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Abstract: The patient in this case is a 60-year-old male who presented to the clinic with shortness of breath after activity for 1 year, aggravated for more than 20 days with hypothermia, no improvement with antibiotics such as intravenous sodium penicillin for injection, and a lung CT 2 months ago showed a bilateral lower lobe, subpleural ground glass shadow with a latticework pattern, diagnosed as idiopathic pulmonary fibrosis, a category of interstitial lung disease, without specific treatment. Through the assessment of the condition, the patient required hospitalization, and the patient was given oxygen + medication. 1 month later, the lung CT was reexamined better than before, and there was no increase in dyspnea.
[Basic information] Male, 60 years old
Disease Type】Idiopathic pulmonary fibrosis, type I respiratory failure
Hospital】Heilongjiang Provincial Hospital
Date of consultation】July 2021
Treatment plan】Medication (sodium penicillin for injection, sodium methylprednisolone succinate for injection, acetylcysteine tablets, pirfenidone capsules)
Treatment period】Inpatient treatment for 14 days, 1 month of outpatient follow-up
Treatment effect] The patient had no significant dyspnea, and the lung CT was better than before.
I. Initial interview
Patient’s description: 1 year ago, shortness of breath appeared after activity without any obvious cause, and the symptoms gradually worsened; more than 20 days ago, the dyspnea became obvious at rest, and the shortness of breath worsened with hypothermia, and the body temperature fluctuated from 37℃ to 38℃, and he felt weak, without night sweats. He was treated with intravenous penicillin sodium and other drugs for nearly 1 week, but his symptoms did not improve and his shortness of breath worsened progressively. The patient denied previous hypertension, diabetes mellitus, coronary heart disease, and connective tissue disease. He had smoked for 35 years, 15 cigarettes/day. He denied any history of “chronic bronchitis”, no history of allergies, no history of choking on food or alcohol, no clear history of inhalation of abnormal gases or exposure to harmful substances, and no pets or special plants. Physical examination: shortness of breath, cyanosis of lips and mouth, Velcro rales could be heard under both lungs on auscultation. Blood count: WBC: 8.3×109/L; Hb: 111 g/L. Serum mycoplasma antibody, virus antibody series, tumor markers, rheumatologic immune series, sputum bacteriology, tuberculosis antibody test, and PPD test were all negative; electrocardiogram was generally normal. Arterial blood gas analysis (without oxygen): PH: 7.423; PaO2: 57.2 mmHg; PaCO2: 41.9 mmHg. Pulmonary function: VC accounted for 32% of the expected value and DLCO accounted for 24% of the expected value, suggesting restrictive ventilatory dysfunction. High-resolution CT of the lungs: grid-like and honeycomb shadows were seen in the lower fields of both lungs (subpleural). The preliminary diagnosis was acute exacerbation of idiopathic pulmonary fibrosis.
(CT of the lungs)
II. Treatment history
After the patient was admitted to the hospital, the patient was diagnosed with acute exacerbation of idiopathic pulmonary fibrosis and type I respiratory failure according to his condition and laboratory tests. First, the patient was given high-flow oxygen, and was treated with sodium penicillin for injection, sodium methylprednisolone succinate for injection, and acetylcysteine tablets for 14 days. After treatment, the patient’s body temperature was normal, shortness of breath was significantly reduced, and malaise improved; lung rales decreased on auscultation; blood gas analysis showed that the partial pressure of oxygen increased compared with before. At the time of discharge, the patient was advised to take pirfenidone capsules and acetylcysteine tablets regularly, to give home oxygen therapy and to perform pulmonary rehabilitation exercises, and to explain to the patient and his family the necessity of taking anti-fibrotic drugs, home oxygen therapy and pulmonary rehabilitation.
III. Treatment effect
The patient was hospitalized for 14 days, and her dyspnea symptoms gradually improved. She felt no complaints of discomfort, and had shortness of breath after heavy activities. Pulmonary auscultation: Velcro rales decreased in the lower part of both lungs, and no dry rales were heard; blood gas analysis: respiratory failure improved, and oxygen partial pressure increased significantly compared with the previous one, and then the patient was discharged. After discharge, the patient was advised to take anti-pulmonary fibrosis medication, pirfenidone capsules and acetylcysteine tablets, and to adhere to oxygenation and pulmonary rehabilitation training. 1 month later, the lung CT was reexamined with no significant dyspnea, and shortness of breath was significantly reduced after activity.
IV. Notes
However, because idiopathic pulmonary fibrosis is an unexplained fibrotic interstitial lung disease commonly found in the elderly, the disease often worsens progressively, and the clinical manifestations are mainly progressive dyspnea and pulmonary hypopnea, with a poor prognosis, so the family and the patient should understand the necessity of taking anti-fibrotic drugs, home oxygen therapy and pulmonary rehabilitation exercises as prescribed by the doctor. Secondly, the patient in this case is a serious “smoker”, so he should be advised to quit smoking, get influenza vaccination and pneumonia vaccination, and avoid exposure to irritating gases and pollutants to avoid acute exacerbation of the disease. Diet should be light and easy to digest, rich in protein and calories, such as egg custard, lean meat porridge, etc., and drink more water to ensure the nutritional health of the body and promote the recovery of the disease.
V. Personal insight
There are many causes of interstitial lung disease. The patient in this case did not see any obvious cause, but the lung CT suggested interstitial lung disease. For such patients, the patient’s medical history should be carefully inquired, paying attention to the home environment, whether pigeons, parrots and other pets are kept; whether long-term blowing of uncleaned air conditioners and the patient’s occupation are long-term exposure to inorganic dust, moldy hay, etc.; also pay attention to whether the patient has a history of connective tissue disease, such as fever, muscle and joint pain, dry mouth and eyes, rash, etc.; whether there is a history of methotrexate, amiodarone, bleomycin and other medications. history of tumor, history of organ transplantation, etc., to exclude the cause of pathogenesis. Patients with idiopathic pulmonary fibrosis should focus on anti-pulmonary fibrosis treatment pulmonary rehabilitation training, long-term oxygen therapy.