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A 60-Year-Old Man with Acute Respiratory Failure and Mental Status Changes

Case Editor - Judd Flesch

Reviewed By Behavioral Science Assembly

Submitted by

Lokesh Venkateshaiah, MD


Division of Pulmonary, Critical Care and Sleep Medicine

The MetroHealth System, Case Western Reserve University

Cleveland, Ohio

Bruce Arthur, MD


Division of Pulmonary, Critical Care and Sleep Medicine

The MetroHealth System, Case Western Reserve University

Cleveland, Ohio

J. Daryl Thornton, MD, MPH

Assistant Professor

Division of Pulmonary, Critical Care and Sleep Medicine, Center for Reducing Health Disparities

The MetroHealth System, Case Western Reserve University

Cleveland, Ohio

Submit your comments to the author(s).


A 60-year-old man presented to the emergency department complaining of persistent right-sided chest pain and cough. The chest pain was pleuritic in nature and had been present for the last month. The associated cough was productive of yellow sputum without hemoptysis. He had unintentionally lost approximately 30 pounds over the last 6 months and had nightly sweats. He had denied fevers, chills, myalgias or vomiting. He also denied sick contacts or a recent travel history. He recalled childhood exposures to persons afflicted with tuberculosis. 

The patient smoked one pack of cigarettes daily for the past 50 years and denied recreational drug use. He reported ingesting twelve beers daily and had had delirium tremens, remote right-sided rib fractures and a wrist fracture as a result of alcohol consumption. He had worked in the steel mills but had discontinued a few years previously. He collected coins and cleaned them with mercury. 

The patient’s past medical history was remarkable for chronic “shakes” of the upper extremities for which he had not sought medical attention. Other than daily multivitamin tablets, he took no regular medications. 

Hospital course 
He was initially admitted to the general medical floor for treatment of community-acquired pneumonia (see Figure 1) and for the prevention of delirium tremens. He was initiated on ceftriaxone, azithromycin, thiamine and folic acid. Diazepam was initiated and titrated using the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWAS-Ar), a measure of withdrawal severity (1).  By hospital day 5, his respiratory status continued to worsen, requiring transfer to the intensive care unit (ICU) for hypoxemic respiratory failure. His neurologic status had also significantly deteriorated with worsening confusion, memory loss, drowsiness, visual hallucinations (patient started seeing worms) and worsening upper extremity tremors without generalized tremulousness despite receiving increased doses of benzodiazepines.

Physical Exam

On arrival at the medical ICU, the patient appeared cachectic and dyspneic. He was unable to complete sentences. His blood pressure was 125/71 mm Hg, heart rate of 122/min, temperature 100 °F, respiratory rate 33/min, and oxygen saturation 77% on room air and 92% on 40% venti-mask. At the time of presentation to the hospital he had oxygen saturation of 92% on room air.  The heart exam revealed tachycardia but regular rhythm, a normal S1 and S2 and no murmurs, gallops or rubs. On auscultation of the lung fields, breath sounds were diminished on the right side in the upper zone without the presence of adventitious sounds. The abdomen was benign without organomegaly. The patient’s extremities were normal with absence of clubbing or edema. He was oriented only to person, and had an inability to pay attention or remember immediate events. He was moving all four extremities with slightly brisk deep tendon reflexes. Neck was supple and the pupils were brisk in reacting to light.


White blood cell count was 11,000/mm3 with 38% neutrophils, 8% lymphocytes, 18 % monocytes and 35% bands

Hematocrit 33%

Platelet count was 187,000/mm3

Serum sodium was 125 mmol/L, potassium 3 mmol/L, chloride 91 mmol/L, bicarbonate 21 mmol/L, blood urea nitrogen 14 mg /dl, serum creatinine  0.6 mg/dl and anion gap of 14.

Urine sodium <10 mmol/L, urine osmolality 630 mosm/kg

Liver function tests revealed albumin 2.1 with total protein 4.6, normal total bilirubin, aspartate transaminase (AST) 49, Alanine transaminase (ALT) 19 and alkaline phosphatase 47.

Three sputum samples were negative for acid-fast bacilli (AFB).

Bronchoalveolar lavage (BAL) white blood cell count 28 cells/µl, red blood cell count 51 cells/µl, negative for AFB and negative Legionella culture.  BAL gram stain was without organisms or polymorphonuclear leukocytes.

Blood cultures were negative for growth.

Sputum cultures showed moderate growth of Pasteurella multocida.

2D transthoracic ECHO of the heart showed normal valves and an ejection fraction of 65% with a normal left ventricular end-diastolic pressure and normal left atrial size.  No vegetations were noted.

Purified protein derivative (PPD) administered via Mantoux testing was 8 mm in size at 72 hr after placement.

Human immunodeficiency virus (HIV) serology was negative. 

Arterial blood gas (ABG) analysis performed on room air on presentation to the ICU: pH 7.49, PaCO2 29 mm Hg, PaO2 49 mm Hg.


Figure 1. Chest radiograph at the time of initial presentation.

Figure 2. Chest radiograph at the time of transfer to the ICU.

Question 1

As this patient’s acute respiratory failure worsens, what is the appropriate means to provide ventilatory support?


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