How to manage a patient with abdominal wound dehiscence, pulmonary embolism, and wheezing, requiring supplemental oxygen?

Management of a Patient with Abdominal Wound Dehiscence, Pulmonary Embolism, and Wheezing Requiring Oxygen

Administration of supplemental oxygen is indicated in patients with pulmonary embolism and SaO₂ <90%, with a target saturation of 94-98% (or 88-92% if at risk of hypercapnic respiratory failure). 1

Oxygen Management

• For patients with pulmonary embolism requiring oxygen, provide supplemental oxygen to maintain a target saturation of 94-98% using nasal cannula or face mask 1
• If the patient has risk factors for hypercapnic respiratory failure (COPD, neuromuscular disease, chest wall deformities, morbid obesity), target a lower oxygen saturation of 88-92% 1
• Monitor oxygen saturation continuously and record oxygen delivery system and flow rate on the patient's chart 2
• Consider high-flow oxygen (high-flow nasal cannula) if conventional oxygen supplementation is insufficient 1
• Non-invasive ventilation should be considered before intubation if the patient has increasing respiratory distress despite oxygen therapy 1

Management of Wheezing in Pulmonary Embolism

• Wheezing can be a presentation feature in approximately 9% of patients with acute pulmonary embolism 3
• Consider bronchodilator therapy with inhaled beta-agonists for symptomatic relief of wheezing 1
• Be aware that wheezing in pulmonary embolism may be a sign of severity and is often associated with dyspnea, cough, and respiratory failure 3
• Recognize that pulmonary embolism can mimic bronchial asthma symptoms, requiring careful differential diagnosis 4

Pulmonary Embolism Management

• Continue anticoagulation therapy as the primary treatment for pulmonary embolism 1
• Assess for right ventricular dysfunction with imaging (echocardiography) or laboratory biomarkers (troponins, natriuretic peptides) 1
• If central venous pressure is low, consider modest fluid challenge (≤500 mL), but avoid aggressive volume expansion which may worsen right ventricular function 1
• Risk-stratify the patient using validated tools like PESI or sPESI to guide management decisions 1

Abdominal Wound Dehiscence Management

• Recognize that pulmonary complications are significant risk factors for abdominal wound dehiscence 5, 6
• Be vigilant for wound infection, which is a major independent risk factor for wound dehiscence 5, 7
• Consider surgical consultation for evaluation and potential closure of the dehiscence 6
• Monitor for other complications that may worsen wound healing, such as coughing (which increases intra-abdominal pressure) 5

Monitoring and Follow-up

• Obtain arterial blood gases within 30-60 minutes of initiating oxygen therapy to assess for hypercapnia 1
• Adjust oxygen delivery device and flow rate to maintain target saturation range 2
• Perform urgent clinical reassessment if oxygen requirements increase 2
• Monitor for signs of respiratory failure requiring escalation of respiratory support 1

Important Considerations and Pitfalls

• Avoid excessive positive end-expiratory pressure in patients with pulmonary embolism as it may reduce venous return and worsen right ventricular failure 1
• If mechanical ventilation becomes necessary, use tidal volumes of approximately 6 mL/kg lean body weight to keep end-inspiratory plateau pressure <30 cmH₂O 1
• Be aware that severe hypoxemia refractory to conventional oxygen therapy could indicate right-to-left shunting through a patent foramen ovale 1
• Recognize that patients with abdominal wound dehiscence who develop pulmonary complications have significantly higher risk of poor outcomes 6, 7
• Avoid intubation if possible, as induction of anesthesia and positive-pressure ventilation can cause severe hypotension in patients with right ventricular failure 1