27). How many of these conditions do you frequently see in your hospital?

Send urgent investigations: o pulse oximetry to measure SpO2 o chest X-ray o haemoglobin o HIV test if status unknown o if fever, send blood cultures and other specimens for culture as clinically indicated o if suspect malaria, do rapid malaria test o if suspect TB, sputum for prompt AFB smear and culture (other diagnostics if suspect

extrapulmonary TB) o if wheezing, check peak flow o if suspect fluid overload, check creatinine and potassium o if suspect cardiac problem check ECG to evaluate ischemia or arrhythmias o if suspect cardiac problem, perform limited echocardiography to evaluate cardiac

function, mitral stenosis, or pericardial effusion o check pregnancy test if woman of childbearing age.

Treat for suspected diagnosis while supporting the patient: Key initial treatments should then be given (if not yet given) and continued for the most likely and most serious diagnosis. Appropriate laboratory tests and chest X-ray may assist in narrowing the differential diagnosis, but DO NOT delay treatments while waiting for results. At district hospitals, chest X-rays may require the patient to leave the emergency area. If this is the case, it is safer for the patient to get the chest X-ray when their clinical condition is more stable. In the DCM (3.2-28) characteristic chest X-ray results for certain clinical conditions are listed. During your hospital visits, try to identify some of these X-ray results in patients you see with severe respiratory distress. In the table below you will see key initial treatments for common diseases. Remember, the patient may have more than one disease, so it is important to identify the most likely cause, initiate appropriate treatments, and reassess frequently.


Discuss the differential diagnosis of severe respiratory distress. Allow the participants to use the DCM to add to the list on the flipchart that was created at the beginning of the chapter. Ask participants what urgent investigations they would get. Write answers on the flipchart. Remind participants not to delay treatment while waiting for test results. Discuss key initial treatments.

KEY TEACHING POINTS

o Treat upper airway obstruction.

o Manage airway.

o Give oxygen and titrate flow.

o If wheezing, give salbutamol.

o Position patient in most comfortable position for breathing.

o Identify and treat cause.

o Monitor-record-respond.

o Remember to take infection control measures to keep yourself, the patient, other staff, and other patients safe.


Key initial treatments for severely ill patients with respiratory distress

Likely diagnosis Initial treatments Upper airway obstruction

Manage airway. See Quick Check page 12−13.

Anaphylaxis Give epinephrine. See Quick Check page 11 and DCM Section 3.1.3.

Pneumothorax If tension, insert needle and/ or chest tube, see Quick Check page 22.

Pericardial tamponade Drain pericardial fluid, see DCM Section 7. Pneumonia Non-severe pneumonia, see DCM Section 10.6.

Severe pneumonia, see DCM Section 3.2.3. Give empirical broad-spectrum antimicrobials within one hour. If PLHIV, also give empirical PCP treatment as well. If suspect influenza, give antivirals. If shock, see DCM Section 3.1.5.

Acute bronchospasm Give salbutamol immediately. See Quick Check page 17 and Section 3.2.4. If suspect asthma or COPD, give hydrocortisone 100 mg IV or equivalent oral dose.

Acute pulmonary oedema (fluid overload condition)

Give furosemide 20 mg IV. For severe hypertension, give vasodilator. See DCM Section 3.2.5.

Acute lung injury (e.g. severe malaria)

Treat underling cause. See DCM Section 3.2.3 If severe malaria, give antimalarials. If severe sepsis, give empirical broad spectrum antimicrobials

Anaemia See DCM Section 10.18 Opioid overdose Give naloxone. See Quick Check page 18. Poisoning See DCM Section 3.8

Severe respiratory distress without shock: Suspect pneumonia or acute lung injury

Severe respiratory distress may develop from a large number of different causes. Make sure you have looked for and treated any rapidly reversible conditions and given first-line emergency treatments and urgent treatments, while searching for the etiology of the respiratory distress. Common causes of respiratory distress to consider are bacterial (community acquired), viral (influenza-seasonal or pandemic), TB-related, or PCP in PLHIV. A chest X-ray may be helpful in distinguishing pathogens, but do not delay empirical antibiotic treatments.

Acute lung injury (ALI) is the result of massive inflammation in the lungs. ALI may develop as a complication of a primary lung infection or from a non-pulmonary source such as sepsis, severe malaria, pancreatitis, or trauma with massive haemorrhage.


Review the key initial treatment table. Do not spend too much time with details, as many of these details will be discussed later in the chapter. Explain that this chapter will help manage patients with severe respiratory distress from suspected pneumonia or acute lung injury.

KEY TEACHING POINTS

Discuss when to suspect severe pneumonia.

Discuss when to suspect acute lung injury (ALI). • ALI, also known as acute respiratory distress syndrome (ARDS), is a clinical syndrome

primarily characterized by: − rapid progression of severe hypoxemia (low blood oxygen) − abnormal chest radiograph (both lungs affected – see diffuse infiltrates) − absence of cardiogenic pulmonary oedema.

• Causes include:

− infectious – pneumonia, severe sepsis, severe malaria, severe dengue − non-infectious – acute pancreatitis, poisonings, blood transfusion-related, severe

haemorrhage, fat emboli − in pregnant patients – pre-eclampsia or eclampsia and tocolytic medications in

pregnant patients.

• These causes lead to a release of inflammatory cells and substances from the small blood vessels surrounding the deep lung tissues (alveoli). − Damages cells that make up the alveoli and blood vessels themselves and makes

them leaky. − Airspaces fill with fluid (distinct to the fluid seen in cardiogenic pulmonary oedema)

which causes the alveoli to collapse. − The widespread filling and collapse of alveoli causes severe hypoxemia.

• Treatment requires:

− Emergent delivery of oxygen therapy. − Treatment of the primary cause, e.g. antimicrobials for pneumonia. − Patients may improve within 3-5 days, or have a much longer sickness of up to

2-3 weeks.


Suspect severe pneumonia if: o fever or suspected infection o cough o RR more than 30 o severe respiratory distress o SpO2 less than 90.

Suspect acute lung injury (ALI) if: o severe hypoxemia (patient requires high flow oxygen therapy) with rapid deterioration o chest X-ray with diffuse infiltrates o no clinical evidence of volume overload from poor cardiac function o known precipitating cause:

o infectious – pneumonia, severe sepsis, severe malaria, severe dengue o non-infectious – acute pancreatitis, poisonings, transfusion-related, severe

haemorrhage, fat emboli o in pregnant patients – pre-eclampsia/eclampsia and tocolytic medication.

Remember to look for signs of fluid overload, and if present consider acute pulmonary oedema from cardiac or renal causes and treat appropriately: o elevated JVP, hepatomegaly or ascites, bilateral lower extremity oedema o chest X-ray with fluffy bilateral opacities, peri-hilar distribution, bilateral effusions.

In the septic shock chapter you learned a time-based approach to management. You learned what to do in the first two hours, two to six hours, six to 24 hours, and post resuscitation. Use the same principles of time-based approach to management when caring for with respiratory distress from suspected severe pneumonia or acute lung injury is the same as septic shock: o recognize o fix the physiology o treat infection o monitor – record – respond.

Quality care Benchmarks are defined as standards of achievement or excellence. Because of the importance of timely treatment in the management of patients with severe respiratory distress, benchmarks have been established for you to achieve as soon as you recognize that someone is in severe respiratory distress.

If the patient presents with severe respiratory distress suspect pneumonia or acute lung injury. The lists below represent the benchmarks you should achieve within 30 minutes and 1 hour of the patient’s arrival.

Within 30 minutes: o oxygen started o SpO2 measured o IV started o if wheezing, salbutamol given o appropriate infection control measures taken.


Explain that this chapter will help manage patients with severe respiratory distress from suspected pneumonia or ALI. Explain that the participants will be using the same tables as in the previous chapter. For this chapter, the focus is on the second column for patients in severe respiratory distress without evidence of severe sepsis or septic shock (SBP is >90). Point out that the principles of management are the same.

KEY TEACHING POINTS

RECOGNIZE Recognize patient with severe respiratory distress. FIX THE PHYSIOLOGY Manage airway. Titrate oxygen. Give salbutamol if wheezing. Give IVF bolus if patient in shock.

TREAT INFECTION Look for and treat source of severe respiratory distress. Antibiotics if suspect bacterial pneumonia. Antivirals if suspect influenza. Antimalarials if suspect malaria.

MONITOR, RECORD, and RESPOND Assess frequently and after any intervention. Record your assessment. Respond to your assessment.

Define benchmarks for the management of severe respiratory distress.


Within 1 hour: o broad-spectrum antibiotics started o if malaria suspected, antimalarial given o if influenza suspected, antiviral given.

These guidelines are intended to help you manage patients with severe respiratory distress, but may not be appropriate for all patients. The district clinician may determine that the guidelines need to be modified if the situation is complicated by other underlying co-morbidities (i.e. cardiac disease renal failure, severe anaemia) or diseases (dengue fever, severe malaria). You may also choose to follow protocols developed by your hospital adapted to the local epidemiology. While these management principles may be used for most patients, they are not intended to replace sound clinical judgement by trained clinicians.

FIRST 2 HOURS

RECOGNIZE

Measure the respiratory rate. Is the RR>30? Consider any patient with a RR>30 to be in severe respiratory distress. Although the respiratory rate will increase if the patient has a primary lung problem, it can also commonly increase from fever, pain, and metabolic acidosis.

Measure the oxygen saturation. Is the SpO2<90% Patients with pneumonia or acute lung injury develop hypoxemia from inflammation resulting in pus or fluid filling the airspaces (alveoli). This inflammation slows down gas exchange between the air and blood supply.

Measure the blood pressure Evaluate for shock. If the systolic BP is <90 mmHg with signs of poor perfusion, the patient is in shock. Use the guidelines for the management of shock discussed in the previous chapter. The guidelines in this chapter are intended for patients with severe respiratory distress who are not in shock.

Evaluate for fluid overload from acute heart failure Suspect heart failure if there is a history of cardiac disease or congestive heart failure, and/or if the following are present: • lower extremity oedema • crackles on auscultation • elevated jugular venous pressure (JVP)

If heart failure is suspected, you should use the guidelines found later in this learning unit for management of heart failure.

Severe respiratory distress without shock: • If respiratory rate >30 or SpO2<90 and • SBP >90 mmHg and • no heart failure • then, suspect pneumonia or acute lung injury.


Show the Severe Respiratory Distress table: First 2 Hours in the Participant manual and on wall chart (if available) and point to the “RECOGNIZE” box. RECOGNIZE

Explain the clinical diagnosis of severe respiratory distress without shock.

KEY TEACHING POINTS To recognize a patient with severe respiratory distress without shock, look for the following;

o Count the respiratory rate. Is the RR> 30? • RR will increase if the patient has a primary lung problem or from fever, pain, and

metabolic acidosis.

o Measure the oxygen saturation. Is the room air SpO2 <90%?

o Measure the blood pressure. Is the SBP>90 mm Hg? • A patient with severe respiratory distress should be out of shock (SBP>90 mm Hg) for

at least 4 hours before using guidelines in this chapter.

o Look for evidence of heart failure. • Suspect heart failure if history of cardiac disease or congestive heart failure, peripheral

oedema, rhonchi or crackles, JVD, or enlarged heart and pulmonary oedema on chest X-ray.

• If suspect heart failure, use appropriate section of DCM.

o If RR>30, or SpO2 <90%, SBP>90 mm Hg, and no evidence of heart failure then suspect pneumonia or ALI and use the guidelines in this chapter.

o Observe the patient frequently using the severely ill patient monitoring form, until the patient has an oxygen saturation >90% on room air for at least 12 hours.


FIX THE PHYSIOLOGY Oxygen

Titrate SpO2 90%. Review what you learned in the Quick Check Essentials, regarding the administration and titration of oxygen using pulse oximetry.

Fluids Give fluids at 1 mg/kg/hour or orally if tolerated. • Patients with severe pneumonia are usually mildly dehydrated. Use caution when

administering fluids to these patients because overly aggressive fluid therapy may worsen hypoxemia and respiratory distress.

• Monitor blood pressure and urine output to determine if hydration is adequate. • If the patient is able to take oral fluids without aspiration risk, oral rehydration is

preferable. • Do not limit oral fluids. If urine output is low, encourage the patient to drink more fluids.

If patient is unable to take fluids, give NS or LR at 1 ml/kg/hour. • Monitor closely for worsening hypoxemia. • If there is evidence of fluid overload, use recommendations for management of

pulmonary oedema. Do not give fluid bolus unless in shock or specific cause of acute lung injury requires more aggressive fluid therapy (e.g. acute pancreatitis, severe haemorrhage).

If wheezing, give salbutamol Treat patients with wheezing and respiratory distress immediately with inhaled salbutamol. Although wheezing can result from many different causes including pulmonary oedema, certain types of pneumonias (e.g. viral) can also present with severe wheezing, while other types (e.g. community acquired) may precipitate acute attacks of asthma or COPD. Make sure you are not confusing stridor with wheezing. Stridor is more commonly heard on inspiration and near the neck and should prompt emergent treatments for upper airway obstruction. Salbutamol acts to dilate the airways and improve flow of air in and out of the lungs in patients with bronchospasm. As salbutamol works directly on the airways, it is most effective if delivered directly to the airways with an MDI or nebulizer.

See Quick Check page 17 for how to deliver sequential bronchodilator therapy.

The next section will cover in more detail how to manage severe wheezing from all causes.

TREAT INFECTION For severe pneumonia, give empirical antimicrobials within one hour (refer to national or institutional guidelines).

Common choices include:

• ceftriaxone 1–2 grams once daily PLUS a macrolide (preferred); OR • ampicillin 2 grams IV 4 times a day PLUS gentamicin PLUS a macrolide. • macrolides include erythromycin 500 mg 4 times a day, azithromycin 500 mg once a

day, clarithromycin 500 mg twice a day


FIX THE PHYSIOLOGY

Show Severe Respiratory Distress table again, and point to the “FIX THE PHYSIOLOGY” box.

KEY TEACHING POINTS Give Oxygen: titrate to SpO2 90% o Oxygen concentration in room air (FiO2) – 21%. o Normal haemoglobin saturation in blood – 96-100%. Need a saturation of at least 90% to

deliver sufficient oxygen to bodily organs. o Low oxygen saturation occurs because either because gas exchange is impaired or there is

insufficient oxygen in the air. o Gas exchange may be impaired with:

• Ventilation problem, e.g. decreased respiratory effort (impaired) or severe bronchospasm (ineffective).

• Airspace filling (slows down gas exchange) e.g. pulmonary oedema, severe pneumonia, acute lung injury.

• Inadequate perfusion, e.g. shock. o Low oxygen in air:

• At high altitudes, there is less oxygen available and this can also lead to low saturation. o Patients with emergency AB signs need to start on oxygen 5L via nasal cannula. o Use pulse oximetry to guide oxygen treatment.

If wheezing, give salbutamol o Salbutamol acts to dilate the airways and improve flow of air in and out of the lungs in

patients with bronchospasm. o Give directly to the airways via MDI or nebulizer (point out the boxes in DCM). o Do not confuse stridor with wheezing. Stridor is heard on inspiration, near the neck, and

should prompt emergency treatment for upper airway obstruction. o There is more detail about managing severe wheezing in next section.

Fluids o Give fluids to patients in respiratory distress to ensure adequate hydration and urine output,

but avoid over-hydration. • Give fluids at 1 ml/kg/hour IV crystalloid or orally.

o Monitor SBP and urine output to see if adequate hydration. o Patients who are alert with no risk of aspiration should be given fluids orally. o Do not limit oral fluids. If urine output is low, encourage the patient to drink more fluids. o If not able to take oral fluids, give NS or LR at 1 ml/kg/hr. o Monitor for worsening hypoxemia. o If evidence of fluid overload and SBP>100, give furosemide 20 mg IV. o Do not give fluid bolus unless in shock or specific cause of acute lung injury requires more

aggressive fluid therapy (e.g. acute pancreatitis, severe haemorrhage). o Monitor blood sugar and replace glucose as needed.

TREAT THE INFECTION

Show Severe Respiratory Distress Table again, and now show the “TREAT THE INFECTION” box.

KEY TEACHING POINTS

Identify source of infection based on the signs, symptoms, and diagnostic tests • If fever, start treatment with antimicrobials within one hour. • Discuss possible antimicrobial choices. • Emphasize that these are general recommendations, and should not replace local

recommendations based on circulating pathogens.


• Alternatives to a macrolide include doxycycline 100 mg twice a day (avoid in pregnancy) or an oral respiratory quinolone (for example, levofloxacin).

• Caution! Use of respiratory quinolones should be avoided in high-prevalence TB areas unless TB can be excluded. The safety of respiratory quinolones in pregnancy has not been established.

o If suspect influenza, also give antivirals according to regional recommendations: o Treat your patient for severe or complicated influenza infection if influenza is known

to be circulating in your community and patient has influenza-like illness and clinical evidence of pneumonia or worsening chronic disease (e.g. acute asthma, COPD exacerbation, diabetic crisis)

• If PLHIV or suspect HIV infection: o Give broad-spectrum empirical PCP treatment early. o Consider TB and obtain prompt AFB smear, chest X-ray and sputum for culture. o Empirical TB treatment may need to be started early in patients who are critically ill

based on suggestive chest X-ray or clinical judgement. Call for help from senior clinician.

For acute lung injury, treat the underlying etiology o If you suspect severe sepsis, give broad spectrum antimicrobials within one hour. o If you suspect severe malaria, check smear and give antimalarials early. o If you suspect aspiration, stop oral feeds and monitor for pneumonia. o For poisoning, acute pancreatitis, or pre-eclampsia/eclampsia give appropriate

treatments as described in appropriate DCM sections.

MONITOR – RECORD As in patients with septic shock, monitor BP, HR, RR, oxygen saturation, and mental every 30 minutes until stable and then every hour after that. Check the results of laboratory investigations. Record all vital signs, test results, and treatments given on the severely ill patient monitoring form.

RESPOND If respiratory function is worsening (increasing RR and decreasing SpO2) for a patient on oxygen: o Check that the cylinder still has sufficient oxygen. o Check that oxygen is flowing out of the prongs or face mask (hold the end close to your

hand and you will feel the airflow). o Check that there are no leaks in the connections of oxygen tubing. Next, check for signs of fluid overload? In the first two hours of treatment it is uncommon for a patient with no history of heart failure and who has not received large amounts of intravenous fluid to develop fluid overload. o Has the patient been given large amounts of intravenous fluid? o Is the amount of intravenous fluid given much more than urine output?

o If YES, stop IV fluids if signs of fluid overload and treat using guidelines for management of pulmonary oedema.


MONITOR, RECORD AND RESPOND

Show Severe Respiratory Distress table again, and now show the “MONITOR, RECORD AND RESPOND” box.

KEY TEACHING POINTS

Continue to MONITOR vital signs, conduct focal physical exams, and check for key laboratories.

• Check vital signs every 30 minutes (BP, HR, RR, SpO2, AVPU) until stable, then every hour.

• Check urine output and temperature. • Re-check Hb if initial value abnormal. • Re-check glucose if initial value abnormal.

RECORD findings on the monitoring form.

RESPOND rapidly and appropriately to changes or new abnormalities. • If respiratory function is worsening (increasing RR and decreasing SpO2), first check

the oxygen supply. − Check that the cylinder still has sufficient oxygen. − Check that they oxygen is flowing out of the prongs or face mask (hold the end

close to your hand and you will feel the airflow). − Check that there are no leaks in the connections of oxygen tubing.

• Consider fluid overload. Look at the patient monitoring form and the input and output. Stop IV fluids and consider IV furosemide 20 mg if signs of fluid overload.

• If patient develops shock, go to shock pathway. − Give a rapid bolus of 1 bag (500-1000) ml of LR or NS. − Reassess. If the BP improves after the IVF bolus, continue to monitor the patient

closely and try to match the fluid input and output.


If patient develops shock: If a patient who initially presents with severe respiratory distress but is not in shock (SBP>90), develops shock (SBP<90) with signs of poor perfusion, follow the guidelines from the septic shock chapter. o Give a rapid bolus of one bag (500-1000) ml of LR or NS. o Reassess. If BP improves after the fluid bolus, continue to monitor the patient closely

and try to match the fluid input and output. Inform the district clinician of the patient’s ongoing condition to help guide further management.

DRILL 3-1: Management of severe respiratory distress first two hours You are caring for a 24 year-old male who presented today with severe respiratory distress and suspected pneumonia.

1. You recheck the vital signs and the BP is now 120/60. A 500 ml bolus of fluid that was started during the Quick Check has just finished. The patient is not able to take oral fluids due to his severe distress. What type of fluid would you now run through the IV line, and at what rate?

1 ml/kg/hour IV NS or LR

2. The patient is on oxygen at 5 litres via nasal cannula. The patient is developing worsening respiratory distress and the SpO2 is now 87%. How would you titrate the oxygen?

Increase oxygen to 6-8 litres via face mask

3. The patient is noted to have bronchospasm and was given a nebulized salbutamol treatment. The patient still has breathlessness and wheezing. What would you do next?

Repeat dose, then give epinephrine

4. Your patient begins to get drowsy and you are having difficulty waking him up. This means that he is getting better and starting to relax. True or False?

False. Often this means that the patient is now retaining carbon dioxide and is rapidly deteriorating.

5. How often should you monitor this patient’s vital signs during the first 2 hours?

Every 30 minutes

6. You recheck the patient’s vital signs and the BP is now 80/40. How would you manage the patient’s fluids?

The patient is now in shock, give 1 litre IV NS or LR bolus.


Have participants do the DRILL 3-1: Management of severe respiratory distress first two hours.


DRILL 3-2: Management of fluids in patient with severe respiratory distress

Review the tables for the management of patients with severe respiratory distress. How would you manage the fluids? Determine the route (oral or IV), fluid type, and the rate.

1. A 22 year-old 70 kg male initially presents with severe respiratory distress. BP 120/60 HR 110 RR 35 sat 92% on 5 litres NC. Give full strength ORS if tolerated

2. A 38 year-old 60 kg female with severe pneumonia 2 hours after arrival. She initially received a 500 ml NS bolus. BP 110/60 HR 122 RR 40 Sat 93 % on 4 litres NC. 1 ml/kg/h (60 ml) IV or orally if tolerated

3. A 56 year-old 75 kg male with severe respiratory distress 4 hours since arrival. He initially received 500 ml bolus LR. BP 130/80 HR 115 RR 42 Sat 91% on 3 litres NC. 1 ml/kg/h (75 ml) IV or orally if tolerated

4. A 28 year-old 70 kg male with severe pneumonia 1 hour after arrival. He initially received 1 litre bolus NS. BP 80/40 HR 130 RR 36 Sat 93% on 6 litres via FM.

Give 500-1000 ml IV

5. A 62 year-old 70 kg male with severe pneumonia on arrival. BP 120/60 HR 110 RR 26 sat 92% on 4 litres NC. 1 ml/kg/h (70 ml) IV or orally if tolerated

2-6 HOURS

RECOGNIZE Is the patient still in severe respiratory distress? Is the patient’s condition worsening or improving? Despite adequate therapy, patients with severe pneumonia who initially improve on oxygen may worsen over the first few days as inflammation and infection worsen. Patients who initially present with severe respiratory distress and are improving still require frequent observation, as their condition may rapidly change.

If a patient is not improving with the initial therapies (oxygen, salbutamol if wheezing, IV fluids, and antibiotics) reconsider your diagnosis. Results from initial laboratory investigations and chest X-ray may be available to assist in determining the etiology of severe respiratory distress.


Have participants do the DRILL 3-2: Management of fluids in patients with severe respiratory distress.


o Does the patient have another type of pneumonia? For example, PCP, TB or fungal. o Does the patient have another cause of severe respiratory distress, instead of or in

addition to pneumonia or acute lung injury? Consider pneumothorax, pleural effusion, fluid overload/heart failure, or poisoning.

o Does the patient have acute lung injury? If so, what is the cause of the acute lung injury? Has the cause been treated appropriately?


Titrate SpO2 90%.Titrate the oxygen flow to keep the SpO2>90%. Some patients with severe pneumonia and acute lung injury may remain hypoxic (SpO2<90%) despite maximal oxygen flow. These patients have developed respiratory failure and may need advanced airway management. The district clinician should be immediately called if a patient on oxygen is worsening and you are unable to keep the SpO2 greater than or equal to 90%. If indicated, advanced airway management may require transfer to a higher level of care. If wheezing, give salbutamol o Give sequential bronchodilator therapy. See next section for more detailed discussion

on management of severe wheezing.

Fluids

Give fluids at 1 mg/kg/hour or orally. Do not limit oral fluids. If possible, monitor urine output and try to match input and output. o Oral rehydration is preferred. o If oral route not possible, then continue LR or NS IV fluids at 1 ml/kg/hour IV. o Watch for the development of fluid overload or worsening hypoxemia.

TREAT INFECTION Results from laboratory tests and the chest X-ray may now be available to assist in prioritizing differential diagnosis. o Continue broad spectrum, empirical antimicrobials until the senior clinician makes

changes based on the likely pathogen causing the pneumonia or the source of infection causing severe sepsis with acute lung injury (e.g. peritonitis).

o Re-dose antibiotics if indicated. o Check that correct antibiotic has been given and correct dose. o Drain surgical infection if required.

MONITOR – RECORD Continue to monitor the blood pressure, RR, SpO2, and mental status every 30 minutes until stable, and then every hour. Record your findings on the patient monitoring form. o Check for JVP and ausculate for crackles (rales), to determine if the patient is

developing pulmonary oedema. o At 6 hours recheck the temperature, check urine output, and repeat the blood glucose

and Hb if the initial result was abnormal.


RECOGNIZE Show the Severe Respiratory Distress table: 2-6 hours, and point to the “RECOGNIZE” box. Explain the need for frequent observation for patients in severe respiratory distress to recognize if the condition is improving or worsening.

KEY TEACHING POINTS

o If the patient is not improving with the initial therapies, reconsider your diagnosis. • Is the patient still in severe respiratory distress? • What is the aetiology of the respiratory distress? If the patient is not improving, look for

pneumothorax, pleural effusion, heart failure, poisoning, PCP pneumonia, TB. • Is the patient developing acute lung injury? Patients with severe pneumonia may

initially improve on oxygen, but the infection and inflammation may still worsen over time.

FIX THE PHYSIOLOGY Show the Severe Respiratory Distress table, and point to the “FIX THE PHYSIOLOGY” box.

KEY TEACHING POINTS Oxygen

o Titrate the oxygen to keep the SpO2>90%.

o At 2-6 hours watch for the development of acute lung injury.

o Discuss briefly that patients not improving (patients with severe pneumonia and ALI who remain hypoxic (SpO2<90%) despite maximal oxygen flow) may need positive pressure with continuous positive airway pressure (CPAP) or mechanical ventilation with positive end-expiratory pressure (PEEP). • The positive pressure helps to open the small alveoli, which may be life-saving for

patients with significant lung injury and inflammation. • If not available, the senior clinician will need to decide if transfer to a higher level of

care is necessary. • Consider the risk of transferring an unstable patient.

Salbutamol o If wheezing, give sequential bronchodilator therapy.

Fluids o At 2-6 hours

• Continue fluids at 1 ml/kg/hour IV or orally. • Do not limit oral fluids. • Match input and output. • Watch for fluid overload.

TREAT THE INFECTION Show the Severe Respiratory Distress table, and point to the “TREAT THE INFECTION” box.

KEY TEACHING POINTS

o Continue broad spectrum antibiotics until the senior clinician makes changes based on the determined focal source of infection.

o Remember that severe respiratory distress may develop from a non-pulmonary source such as peritonitis or pancreatitis.

o At 2-6 hours • Re-dose antibiotics if indicated. • Check that correct antibiotic has been given and correct dose.


RESPOND o If patient develops shock (SBP<90), manage as septic shock. o If respiratory function is worsening check oxygen supply, titrate oxygen flow rate, and

evaluate for fluid overload. o If wheezing give patient salbutamol. o Check that antimicrobials have been given, and the district clinician may consider

broadening antimicrobial coverage. o If there are signs of fluid overload and patient is not in shock:

o stop IV fluids o give furosemide 20 mg iv o raise head of bed.

DRILL 3-3: Managing severe respiratory distress 2–6 hours You are caring for a 45 year-old female who presented to the hospital about 2 hours ago with severe pneumonia and respiratory distress. She has just been transferred to the ward.

1. You check the vital signs. Temp 39°C, BP 110/60, RR 35, pulse 90, Sat 88% on 3 litres NC. The patient is no longer in severe respiratory distress. True or False? False

2. How would you titrate the oxygen flow? Increase to 5 litres NC

3. The patient is unable to take oral fluids. What type of fluid would you give IV and at what rate? 1 ml/kg/hour IV NS or LR

4. The patient is wheezing and breathless, but has already been given a dose of salbutamol. Would you give another dose of salbutamol? YES

5. How often should you monitor vital signs on this patient? Every 30 minutes

6. Some diagnostic test results are back. The malaria smear is positive. Given the positive malaria smear, would you continue antibiotics to cover the patient for a possible bacterial pneumonia in this patient?

Yes, continue antibiotics. In addition, add antimalarial.

7. List the actions you would take if the patient develops worsening respiratory distress? - Check oxygen supply. - Check that correct antimicrobials have been given. - Look for non-pulmonary cause (heart failure, source of infection not in lungs). - If suspect fluid overload and patient is not in shock, stop IV fluids. Consider treatment with furosemide after consulting with senior clinician.


MONITOR, RECORD AND RESPOND Show the Severe Respiratory Distress table again, and now show the “MONITOR, RECORD AND RESPOND” box. KEY TEACHING POINTS

Continue frequent, systematic clinical assessments, including vital signs, physical exam, and diagnostic findings. Respond rapidly and appropriately to changes.

Ask participants to do DRILL 3-3: Severe Respiratory Distress 2-6 hours.


6-24 HOURS

RECOGNIZE By this time, the patient’s condition may have worsened, improved, or stabilized. At 6–24 hours, patients who have been in severe respiratory distress for many hours may begin to tire and can rapidly deteriorate during this period. Review the differential diagnosis and determine the appropriate treatment based on any new information. If patient has poor response to treatment, reconsider pneumothorax, pleural effusion, heart failure, poisoning, TB, PCP pneumonia.


Titrate SpO2 90%.Consider advanced airway management if not responding to maximal oxygen therapy.

Fluids o Oral rehydration is preferred. o If oral route not possible, then continue LR or NS IV fluids at 1 ml/kg/hour IV. o Watch for the development of fluid overload or worsening hypoxemia.

If wheezing, give salbutamol o Continue to give the patients sequential bronchodilator therapy. o Watch for development of symptomatic tachycardia or dysrhythmias in patients who

have had continuous salbutamol treatments.

TREAT INFECTION Review diagnostic results. Senior clinician may choose to narrow antibiotic spectrum if clear source is identified.

MONITOR – RECORD

Continue to monitor patient as you did during 2–6 hour phase and record results on severely ill patient monitoring form.

RESPOND Respond to patient’s changing condition as discussed during the 2–6 hour period.


Show the Severe Respiratory Distress table: 6-24 Hours in the Participant manual and on wall chart (if available).

KEY TEACHING POINTS

o At 6-24 hours, patients who have been in severe respiratory distress may begin to tire and can rapidly deteriorate during this period. These patients still require frequent assessment.

o Check diagnostic test results.

o Review the differential diagnosis and determine the appropriate treatment based on any new information. The senior clinician may at this point start to revise the antimicrobials based on laboratory or diagnostic results.

o Continue to titrate oxygen.

o Encourage oral hydration for those patients who are stabilizing and able to tolerate oral fluids.

o For patients who have received multiple doses of salbutamol, watch for the development of symptomatic tachycardia or dysrhythmias.


DRILL 3-4: Managing severe respiratory distress 6–24 hours

You are caring for a 36 year-old female with severe pneumonia and respiratory distress who presented to the hospital 12 hours ago.

• The SpO2 is 94% on 5 litres NC. How would you titrate the oxygen flow? Can decrease to 2-3 litres NC and reassess

• The patient is taking a few sips of fluid, but not very much. Would you continue IV fluids and if so at what rate? YES, 1 ml/kg/hour IV NS or LR

• The patient received a dose of antibiotics 8 hours ago, and the antibiotic is scheduled to be given every 8 hours. The patient is improving. Since the patient is improving you do not need to give the second dose of antibiotics. True or False? False

• How often would you monitor vital signs for this patient? Every 2 hours

POST-RESUSCITATION RECOGNIZE The post-resuscitation phase starts when the patient has had stable blood pressure and oxygenation requirements for at least six hours. These patients still are considered severely ill and require a high level of attention, but their clinical condition is stable.

If the blood pressure falls or oxygenation requirements increase, the patient is not considered stable, and should be monitored frequently as during the resuscitation phase.

FIX THE PHYSIOLOGY Oxygen o Titrate oxygen to SpO2 of 90%.

Discontinue oxygen when SpO2 is 90% on room air.

Fluids o If patient is alert and not at risk for aspiration, transition to oral fluids, if patient is not yet

taking fluids by mouth. o If patient is not alert and continues to require intravenous fluids, transition to

maintenance fluids (D51/2 NS) at 1 mg/kg/hr. Match input and output.


Have participants do the DRILL 3-4: Severe respiratory distress 6-24 hours. Show Severe Respiratory Distress table: Post-resuscitation in the Participant manual and on wall chart (if available).

KEY TEACHING POINTS

o Explain that this phase starts when the patient has had stable blood pressure and oxygenation requirements for at least 6 hours.

o Explain that the patient’s clinical condition is considered stable although they still need frequent monitoring. If the BP falls or oxygenation requirements increase, the patient is not considered stable still, and should be monitored frequently as during the resuscitation phase.

o Emphasize the importance of nutrition in the post-resuscitation phase.

o Review the specific recommendations for monitoring in the post-resuscitation phase.


If wheezing, give salbutamol o Continue to give sequential bronchodilator therapy.

TREAT INFECTION o Give the next dose of antimicrobials. o Give appropriate antibiotic regimen (type and course) as determined by district

clinician.

NUTRITION Early attention to nutrition is important to help patients recover. Oral nutrition or NG feeds should be started at this time. Watch for risk of aspiration. Use guidance on nutrition discussed in previous section on septic shock.

MONITOR – RECORD Patients who are admitted to the hospital with severe respiratory distress, may develop a hospital acquired infection and septic shock during the course of illness.

o Check vital signs every eight hours and record using the patient monitoring form.

RESPOND o Respond quickly to any changes in the patient’s clinical condition.

DRILL 3-5: Managing severe respiratory distress post-resuscitation

You are caring for a 55 year-old male who has been treated for severe pneumonia. The patient is now improving.

1. For how many hours should the blood pressure and oxygenation requirements remain stable to determine that he is in the post-resuscitation phase? 6 hours

2. The patient’s HIV test is positive. What specific respiratory infection should also have been considered in this patient? PCP pneumonia

3. The SpO2 is 94% on 2 LNC. You decide to stop the oxygen and the patients SpO2 remains >90% when you monitor the patient over the next hour. The oxygen should be discontinued at this time. True or False? True

4. The patient has not had anything to eat or drink. You assess the patient, and he is awake and alert He is not at risk of aspiration and is asking for something to drink. Would you allow the patient to drink something at this time? YES

5. How often would you monitor vital signs in this patient? Every 8 hours


Have participants do the DRILL 3-5: Severe respiratory distress post-resuscitation.


Severe respiratory

distress from acute bronchospasm (wheezing) Wheezing results from narrowing of the airways or bronchioles within the lungs. Wheezing is also known as bronchospasm. Imagine breathing through a straw. The patient must work harder for each breath and uses accessory muscles to do the extra work. A patient with severe, acute wheezing will rapidly deteriorate if not treated emergently.

During the Quick Check chapter on Airway and Breathing, you learned how to deliver sequential bronchodilator therapy to patients with wheezing. The key message is to give inhaled salbutamol immediately and then to reassess the patient for a clinical response. At this time, continue with bronchodilator treatment, as determined by severity of wheezing. Perform a targeted history and physical examination and prioritize your differential diagnosis and give appropriate urgent treatments.

Why is wheezing dangerous? It is important to remember that oxygen levels may still be normal when patient is in severe distress from acute bronchospasm. Impaired ventilation occurs when carbon dioxide and acid accumulate in blood. This results in decreased oxygen levels. If hypoxemia develops, it is usually easily corrected with oxygen therapy, but impaired ventilation can still persist. Once the ventilation becomes inadequate, the patient will develop altered level of consciousness and respiratory failure. If mechanical ventilation is not available, death can ensue. Early and aggressive bronchodilator therapy can prevent this poor outcome.

Why is inhaled bronchodilator therapy important? Airway narrowing usually results from a combination of inflammation (swelling) of the tissue surrounding the airways, constriction of the smooth muscles surrounding the airways, mucous accumulation, and plugging of airways. Bronchodilator therapies act immediately upon the airway smooth muscles by relaxing them and opening them up so the patient can breathe easily. Inhaled salbutamol works almost immediately on the airways. The effects of salbutamol may not be sustained, so frequent or continuous dosing is essential until there is sustained improvement. Bronchodilator therapy saves lives when given correctly.

Consider the patient to have severe respiratory distress from acute bronchospasm if wheezing and any of the following are present: o breathless at rest o cannot complete sentences in one breath o respiratory rate ≥25 breaths/minute o pulse ≥ 100. When you provide sequential bronchodilator therapy, you must also consider the etiology of the wheezing. You should treat the underlying cause in a timely fashion. Below is a table of common causes of acute bronchospasm.


RECOGNIZE Ask participants to list signs or symptoms for patient presenting with severe wheezing.

KEY TEACHING POINTS A patient should be considered to have if severe bronchospasm and acute respiratory distress if wheezing and the following are present: o breathless at rest o cannot complete sentences in one breath o respiratory rate ≥25 breaths/minute o pulse ≥ 100.

Explain why wheezing is dangerous, and discuss the importance of inhaled bronchodilator

therapy. Have participants volunteer to read aloud the boxes, or provide a few minutes for them to read

on their own and then ask questions.

KEY TEACHING POINTS Acute bronchospasm o Wheezing results from narrowing of the airways, also called bronchospasm. o Acute bronchospasm can result in impaired ventilation. o Inadequate ventilation can lead to an altered level of consciousness and respiratory

failure, and eventually death if no mechanical ventilation is available. Inhaled bronchodilator therapy o Acts by relaxing smooth muscles in the airway and dilating them so the patient can

breathe more easily. o Works immediately but effects are not long lasting, so frequent or continuous dosing is

essential.


Etiology of acute wheeze In favour

Acute bronchitis Diffuse wheezing and/or rhonchi Productive cough Preceded by viral upper respiratory tract infection (e.g. fever, cough, runny or stuffy nose)

Bacterial or viral pneumonia More common in viral pneumonia Diffuse or localized wheezing Usually acute onset fever and productive cough Chest X-ray with infiltrate

Foreign body aspiration Localized wheezing Acute onset, can have cough and shortness of breath

Asthma attack Episodic chest tightness, shortness of breath and diffuse wheezing Night time symptoms and cough are common Precipitated by exercise, viral syndrome, strong smells Personal history of asthma or allergies Family history of asthma

COPD exacerbation Increase in baseline breathlessness, cough, sputum quantity and/or purulence Diffuse wheezing and rhonchi Personal history of COPD or exposure to long term tobacco smoke or indoor air pollution (e.g. open fire stoves)

Inhalation of airway irritants (e.g. smoke, chemicals, vapours)

Diffuse wheezing and breathlessness Immediately precipitated by inhalation of large amounts of irritating agent

Etiology of acute wheeze In favour

Ingested poisons

see DCM Section 3.8

Organophosphate poisoning− pinpoint pupils, urination, defecation, lacrimation

Bronchiectasis Wheeze can be diffuse or localized Increase in baseline or new cough productive of purulent sputum Haemoptysis is common Personal history of TB infection or severe pneumonia

Cancer Localized wheeze Chronic cough, haemoptysis are common Associated with weight loss, anorexia Personal history of exposure to tobacco smoke, exposure to indoor air pollution (e.g. indoor coal stoves)

Acute pulmonary oedema Atypical presentation with diffuse wheezing and crackles (rales) Fluid overload (elevated JVP, lower extremity oedema) History of cardiomyopathy, valvular heart disease, hypertension, ischaemia, renal disease

Take a history

• What are the main symptoms? Is there chest tightness, shortness of breath, cough, wheezing?

• When did the symptoms start? • Are there other associated symptoms such as fever? • Are there any acute precipitating factors such as cold weather, exercise, strong smell,

or a viral syndrome? • Are other risk factors for developing wheezing present such as exposure to tobacco

smoke or indoor air pollution? • What is the past medical and surgical history? In patient with a history of asthma or

COPD, is there a history of previous hospitalizations?


Write possible etiologies of acute wheezing on the flipchart, with the help of participants. Ask participants what would make certain causes more likely. Discuss history, examination, and urgent investigations for a patient who is wheezing.

KEY TEACHING POINTS

o History: symptoms, onset, associated symptoms, precipitating factors, medical history, risk factors, medications.

o Examination: RR, HR, BP, level of breathlessness, ability to speak, accessory muscle use, loud or silent wheezing.

o Urgent investigations: SpO2, peak flow after initial bronchodilator, measure pulsus paradoxus, chest X-ray.


o What medications is the patient taking? Has the patient recently used salbutamol or

steroids?

Perform a focused examination to identify likely cause o Check vital signs. o Determine the level of breathlessness: is the patient breathless at rest, with talking or

with walking? o Listen to the patient speaking. Is the patient silent, unable to speak, speaking in single

words, in phrases, or in full sentences? o Look for accessory muscle use, chest wall excursion. o Listen for wheezing. The chest may be silent in very severe bronchospam because

very little air is moving. Determine if breath sounds are equal on both sides. If unequal breath sounds consider pleural effusion of pneumothorax.

o Look for signs of chest trauma. o Look for evidence of congestive heart failure such as elevated jugular venous

pressure, lower extremity oedema. These patients may also develop wheezing.

Develop a differential diagnosis While gathering information and treating the patient, begin to develop a differential diagnosis to determine the need for further investigations and treatment. Take a few minutes to review the differential diagnosis table above from the DCM. How many of these conditions do you see frequently in your hospital?

Send urgent investigations o Pulse oximetry to measure SpO2. o Peak flow after initial bronchodilator, if available, compare to predicted or personal

best. o Measure pulsus paradoxus. o Chest X-ray if suspect pneumonia.

Treat for suspected diagnosis while supporting the patient The general principles to manage a patient with respiratory distress from bronchospasm are the same as described before. o Manage airway. o Give oxygen therapy. o Give sequential bronchodilator therapy. o Treat underlying cause. o Monitor and record. o Respond.

How to give sequential bronchodilator therapy for moderate, severe or life-threatening wheezing

RECOGNIZE Determine if the patient has life-threatening, severe, or moderate wheezing.

o Suspect life-threatening wheezing if one or more of the following are present: o silent chest


KEY TEACHING POINTS

Discuss the difference between life-threatening, severe, or moderate wheezing

Explain silent chest: a patient who has life-threatening bronchospasm may be moving very little air in and out of the lungs. When you auscultate the lungs of these patients you may hear no air movement or very quiet air movement or wheezing. In a patient who is in severe respiratory distress, this is a very poor sign and indicates the patient is in life-threatening danger.


o cyanosis o poor respiratory effort o altered consciousness, confusion, or patient is combative or agitated o exhaustion.

o Suspect severe wheezing if one or more of the following are present: o breathless at rest o cannot complete sentences in one breath o respiratory rate ≥25 breaths/min o pulse ≥100.

o Suspect moderate wheezing if: o wheezing with no features of life-threatening or severe wheezing.

*Caution: some patients with severe bronchospasm may present with no wheezing at all. This occurs because air movement is so limited that no noise is made. These patients have life-threatening wheezing.

When available, a peak flow metre measurement can assist in assessing the severity of wheezing. When not available, a pulsus paradoxicus can be measured with a stethoscope and cuff at the bedside.

SpO2<90 on room air Peak flow <33% of predicted or personal best Absence of pulsus paradoxicus (when respiratory arrest imminent, absence suggests muscle fatigue)

LIFE THREATENING WHEEZE

SpO2>90% Peak flow 33-50% of predicted or personal best Pulsus paradoxus >25 mm Hg

SEVERE

WHEEZING

SpO2>90% Peak flow 50-75% of predicted or personal best Pulsus paradoxus may be present – 10–25 mmHg

MODERATE

WHEEZING

FIX THE PHYSIOLOGY Life-threatening wheezing: Mange airway (see Quick Check pp. 12–13). Give oxygen (see Quick Check pp. 14–16). Give salbutamol by continuous nebulizer. See Quick Check p. 17 for how to give sequential bronchodilators. Reassess immediately, do not leave patient alone. If no improvement, give salbutamol continuously. Add ipratropium by nebulizer. If no improvement, give intravenous magnesium (2 grams over 20 minutes). If fever, give IM/IV antibiotic. Severe wheezing: Give oxygen (see Quick Check pp. 14–16). Give salbutamol by nebulizer (continuous or every 20 minutes). See Quick Check p. 17 for how to give sequential bronchodilators.


KEY TEACHING POINTS Discuss the use of a peak flow meter or measuring pulsus paradoxus to classify the severity of wheezing.

Review the treatments for life-threatening, severe, and moderate wheezing.


Reassess immediately (15–30 minutes). If not improving, give more salbutamol every 20 minutes or continuously if deteriorating. Add ipratropium by nebulizer. If deteriorating, also give magnesium (2 grams over 20 minutes). If fever, give IM/IV antibiotic.

Moderate wheezing: Give oxygen. Give salbutamol by primed spacer with 5 puffs then give 2 puffs via spacer every 2 minutes. If patient with wheezing is clearly improving, then give salbutamol less frequently. If on continuous, titrate to every 20 minutes. If every 20 minutes, titrate to every one or two hours.

Common side-effects in patients who are given repeat doses of salbutamol include tachycardia, tremulousness, and nausea. The tachycardia is usually well-tolerated in most patients but should be monitored, and extra caution is required in elderly patients. These side-effects usually resolve spontaneously within 1 hour after the last dose of medication is given.

Treat the cause

If you suspect acute asthma or COPD, give steroids immediately. Steroid treatment is necessary to decrease the inflammation and swelling around the airways in patients with asthma or COPD. It usually takes several hours to see improvement, so the earlier you give it, the sooner you will see results. Remember, this may be the first presentation of the patient with either asthma or COPD, so look for other clues. o Suspect COPD if there are risk factors such as history of tobacco or exposure to indoor

smoke from cooking over open fires. o Suspect asthma if there is history of allergies or episodic chest tightness and wheezing

precipitated by exercise, cold, or strong smells. o Give either 100 mg hydrocortisone IV or 40–60 mg methylprednisolone IV or oral

prednisone 40–60 mg.

If there is no inhaled salbutamol available, consider either of the following for severe bronchospasm

Salbutamol 250 mcg slowly by IV for severe acute bronchospasm and if there is no inhaled salbutamol available (beware that this can lead to hypokalaemia).

Aminophylline 5 mg/kg slowly over 20 minutes.

Epinephrine 0.5 mg (0.5 ml of 1:1000) IM.

Note that theophylline and aminophylliine are not recommended due to toxicity and therefore not included on the WHO Model List, but may be effective by slow IV if no other drugs are available.


Emphasize that the primary acute treatment is inhaled salbutamol; other medications are adjunct treatments. Discuss the side-effects of repeated doses of salbutamol. Explain that if inhaled salbutamol is not available, other options include: IV salbutamol (watch for hypokalaemia), aminophylline (watch for toxicity), epinephrine. Discuss how to manage the patient with wheezing who is improving.


If fever, give empirical antimicrobials. Initially, it may be difficult to assess if there is also a concurrent community acquired pneumonia, or if the patient has asthma or COPD or if the etiology of acute wheezing is non-infectious. o Give empirical antibiotics early for possible community acquired pneumonia. o If influenza is circulating and patient has had symptoms of ILI and now has acute

wheezing, consider severe or complicated influenza infection and give antivirals. o Remember to adjust antimicrobial regimen once the etiology of wheeze is known.

MONITOR – RECORD – RESPOND o Do not leave patients with life-threatening wheezing alone. These patients need

continuous monitoring and treatments. o Patients with severe wheezing need to be assessed every 15–30 minutes and after

every salbutamol treatment so that sequential bronchodilator treatment can be administered.

o Monitor similar clinical parameters as done for other severely ill patients but also include peak flow.

o If patient fails to improve, consider the following: o Is oxygen supply working? o Is salbutamol delivery system working? o If suspected acute asthma or COPD, have steroids been given? o Is there an alternate diagnosis? Pneumothorax, fluid overload/pulmonary oedema

Quality care Benchmarks are defined as standards of achievement or excellence. Because of the importance of time in the management of patients with severe respiratory distress, benchmarks have been established for you to achieve as soon as you recognize that someone is in severe respiratory distress. If the patient presents with severe respiratory distress from acute bronchospasm (wheezing), within 30 minutes: o salbutamol given o if asthma/COPD, steroid given.


Emphasize the importance of a broad differential diagnosis and searching for the underlying cause of wheezing (e.g. primary asthma exacerbation, pneumonia, pulmonary oedema, inhalation injury). Explain that if acute asthma or COPD is suspected, steroids should be given immediately. Discuss the importance of empirical antimicrobials if fever is suspected, even if the exact pathogen is not known. Discuss the importance of continuous monitoring and treatments for patients with life-threatening wheezing. Explain that patients with severe wheezing need to be assessed every 15 to 30 minutes and after every salbutamol treatment. Record similar clinical parameters and include peak flow on the severe illness patient monitoring form. Ask participants what they should consider in patients who fail to improve.


DRILL 3-6: Wheezing

1. A patient with asthma and wheezing is able to speak in full sentences without signs of distress. The patient should be monitored using the severe illness patient monitoring form. True or False? False

2. Read the scenarios listed below. Does the patient have severe wheezing?

• 34 year-old female who is breathless at rest. Yes or No

• 26 year-old male who is speaking in single words. Yes or No

• 18 year-old male who is breathless when talking. Yes or No

• 38 year-old female who is breathless only when walking. Yes or No

• 45 year-old male who is comfortable lying down. Yes or No

• 48 year-old female who is speaking in incomplete phrases. Yes or No

• 35 year-old female who is confused, agitated, and anxious and appears breathless. Yes or No

• 55 year-old male who is speaking in full sentences. Yes or No

• 22 year-old female who has a presents with a silent chest (you hear no wheezing and very little breath sounds when listening to chest) with cyanosis. Yes or No

3. A 22 year-old previously healthy male presents with severe wheezing. You have started the patient on oxygen, and given salbutamol two puffs via MDI with spacer. The patient appears to be worsening and is now is only able to speak in single words secondary to the respiratory distress. What would do next for the patient? - Increase oxygen flow - Give salbutamol up to 5 puffs via MDI with spacer, then 2 puffs every 2 minutes or via continuous nebulizer - Give steroids - Give IV magnesium

4. Salbutamol tablets are not as effective as salbutamol via a nebulizer or MDI with spacer. True or False? True


Have participants do DRILL 3-6: Wheezing.


Managing a patient with acute pulmonary oedema Pulmonary oedema occurs when the lungs are abnormally full of fluid. A common cause of oedema is congestive heart failure. This occurs because the heart does not pump normally due to valve problems or weak heart muscles. This increased pressure in the heart also affects the small vessels of the lungs by pushing the fluid out of the vessels and into the lung tissues. Increased pressure is also caused by severe kidney disease, hypertension, toxins, or snake-bites.

During the Quick Check, you provided emergency treatments. Now, it is time to identify patients with acute pulmonary oedema or fluid overload so that urgent treatments are given. Take a history and perform a physical examination.

Recognize patients with severe acute pulmonary oedema: o respiratory rate more than 30 o SpO2 less than 90 o bilateral crackles or rales on auscultation o signs of fluid overload, elevated JVP, hepatomegaly or ascites, bilateral lower extremity

oedema o chest X-ray with fluffy bilateral infiltrates, peri-hilar distribution, bilateral effusions o history or signs of cardiac or kidney disease.

Take a history o How quickly did symptoms develop, over months, weeks, days or hours? o Are there any associated symptoms such fever, cough, chest pain, or abdominal pain? o Is there difficulty breathing at rest, during exercise (exertional dyspnoea), when lying

flat (orthopnoea), at night that wake the patient from sleep (nocturnal dyspnoea)? o Are there any precipitating factors such as increased intake of salty foods, recent

infection, irregular heart palpitations (atrial fibrillation), chest pain, or a history of a toxin exposure, drug overdose, or snake-bite?

o What is the past medical history? Are there any chronic diseases such as HIV infection, cardiomyopathy, liver disease, renal disease?

o Is the patient pregnant? Women with mitral stenosis will often decompensate in the middle of their pregnancy. Peripartum cardiomyopathy develops in the last month of pregnancy or within six months of delivery. Women with pre-eclampsia or eclampsia may have convulsions, high blood pressure and develop pulmonary oedema.

o What medications is the patient currently taking? Has the patient been compliant with his or her medications?

o What are the patient’s wishes for intensity of therapy? Patients with very advanced heart failure may not want intensive therapies.

Perform a focused examination to identify likely cause o Look for tachycardia: A pulse more than 120 is common in acute heart failure. o Check the blood pressure: Depending on the cause, the patient’s blood pressure may

be high, low or normal. A wide pulse pressure (such as 120/30 mmHg) suggests possible severe aortic insufficiency.

o Check for fever which may suggest concurrent and/or exacerbating pneumonia or other infection.

o In patients with congestive heart failure or renal failure check the patient’s weight and compare to previous weights.

o Look for poor perfusion (blood flow): cold extremities.


o Ask for a volunteer to explain what pulmonary oedema means. o Write a list of possible causes of acute pulmonary oedema. o Discuss how a patient with acute pulmonary oedema may present. What other disease

processes may have similar signs and symptoms? o Review the key points of the history and physical exam. Discuss how this information may

help to rule in or rule out a diagnosis.


Cardiovascular system: o Check for displaced point of maximum impulse, extra heart sounds, or loud murmurs. o Check for distended neck veins and lower-extremity oedema. Respiratory: o Listen for bilateral crackles. o Listen for decreased breath sounds at bases. Gastrointestinal: o Palpate for hepatomegaly and ascites.

Send urgent investigations: o creatinine, potassium, haemoglobin o recommend HIV test o if suspect infection, check blood cultures and other cultures as appropriate o chest X-ray o ECG: evaluate for ischaemia, ventricular hypertrophy, arrhythmias o Limited echocardiography: Assess cardiac function, presence of mitral stenosis, or a

pericardial effusion. This does not require a cardiologist or a radiologist and can be done with basic ultrasound equipment without Doppler.

Treat for suspected diagnosis while supporting the patient

The general principles of managing a patient with acute pulmonary oedema are similar to the management of other patients with acute severe respiratory distress, with the addition of treating with diuretics and treating severe hypertension.

o Have patient assume a position of comfort. o Manage the airway. o Give oxygen therapy. o Give diuretic therapy. o Treat severe hypertension. o Treat precipitating cause. o Monitor and record. o Respond. As in earlier sections, use a time-based approach to manage patients with acute pulmonary oedema.

Quality care Benchmarks are defined as standards of achievement or excellence. Because of the importance of time in the management of patients with severe respiratory distress, benchmarks have been established for you to achieve as soon as you recognize that someone is in severe respiratory distress.

If the patient presents with severe respiratory distress and suspect acute pulmonary oedema, within 30 minutes: o oxygen started o SpO2 measured o furosemide 20 mg IV given o if hypertensive, isosorbide dinitrate given o if ischaemia (chest pain), aspirin given.


Review the benchmarks for the management of acute pulmonary oedema.

KEY TEACHING POINTS

Discuss the urgent investigations for a patient with acute pulmonary oedema and why they are indicated. Ask the participants barriers to obtaining these tests in their facilities.

Explain that the basic initial management principles are the same for acute pulmonary oedema as for treating other patients with severe respiratory distress. However, these patients may require other urgent interventions such as the use of diuretics and antihypertensives.

Discuss the common causes that trigger acute pulmonary oedema. • Common cardiac causes include: myocardial ischaemia, arrhythmia, severe

hypertension, pericardial effusion. • Other causes include: pneumonia, medication non-adherence, increased salt and water

intake, pulmonary embolism.


SEVERE ACUTE PULMONARY OEDEMA/FLUID OVERLOAD

FIRST 2 HOURS

RECOGNIZE The clinical diagnosis of severe acute pulmonary oedema/fluid overload should be suspected when: o respiratory rate >30 or SpO2 <90

and o bilateral crackles on lung exam o signs of volume overload: distended neck veins, hepatomegaly, ascites, lower-

extremity oedema o history of cardiomyopathy or kidney disease.

FIX THE PHYSIOLOGY Give oxygen: Titrate to SpO2 90 As with other diseases, give oxygen as you learned to do in the Quick Check.

Give furosemide 20 mg IV Diuretic therapy helps reduce congestion in the lungs. The required dose of furosemide depends on whether the patient has been taking this drug as an outpatient and whether the patient has kidney disease. Furosemide works rather quickly at the level of the kidney, so expect to see an increase in urine output within 30 minutes. Remember, IV furosemide is twice as effective as the oral form. Patients with kidney disease will likely need higher doses than those with normal kidney function. o If patient has not been on furosemide as an outpatient, then give furosemide 20 mg IV. o If patient has been on furosemide, then give the oral dose as an IV dose. o Monitor urine output and SBP. Hypotension can occur if urine output is brisk.

TREAT THE TRIGGER Patients with cardiomyopathies or chronic kidney disease usually decompensate and develop acute pulmonary oedema because of a triggering event. You should try to identify the cause and treat it appropriately. Common cardiac causes include myocardial ischemia, arrhythmia, severe hypertension, and pericardial effusion. Other causes include pneumonia, medication non-adherence, increased salt and water intake, pulmonary embolism.

Treat severe hypertension, if present Decreasing the blood pressure will help to reduce the congestion in the lungs as well. o Start with low dose of isorbide dinitrate 5 ml sublingual. This can be repeated in

15 minutes if still hypertensive, but do not give more than 10 mg every 2 to 3 hours. o If isorbide dinitrate is not available, give hydralazine 5 mg IV. This can be repeated in

30 minutes if still hypertensive. If suspect myocardial ischemia, give aspirin 300 mg.

If suspect infection, give empirical antimicrobials.


FIX THE PHYSIOLOGY

Explain that diuretic therapy helps to reduce the congestion in the lungs.

KEY TEACHING POINTS

Give oxygen Titrate to SpO2 90.

Give furosemide. Expect to see an increase in urine output within 30 minutes. Remember, IV furosemide is twice as effective as the oral form. If the patient has not been on furosemide as an outpatient, then give furosemide 20 mg IV. If the patient has been on furosemide, then give the oral dose as an IV dose. Monitor urine output and SBP. Hypotension can happen if urine output is brisk.

TREAT THE TRIGGER

Discuss the common triggers of acute pulmonary oedema.

KEY TEACHING POINTS

Common cardiac causes include: myocardial ischaemia, arrhythmia, severe hypertension, pericardial effusion.

Other causes include: pneumonia, medication non-adherence, increased salt and water intake, pulmonary embolism.

Treat severe hypertension, if present Start with low dose of isorbide dinitrate 5 ml sublingual. This can be repeated in 15 minutes if still hypertensive, but do not give more than 10 mg every 2 to 3 hours. If isorbide dinitrate is not available, give hydralazine 5 mg IV. This can be repeated in 30 minutes if still hypertensive. If suspect myocardial ischemia, give aspirin 300 mg. If suspect infection, give empirical antimicrobials.

KEY TEACHING POINTS Discuss when to suspect a clinical diagnosis of acute pulmonary oedema.


MONITOR – RECORD Patients with acute pulmonary oedema need close monitoring, just as you learned to do with other patients. However, there are key distinctions that are different. o Urine output needs to be monitored very closely (within 30 minutes of first dose) to

assess the early response to furosemide and in order to effectively titrate furosemide therapy.

o Potassium and creatinine must also be measured once to monitor for side-effects of diuresis with furosemide.

Check creatinine, potassium on admission Monitor every 30 minutes until stable then every 1 hour: o SBP, pulse, RR, SpO2, mental status (AVPU), urine output o JVP, auscultate for crackles (rales) Check weight on admission.

RESPOND If respiratory distress fails to improve or worsens and not adequate urine output: o Check oxygen supply, increase oxygen flow. o Give furosemide IV 40 mg (double dose). o If renal failure, call for help and consider higher doses of furosemide and additional

diuretics.

2-6 HOURS

RECOGNIZE As with other causes of severe respiratory distress, patients with acute pulmonary oedema need to be reassessed to see if they are improving or not. If the patient is not improving, consider the following: o Is the furosemide dose effective? Has there been sufficient urine output (150–200 ml)? o Are the triggers being treated? Is there ongoing myocardial ischemia? Is there still

severe hypertension? o If diuresis has been effective and the patient is not improving, is there another cause of

the severe respiratory distress? o If poor response to initial treatment reconsider your diagnosis. Look for severe

pneumonia, acute lung injury, pneumothoral, pleural effusion, poisoning, TB, PCP in PLHIV, severe malaria.

FIX THE PHYSIOLOGY Give oxygen: Titrate to SpO2 90 Continue to give oxygen as you learned to do in the Quick Check.

Give higher furosemide dose, if inadequate urinary response to first dose o If urine output less than 150-200 ml after first dose of furosemide, give furosemide

40 mg IV. If urine output adequate, do not give additional dose of furosemide. o Monitor urine output and SBP. Hypotension can happen if urine output is brisk.


MONITOR-RECORD-RESPOND

Explain that patients with pulmonary oedema need close monitoring. Repeat dosing of furosemide may be indicated if not improving.

Acute pulmonary oedema: 2-6 hours

RECOGNIZE

Ask participants to consider reasons that the patient may not be improving.

FIX THE PHYSIOLOGY

Discuss oxygen therapy and diuresis.

TREAT THE TRIGGER

Discuss the management of severe hypertension if still present.


Record observations on patient monitoring form.

KEY TEACHING POINTS If respiratory function declining

Check oxygen supply and increase flow rate.

If unresponsive to escalating diuretic therapy, call for help from senior clinician to give higher dose of furosemide or add another diuretic agent. If in renal failure, consider transfer to a centre with haemodialysis.

If responsive to diuretic therapy, consider alternate diagnosis – pneumonia, acute lung injury, pneumothorax, pleural effusion.

If patient develops shock (SBP <90 and signs of poor perfusion)

Stop diuresis.

Give 250 LR or NS bolus.

Call for help from senior clinician – if cardiogenic shock, consider vasopressors.


TREAT THE TRIGGER

Continue to treat severe hypertension, if still present.

• Give additional isorbide dinitrate 5–10 ml sublingual every 2 to 3 hours.

If concern for cardiac ischemia, give aspirin. Refer to section 3.5 of DCM for additional information.

If suspect arrhythmia, refer to section 3.5 of DCM for specific treatment of arrhythmias.

If fever, give empirical antimicrobials.

MONITOR – RECORD Continue to monitor the patient closely and record observations on patient monitoring form. Every 30 minutes until stable then every 1 hour• SBP, pulse. RR

:

• mental status (AVPU) • urine output • JVP, auscultate for crackles (rales)

RESPOND If respiratory function declining: • Check oxygen supply and increase flow rate. • If unresponsive to escalating diuretic therapy (i.e. low urine output after administration

of diuretics), call for help from senior clinician to give higher dose of furosemide or add another diuretic agent. If in renal failure, consider transfer to a centre with haemodialysis.

• If responsive to diuretic therapy (i.e. patient with increased urine output after administration of diuretics), consider alternate diagnosis – pneumonia, acute lung injury, pneumothorax, pleural effusion.

If patient develops shock (SBP <90 and signs of poor perfusion):

• stop diuresis • give 250 LR or NS bolus • call for help from senior clinician – if cardiogenic shock consider vasopressors.

6-24 HOUR

RECOGNIZE As with other causes of severe respiratory distress, patients with acute pulmonary oedema need to be reassessed to see if they are improving. Use laboratory results and chest X-ray to prioritize the differential diagnosis. If the patient is not improving, consider the following:

• Is the furosemide dose effective? Has there been sufficient urine output (150–200 ml)? • Are the triggers being treated? Is there ongoing myocardial ischemia? Is there still

severe hypertension?


RECOGNIZE

Ask participants to consider reasons that the patient may not be improving

KEY TEACHING POINTS

o Is the furosemide dose effective? Has there been sufficient urine output (150–200 ml)?

o Are the triggers being treated? Is there on-going myocardial ischemia? Is there still severe hypertension?

o If diuresis has been effective and the patient is not improving, is there another cause of the severe respiratory distress?


If diuresis has been effective and the patient is not improving, is there another cause of the severe respiratory distress?

FIX THE PHYSIOLOGY Give oxygen: titrate to SpO2 90

Repeat effective furosemide dose

• Once effective dose has been determined, repeat this dose every 6-8 hours. • Monitor urine output and SBP. Hypotension can happen if urine output is brisk.

TREAT THE TRIGGER Treat hypertension o If the patient has responded well to vasodilator therapy, transition to oral ace inhibitor

of creatinine is normal, such as enalapril 5 mg daily by mouth. If patient does not have normal renal function, discuss other antihypertensive options with senior clinician.

• If it is determined that the patient has another trigger such as myocardial ischemia, arrhythmia, or pneumonia, give next dose of medication to treat the trigger.

MONITOR – RECORD Continue to monitor patient closely. Every hour if SBP <90 or on vasopressors, otherwise every 2 hours• SBP, pulse

:

• respiratory rate • oxygen saturation • mental status (AVPU) • JVP, auscultate for crackles (rales). Monitor every 6 hours• temperature

:

• urine output. Repeat glucose and Hb if initial value is abnormal.

RESPOND Using similar guidance as in 2-6 hours, respond to changes in the patient’s respiratory or cardiovascular status.

POST-RESUSCITATION

RECOGNIZE Now that the patient is stabilized, make sure you are treating underlying chronic conditions and acute triggers according to national or hospital guidelines.


FIX THE PHYSIOLOGY

Continue to give oxygen and furosemide

KEY TEACHING POINTS

o Give oxygen

• Titrate to SpO2 90.

o Repeat effective furosemide dose

• Once effective dose has been determined, repeat this dose every 6-8 hours.

• Monitor urine output and SBP. Hypotension can happen if urine output is brisk.

TREAT THE TRIGGER

Continue to treat hypertension, myocardial ischaemia, arrhythmia, and pneumonia.

KEY TEACHING POINTS

o If there has been good response to vasodilator therapy, transition to oral ace inhibitor if creatinine is normal. If not normal, discuss other antihypertensive options with senior clinician.


Continue to monitor patient and record observations on the monitoring form.


FIX THE PHYSIOLOGY Give oxygen: Titrate to SpO2 90 Titrate oxygen down and discontinue when room air is SpO2 90%.

Continue to give furosemide if signs of fluid overload persist Continue to give furosemide at effective dose until signs of fluid overload are improved. Titrate down frequency to every 8-12 hours, and switch to oral dose.

TREAT THE TRIGGER: POST-RESUSCITATION Give the next dose of medication to treat hypertension, myocardial ischemia, or arrhythmia.

NUTRITION As discussed earlier in the chapter, nutrition therapy is important in the recovery of severely ill patients. Once the patient has stabilized, begin nutrition via nasogastric tube. If patient is able to tolerate it, start oral feeds. If uncontrolled hypertension or congestive heart failure is the suspected etiology of the pulmonary oedema, feed the patient a low sodium diet.

MONITOR – RECORD Continue to monitor the patient and record observations on patient monitoring form. Every 8 hours (check SBP hourly if weaning off vasopressors) then daily: • SBP • respiratory rate • oxygen saturation • mental status (AVPU).

RESPOND Respond to changes in the clinical condition.


RECOGNIZE

Explain that at this point participants should make sure to treat underlying conditions and acute triggers according to national or hospital guidelines.

FIX THE PHYSIOLOGY

Continue with oxygen and furosemide if signs of fluid overload persist.

KEY TEACHING POINTS

o Give oxygen

Titrate oxygen down and discontinue when room air SpO2 90%.

o Continue to give furosemide if signs of fluid overload persist

Continue to give furosemide at effective dose until signs of fluid overload are improved.

TREAT THE TRIGGER

Continue to treat hypertension, myocardial ischaemia, or arrhythmia.


Remember to record the daily weight.

KEY TEACHING POINTS Every 8 hours (check SBP hourly if weaning off pressors), then daily

o SBP

:

o respiratory rate

o oxygen saturation

o mental status (AVPU)

o weight.


GROUP EXERCISE: Acute pulmonary oedema Do the following exercises in groups and discuss your answers. 1. A 35 year-old woman with history of some type of heart disease arrives with severe

respiratory distress and is started immediately on oxygen therapy, her saturation is now 90% on 5 litres/minute. Her vitals are: SBP 135/70, HR 110, T=36, RR 25. On examination, she has elevated JVP, a loud murmur, crackles on ausculation of her lungs and bilateral lower leg oedema. What do you do next? Give furosemide 20 mg IV. If patient is on furosemide at home give her normal oral dose IV instead.

2. After 30 minutes, you evaluate her urine output. She has produced only 20 ml of urine, her clinical parameters have not changed. What do you do next? Repeat dose of furosemide

3. 50 year-old man with known ischemic cardiomyopathy, takes 40 mg oral furosemide daily as an outpatient but has missed a few doses recently because he has had an influenza-like illness and is too fatigued to get out of bed. He is started on oxygen therapy and his saturation is 92% on 5 litres/minute and his other vitals are: T=39, SBP 175/85, HR 120, RR 30 and has signs of fluid overload. What would you do now? - Give furosemide 40 mg IV - Treat hypertension with sublingual isosorbide dintrate

4. After 30 minutes, you evaluate his urine output and other vitals. Urine output is about 150 ml and SBP is now 130/50. He still has signs of severe respiratory distress, his saturation remains at 92% on 5 litres/minute, his RR is 30 and HR is 115. What other urgent treatments should this patient get? Consider antibiotics and antivirals

5. 50 year-old man who smokes and has diabetes presents with chest pain and severe respiratory distress. He is started on oxygen therapy and his saturation is 94% on 5 litres/minute. His other vitals sings are: BP 110/60, HR 110, T=36, RR 25. On examination, he has signs of fluid overload and pulmonary oedema. What do you do next? - Give furosemide - Give aspirin

6. After 30 minutes, the chest pain has resolved, but his BP is now dropped to 85/55. What do you do next? Repeat blood pressure to ensure measurement is correct. If patient is symptomatic from low blood pressure, give 250 ml bolus of NS.


Ask participants to divide into small groups and do the GROUP EXERCISE: Acute pulmonary oedema. Then discuss the answers in the larger group.


Summary of severe respiratory distress

Recognize severe respiratory distress If respiratory rate >30 or SPO2<90, and o SBP >90 mm Hg and

o no heart failure

o then, suspect pneumonia or acute lung injury. If bilateral crackles or rales o signs of fluid overload (increased JVP, hepatomegalay, ascites, or lower extremity

oedema)

o chest xray with fluffy bilateral infiltrates, peri-hilar distribution, bilateral effusions

o history or signs of cardiac or kidney disease

o then suspect acute pulmonary oedema. Fix the physiology Monitor SpO2, give and titrate oxygen to target SpO2 of 90%.

Treat wheezing with salbutamol.

Give conservative fluids orally or through IV as indicated, and monitor for pulmonary oedema.

If possible monitor urine output to match input and output.

If patient develops hypotension (SBP<90), treat as shock.

Treat acute pulmonary oedema with diuretics. Treat the infection Give early empirical antibiotics, antimalarials (endemic areas) and antivirals (when appropriate).

Reconsider diagnosis and choice of treatment if patient not improving. Monitor – record – respond to abnormal signs and laboratory results Reassess patient frequently, every 30 minutes initially

Look for changes in vital signs, urine output, laboratories and physical examination

Record all clinical information on the patient monitoring form.



Assessment questions: Severe respiratory distress

1. True/False. Any patient who has emergency signs of airway or breathing and does not rapidly respond to treatment should be considered to have severe respiratory distress. True

2. During the first two hours, how often should you monitor the vital signs for a patient in severe respiratory distress? 30 minutes until stable, and then every hour after that.

3. For a patient in severe respiratory distress, oxygen saturation should be titrated to what SpO2? 90%

4. List three diagnostic tests that may help you determine the cause of a patient’s severe respiratory distress? Any of following answers: chest X-ray, haemoglobin, HIV test, blood cultures, sputum for AFB, peak flow, creatinine, ECG, echocardiogram, pregnancy test.

5. You should wait for a chest X-ray results to come back, before starting antibiotics on a patient with suspected pneumonia. True or False? False

6. If the respiratory function is declining in a patient in severe respiratory distress who is on oxygen, list four things that you would do? - Increase oxygen flow - Check equipment (cylinder has sufficient oxygen, oxygen is flowing out of the prongs or face mask, no leaks in the connections of oxygen tubing) - Check for signs of fluid overload - Check for wheezing.


• Now ask the participants to answer the Assessment questions: Severe respiratory distress.


7. What type of fluid should be given in the first hour for a patient in severe respiratory distress and a respiratory rate of 40? How much fluid should be given? NS or LR at 1 ml/kg/h

8. If you check the vital signs in a patient in severe respiratory distress and their blood pressure is now 70/30 you should at that point begin to use the recommendations in the section on septic shock to guide the resuscitation of the patient. True or False? True

9. What is the initially recommended dose of furosemide for a patient with suspected

acute pulmonary oedema who is not on chronic diuretic therapy? 20 mg IV

10. True or False. Salbutomal, when available, should always be given inhaled.

True



Practice cases CASE 3-1 JR is a 22 year-old male who was admitted to the ward with a diagnosis of pneumonia. When walking past his bed, you note that he appears to be breathing very fast, shallow, and is only able to speak in one or two words. He is not on oxygen. You call for help and ask the nursing assistant to get you oxygen. While waiting for the oxygen to arrive you check the vital signs: RR: 34 HR: 125 T: 37°C BP: 130/80 SpO2: 88% 1. Does this patient meet the criteria for severe respiratory distress?

Yes. 2. How would you administer oxygen to JR (flow/method) Start at 5 L NC. 3. How often would you monitor the oxygen saturation? At least every 30 minutes until stable.

CASE 3-2 RH is a 24 year-old female who was admitted to the ward with pneumonia. RH is awake, alert, and not vomiting. The vital signs are: RR: 26 HR: 110 T: 37 °C BP: 122/70 SpO2: 92 on 5 L via NC 1. Over the first hour, how would you administer fluids to RH and at what rate?

If able to take fluids orally, encourage oral fluids. If unable to take fluids orally start NS or LR at 1 ml/kg/h



CASE 3-3 HS is an 18 year-old male who was diagnosed with influenza and is having difficulty breathing. You can hear diffuse wheezing when you listen with your stethoscope. HS can speak 3-4 words at a time. His vital signs are: BP 130/70, HR 110, RR 35. 1. What would you do next?

Start oxygen at 5 L via NC Give salbutamol 2 puffs Position patient in comfortable position

2. After 2 puffs with a salbutomol MDI, HS is still in moderate distress and wheezing

loudly. SpO2 is 98. What would you do next? SpO2 is 98. What would you do next? Repeat salbutamol 2 puffs every 2 minutes

3. After 10 minutes, you note that HS is worsening and he is in severe distress, wheezes

are less loud. What other medications can you give? Magnesium 3 grams IV over 20 minutes Epinephrine 0.5 ml of 1:1000 dilution IM Hydrocortisone 200 mg IV or methylprenisilone 60 mg IV

[Review with participants why wheezing in a patient with a severe asthma exacerbation and who is becoming confused, sleepy or has increased distress may mean that the patient is worsening. If air movement is decresed due to worsening brochospasm, you will hear less wheezing.]

CASE 3-4 BL is a 56 year-old HIV positive female who was admitted for pneumonia. She has received oxygen, antibiotics and antivirals. After 6 hours she is not improving, she continues to have fever and respiratory distress. You call the district clinician for help, who reconsiders the initial diagnosis. 1. What are general reasons the patient may not be improving?

General course of disease Wrong diagnosis Wrong choice of antibiotic

2. List other diagnoses that you would consider.

PCP pneumonia, TB, acute heart failure, pleural effusion, emphysema, pulmonary embolism



CASE 3-5 HT is a 16 year-old female with a history of asthma who has had fever, cough, and shortness of breath for 3 days. She was started on oxygen 5 L, given antibiotics, and given salbutamol via nebulizer for wheezing. After 3 hours, she is having increased breathlessness, the RR is now 40 and SpO2 is 85. 1. List things that you would do to respond at this time?

Increase oxygen flow, change to face mask. Check oxygen to see if supply, tubing, and device are working. Examine patient for continued wheezing, give salbutamol again if needed. If patient has severe wheezing and is not responding to salbutamol, also give epinephrine, magnesium, and steroids. Consider alternate diagnosis.

CASE 3-6 TG is a 30 year-old male know to be HIV positive for 6 months but not on ART. He was initially started on cotrimoxazole but discontinued 3 months ago because of abdominal discomfort. He presented with dry cough and fever which he has had for 3 weeks. He is alert but restless. He is breathing fast and unable to speak a full sentence, and has a weak and fast pulse.. His lips appear blue. His weight is estimated to be 50 kg. RR: 44/min HR: 130/min BP: 85/60 T: 39.5 °C SpO2: 85 White patches in the mouth Bilateral lower lung crackles 1. List any Quick Check emergency signs that are present.

Airway and breathing (severe respiratory distress) Circulation (weak and fast pulse)

2. What first-line emergency treatments would you start?

Start oxygen at 5 L via NC Insert IV and given 1 litre bolus of NS or LR.

3. What urgent treatments would you give?

Give antimicrobials: antibiotics, antimalarias (if endemic area) and antivirals (if circulating influenza). Also consider treating PCP pneumonia if suspected. Send initial laboratory investigations, including chest radiograph.

4. How often would you monitor the patient?

At least every 30 minutes.



Record the patient’s clinical data using blank severe illness monitoring form. After 30 minutes of arrival patient's breathing is still laboured and restless. RR: 40/min HR: 120 BP: 100/60 SpO2: 86 The district clinician evaluated the patient and his chest X-ray and started CTX and prednisone. Update the monitoring form. 5. What actions would you take?

Increase oxygen flow rate. Check oxygen to see if supply, tubing, and device are working.

Patient re-evaluated after 60 minutes since arriving. He is calm and breathing is less laboured now. Vital signs: RR: 32/min BP: 100/60 HR: 110 T: 38 °C SpO2: 90 Update the monitoring form. 6. List the benchmarks for this patient and circle which benchmarks were achieved.

Oxygen started. SpO2 measured. IV started and fluid bolus given. Antimicrobials given.

CASE 3-7 TR is a 26 year-old male who presented with a 1 week history of difficulty breathing and wheezing. TR has a history of asthma and has no medications at home. Over the past week, he has had slight cough, fever, and myalgia. A family member was diagnosed with H1N1 last week. Today, TR’s symptoms became much worse and he is in severe respiratory distress. He can speak 2–3 words at a time. He does not have upper airway obstruction. His pulse is strong and fast. His mental status is normal. Estimated weight is 60 kg. 1. List any Quick Check emergency signs that are present.

Airway and Breathing (severe respiratory distress).



2. What would you do for this patient? Given oxygen 5 L via NC Help patient assume position of comfort If wheezing give salbutamol 2 puffs with primed spacer

You check the vital signs and note: RR: 44 BP:130/80 T: 38.6 °C PR: 120 SpO2: 98 on 5 L nc He is wheezing in both lungs Record this patient’s clinical data in the monitoring form. 3. What other treatments are needed?

Insert IV and give NS or LR at 1 ml/kg/h Give antimicrobials: antibiotics, antivirals if circulating influenza, antimalarials if endemic area Repeat 2 puffs salbutamol

After 30 minutes: Breathing is less laboured, but TR is still having diffuse inspiratory and expiratory wheezing. He can speak in full sentences now, but becomes very short of breath with minimal exertion. RR: 28 BP: 120/60 PR: 135 SpO2: 98 on 5L Update the monitoring form. 4. If TR is symptomatically improving, why do you think his pulse now is higher?

Salbutamol can cause tachycardia (elevated pulse). 5. Circle the benchmarks achieved? (CIRCLE ALL)

• Oxygen started • SpO2 measured • IV started • Antibiotics given • If wheezing, salbutamol given • If malaria area, antimalarials given • Appropriate infection control

6. How often would you now monitor TR?

Every 30 minutes


Facilitator guide: Management of the patient with severe respiratory distress or septic shock Appendix 1

APPENDIX 1: Answer forms for Activity: Practice filling out the monitoring form, page 12.

Facilitator guide: Management of the patient with severe respiratory distress or septic shock Appendix 1

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