From the Guidelines
This 79-year-old patient with bilateral pneumonia who still requires oxygen at 4L/min after hospital discharge and has CXR findings of pulmonary fibrosis needs further evaluation and management to prioritize morbidity, mortality, and quality of life.
Current Situation
The patient is currently on supplemental oxygen therapy at 4L/min via nasal cannula, which is within the recommended range for initial oxygen therapy according to the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. The guideline suggests that for patients not at risk of hypercapnic respiratory failure who have saturation below 85%, treatment should be started with a reservoir mask at 15 L/min, but since the patient's current oxygen saturation is not provided, it is assumed that the current oxygen therapy is adequate.
Recommendations
- Continue supplemental oxygen therapy at 4L/min via nasal cannula to maintain oxygen saturation above 92% as recommended by the BTS guidelines for the management of community-acquired pneumonia in adults 1.
- Order complete pulmonary function tests to quantify the degree of restriction and diffusion impairment.
- A high-resolution CT scan of the chest would provide better characterization of the fibrotic changes than the CXR.
- Consider starting prednisone 40mg daily for 5 days if there is significant inflammation contributing to symptoms, then taper to 20mg for 5 days, then 10mg for 5 days.
- Monitor for improvement in oxygen requirements and symptoms.
- A pulmonology consultation within 1-2 weeks is recommended to assess the persistent oxygen requirement and evaluate the suspected pulmonary fibrosis, as the persistent oxygen requirement after antibiotic treatment suggests either slow-resolving pneumonia or underlying interstitial lung disease that was exacerbated or unmasked by the infection 1.
- Antifibrotic therapy such as pirfenidone or nintedanib may be indicated depending on the specific type of fibrosis, which the pulmonologist can determine.
Key Considerations
- Pulmonary fibrosis can cause permanent scarring and reduced lung function, explaining the continued oxygen needs despite treating the infection.
- The BTS guideline for oxygen use in adults in healthcare and emergency settings recommends aiming for a saturation of 88-92% in patients with coexisting COPD or other risk factors for hypercapnic respiratory failure, but since this patient's COPD status is not mentioned, the target saturation is set at above 92% 1.
From the Research
Patient's Condition and Oxygen Needs
- The patient is 79 years old with bilateral pneumonia and has completed a course of rocephin and doxycycline.
- The patient still requires oxygen via nasal cannula (NC) at 4LPM.
- A chest X-ray (CXR) suggests pulmonary fibrosis.
Management of Pulmonary Fibrosis
- Supplemental oxygen is prescribed to patients with pulmonary fibrosis to normalize oxygen saturations, decrease symptoms, and improve quality of life 2.
- Pulmonary rehabilitation is an effective intervention that leads to significant improvements in exercise tolerance, symptoms, and quality of life for people with idiopathic pulmonary fibrosis (IPF) 3, 4, 5.
- Early referral to pulmonary rehabilitation is encouraged to promote longer-lasting effects 3.
Oxygen Therapy
- The American Association for Respiratory Care (AARC) recommends aiming for an oxygen saturation range of 94-98% for most hospitalized patients, including those with pulmonary fibrosis 6.
- Humidification of supplemental oxygen should be considered when flows exceed 4 L/min 6.
Benefits of Pulmonary Rehabilitation
- Pulmonary rehabilitation improves functional capacity and fatigue in patients with IPF 5.
- It may also lead to improvements in anxiety, depression, and health status, although further research is needed to confirm these benefits 5.
- High-intensity interval training may optimize the benefits of exercise training in pulmonary rehabilitation 3.