Respiratory Failure CDI Scenario – March 2022

Patient: 68 yr. old male admitted from home through the ED with complaints of SOB and lower extremity swelling. Pt with bilateral lower extremity 2+ edema, expiratory wheezing, dyspnea at rest, use of accessory muscles.

PMH: CHF, HTN, COPD on continuous home 02 at 2L, BMI 44.5

Vitals: HR 98, RR 26, temp 98.2, BP 130/72, 02 Sat 84% on 02 at 2L, improved to 95% on 5 liters of O2.

Labs: ABG’s:  pH 7.29, PO2 48, PCO2 60, Echocardiogram: EF 35%, with systolic dysfunction

Chest x-ray: – bilateral pleural effusion and pulmonary edema consistent with CHF.

PE: Rhonchi and rales bilaterally, cough, + sputum, +2 edema bilaterally lower extremities

Treatment: O2 to keep Sa02 above 90%, Dietary Consult for BMI > 40, 1800 calorie Cardiac diet, Cardiology Consult, Bariatric hospital bed, Physical therapy evaluation for decreased exercise tolerance

Meds Ordered: Lasix 40 mg IVP BID changed to Lasix 20mg po bid on day 3, Lisinopril 10 mg PO daily, Solumedrol 60 mg IV q 6 hours, Albuterol aerosol q 6 hours

Cardiology Consult: Patient continues to be short of breath, Diagnosis: Acute Exacerbation of Systolic CHF

Discharge Summary: Patient admitted due to shortness of breath and lower extremity swelling. Given IV Lasix, found to be in exacerbation of CHF. Final diagnosis: Acute exacerbation of systolic CHF, COPD, hypoxia

Question: Are there query opportunities based on the scenario stated above?

Discussion: Patient presents with indicators of acute on chronic hypercapnic respiratory failure, COPD exacerbation, and BMI elevated indicative of morbid obesity. Patient’s risk factors/clinical indicators:

  • Acute on chronic systolic CHF
  • BMI 44.5
  • COPD on home O2 at 2L w expiratory wheezing, dyspnea at rest, cough, sputum, accessory muscle use
  • VS of elevated RR 26, O2 Sat of 84% on o2 2L N/C which improved to 95% on 5L of O2
  • ABGs with pH 7.29, PO2 48, PCO2 60
  • CXR positive for bilateral pleural effusion and pulmonary edema
  • Treatment included oxygen therapy, ABGs, IV diuretics, IV Solumedrol, Albuterol neb.

UASI Recommends: 

  • Query for acute on chronic hypercapnic respiratory failure
  • Query for morbid obesity
  • Query for COPD Exacerbation 

Documentation without Clarification:

  • Principal Diagnosis:  Hypertensive heart disease with heart failure (I11.0)
  • Secondary Diagnosis: Acute on chronic systolic CHF (I50.23), COPD unspecified (J44.9), dependence on oxygen (Z99.81), hypoxia (R09.02)
  • Working DRG:  291 Heart Failure & Shock w MCC
  • RW:  1.2683    GLMOS: 4.9     SOI/ROM: 1/1

Documentation with Clarification:

  • Principal Diagnosis: Hypertensive heart disease with heart failure (I11.0)
  • Secondary Diagnosis: Acute on chronic systolic CHF (I50.23), morbid obesity (E66.01), BMI 44.5 (Z68.41), COPD exacerbation (J44.1), acute on chronic hypercapnic respiratory failure (J96.22), dependence on 02 (Z99.81),
  • Working DRG:  291 Heart Failure & Shock w MCC
  • RW: 1.2683     GLMOS: 4.9     SOI/ROM: 3/3

CDI Educational Tips: 

  • Clinical Indicators for COPD Exacerbation:
    • Medical problems such as CHF can prompt an exacerbation of COPD
    • Increased cough with sputum production
  • Treatment to look for to support a diagnosis of acute exacerbation of COPD
    • Initiation of IV meds. – i.e. corticosteroids, increase/initiation bronchodilators, increase/initiation 02
  • Clinical Indicators for Acute Respiratory Failure:
    • Labs – ABGs pH < 7.35, PO2 < 55, PCO2 > 50 (please note a patient with COPD / chronic lung disease may have an abnormal ABG level that could be considered at baseline for that patient) 
    • P/F Ratio (on oxygen) < 300:  Calculation of P/F Ratio – p02 divided by FI02 = P/F Ratio,
      • please note cannot be used in a setting of chronic hypoxemic respiratory failure  
    • O2 Sat < 91% on room air and/or < 95% on oxygen, Tachypnea/RR > 20; or decreased RR < 10
    • Shortness of breath/dyspnea, Cyanosis, Pursed lip breathing, use of accessory muscles, Difficulty/inability to speak
    • Additional s/sx’s that might be seen are anxiety/restlessness, tachycardia, and profuse sweating, confusion/lethargy
  • Common causes/treatment to support a diagnosis of Respiratory Failure:
    • Common causes:
      • Pneumonia, Heart Failure Exacerbation, COPD Exacerbation
      • Additional causes (not all inclusive): PE, asthma exacerbation, cardiac arrest, chest trauma, pulmonary fibrosis, obesity hypoventilation syndrome
    • Treatment:
      • Oxygen therapy: look for increase in amount of oxygen; i.e. Increased to high flow, bipap, mechanical ventilation, prolonged mechanical vent after surgery; documentation of continuous home O2 for an indication of chronic respiratory failure
      • Pulmonology consult
      • Breathing Treatments
      • Labs, and Radiology – ABGs, serial CXR’s, CT Chest

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.

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